60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2140-10-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":345245,"text":"Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n - Hct stable @ 34\n - D/W pt\ns cardiologist and pt risk of bleeding on coumadin\n and risk of stroke from AF, decided to discontinue coumadin; also\n discussed possibility of ischemic colitis as etiology of pt\ns sxs.\n - GI: will not rescope now, PPI and misoprostil\n - Pt had episode of diaphoresis, ongoing chest pain, CE\n negative\n - TTE: EF 20-25%, mod to severe AS, moderate MR; compared with\n prior,.\n - TTE: Increased dilation of the aortic sinus and increased MR\n since prior study.\n -\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 75 (75 - 79) bpm\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Total In:\n 360 mL\n 400 mL\n PO:\n 300 mL\n 400 mL\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 100 mL\n Respiratory support\n SpO2: 95%\n ABG: ////\n Physical Examination\n Gen:\n HEENT:\n Lungs:\n Heart:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 35.4 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n CXR:\n Micro:\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\n takes ASA), had a normal in . Also consider ischemic colitis,\n particularly given risk factors (decreased CO, diuretics). Pt has had\n no further BMs since admission.\n - Hct stabilized ~ 34\n - 2 large bore IVs in place\n - IV PPI: switch to PO\n - GI recs: no plan to scope emergently, recent scope done and Hct\n stable\n - Held diuretics: concern is restarting could exacerbate possible\n ischemic colitis\n - D/W pt\ns cardiologist, plan is to d/c coumadin given risk/benefit\n .\n 2. Chest pain: Pain has been ongoing intermittently, similar to past\n pain. Unlikely to be active cardiac ischemia given time course, pain\n not typical for aortic dissection.\n - telemetry\n - repeat Echo yesterday\n - CE: negative thus far\n - continue statin\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L, has not\n received diuretics x 2 days. Echo yesterday similar to prior, with EF\n 20-25%, mod to severe AS, moderate MR; compared with prior,. Increased\n dilation of the aortic sinus and increased MR since prior study.\n - Hold lasix and spironolactone\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin and sotolol\n - s/p reversal of INR given GIB, plan per his cardiologist is to d/c\n coumadin\n .\n 5. Chronic renal insufficiency: BL creat 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2140-10-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":345263,"text":"Chief Complaint: Gi bleed\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n No events overnight\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Synthroid\n Mexilitine\n Seroquel\n Fluticasone INH\n Celexa\n Digoxin\n ASA\n Sotalol\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: Chest pain\n Respiratory: No(t) Cough, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 79) bpm\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Total In:\n 360 mL\n 610 mL\n PO:\n 300 mL\n 600 mL\n TF:\n IVF:\n 60 mL\n 10 mL\n Blood products:\n Total out:\n 1,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 121 K/uL\n 68 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 103 mEq/L\n 142 mEq/L\n 34.7 %\n 7.8 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n 06:38 AM\n WBC\n 7.0\n 7.4\n 7.8\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n 34.7\n Plt\n 134\n 120\n 121\n Cr\n 2.0\n 1.9\n 1.5\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n 68\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\n possible ischemic colitis.\n 1) Colitis: Continued abdominal pain with perhaps some subjective\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\n gram negative coverage.\n Antiemetics. Advance diet slowly.\n 2) Afib: Holding coumadin per cardiology.\n 3) CAD: Continue current regimen.\n 4) CKD: Cr is stable\n 5) Asthma: Restart home Advair.\n ICU Care\n Nutrition:\n Comments: Advance diet as tolerated.\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"},{"category":"Nursing","chartdate":"2140-10-13 00:00:00.000","description":"Nursing Transfer Note","row_id":345295,"text":"72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\n diverticulosis. H/O GIB with most recent admission on . Now\n admiited with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\n tender , audible bowel sounds. C/O nausea.\n Action:\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\n given. Zofran 4 mg X1 IVPB given.\n Response:\n Abdominal pain tolerable. Cardiac enzymes being negative.\n Plan:\n Cont to assess the pain. F/U with GI .\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\n then.\n Action:\n Follow HCT curve (stable)\n Response:\n No active bleeding noted.\n Plan:\n Follow HCT.\n"},{"category":"Nursing","chartdate":"2140-10-13 00:00:00.000","description":"Nursing Transfer Note","row_id":345344,"text":"72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\n diverticulosis. H/O GIB with most recent admission on . Now\n admiited with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\n tender , audible bowel sounds. C/O nausea.\n Action:\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\n tolerating well.\n Response:\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\n abdominal pain. Cardiac enzymes being negative.\n Plan:\n Cont to assess the pain. F/U with GI .\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\n then.\n Action:\n Follow HCT curve (stable)\n Response:\n No active bleeding noted.\n Plan:\n Follow HCT.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n CHEST PAIN;TELEMETRY;GI BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 104.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Asthma, GI Bleed\n CV-PMH: Angina, Arrhythmias, CAD, Pacemaker\n Additional history: ckd; barrett's esphogus; diverticulosis; asthma;\n hyperlipidemia; of note, pt's ef is 15%; s/p choly; hypothyroidism;\n gerd; anxiety; alzheimers dementia\n Surgery / Procedure and date: s/p cabg with aaa repair in ; s/p icd\n placement in ; s/p choly\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:95\n D:54\n Temperature:\n 97.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,160 mL\n 24h total out:\n 1,600 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 06:38 AM\n Potassium:\n 4.1 mEq/L\n 06:38 AM\n Chloride:\n 103 mEq/L\n 06:38 AM\n CO2:\n 27 mEq/L\n 06:38 AM\n BUN:\n 26 mg/dL\n 06:38 AM\n Creatinine:\n 1.5 mg/dL\n 06:38 AM\n Glucose:\n 68 mg/dL\n 06:38 AM\n Hematocrit:\n 34.7 %\n 06:38 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: micu7\n Transferred to: cc727\n Date & time of Transfer: 2130\n"},{"category":"Physician ","chartdate":"2140-10-12 00:00:00.000","description":"Physician Resident Admission Note","row_id":345059,"text":"Chief Complaint: Black stools, chest pain, abdominal pain\n HPI:\n Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stools since MN accompanied by mid-sternal CP with\n radiation to left arm. Took all BP meds this AM. Also c/o\n lightheadedness and SOB.\n .\nIn the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. per resident had guaiac pos bla\nck stool. Patient received morphine for CP with mild improvement in pain. EKG wa\ns v-paced with no obvious ST/TW changes. NG lavage was negative x 2. He received\n 2U FFP and 5 mg PO vitamin K for INR reversal and 1L IVFs. Seen by Cards in ED\n, recommend echo in AM. Of note, last , the patient had a similar presentat\nion and EGD, c-scope, and capsule endoscopy demonstrated gastritis, Barrett's, a\nnd grade 1 hemorrhoids, without any active bleeding.\n .\n On arrival to the MICU, pt states his discomfort has improved, down\n from to , described as dull ache in chest, non-radiating,\n constant since 11 PM last night, as well as discomfort in the lower\n abdomen (identical to past abd pain in setting of past GIB x 2). +\n nausea.\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 Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n --GI bleed of unknown etiology . EGD revealed esophagitis,\n Barrett's esophagus, and duodenitis. No ulcers.\n --CAD status post CABG with simultaneous thoracic aortic aneurysm\n repair\n in , history of stenting of the left circumflex artery \n --s/p VT/VF arrest, s/p ICD placement in \n --Ischemic cardiomyopathy with an EF of 20%, s/p BiV pacer \n --Chest wall cellulitis over pacer site vs. ICD pacer\n pocket infection\n --PAF on coumadin\n --CKD with baseline Cr. 1.6-2.0\n --Hyperlipidemia\n --Asthma\n --Anxiety\n --Alzheimer's dementia\n --Hypothyroidism\n --Diverticulosis\n --GERD\n --S/P Cholecystectomy\n Meds at home:\n Sotalol 80mg \n Lipitor 20mg daily\n Donepezil 5mg daily\n Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS\n Celexa 60mg daily\n Protonix 40mg daily\n ASA 81mg daily\n Clonazepam 0.5mg TID PRN\n Lisinopril 5mg daily\n Digoxin 125mcg, tab daily\n K-Dur daily\n Spironolactone 25mg daily\n Levothyroxin3e 112mcg daily\n Trazodone 25mg qHS\n Mexiletine 150mg TID\n Albuterol MDI 2puf q6hPRN\n Fluticasone 110mcg 2puff \n Toprol SL 50mg daily\n Lasix 40mg TID\n Coumadin\n NC\n Occupation: retired\n Drugs: none\n Tobacco: none\n Alcohol: former, none x 20 yrs\n Other: Patient originally from and moved to the United States\n in . Worked as an off-set printer. Father of five children.\n Retired 6 years ago, and since his recent heart problems, says\n he rarely leaves the house. No history of smoking, past or present.\n Patient was a heavy drinker until 20 years ago, when he stopped\n completely after attending AA. No history of illicit drug use\n Review of systems:\n Cardiovascular: Chest pain\n Respiratory: SOB\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Pain: Mild\n Pain location: chest abd\n Flowsheet Data as of 07:35 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 78) bpm\n BP: 100/73(64) {100/73(64) - 100/73(80)} mmHg\n RR: 11 (11 - 17) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\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: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: No edema\n Rectal: Trace guaiac positive black stool\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 149\n 2.0\n 31\n 30\n 100\n 3.9\n 140\n 39.8\n 9.9\n [image002.jpg]\n Other labs: PT / PTT / INR:24.7/29.8/2.4, CK / CKMB / Troponin-T:97/MB\n not done/ trop 0.01, Differential-Neuts:77, Lymph:11, Mono:8, Ca++:9.5,\n Mg++:2.2, PO4:2.7\n Imaging: CXR: NAD\n ECG: V-paced, similar to prior\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed: Hx GI bleeding in the past, recent EGD by GI showed\n erosions in stomach and duodenum c/w NSAID gastropathy (only takes\n ASA), had a normal in .\n - monitor HCTs q4hrs initially and then less frequently if stable\n - 2 large bore IVs in place\n - IVFs PRN\n - Transfuse for HCT < 30 given ? of active ischemia\n - IV PPI\n - F/u GI recs: no plan to scope emergently, await resolution of chest\n pain\n .\n 2. Chest pain:\n - telemetry\n - cards recs: repeat Echo\n - F/U CE's\n - F/U cards recs: plan for TTE tomorrow\n - continue statin,\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone overnight and restart in AM if patient\n is stable\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin (held sotalol tonight)\n - s/p reversal of INR given GIB. Will hold off on further\n anticoagulation for now except for ASA in AM\n .\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n CODE: presumed full\n .\n Communication: Pt, wife )\n .\n DISPO: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2140-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":345213,"text":"Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2140-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":345216,"text":"Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o some abd pain . c/o of feeling sweaty and anxious. At 0530\n pt c/o abd .\n Action:\n Pt refused mso4, at beginning of shift stated pain was not that bad. Pt\n afebrile and was started back on seroquel and trazadone. At o530 pt\n requested the mso4 2mg ivp. Ck and troponin drawn d/t diaphoresis.\n Response:\n Pt less sweaty and was able to fall asleep for the night. pt stated\n that he was able to get some quality sleepl pt stated that the mso4\n gives him relief. Ck;s and troponin neg.\n Plan:\n Continue to monitor level of pain and med as needed.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct stable, vss, c/o abd pain but has not passed any stool at this\n time.\n Action:\n Following hct\ns. med abd with mso4.\n Response:\n Pt obtains relief from the morphine\n Plan:\n Cont to follow hct\n"},{"category":"Nursing","chartdate":"2140-10-13 00:00:00.000","description":"Nursing Progress Note","row_id":345217,"text":"Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o some abd pain . c/o of feeling sweaty and anxious. At 0530\n pt c/o abd .\n Action:\n Pt refused mso4, at beginning of shift stated pain was not that bad. Pt\n afebrile and was started back on seroquel and trazadone. At o530 pt\n requested the mso4 2mg ivp. Ck and troponin drawn d/t diaphoresis.\n Response:\n Pt less sweaty and was able to fall asleep for the night. pt stated\n that he was able to get some quality sleepl pt stated that the mso4\n gives him relief. Ck;s and troponin neg.\n Plan:\n Continue to monitor level of pain and med as needed.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct stable, vss, c/o abd pain but has not passed any stool at this\n time.\n Action:\n Following hct\ns. med abd with mso4.\n Response:\n Pt obtains relief from the morphine\n Plan:\n Cont to follow hct\n"},{"category":"Nursing","chartdate":"2140-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":345044,"text":"Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2140-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":345046,"text":"Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stools since MN accompanied by mid-sternal CP with\n radiation to left arm. Took all BP meds this AM. Also c/o\n lightheadedness and SOB.\n .\n In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black\n stool. Patient received morphine for CP with mild improvement in pain.\n EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x\n 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L\n IVFs. Seen by Cards in ED, recommennd echo in AM,\n .\n On arrival to the MICU, pt states his discomfort has imporved,d own\n from to , described as dull ache in chest, non-radiating,\n constant since 11 PM last night, as well as discomfort in the lower\n abdomen (identical to past abd pain in setting of past GIB x 2). +\n nausea.\n Abdominal pain, chest pain\n Assessment:\n Pt c/o of low ABD pain,no tenderness, ABD soft/dist, BS +, no stool.\n c/oof chest pain \n Action:\n Given morphin 2mg x2 IV. Cardia enzymes sent x2, flat\n Response:\n Minimal repsosne of ABD pain to Morphin. Md aware.\n Plan:\n Cont follow ABD pain. Given Morphin as needed EChO in am.last sent of\n cardiac enzymes at 1100\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No stool , no c/o N/V\n Action:\n HCT done q6hr\n Response:\n Last HCT 32\n Plan:\n Cont follow HCT q6hr\n"},{"category":"Nursing","chartdate":"2140-10-12 00:00:00.000","description":"Nursing Progress Note","row_id":345131,"text":"Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stool,chest pain and abd pain.\n Events:\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain ,chest pain \n Action:\n Received morphine 2 mg iv x2,started on flagyl,ceftraixone for concern\n of ischemic colitis,pt had TTE done to r/o AS,all cardiac meds(except\n diuretics)restarted\n Response:\n Abd pain better after morphine,as per the pt his chest pain is\n stable(),3 sets of cardiac enzymes were neg.\n Plan:\n Cont to assess the pain.GI is following the pt,\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm,no stooling then\n Action:\n Checked hct\n Response:\n No active bleeding\n Plan:\n Cont to check hct q6-8hrly,\n"},{"category":"General","chartdate":"2140-10-12 00:00:00.000","description":"Generic Note","row_id":345041,"text":"TITLE: Addendum to Dr. \ns note\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 72M with CAD, CHF, CRI, a-fib, VF, EF 20%, diverticulosis, UGI bleed\n due to gastritis\n admitted with melena, chest pain, dyspnea. In ER\n guaiac positive, negative NG lavage. Given FFP and vitamin K for INR\n 2.4. Hct 40.\n Exam notable for Tm HR 76 BP 96/61 RR 21 with 97 sat on 2L\n Comfortable, no distress, lungs clear, heart regular, abdomen benign,\n trace guaiac pos\n Labs notable for WBC 10 K, HCT 33, HCO3 30 ,Cr 2.0, lactate 0.7 cardiac\n enzymes negative\n EKG: v-paced\n Imaging: chest x-ray reviewed\n PPM, cardiomegaly\n Problems:\n GIB\n Chest pain\n a-fib\n CRI\n Agree with plan to follow Hct, maintain adequate IV access, PPI, GI\n involved, more FFP and vitamin K if Hct falls, complete rule out\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 35 min\n"},{"category":"Physician ","chartdate":"2140-10-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":345119,"text":"Chief Complaint:\n 24 Hour Events:\n - Hct stabilized at 32\n - Lactate 0.7\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\n - BP stable overnight\n - Pain improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:23 PM\n Morphine Sulfate - 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 75 (75 - 80) bpm\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\n RR: 19 (9 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 60 mL\n 100 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: No edema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, MAE\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 34.5 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\n takes ASA), had a normal in . Also consider ischemic colitis,\n although abd is benign, with trace guaiac positive stool.\n - monitor HCTs q4hrs initially and then less frequently if stable\n - 2 large bore IVs in place\n - IVFs PRN\n - Transfuse for HCT < 30 given ? of active ischemia\n - IV PPI\n - F/u GI recs: no plan to scope emergently, await resolution of chest\n pain\n - Hold diuretics\n .\n 2. Chest pain:\n - telemetry\n - cards recs: repeat Echo\n - F/U CE's\n - F/U cards recs: plan for TTE tomorrow\n - continue statin,\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin (held sotalol last night)\n - s/p reversal of INR given GIB. Will hold off on further\n anticoagulation for now except for ASA in AM\n .\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n .\n DISPO: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2140-10-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":345120,"text":"Chief Complaint:\n 24 Hour Events:\n - Hct stabilized at 32\n - Lactate 0.7\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\n - BP stable overnight\n - Pain improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:23 PM\n Morphine Sulfate - 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 75 (75 - 80) bpm\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\n RR: 19 (9 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 60 mL\n 100 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: No edema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, MAE\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 34.5 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\n takes ASA), had a normal in . Also consider ischemic colitis,\n although abd is benign, with trace guaiac positive stool.\n - monitor HCTs q4hrs initially and then less frequently if stable\n - 2 large bore IVs in place\n - IVFs PRN\n - Transfuse for HCT < 30 given ? of active ischemia\n - IV PPI\n - F/u GI recs: no plan to scope emergently, await resolution of chest\n pain\n - Hold diuretics\n .\n 2. Chest pain:\n - telemetry\n - cards recs: repeat Echo\n - F/U CE's\n - F/U cards recs: plan for TTE tomorrow\n - continue statin,\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin (held sotalol last night)\n - s/p reversal of INR given GIB. Will hold off on further\n anticoagulation for now except for ASA in AM\n .\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n .\n DISPO: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2140-10-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":345282,"text":"Chief Complaint: Gi bleed\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n No events overnight\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Synthroid\n Mexilitine\n Seroquel\n Fluticasone INH\n Celexa\n Digoxin\n ASA\n Sotalol\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: Chest pain\n Respiratory: No(t) Cough, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 79) bpm\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Total In:\n 360 mL\n 610 mL\n PO:\n 300 mL\n 600 mL\n TF:\n IVF:\n 60 mL\n 10 mL\n Blood products:\n Total out:\n 1,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 121 K/uL\n 68 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 103 mEq/L\n 142 mEq/L\n 34.7 %\n 7.8 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n 06:38 AM\n WBC\n 7.0\n 7.4\n 7.8\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n 34.7\n Plt\n 134\n 120\n 121\n Cr\n 2.0\n 1.9\n 1.5\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n 68\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\n possible ischemic colitis.\n 1) Colitis: Continued abdominal pain with perhaps some subjective\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\n gram negative coverage.\n Antiemetics. Advance diet slowly.\n 2) Afib: Holding coumadin per cardiology.\n 3) CAD: Continue current regimen.\n 4) CKD: Cr is stable\n 5) Asthma: Restart home Advair.\n ICU Care\n Nutrition:\n Comments: Advance diet as tolerated.\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"},{"category":"Echo","chartdate":"2140-10-12 00:00:00.000","description":"Report","row_id":68785,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nHeight: (in) 70\nWeight (lb): 222\nBSA (m2): 2.18 m2\nBP (mm Hg): 113/56\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 11:36\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Severe\nregional LV systolic dysfunction. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic; basal anterolateral - akinetic;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Moderately dilated aortic sinus. Focal calcifications in aortic root.\nNormal ascending aorta diameter. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets.\nModerate-severe AS (area 0.8-1.0cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Moderate (2+) MR. Uninterpretable LV inflow pattern due\nto MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic 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 dilated. Left ventricular wall thicknesses are normal. The\nleft ventricular cavity is severely dilated. There is severe regional left\nventricular systolic dysfunction with akinesis of all inferior and\ninferolateral segments and of the basal lateral segments. The other segments\nare severely hypokinetic. There is no ventricular septal defect. The right\nventricular cavity is mildly dilated with mild global free wall hypokinesis.\nThe aortic root is moderately dilated at the sinus level. The aortic valve\nleaflets are severely thickened/deformed. There is moderate to severe aortic\nvalve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\nModerate (2+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Severe focal and global LV systolic dysfunction. Moderate to\nsevere aortic stenosis. Moderate mitral regurgitation.\n\nCompared with the report of the prior study (images unavailable for review) of\n, the degrees of aortic stenosis, ventricular dilatation and left\nventricular dysfunction are similar. The aortic sinus is more dilated and the\ndegree of mitral regurgitation has increased.\n\n\n"},{"category":"ECG","chartdate":"2140-10-12 00:00:00.000","description":"Report","row_id":149422,"text":"Atrial sensed and ventricular paced rhythm\nAtrial mechanism may be ectopic atrial rhythm or possibly paced\nVentricular premature complex\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2140-10-11 00:00:00.000","description":"Report","row_id":149423,"text":"Sinus rhythm with demand ventricular pacing\nVentricular premature complexes\nSince previous tracing of the same date, QRS width shorter, assess LV pacing\n\n"},{"category":"ECG","chartdate":"2140-10-11 00:00:00.000","description":"Report","row_id":149424,"text":"Sinus rhythm with ventricular demand pacing\nVentricular premature complex\nSince previous tracing of , QRS width wider, consider check pacer\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345129,\n \"text\": \"Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\\n Now with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness)\\n Assessment:\\n c/o abd pai\\n Action:\\n Response:\\n Plan:\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"ICU Attending Addendum\",\n \"row_id\": 345108,\n \"text\": \"CRITICAL CARE STAFF ADDENDUM\\n 10:20a\\n I saw and examined Mr. with the ICU team, whose note from today\\n reflects my input. I would add/emphasize that he is a 72-year-old man\\n with a complicated PMH [CAD/CABG, thoracic aneurysm s/p repair, VFib\\n arrest, AICD, EF 20%, biV pacer, PAF on warfarin, CKD (baseline\\n 1.6-2.0), dementia, divericulosis, GERD, etc.] who presents now with\\n melena and chest pain. See Dr. \\ns and Dr. \\ns notes for\\n details.\\n Overnight: admitted to ICU.\\n This morning, he says his chest discomfort feels better but that his\\n abdominal discomfort is a bit worse.\\n On exam he is comfortable. 75, 100/61, 13, 95%.\\n Meds are as per (reviewed).\\n Labs, and imaging reviewed on rounds and especially notable for:\\n Hct 39.8\\n 32.8\\n 32.5\\n 34.5\\n INR 2.4\\n 2.2\\n Cr 1.9\\n Troponin 0.02\\n Dig 0.4\\n Assessment and Plan\\n 72 y/o man with complicated PMH now with a small-volume GI bleed, chest\\n pain, and abdominal discomfort.\\n GI bleed\\n Clinically stable. On PPI. GI is following.\\n Chest discomfort\\n He has had similar issues before, and cardiac enzymes are reassuring.\\n Cardiology following\\n TTE to evaluate AS\\n Resume cardiac meds today except for diuretics.\\n Abdominal discomfort\\n I am concerned that he may have ischemic colitis (as distinct from\\n mesenteric arterial ischemia); he is certainly at risk for it. Will\\n discuss with GI today. For now, hold diuretics and give\\n ceftriaxone/flagyl until this is sorted out.\\n Chronic kidney disease\\n At baseline. Follow.\\n Heart failure, systolic, chronic\\n Mgmt as above\\n Other issues as detailed in ICU team note today\\n Critical care time: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 345316,\n \"text\": \"72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\\n diverticulosis. H/O GIB with most recent admission on . Now\\n admiited with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\\n tender , audible bowel sounds. C/O nausea.\\n Action:\\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\\n tolerating well.\\n Response:\\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\\n abdominal pain. Cardiac enzymes being negative.\\n Plan:\\n Cont to assess the pain. F/U with GI .\\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\\n then.\\n Action:\\n Follow HCT curve (stable)\\n Response:\\n No active bleeding noted.\\n Plan:\\n Follow HCT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345317,\n \"text\": \"72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\\n diverticulosis. H/O GIB with most recent admission on . Now\\n admiited with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\\n tender , audible bowel sounds. C/O nausea.\\n Action:\\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\\n tolerating well.\\n Response:\\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\\n abdominal pain. Cardiac enzymes being negative.\\n Plan:\\n Cont to assess the pain. F/U with GI .\\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\\n then.\\n Action:\\n Follow HCT curve (stable)\\n Response:\\n No active bleeding noted.\\n Plan:\\n Follow HCT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345191,\n \"text\": \"Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\\n Now with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain ,chest pain \\n Action:\\n Received morphine 2 mg iv x3,started on flagyl,ceftraixone for concern\\n of ischemic colitis,pt had TTE done to r/o AS,all cardiac meds(except\\n diuretics)restarted\\n Response:\\n Abd pain better after morphine,as per the pt his chest pain is resolved\\n ,3 sets of cardiac enzymes were neg.\\n Plan:\\n Cont to assess the pain.GI is following the pt,prn morphine\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm,no stooling then\\n Action:\\n Checked hct iv protonix increased to \\n Response:\\n No active bleeding,hct stable 34.5\\n Plan:\\n Cont to check hct q6-8hrly,next @1900 hrs\\n .pt complaints of sweating,no chest pain,vs stable,ekg done,fs 83,md\\n notified\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345085,\n \"text\": \"Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\\n Now with black stools since MN accompanied by mid-sternal CP with\\n radiation to left arm. Took all BP meds this AM. Also c/o\\n lightheadedness and SOB.\\n .\\n In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black\\n stool. Patient received morphine for CP with mild improvement in pain.\\n EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x\\n 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L\\n IVFs. Seen by Cards in ED, recommennd echo in AM,\\n .\\n On arrival to the MICU, pt states his discomfort has imporved,d own\\n from to , described as dull ache in chest, non-radiating,\\n constant since 11 PM last night, as well as discomfort in the lower\\n abdomen (identical to past abd pain in setting of past GIB x 2). +\\n nausea.\\n Abdominal pain, chest pain\\n Assessment:\\n Pt c/o of low ABD pain,no tenderness, ABD soft/dist, BS +, no stool.\\n c/oof chest pain \\n Action:\\n Given morphin 2mg x3 IV. Cardia enzymes sent x2, flat\\n Response:\\n Minimal repsosne of ABD pain to Morphin. Md aware.\\n Plan:\\n Cont follow ABD pain. Given Morphin as needed EChO in am.last sent of\\n cardiac enzymes at 1100\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n No stool , no c/o N/V\\n Action:\\n HCT done q6hr\\n Response:\\n Last HCT 32. morning HCT 34\\n Plan:\\n Cont follow HCT q6hr\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345087,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Hct stabilized at 32\\n - Lactate 0.7\\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\\n - BP stable overnight\\n - Pain improved\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:23 PM\\n Morphine Sulfate - 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 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.1\\nC (96.9\\n HR: 75 (75 - 80) bpm\\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\\n RR: 19 (9 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 60 mL\\n 100 mL\\n PO:\\n 50 mL\\n 100 mL\\n TF:\\n IVF:\\n 10 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 450 mL\\n Urine:\\n 450 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n -350 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///34/\\n Physical Examination\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 34.5 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345089,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Hct stabilized at 32\\n - Lactate 0.7\\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\\n - BP stable overnight\\n - Pain improved\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:23 PM\\n Morphine Sulfate - 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 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.1\\nC (96.9\\n HR: 75 (75 - 80) bpm\\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\\n RR: 19 (9 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 60 mL\\n 100 mL\\n PO:\\n 50 mL\\n 100 mL\\n TF:\\n IVF:\\n 10 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 450 mL\\n Urine:\\n 450 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n -350 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///34/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\\n (Murmur: Systolic), displaced PMI laterally\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\\n no rebound or guarding\\n Extremities: No edema\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x 3, MAE\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 34.5 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345091,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Hct stabilized at 32\\n - Lactate 0.7\\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\\n - BP stable overnight\\n - Pain improved\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:23 PM\\n Morphine Sulfate - 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 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.1\\nC (96.9\\n HR: 75 (75 - 80) bpm\\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\\n RR: 19 (9 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 60 mL\\n 100 mL\\n PO:\\n 50 mL\\n 100 mL\\n TF:\\n IVF:\\n 10 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 450 mL\\n Urine:\\n 450 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n -350 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///34/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\\n (Murmur: Systolic), displaced PMI laterally\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\\n no rebound or guarding\\n Extremities: No edema\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x 3, MAE\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 34.5 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\\n .\\n 1. GI bleed: Hx GI bleeding in the past, recent EGD by GI showed\\n erosions in stomach and duodenum c/w NSAID gastropathy (only takes\\n ASA), had a normal in .\\n - monitor HCTs q4hrs initially and then less frequently if stable\\n - 2 large bore IVs in place\\n - IVFs PRN\\n - Transfuse for HCT < 30 given ? of active ischemia\\n - IV PPI\\n - F/u GI recs: no plan to scope emergently, await resolution of chest\\n pain\\n .\\n 2. Chest pain:\\n - telemetry\\n - cards recs: repeat Echo\\n - F/U CE's\\n - F/U cards recs: plan for TTE tomorrow\\n - continue statin,\\n - restart b-blocker, ACE-I tomorrow if stable\\n - restart ASA if Hct stable in AM\\n .\\n 3. Systolic heart failure: Currently satting well on 2L\\n - Hold lasix and spironolactone overnight and restart in AM if patient\\n is stable\\n - Continue digoxin for afterload reduction\\n - monitor I/O's, daily weights\\n .\\n 4. Afib:\\n - continue mexilitine and digoxin (held sotalol last night)\\n - s/p reversal of INR given GIB. Will hold off on further\\n anticoagulation for now except for ASA in AM\\n .\\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\\n - avoid nephrotoxins if possible\\n - keep MAP >60.\\n .\\n 6. Hyperlipidemia:\\n - continue statin\\n .\\n 7. Hypothyroidism:\\n - continue levothyroxine\\n .\\n 8. Asthma:\\n - continue home meds\\n .\\n 9. Psych:\\n - continue meds\\n .\\n FEN: NPO, replete lytes PRN, IVFs\\n .\\n PPX: IV PPI , no anticoagulation, boots\\n .\\n ACCESS: 2 18g IVs in place\\n .\\n CODE: presumed full\\n .\\n Communication: Pt, wife )\\n .\\n DISPO: ICU for now\\n ICU Care\\n Nutrition:\\n Comments: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments: Family updated\\n Code status: Full code\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-11 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 345025,\n \"text\": \"Chief Complaint: Black stools, chest pain, abdominal pain\\n HPI:\\n Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\\n Now with black stools since MN accompanied by mid-sternal CP with\\n radiation to left arm. Took all BP meds this AM. Also c/o\\n lightheadedness and SOB.\\n .\\n In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black\\n stool. Patient received morphine for CP with mild improvement in pain.\\n EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x\\n 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L\\n IVFs. Seen by Cards in ED, recommennd echo in AM,\\n .\\n On arrival to the MICU, pt states his discomfort has imporved,d own\\n from to , described as dull ache in chest, non-radiating,\\n constant since 11 PM last night, as well as discomfort in the lower\\n abdomen (identical to past abd pain in setting of past GIB x 2). +\\n nausea.\\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 Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n --GI bleed of unknown etiology . EGD revealed esophagitis,\\n Barrett's esophagus, and duodenitis. No ulcers.\\n --CAD status post CABG with simultaneous aortic aneurysm repair\\n in , history of stenting of the left circumflex artery \\n --s/p VT/VF arrest, s/p ICD placement in \\n --Ischemic cardiomyopathy with an EF of 20%, s/p BiV pacer \\n --Chest wall cellulitis over pacer site vs. ICD pacer\\n pocket infection\\n --PAF on coumadin\\n --CKD with baseline Cr. 1.6-2.0\\n --Hyperlipidemia\\n --Asthma\\n --Anxiety\\n --Alzheimer's dementia\\n --Hypothyroidism\\n --Diverticulosis\\n --GERD\\n --S/P Cholecystectomy\\n Meds at home:\\n Sotalol 80mg \\n Lipitor 20mg daily\\n Donepezil 5mg daily\\n Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS\\n Celexa 60mg daily\\n Protonix 40mg daily\\n ASA 81mg daily\\n Clonazepam 0.5mg TID PRN\\n Lisinopril 5mg daily\\n Digoxin 125mcg, tab daily\\n K-Dur daily\\n Spironolactone 25mg daily\\n Levothyroxin3e 112mcg daily\\n Trazodone 25mg qHS\\n Mexiletine 150mg TID\\n Albuterol MDI 2puf q6hPRN\\n Fluticasone 110mcg 2puff \\n Toprol SL 50mg daily\\n Lasix 40mg TID\\n Coumadin\\n NC\\n Occupation: retired\\n Drugs: none\\n Tobacco: none\\n Alcohol: former, none x 20 yrs\\n Other: Patient originally from and moved to the United States\\n in . Worked as an off-set printer. Father of five children.\\n Retired 6 years ago, and since his recent heart problems, says\\n he rarely leaves the house. No history of smoking, past or present.\\n Patient was a heavy drinker until 20 years ago, when he stopped\\n completely after attending AA. No history of illicit drug use\\n Review of systems:\\n Cardiovascular: Chest pain\\n Respiratory: SOB\\n Gastrointestinal: Abdominal pain, Nausea\\n Endocrine: History of thyroid disease\\n Pain: Mild\\n Pain location: chest abd\\n Flowsheet Data as of 07:35 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 75 (75 - 78) bpm\\n BP: 100/73(64) {100/73(64) - 100/73(80)} mmHg\\n RR: 11 (11 - 17) insp/min\\n SpO2: 97%\\n Heart rhythm: AV Paced\\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: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\\n (Murmur: Systolic), displaced PMI laterally\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\\n no rebound or guarding\\n Extremities: Right: Absent\\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 149\\n 2.0\\n 31\\n 30\\n 100\\n 3.9\\n 140\\n 39.8\\n 9.9\\n [image002.jpg]\\n Other labs: PT / PTT / INR:24.7/29.8/2.4, CK / CKMB / Troponin-T:97/MB\\n not done/ trop 0.01, Differential-Neuts:77, Lymph:11, Mono:8, Ca++:9.5,\\n Mg++:2.2, PO4:2.7\\n Imaging: CXR: NAD\\n ECG: V-paced\\n Assessment and Plan\\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\\n .\\n GI bleed: Hx GI bleeding in the past, recent EGD by GI showed erosiions\\n in stomach and duodenum c/w NSAID gastropathy, had a normal in\\n .\\n - monitor HCTs q4hrs initially and then less frequently if stable\\n - 2 large bore IVs in place\\n - IVFs PRN\\n - Transfuse for HCT < 30 given ? of active ischemia\\n - IV PPI\\n - F/u GI recs: no plan to scope emergently, await resolution of chest\\n pain\\n .\\n Chest pain:\\n - telemetry\\n - cards recs: repeat Echo\\n - F/U CE's\\n - F/U cards recs\\n - continue ASA, statin, bblocker, ACE-I\\n .\\n Systolic heart failure: Currently satting well on 2L\\n - Hold lasix and spironolactone overnight and restart in AM if patient\\n is stable\\n - Continue digoxin for afterload reduction\\n - monitor I/O's, daily weights\\n .\\n Afib:\\n - continue sotalol, mexilitine and dig\\n - s/p reversal of INR given GIB. Will hold off on further\\n anticoagulation for now except for ASA\\n .\\n Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\\n - avoid nephrotoxins if possible\\n - keep MAP >60.\\n .\\n Hyperlipidemia:\\n - continue statin\\n .\\n Hypothyroidism:\\n - continue levothyroxine\\n .\\n Asthma:\\n - continue home meds\\n .\\n Psych:\\n - continue meds\\n .\\n FEN: NPO, replete lytes PRN, IVFs\\n .\\n PPX: IV PPI , no anticoagulation, boots\\n .\\n ACCESS: 2 18g IVs in place\\n .\\n CONTACT:\\n .\\n CODE: presumed full\\n .\\n Communication: Pt, wife )\\n .\\n DISPO: ICU for now\\n ICU Care\\n Nutrition:\\n Comments: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments: Family updated\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345174,\n \"text\": \"Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\\n Now with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain ,chest pain \\n Action:\\n Received morphine 2 mg iv x2,started on flagyl,ceftraixone for concern\\n of ischemic colitis,pt had TTE done to r/o AS,all cardiac meds(except\\n diuretics)restarted\\n Response:\\n Abd pain better after morphine,as per the pt his chest pain is resolved\\n ,3 sets of cardiac enzymes were neg.\\n Plan:\\n Cont to assess the pain.GI is following the pt,prn morphine\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm,no stooling then\\n Action:\\n Checked hct iv protonix increased to \\n Response:\\n No active bleeding,hct stable 34.5\\n Plan:\\n Cont to check hct q6-8hrly,next @1900 hrs\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 345307,\n \"text\": \"72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\\n diverticulosis. H/O GIB with most recent admission on . Now\\n admiited with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\\n tender , audible bowel sounds. C/O nausea.\\n Action:\\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\\n tolerating well.\\n Response:\\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\\n abdominal pain. Cardiac enzymes being negative.\\n Plan:\\n Cont to assess the pain. F/U with GI .\\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\\n then.\\n Action:\\n Follow HCT curve (stable)\\n Response:\\n No active bleeding noted.\\n Plan:\\n Follow HCT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345016,\n \"text\": \"awoke this am with +CP and dark stools. (pt had similar episode 1 month\\n ago with EGD done). Received SL NTG and IV morphine. INR 2.4->5 mg Vit\\n K given and 1st of 2 u FFP ^. Received total of 1.5 L NS, Zofran for N\\n and IV protonix. NG lavage negative.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345017,\n \"text\": \"awoke this am with +CP and dark stools. (pt had similar episode 1 month\\n ago with EGD done). Received SL NTG and IV morphine. INR 2.4->5 mg Vit\\n K given and 1st of 2 u FFP ^. Received total of 1.5 L NS, Zofran for N\\n and IV protonix. NG lavage negative.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345018,\n \"text\": \"awoke this am with +CP and dark stools. (pt had similar episode 1 month\\n ago with EGD done). Received SL NTG and IV morphine. INR 2.4->5 mg Vit\\n K given and 1st of 2 u FFP ^. Received total of 1.5 L NS, Zofran for N\\n and IV protonix. NG lavage negative.\\n Please see FHPA and assessment for other details. Awaiting orders from\\n MICU team. HD stable.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 345296,\n \"text\": \"72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\\n diverticulosis. H/O GIB with most recent admission on . Now\\n admiited with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\\n tender , audible bowel sounds. C/O nausea.\\n Action:\\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\\n tolerating well.\\n Response:\\n Abdominal pain tolerable. Cardiac enzymes being negative.\\n Plan:\\n Cont to assess the pain. F/U with GI .\\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\\n then.\\n Action:\\n Follow HCT curve (stable)\\n Response:\\n No active bleeding noted.\\n Plan:\\n Follow HCT.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Physician Fellow/Attending Progress Note - MICU\",\n \"row_id\": 345305,\n \"text\": \"Chief Complaint: Gi bleed\\n HPI:\\n 72 y.o. man with CAD, AFib, h/o GI bleed of unclear etiology p/w melena\\n and abdominal pain.\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 10:09 AM\\n Overnight, one episode of chest pain with diaphoresis. ECG was\\n unchanged and cardiac enzymes were checked and normal.\\n He continues to c/o lower abdominal pain with nausea though he was able\\n to tolerate broth for breakfast. His chest pain has resolved.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:51 PM\\n Metronidazole - 08:29 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:51 PM\\n Pantoprazole (Protonix) - 08:00 AM\\n Other medications:\\n Synthroid\\n Mexilitine\\n Seroquel\\n Fluticasone INH\\n Celexa\\n Digoxin\\n ASA\\n Sotalol\\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: Chest pain\\n Respiratory: No(t) Cough, No(t) Wheeze\\n Gastrointestinal: Abdominal pain, Nausea\\n Endocrine: History of thyroid disease\\n Flowsheet Data as of 10:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 75 (75 - 79) bpm\\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\\n RR: 13 (10 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: AV Paced\\n Total In:\\n 360 mL\\n 610 mL\\n PO:\\n 300 mL\\n 600 mL\\n TF:\\n IVF:\\n 60 mL\\n 10 mL\\n Blood products:\\n Total out:\\n 1,550 mL\\n 400 mL\\n Urine:\\n 1,550 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,190 mL\\n 210 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 94%\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender\\n Extremities: Edema Right: Absent, Left: Absent, No(t) Cyanosis\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 11.7 g/dL\\n 121 K/uL\\n 68 mg/dL\\n 1.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 26 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 34.7 %\\n 7.8 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n 10:54 AM\\n 06:47 PM\\n 10:26 PM\\n 06:38 AM\\n WBC\\n 7.0\\n 7.4\\n 7.8\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n 34.5\\n 35.4\\n 34.7\\n Plt\\n 134\\n 120\\n 121\\n Cr\\n 2.0\\n 1.9\\n 1.5\\n TropT\\n 0.01\\n 0.02\\n 0.01\\n Glucose\\n 92\\n 79\\n 68\\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\\n ischemic colitis.\\n 1) Colitis: Continued abdominal pain with perhaps some subjective\\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\\n gram negative coverage.\\n Antiemetics. Advance diet slowly.\\n 2) Afib: Holding coumadin per cardiology.\\n 3) CAD: Continue current regimen.\\n 4) CKD: Cr is stable\\n 5) Asthma: Restart home Advair.\\n ICU Care\\n Nutrition:\\n Comments: Advance diet as tolerated.\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent:\\n ------ Protected Section ------\\n CRITICAL CARE STAFF ADDENDUM\\n 3p\\n I saw and examined Mr. with the ICU team today; Dr. \\ns note\\n reflects my input. I would add/emphasize that he is a 72-year-old man\\n with a complicated PMH [CAD/CABG, thoracic aneurysm s/p repair, VFib\\n arrest, AICD, EF 20%, biV pacer, PAF on warfarin, CKD (baseline\\n 1.6-2.0), dementia, divericulosis, GERD, etc.] now admitted with\\n melena, abdominal pain, and chest pain. His chest pain has resolved\\n and his GI bleeding has not recurred. Some abdominal discomfort\\n persists, though he was able to tolerate clears at breakfast.\\n Examination as per Dr. \\ns note and the ICU team note today. In\\n particular, his abdomen is soft and he does not have clinically\\n decompensated heart failure.\\n Assessment and Plan\\n 72 y/o man with complicated PMH now with a small-volume GI bleed, chest\\n pain, and abdominal discomfort.\\n GI bleed\\n Clinically stable. On PPI. GI is following and does not plan\\n endoscopy.\\n Chest discomfort\\n Has resolved. Echo showed stable abnormalities compared with prior.\\n Probable ischemic colitis\\n I am concerned that he may have non-occlusive ischemic colitis (as\\n distinct from mesenteric arterial ischemia); he is certainly at risk\\n for it. Awaiting GI\\ns thoughts on this. For today, will hold\\n diuretics and continue abx (high risk for translocation, and AICD\\n increased the risk of seeding).\\n Chronic kidney disease\\n At baseline. Follow.\\n Heart failure, systolic, chronic\\n Mgmt as above\\n Other issues as detailed in Dr. \\ns note and ICU team note today\\n To floor.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 03:21 PM ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Physician Fellow/Attending Progress Note - MICU\",\n \"row_id\": 345283,\n \"text\": \"Chief Complaint: Gi bleed\\n HPI:\\n 72 y.o. man with CAD, AFib, h/o GI bleed of unclear etiology p/w melena\\n and abdominal pain.\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 10:09 AM\\n Overnight, one episode of chest pain with diaphoresis. ECG was\\n unchanged and cardiac enzymes were checked and normal.\\n He continues to c/o lower abdominal pain with nausea though he was able\\n to tolerate broth for breakfast. His chest pain has resolved.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:51 PM\\n Metronidazole - 08:29 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:51 PM\\n Pantoprazole (Protonix) - 08:00 AM\\n Other medications:\\n Synthroid\\n Mexilitine\\n Seroquel\\n Fluticasone INH\\n Celexa\\n Digoxin\\n ASA\\n Sotalol\\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: Chest pain\\n Respiratory: No(t) Cough, No(t) Wheeze\\n Gastrointestinal: Abdominal pain, Nausea\\n Endocrine: History of thyroid disease\\n Flowsheet Data as of 10:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 75 (75 - 79) bpm\\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\\n RR: 13 (10 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: AV Paced\\n Total In:\\n 360 mL\\n 610 mL\\n PO:\\n 300 mL\\n 600 mL\\n TF:\\n IVF:\\n 60 mL\\n 10 mL\\n Blood products:\\n Total out:\\n 1,550 mL\\n 400 mL\\n Urine:\\n 1,550 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,190 mL\\n 210 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 94%\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender\\n Extremities: Edema Right: Absent, Left: Absent, No(t) Cyanosis\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 11.7 g/dL\\n 121 K/uL\\n 68 mg/dL\\n 1.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 26 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 34.7 %\\n 7.8 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n 10:54 AM\\n 06:47 PM\\n 10:26 PM\\n 06:38 AM\\n WBC\\n 7.0\\n 7.4\\n 7.8\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n 34.5\\n 35.4\\n 34.7\\n Plt\\n 134\\n 120\\n 121\\n Cr\\n 2.0\\n 1.9\\n 1.5\\n TropT\\n 0.01\\n 0.02\\n 0.01\\n Glucose\\n 92\\n 79\\n 68\\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\\n ischemic colitis.\\n 1) Colitis: Continued abdominal pain with perhaps some subjective\\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\\n gram negative coverage.\\n Antiemetics. Advance diet slowly.\\n 2) Afib: Holding coumadin per cardiology.\\n 3) CAD: Continue current regimen.\\n 4) CKD: Cr is stable\\n 5) Asthma: Restart home Advair.\\n ICU Care\\n Nutrition:\\n Comments: Advance diet as tolerated.\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345287,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 10:09 AM\\n - Hct stable @ 34\\n - D/W pt\\ns cardiologist and pt risk of bleeding on coumadin\\n and risk of stroke from AF, decided to discontinue coumadin; also\\n discussed possibility of ischemic colitis as etiology of pt\\ns sxs.\\n - GI: will not rescope now, PPI and misoprostil\\n - Pt had episode of diaphoresis, ongoing chest pain, CE\\n negative\\n - TTE: EF 20-25%, mod to severe AS, moderate MR; compared with\\n prior,.\\n - TTE: Increased dilation of the aortic sinus and increased MR\\n since prior study.\\n -\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:51 PM\\n Metronidazole - 08:29 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:51 PM\\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.6\\nC (96.1\\n HR: 75 (75 - 79) bpm\\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\\n RR: 12 (10 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: V Paced\\n Total In:\\n 360 mL\\n 400 mL\\n PO:\\n 300 mL\\n 400 mL\\n TF:\\n IVF:\\n 60 mL\\n Blood products:\\n Total out:\\n 1,550 mL\\n 300 mL\\n Urine:\\n 1,550 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,190 mL\\n 100 mL\\n Respiratory support\\n SpO2: 95%\\n ABG: ////\\n Physical Examination\\n Gen: NAD, comfortable\\n HEENT: PERRL\\n Neck: No JVD\\n Lungs: CTAB, no crackles\\n Heart: s1s2 RRR, +SEM\\n Abd:+BS, obese, soft, nontender to palpation of the lower quadrants, no\\n rebound or guarding\\n Ext: No edema, warm/well-perfused\\n Neuro: Nonfocal\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 35.4 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n 10:54 AM\\n 06:47 PM\\n 10:26 PM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n 34.5\\n 35.4\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n 0.01\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n CXR: None today\\n Micro: None\\n Assessment and Plan\\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\\n .\\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\\n takes ASA), had a normal in . Also consider ischemic colitis,\\n particularly given risk factors (low CO, diuretics). A CTA of the\\n abdomen in when he had a similar episode revealed no acute\\n abnormality but did show narrowing at the proximal aspect of the celiac\\n axis but normal SMA/. Pt has had no further BMs since admission but\\n has been NPO.\\n - Hct stabilized ~ 34\\n - 2 large bore IVs in place\\n - IV PPI: switch to PO PPI\\n - GI recs: no plan to scope emergently, recent scope done and Hct\\n stable\\n - Will ask GI about possible ischemic colitis given clinical picture\\n - Continue CTX/flagyl while pt still having pain and ischemic colitis\\n is in differential, given risk of gut bacteria translocation\\n - Advance to clears\\n - No imaging at this time given overall reassuring and improving\\n clinical picture\\n - Held diuretics: concern is restarting could exacerbate possible\\n ischemic colitis, continue to hold for now given pt still having sxs\\n and does not seem fluid overloaded currently\\n - D/W pt\\ns cardiologist, plan is to d/c coumadin given risk/benefit\\n .\\n 2. Chest pain: Pain has been ongoing intermittently, similar to past\\n pain. Unlikely to be active cardiac ischemia given time course, pain\\n not typical for aortic dissection.\\n - telemetry\\n - repeat Echo yesterday\\n no significant change from prior\\n - CE: negative thus far\\n - continue statin\\n - restart b-blocker, ACE-I tomorrow if stable\\n - restart ASA if Hct stable in AM\\n - poor candidate for aortic valve replacement\\n .\\n 3. Systolic heart failure: Currently satting well on 2L, has not\\n received diuretics x 2 days. Echo yesterday similar to prior, with EF\\n 20-25%, mod to severe AS, moderate MR; compared with prior,. Increased\\n dilation of the aortic sinus and increased MR since prior study.\\n - Hold lasix and spironolactone\\n - Continue digoxin for afterload reduction\\n - monitor I/O's, daily weights\\n .\\n 4. Afib:\\n - continue mexilitine and digoxin and sotolol\\n - s/p reversal of INR given GIB, plan per his cardiologist is to d/c\\n coumadin\\n .\\n 5. Chronic renal insufficiency: BL creat 1.6-2. Currently at baseline.\\n - avoid nephrotoxins if possible\\n - keep MAP >60.\\n .\\n 6. Hyperlipidemia:\\n - continue statin\\n .\\n 7. Hypothyroidism:\\n - continue levothyroxine\\n .\\n 8. Asthma:\\n - continue home meds\\n .\\n 9. Psych:\\n - continue meds\\n .\\n FEN: NPO, replete lytes PRN, IVFs\\n .\\n PPX: PPI , no anticoagulation, boots\\n .\\n ACCESS: 2 18g IVs in place\\n .\\n Communication: Pt, wife )\\n ICU Care\\n Nutrition:\\n Comments: Clears\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments: Family updated\\n Code status: Full code\\n Disposition: Call out to the medical floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345243,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 10:09 AM\\n - Hct stable @ 34\\n - D/W pt\\ns cardiologist and pt risk of bleeding on coumadin\\n and risk of stroke from AF, decided to discontinue coumadin; also\\n discussed possibility of ischemic colitis as etiology of pt\\ns sxs\\n - GI: will not rescope now, PPI and misoprostil\\n - Pt had episode of diaphoresis, ongoing chest pain, CE\\n negative\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:51 PM\\n Metronidazole - 08:29 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:51 PM\\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.6\\nC (96.1\\n HR: 75 (75 - 79) bpm\\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\\n RR: 12 (10 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: V Paced\\n Total In:\\n 360 mL\\n 400 mL\\n PO:\\n 300 mL\\n 400 mL\\n TF:\\n IVF:\\n 60 mL\\n Blood products:\\n Total out:\\n 1,550 mL\\n 300 mL\\n Urine:\\n 1,550 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,190 mL\\n 100 mL\\n Respiratory support\\n SpO2: 95%\\n ABG: ////\\n Physical Examination\\n Gen:\\n HEENT:\\n Lungs:\\n Heart:\\n Abd:\\n Ext:\\n Neuro:\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 35.4 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n 10:54 AM\\n 06:47 PM\\n 10:26 PM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n 34.5\\n 35.4\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n 0.01\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n CXR:\\n Micro:\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345244,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 10:09 AM\\n - Hct stable @ 34\\n - D/W pt\\ns cardiologist and pt risk of bleeding on coumadin\\n and risk of stroke from AF, decided to discontinue coumadin; also\\n discussed possibility of ischemic colitis as etiology of pt\\ns sxs\\n - GI: will not rescope now, PPI and misoprostil\\n - Pt had episode of diaphoresis, ongoing chest pain, CE\\n negative\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:51 PM\\n Metronidazole - 08:29 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:51 PM\\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.6\\nC (96.1\\n HR: 75 (75 - 79) bpm\\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\\n RR: 12 (10 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: V Paced\\n Total In:\\n 360 mL\\n 400 mL\\n PO:\\n 300 mL\\n 400 mL\\n TF:\\n IVF:\\n 60 mL\\n Blood products:\\n Total out:\\n 1,550 mL\\n 300 mL\\n Urine:\\n 1,550 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,190 mL\\n 100 mL\\n Respiratory support\\n SpO2: 95%\\n ABG: ////\\n Physical Examination\\n Gen:\\n HEENT:\\n Lungs:\\n Heart:\\n Abd:\\n Ext:\\n Neuro:\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 35.4 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n 10:54 AM\\n 06:47 PM\\n 10:26 PM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n 34.5\\n 35.4\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n 0.01\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n CXR:\\n Micro:\\n Assessment and Plan\\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\\n .\\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\\n takes ASA), had a normal in . Also consider ischemic colitis,\\n particularly given risk factors (decreased CO, diuretics). Pt has had\\n no further BMs since admission.\\n - Hct stabilized ~ 34\\n - 2 large bore IVs in place\\n - IV PPI: switch to PO\\n - GI recs: no plan to scope emergently, recent scope done and Hct\\n stable\\n - Held diuretics: concern is restarting could exacerbate possible\\n ischemic colitis\\n - D/W pt\\ns cardiologist, plan is to d/c coumadin given risk/benefit\\n .\\n 2. Chest pain: Pain has been ongoing intermittently, similar to past\\n pain. Unlikely to be active cardiac ischemia given time course, pain\\n not typical for aortic dissection.\\n - telemetry\\n - repeat Echo yesterday\\n - CE: negative thus far\\n - continue statin\\n - restart b-blocker, ACE-I tomorrow if stable\\n - restart ASA if Hct stable in AM\\n .\\n 3. Systolic heart failure: Currently satting well on 2L\\n - Hold lasix and spironolactone\\n - Continue digoxin for afterload reduction\\n - monitor I/O's, daily weights\\n .\\n 4. Afib:\\n - continue mexilitine and digoxin and sotolol\\n - s/p reversal of INR given GIB, plan per his cardiologist is to d/c\\n coumadin\\n .\\n 5. Chronic renal insufficiency: BL creat 1.6-2. Currently at baseline.\\n - avoid nephrotoxins if possible\\n - keep MAP >60.\\n .\\n 6. Hyperlipidemia:\\n - continue statin\\n .\\n 7. Hypothyroidism:\\n - continue levothyroxine\\n .\\n 8. Asthma:\\n - continue home meds\\n .\\n 9. Psych:\\n - continue meds\\n .\\n FEN: NPO, replete lytes PRN, IVFs\\n .\\n PPX: IV PPI , no anticoagulation, boots\\n .\\n ACCESS: 2 18g IVs in place\\n .\\n Communication: Pt, wife )\\n ICU Care\\n Nutrition:\\n Comments: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments: Family updated\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345245,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 10:09 AM\\n - Hct stable @ 34\\n - D/W pt\\ns cardiologist and pt risk of bleeding on coumadin\\n and risk of stroke from AF, decided to discontinue coumadin; also\\n discussed possibility of ischemic colitis as etiology of pt\\ns sxs.\\n - GI: will not rescope now, PPI and misoprostil\\n - Pt had episode of diaphoresis, ongoing chest pain, CE\\n negative\\n - TTE: EF 20-25%, mod to severe AS, moderate MR; compared with\\n prior,.\\n - TTE: Increased dilation of the aortic sinus and increased MR\\n since prior study.\\n -\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:51 PM\\n Metronidazole - 08:29 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:51 PM\\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 35.6\\nC (96.1\\n HR: 75 (75 - 79) bpm\\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\\n RR: 12 (10 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: V Paced\\n Total In:\\n 360 mL\\n 400 mL\\n PO:\\n 300 mL\\n 400 mL\\n TF:\\n IVF:\\n 60 mL\\n Blood products:\\n Total out:\\n 1,550 mL\\n 300 mL\\n Urine:\\n 1,550 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,190 mL\\n 100 mL\\n Respiratory support\\n SpO2: 95%\\n ABG: ////\\n Physical Examination\\n Gen:\\n HEENT:\\n Lungs:\\n Heart:\\n Abd:\\n Ext:\\n Neuro:\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 35.4 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n 10:54 AM\\n 06:47 PM\\n 10:26 PM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n 34.5\\n 35.4\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n 0.01\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n CXR:\\n Micro:\\n Assessment and Plan\\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\\n .\\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\\n takes ASA), had a normal in . Also consider ischemic colitis,\\n particularly given risk factors (decreased CO, diuretics). Pt has had\\n no further BMs since admission.\\n - Hct stabilized ~ 34\\n - 2 large bore IVs in place\\n - IV PPI: switch to PO\\n - GI recs: no plan to scope emergently, recent scope done and Hct\\n stable\\n - Held diuretics: concern is restarting could exacerbate possible\\n ischemic colitis\\n - D/W pt\\ns cardiologist, plan is to d/c coumadin given risk/benefit\\n .\\n 2. Chest pain: Pain has been ongoing intermittently, similar to past\\n pain. Unlikely to be active cardiac ischemia given time course, pain\\n not typical for aortic dissection.\\n - telemetry\\n - repeat Echo yesterday\\n - CE: negative thus far\\n - continue statin\\n - restart b-blocker, ACE-I tomorrow if stable\\n - restart ASA if Hct stable in AM\\n .\\n 3. Systolic heart failure: Currently satting well on 2L, has not\\n received diuretics x 2 days. Echo yesterday similar to prior, with EF\\n 20-25%, mod to severe AS, moderate MR; compared with prior,. Increased\\n dilation of the aortic sinus and increased MR since prior study.\\n - Hold lasix and spironolactone\\n - Continue digoxin for afterload reduction\\n - monitor I/O's, daily weights\\n .\\n 4. Afib:\\n - continue mexilitine and digoxin and sotolol\\n - s/p reversal of INR given GIB, plan per his cardiologist is to d/c\\n coumadin\\n .\\n 5. Chronic renal insufficiency: BL creat 1.6-2. Currently at baseline.\\n - avoid nephrotoxins if possible\\n - keep MAP >60.\\n .\\n 6. Hyperlipidemia:\\n - continue statin\\n .\\n 7. Hypothyroidism:\\n - continue levothyroxine\\n .\\n 8. Asthma:\\n - continue home meds\\n .\\n 9. Psych:\\n - continue meds\\n .\\n FEN: NPO, replete lytes PRN, IVFs\\n .\\n PPX: IV PPI , no anticoagulation, boots\\n .\\n ACCESS: 2 18g IVs in place\\n .\\n Communication: Pt, wife )\\n ICU Care\\n Nutrition:\\n Comments: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments: Family updated\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 345263,\n \"text\": \"Chief Complaint: Gi bleed\\n HPI:\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 10:09 AM\\n No events overnight\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:51 PM\\n Metronidazole - 08:29 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:51 PM\\n Pantoprazole (Protonix) - 08:00 AM\\n Other medications:\\n Synthroid\\n Mexilitine\\n Seroquel\\n Fluticasone INH\\n Celexa\\n Digoxin\\n ASA\\n Sotalol\\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: Chest pain\\n Respiratory: No(t) Cough, No(t) Wheeze\\n Gastrointestinal: Abdominal pain, Nausea\\n Endocrine: History of thyroid disease\\n Flowsheet Data as of 10:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 75 (75 - 79) bpm\\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\\n RR: 13 (10 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: AV Paced\\n Total In:\\n 360 mL\\n 610 mL\\n PO:\\n 300 mL\\n 600 mL\\n TF:\\n IVF:\\n 60 mL\\n 10 mL\\n Blood products:\\n Total out:\\n 1,550 mL\\n 400 mL\\n Urine:\\n 1,550 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,190 mL\\n 210 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 94%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 11.7 g/dL\\n 121 K/uL\\n 68 mg/dL\\n 1.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 26 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 34.7 %\\n 7.8 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n 10:54 AM\\n 06:47 PM\\n 10:26 PM\\n 06:38 AM\\n WBC\\n 7.0\\n 7.4\\n 7.8\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n 34.5\\n 35.4\\n 34.7\\n Plt\\n 134\\n 120\\n 121\\n Cr\\n 2.0\\n 1.9\\n 1.5\\n TropT\\n 0.01\\n 0.02\\n 0.01\\n Glucose\\n 92\\n 79\\n 68\\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\\n possible ischemic colitis.\\n 1) Colitis: Continued abdominal pain with perhaps some subjective\\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\\n gram negative coverage.\\n Antiemetics. Advance diet slowly.\\n 2) Afib: Holding coumadin per cardiology.\\n 3) CAD: Continue current regimen.\\n 4) CKD: Cr is stable\\n 5) Asthma: Restart home Advair.\\n ICU Care\\n Nutrition:\\n Comments: Advance diet as tolerated.\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 345295,\n \"text\": \"72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\\n diverticulosis. H/O GIB with most recent admission on . Now\\n admiited with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\\n tender , audible bowel sounds. C/O nausea.\\n Action:\\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\\n given. Zofran 4 mg X1 IVPB given.\\n Response:\\n Abdominal pain tolerable. Cardiac enzymes being negative.\\n Plan:\\n Cont to assess the pain. F/U with GI .\\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\\n then.\\n Action:\\n Follow HCT curve (stable)\\n Response:\\n No active bleeding noted.\\n Plan:\\n Follow HCT.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 345344,\n \"text\": \"72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\\n diverticulosis. H/O GIB with most recent admission on . Now\\n admiited with black stool,chest pain and abd pain.\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\\n tender , audible bowel sounds. C/O nausea.\\n Action:\\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\\n tolerating well.\\n Response:\\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\\n abdominal pain. Cardiac enzymes being negative.\\n Plan:\\n Cont to assess the pain. F/U with GI .\\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\\n then.\\n Action:\\n Follow HCT curve (stable)\\n Response:\\n No active bleeding noted.\\n Plan:\\n Follow HCT.\\n Demographics\\n Attending MD:\\n D.\\n Admit diagnosis:\\n CHEST PAIN;TELEMETRY;GI BLEED\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 104.9 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: Asthma, GI Bleed\\n CV-PMH: Angina, Arrhythmias, CAD, Pacemaker\\n Additional history: ckd; barrett's esphogus; diverticulosis; asthma;\\n hyperlipidemia; of note, pt's ef is 15%; s/p choly; hypothyroidism;\\n gerd; anxiety; alzheimers dementia\\n Surgery / Procedure and date: s/p cabg with aaa repair in ; s/p icd\\n placement in ; s/p choly\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:95\\n D:54\\n Temperature:\\n 97.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 11 insp/min\\n Heart Rate:\\n 75 bpm\\n Heart rhythm:\\n V Paced\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 94% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 24h total in:\\n 1,160 mL\\n 24h total out:\\n 1,600 mL\\n Pertinent Lab Results:\\n Sodium:\\n 142 mEq/L\\n 06:38 AM\\n Potassium:\\n 4.1 mEq/L\\n 06:38 AM\\n Chloride:\\n 103 mEq/L\\n 06:38 AM\\n CO2:\\n 27 mEq/L\\n 06:38 AM\\n BUN:\\n 26 mg/dL\\n 06:38 AM\\n Creatinine:\\n 1.5 mg/dL\\n 06:38 AM\\n Glucose:\\n 68 mg/dL\\n 06:38 AM\\n Hematocrit:\\n 34.7 %\\n 06:38 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: micu7\\n Transferred to: cc727\\n Date & time of Transfer: 2130\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 345059,\n \"text\": \"Chief Complaint: Black stools, chest pain, abdominal pain\\n HPI:\\n Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\\n Now with black stools since MN accompanied by mid-sternal CP with\\n radiation to left arm. Took all BP meds this AM. Also c/o\\n lightheadedness and SOB.\\n .\\nIn the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. per resident had guaiac pos bla\\nck stool. Patient received morphine for CP with mild improvement in pain. EKG wa\\ns v-paced with no obvious ST/TW changes. NG lavage was negative x 2. He received\\n 2U FFP and 5 mg PO vitamin K for INR reversal and 1L IVFs. Seen by Cards in ED\\n, recommend echo in AM. Of note, last , the patient had a similar presentat\\nion and EGD, c-scope, and capsule endoscopy demonstrated gastritis, Barrett's, a\\nnd grade 1 hemorrhoids, without any active bleeding.\\n .\\n On arrival to the MICU, pt states his discomfort has improved, down\\n from to , described as dull ache in chest, non-radiating,\\n constant since 11 PM last night, as well as discomfort in the lower\\n abdomen (identical to past abd pain in setting of past GIB x 2). +\\n nausea.\\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 Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n --GI bleed of unknown etiology . EGD revealed esophagitis,\\n Barrett's esophagus, and duodenitis. No ulcers.\\n --CAD status post CABG with simultaneous thoracic aortic aneurysm\\n repair\\n in , history of stenting of the left circumflex artery \\n --s/p VT/VF arrest, s/p ICD placement in \\n --Ischemic cardiomyopathy with an EF of 20%, s/p BiV pacer \\n --Chest wall cellulitis over pacer site vs. ICD pacer\\n pocket infection\\n --PAF on coumadin\\n --CKD with baseline Cr. 1.6-2.0\\n --Hyperlipidemia\\n --Asthma\\n --Anxiety\\n --Alzheimer's dementia\\n --Hypothyroidism\\n --Diverticulosis\\n --GERD\\n --S/P Cholecystectomy\\n Meds at home:\\n Sotalol 80mg \\n Lipitor 20mg daily\\n Donepezil 5mg daily\\n Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS\\n Celexa 60mg daily\\n Protonix 40mg daily\\n ASA 81mg daily\\n Clonazepam 0.5mg TID PRN\\n Lisinopril 5mg daily\\n Digoxin 125mcg, tab daily\\n K-Dur daily\\n Spironolactone 25mg daily\\n Levothyroxin3e 112mcg daily\\n Trazodone 25mg qHS\\n Mexiletine 150mg TID\\n Albuterol MDI 2puf q6hPRN\\n Fluticasone 110mcg 2puff \\n Toprol SL 50mg daily\\n Lasix 40mg TID\\n Coumadin\\n NC\\n Occupation: retired\\n Drugs: none\\n Tobacco: none\\n Alcohol: former, none x 20 yrs\\n Other: Patient originally from and moved to the United States\\n in . Worked as an off-set printer. Father of five children.\\n Retired 6 years ago, and since his recent heart problems, says\\n he rarely leaves the house. No history of smoking, past or present.\\n Patient was a heavy drinker until 20 years ago, when he stopped\\n completely after attending AA. No history of illicit drug use\\n Review of systems:\\n Cardiovascular: Chest pain\\n Respiratory: SOB\\n Gastrointestinal: Abdominal pain, Nausea\\n Endocrine: History of thyroid disease\\n Pain: Mild\\n Pain location: chest abd\\n Flowsheet Data as of 07:35 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 75 (75 - 78) bpm\\n BP: 100/73(64) {100/73(64) - 100/73(80)} mmHg\\n RR: 11 (11 - 17) insp/min\\n SpO2: 97%\\n Heart rhythm: AV Paced\\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: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\\n (Murmur: Systolic), displaced PMI laterally\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\\n no rebound or guarding\\n Extremities: No edema\\n Rectal: Trace guaiac positive black stool\\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 149\\n 2.0\\n 31\\n 30\\n 100\\n 3.9\\n 140\\n 39.8\\n 9.9\\n [image002.jpg]\\n Other labs: PT / PTT / INR:24.7/29.8/2.4, CK / CKMB / Troponin-T:97/MB\\n not done/ trop 0.01, Differential-Neuts:77, Lymph:11, Mono:8, Ca++:9.5,\\n Mg++:2.2, PO4:2.7\\n Imaging: CXR: NAD\\n ECG: V-paced, similar to prior\\n Assessment and Plan\\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\\n .\\n 1. GI bleed: Hx GI bleeding in the past, recent EGD by GI showed\\n erosions in stomach and duodenum c/w NSAID gastropathy (only takes\\n ASA), had a normal in .\\n - monitor HCTs q4hrs initially and then less frequently if stable\\n - 2 large bore IVs in place\\n - IVFs PRN\\n - Transfuse for HCT < 30 given ? of active ischemia\\n - IV PPI\\n - F/u GI recs: no plan to scope emergently, await resolution of chest\\n pain\\n .\\n 2. Chest pain:\\n - telemetry\\n - cards recs: repeat Echo\\n - F/U CE's\\n - F/U cards recs: plan for TTE tomorrow\\n - continue statin,\\n - restart b-blocker, ACE-I tomorrow if stable\\n - restart ASA if Hct stable in AM\\n .\\n 3. Systolic heart failure: Currently satting well on 2L\\n - Hold lasix and spironolactone overnight and restart in AM if patient\\n is stable\\n - Continue digoxin for afterload reduction\\n - monitor I/O's, daily weights\\n .\\n 4. Afib:\\n - continue mexilitine and digoxin (held sotalol tonight)\\n - s/p reversal of INR given GIB. Will hold off on further\\n anticoagulation for now except for ASA in AM\\n .\\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\\n - avoid nephrotoxins if possible\\n - keep MAP >60.\\n .\\n 6. Hyperlipidemia:\\n - continue statin\\n .\\n 7. Hypothyroidism:\\n - continue levothyroxine\\n .\\n 8. Asthma:\\n - continue home meds\\n .\\n 9. Psych:\\n - continue meds\\n .\\n FEN: NPO, replete lytes PRN, IVFs\\n .\\n PPX: IV PPI , no anticoagulation, boots\\n .\\n ACCESS: 2 18g IVs in place\\n .\\n CODE: presumed full\\n .\\n Communication: Pt, wife )\\n .\\n DISPO: ICU for now\\n ICU Care\\n Nutrition:\\n Comments: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments: Family updated\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345213,\n \"text\": \"Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345216,\n \"text\": \"Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pt c/o some abd pain . c/o of feeling sweaty and anxious. At 0530\\n pt c/o abd .\\n Action:\\n Pt refused mso4, at beginning of shift stated pain was not that bad. Pt\\n afebrile and was started back on seroquel and trazadone. At o530 pt\\n requested the mso4 2mg ivp. Ck and troponin drawn d/t diaphoresis.\\n Response:\\n Pt less sweaty and was able to fall asleep for the night. pt stated\\n that he was able to get some quality sleepl pt stated that the mso4\\n gives him relief. Ck;s and troponin neg.\\n Plan:\\n Continue to monitor level of pain and med as needed.\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n Hct stable, vss, c/o abd pain but has not passed any stool at this\\n time.\\n Action:\\n Following hct\\ns. med abd with mso4.\\n Response:\\n Pt obtains relief from the morphine\\n Plan:\\n Cont to follow hct\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345217,\n \"text\": \"Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Pt c/o some abd pain . c/o of feeling sweaty and anxious. At 0530\\n pt c/o abd .\\n Action:\\n Pt refused mso4, at beginning of shift stated pain was not that bad. Pt\\n afebrile and was started back on seroquel and trazadone. At o530 pt\\n requested the mso4 2mg ivp. Ck and troponin drawn d/t diaphoresis.\\n Response:\\n Pt less sweaty and was able to fall asleep for the night. pt stated\\n that he was able to get some quality sleepl pt stated that the mso4\\n gives him relief. Ck;s and troponin neg.\\n Plan:\\n Continue to monitor level of pain and med as needed.\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n Hct stable, vss, c/o abd pain but has not passed any stool at this\\n time.\\n Action:\\n Following hct\\ns. med abd with mso4.\\n Response:\\n Pt obtains relief from the morphine\\n Plan:\\n Cont to follow hct\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345044,\n \"text\": \"Abdominal pain (including abdominal tenderness)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345046,\n \"text\": \"Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\\n Now with black stools since MN accompanied by mid-sternal CP with\\n radiation to left arm. Took all BP meds this AM. Also c/o\\n lightheadedness and SOB.\\n .\\n In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black\\n stool. Patient received morphine for CP with mild improvement in pain.\\n EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x\\n 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L\\n IVFs. Seen by Cards in ED, recommennd echo in AM,\\n .\\n On arrival to the MICU, pt states his discomfort has imporved,d own\\n from to , described as dull ache in chest, non-radiating,\\n constant since 11 PM last night, as well as discomfort in the lower\\n abdomen (identical to past abd pain in setting of past GIB x 2). +\\n nausea.\\n Abdominal pain, chest pain\\n Assessment:\\n Pt c/o of low ABD pain,no tenderness, ABD soft/dist, BS +, no stool.\\n c/oof chest pain \\n Action:\\n Given morphin 2mg x2 IV. Cardia enzymes sent x2, flat\\n Response:\\n Minimal repsosne of ABD pain to Morphin. Md aware.\\n Plan:\\n Cont follow ABD pain. Given Morphin as needed EChO in am.last sent of\\n cardiac enzymes at 1100\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n No stool , no c/o N/V\\n Action:\\n HCT done q6hr\\n Response:\\n Last HCT 32\\n Plan:\\n Cont follow HCT q6hr\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 345131,\n \"text\": \"Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\\n Now with black stool,chest pain and abd pain.\\n Events:\\n Abdominal pain (including abdominal tenderness),including chest pain\\n Assessment:\\n c/o abd pain ,chest pain \\n Action:\\n Received morphine 2 mg iv x2,started on flagyl,ceftraixone for concern\\n of ischemic colitis,pt had TTE done to r/o AS,all cardiac meds(except\\n diuretics)restarted\\n Response:\\n Abd pain better after morphine,as per the pt his chest pain is\\n stable(),3 sets of cardiac enzymes were neg.\\n Plan:\\n Cont to assess the pain.GI is following the pt,\\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\\n Assessment:\\n h/o malenic stool,as per the pt last bm on 1 pm,no stooling then\\n Action:\\n Checked hct\\n Response:\\n No active bleeding\\n Plan:\\n Cont to check hct q6-8hrly,\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 345041,\n \"text\": \"TITLE: Addendum to Dr. \\ns note\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points:\\n 72M with CAD, CHF, CRI, a-fib, VF, EF 20%, diverticulosis, UGI bleed\\n due to gastritis\\n admitted with melena, chest pain, dyspnea. In ER\\n guaiac positive, negative NG lavage. Given FFP and vitamin K for INR\\n 2.4. Hct 40.\\n Exam notable for Tm HR 76 BP 96/61 RR 21 with 97 sat on 2L\\n Comfortable, no distress, lungs clear, heart regular, abdomen benign,\\n trace guaiac pos\\n Labs notable for WBC 10 K, HCT 33, HCO3 30 ,Cr 2.0, lactate 0.7 cardiac\\n enzymes negative\\n EKG: v-paced\\n Imaging: chest x-ray reviewed\\n PPM, cardiomegaly\\n Problems:\\n GIB\\n Chest pain\\n a-fib\\n CRI\\n Agree with plan to follow Hct, maintain adequate IV access, PPI, GI\\n involved, more FFP and vitamin K if Hct falls, complete rule out\\n Remainder of plan as outlined above.\\n Patient is critically ill.\\n Total time: 35 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345119,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Hct stabilized at 32\\n - Lactate 0.7\\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\\n - BP stable overnight\\n - Pain improved\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:23 PM\\n Morphine Sulfate - 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 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.1\\nC (96.9\\n HR: 75 (75 - 80) bpm\\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\\n RR: 19 (9 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 60 mL\\n 100 mL\\n PO:\\n 50 mL\\n 100 mL\\n TF:\\n IVF:\\n 10 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 450 mL\\n Urine:\\n 450 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n -350 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///34/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\\n (Murmur: Systolic), displaced PMI laterally\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\\n no rebound or guarding\\n Extremities: No edema\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x 3, MAE\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 34.5 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\\n .\\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\\n takes ASA), had a normal in . Also consider ischemic colitis,\\n although abd is benign, with trace guaiac positive stool.\\n - monitor HCTs q4hrs initially and then less frequently if stable\\n - 2 large bore IVs in place\\n - IVFs PRN\\n - Transfuse for HCT < 30 given ? of active ischemia\\n - IV PPI\\n - F/u GI recs: no plan to scope emergently, await resolution of chest\\n pain\\n - Hold diuretics\\n .\\n 2. Chest pain:\\n - telemetry\\n - cards recs: repeat Echo\\n - F/U CE's\\n - F/U cards recs: plan for TTE tomorrow\\n - continue statin,\\n - restart b-blocker, ACE-I tomorrow if stable\\n - restart ASA if Hct stable in AM\\n .\\n 3. Systolic heart failure: Currently satting well on 2L\\n - Hold lasix and spironolactone\\n - Continue digoxin for afterload reduction\\n - monitor I/O's, daily weights\\n .\\n 4. Afib:\\n - continue mexilitine and digoxin (held sotalol last night)\\n - s/p reversal of INR given GIB. Will hold off on further\\n anticoagulation for now except for ASA in AM\\n .\\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\\n - avoid nephrotoxins if possible\\n - keep MAP >60.\\n .\\n 6. Hyperlipidemia:\\n - continue statin\\n .\\n 7. Hypothyroidism:\\n - continue levothyroxine\\n .\\n 8. Asthma:\\n - continue home meds\\n .\\n 9. Psych:\\n - continue meds\\n .\\n FEN: NPO, replete lytes PRN, IVFs\\n .\\n PPX: IV PPI , no anticoagulation, boots\\n .\\n ACCESS: 2 18g IVs in place\\n .\\n Communication: Pt, wife )\\n .\\n DISPO: ICU for now\\n ICU Care\\n Nutrition:\\n Comments: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments: Family updated\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 345120,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - Hct stabilized at 32\\n - Lactate 0.7\\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\\n - BP stable overnight\\n - Pain improved\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 09:23 PM\\n Morphine Sulfate - 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 06:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98\\n Tcurrent: 36.1\\nC (96.9\\n HR: 75 (75 - 80) bpm\\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\\n RR: 19 (9 - 26) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 60 mL\\n 100 mL\\n PO:\\n 50 mL\\n 100 mL\\n TF:\\n IVF:\\n 10 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 450 mL\\n Urine:\\n 450 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 60 mL\\n -350 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n ABG: ///34/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, Overweight /\\n Obese\\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\\n (Murmur: Systolic), displaced PMI laterally\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\\n no rebound or guarding\\n Extremities: No edema\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x 3, MAE\\n Labs / Radiology\\n 120 K/uL\\n 11.5 g/dL\\n 79 mg/dL\\n 1.9 mg/dL\\n 34 mEq/L\\n 4.1 mEq/L\\n 27 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 34.5 %\\n 7.4 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n WBC\\n 7.0\\n 7.4\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n Plt\\n 134\\n 120\\n Cr\\n 2.0\\n 1.9\\n TropT\\n 0.01\\n 0.02\\n Glucose\\n 92\\n 79\\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\\n mg/dL, PO4:3.1 mg/dL\\n Assessment and Plan\\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\\n .\\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\\n takes ASA), had a normal in . Also consider ischemic colitis,\\n although abd is benign, with trace guaiac positive stool.\\n - monitor HCTs q4hrs initially and then less frequently if stable\\n - 2 large bore IVs in place\\n - IVFs PRN\\n - Transfuse for HCT < 30 given ? of active ischemia\\n - IV PPI\\n - F/u GI recs: no plan to scope emergently, await resolution of chest\\n pain\\n - Hold diuretics\\n .\\n 2. Chest pain:\\n - telemetry\\n - cards recs: repeat Echo\\n - F/U CE's\\n - F/U cards recs: plan for TTE tomorrow\\n - continue statin,\\n - restart b-blocker, ACE-I tomorrow if stable\\n - restart ASA if Hct stable in AM\\n .\\n 3. Systolic heart failure: Currently satting well on 2L\\n - Hold lasix and spironolactone\\n - Continue digoxin for afterload reduction\\n - monitor I/O's, daily weights\\n .\\n 4. Afib:\\n - continue mexilitine and digoxin (held sotalol last night)\\n - s/p reversal of INR given GIB. Will hold off on further\\n anticoagulation for now except for ASA in AM\\n .\\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\\n - avoid nephrotoxins if possible\\n - keep MAP >60.\\n .\\n 6. Hyperlipidemia:\\n - continue statin\\n .\\n 7. Hypothyroidism:\\n - continue levothyroxine\\n .\\n 8. Asthma:\\n - continue home meds\\n .\\n 9. Psych:\\n - continue meds\\n .\\n FEN: NPO, replete lytes PRN, IVFs\\n .\\n PPX: IV PPI , no anticoagulation, boots\\n .\\n ACCESS: 2 18g IVs in place\\n .\\n Communication: Pt, wife )\\n .\\n DISPO: ICU for now\\n ICU Care\\n Nutrition:\\n Comments: NPO for now\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: ICU consent signed Comments: Family updated\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2140-10-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 345282,\n \"text\": \"Chief Complaint: Gi bleed\\n HPI:\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 10:09 AM\\n No events overnight\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ceftriaxone - 03:51 PM\\n Metronidazole - 08:29 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:51 PM\\n Pantoprazole (Protonix) - 08:00 AM\\n Other medications:\\n Synthroid\\n Mexilitine\\n Seroquel\\n Fluticasone INH\\n Celexa\\n Digoxin\\n ASA\\n Sotalol\\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: Chest pain\\n Respiratory: No(t) Cough, No(t) Wheeze\\n Gastrointestinal: Abdominal pain, Nausea\\n Endocrine: History of thyroid disease\\n Flowsheet Data as of 10:20 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.3\\nC (97.4\\n HR: 75 (75 - 79) bpm\\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\\n RR: 13 (10 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: AV Paced\\n Total In:\\n 360 mL\\n 610 mL\\n PO:\\n 300 mL\\n 600 mL\\n TF:\\n IVF:\\n 60 mL\\n 10 mL\\n Blood products:\\n Total out:\\n 1,550 mL\\n 400 mL\\n Urine:\\n 1,550 mL\\n 400 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,190 mL\\n 210 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 94%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\\n Skin: Not assessed, No(t) Rash:\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 11.7 g/dL\\n 121 K/uL\\n 68 mg/dL\\n 1.5 mg/dL\\n 27 mEq/L\\n 4.1 mEq/L\\n 26 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 34.7 %\\n 7.8 K/uL\\n [image002.jpg]\\n 07:15 PM\\n 10:50 PM\\n 03:22 AM\\n 10:54 AM\\n 06:47 PM\\n 10:26 PM\\n 06:38 AM\\n WBC\\n 7.0\\n 7.4\\n 7.8\\n Hct\\n 32.8\\n 32.5\\n 34.5\\n 34.5\\n 35.4\\n 34.7\\n Plt\\n 134\\n 120\\n 121\\n Cr\\n 2.0\\n 1.9\\n 1.5\\n TropT\\n 0.01\\n 0.02\\n 0.01\\n Glucose\\n 92\\n 79\\n 68\\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\\n mg/dL, PO4:3.3 mg/dL\\n Assessment and Plan\\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\\n possible ischemic colitis.\\n 1) Colitis: Continued abdominal pain with perhaps some subjective\\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\\n gram negative coverage.\\n Antiemetics. Advance diet slowly.\\n 2) Afib: Holding coumadin per cardiology.\\n 3) CAD: Continue current regimen.\\n 4) CKD: Cr is stable\\n 5) Asthma: Restart home Advair.\\n ICU Care\\n Nutrition:\\n Comments: Advance diet as tolerated.\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:08 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 68785,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease.\\nHeight: (in) 70\\nWeight (lb): 222\\nBSA (m2): 2.18 m2\\nBP (mm Hg): 113/56\\nHR (bpm): 75\\nStatus: Inpatient\\nDate/Time: at 11:36\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the report of the prior study (images not\\navailable) of .\\n\\n\\nLEFT ATRIUM: Dilated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Severe\\nregional LV systolic dysfunction. No resting LVOT gradient. No VSD.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\\n- akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\\ninferolateral - akinetic; basal anterolateral - akinetic;\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\\nhypokinesis.\\n\\nAORTA: Moderately dilated aortic sinus. Focal calcifications in aortic root.\\nNormal ascending aorta diameter. No 2D or Doppler evidence of distal arch\\ncoarctation.\\n\\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets.\\nModerate-severe AS (area 0.8-1.0cm2). No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Moderate (2+) MR. Uninterpretable LV inflow pattern due\\nto MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\\nsystolic 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 dilated. Left ventricular wall thicknesses are normal. The\\nleft ventricular cavity is severely dilated. There is severe regional left\\nventricular systolic dysfunction with akinesis of all inferior and\\ninferolateral segments and of the basal lateral segments. The other segments\\nare severely hypokinetic. There is no ventricular septal defect. The right\\nventricular cavity is mildly dilated with mild global free wall hypokinesis.\\nThe aortic root is moderately dilated at the sinus level. The aortic valve\\nleaflets are severely thickened/deformed. There is moderate to severe aortic\\nvalve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral\\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\\nModerate (2+) mitral regurgitation is seen. There is mild pulmonary artery\\nsystolic hypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Severe focal and global LV systolic dysfunction. Moderate to\\nsevere aortic stenosis. Moderate mitral regurgitation.\\n\\nCompared with the report of the prior study (images unavailable for review) of\\n, the degrees of aortic stenosis, ventricular dilatation and left\\nventricular dysfunction are similar. The aortic sinus is more dilated and the\\ndegree of mitral regurgitation has increased.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-10-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149422,\n \"text\": \"Atrial sensed and ventricular paced rhythm\\nAtrial mechanism may be ectopic atrial rhythm or possibly paced\\nVentricular premature complex\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149423,\n \"text\": \"Sinus rhythm with demand ventricular pacing\\nVentricular premature complexes\\nSince previous tracing of the same date, QRS width shorter, assess LV pacing\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-10-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 149424,\n \"text\": \"Sinus rhythm with ventricular demand pacing\\nVentricular premature complex\\nSince previous tracing of , QRS width wider, consider check pacer\\n\\n\"\n }\n]"}}},{"rowIdx":771,"cells":{"subject_id":{"kind":"number","value":22438,"string":"22,438"},"hadm_id":{"kind":"number","value":118722,"string":"118,722"},"target_text":{"kind":"string","value":"Addressed by problem: . # ID: The patient arrived on the floor afebrile with stable hemodynamics. She was continued on vancomycin for treatment of her recent MRSA bacteremia and port-a-cath infection with L5-S1 disciitis and right sacroiliitis. There was no evidence of cellulitis at the former port-a-cath site in the right upper chest wall. The surgical site appeared well-healed and no drainage was noted. Ultrasound was performed at this site and revealed a small simple fluid collection (0.8x0.8x1.8cm) that was likely due to post-operative changes. Surgery evaluated the former port-a-cath site and recommended no need for drainage. MR of the right hip, lumbar, and thoracic spine were performed and revealed resolving discitis, sacroiliitis, and no evidence of osteomyelitis or epidural abscess. The patient requested HIV test and was antibody negative. C. Diff stool toxin was negative x 1. On hospital day #2, surveillance blood cultures drawn in the ED grew high-grade vancomycin-resistant enterococcus. The patient remained afebrile with stable vitals. The source of this bacteremia was unknown but thought to be most likely related to the indwelling PICC line. ID team was consulted and the patient was switched to IV daptomycin. Her right antcubital PICC line was removed on . Subsequent daily blood cultures have shown no growth. A new PICC line was placed in the right upper extremity by Interventional on for antibiotics and blood draws as there was no other venous access available despite multiple attempts by both IV nursing and the MICU team (failed left subclavian line placement, no complications). Regarding the etiology of her VRE bacteremia: line infection, cardiac, and GI sources were considered. Although believed to be the most likely source, there was no evidence of line infection as the culture from the PICC tip was negative. There was also no evidence of endocarditis or valvular vegetations on both TTE and TEE. Abdominal sources were considered but believed unlikely given no complaints, normal exam and LFTs, and therefore an abdominal CT scan was not performed. ID desired to transition the patient to oral antibiotics, however the patient was taking effexor and had to be weaned off this medication given the theoretical risk for serotonin syndrome. Pharmacy and psychiatry were consulted regarding effexor weaning which was successfully performed over 5 days without noted withdrawal symptoms and then discontinued completely on . Daptomycin was discontinued on and the patient was started on linezolid PO 600mg to complete at least a 2 week course. She remained afebrile with stable vital signs and serial neurological exams revealed no evidence of serotonin syndrome. She will need weekly CBC, BUN, Creatinine, and LFTs to monitor for side effects while on linezolid. She will f/u with Dr. from Infectious Disease. - CBC, BUN, Creatinine, LFTs qweekly --> fax results to Dr. @ . # Loss of consciousness: On , the patient was found by staff lying on the floor of her room responding only to painful stimuli with no spontaneous movement of extremities. The event was unwitnessed. She was placed in a hard cervical collar. CT head was negative; CT c-spine revealed no fracture but there was a question of C1-C2 rotational instability. She was transferred to the MICU for close observation. Neurology who suggested unlikely to be CVA. Neurosurgery requested c-spine flexion and extension films which showed no signs of instability, however given the C1-C2 rotational instability noted in her c-spine she was continued with a hard collar. She was ruled-out for MI with serial cardiac enzymes. EEG suggested encephalopathy medications vs. toxic/metabolic vs. infection. As her symptoms resolved, she displayed evidence of a post-ictal state. Her mental status gradually improved and her neurological exam resolved back to baseline. Given her h/o seizure disorder, this event appeared to be most likely a seizure, however her dilantin level was therapeutic. Given her positive blood cx, there was concern for septic emboli, however given the transient nature of her symptoms it was believed less likely. One possible etiology in light of the cervical CT findings was atlantoaxial subluxation. The patient stabilized in the MICU and was transferred back to the floor for continued care on . Daily dilantin levels were followed and were therapeutic. Per neurology, she was transitioned to keppra 1000mg po bid and weaned off dilantin. She had no further LOC episodes while on the floor and her neurological examination remained non-focal. She is scheduled to follow-up in with Dr. in Clinic. . # C1/C2 rotational instability: (see above LOC for description of event) Neurosurgery evaluated the patient s/p unwitness fall. C-spine flexion/extension films were stable but rotation of C1 on C2 was noted on c-spine CT. It was recommended that the patient wear a hard cervical collar (Aspen) for 4 weeks given concern about rotational instability in her cervical spine. Despite frequent reminders about the severity of this potential problem, the patient continued to occasionally remove and refuse to wear the cervical collar. She was counseled extensively regarding the risks including paralyzation and death. She should call to schedule a f/u appointment with Dr. from Neurosurgery in 3 weeks for evaluation. . # Dysphagia: The patient reported difficulty swallowing large pieces of meat for at least one year. She stated that frequently she would have to vomit to remove the obstruction. Denies difficulty swallowing liquids or odynophagia. Also states she was told by her PCP that she had an esophageal stricture that needed to be dilated. Her last EGD was approximately following partial gastrectomy for peptic ulcers. GI and was consulted for evaluation, and believed the problem to likely be oropharyngeal in nature. She was noted to have a small cervical esophageal web on video swallow study; barium swallow was limited due to cervical collar but revealed no evidence of obstruction or stricture. Speech and swallow evaluation was performed and negative for signs of aspiration, however it she did struggle swallowing mixed consistency liquids (e.g. cereal with milk, soup with peas) and therefore her diet was changed to eliminate these components. GI suggested outpatient evaluation including EGD. She will follow-up with Dr. from GI after discharge. . # HTN: Her BP was well-controlled throughout admission, however chagnes were made to her regimen to optimize long-term management. She was changed from metoprolol to atenolol 100mg po qd. Lisinopril was started and increased 2.5mg qod to reach goal dose of 10mg qd. She was begun to be weaned off clonidine by decreasing 0.1mg qod. She tolerated these medication changes without difficulty and showed no signs of rebound hypertension during clonipine taper. She should be monitored as an outpatient by her PCP and her medications titrated for goal BP<130/80. - follow BP's as outpatient and titrate regimen . # CAD: The patient is s/p CABG . Cardiac cath with patent grafts. ETT c myoview normal. Stable c no active ischemia. She was r/o for MI with serial cardiac enzymes. EKG's were unchanged from prior studies. She was continued on beta blocker, lipitor, and imdur. Plavix (patient has aspirin allergy) was briefly discontinued s/p fall and transfer to MICU but reinstituted shortly after returning to the floor. Of note, on TEE the patient had mobile atheroma present in the aortic arch. . # CHF: Carries this diagnosis but EF 60-70% and requires no diuretics at home. She had both TTE and TEE while inpatient which were within normal limits. She remained euvolemic throughout admission. I&Os and daily weights were monitored. She had no SOB or signs of volume overload during admission and required no lasix. . # Hypothyroidism: Currently euthyroid with TSH 0.73 at admission. She was continued on her home dose of levothyroxine. . # Chronic Anemia: Etiology is likely due to chronic disease. B12 and folate levels were within normal levels. She was guaiac negative x 1 and positive x 1. The patient reports occasional BRBPR that she attributes to hemorrhoids. Reports colonoscopy approximately 5 years ago at (Dr. which was negative. Her hematocrit remained stable throughout admission. - consider outpatient colonoscopy referral, patient has appointment for clinic . # GERD: No active issues, she was continued on proton pump inhibitor. . # Chronic LBP: Possibly related to disciitis, although per report and prior notes obtained from Medical Center this appears to be a chronic problem. She has had prior back surgery while a teenager. She was continued on her outpatient regimen while in house and required no breakthrough pain medications. . # Psych: Patient wih history of depression and anxiety. Initially she was continued on effexor, xanax, and serax. As it was desired that she start linezolid, she was weaned off of effexor with no obvious adverse side effects noted. Psychiatry was consulted regarding management of depression off effexor and benzodiazepines. She was not restarted on a new anti-depressant as she was not currently showing signs of major depression and did not desire continued treatment. Regarding her benzodiazepines, zanax and serax were discontinued and she was started on klonapin 0.5mg po tid and slowly weaned to klonapin 0.5mg po qd prn prior to discharge. She was closely monitored and displayed no active signs of benzo withdrawal . # Tremors: The patient complained of occasional chronic tremors involving her arms and legs that occur with activity. She was evaluated by neurology. No resting or intention tremors were noted and she had a normal neurological exam. It was though that this may be related to deconditioning and chronic illness, however other possibilities include medication side effects from her polypharmacy. She will be followed by Neurlogy as an outpatient. . # Osteoporosis: The patient was continued with vitamin D and calcium supplements. Consideration should be given for starting alendronate after the cervical collar is removed. Outpatient bone density scan may also be helpful in management. . # Cough: Patient complained of a dry cough on day of discharge. Afebrile, no leukocytosis. CXR without PNA. . # FEN: diabetic/cardiac diet (no mixed consistency liquids, give pills in applesauce); electrolytes were monitored daily and repleted as needed . # PPX: pneumoboots (pt refuses sc heparin), PPI . # Dispo: return to Rehabilitation Facility"},"extractive_notes_summ":{"kind":"string","value":"Focal calcifications in aortic root.Normal ascending aorta diameter. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass orvegetation on mitral valve.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal main PA. NoDoppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The absence of a vegetation by 2D echocardiography does notexclude endocarditis if clinically suggested.Conclusions:The left atrium is mildly dilated. Normal LV inflowpattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single-lumen PICC line placement via the right brachial vein with the tip positioned in SVC. No mass orvegetation on tricuspid valve.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. FINDINGS: From T1-T2 to T12-L1, mild disc degenerative changes are seen without significant bulging, herniation or spinal stenosis. Following gadolinium, no abnormal intraspinal enhancement seen. T1 sagittal and axial images were obtained following the administration of gadolinium. PATIENT/TEST INFORMATION:Indication: Endocarditis, rule out vegetation.Height: (in) 59Weight (lb): 190BSA (m2): 1.81 m2BP (mm Hg): 160/85HR (bpm): 60Status: InpatientDate/Time: at 11:35Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal LV cavity size. PATIENT/TEST INFORMATION:Indication: Evaluate for endocarditis.Height: (in) 60Weight (lb): 175BSA (m2): 1.77 m2BP (mm Hg): 151/74HR (bpm): 63Status: InpatientDate/Time: at 17:47Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Nomasses or vegetations are seen on the aortic valve. Normal tricuspid valve supporting structures.Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. From L1-L2 to L4-L5, mild disc degenerative changes are noted without spinal stenosis. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Mild mitral annular calcification. T1 sagittal images were obtained following gadolinium. PT CLEARED BY NEURO SURGERY, COLLAR REMOVED R/T PT DENIES NECK PAIN AND C-SPIN XRAY NEGATIVE. Non-specific ST-T wave changes. LS= CLEAR/DIM. Anterior ST segment depression and T wave inversionsuggestive of ischemia. Mildly thickened aortic valveleaflets. THORACIC SPINE: TECHNIQUE: T1, T2 and inversion-recovery sagittal images were obtained before gadolinium. IMPRESSION: Mild degenerative changes. EKG CHANGES NOTED S/P FALL, T WAVE CHANGES. CONTINUE ICU SUPPORTIVE CARE. IMPRESSION: Slight improvement of right sacroiliitis at the inferior/posterior aspects of the joint, with unchanged appearance at the anterior/superior aspect of the joint. Small amount of presacral fluid remains unchanged. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Complex (mobile) atheroma in the aortic arch.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). PORTACATH SITE W/ GUAZE INTACT, NO DRAINAGE NOTED AT THIS TIME. Mild degenerative changes. IV VANCO Q24HRS CONTINUES. Possible left atrial abnormality. Mild thickeningof mitral valve chordae. The subtle signal changes and enhancement seen at the L5-S1 disc are less than , and unchanged compared to . Compared to the previoustracing of the anterior ST-T wave changes are much less.TRACING #2 0.1 mg of IV glycopyrrolate was given as an antisialogogueprior to TEE probe insertion. CARDIOLOGY TEAM CONSULTED, TEE ORDERED, CKMB AND TROPONIN PENDING. Theestimated pulmonary artery systolic pressure is normal. LUMBAR SPINE: TECHNIQUE: T1, T2 and inversion-recovery sagittal and T1 and T2 axial images were obtained before gadolinium. The left ventricular cavity size is normal. There is no pericardial effusion.Compared with the findings of the prior study (images reviewed) of , no major change is evident. Nursing Progress Note:Pt. There is no aortic valvestenosis. No LV mass/thrombus. Left ventricular wall thickness, cavitysize, and systolic function are normal (LVEF 70%). Clinicalcorrelation is suggested. Note is again made of mild edema along the deep fibers of the right iliacus muscle, similar to the prior examinations. Anterolateral ST-T waveabnormalities are non-specific but cannot exclude ischemia. UPON ARRIVAL TO MICU, PT SLIGHTLY DIFFICULT TO AROUSE AND DISORIENTED. NBP= 101-167/55-72. Since the previous tracing of nosignificant change. CERVICAL COLLAR APPLIED AND STAT C-SPINE COMPLETED. PMH OF SEIZURE DISORDER, PT TAKES DILANTIN. Overall left ventricularsystolic function is normal (LVEF>55%).3. A single-lumen PICC line was then placed through the sheath over the wire and its tip positioned in SVC under fluoroscopic guidance. This is need until cultures clear and permanent PICC can be put back in. FINDINGS: Changes of abnormally elevated signal on STIR imaging as well as post-gadolinium imaging remains present at the right sacroiliac joint, involving both the sacral and the iliac sides of the joint. ABD SOFT/ DISTENDED. REASON FOR THIS EXAMINATION: r/o osteomeylitis FINAL REPORT INDICATION: Sacroiliitis, cellulitis. ASSESS NEURO STATUS CLOSELY. There are mobile, complex (mobile) atheroma in the aortic arch.4. These findings indicate stable appearances of previously described improving disc space infection. siezure, transferred to MICU for further evaluation.Neuro: Pt. PT ARRIVED TO MICU W/ C-COLLAR ON, ACCOMPANIED BY MEDICAL FLOOR MD. Needs new CVL or midline(temporary - any site OK) for antibiotic therapy. Sinus rhythm. No masses or thrombi areseen in the left ventricle. Pt.taken for C-spine flexion and extension x-ray, results pending.CV: HR 50s-60s. Rightventricular chamber size and free wall motion are normal. The patient was sedated for the TEE.Medications and dosages are listed above (see Test Information section). Sinus bradycardia. Sinus bradycardia. The absence of a vegetation by 2Dechocardiography does not exclude endocarditis if clinically suggested. No TEE relatedcomplications. No previous tracing available forcomparison.TRACING #1 has R PICC which is patent and WNL. No masses orvegetations on aortic valve. Following gadolinium, enhancement is seen near the posterior margin of the disc. Calcified tips of papillary muscles. PT FOUND ON FLOOR W/ NECK HYPEREXTENDED."},"n_notes":{"kind":"number","value":11,"string":"11"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2188-08-21 00:00:00.000","description":"Report","row_id":1555890,"text":"0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND ADMISSION DATABASE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT TRANSFER FROM CC7 TO MICU AT APPROX 1600, S/P FALL. PT FOUND ON FLOOR W/ NECK HYPEREXTENDED. CERVICAL COLLAR APPLIED AND STAT C-SPINE COMPLETED. PT ARRIVED TO MICU W/ C-COLLAR ON, ACCOMPANIED BY MEDICAL FLOOR MD. FALL, PT ALERT AND ORIENTED X3 AND AMBULATING INDEP. S/P FALL, SLURRED SPEECH TO NO SPEECH W/ CHANGE IN MS, DIFFICULTY AROUSING. SEEN BY NEURO TEAM AND NEURO SURGERY TEAM UPON ARRIVAL TO MICU. PT CLEARED BY NEURO SURGERY, COLLAR REMOVED R/T PT DENIES NECK PAIN AND C-SPIN XRAY NEGATIVE. UPON ARRIVAL TO MICU, PT SLIGHTLY DIFFICULT TO AROUSE AND DISORIENTED. APPROX 1HR LATER, PT AWAKE AND ALERT/ORIENTED X3. FOLLOWING COMMANDS, NO SLURRED SPEECH, MAE, PERLA. HOWEVER PT HAS NO MEMORY OF EVENT ON CCY. PMH OF SEIZURE DISORDER, PT TAKES DILANTIN. EKG CHANGES NOTED S/P FALL, T WAVE CHANGES. CARDIOLOGY TEAM CONSULTED, TEE ORDERED, CKMB AND TROPONIN PENDING. SB TO NSR @ 59-64. NBP= 101-167/55-72. AFEBRILE. 02 SAT 98%. RR=14-18. LS= CLEAR/DIM. ABD SOFT/ DISTENDED. PRESENT BS. SOFT BROWN STOOL X2, FOLEY CATH DRAINING CLEAR YELLOW URINE 50-100CC/HR. PORTACATH SITE W/ GUAZE INTACT, NO DRAINAGE NOTED AT THIS TIME. FULL CODE. CONTACT PRECAUTIONS FOR MRSA BACTREMIA, 4 BOTTLES POSITVIE FOR GPC. IV VANCO Q24HRS CONTINUES. FS QID, FS= 77-246. NPO STATUS MAINTAINED AT THIS TIME.\n\nPLAN- POSSIBLE NECK FLEXION/EXTENSION SERIES NEEDED TONIGHT OR IN AM PER NEURO SURGERY TEAM RECOMM. TEE TO BE DONE IN NEAR FUTURE AFTER NECK SERIES. ASSESS NEURO STATUS CLOSELY. CONTINUE IV ABX. FOLLOW CARDIAC ENZYMES, NEXT DUE AT 2200. CONTINUE ICU SUPPORTIVE CARE.\n"},{"category":"Nursing/other","chartdate":"2188-08-22 00:00:00.000","description":"Report","row_id":1555891,"text":"Nursing Progress Note:\n\nPt. is a 62yo woman who was being trated for a port-o-cath line infection on CC7 and was found on floor unresponsive with her neck hyperextended, evaluated by neurology, head CT done (no evidence of bleed or CVA),? siezure, transferred to MICU for further evaluation.\n\nNeuro: Pt. is alert, OX3, very pleasant and cooperative, MAE, with no c/o numbness, tingling or lateralizing signs. She c/o pain to her back which is chronic and for which she takes Morphine SR and Percocet. She also takes Fioricet for headaches. Her pain was well contolled with medication and she slept well. She did not have any generalized seizure activity but did have a twitch to her hand and head which she noticed but was not observed. Pt.taken for C-spine flexion and extension x-ray, results pending.\n\nCV: HR 50s-60s. NBP 100s-120s/50s-60s. Pt. has R PICC which is patent and WNL. Enzymes cycled s/p fall and are WNL, TEE planned for today to r/o vegetation.\n\nResp: RR teens, 02 sats >96% on 2L NC, lungs sounds clear to all lobes.\n\nGI: Pt. is NPO for possible TEE, taking PO meds with sips. BSX4, golden, liquid stool, mushroom catheter placed, C-diff culture sent.\n\nGU: UO initially WNL but became <30cc/hour, team notified and NS@125cc/hour for 1L initiated (fluids being given slowly due to hx of CHF). UO now hovering around 30cc/hour. Urine tox sent.\n\nID: Pt. being treated for MRSA bacteremia, blood cultures sent. Pt. is growing 4/4 bottles GPC pairs/chains. HIV test ordered with AM labs but consent is needed so this will need to be resent.\n\nSkin: Intact except for healing incision in R chest (site of old port-o-cath).\n\n\n"},{"category":"Echo","chartdate":"2188-08-28 00:00:00.000","description":"Report","row_id":61236,"text":"PATIENT/TEST INFORMATION:\nIndication: Evaluate for endocarditis.\nHeight: (in) 60\nWeight (lb): 175\nBSA (m2): 1.77 m2\nBP (mm Hg): 151/74\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 17:47\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (mobile) atheroma in the aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related\ncomplications. 0.1 mg of IV glycopyrrolate was given as an antisialogogue\nprior to TEE probe insertion. The patient appears to be in sinus rhythm.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\n1. The left atrium is dilated.\n2. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%).\n3. There are mobile, complex (mobile) atheroma in the aortic arch.\n4. The aortic valve leaflets (3) are mildly thickened.\n5. No echocardiographic evidence of endocarditis is seen.\n\n\n"},{"category":"Echo","chartdate":"2188-08-26 00:00:00.000","description":"Report","row_id":61237,"text":"PATIENT/TEST INFORMATION:\nIndication: Endocarditis, rule out vegetation.\nHeight: (in) 59\nWeight (lb): 190\nBSA (m2): 1.81 m2\nBP (mm Hg): 160/85\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:35\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: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient. No LV mass/thrombus. 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: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No masses or vegetations on aortic valve. No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\nof mitral valve chordae. Calcified tips of papillary muscles. Normal LV inflow\npattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Normal tricuspid valve supporting structures.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\nDoppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The absence of a vegetation by 2D echocardiography does not\nexclude endocarditis if clinically suggested.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF 70%). No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. There are three\naortic valve leaflets. The aortic valve leaflets are mildly thickened. No\nmasses or vegetations are seen on the aortic valve. There is no aortic valve\nstenosis. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. No mass or vegetation is seen on the mitral valve. The\nestimated pulmonary artery systolic pressure is normal. No vegetation/mass is\nseen on the pulmonic valve. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , no major change is evident. The absence of a vegetation by 2D\nechocardiography does not exclude endocarditis if clinically suggested.\n\n\n"},{"category":"ECG","chartdate":"2188-08-24 00:00:00.000","description":"Report","row_id":116097,"text":"Sinus rhythm. Possible left atrial abnormality. Anterolateral ST-T wave\nabnormalities are non-specific but cannot exclude ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of no\nsignificant change.\n\n"},{"category":"ECG","chartdate":"2188-08-23 00:00:00.000","description":"Report","row_id":116098,"text":"Sinus rhythm\nAnteroseptal T wave changes may be due to ischemia\nSince previous tracing of , increased rate\n\n"},{"category":"ECG","chartdate":"2188-08-22 00:00:00.000","description":"Report","row_id":116099,"text":"Sinus bradycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing of the anterior ST-T wave changes are much less.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2188-08-21 00:00:00.000","description":"Report","row_id":116100,"text":"Sinus bradycardia. Anterior ST segment depression and T wave inversion\nsuggestive of ischemia. Late transition. No previous tracing available for\ncomparison.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2188-08-26 00:00:00.000","description":"FLUOR GUID PLCT/REPLCT/REMOVE","row_id":924906,"text":" 7:44 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Patient with very difficult access, in collar for cervical i\n Admitting Diagnosis: CELLULITIS\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 62 year old woman with recent osteomyelitis and bactermeia, now with line\n sepsis - PICC pulled on Sunday.\n REASON FOR THIS EXAMINATION:\n Patient with very difficult access, in collar for cervical instability, now\n with VRE bacteremia secondary to PICC line which was pulled on /6 after a\n lower-extremity was placed. Needs new CVL or midline(temporary - any site OK)\n for antibiotic therapy. This is need until cultures clear and permanent PICC\n can be put back in. Please page if problem.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: 62-year-old woman with osteomyelitis, needs IV access.\n\n Details of the procedure were explained to the patient.\n\n RADIOLOGIST: Dr. was performing the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia the right brachial\n vein was localized with ultrasound and punctured under direct ultrasound\n guidance using a micropuncture set. Hard copies of the ultrasound images were\n obtained before and immediately after obtaining intravenous access. A peel-\n away sheath was then placed. A single-lumen PICC line was then placed through\n the sheath over the wire and its tip positioned in SVC under fluoroscopic\n guidance. Position of the catheter was confirmed by chest x-ray in one view.\n\n A guidewire and a peel-away sheath were then removed. The catheter was\n secured to the skin.\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 right brachial vein with the tip positioned in\n SVC. Total length of the catheter 34 cm.\n\n\n\n\n\n\n\n\n (Over)\n\n 7:44 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Patient with very difficult access, in collar for cervical i\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2188-08-21 00:00:00.000","description":"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS","row_id":924320,"text":" 7:21 AM\n MRI PELVIS W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: LOWER EXTREMITY AND BILATERAL HIPS PAIN AND LOSS OF MOTION\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with multiple medical problems recent MRSA bacteremia,\n sacroiliitis, presents with cellulitis, new GPC bacteremia, low back pain.\n REASON FOR THIS EXAMINATION:\n r/o osteomeylitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sacroiliitis, cellulitis. Evaluate interval change.\n\n TECHNIQUE: Multiplanar MR imaging of the pelvis was performed with images\n obtained both before and after the administration of IV contrast, with imaging\n on a 1.5 Tesla magnet. Comparison was made to examinations dated and\n .\n\n FINDINGS: Changes of abnormally elevated signal on STIR imaging as well as\n post-gadolinium imaging remains present at the right sacroiliac joint,\n involving both the sacral and the iliac sides of the joint. While the\n inferior/posterior aspect of involvement appears slightly improved on post-\n contrast imaging, the anterior/superior aspects are not significantly changed.\n There are no loculated/drainable fluid collections seen.\n\n Note is again made of mild edema along the deep fibers of the right iliacus\n muscle, similar to the prior examinations. Note is also made of atrophy\n involving both gluteus maximus muscles, and edema seen within the subcutaneous\n soft tissues. Small amount of presacral fluid remains unchanged. There is no\n hip joint effusion.\n\n IMPRESSION: Slight improvement of right sacroiliitis at the\n inferior/posterior aspects of the joint, with unchanged appearance at the\n anterior/superior aspect of the joint. No drainable fluid collection.\n\n"},{"category":"Radiology","chartdate":"2188-08-22 00:00:00.000","description":"MR L-SPINE W & W/O CONTRAST","row_id":924558,"text":" 5:40 PM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: vertebral osteomyelitis\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL ADDENDUM\n Comparison was made with the prior studies of and . The subtle\n signal changes and enhancement seen at the L5-S1 disc are less than ,\n and unchanged compared to . These findings indicate stable appearances\n of previously described improving disc space infection. No new findings are\n seen.\n\n\n 5:40 PM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: vertebral osteomyelitis\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with MRSA bacteremia and sacroilitis, concern for seeding.\n REASON FOR THIS EXAMINATION:\n vertebral osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI OF THE THORACIC AND LUMBAR SPINE.\n\n CLINICAL INFORMATION: Patient with MRSA bacteremia and concerning for\n vertebral osteomyelitis.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1, T2 and inversion-recovery sagittal images were obtained before\n gadolinium. T1 sagittal images were obtained following gadolinium.\n\n FINDINGS: From T1-T2 to T12-L1, mild disc degenerative changes are seen\n without significant bulging, herniation or spinal stenosis. The vertebral\n bodies and discs demonstrate no evidence of abnormal signal indicative of\n discitis or osteomyelitis. Following gadolinium, no abnormal intraspinal\n enhancement seen.\n\n IMPRESSION: Mild degenerative changes. No evidence of discitis or\n osteomyelitis in the thoracic region. No evidence of spinal cord compression\n or abnormal intrinsic signal within the spinal cord.\n\n LUMBAR SPINE:\n\n TECHNIQUE: T1, T2 and inversion-recovery sagittal and T1 and T2 axial images\n were obtained before gadolinium. T1 sagittal and axial images were obtained\n following the administration of gadolinium.\n\n FINDINGS: The L5-S1 disc demonstrate increased signal on T2 and inversion-\n recovery images with subtle decreased signal along the endplates on T1-\n weighted images. Following gadolinium, enhancement is seen near the posterior\n margin of the disc. There is no epidural phlegmon identified. No evidence of\n paraspinal mass seen.\n\n At L4-L5 level, there has been previous spinal fusion noted posteriorly.\n\n From L1-L2 to L4-L5, mild disc degenerative changes are noted without spinal\n stenosis.\n\n IMPRESSION: Signal changes within the L5-S1 disc with subtle enhancement are\n suspicious for early changes of discitis. No epidural mass or epidural\n phlegmon seen or paraspinal abscess identified. Mild degenerative changes.\n Findings suggestive of previous fusion at L4-L5 level.\n (Over)\n\n 5:40 PM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: vertebral osteomyelitis\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2188-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1555890,\n \"text\": \"0700-1900 NPN:\\n\\nPLEASE SEE CAREVUE FLOWSHEET AND ADMISSION DATABASE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT TRANSFER FROM CC7 TO MICU AT APPROX 1600, S/P FALL. PT FOUND ON FLOOR W/ NECK HYPEREXTENDED. CERVICAL COLLAR APPLIED AND STAT C-SPINE COMPLETED. PT ARRIVED TO MICU W/ C-COLLAR ON, ACCOMPANIED BY MEDICAL FLOOR MD. FALL, PT ALERT AND ORIENTED X3 AND AMBULATING INDEP. S/P FALL, SLURRED SPEECH TO NO SPEECH W/ CHANGE IN MS, DIFFICULTY AROUSING. SEEN BY NEURO TEAM AND NEURO SURGERY TEAM UPON ARRIVAL TO MICU. PT CLEARED BY NEURO SURGERY, COLLAR REMOVED R/T PT DENIES NECK PAIN AND C-SPIN XRAY NEGATIVE. UPON ARRIVAL TO MICU, PT SLIGHTLY DIFFICULT TO AROUSE AND DISORIENTED. APPROX 1HR LATER, PT AWAKE AND ALERT/ORIENTED X3. FOLLOWING COMMANDS, NO SLURRED SPEECH, MAE, PERLA. HOWEVER PT HAS NO MEMORY OF EVENT ON CCY. PMH OF SEIZURE DISORDER, PT TAKES DILANTIN. EKG CHANGES NOTED S/P FALL, T WAVE CHANGES. CARDIOLOGY TEAM CONSULTED, TEE ORDERED, CKMB AND TROPONIN PENDING. SB TO NSR @ 59-64. NBP= 101-167/55-72. AFEBRILE. 02 SAT 98%. RR=14-18. LS= CLEAR/DIM. ABD SOFT/ DISTENDED. PRESENT BS. SOFT BROWN STOOL X2, FOLEY CATH DRAINING CLEAR YELLOW URINE 50-100CC/HR. PORTACATH SITE W/ GUAZE INTACT, NO DRAINAGE NOTED AT THIS TIME. FULL CODE. CONTACT PRECAUTIONS FOR MRSA BACTREMIA, 4 BOTTLES POSITVIE FOR GPC. IV VANCO Q24HRS CONTINUES. FS QID, FS= 77-246. NPO STATUS MAINTAINED AT THIS TIME.\\n\\nPLAN- POSSIBLE NECK FLEXION/EXTENSION SERIES NEEDED TONIGHT OR IN AM PER NEURO SURGERY TEAM RECOMM. TEE TO BE DONE IN NEAR FUTURE AFTER NECK SERIES. ASSESS NEURO STATUS CLOSELY. CONTINUE IV ABX. FOLLOW CARDIAC ENZYMES, NEXT DUE AT 2200. CONTINUE ICU SUPPORTIVE CARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2188-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1555891,\n \"text\": \"Nursing Progress Note:\\n\\nPt. is a 62yo woman who was being trated for a port-o-cath line infection on CC7 and was found on floor unresponsive with her neck hyperextended, evaluated by neurology, head CT done (no evidence of bleed or CVA),? siezure, transferred to MICU for further evaluation.\\n\\nNeuro: Pt. is alert, OX3, very pleasant and cooperative, MAE, with no c/o numbness, tingling or lateralizing signs. She c/o pain to her back which is chronic and for which she takes Morphine SR and Percocet. She also takes Fioricet for headaches. Her pain was well contolled with medication and she slept well. She did not have any generalized seizure activity but did have a twitch to her hand and head which she noticed but was not observed. Pt.taken for C-spine flexion and extension x-ray, results pending.\\n\\nCV: HR 50s-60s. NBP 100s-120s/50s-60s. Pt. has R PICC which is patent and WNL. Enzymes cycled s/p fall and are WNL, TEE planned for today to r/o vegetation.\\n\\nResp: RR teens, 02 sats >96% on 2L NC, lungs sounds clear to all lobes.\\n\\nGI: Pt. is NPO for possible TEE, taking PO meds with sips. BSX4, golden, liquid stool, mushroom catheter placed, C-diff culture sent.\\n\\nGU: UO initially WNL but became <30cc/hour, team notified and NS@125cc/hour for 1L initiated (fluids being given slowly due to hx of CHF). UO now hovering around 30cc/hour. Urine tox sent.\\n\\nID: Pt. being treated for MRSA bacteremia, blood cultures sent. Pt. is growing 4/4 bottles GPC pairs/chains. HIV test ordered with AM labs but consent is needed so this will need to be resent.\\n\\nSkin: Intact except for healing incision in R chest (site of old port-o-cath).\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2188-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 61236,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Evaluate for endocarditis.\\nHeight: (in) 60\\nWeight (lb): 175\\nBSA (m2): 1.77 m2\\nBP (mm Hg): 151/74\\nHR (bpm): 63\\nStatus: Inpatient\\nDate/Time: at 17:47\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Dilated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Complex (mobile) atheroma in the aortic arch.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\\nvegetations on aortic valve. No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\\nvegetation on mitral valve.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\\nvegetation on tricuspid valve.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was monitored\\nby a nurse throughout the procedure. Local anesthesia was\\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\\nMedications and dosages are listed above (see Test Information section). The\\nposterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related\\ncomplications. 0.1 mg of IV glycopyrrolate was given as an antisialogogue\\nprior to TEE probe insertion. The patient appears to be in sinus rhythm.\\nEchocardiographic results were reviewed by telephone with the houseofficer\\ncaring for the patient.\\n\\nConclusions:\\n1. The left atrium is dilated.\\n2. The left ventricular cavity size is normal. Overall left ventricular\\nsystolic function is normal (LVEF>55%).\\n3. There are mobile, complex (mobile) atheroma in the aortic arch.\\n4. The aortic valve leaflets (3) are mildly thickened.\\n5. No echocardiographic evidence of endocarditis is seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2188-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 61237,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Endocarditis, rule out vegetation.\\nHeight: (in) 59\\nWeight (lb): 190\\nBSA (m2): 1.81 m2\\nBP (mm Hg): 160/85\\nHR (bpm): 60\\nStatus: Inpatient\\nDate/Time: at 11:35\\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: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%). No resting LVOT gradient. No LV mass/thrombus. 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: Three aortic valve leaflets. Mildly thickened aortic valve\\nleaflets. No masses or vegetations on aortic valve. No AS.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\\nof mitral valve chordae. Calcified tips of papillary muscles. Normal LV inflow\\npattern for age.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\\nvegetation on tricuspid valve. Normal tricuspid valve supporting structures.\\nNormal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\\nDoppler evidence for PDA\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: The absence of a vegetation by 2D echocardiography does not\\nexclude endocarditis if clinically suggested.\\n\\nConclusions:\\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\\nsize, and systolic function are normal (LVEF 70%). No masses or thrombi are\\nseen in the left ventricle. There is no ventricular septal defect. Right\\nventricular chamber size and free wall motion are normal. There are three\\naortic valve leaflets. The aortic valve leaflets are mildly thickened. No\\nmasses or vegetations are seen on the aortic valve. There is no aortic valve\\nstenosis. The mitral valve leaflets are mildly thickened. There is no mitral\\nvalve prolapse. No mass or vegetation is seen on the mitral valve. The\\nestimated pulmonary artery systolic pressure is normal. No vegetation/mass is\\nseen on the pulmonic valve. There is no pericardial effusion.\\n\\nCompared with the findings of the prior study (images reviewed) of , no major change is evident. The absence of a vegetation by 2D\\nechocardiography does not exclude endocarditis if clinically suggested.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2188-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 116097,\n \"text\": \"Sinus rhythm. Possible left atrial abnormality. Anterolateral ST-T wave\\nabnormalities are non-specific but cannot exclude ischemia. Clinical\\ncorrelation is suggested. Since the previous tracing of no\\nsignificant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2188-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 116098,\n \"text\": \"Sinus rhythm\\nAnteroseptal T wave changes may be due to ischemia\\nSince previous tracing of , increased rate\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2188-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 116099,\n \"text\": \"Sinus bradycardia. Non-specific ST-T wave changes. Compared to the previous\\ntracing of the anterior ST-T wave changes are much less.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2188-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 116100,\n \"text\": \"Sinus bradycardia. Anterior ST segment depression and T wave inversion\\nsuggestive of ischemia. Late transition. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-08-26 00:00:00.000\",\n \"description\": \"FLUOR GUID PLCT/REPLCT/REMOVE\",\n \"row_id\": 924906,\n \"text\": \" 7:44 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Patient with very difficult access, in collar for cervical i\\n Admitting Diagnosis: CELLULITIS\\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 62 year old woman with recent osteomyelitis and bactermeia, now with line\\n sepsis - PICC pulled on Sunday.\\n REASON FOR THIS EXAMINATION:\\n Patient with very difficult access, in collar for cervical instability, now\\n with VRE bacteremia secondary to PICC line which was pulled on /6 after a\\n lower-extremity was placed. Needs new CVL or midline(temporary - any site OK)\\n for antibiotic therapy. This is need until cultures clear and permanent PICC\\n can be put back in. Please page if problem.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PICC LINE PLACEMENT\\n\\n INDICATION: 62-year-old woman with osteomyelitis, needs IV access.\\n\\n Details of the procedure were explained to the patient.\\n\\n RADIOLOGIST: Dr. was performing the procedure.\\n\\n TECHNIQUE: Using sterile technique and local anesthesia the right brachial\\n vein was localized with ultrasound and punctured under direct ultrasound\\n guidance using a micropuncture set. Hard copies of the ultrasound images were\\n obtained before and immediately after obtaining intravenous access. A peel-\\n away sheath was then placed. A single-lumen PICC line was then placed through\\n the sheath over the wire and its tip positioned in SVC under fluoroscopic\\n guidance. Position of the catheter was confirmed by chest x-ray in one view.\\n\\n A guidewire and a peel-away sheath were then removed. The catheter was\\n secured to the skin.\\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 right brachial vein with the tip positioned in\\n SVC. Total length of the catheter 34 cm.\\n\\n\\n\\n\\n\\n\\n\\n\\n (Over)\\n\\n 7:44 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Patient with very difficult access, in collar for cervical i\\n Admitting Diagnosis: CELLULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-08-21 00:00:00.000\",\n \"description\": \"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\",\n \"row_id\": 924320,\n \"text\": \" 7:21 AM\\n MRI PELVIS W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: LOWER EXTREMITY AND BILATERAL HIPS PAIN AND LOSS OF MOTION\\n Admitting Diagnosis: CELLULITIS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with multiple medical problems recent MRSA bacteremia,\\n sacroiliitis, presents with cellulitis, new GPC bacteremia, low back pain.\\n REASON FOR THIS EXAMINATION:\\n r/o osteomeylitis\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Sacroiliitis, cellulitis. Evaluate interval change.\\n\\n TECHNIQUE: Multiplanar MR imaging of the pelvis was performed with images\\n obtained both before and after the administration of IV contrast, with imaging\\n on a 1.5 Tesla magnet. Comparison was made to examinations dated and\\n .\\n\\n FINDINGS: Changes of abnormally elevated signal on STIR imaging as well as\\n post-gadolinium imaging remains present at the right sacroiliac joint,\\n involving both the sacral and the iliac sides of the joint. While the\\n inferior/posterior aspect of involvement appears slightly improved on post-\\n contrast imaging, the anterior/superior aspects are not significantly changed.\\n There are no loculated/drainable fluid collections seen.\\n\\n Note is again made of mild edema along the deep fibers of the right iliacus\\n muscle, similar to the prior examinations. Note is also made of atrophy\\n involving both gluteus maximus muscles, and edema seen within the subcutaneous\\n soft tissues. Small amount of presacral fluid remains unchanged. There is no\\n hip joint effusion.\\n\\n IMPRESSION: Slight improvement of right sacroiliitis at the\\n inferior/posterior aspects of the joint, with unchanged appearance at the\\n anterior/superior aspect of the joint. No drainable fluid collection.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-08-22 00:00:00.000\",\n \"description\": \"MR L-SPINE W & W/O CONTRAST\",\n \"row_id\": 924558,\n \"text\": \" 5:40 PM\\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \\n Reason: vertebral osteomyelitis\\n Admitting Diagnosis: CELLULITIS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n Comparison was made with the prior studies of and . The subtle\\n signal changes and enhancement seen at the L5-S1 disc are less than ,\\n and unchanged compared to . These findings indicate stable appearances\\n of previously described improving disc space infection. No new findings are\\n seen.\\n\\n\\n 5:40 PM\\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \\n Reason: vertebral osteomyelitis\\n Admitting Diagnosis: CELLULITIS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with MRSA bacteremia and sacroilitis, concern for seeding.\\n REASON FOR THIS EXAMINATION:\\n vertebral osteomyelitis\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRI OF THE THORACIC AND LUMBAR SPINE.\\n\\n CLINICAL INFORMATION: Patient with MRSA bacteremia and concerning for\\n vertebral osteomyelitis.\\n\\n THORACIC SPINE:\\n\\n TECHNIQUE: T1, T2 and inversion-recovery sagittal images were obtained before\\n gadolinium. T1 sagittal images were obtained following gadolinium.\\n\\n FINDINGS: From T1-T2 to T12-L1, mild disc degenerative changes are seen\\n without significant bulging, herniation or spinal stenosis. The vertebral\\n bodies and discs demonstrate no evidence of abnormal signal indicative of\\n discitis or osteomyelitis. Following gadolinium, no abnormal intraspinal\\n enhancement seen.\\n\\n IMPRESSION: Mild degenerative changes. No evidence of discitis or\\n osteomyelitis in the thoracic region. No evidence of spinal cord compression\\n or abnormal intrinsic signal within the spinal cord.\\n\\n LUMBAR SPINE:\\n\\n TECHNIQUE: T1, T2 and inversion-recovery sagittal and T1 and T2 axial images\\n were obtained before gadolinium. T1 sagittal and axial images were obtained\\n following the administration of gadolinium.\\n\\n FINDINGS: The L5-S1 disc demonstrate increased signal on T2 and inversion-\\n recovery images with subtle decreased signal along the endplates on T1-\\n weighted images. Following gadolinium, enhancement is seen near the posterior\\n margin of the disc. There is no epidural phlegmon identified. No evidence of\\n paraspinal mass seen.\\n\\n At L4-L5 level, there has been previous spinal fusion noted posteriorly.\\n\\n From L1-L2 to L4-L5, mild disc degenerative changes are noted without spinal\\n stenosis.\\n\\n IMPRESSION: Signal changes within the L5-S1 disc with subtle enhancement are\\n suspicious for early changes of discitis. No epidural mass or epidural\\n phlegmon seen or paraspinal abscess identified. Mild degenerative changes.\\n Findings suggestive of previous fusion at L4-L5 level.\\n (Over)\\n\\n 5:40 PM\\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \\n Reason: vertebral osteomyelitis\\n Admitting Diagnosis: CELLULITIS\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\\n\\n\\n\"\n }\n]"}}},{"rowIdx":772,"cells":{"subject_id":{"kind":"number","value":99472,"string":"99,472"},"hadm_id":{"kind":"number","value":161362,"string":"161,362"},"target_text":{"kind":"string","value":"82 yo female with PMH of HTN, HL, presenting to OSH with respiratory distress, intubated, hypotensive on pressors, found to have NSTEMI with TropI>100. Cath showing significant 2VD, and complicated by hypotension intraprocedurally. Transferred to for eval for urgent CABG. . # NSTEMI: Pt initially presenting to OSH with respiratory distress complicated by refractory hypotension requiring dopamine for pressor support likely NSTEMI. Her enzymes were followed showing troponin >100 and cath significant for 2VD and requiring placement of balloon pump. Bedside echo on admission showed EF of 35-40% with moderate regional left ventricular systolic dysfunction with basal and mid anterioseptal, anterior, anteriolateral, and apical hypokenesis. Patient was continued on medical management with heparin ggt, asa 325, atorva 80. Dopamine and levophed were weaned off over the course of 3 days. IABP remained in at one to one. Echo showed a preserved EF 55%. Patient was taken for CABG.... . # Respiratory failure: Patient remained intubated. Oxygen was weaned down to 40% over the next 24 hours after arrival. Initial cause of respiratory distress likely secondary to NSTEMI with resultant CHF. As she began to spike fevers and CXR showed probable pneumonia, she was experically treated for pneumonia with vancomycin and zosyn. . # Hypotension: On arrival to , patient was maxed out on dopamine 20mcg/kg/hr. Initial PA catheter readings indicated a mixed picture of cardiogenic and distributive shock. Patient's calculated SVR then began to decrease, and echo showed globally normal LVEF without major wall motion abnormalities. It was determined that she was in distributive/septic shock. She was weaned off dopamine, and transitioned to levophed. After 2 days on levophed, her MAPs remained > 60 and she was weaned off. . #. Carotid Artery: During replacement of PA catheter, cordis sheath was placed in the carotid artery. CT aorta showed no evidence of hematoma. Patient was evaluated by vascular surgery and cardiac surgery. On the patient was brought to the operating room for sternotomy and removal of cordis sheath as well as coronary bypass grafting by cardiac and vascular surgery. Please see the operative report for details. Following the operation she was transferred to the cardiac surgery ICU paralyzed and sedated in critical condition on multiple pressors and inotropes with an open chest. Over the next several days she remained with an open chest on multiple pressors, she eventually developed acute renal failure and was begun on CVVHD. Her condition continued to deteriorate and on POD 5 she was made comfort measures only. She expired on POD 5 with family present"},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: As compared to the previous radiograph, the tip of the Swan-Ganz catheter is still located distally in the right pulmonary artery. FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post CABG, dropping saturation. A new right internal jugular approach sheath is identified, seen to terminate in the upper right-sided mediastinum corresponding to the area of the right jugular/subclavian venous junction. New Swan-Ganz catheter from the left IJ approach extends to the right pulmonary artery. Previously described Swan-Ganz catheter, approached from below, has been withdrawn. Left IJ at confluence of svc and left brachiocephalic v. There is bilateral atelectasis and pulmonary edema. Increased right lower lung atelectasis and unchanged left lower lung atelectasis. UNDER FLUORO Admitting Diagnosis: CORONARY ARTERY DISEASE FINAL REPORT HISTORY: Jugular catheter placement under fluoroscopy. FINDINGS: Since the prior study, endotracheal tube has advanced distally with its tip now at the carina. 7:46 PM CHEST (PORTABLE AP) Clip # Reason: Eval for acute process and balloon pump location. Aberrant placement of the right-sided central venous introducer sheath, which traverses both the external jugular and internal jugular veins, with its tip within the right brachiocephalic artery at the origin of the right subclavian artery. via carotid. COMPARISON: Chest radiograph from FINDINGS: Targeted son is performed in the right supraclavicular tissues, at the site of catheter exit from the skin. At the right lung base, however, a subtle remnant pulmonary opacity is still visible. COMPARISON: Portable chest x-ray from . CHEST: The tip of the Swan-Ganz catheter lies in the right pulmonary artery. carotid WET READ: SPfc 5:21 PM nonvisualization of the intraluminal course, if any, of the right neck catheter. Right Swan-Ganz sheath seen traversing the external jugular and internal jugular with the tip within the right brachiocephalic at the location where the right subclavian originates. Right Swan-Ganz sheath seen traversing the external jugular and internal jugular with the tip within the right brachiocephalic at the location where the right subclavian originates. (Over) 10:28 AM CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # Reason: please eval neck down to carina to look at aortic arch archi Admitting Diagnosis: CORONARY ARTERY DISEASE FINAL REPORT (Cont) IMPRESSION: 1. Mild (1+)aortic regurgitation is seen. Mild (1+)aortic regurgitation is seen. Mild (1+) aorticregurgitation is seen. Mild(1+) mitral regurgitation is seen. Mild aortic regurgitation. Mild mitral annularcalcification. There is mild regional leftventricular systolic dysfunction with anterior hypokinesis. Moderate pulmonaryhypertension. Thereis mild aortic valve stenosis (valve area 1.2-1.9cm2). The right ventricular cavity is mildly dilated with normal free wallcontractility. There is mild pulmonary artery systolichypertension. There are simple atheroma in the descendingthoracic aorta. There is an anterior space which most likelyrepresents a prominent fat pad.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.Cannot exclude hemodynamically-significant aortic stenosis. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. ]TRICUSPID VALVE: Mild to moderate [+] TR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. There is an anterior space which mostlikely represents a fat pad, though a loculated anterior pericardial effusioncannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor parasternal views.Conclusions:The left atrium is normal in size. Mild mitralregurgitation. Trivial mitral regurgitation is seen. Mild to moderate [+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Mild-moderate tricuspidregurgitation. Moderate mitralannular calcification. Mild regional LVsystolic dysfunction. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal ascending aortadiameter.AORTIC VALVE: Moderately thickened aortic valve leaflets. The gallbladder is moderately distended. Mild [1+]TR. Mild [1+] TR. ]TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Shortness of breath.Height: (in) 63Weight (lb): 189BSA (m2): 1.89 m2BP (mm Hg): 118/74HR (bpm): 74Status: InpatientDate/Time: at 20:43Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion. Mildmitral regurgitation. Unchanged appearance of the lung parenchyma and the cardiac silhouette. There is ananterior space which most likely represents a prominent fat pad.IMPRESSION: Suboptimal image quality.Mild aortic regurgitation. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Preservedglobal biventricular systolic function. Normal RV systolic function.AORTA: Normal aortic diameter at the sinus level. There is moderate pulmonary artery systolic hypertension.There is no pericardial effusion. There is no pericardial effusion.IMPRESSION: Normal global and regional biventricular systolic function.Calcific aortic valve disease with mild stenosis/mild regurgbitation. Mild pulmonary hypertension.Compared with the prior study (images reviewed) of , anteriorhypokinesis is no longer appreciated (prior study technically-suboptimal). If there is any pleural effusion it is minimal. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Distended and edematous gallbladder without gallstones. Trace aorticregurgitation is seen. Regional left ventricular wall motion isnormal. The mitral valve leaflets are mildly thickened.No mitral regurgitation is seen. Mild AS (area1.2-1.9cm2). No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. The aortic valve leaflets are mildly thickened (?#)."},"n_notes":{"kind":"number","value":30,"string":"30"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2193-12-23 00:00:00.000","description":"P ABDOMEN (SUPINE ONLY) PORT","row_id":1172807,"text":" 9:37 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: Location of balloon tip\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with IABP, ? position of balloon tip\n REASON FOR THIS EXAMINATION:\n Location of balloon tip\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Intra-aortic balloon pump, check position of tip.\n\n What appears to be the tip of the tube lies in the lower abdominal aorta at\n the level of the interspace of L2 and L3.\n\n The bowel gas appears normal.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1173708,"text":" 1:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, evaluation for pleural effusion.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lungs have improved in\n transparency, likely reflecting improved ventilation. At the right lung base,\n however, a subtle remnant pulmonary opacity is still visible.\n\n No newly occurred parenchymal opacities, no edema.\n\n"},{"category":"Radiology","chartdate":"2193-12-24 00:00:00.000","description":"O CHEST (SINGLE VIEW) IN O.R.","row_id":1173004,"text":" 2:44 PM\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: RT JUGULAR LINE PL. UNDER FLUORO\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Jugular catheter placement under fluoroscopy.\n\n FINDINGS: Single image fails to show a definite jugular catheter. Further\n information can be gathered from the operative report.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-24 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1173005,"text":" 2:47 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 82 Y.O. WOMAN WITH SWAN PLACED IN ARTERY, PLEASE ECALUATE FOR PNEUMO\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with Swan placed in artery, please evaluate for pneumo\n REASON FOR THIS EXAMINATION:\n Thanks\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: 82-year-old female patient with Swan-Ganz catheter placed in\n artery, evaluate for pneumothorax.\n\n AP single view of the chest has been obtained with patient in sitting\n semi-upright position. Comparison is made with the next preceding similar\n study dated . Previously described Swan-Ganz catheter,\n approached from below, has been withdrawn. A new right internal jugular\n approach sheath is identified, seen to terminate in the upper right-sided\n mediastinum corresponding to the area of the right jugular/subclavian venous\n junction. No pneumothorax has developed, and in comparison with the previous\n chest, no significantly increased width of the superior mediastinum is noted.\n Previously identified intra-aortic balloon pump device remains in unchanged\n position. Central pulmonary edema slightly improved. No new pulmonary\n infiltrates are seen, and the lateral pleural sinuses remain free. Heart size\n as before moderately enlarged and typical dense mitral ring calcification is\n observed.\n\n IMPRESSION: No evidence of pneumothorax or significant superior mediastinal\n hematoma following unintended arterial stick.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-24 00:00:00.000","description":"CAROTID LMTD/ DPP","row_id":1173023,"text":" 4:24 PM\n CAROTID LMTD/ DPP Clip # \n Reason: Please evaluate for placement of the cannula, ? carotid\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cannulization of brachiocephalic, ? via carotid.\n REASON FOR THIS EXAMINATION:\n Please evaluate for placement of the cannula, ? carotid\n ______________________________________________________________________________\n WET READ: SPfc 5:21 PM\n nonvisualization of the intraluminal course, if any, of the right neck\n catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Placement of a catheter into the arterial system with question\n of carotid versus brachiocephalic position.\n\n COMPARISON: Chest radiograph from \n\n FINDINGS: Targeted son is performed in the right supraclavicular\n tissues, at the site of catheter exit from the skin. At this level, note is\n made of a structure with posterior acoustic shadowing in the subcutaneous soft\n tissues, presumably related to the superficial component of the catheter. Due\n to limited acoustic windows, the intraluminal course of the catheter, if any,\n is not visualized on the current study. Note is made of a trace amount of\n atherosclerotic disease in the carotid artery.\n\n IMPRESSION: Nonvisualization of the intraluminal portion of the catheter, if\n any. If further confirmation is required, would recommend direct contrast\n injection under fluoroscopy.\n\n Results discussed via telephone with Dr. by Dr. at\n 17:15 on \n\n"},{"category":"Radiology","chartdate":"2193-12-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1172738,"text":" 7:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for acute process and balloon pump location.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cardiogenic shock, intubated and w/ ballon pump. Eval\n for acute process and balloon pump location.\n REASON FOR THIS EXAMINATION:\n Eval for acute process and balloon pump location.\n ______________________________________________________________________________\n WET READ: NATg 8:54 PM\n Right groin S-G catheter is in right PA. Aortic balloon pump tip is 5cm from\n arch. ETT 3cm from carina. Left IJ at confluence of svc and left\n brachiocephalic v. There is bilateral atelectasis and pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cardiogenic shock, intubated with balloon pump.\n\n CHEST:\n\n The tip of the Swan-Ganz catheter lies in the right pulmonary artery. The\n aortic balloon tip lies 5 cm from the aortic arch which shows some unwinding.\n The endotracheal tube lies 3 cm from the carinal angle. The tip of the left\n IJ line lies at the junction of the left brachiocephalic and SVC.\n\n Bilateral interstitial edema is present.\n\n The tip of the nasogastric tube and the side hole lie within the stomach.\n\n IMPRESSION:\n Support tubes and lines as described. Pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2193-12-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1173076,"text":" 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tubes, lines, interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with nstemi, intubated sedated for resp failure\n REASON FOR THIS EXAMINATION:\n tubes, lines, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post NSTEMI, intubated for respiratory failure.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The right large-bore sheath ends over the right superior\n mediastinum; there is no evidence of bleeding adjacent to the catheter tip.\n The ET tube ends 4.5 cm above the carina. The intra-aortic balloon pump tip\n is midway between the upper margin of the left main bronchus and apex of the\n aortic arch. The NG tube ends within the stomach. Mild pulmonary edema has\n minimally improved. Right lower lung atelectasis is increased and left\n basilar atelectasis is unchanged. There is no pneumothorax. Dense\n calcification of the mitral annulus is unchanged.\n\n IMPRESSION:\n 1. Right large bore sheath ending over the right superior mediastinum. No\n evidence of adjacent bleeding.\n 2. Increased right lower lung atelectasis and unchanged left lower lung\n atelectasis.\n\n"},{"category":"Radiology","chartdate":"2193-12-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1173246,"text":" 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with NSTEMI, resp failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with non-ST elevation MI.\n\n Portable AP chest radiograph was compared to prior study obtained on , .\n\n The NG tube tip is now at the gastroesophageal junction with the sidehole in\n the mid esophagus and should be repositioned. The ET tube tip is obscured by\n the NG tube tip and most likely is in an appropriate position. The right\n internal jugular line is appropriate. Cardiomediastinal silhouette is stable.\n Intra-aortic balloon pump is approximately 4.5 cm below the superior margin of\n the aortic arch. The left retrocardiac opacity is unchanged.\n\n Widespread parenchymal opacities are redemonstrated, unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-25 00:00:00.000","description":"CT NECK W/O CONTRAST (EG: PAROTIDS)","row_id":1173106,"text":", 10:28 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: please eval neck down to carina to look at aortic arch archi\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with multivessel CAD, swan incidentally floated in carotid.\n Aortic balloon in place.\n REASON FOR THIS EXAMINATION:\n please eval neck down to carina to look at aortic arch architecture\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PFI REPORT\n 1. Right Swan-Ganz sheath seen traversing the external jugular and internal\n jugular with the tip within the right brachiocephalic at the location where\n the right subclavian originates. There is no evidence of organizing hematoma\n in this location.\n 2. Constellation of findings suggestive of congestive heart failure.\n\n\n\n"},{"category":"Radiology","chartdate":"2193-12-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1172893,"text":" 9:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Tip of Swan\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with shock, Swan-Ganz catheter\n REASON FOR THIS EXAMINATION:\n Tip of Swan\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Swan-Ganz catheter.\n\n COMPARISON: , 8:29 a.m.\n\n FINDINGS: As compared to the previous radiograph, the tip of the Swan-Ganz\n catheter is still located distally in the right pulmonary artery. The tip\n should be pulled back by approximately 6 cm. The other monitoring and support\n devices are unchanged. The pre-existing right parenchymal opacities have\n decreased in extent. Unchanged size of the cardiac silhouette.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1173393,"text":" 10:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p CABG w/dropping PO2 r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/dropping PO2 r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG with dropping pO2.\n\n FINDINGS: In comparison with the study of , there is little overall\n change in the appearance of the heart and lungs. Monitoring and support\n devices remain in place. Some continued widening of the upper mediastinum is\n again seen.\n\n\n"},{"category":"Radiology","chartdate":"2194-01-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1174078,"text":" 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/elevated INR and decreased SpO2 r/o collapse\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/elevated INR and decreased SpO2 r/o collapse\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, elevated INR, decreased oxygen saturation.\n\n COMPARISON: multiple prior radiographs.\n\n FINDINGS: Since the prior study, endotracheal tube has advanced distally with\n its tip now at the carina. Numerous other monitoring and support devices are\n stable including a left internal jugular Swan-Ganz catheter and orogastric\n tube and three chest tubes. Diffuse bilateral pulmonary markings are still\n present in both lungs consistent with elevated pulmonary venous pressure.\n\n IMPRESSION: Endotracheal tube at the carina which is advanced since prior\n study. Tube should be pulled back by 4 cm for optimal positioning. This\n finding was communicated with on CC7 at 10 a.m. on .\n\n\n"},{"category":"Radiology","chartdate":"2193-12-26 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1173376,"text":" 6:46 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: CARDIAC SURGERY. Pleural effusion, pulmonary edema, tamponad\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CABG\n REASON FOR THIS EXAMINATION:\n CARDIAC SURGERY. Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n ______________________________________________________________________________\n WET READ: 8:23 PM\n NGT in stomach. ETT 1.6 cm above carina, pls retract at least 2 cm. New\n Swan-Ganz in prox RPA, mediastinal and drains. Low lung vols w/o PTX.\n Bibasilar opacities L>R, likely atelectasis, cannot r/o infx. Prominent\n mediastinum - likely projectional, pls correlate clinically for possible\n hematoma formation. Mitral annular Ca.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , the endotracheal tube tip lies\n only 1.6 cm above the carina and should be pulled back about 2 cm. New\n Swan-Ganz catheter from the left IJ approach extends to the right pulmonary\n artery. Nasogastric tube tip is in the upper stomach, though the side hole is\n within the distal esophagus. Left chest tube is in place and there is no\n evidence of pneumothorax. Mild bibasilar atelectasis is seen. Prominence of\n the mediastinum most likely represents post-surgical change, though this\n should be correlated clinically to assess for possible hematoma formation.\n Dense calcification of the mitral annulus persists.\n\n This information was discussed with Dr. by the resident on call.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-25 00:00:00.000","description":"CT NECK W/O CONTRAST (EG: PAROTIDS)","row_id":1173105,"text":" 10:28 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: please eval neck down to carina to look at aortic arch archi\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with multivessel CAD, swan incidentally floated in carotid.\n Aortic balloon in place.\n REASON FOR THIS EXAMINATION:\n please eval neck down to carina to look at aortic arch architecture\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SZm WED 8:32 PM\n 1. Right Swan-Ganz sheath seen traversing the external jugular and internal\n jugular with the tip within the right brachiocephalic at the location where\n the right subclavian originates. There is no evidence of organizing hematoma\n in this location.\n 2. Constellation of findings suggestive of congestive heart failure.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old female with multivessel CAD and Swan incidentally\n forced into the carotid.\n\n COMPARISON: Portable chest x-ray from .\n\n TECHNIQUE: CT of the neck done without contrast due to the patient's renal\n insufficiency.\n\n FINDINGS: A Cordis-type central venous access introducer sheath traverses the\n right external jugular and right internal jugular veins, following an\n oblique-inferior course with its tip at the take-off of the right subclavian\n from the brachiocephalic artery. There is an approximately 9-mm fascial\n interval between the right IJ venous exit and the brachiocephalic arterial\n entry site. There is no evidence of organizing hematoma in the region, at\n either the skin entry or the site where the sheath traverses the internal\n jugular vein. Extravasation cannot be assessed in the absence of intravenous\n contrast.\n\n An endotracheal tube has its tip 2.8 cm from the carina. The tip of the\n oro-enteric tube is not included in the imaging volume.\n\n There are bilateral pleural effusions, right greater than left and pleural\n seen in the oblique fissures bilaterally. There is thickening of the\n interlobular septae and ground-glass opacities consistent with pulmonary\n edema. Evaluation of cervical lymph chain demonstrates no lymphadenopathy by\n imaging criteria. There are several nodules seen within the thyroid gland,\n the largest measuring 1.3 cm in the lower pole of its left lobe. There are\n multilevel degenerative changes of the spine seen with near-complete loss of\n disc space height between C2 and C3 as well as loss of disc space height\n between C4 and C5. There is no evidence of fracture.\n (Over)\n\n 10:28 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: please eval neck down to carina to look at aortic arch archi\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Aberrant placement of the right-sided central venous introducer sheath,\n which traverses both the external jugular and internal jugular veins, with its\n tip within the right brachiocephalic artery at the origin of the right\n subclavian artery.\n 2. No evidence of signficant organizing hematoma in this location.\n 2. Findings of CHF, with mild pulmonary edema.\n\n COMMENT: These findings concerning the aberrant arterial placement of this\n catheter were discussed with Dr. (Cardiology service) by Dr. ,\n at 1200H, and again by Dr. , at 1230H, , who conveyed information\n regarding the traversal of the right internal jugular vein.\n\n"},{"category":"Radiology","chartdate":"2193-12-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1173646,"text":" 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for collapse/ effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p cabg with dropping sats\n REASON FOR THIS EXAMINATION:\n eval for collapse/ effusion\n ______________________________________________________________________________\n WET READ: JMGw SAT 7:29 PM\n increased bilateral pulmonary markings concerning for new pulmonary edema.\n small left effusion. stable appearance to support lines.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, dropping saturation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is an increase in\n bilateral radiodensity of the lungs, predominantly caused by bilateral\n pulmonary markings that are concerning for newly occurred pulmonary edema.\n Unchanged small retrocardiac atelectasis. Unchanged monitoring and support\n devices. No focal parenchymal opacities suggesting pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1172797,"text":" 7:51 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: 82 year old woman with NSTEMI and cardiogenic shock. Intubat\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with NSTEMI and cardiogenic shock. Intubated. Eval for\n change.\n REASON FOR THIS EXAMINATION:\n 82 year old woman with NSTEMI and cardiogenic shock. Intubated. Eval for\n change.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Heart attack, cardiogenic shock.\n\n CHEST: There has been some change in distribution of fluid with some clearing\n of the left side but increased opacifications on the right suggesting\n unchanged degree of pulmonary edema.\n\n IMPRESSION: Failure persists.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1173466,"text":" 12:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with open chest s/p CABG/carotid repair\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 01:26 P.M., \n\n HISTORY: Open chest following CABG and carotid repair. Evaluate for pleural\n effusions.\n\n IMPRESSION: AP chest compared to through 20:\n\n Hazy opacification projecting over the right lower lung is probably residual\n edema. If there is any pleural effusion it is minimal. The upper mediastinum\n has been stably widened postoperatively. Left lung is clear. No\n pneumothorax. ET tube and Swan-Ganz catheter and intra-aortic balloon pump\n are in standard placements. Nasogastric tube would need to be advanced 5 cm\n to move all the side ports into the stomach.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1172895,"text":" 10:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Location\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with PA catheter, pulled back 6-7 cm\n REASON FOR THIS EXAMINATION:\n Location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PA catheter, pulled back 6-7 mm.\n\n COMPARISON: , 9:48 p.m.\n\n FINDINGS: As compared to the previous radiograph, the pulmonary artery\n catheter has been pulled back by approximately 6 cm. The tip now projects\n over the outflow tract of the right ventricle. The other monitoring and\n support devices are unchanged. Unchanged appearance of the lung parenchyma\n and the cardiac silhouette.\n\n\n"},{"category":"Radiology","chartdate":"2193-12-30 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1173783,"text":" 8:37 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: assess for stone\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n assess for stone\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, assess for stone.\n\n COMPARISON: None.\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n FINDINGS: The examination is markedly limited by patient body habitus and\n inability to position as well as bandage material. There is no gross evidence\n of intra- or extra-hepatic biliary dilation. The common hepatic duct measures\n 4 mm. The portal vein is patent with flow in the appropriate direction. The\n gallbladder is moderately distended. There is gallbladder wall edema. No\n gallstones are identified and there is no evidence of pericholecystic fluid.\n Kidneys are echogenic. Right kidney measures 10.4 cm. Left kidney was\n difficult to visualize due to positioning. The spleen was also not adequately\n visualized due to positioning and bowel gas.\n\n IMPRESSION:\n 1. Markedly limited study. Distended and edematous gallbladder without\n gallstones. Gallbladder wall edema may result from a number of factors\n including congestive heart failure, hypoalbuminemia, but acalculous\n cholecystitis cannot be excluded by the ultrasound findings. If clinical\n suspicion warrants, then HIDA is recommended for further assessment. A page\n was sent to at 11:17 a.m. on to discuss these\n findings and results were discussed at 12:08 PM.\n 2. Echogenic appearance of the right kidney suggestive of medical renal\n disease. Left kidney poorly visualized.\n\n\n"},{"category":"Echo","chartdate":"2193-12-30 00:00:00.000","description":"Report","row_id":92218,"text":"PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery. Left ventricular function. ?pericardial effusion. Pressor dependent.\nHeight: (in) 65\nWeight (lb): 180\nBSA (m2): 1.89 m2\nBP (mm Hg): 124/71\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 18:12\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Good RAA ejection velocity (>20cm/s). Dynamic\ninteratrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No glycopyrrolate was\nadministered. The rhythm appears to be atrial fibrillation. MD caring for the\npatient was notified of the echocardiographic results by e-mail.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. Right atrial appendage ejection velocity is good (>20 cm/s). 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 simple atheroma in the descending\nthoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Preserved biventricular global systolic function. Mild mitral\nregurgitation. Mild aortic regurgitation. Mild-moderate tricuspid\nregurgitation.\n\n\n"},{"category":"Echo","chartdate":"2193-12-29 00:00:00.000","description":"Report","row_id":92219,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. ?tamponade.\nHeight: (in) 65\nWeight (lb): 180\nBSA (m2): 1.89 m2\nBP (mm Hg): 100/60\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 13:43\nTest: Portable TTE (Focused views)\nDoppler: Limited 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 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.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\nmotion/position.\n\nAORTIC VALVE: Aortic valve not well seen. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. [Due to acoustic\nshadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mild to moderate [+] TR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nLeft ventricular 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. Right ventricular chamber size and free\nwall motion are normal. There is abnormal septal motion/position. Mild (1+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nNo mitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] There is an\nanterior space which most likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality.Mild aortic regurgitation. Preserved\nglobal biventricular systolic function. No significant pericardial effusion\nidentified.\nCompared with the prior study (images reviewed) of \n\n\n"},{"category":"Echo","chartdate":"2193-12-24 00:00:00.000","description":"Report","row_id":92220,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease.\nHeight: (in) 64\nWeight (lb): 192\nBSA (m2): 1.92 m2\nBP (mm Hg): 108/53\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 10:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n Fagenholz, fellow did study\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic 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. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). There\nis no ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets are moderately thickened. There\nis mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\nCalcific aortic valve disease with mild stenosis/mild regurgbitation. Mild\nmitral regurgitation. Mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , anterior\nhypokinesis is no longer appreciated (prior study technically-suboptimal).\n\n\n"},{"category":"Echo","chartdate":"2193-12-22 00:00:00.000","description":"Report","row_id":92221,"text":"PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Murmur. Myocardial infarction. Preoperative assessment. Shortness of breath.\nHeight: (in) 63\nWeight (lb): 189\nBSA (m2): 1.89 m2\nBP (mm Hg): 118/74\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 20:43\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Cannot exclude AS. Trace\nAR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Mild functional MS due to MAC. Trivial MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\n\nConclusions:\nThe left atrium is normal in size. The left atrium is elongated. No atrial\nseptal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. There is mild regional left\nventricular systolic dysfunction with anterior hypokinesis. The remaining\nsegments appear to contract normally, though images are suboptimal (LVEF =\n40%). The right ventricular cavity is mildly dilated with normal free wall\ncontractility. The aortic valve leaflets are mildly thickened (?#). The study\nis inadequate to exclude significant aortic valve stenosis. Trace aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nThere is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral\nannular calcification. Trivial 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. There is an anterior space which most likely\nrepresents a prominent fat pad.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.\nCannot exclude hemodynamically-significant aortic stenosis. Moderate pulmonary\nhypertension.\n\n\n"},{"category":"ECG","chartdate":"2193-12-29 00:00:00.000","description":"Report","row_id":256498,"text":"Atrial fibrillation with a controlled ventricular response. Low limb lead\nvoltage. Since the previous tracing of the rhythm is now probably\natrial fibrillation.\n\n"},{"category":"ECG","chartdate":"2193-12-27 00:00:00.000","description":"Report","row_id":256499,"text":"Sinus rhythm with prolonged P-R interval. Non-specific ST-T wave changes.\nCompared to tracing #1 the rhythm is clearly sinus with the long P-R interval.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2193-12-26 00:00:00.000","description":"Report","row_id":256720,"text":"Sinus rhythm with A-V conduction delay. Left atrial abnormality. Modest\nST-T wave abnormalities with borderline prolonged QTc interval are\nnon-specific but cannot exclude drug/electrolyte/metabolic effect or possible\nischemia. Clinical correlation is suggested. Since the previous tracing\nof the rate is slower and ST-T wave abnormalities have decreased.\n\n"},{"category":"ECG","chartdate":"2193-12-25 00:00:00.000","description":"Report","row_id":256721,"text":"Sinus rhythm. Borderline P-R interval prolongation. ST-T wave abnormalities.\nSince the previous tracing of there is probably no significant change.\n\n\n"},{"category":"ECG","chartdate":"2193-12-24 00:00:00.000","description":"Report","row_id":256722,"text":"Sinus rhythm. P-R interval prolongation. ST segment depression. Since the\nprevious tracing of ST segment depression may be more prominent.\n\n"},{"category":"ECG","chartdate":"2193-12-23 00:00:00.000","description":"Report","row_id":256723,"text":"Sinus rhythm. Prolonged P-R interval. Anterolateral ST-T wave changes may be\nsecondary to myocardial ischemia. No previous tracing available for comparison.\n\n\n"},{"category":"ECG","chartdate":"2193-12-26 00:00:00.000","description":"Report","row_id":256719,"text":"Undetermined rhythm may be sinus but with slightly long P-R interval,\nectopic atrial rhythm or an accelerated junctional rhythm. P waves are seen in\nsome of the limb leads which makes it more likely that this is sinus rhythm.\nNon-specific inferolateral ST-T wave changes. Compared to the previous tracing\nof the rhythm is less clearly sinus with the long P-R on the current\ntracing. The ST-T wave changes are similar.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-23 00:00:00.000\",\n \"description\": \"P ABDOMEN (SUPINE ONLY) PORT\",\n \"row_id\": 1172807,\n \"text\": \" 9:37 AM\\n ABDOMEN (SUPINE ONLY) PORT Clip # \\n Reason: Location of balloon tip\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with IABP, ? position of balloon tip\\n REASON FOR THIS EXAMINATION:\\n Location of balloon tip\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Intra-aortic balloon pump, check position of tip.\\n\\n What appears to be the tip of the tube lies in the lower abdominal aorta at\\n the level of the interspace of L2 and L3.\\n\\n The bowel gas appears normal.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1173708,\n \"text\": \" 1:35 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for effusion\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman s/p cabg\\n REASON FOR THIS EXAMINATION:\\n eval for effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post CABG, evaluation for pleural effusion.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the lungs have improved in\\n transparency, likely reflecting improved ventilation. At the right lung base,\\n however, a subtle remnant pulmonary opacity is still visible.\\n\\n No newly occurred parenchymal opacities, no edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-24 00:00:00.000\",\n \"description\": \"O CHEST (SINGLE VIEW) IN O.R.\",\n \"row_id\": 1173004,\n \"text\": \" 2:44 PM\\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST Clip # \\n Reason: RT JUGULAR LINE PL. UNDER FLUORO\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Jugular catheter placement under fluoroscopy.\\n\\n FINDINGS: Single image fails to show a definite jugular catheter. Further\\n information can be gathered from the operative report.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-24 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1173005,\n \"text\": \" 2:47 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: 82 Y.O. WOMAN WITH SWAN PLACED IN ARTERY, PLEASE ECALUATE FOR PNEUMO\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with Swan placed in artery, please evaluate for pneumo\\n REASON FOR THIS EXAMINATION:\\n Thanks\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest, AP portable single view.\\n\\n INDICATION: 82-year-old female patient with Swan-Ganz catheter placed in\\n artery, evaluate for pneumothorax.\\n\\n AP single view of the chest has been obtained with patient in sitting\\n semi-upright position. Comparison is made with the next preceding similar\\n study dated . Previously described Swan-Ganz catheter,\\n approached from below, has been withdrawn. A new right internal jugular\\n approach sheath is identified, seen to terminate in the upper right-sided\\n mediastinum corresponding to the area of the right jugular/subclavian venous\\n junction. No pneumothorax has developed, and in comparison with the previous\\n chest, no significantly increased width of the superior mediastinum is noted.\\n Previously identified intra-aortic balloon pump device remains in unchanged\\n position. Central pulmonary edema slightly improved. No new pulmonary\\n infiltrates are seen, and the lateral pleural sinuses remain free. Heart size\\n as before moderately enlarged and typical dense mitral ring calcification is\\n observed.\\n\\n IMPRESSION: No evidence of pneumothorax or significant superior mediastinal\\n hematoma following unintended arterial stick.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-24 00:00:00.000\",\n \"description\": \"CAROTID LMTD/ DPP\",\n \"row_id\": 1173023,\n \"text\": \" 4:24 PM\\n CAROTID LMTD/ DPP Clip # \\n Reason: Please evaluate for placement of the cannula, ? carotid\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with cannulization of brachiocephalic, ? via carotid.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for placement of the cannula, ? carotid\\n ______________________________________________________________________________\\n WET READ: SPfc 5:21 PM\\n nonvisualization of the intraluminal course, if any, of the right neck\\n catheter.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Placement of a catheter into the arterial system with question\\n of carotid versus brachiocephalic position.\\n\\n COMPARISON: Chest radiograph from \\n\\n FINDINGS: Targeted son is performed in the right supraclavicular\\n tissues, at the site of catheter exit from the skin. At this level, note is\\n made of a structure with posterior acoustic shadowing in the subcutaneous soft\\n tissues, presumably related to the superficial component of the catheter. Due\\n to limited acoustic windows, the intraluminal course of the catheter, if any,\\n is not visualized on the current study. Note is made of a trace amount of\\n atherosclerotic disease in the carotid artery.\\n\\n IMPRESSION: Nonvisualization of the intraluminal portion of the catheter, if\\n any. If further confirmation is required, would recommend direct contrast\\n injection under fluoroscopy.\\n\\n Results discussed via telephone with Dr. by Dr. at\\n 17:15 on \\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1172738,\n \"text\": \" 7:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for acute process and balloon pump location.\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with cardiogenic shock, intubated and w/ ballon pump. Eval\\n for acute process and balloon pump location.\\n REASON FOR THIS EXAMINATION:\\n Eval for acute process and balloon pump location.\\n ______________________________________________________________________________\\n WET READ: NATg 8:54 PM\\n Right groin S-G catheter is in right PA. Aortic balloon pump tip is 5cm from\\n arch. ETT 3cm from carina. Left IJ at confluence of svc and left\\n brachiocephalic v. There is bilateral atelectasis and pulmonary edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Cardiogenic shock, intubated with balloon pump.\\n\\n CHEST:\\n\\n The tip of the Swan-Ganz catheter lies in the right pulmonary artery. The\\n aortic balloon tip lies 5 cm from the aortic arch which shows some unwinding.\\n The endotracheal tube lies 3 cm from the carinal angle. The tip of the left\\n IJ line lies at the junction of the left brachiocephalic and SVC.\\n\\n Bilateral interstitial edema is present.\\n\\n The tip of the nasogastric tube and the side hole lie within the stomach.\\n\\n IMPRESSION:\\n Support tubes and lines as described. Pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1173076,\n \"text\": \" 7:17 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: tubes, lines, interval change\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with nstemi, intubated sedated for resp failure\\n REASON FOR THIS EXAMINATION:\\n tubes, lines, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post NSTEMI, intubated for respiratory failure.\\n\\n COMPARISON: Chest radiograph from .\\n\\n FINDINGS: The right large-bore sheath ends over the right superior\\n mediastinum; there is no evidence of bleeding adjacent to the catheter tip.\\n The ET tube ends 4.5 cm above the carina. The intra-aortic balloon pump tip\\n is midway between the upper margin of the left main bronchus and apex of the\\n aortic arch. The NG tube ends within the stomach. Mild pulmonary edema has\\n minimally improved. Right lower lung atelectasis is increased and left\\n basilar atelectasis is unchanged. There is no pneumothorax. Dense\\n calcification of the mitral annulus is unchanged.\\n\\n IMPRESSION:\\n 1. Right large bore sheath ending over the right superior mediastinum. No\\n evidence of adjacent bleeding.\\n 2. Increased right lower lung atelectasis and unchanged left lower lung\\n atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1173246,\n \"text\": \" 7:51 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with NSTEMI, resp failure\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of the patient with non-ST elevation MI.\\n\\n Portable AP chest radiograph was compared to prior study obtained on , .\\n\\n The NG tube tip is now at the gastroesophageal junction with the sidehole in\\n the mid esophagus and should be repositioned. The ET tube tip is obscured by\\n the NG tube tip and most likely is in an appropriate position. The right\\n internal jugular line is appropriate. Cardiomediastinal silhouette is stable.\\n Intra-aortic balloon pump is approximately 4.5 cm below the superior margin of\\n the aortic arch. The left retrocardiac opacity is unchanged.\\n\\n Widespread parenchymal opacities are redemonstrated, unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-25 00:00:00.000\",\n \"description\": \"CT NECK W/O CONTRAST (EG: PAROTIDS)\",\n \"row_id\": 1173106,\n \"text\": \", 10:28 AM\\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \\n Reason: please eval neck down to carina to look at aortic arch archi\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with multivessel CAD, swan incidentally floated in carotid.\\n Aortic balloon in place.\\n REASON FOR THIS EXAMINATION:\\n please eval neck down to carina to look at aortic arch architecture\\n CONTRAINDICATIONS for IV CONTRAST:\\n ARF\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Right Swan-Ganz sheath seen traversing the external jugular and internal\\n jugular with the tip within the right brachiocephalic at the location where\\n the right subclavian originates. There is no evidence of organizing hematoma\\n in this location.\\n 2. Constellation of findings suggestive of congestive heart failure.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1172893,\n \"text\": \" 9:27 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: Tip of Swan\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with shock, Swan-Ganz catheter\\n REASON FOR THIS EXAMINATION:\\n Tip of Swan\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Swan-Ganz catheter.\\n\\n COMPARISON: , 8:29 a.m.\\n\\n FINDINGS: As compared to the previous radiograph, the tip of the Swan-Ganz\\n catheter is still located distally in the right pulmonary artery. The tip\\n should be pulled back by approximately 6 cm. The other monitoring and support\\n devices are unchanged. The pre-existing right parenchymal opacities have\\n decreased in extent. Unchanged size of the cardiac silhouette.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1173393,\n \"text\": \" 10:15 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: s/p CABG w/dropping PO2 r/o effusion\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with as above\\n REASON FOR THIS EXAMINATION:\\n s/p CABG w/dropping PO2 r/o effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CABG with dropping pO2.\\n\\n FINDINGS: In comparison with the study of , there is little overall\\n change in the appearance of the heart and lungs. Monitoring and support\\n devices remain in place. Some continued widening of the upper mediastinum is\\n again seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2194-01-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1174078,\n \"text\": \" 7:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p CABG w/elevated INR and decreased SpO2 r/o collapse\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with as above\\n REASON FOR THIS EXAMINATION:\\n s/p CABG w/elevated INR and decreased SpO2 r/o collapse\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post CABG, elevated INR, decreased oxygen saturation.\\n\\n COMPARISON: multiple prior radiographs.\\n\\n FINDINGS: Since the prior study, endotracheal tube has advanced distally with\\n its tip now at the carina. Numerous other monitoring and support devices are\\n stable including a left internal jugular Swan-Ganz catheter and orogastric\\n tube and three chest tubes. Diffuse bilateral pulmonary markings are still\\n present in both lungs consistent with elevated pulmonary venous pressure.\\n\\n IMPRESSION: Endotracheal tube at the carina which is advanced since prior\\n study. Tube should be pulled back by 4 cm for optimal positioning. This\\n finding was communicated with on CC7 at 10 a.m. on .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-26 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1173376,\n \"text\": \" 6:46 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: CARDIAC SURGERY. Pleural effusion, pulmonary edema, tamponad\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with CABG\\n REASON FOR THIS EXAMINATION:\\n CARDIAC SURGERY. Pleural effusion, pulmonary edema, tamponade, pneumothorax.\\n ______________________________________________________________________________\\n WET READ: 8:23 PM\\n NGT in stomach. ETT 1.6 cm above carina, pls retract at least 2 cm. New\\n Swan-Ganz in prox RPA, mediastinal and drains. Low lung vols w/o PTX.\\n Bibasilar opacities L>R, likely atelectasis, cannot r/o infx. Prominent\\n mediastinum - likely projectional, pls correlate clinically for possible\\n hematoma formation. Mitral annular Ca.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: CABG.\\n\\n FINDINGS: In comparison with study of , the endotracheal tube tip lies\\n only 1.6 cm above the carina and should be pulled back about 2 cm. New\\n Swan-Ganz catheter from the left IJ approach extends to the right pulmonary\\n artery. Nasogastric tube tip is in the upper stomach, though the side hole is\\n within the distal esophagus. Left chest tube is in place and there is no\\n evidence of pneumothorax. Mild bibasilar atelectasis is seen. Prominence of\\n the mediastinum most likely represents post-surgical change, though this\\n should be correlated clinically to assess for possible hematoma formation.\\n Dense calcification of the mitral annulus persists.\\n\\n This information was discussed with Dr. by the resident on call.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-25 00:00:00.000\",\n \"description\": \"CT NECK W/O CONTRAST (EG: PAROTIDS)\",\n \"row_id\": 1173105,\n \"text\": \" 10:28 AM\\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \\n Reason: please eval neck down to carina to look at aortic arch archi\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with multivessel CAD, swan incidentally floated in carotid.\\n Aortic balloon in place.\\n REASON FOR THIS EXAMINATION:\\n please eval neck down to carina to look at aortic arch architecture\\n CONTRAINDICATIONS for IV CONTRAST:\\n ARF\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SZm WED 8:32 PM\\n 1. Right Swan-Ganz sheath seen traversing the external jugular and internal\\n jugular with the tip within the right brachiocephalic at the location where\\n the right subclavian originates. There is no evidence of organizing hematoma\\n in this location.\\n 2. Constellation of findings suggestive of congestive heart failure.\\n\\n\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 82-year-old female with multivessel CAD and Swan incidentally\\n forced into the carotid.\\n\\n COMPARISON: Portable chest x-ray from .\\n\\n TECHNIQUE: CT of the neck done without contrast due to the patient's renal\\n insufficiency.\\n\\n FINDINGS: A Cordis-type central venous access introducer sheath traverses the\\n right external jugular and right internal jugular veins, following an\\n oblique-inferior course with its tip at the take-off of the right subclavian\\n from the brachiocephalic artery. There is an approximately 9-mm fascial\\n interval between the right IJ venous exit and the brachiocephalic arterial\\n entry site. There is no evidence of organizing hematoma in the region, at\\n either the skin entry or the site where the sheath traverses the internal\\n jugular vein. Extravasation cannot be assessed in the absence of intravenous\\n contrast.\\n\\n An endotracheal tube has its tip 2.8 cm from the carina. The tip of the\\n oro-enteric tube is not included in the imaging volume.\\n\\n There are bilateral pleural effusions, right greater than left and pleural\\n seen in the oblique fissures bilaterally. There is thickening of the\\n interlobular septae and ground-glass opacities consistent with pulmonary\\n edema. Evaluation of cervical lymph chain demonstrates no lymphadenopathy by\\n imaging criteria. There are several nodules seen within the thyroid gland,\\n the largest measuring 1.3 cm in the lower pole of its left lobe. There are\\n multilevel degenerative changes of the spine seen with near-complete loss of\\n disc space height between C2 and C3 as well as loss of disc space height\\n between C4 and C5. There is no evidence of fracture.\\n (Over)\\n\\n 10:28 AM\\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \\n Reason: please eval neck down to carina to look at aortic arch archi\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n IMPRESSION:\\n 1. Aberrant placement of the right-sided central venous introducer sheath,\\n which traverses both the external jugular and internal jugular veins, with its\\n tip within the right brachiocephalic artery at the origin of the right\\n subclavian artery.\\n 2. No evidence of signficant organizing hematoma in this location.\\n 2. Findings of CHF, with mild pulmonary edema.\\n\\n COMMENT: These findings concerning the aberrant arterial placement of this\\n catheter were discussed with Dr. (Cardiology service) by Dr. ,\\n at 1200H, and again by Dr. , at 1230H, , who conveyed information\\n regarding the traversal of the right internal jugular vein.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1173646,\n \"text\": \" 7:06 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for collapse/ effusion\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman s/p cabg with dropping sats\\n REASON FOR THIS EXAMINATION:\\n eval for collapse/ effusion\\n ______________________________________________________________________________\\n WET READ: JMGw SAT 7:29 PM\\n increased bilateral pulmonary markings concerning for new pulmonary edema.\\n small left effusion. stable appearance to support lines.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post CABG, dropping saturation.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is an increase in\\n bilateral radiodensity of the lungs, predominantly caused by bilateral\\n pulmonary markings that are concerning for newly occurred pulmonary edema.\\n Unchanged small retrocardiac atelectasis. Unchanged monitoring and support\\n devices. No focal parenchymal opacities suggesting pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1172797,\n \"text\": \" 7:51 AM\\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: 82 year old woman with NSTEMI and cardiogenic shock. Intubat\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with NSTEMI and cardiogenic shock. Intubated. Eval for\\n change.\\n REASON FOR THIS EXAMINATION:\\n 82 year old woman with NSTEMI and cardiogenic shock. Intubated. Eval for\\n change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Heart attack, cardiogenic shock.\\n\\n CHEST: There has been some change in distribution of fluid with some clearing\\n of the left side but increased opacifications on the right suggesting\\n unchanged degree of pulmonary edema.\\n\\n IMPRESSION: Failure persists.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1173466,\n \"text\": \" 12:42 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for pleural effusions\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with open chest s/p CABG/carotid repair\\n REASON FOR THIS EXAMINATION:\\n eval for pleural effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 01:26 P.M., \\n\\n HISTORY: Open chest following CABG and carotid repair. Evaluate for pleural\\n effusions.\\n\\n IMPRESSION: AP chest compared to through 20:\\n\\n Hazy opacification projecting over the right lower lung is probably residual\\n edema. If there is any pleural effusion it is minimal. The upper mediastinum\\n has been stably widened postoperatively. Left lung is clear. No\\n pneumothorax. ET tube and Swan-Ganz catheter and intra-aortic balloon pump\\n are in standard placements. Nasogastric tube would need to be advanced 5 cm\\n to move all the side ports into the stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1172895,\n \"text\": \" 10:22 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: Location\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with PA catheter, pulled back 6-7 cm\\n REASON FOR THIS EXAMINATION:\\n Location\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: PA catheter, pulled back 6-7 mm.\\n\\n COMPARISON: , 9:48 p.m.\\n\\n FINDINGS: As compared to the previous radiograph, the pulmonary artery\\n catheter has been pulled back by approximately 6 cm. The tip now projects\\n over the outflow tract of the right ventricle. The other monitoring and\\n support devices are unchanged. Unchanged appearance of the lung parenchyma\\n and the cardiac silhouette.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2193-12-30 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1173783,\n \"text\": \" 8:37 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: assess for stone\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman s/p cabg\\n REASON FOR THIS EXAMINATION:\\n assess for stone\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post CABG, assess for stone.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Right upper quadrant ultrasound.\\n\\n FINDINGS: The examination is markedly limited by patient body habitus and\\n inability to position as well as bandage material. There is no gross evidence\\n of intra- or extra-hepatic biliary dilation. The common hepatic duct measures\\n 4 mm. The portal vein is patent with flow in the appropriate direction. The\\n gallbladder is moderately distended. There is gallbladder wall edema. No\\n gallstones are identified and there is no evidence of pericholecystic fluid.\\n Kidneys are echogenic. Right kidney measures 10.4 cm. Left kidney was\\n difficult to visualize due to positioning. The spleen was also not adequately\\n visualized due to positioning and bowel gas.\\n\\n IMPRESSION:\\n 1. Markedly limited study. Distended and edematous gallbladder without\\n gallstones. Gallbladder wall edema may result from a number of factors\\n including congestive heart failure, hypoalbuminemia, but acalculous\\n cholecystitis cannot be excluded by the ultrasound findings. If clinical\\n suspicion warrants, then HIDA is recommended for further assessment. A page\\n was sent to at 11:17 a.m. on to discuss these\\n findings and results were discussed at 12:08 PM.\\n 2. Echogenic appearance of the right kidney suggestive of medical renal\\n disease. Left kidney poorly visualized.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2193-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 92218,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: H/O cardiac surgery. Left ventricular function. ?pericardial effusion. Pressor dependent.\\nHeight: (in) 65\\nWeight (lb): 180\\nBSA (m2): 1.89 m2\\nBP (mm Hg): 124/71\\nHR (bpm): 90\\nStatus: Inpatient\\nDate/Time: at 18:12\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\\nand extending into the RV. Good RAA ejection velocity (>20cm/s). Dynamic\\ninteratrial septum. No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Simple atheroma in descending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was monitored\\nby a nurse throughout the procedure. The patient was under\\ngeneral anesthesia throughout the procedure. No glycopyrrolate was\\nadministered. The rhythm appears to be atrial fibrillation. MD caring for the\\npatient was notified of the echocardiographic results by e-mail.\\n\\nConclusions:\\nNo spontaneous echo contrast or thrombus is seen in the body of the left\\natrium/left atrial appendage or the body of the right atrium/right atrial\\nappendage. Right atrial appendage ejection velocity is good (>20 cm/s). 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 simple atheroma in the descending\\nthoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+)\\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion.\\n\\nIMPRESSION: Preserved biventricular global systolic function. Mild mitral\\nregurgitation. Mild aortic regurgitation. Mild-moderate tricuspid\\nregurgitation.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2193-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 92219,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion. ?tamponade.\\nHeight: (in) 65\\nWeight (lb): 180\\nBSA (m2): 1.89 m2\\nBP (mm Hg): 100/60\\nHR (bpm): 70\\nStatus: Inpatient\\nDate/Time: at 13:43\\nTest: Portable TTE (Focused views)\\nDoppler: Limited 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 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.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\\nmotion/position.\\n\\nAORTIC VALVE: Aortic valve not well seen. Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. [Due to acoustic\\nshadowing, the severity of MR may be significantly UNDERestimated.]\\n\\nTRICUSPID VALVE: Mild to moderate [+] TR.\\n\\nPERICARDIUM: There is an anterior space which most likely represents a fat\\npad, though a loculated anterior pericardial effusion cannot be excluded.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\\nstudy performed by the cardiology fellow on call. Results were personally\\nreviewed with the MD caring for the patient.\\n\\nConclusions:\\nLeft ventricular 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. Right ventricular chamber size and free\\nwall motion are normal. There is abnormal septal motion/position. Mild (1+)\\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\\nNo mitral regurgitation is seen. [Due to acoustic shadowing, the severity of\\nmitral regurgitation may be significantly UNDERestimated.] There is an\\nanterior space which most likely represents a prominent fat pad.\\n\\nIMPRESSION: Suboptimal image quality.Mild aortic regurgitation. Preserved\\nglobal biventricular systolic function. No significant pericardial effusion\\nidentified.\\nCompared with the prior study (images reviewed) of \\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2193-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 92220,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. Coronary artery disease.\\nHeight: (in) 64\\nWeight (lb): 192\\nBSA (m2): 1.92 m2\\nBP (mm Hg): 108/53\\nHR (bpm): 72\\nStatus: Inpatient\\nDate/Time: at 10:58\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\n Fagenholz, fellow did study\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\\nand extending into the RV.\\n\\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\\n(>55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\\n1.2-1.9cm2). Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\\nsystolic 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. Regional left ventricular wall motion is\\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). There\\nis no ventricular septal defect. Right ventricular chamber size and free wall\\nmotion are normal. The aortic valve leaflets are moderately thickened. There\\nis mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic\\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\\n(1+) mitral regurgitation is seen. There is mild pulmonary artery systolic\\nhypertension. There is no pericardial effusion.\\n\\nIMPRESSION: Normal global and regional biventricular systolic function.\\nCalcific aortic valve disease with mild stenosis/mild regurgbitation. Mild\\nmitral regurgitation. Mild pulmonary hypertension.\\n\\nCompared with the prior study (images reviewed) of , anterior\\nhypokinesis is no longer appreciated (prior study technically-suboptimal).\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2193-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 92221,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Murmur. Myocardial infarction. Preoperative assessment. Shortness of breath.\\nHeight: (in) 63\\nWeight (lb): 189\\nBSA (m2): 1.89 m2\\nBP (mm Hg): 118/74\\nHR (bpm): 74\\nStatus: Inpatient\\nDate/Time: at 20:43\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size. Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\\nsystolic dysfunction. No resting LVOT gradient.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\\n- hypo; mid anterior - hypo;\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Cannot exclude AS. Trace\\nAR.\\n\\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\\nannular calcification. Mild functional MS due to MAC. Trivial MR. [Due to\\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\\nTR. Moderate PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\\nlikely represents a fat pad, though a loculated anterior pericardial effusion\\ncannot be excluded.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\\n\\nConclusions:\\nThe left atrium is normal in size. The left atrium is elongated. No atrial\\nseptal defect is seen by 2D or color Doppler. Left ventricular wall\\nthicknesses and cavity size are normal. There is mild regional left\\nventricular systolic dysfunction with anterior hypokinesis. The remaining\\nsegments appear to contract normally, though images are suboptimal (LVEF =\\n40%). The right ventricular cavity is mildly dilated with normal free wall\\ncontractility. The aortic valve leaflets are mildly thickened (?#). The study\\nis inadequate to exclude significant aortic valve stenosis. Trace aortic\\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\\nThere is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral\\nannular calcification. Trivial 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. There is an anterior space which most likely\\nrepresents a prominent fat pad.\\n\\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.\\nCannot exclude hemodynamically-significant aortic stenosis. Moderate pulmonary\\nhypertension.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 256498,\n \"text\": \"Atrial fibrillation with a controlled ventricular response. Low limb lead\\nvoltage. Since the previous tracing of the rhythm is now probably\\natrial fibrillation.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 256499,\n \"text\": \"Sinus rhythm with prolonged P-R interval. Non-specific ST-T wave changes.\\nCompared to tracing #1 the rhythm is clearly sinus with the long P-R interval.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 256720,\n \"text\": \"Sinus rhythm with A-V conduction delay. Left atrial abnormality. Modest\\nST-T wave abnormalities with borderline prolonged QTc interval are\\nnon-specific but cannot exclude drug/electrolyte/metabolic effect or possible\\nischemia. Clinical correlation is suggested. Since the previous tracing\\nof the rate is slower and ST-T wave abnormalities have decreased.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 256721,\n \"text\": \"Sinus rhythm. Borderline P-R interval prolongation. ST-T wave abnormalities.\\nSince the previous tracing of there is probably no significant change.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 256722,\n \"text\": \"Sinus rhythm. P-R interval prolongation. ST segment depression. Since the\\nprevious tracing of ST segment depression may be more prominent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 256723,\n \"text\": \"Sinus rhythm. Prolonged P-R interval. Anterolateral ST-T wave changes may be\\nsecondary to myocardial ischemia. No previous tracing available for comparison.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2193-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 256719,\n \"text\": \"Undetermined rhythm may be sinus but with slightly long P-R interval,\\nectopic atrial rhythm or an accelerated junctional rhythm. P waves are seen in\\nsome of the limb leads which makes it more likely that this is sinus rhythm.\\nNon-specific inferolateral ST-T wave changes. Compared to the previous tracing\\nof the rhythm is less clearly sinus with the long P-R on the current\\ntracing. The ST-T wave changes are similar.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":773,"cells":{"subject_id":{"kind":"number","value":56872,"string":"56,872"},"hadm_id":{"kind":"number","value":187216,"string":"187,216"},"target_text":{"kind":"string","value":"The patient was admitted to the hospital and underwent a flexible bronchoscopy which showed small/ moderate granulation tissue/ridge in proximal trachea anterior wall with severe cervical malacia proximal to the trach tube with complete dynamic collapse. She underwent exchange trach cannulation and was capped with no significant result in the immediate period. She was saturating well and had no major issues and was without stridor. . On telemetry on at around 6pm, she was noted to become bradycardic for about 45 seconds down to the 30s. MD was immediately aware and entered the room to notice her cyanotic and minimally responsive. At this time, her pulses were weak and she was notably hypoxic and without spontaneous respirations. She was minimally arousable to sternal rub. A code blue was initiated. Her trach was immediately uncapped and her airway was suctioned vigorously with good response. Her ABG was notable for mild respiratory acidosis consistent with respiratory failure. She responded well to positive pressure ventilation and was brought to the MICU for further intensive monitoring. She regained mental status. . MICU course: This is an 81 y/o woman with PMH notable for Parkinson's disease and C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia admitted to MICU after PEA arrest on the floor. . # Respiratory distress: Patient was noted to be apneic on the floor prior to PEA arrest. Likely related to mucous plugging but patient reportedly had dinner so could be related to aspiration. Per notes from Rehab was eating a soft diet there with thin liquids. Do not feel that there is evidence of new pneumonia at this time (no WBC elevation, no fever); will continue to monitor for signs/symptoms of infection. CXR with LLL opacity consistant with resolving mucous plugging - npo for now, consider soft diet after stable on trach mask - weaned off ventilation, now on TM at 40% - continue to monitor closely and suction prn - IP team to see today to decide dispo ?????? d/w IP team pt to go to floor - continue albuterol/atrovent nebs with mucomyst nebs - further trach interventions (i.e., rigid bronch) per IP team -CXR tomorrow to eval change in LLL opacity ?????? persistent LLL opacity, c/w atelectasis, PA and lateral may be better to assess -blood gas this AM to better assess pulmonary status in presence of increased CO2 . # s/p PEA arrest: Likely related to hypoxia secondary to the above. Telemetry monitoring during time of event appears to have artifact (versus VT but out of sync on 2 leads so this is unlikely) followed by bradycardia. Artifact could represent chest compressions and no other telemetry strips printed from time of event. Cardiac enzymes sent peri-code negative and ekg is unchanged from prior. - repeat EKG without any new changes - cardiac enzymes neg x2 hrs apart, no need for 3rd set. - monitor respiratory status closely as above . # Osteoporosis: Continue calcium and vitamin D. . # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and entacapone (the last two ordered non-formulary) . # FEN: npo for now while on positive pressure ventilation, soft diet with thick nectar liquids when back on trach collar/cap, replete lytes prn . # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care . ______________________________________________________________ After her MICU course, the patient was stable and received a T-Tube on which she tolerated well. There were some proximal narrowing points found on her bronchoscopy, so the patient was left uncapped with a PM valve intermittently. She tolerated this well. She then subsequently was admitted to the SICU on for increased secretions and was discharged to the floor on after aggressive suctioning. Throughout the rest of her stay, she continued uncapped with intermittent PM valve utilization for speaking, and was noted to have some minor breath stacking when her PM was placed for long periods. Therefore, it was deemed that she was not a strong candidate for capping completely. She is, however, a good candidate for intermittent usage of PM for vocalization. She underwent diagnostic/therapeutic bronchoscopy on and mucus was cleared from her airways. She tolerated the procedure well and was brought to the floor, again uncapped, because of upper airway edema. Therefore, we are sending her out on steriods for a few more days. She is able to suction herself and maintain her airway with the t-tube uncapped."},"extractive_notes_summ":{"kind":"string","value":"Possible to floor today .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: CXR: rotated, sig kyphosis, partial LLL collapse, ECG--atrial ectopy and freq PACs, sinus rhythm, no acute ischemic changes ISSUES: * s/p PEA arrest presumably from mucus plugging * TBM * Parkinsons ds Agree with plan to transition to trach mask with close monitoring. Awake and alert, following commands, sig kyphosis, trach site clean, lungs CTA with decreased b/b BS, RR, peg site without erythema, abd benign, baseline tremor and cogwheeling Labs notable for WBC 9.5 (11)K, 30 HCT , 3.9K+ , 0.6Cr . # DISP: pending overnight monitoring, tolerating trach mask .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Gastrointestinal / Abdomen: G-tube Nutrition: Speech and Swallow eval, G-tube feeds Renal: Foley, foley placed for incontinence; will diuresis for CHF Hematology: stable Endocrine: RISS Infectious Disease: Sputum cultures today, Levo for RLL infiltrate. # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care . # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care . # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care . Possible to floor today .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Awake and alert, following commands and speaking appropriately, kyphoitc, trach site clean, lungs CTA with decreased b/b BS, RR, abd benign, baseline tremor and cogwheeling Labs notable for WBC 6.0, cr 0.5, serum CO2 34 (29). # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU team for the key portions of the services provided. IMPRESSION: New dense opacity in the right lower lobe status post bronchoscopy and tracheal T-tube change. Admitted for stridor/desats w/ when cap placed on trach. LLL opacity on previous CXR REASON FOR THIS EXAMINATION: interval change LLL FINAL REPORT STUDY: AP chest, . underwent trach change for malpositioned tube. Voltage criteriafor left ventricular hypertrophy. Sinus rhythm with occasional ventricular ectopy and occasional atrial ectopy.Non-specific inferior ST-T wave changes. BLS x1-2mins w/ trach suction. .H/O airway obstruction, Central / Upper Assessment: Action: Mucomyst nebs given Q 6. Lucency projecting over the mid thoracic spine, compatible with patient's known hiatal hernia appears similar to previous studies. 7:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for progressing ? t/c echo Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway edema; ?RLL infiltrate started on levo; Pt able to cough up secretion, self suction. # DISP: pending overnight monitoring, tolerating trach mask .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Plan to go to Rehab this AM. FINAL REPORT PORTABLE CHEST CLINICAL INFORMATION: Pneumothorax. Response: Tolerating trach mask. Flex bronch performed (no rigid bronch concern of hyperextension) showed mod granulation tissue in prox trachea ant wall w/ severe cervical malacia proximal to trach."},"n_notes":{"kind":"number","value":46,"string":"46"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2141-11-14 00:00:00.000","description":"Intensivist Note","row_id":548551,"text":"SICU\n HPI:\n ADMISSION NOTE:\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\n T-tube secretions.\n Chief complaint:\n tracheal stenosis, inct T-tube secretions\n PMHx:\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\n fusion at , Recurrent pneumonia\n Current medications:\n 24 Hour Events:\n CALLED OUT\n Post operative day:\n HD 5, POD 1 (T-tube)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:27 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.9\nC (98.5\n HR: 68 (68 - 71) bpm\n BP: 145/59(80) {142/59(80) - 145/62(84)} mmHg\n RR: 25 (12 - 25) insp/min\n SPO2: 98%\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 240 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -240 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : bilateral), (Sternum: Stable )\n Abdominal: Soft, Non-distended, G-tube\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli), Moves all extremities,\n hard of hearing, able to communicate w/ writing.\n Labs / Radiology\n 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n 02:34 PM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Creatinine\n 0.6\n 0.5\n Troponin T\n <0.01\n TCO2\n 35\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 81yo F w/ trach and tracheal stenosis who is s/p\n T-tube placement.\n Neurologic: h/o parkinson on sinemet, entacapone; Modafinil;\n Mirtazapine for depression\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \n will diuresis w/ Lasix 20mg. Plan to get 500-1000mL negative\n Pulmonary: T-tube, on trach collar. maintining saturations. Self\n suction and suction by nursing. Dexamethasone for edema. Cont atrovent\n nebs, mucomyst nebs; ?RLL infiltrate, started on Levo.\n Gastrointestinal / Abdomen: G-tube\n Nutrition: Speech and Swallow eval, G-tube feeds\n Renal: Foley, foley placed for incontinence; will diuresis for CHF\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: Sputum cultures today, Levo for RLL infiltrate.\n Lines / Tubes / Drains: Foley, T-tube\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Thoracic, Interventional Pulm\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:12 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2141-11-15 00:00:00.000","description":"Intensivist Note","row_id":548606,"text":"SICU\n HPI:\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\n T-tube secretions.\n Chief complaint:\n tracheal stenosis\n PMHx:\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\n fusion at , Recurrent pneumonia\n Current medications:\n 24 Hour Events:\n SPUTUM CULTURE - At 05:27 AM\n NASAL SWAB - At 05:29 AM\n CALLED OUT\n Post operative day:\n HD 6, POD 2 (T-tube)\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 03:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.7\nC (98\n HR: 68 (55 - 71) bpm\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\n RR: 22 (12 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 229 mL\n PO:\n Tube feeding:\n 65 mL\n IV Fluid:\n 164 mL\n Blood products:\n Total out:\n 880 mL\n 1,480 mL\n Urine:\n 880 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -1,251 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, hard of hearing, able to communicate w/ writing.\n Labs / Radiology\n 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n 02:34 PM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Creatinine\n 0.6\n 0.5\n Troponin T\n <0.01\n TCO2\n 35\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\n placement.\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\n Modafinil, Mirtazapine\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \n will diuresis. t/c echo\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\n self suction.\n Gastrointestinal / Abdomen: g-tube\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: levoquin for RLL infiltrate by team\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\n Wounds: none\n Imaging: cxr\n Fluids: KVO\n Consults: Thoracic, Interventional Pulm\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 11:08 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2141-11-15 00:00:00.000","description":"Intensivist Note","row_id":548607,"text":"SICU\n HPI:\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\n T-tube secretions.\n Chief complaint:\n tracheal stenosis\n PMHx:\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\n fusion at , Recurrent pneumonia\n Current medications:\n 24 Hour Events:\n SPUTUM CULTURE - At 05:27 AM\n NASAL SWAB - At 05:29 AM\n CALLED OUT\n Post operative day:\n HD 6, POD 2 (T-tube)\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 03:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.7\nC (98\n HR: 68 (55 - 71) bpm\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\n RR: 22 (12 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 229 mL\n PO:\n Tube feeding:\n 65 mL\n IV Fluid:\n 164 mL\n Blood products:\n Total out:\n 880 mL\n 1,480 mL\n Urine:\n 880 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -1,251 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable ). Some secretions\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, hard of hearing, able to communicate w/ writing.\n Speaking with Passemuir valve.\n Labs / Radiology\n 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n 02:34 PM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Creatinine\n 0.6\n 0.5\n Troponin T\n <0.01\n TCO2\n 35\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\n placement.\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\n Modafinil, Mirtazapine\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \n . Diuresis. t/c echo\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\n self suction.\n Gastrointestinal / Abdomen: g-tube\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: levoquin for RLL infiltrate by team\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\n Wounds: none\n Imaging: cxr\n Fluids: KVO\n Consults: Thoracic, Interventional Pulm\n Billing Diagnosis: Resp Abnormaliity\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 11:08 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2141-11-15 00:00:00.000","description":"Nursing Transfer Note","row_id":548631,"text":"81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for\n increased T-tube secretions.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Sats 99% on 50% o2 via trach mask. Able to expectorate secretions and\n suction independently with Yankauer. Tolerating Passey-muir valve. LS\n coarse at times, clears with cough.\n Action:\n Encouraged cough, deep breaths. Sputum sample sent for culture.\n Response:\n Resp status stable.\n Plan:\n continue aggressive pulm hygiene.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n AIRWAY OBSTRUCTION\n Code status:\n Full code\n Height:\n Admission weight:\n 70.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\n spinal fusion,s/p trach following that. s/p mechanical fall few months\n ago w/ C2-4 fx s/p spinal fusion/ hardware placement.Trache placed d/t\n unstable cervical spine. Admitted from rehab to floor d/t\n stridor and desats while trying to cap trache. Flex Bronch which\n revealed granulation tissue in the proximal trachea\n (tracheobroncomalacia). Trach changed from boniva to portex. on \n trach capped, pt w/ pea arrest on the floor while eating. OR\n trach tube changed to t tube and bronch.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:56\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 37 insp/min\n Heart Rate:\n 64 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 97% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 588 mL\n 24h total out:\n 1,795 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:49 AM\n Potassium:\n 3.8 mEq/L\n 04:49 AM\n Chloride:\n 100 mEq/L\n 04:49 AM\n CO2:\n 34 mEq/L\n 04:49 AM\n BUN:\n 14 mg/dL\n 04:49 AM\n Creatinine:\n 0.6 mg/dL\n 04:49 AM\n Glucose:\n 89 mg/dL\n 04:49 AM\n Hematocrit:\n 29.8 %\n 04:49 AM\n Finger Stick Glucose:\n 101\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 716\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2141-11-15 00:00:00.000","description":"Nursing Transfer Note","row_id":548614,"text":".H/O airway obstruction, Central / Upper\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2141-11-15 00:00:00.000","description":"Nursing Transfer Note","row_id":548615,"text":"81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for\n increased T-tube secretions.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Sats 99% on 50% o2 via trach mask. Able to expectorate secretions and\n suction independently with Yankauer. Tolerating Passey-muir valve. LS\n coarse at times, clears with cough.\n Action:\n Encouraged cough, deep breaths. Sputum sample sent for culture.\n Response:\n Resp status stable.\n Plan:\n continue aggressive pulm hygiene.\n"},{"category":"Nutrition","chartdate":"2141-11-15 00:00:00.000","description":"Clinical Nutrition Note","row_id":548621,"text":"Subjective: Pt is very HOH, unable to converse with her.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 163 cm\n 70.7 kg\n 26.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 54.4kg\n 130%\n 58.5kg\n Diagnosis: Airway Obstruction\n PMH : Parkinson's disease, Fall with C2-4 fracture in , s/p\n cervical fusion at , Recurrent pneumonia, h/o PEG feeding\n Food allergies and intolerances:\n Pertinent medications: Abx, others noted\n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 04:49 AM\n Glucose Finger Stick\n 101\n 10:00 AM\n BUN\n 14 mg/dL\n 04:49 AM\n Creatinine\n 0.6 mg/dL\n 04:49 AM\n Sodium\n 142 mEq/L\n 04:49 AM\n Potassium\n 3.8 mEq/L\n 04:49 AM\n Chloride\n 100 mEq/L\n 04:49 AM\n TCO2\n 34 mEq/L\n 04:49 AM\n PO2 (arterial)\n 136 mm Hg\n 02:34 PM\n PCO2 (arterial)\n 51 mm Hg\n 02:34 PM\n pH (arterial)\n 7.43 units\n 02:34 PM\n pH (urine)\n 5.0 units\n 04:44 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 02:34 PM\n Calcium non-ionized\n 9.2 mg/dL\n 04:49 AM\n Phosphorus\n 3.5 mg/dL\n 04:49 AM\n Magnesium\n 1.9 mg/dL\n 04:49 AM\n WBC\n 6.9 K/uL\n 04:49 AM\n Hgb\n 10.2 g/dL\n 04:49 AM\n Hematocrit\n 29.8 %\n 04:49 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 40cc/hr (960kcal, 60g protein)\n Diet: NPO\n GI: soft, +BS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to:\n Estimated Nutritional Needs\n Calories: 1400-1640 (BEE x or / 24-28 cal/kg)\n Protein: 58-70 (1-1.2 g/kg)\n Fluid: per team\n Specifics:\n 81 y.o. F with h/o Parkinson\ns Disease s/p mechanical with\n C2=C4 fracture, s/p spinal fusion/hardware placement with trach placed\n due to ? of unstable C-spine. Pt now adm with stridor and destatting.\n Flex bronch showed moderate granulation tissue in proximal trachea, and\n trach tube was changed for malpositioning (). Trach was capped,\n and pt went into brady/PEA arrest. Pt then had a rigid bronch and was\n changed to a T-tube (). Pt is now in ICU for the management of\n T-tube secretions. Pt has a PEG, but had been weaned off her TF at her\n care facility, and was tolerating a soft diet. But TF are now\n restarted, and pt unable to take po\ns until S/S eval can be done with\n PMV today. If pt is able to take po\ns, TF\ns might not be needed at\n this time. Will follow results of PMV/speech/swallow eval.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Until pt can take po\ns, rec TF goal of Fibersource @ 50cc/hr\n (1440kcal, 64g protein) via PEG.\n 2) S/S eval, advance diet as recommended by SLP.\n 3) Monitor lytes, hydration.\n Please page with ?\ns #\n"},{"category":"Nursing","chartdate":"2141-11-11 00:00:00.000","description":"Nursing Progress Note","row_id":548002,"text":"Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n On , the patient underwent flexible bronchoscopy which revealed\n TBM with trach malpositioned. Her trach was changed from Bovona to\n Portex 6 mm cuffed with inner cannula.\n On the evening of , the patient was doing well on the Thoracics\n floor. At about 1817, the patient was noted to have bradycardia on\n telemetry and the patient was noted to be pulseless. She was cyanotic\n and apneic at that time. Her trach cap was uncapped and she was\n suctioned with good result. She had about 1-2 minutes of chest\n compressions and no medications and regained a good femoral pulse. BP\n following this was in the 160s systolic. The patient was immediately\n more alert but not answering questions. ABG during this time was\n 7.29/64/290..\n On arrival to the ICU, the patient is alert and answering questions\n appropriately. She denies any pain. She denies any difficulty with her\n breathing.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Received the pt on 100%CPAP with RR 20-30.LS rhonchi with diminished\n base.Pt apneic frequently.\n Action:\n Put on MMV with 40%.Suctioned for thick yellow secretion.CXR revealed\n atelectasis on LLL.\n Response:\n Saturating well on the current settings.\n Plan:\n Transition to trach collar in the am,Pt uses psm valve,?decannulation\n given recent events.?c/o.\n"},{"category":"General","chartdate":"2141-11-11 00:00:00.000","description":"ICU Attending Note","row_id":547990,"text":"TITLE:\n Chart reviewed, pt examined, case discussed in detail with Dr. . I\n agree with her note and in addition would add/emphasize:\n 81F h/o Parkinson\ns dz, recurrent PNA, s/p tracheostomy at ,\n admitted from rehab after dev stridor and desat after placing cap\n on trache. FOB on notable for tracheobroncheofmalacia. \n trache changed. Post-proc on floor, brady to 40s noted on tele, pulse\n lost\n code blue called\n CPR performed, pulse rapidly returned within\n 1-2 minutes, suctioned with good result. Arrest presumed secondary to\n plugging. Transferred to MICU for close observation / care s/p\n arrest. Mental status rapidly improving. Close pulm toilet. Cont\n PSV settings for now, TM trial in morning. Cycle enzymes.\n Pt is critically ill.\n Time spent: 35min\n"},{"category":"Physician ","chartdate":"2141-11-11 00:00:00.000","description":"Physician Resident Admission Note","row_id":547994,"text":"Chief Complaint: respiratory distress, PEA arrest\n HPI:\n Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n .\n The patient was evaluated by neurosurgery on due to recent spinal\n fusion and ? of rigid bronchoscopy. Based on her recent surgery, rigid\n bronch is not indicated but the patient is apparently physically unable\n to hyperextend her neck. On , the patient underwent flexible\n bronchoscopy which revealed TBM with trach malpositioned. Her trach was\n changed from Bovona to Portex 6 mm cuffed with inner cannula by Dr.\n . She tolerated the procedure well with exception of atrial\n tachyarrhythmia intermittently.\n .\n On the evening of , the patient was doing well on the Thoracics\n floor. She was noted to be talking with her trach cap in place and had\n her dinner. At about 1817, the patient was noted to have bradycardia on\n telemetry monitoring. RN and MD personnel quickly went to the\n bedside and the patient was noted to be pulseless. She was cyanotic and\n apneic at that time. Her trach cap was uncapped and she was suctioned\n with good result. She had about 1-2 minutes of chest compressions and\n no medications and regained a good femoral pulse. BP following this was\n in the 160s systolic. The patient was immediately more alert but not\n answering questions. ABG during this time was 7.29/64/290.\n .\n On arrival to the ICU, the patient is alert and answering questions\n appropriately. She denies any pain. She denies any difficulty with her\n breathing.\n Patient admitted from: \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meds at rehab:\n acetylcysteine neb \n albuterol neb q6h\n calcium carbonate 650 mg (via peg)\n carbidopa/levodopa 37.5/150 tid (give at 0630, 1100, and 1600)\n carbodopa/levodopa 12.5/50 at 0830\n carbidopa/levodopa 37.5/150 at 1400\n vit d 1000 U daily\n cyanocobalamin 1000 mcg daily\n bisacodyl 10 mg daily prn\n mag hydroxide 30 ml once daily prn\n ambien 5 mg prn\n miconazole powder prn\n mupirocin to anterior neck \n senna 17.2 mg at bedtime\n omeprazole 20 mg \n modafinil 50 mg (0800, 1400)\n mirtazapine 30 mg at bedtime\n atrovent neb q6h\n ferrous sulfate 325 mg at bedtime (g tube)\n entacapone 200 mg at 0630, 11, 1400, 1600 (with sinemet)\n .\n MEDS on transfer:\n acetylcysteine 20% neb \n calcium carbonate 500 (given via PEG)\n vit d 800 U daily\n cyanocobalamin 1000 mcg daily\n ambien 5 mg qhs\n colace 100 mg \n omeprazole 20 mg \n hep sc tid\n sinemet 25/100, 1.5 tab tid\n albuterol inhalers prn\n Past medical history:\n Family history:\n Social History:\n * Parkinson's disease\n * Fall with C2-4 fracture in , s/p cervical fusion at \n * Recurrent pneumonia, s/p trach after difficulty weaning from vent\n after surgery\n Occupation:\n Drugs:\n Tobacco: denies\n Alcohol: denies\n Other: Recently living at Rehab.\n Review of systems:\n Flowsheet Data as of 02:00 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 (98.2\n HR: 64 (63 - 80) bpm\n BP: 124/59(73) {80/43(52) - 137/68(85)} mmHg\n RR: 13 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 250 mL\n 10 mL\n PO:\n TF:\n IVF:\n 250 mL\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n 10 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 515 (103 - 515) mL\n PS : 15 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 22 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 11 L/min\n Physical Examination\n T: 98.6 BP: 134/61 HR: 78 RR: 20 O2 100% on PS 15/5, FiO2 100%\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: coarse breath sounds bilaterally, no wheezing\n ABD: soft, PEG in place in LUQ, normoactive bowel sounds, nontender to\n palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Labs / Radiology\n 253\n 10.5\n 140\n 0.6\n 14\n 34\n 101\n 3.7\n 141\n 31.1\n 11.1\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2, CK / CKMB / Troponin-T:29 / / < 0.01,\n Lactic Acid:2.8, Ca++:9.4, Mg++:2.1, PO4:4.2\n Fluid analysis / Other labs: ABG: 7.29/64/290\n Imaging: Bronch (): superior glottis + edema, mucosal ridge seen\n in anterior tracheal wall, just below cricoid + malacia at cervical\n trachea, trach tube found Right lateral wall, distal trach/LMS with\n malacia\n .\n CXR: No pneumothorax identified. Retrocardiac opacity may represent\n left lower lobe atelectasis. Right basilar atelectasis also likely.\n ECG: ekg: sinus rhythm at 70, normal axis, t wave flattening in v4-6,\n III, avf, overall similar to prior from \n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection.\n - npo for now\n - positive pressure ventilation this evening with repeat ABG\n - transition back to trach mask, hopefully by tomorrow AM\n - continue to monitor closely and suction prn\n - IP team to see tomorrow to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg in the Am\n - cycle cardiac enzymes\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\n formulary.\n - resume home mirtazapine\n - resume home modafinil on transfer to Rehab\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending overnight monitoring, tolerating trach mask\n ICU Care\n Nutrition:\n Comments: npo for now until off ventilator\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 08:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2141-11-11 00:00:00.000","description":"Nursing Progress Note","row_id":547999,"text":"Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n On , the patient underwent flexible bronchoscopy which revealed\n TBM with trach malpositioned. Her trach was changed from Bovona to\n Portex 6 mm cuffed with inner cannula.\n On the evening of , the patient was doing well on the Thoracics\n floor. At about 1817, the patient was noted to have bradycardia on\n telemetry and the patient was noted to be pulseless. She was cyanotic\n and apneic at that time. Her trach cap was uncapped and she was\n suctioned with good result. She had about 1-2 minutes of chest\n compressions and no medications and regained a good femoral pulse. BP\n following this was in the 160s systolic. The patient was immediately\n more alert but not answering questions. ABG during this time was\n 7.29/64/290..\n On arrival to the ICU, the patient is alert and answering questions\n appropriately. She denies any pain. She denies any difficulty with her\n breathing.\n"},{"category":"Nursing","chartdate":"2141-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":548124,"text":"Events: Off vent to track mask- tolerating weel. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Likely will return as\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\n Rehab- reviewing POC and events, daughter (HCP) and family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt sating 95-100% on trach mask 40%, rec\nd pt with PMV in, tolerating\n well, A&Ox3- able to make needs known.\n Action:\n PMV taken out by respiratory for night, Close monitoring s/s\n aspiration. Sxned x2 for sm-mod. Amounts of white thick sputum. Pt\n able to raise most secretions on own, using yankuer by self.\n Response:\n Tolerating trach mask.\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n PRN. Plan to go to Rehab this AM.\n"},{"category":"Nursing","chartdate":"2141-11-11 00:00:00.000","description":"Nursing Progress Note","row_id":548034,"text":"Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n On , the patient underwent flexible bronchoscopy which revealed\n TBM with trach malpositioned. Her trach was changed from Bovona to\n Portex 6 mm cuffed with inner cannula.\n On the evening of , the patient was doing well on the Thoracics\n floor. At about 1817, the patient was noted to have bradycardia on\n telemetry and the patient was noted to be pulseless. She was cyanotic\n and apneic at that time. Her trach cap was uncapped and she was\n suctioned with good result. She had about 1-2 minutes of chest\n compressions and no medications and regained a good femoral pulse. BP\n following this was in the 160s systolic. The patient was immediately\n more alert but not answering questions. ABG during this time was\n 7.29/64/290..\n On arrival to the ICU, the patient is alert and answering questions\n appropriately. She denies any pain. She denies any difficulty with her\n breathing.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Received the pt on 100%CPAP with RR 20-30.LS rhonchi with diminished\n base.Pt apneic frequently.\n Action:\n Put on MMV with 40%.Suctioned for thick yellow secretion.CXR revealed\n atelectasis on LLL.\n Response:\n Saturating well on the current settings.\n Plan:\n Transition to trach collar in the am,Pt uses psm valve,?decannulation\n given recent events.?c/o.\n"},{"category":"Physician ","chartdate":"2141-11-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":548054,"text":"Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Entacapone\n Modadinil\n Mirtazapine\n Carbidopa-levodopa\n Albuterol\n Chlorhexidine\n Heparin SQ\n Omeprazole\n Colace\n Bisacodyl\n Tylenol\n MOM\n Cyanocobalamin\n Vit D\n Calcium carbonate\n Albuterol\n Mucomyst\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100% (97-100)\n Heart rhythm: SR (Sinus Rhythm)\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: clear BS, no wheezing\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Peripheral 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n CXR: retrocardiac opacity likely LLL ateletasis\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection.\n - npo for now\n - positive pressure ventilation this evening with repeat ABG\n - transition back to trach mask, hopefully by tomorrow AM\n - continue to monitor closely and suction prn\n - IP team to see tomorrow to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg in the Am\n - cycle cardiac enzymes\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\n formulary.\n - resume home mirtazapine\n - resume home modafinil on transfer to Rehab\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending overnight monitoring, tolerating trach mask\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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":"2141-11-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":548055,"text":"Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Entacapone\n Modadinil\n Mirtazapine\n Carbidopa-levodopa\n Albuterol\n Chlorhexidine\n Heparin SQ\n Omeprazole\n Colace\n Bisacodyl\n Tylenol\n MOM\n Cyanocobalamin\n Vit D\n Calcium carbonate\n Albuterol\n Mucomyst\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100% (97-100)\n Heart rhythm: SR (Sinus Rhythm)\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: clear BS, no wheezing\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Peripheral 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n CXR: retrocardiac opacity likely LLL ateletasis\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaning off positive pressure ventilation am\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n -CXR tomorrow to eval change in LLL opacity\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg this am\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet.\n - resume home mirtazapine\n - NF request for modafinil and entacapone\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\n Possible to floor today\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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":"2141-11-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":548060,"text":"Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Entacapone\n Modadinil\n Mirtazapine\n Carbidopa-levodopa\n Albuterol\n Chlorhexidine\n Heparin SQ\n Omeprazole\n Colace\n Bisacodyl\n Tylenol\n MOM\n Cyanocobalamin\n Vit D\n Calcium carbonate\n Albuterol\n Mucomyst\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100% (97-100)\n Heart rhythm: SR (Sinus Rhythm)\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: clear BS, no wheezing\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Peripheral 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n CXR: retrocardiac opacity likely LLL ateletasis\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaning off positive pressure ventilation am\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n -CXR tomorrow to eval change in LLL opacity\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg this am\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet.\n - resume home mirtazapine\n - NF request for modafinil and entacapone\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\n Possible to floor today\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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: 81 yo F with h/o Parkinson\ns dz, recurrent\n PNA, s/p tracheostomy at , admitted from rehab after\n developing stridor and desaturations after placing cap on trach. FOB\n on notable for tracheobroncheomalacia and malpositioning of\n trache. \n> trache changed. Post-proc on floor became brady to\n 40s with pea arrest\n code blue called\n > CPR performed with pulse\n returned within 1-2 minutes, suctioned with good result. Arrest\n presumed secondary to mucus plugging. Transferred to MICU for close\n observation / care s/p arrest. Remained on PP vent overnight.\n Exam notable for Tm AF 98.8 BP 80/37-137/68 HR 64 (63-80) RR with sat\n 97-100 on 40% PS 5/5. Awake and alert, following commands, sig\n kyphosis, trach site clean, lungs CTA with decreased b/b BS, RR, peg\n site without erythema, abd benign, baseline tremor and cogwheeling\n Labs notable for WBC 9.5 (11)K, 30 HCT , 3.9K+ , 0.6Cr .\n CXR: rotated, sig kyphosis, partial LLL collapse,\n ECG--atrial ectopy and freq PACs, sinus rhythm, no acute ischemic\n changes\n ISSUES:\n * s/p PEA arrest presumably from mucus plugging\n * TBM\n * Parkinson\ns ds\n Agree with plan to transition to trach mask with close monitoring.\n Continue mucomyst, nebs, pulm toilet. Repeat cxr in am to monitor LLL\n though no fever or wbc to suggest asp pna. IP service following. Given\n significant TBM will likely require long term trach. Remains stable\n from hemodynamic standpoint since PEA arrest.Neg CEs. Follow/replete\n lytes given atrial ectopy on monitor. Continue Parkinson's regimen per\n Rehab. Remainder of plan as outlined above.\n Patient is critically ill, Once stable off PP on trach collar will\n transfer to surgical floor.\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:45 PM ------\n"},{"category":"Nursing","chartdate":"2141-11-11 00:00:00.000","description":"Nursing Progress Note","row_id":548118,"text":"Events: Off vent to track mask- tolerating weel. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Likely will return as\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\n Rehab- reviewing POC and events, daughter (HCP) and family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"},{"category":"General","chartdate":"2141-11-12 00:00:00.000","description":"Generic Note","row_id":548131,"text":"TITLE: Resp Care Note, Pt remains on t-collar 40%. Instilled with\n mucomyst and given MDI albuterol. Suctioned for thick tan plugs. Inner\n cannula inn cuff inflated at this time.Needs inner cannula out during\n suctioning. H20 filled all equipment present. Will cont to monitor resp\n status.\n"},{"category":"Respiratory ","chartdate":"2141-11-11 00:00:00.000","description":"Respiratory Care Shift Note","row_id":548091,"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 Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 6.0mm\n PMV: Yes\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\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:\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":"Physician ","chartdate":"2141-11-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":548187,"text":"Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaned off ventilation, now on TM at 40%\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n d/w IP team pt to go to floor\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) per IP team\n -CXR tomorrow to eval change in LLL opacity\n persistent LLL opacity,\n c/w atelectasis, PA and lateral may be better to assess\n -blood gas this AM to better assess pulmonary status in presence\n of increased CO2\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - repeat EKG without any new changes\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\n entacapone (the last two ordered non-formulary)\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thick nectar liquids when back on trach collar/cap, replete lytes\n prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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":"2141-11-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":548188,"text":"Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Producing thin, nonpurulent sputum\n CV: RRR. normal S1, S2\n LUNGS: clear at apices, mild crackles at bases\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, masked\n facies, rhythmic tremor R > L hand with pillrolling\n Peripheral 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaned off ventilation, now on TM at 40%\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n d/w IP team pt to go to floor\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) per IP team\n -CXR tomorrow to eval change in LLL opacity\n persistent LLL opacity,\n c/w atelectasis, PA and lateral may be better to assess\n -blood gas this AM to better assess pulmonary status in presence\n of increased CO2\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - repeat EKG without any new changes\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\n entacapone (the last two ordered non-formulary)\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thick nectar liquids when back on trach collar/cap, replete lytes\n prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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":"2141-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":548202,"text":"Events: Off vent to track mask- tolerating well. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Pt very anxious to go\n back t o Rehab- reviewing POC and events, daughter (HCP) and\n family. IP/surgery following - plan for flexible broncoscopy in AM for\n re-eval for regarding ? T tube placement in house. C/O to floor.\n Returning to Rehab pending results of broncoscopy.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up secretios\n to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\n"},{"category":"Nursing","chartdate":"2141-11-12 00:00:00.000","description":"Nursing Transfer Note","row_id":548203,"text":"Events: Occ suctioning sm amts of thick yellow secretions- pt able to\n bring up secretions to RN able to easily suction out- occ deep\n suctioning. Very anxious to go back t o Rehab- reviewing POC\n and events, daughter (HCP) and family. IP/surgery following - plan for\n flexible broncoscopy in AM for re-eval for regarding ? T tube placement\n in house. C/O to floor. Returning to Rehab pending results of\n broncoscopy.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up\n secretions to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\n Demographics\n Attending MD:\n \n Admit diagnosis:\n AIRWAY OBSTRUCTION\n Code status:\n Full code\n Height:\n Admission weight:\n 71.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\n spinal fusion,s/p trach following that.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:59\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 98% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 420 mL\n 24h total out:\n 740 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 02:57 AM\n Potassium:\n 3.7 mEq/L\n 02:57 AM\n Chloride:\n 106 mEq/L\n 02:57 AM\n CO2:\n 34 mEq/L\n 02:57 AM\n BUN:\n 11 mg/dL\n 02:57 AM\n Creatinine:\n 0.5 mg/dL\n 02:57 AM\n Glucose:\n 83 mg/dL\n 02:57 AM\n Hematocrit:\n 30.6 %\n 02:57 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: red and white shirt, white shoes, head phone to\n increase hearing\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 6\n Transferred to: 7\n Date & time of Transfer: 12:00 AM\n"},{"category":"Nursing","chartdate":"2141-11-12 00:00:00.000","description":"Nursing Transfer Note","row_id":548205,"text":"Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n .\n The patient was evaluated by neurosurgery on due to recent spinal\n fusion and ? of rigid bronchoscopy. Based on her recent surgery, rigid\n bronch is not indicated but the patient is apparently physically unable\n to hyperextend her neck. On , the patient underwent flexible\n bronchoscopy which revealed TBM with trach malpositioned. Her trach was\n changed from Bovona to Portex 6 mm cuffed with inner cannula by Dr.\n . She tolerated the procedure well with exception of atrial\n tachyarrhythmia intermittently.\n .\n On the evening of , the patient was doing well on the Thoracics\n floor. She was noted to be talking with her trach cap in place and had\n her dinner. At about 1817, the patient was noted to have bradycardia on\n telemetry monitoring. RN and MD personnel quickly went to the\n bedside and the patient was noted to be pulseless. She was cyanotic and\n apneic at that time. Her trach cap was uncapped and she was suctioned\n with good result. She had about 1-2 minutes of chest compressions and\n no medications and regained a good femoral pulse. BP following this was\n in the 160s systolic. The patient was immediately more alert but not\n answering questions. ABG during this time was 7.29/64/290.\n Events: Occ suctioning sm amts of thick yellow secretions- pt able to\n bring up secretions to RN able to easily suction out- occ deep\n suctioning. Very anxious to go back t o Rehab- reviewing POC\n and events, daughter (HCP) and family. IP/surgery following - plan for\n flexible broncoscopy in AM for re-eval for regarding ? T tube placement\n in house. C/O to floor. Returning to Rehab pending results of\n broncoscopy.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up\n secretions to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\n Demographics\n Attending MD:\n \n Admit diagnosis:\n AIRWAY OBSTRUCTION\n Code status:\n Full code\n Height:\n Admission weight:\n 71.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\n spinal fusion,s/p trach following that.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:59\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 98% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 420 mL\n 24h total out:\n 740 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 02:57 AM\n Potassium:\n 3.7 mEq/L\n 02:57 AM\n Chloride:\n 106 mEq/L\n 02:57 AM\n CO2:\n 34 mEq/L\n 02:57 AM\n BUN:\n 11 mg/dL\n 02:57 AM\n Creatinine:\n 0.5 mg/dL\n 02:57 AM\n Glucose:\n 83 mg/dL\n 02:57 AM\n Hematocrit:\n 30.6 %\n 02:57 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: red and white shirt, white shoes, head phone to\n increase hearing\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 6\n Transferred to: 7\n Date & time of Transfer: 12:00 AM\n"},{"category":"Nursing","chartdate":"2141-11-11 00:00:00.000","description":"Nursing Progress Note","row_id":548093,"text":"Events: Off vent to track mask- tolerating weel. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Likely will return as\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\n Rehab- reviewing POC and events, daughter (HCP) and family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"},{"category":"Nursing","chartdate":"2141-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":548191,"text":"Events: Off vent to track mask- tolerating well. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Pt very anxious to go\n back t o Rehab- reviewing POC and events, daughter (HCP) and\n family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up secretios\n to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"},{"category":"Nursing","chartdate":"2141-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":548192,"text":"Events: Off vent to track mask- tolerating well. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Pt very anxious to go\n back t o Rehab- reviewing POC and events, daughter (HCP) and\n family. Plan to consult pt MD regarding ? T place\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up secretios\n to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"},{"category":"Nursing","chartdate":"2141-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":548193,"text":"Events: Off vent to track mask- tolerating well. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Pt very anxious to go\n back t o Rehab- reviewing POC and events, daughter (HCP) and\n family. IP/surgery following - plan for flexible broncoscopy in AM for\n re-eval for regarding ? T tube placement in house. C/O to floor.\n Returning to Rehab pending results of broncoscopy.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up secretios\n to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"},{"category":"Physician ","chartdate":"2141-11-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":548194,"text":"Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Producing thin, nonpurulent sputum\n CV: RRR. normal S1, S2\n LUNGS: clear at apices, mild crackles at bases\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, masked\n facies, rhythmic tremor R > L hand with pillrolling\n Peripheral 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaned off ventilation, now on TM at 40%\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n d/w IP team pt to go to floor\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) per IP team\n -CXR tomorrow to eval change in LLL opacity\n persistent LLL opacity,\n c/w atelectasis, PA and lateral may be better to assess\n -blood gas this AM to better assess pulmonary status in presence\n of increased CO2\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - repeat EKG without any new changes\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\n entacapone (the last two ordered non-formulary)\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thick nectar liquids when back on trach collar/cap, replete lytes\n prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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: 81 yo F with h/o Parkinson\ns dz, recurrent\n PNA, s/p tracheostomy at , admitted from rehab after\n developing stridor and desaturations after placing cap on trach. FOB\n on notable for tracheobroncheomalacia and malpositioning of\n trache. \n> trache changed. Post-proc on floor became brady to\n 40s with pea arrest\nwith pulse returned within 1-2 minutes, suctioned\n with good result. Arrest presumed secondary to mucus plugging.\n Transferred to MICU for close observation / care s/p arrest.\n Tolerating TM since yesterday. Diet advanced to prior.\n Exam notable for Tm 97.8 BP 138/64 HR 62 RR 23 with sat 98% on\n TM--40%. Awake and alert, following commands and speaking\n appropriately, kyphoitc, trach site clean, lungs CTA with decreased b/b\n BS, RR, abd benign, baseline tremor and cogwheeling\n Labs notable for WBC 6.0, cr 0.5, serum CO2 34 (29).\n CXR: rotated, sig kyphosis, underpenetrated\nstable partial LLL\n collapse\n Active issues include:\n * s/p PEA arrest, presumably from mucus plugging\n * TBM\n * Parkinson\ns ds\n Has tolerated trach mask X 24 hrs. Managing secretions well. Continue\n mucomyst, nebs, pulm toilet, sx\ning. CXR with stable partial LLL\n collapse in setting of significant kyphosis, though clinically without\n fever or leukcoytosis to suggest pna/tracheobronchitis. Secretions are\n clear/nonpurulent. Tolerating prior diet without evidence of\n aspiration. Given significant TBM will likely require long term trach.\n Remains stable from hemodynamic standpoint since PEA arrest with less\n ectopy on monitor. Serum CO2 is elevated today--may be from mild\n contraction as put out sig urine. Is at risk for hypoventilation and\n co2 retention given kyphosis and probable restrictive lung ds. Will\n check abg to assess baseline CO2 but has remained very alert and\n mentating appropriately. Would suggest monitoring of this at rehab.\n Continue Parkinson's regimen. Remainder of plan as outlined above.\n Stable for rehab transfer.\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:18 PM ------\n"},{"category":"Respiratory ","chartdate":"2141-11-11 00:00:00.000","description":"Respiratory Care Shift Note","row_id":548008,"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 Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 6.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details. Pt rested on MMV overnight for periods of apnea. RSBI done on\n 0 peep 5 ips 56. Pt awake and alert.Will consider weaning to t- collar\n this AM.\n"},{"category":"Physician ","chartdate":"2141-11-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":548154,"text":"Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of RLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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":"2141-11-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":548155,"text":"Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of RLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaning off positive pressure ventilation am\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n -CXR tomorrow to eval change in LLL opacity\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg this am\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet.\n - resume home mirtazapine\n - NF request for modafinil and entacapone\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\n Possible to floor today\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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":"2141-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":548142,"text":"Events: Off vent to track mask- tolerating weel. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Likely will return as\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\n Rehab- reviewing POC and events, daughter (HCP) and family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt sating 95-100% on trach mask 40%, rec\nd pt with PMV in, tolerating\n well, A&Ox3- able to make needs known.\n Action:\n PMV taken out by respiratory for night, Close monitoring s/s\n aspiration. Sxned x2 for sm-mod. Amounts of white thick sputum. Pt\n able to raise most secretions on own, using yankuer by self.\n Response:\n Tolerating trach mask.\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n PRN. Plan to go to Rehab this AM.\n"},{"category":"Nursing","chartdate":"2141-11-15 00:00:00.000","description":"Nursing Progress Note","row_id":548588,"text":".H/O airway obstruction, Central / Upper\n Assessment:\n 02 sats 95-100% on 50% fi02 trache collar. LS w/ rhonch throughout.\n Scant tan secretions noted.\n Action:\n Mucomyst nebs given Q 6. IV levaquin started. Sputum sample sent.\n Response:\n 02 sats 95-100% throughout the noc. No c/o sob. Pt able to expectorate\n own scant, tan secretions.\n Plan:\n Continue pulmonary toilet. Q 6 hour mucomyst nebs. Follow up on results\n of sputum sample sent.\n"},{"category":"Nursing","chartdate":"2141-11-15 00:00:00.000","description":"Nursing Progress Note","row_id":548579,"text":".H/O airway obstruction, Central / Upper\n Assessment:\n Action:\n Mucomyst nebs given Q 6. IV levaquin started. Sputum sample sent.\n Response:\n 02 sats 95-100% throughout the noc. No c/o sob. Pt able to expectorate\n own scant, tan secretions.\n Plan:\n Continue pulmonary toilet. Q 6 hour mucomyst nebs. Follow up on results\n of sputum sample sent.\n"},{"category":"Physician ","chartdate":"2141-11-15 00:00:00.000","description":"Intensivist Note","row_id":548580,"text":"SICU\n HPI:\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\n T-tube secretions.\n Chief complaint:\n tracheal stenosis\n PMHx:\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\n fusion at , Recurrent pneumonia\n Current medications:\n 24 Hour Events:\n SPUTUM CULTURE - At 05:27 AM\n NASAL SWAB - At 05:29 AM\n CALLED OUT\n Post operative day:\n HD 6, POD 2 (T-tube)\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 03:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.7\nC (98\n HR: 68 (55 - 71) bpm\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\n RR: 22 (12 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 229 mL\n PO:\n Tube feeding:\n 65 mL\n IV Fluid:\n 164 mL\n Blood products:\n Total out:\n 880 mL\n 1,480 mL\n Urine:\n 880 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -1,251 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, hard of hearing, able to communicate w/ writing.\n Labs / Radiology\n 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n 02:34 PM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Creatinine\n 0.6\n 0.5\n Troponin T\n <0.01\n TCO2\n 35\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\n placement.\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\n Modafinil, Mirtazapine\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \n will diuresis. t/c echo\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\n self suction.\n Gastrointestinal / Abdomen: g-tube\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: levoquin for RLL infiltrate by team\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Thoracic, Interventional Pulm\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 11:08 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2141-11-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":548022,"text":"Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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":"2141-11-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":548023,"text":"Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: coarse breath sounds bilaterally, no wheezing\n ABD: soft, PEG in place in LUQ, normoactive bowel sounds, nontender to\n palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Peripheral 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection.\n - npo for now\n - positive pressure ventilation this evening with repeat ABG\n - transition back to trach mask, hopefully by tomorrow AM\n - continue to monitor closely and suction prn\n - IP team to see tomorrow to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg in the Am\n - cycle cardiac enzymes\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\n formulary.\n - resume home mirtazapine\n - resume home modafinil on transfer to Rehab\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending overnight monitoring, tolerating trach mask\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Radiology","chartdate":"2141-11-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1051013,"text":" 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change LLL\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with trach s/p PEA arrest after likely mucous plug. Fully\n recoved. LLL opacity on previous CXR\n REASON FOR THIS EXAMINATION:\n interval change LLL\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 81-year-old woman with tracheostomy, status post PEA arrest. Likely\n mucous plug. Evaluate left lower lobe opacity.\n\n FINDINGS: Comparison is made to previous study from .\n\n There has been decrease in the amount of gas within the known hiatal hernia.\n There remains cardiomegaly stable. There is improvement of the air\n bronchograms within the left base; however, there remains consolidation in\n this location. There are no signs for overt pulmonary edema. There has also\n been improvement of the infiltrate at the right base.\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2141-11-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1050857,"text":" 7:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumothorax\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with\n REASON FOR THIS EXAMINATION:\n pneumothorax\n ______________________________________________________________________________\n WET READ: ARHb FRI 8:43 PM\n No pneumothorax identified. Retrocardiac opacity may represent left lower lobe\n atelectasis. Right basilar atelectasis also likely. D/ @\n 20:40.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Pneumothorax.\n\n FINDINGS:\n\n There is a very large hiatal hernia which occupies the mid section of the\n chest. There is large left lower lobe consolidation with air bronchograms and\n a moderate left pleural effusion. These findings have increased since prior\n study. There is also focal right lower lobe consolidation. Heart is\n enlarged. Aorta is tortuous. Tracheostomy remains in the midline.\n\n\n"},{"category":"Radiology","chartdate":"2141-11-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1051468,"text":" 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with T-tube and rigid bronch yesterday, increased secretions\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj TUE 12:21 PM\n New right lower lobe opacity may represent aspiration or less likely\n hemorrhage/edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female status post tracheal T-tube change and rigid\n bronchoscopy on .\n\n PORTABLE AP CHEST: Comparison is made to . The cardiomediastinal\n contours are stable. A new right lower lobe opacity is evident. Dense\n consolidation versus atelectasis at the left lung base is unchanged. The\n upper lungs are well aerated. Lucency projecting over the mid thoracic spine,\n compatible with patient's known hiatal hernia appears similar to previous\n studies.\n\n IMPRESSION: New dense opacity in the right lower lobe status post\n bronchoscopy and tracheal T-tube change. The differential diagnosis includes\n aspiration given recent procedure. Other diagnostic considerations include\n hemorrhage or edema. Close interval followup is recommended.\n\n Findings were discussed with Dr. on the morning of by Dr.\n over the telephone.\n\n"},{"category":"Radiology","chartdate":"2141-11-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1051469,"text":", TSURG FA7A 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with T-tube and rigid bronch yesterday, increased secretions\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n PFI REPORT\n New right lower lobe opacity may represent aspiration or less likely\n hemorrhage/edema.\n\n"},{"category":"Radiology","chartdate":"2141-11-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1051625,"text":" 7:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for progressing ? PNA\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with purulent secretions\n REASON FOR THIS EXAMINATION:\n eval for progressing ? PNA\n ______________________________________________________________________________\n WET READ: KYg TUE 8:42 PM\n PRELIMINARY REPORT: MULTIFOCAL BILATERAL OPACITIES WORRISOME FOR PNEUMONIA.\n COMPARED TO THE PRIOR EXAM THERE IS SLIGLHTLY IMPROVED AERATION OF THE RIGHT\n LUNG BASE. NO PNEUMOTHORAX. NOTE IS MADE OF CHANGES RELATED TO CERVICAL FUSION\n AND LAMINECTOMY. \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:49 P.M. \n\n HISTORY: Purulent secretions.\n\n IMPRESSION: AP chest compared to and 16:\n\n Severe bibasilar consolidation which developed between and has worsened on the right since , stable on the left since\n though associated moderate left pleural effusion is slightly\n smaller today than on . Moderate-to-severe cardiomegaly is stable.\n Esophagus is distended above a large gastric hiatus hernia. No pneumothorax.\n\n\n"},{"category":"ECG","chartdate":"2141-11-13 00:00:00.000","description":"Report","row_id":224169,"text":"Sinus rhythm with occasional ventricular ectopy and occasional atrial ectopy.\nNon-specific inferior ST-T wave changes. Compared to the previous tracing\nof the limb lead voltage has diminished and ventricular ectopy has\nappeared. Otherwise no diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2141-11-11 00:00:00.000","description":"Report","row_id":224170,"text":"Sinus rhythm. Frequent premature atrial contractions. Voltage criteria\nfor left ventricular hypertrophy. Lateral ST-T wave abnormalities which are\nnon-specific. Compared to the previous tracing of frequent atrial\npremature beats are new. There are voltage criteria for left ventricular\nhypertrophy which are new.\n\n"},{"category":"ECG","chartdate":"2141-11-10 00:00:00.000","description":"Report","row_id":224171,"text":"Sinus rhythm. Poor R wave progression. Non-specific low amplitude\nT waves in the inferior and lateral leads. Compared to the previous tracing\nof T wave flattening is more pronounced and the Q-T interval is\nshorter.\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-14 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 548551,\n \"text\": \"SICU\\n HPI:\\n ADMISSION NOTE:\\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\\n placed for concern of unstable C-spine. Admitted for\\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\\n rigid bronch concern of hyperextension) showed mod granulation\\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\\n trach. underwent trach change for malpositioned tube. That\\n night after capping trach, pt went to brady/PEA arrest thought to be\\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\\n T-tube secretions.\\n Chief complaint:\\n tracheal stenosis, inct T-tube secretions\\n PMHx:\\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\\n fusion at , Recurrent pneumonia\\n Current medications:\\n 24 Hour Events:\\n CALLED OUT\\n Post operative day:\\n HD 5, POD 1 (T-tube)\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 09:27 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.9\\nC (98.5\\n T current: 36.9\\nC (98.5\\n HR: 68 (68 - 71) bpm\\n BP: 145/59(80) {142/59(80) - 145/62(84)} mmHg\\n RR: 25 (12 - 25) insp/min\\n SPO2: 98%\\n Total In:\\n PO:\\n Tube feeding:\\n IV Fluid:\\n Blood products:\\n Total out:\\n 0 mL\\n 240 mL\\n Urine:\\n 240 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -240 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SPO2: 98%\\n ABG: ////\\n Physical Examination\\n General Appearance: No acute distress, Anxious\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\\n Rhonchorous : bilateral), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, G-tube\\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli, Tactile stimuli), Moves all extremities,\\n hard of hearing, able to communicate w/ writing.\\n Labs / Radiology\\n 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n 02:34 PM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Creatinine\\n 0.6\\n 0.5\\n Troponin T\\n <0.01\\n TCO2\\n 35\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n Assessment and Plan: 81yo F w/ trach and tracheal stenosis who is s/p\\n T-tube placement.\\n Neurologic: h/o parkinson on sinemet, entacapone; Modafinil;\\n Mirtazapine for depression\\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \\n will diuresis w/ Lasix 20mg. Plan to get 500-1000mL negative\\n Pulmonary: T-tube, on trach collar. maintining saturations. Self\\n suction and suction by nursing. Dexamethasone for edema. Cont atrovent\\n nebs, mucomyst nebs; ?RLL infiltrate, started on Levo.\\n Gastrointestinal / Abdomen: G-tube\\n Nutrition: Speech and Swallow eval, G-tube feeds\\n Renal: Foley, foley placed for incontinence; will diuresis for CHF\\n Hematology: stable\\n Endocrine: RISS\\n Infectious Disease: Sputum cultures today, Levo for RLL infiltrate.\\n Lines / Tubes / Drains: Foley, T-tube\\n Wounds:\\n Imaging:\\n Fluids: KVO\\n Consults: Thoracic, Interventional Pulm\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 08:12 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 548606,\n \"text\": \"SICU\\n HPI:\\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\\n placed for concern of unstable C-spine. Admitted for\\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\\n rigid bronch concern of hyperextension) showed mod granulation\\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\\n trach. underwent trach change for malpositioned tube. That\\n night after capping trach, pt went to brady/PEA arrest thought to be\\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\\n T-tube secretions.\\n Chief complaint:\\n tracheal stenosis\\n PMHx:\\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\\n fusion at , Recurrent pneumonia\\n Current medications:\\n 24 Hour Events:\\n SPUTUM CULTURE - At 05:27 AM\\n NASAL SWAB - At 05:29 AM\\n CALLED OUT\\n Post operative day:\\n HD 6, POD 2 (T-tube)\\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 03:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 06:00 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37\\nC (98.6\\n T current: 36.7\\nC (98\\n HR: 68 (55 - 71) bpm\\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\\n RR: 22 (12 - 26) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 229 mL\\n PO:\\n Tube feeding:\\n 65 mL\\n IV Fluid:\\n 164 mL\\n Blood products:\\n Total out:\\n 880 mL\\n 1,480 mL\\n Urine:\\n 880 mL\\n 1,480 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -880 mL\\n -1,251 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SPO2: 98%\\n ABG: ////\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities, hard of hearing, able to communicate w/ writing.\\n Labs / Radiology\\n 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n 02:34 PM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Creatinine\\n 0.6\\n 0.5\\n Troponin T\\n <0.01\\n TCO2\\n 35\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\\n placement.\\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\\n Modafinil, Mirtazapine\\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \\n will diuresis. t/c echo\\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\\n self suction.\\n Gastrointestinal / Abdomen: g-tube\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\\n Hematology: stable\\n Endocrine: RISS\\n Infectious Disease: levoquin for RLL infiltrate by team\\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\\n Wounds: none\\n Imaging: cxr\\n Fluids: KVO\\n Consults: Thoracic, Interventional Pulm\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 11:08 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 548607,\n \"text\": \"SICU\\n HPI:\\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\\n placed for concern of unstable C-spine. Admitted for\\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\\n rigid bronch concern of hyperextension) showed mod granulation\\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\\n trach. underwent trach change for malpositioned tube. That\\n night after capping trach, pt went to brady/PEA arrest thought to be\\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\\n T-tube secretions.\\n Chief complaint:\\n tracheal stenosis\\n PMHx:\\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\\n fusion at , Recurrent pneumonia\\n Current medications:\\n 24 Hour Events:\\n SPUTUM CULTURE - At 05:27 AM\\n NASAL SWAB - At 05:29 AM\\n CALLED OUT\\n Post operative day:\\n HD 6, POD 2 (T-tube)\\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 03:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 06:00 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37\\nC (98.6\\n T current: 36.7\\nC (98\\n HR: 68 (55 - 71) bpm\\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\\n RR: 22 (12 - 26) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 229 mL\\n PO:\\n Tube feeding:\\n 65 mL\\n IV Fluid:\\n 164 mL\\n Blood products:\\n Total out:\\n 880 mL\\n 1,480 mL\\n Urine:\\n 880 mL\\n 1,480 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -880 mL\\n -1,251 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SPO2: 98%\\n ABG: ////\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable ). Some secretions\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities, hard of hearing, able to communicate w/ writing.\\n Speaking with Passemuir valve.\\n Labs / Radiology\\n 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n 02:34 PM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Creatinine\\n 0.6\\n 0.5\\n Troponin T\\n <0.01\\n TCO2\\n 35\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\\n placement.\\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\\n Modafinil, Mirtazapine\\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \\n . Diuresis. t/c echo\\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\\n self suction.\\n Gastrointestinal / Abdomen: g-tube\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\\n Hematology: stable\\n Endocrine: RISS\\n Infectious Disease: levoquin for RLL infiltrate by team\\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\\n Wounds: none\\n Imaging: cxr\\n Fluids: KVO\\n Consults: Thoracic, Interventional Pulm\\n Billing Diagnosis: Resp Abnormaliity\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 11:08 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 548631,\n \"text\": \"81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\\n placed for concern of unstable C-spine. Admitted for\\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\\n rigid bronch concern of hyperextension) showed mod granulation\\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\\n trach. underwent trach change for malpositioned tube. That\\n night after capping trach, pt went to brady/PEA arrest thought to be\\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for\\n increased T-tube secretions.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Sats 99% on 50% o2 via trach mask. Able to expectorate secretions and\\n suction independently with Yankauer. Tolerating Passey-muir valve. LS\\n coarse at times, clears with cough.\\n Action:\\n Encouraged cough, deep breaths. Sputum sample sent for culture.\\n Response:\\n Resp status stable.\\n Plan:\\n continue aggressive pulm hygiene.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n AIRWAY OBSTRUCTION\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 70.7 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\\n spinal fusion,s/p trach following that. s/p mechanical fall few months\\n ago w/ C2-4 fx s/p spinal fusion/ hardware placement.Trache placed d/t\\n unstable cervical spine. Admitted from rehab to floor d/t\\n stridor and desats while trying to cap trache. Flex Bronch which\\n revealed granulation tissue in the proximal trachea\\n (tracheobroncomalacia). Trach changed from boniva to portex. on \\n trach capped, pt w/ pea arrest on the floor while eating. OR\\n trach tube changed to t tube and bronch.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:112\\n D:56\\n Temperature:\\n 98\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 37 insp/min\\n Heart Rate:\\n 64 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Trach mask\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 12 L/min\\n FiO2 set:\\n 50% %\\n 24h total in:\\n 588 mL\\n 24h total out:\\n 1,795 mL\\n Pertinent Lab Results:\\n Sodium:\\n 142 mEq/L\\n 04:49 AM\\n Potassium:\\n 3.8 mEq/L\\n 04:49 AM\\n Chloride:\\n 100 mEq/L\\n 04:49 AM\\n CO2:\\n 34 mEq/L\\n 04:49 AM\\n BUN:\\n 14 mg/dL\\n 04:49 AM\\n Creatinine:\\n 0.6 mg/dL\\n 04:49 AM\\n Glucose:\\n 89 mg/dL\\n 04:49 AM\\n Hematocrit:\\n 29.8 %\\n 04:49 AM\\n Finger Stick Glucose:\\n 101\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: SICU A\\n Transferred to: 716\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 548614,\n \"text\": \".H/O airway obstruction, Central / Upper\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 548615,\n \"text\": \"81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\\n placed for concern of unstable C-spine. Admitted for\\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\\n rigid bronch concern of hyperextension) showed mod granulation\\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\\n trach. underwent trach change for malpositioned tube. That\\n night after capping trach, pt went to brady/PEA arrest thought to be\\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for\\n increased T-tube secretions.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Sats 99% on 50% o2 via trach mask. Able to expectorate secretions and\\n suction independently with Yankauer. Tolerating Passey-muir valve. LS\\n coarse at times, clears with cough.\\n Action:\\n Encouraged cough, deep breaths. Sputum sample sent for culture.\\n Response:\\n Resp status stable.\\n Plan:\\n continue aggressive pulm hygiene.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 548621,\n \"text\": \"Subjective: Pt is very HOH, unable to converse with her.\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 163 cm\\n 70.7 kg\\n 26.8\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 54.4kg\\n 130%\\n 58.5kg\\n Diagnosis: Airway Obstruction\\n PMH : Parkinson's disease, Fall with C2-4 fracture in , s/p\\n cervical fusion at , Recurrent pneumonia, h/o PEG feeding\\n Food allergies and intolerances:\\n Pertinent medications: Abx, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 89 mg/dL\\n 04:49 AM\\n Glucose Finger Stick\\n 101\\n 10:00 AM\\n BUN\\n 14 mg/dL\\n 04:49 AM\\n Creatinine\\n 0.6 mg/dL\\n 04:49 AM\\n Sodium\\n 142 mEq/L\\n 04:49 AM\\n Potassium\\n 3.8 mEq/L\\n 04:49 AM\\n Chloride\\n 100 mEq/L\\n 04:49 AM\\n TCO2\\n 34 mEq/L\\n 04:49 AM\\n PO2 (arterial)\\n 136 mm Hg\\n 02:34 PM\\n PCO2 (arterial)\\n 51 mm Hg\\n 02:34 PM\\n pH (arterial)\\n 7.43 units\\n 02:34 PM\\n pH (urine)\\n 5.0 units\\n 04:44 PM\\n CO2 (Calc) arterial\\n 35 mEq/L\\n 02:34 PM\\n Calcium non-ionized\\n 9.2 mg/dL\\n 04:49 AM\\n Phosphorus\\n 3.5 mg/dL\\n 04:49 AM\\n Magnesium\\n 1.9 mg/dL\\n 04:49 AM\\n WBC\\n 6.9 K/uL\\n 04:49 AM\\n Hgb\\n 10.2 g/dL\\n 04:49 AM\\n Hematocrit\\n 29.8 %\\n 04:49 AM\\n Current diet order / nutrition support: TF: Replete with Fiber @\\n 40cc/hr (960kcal, 60g protein)\\n Diet: NPO\\n GI: soft, +BS\\n Assessment of Nutritional Status\\n At risk for malnutrition\\n Pt at risk due to:\\n Estimated Nutritional Needs\\n Calories: 1400-1640 (BEE x or / 24-28 cal/kg)\\n Protein: 58-70 (1-1.2 g/kg)\\n Fluid: per team\\n Specifics:\\n 81 y.o. F with h/o Parkinson\\ns Disease s/p mechanical with\\n C2=C4 fracture, s/p spinal fusion/hardware placement with trach placed\\n due to ? of unstable C-spine. Pt now adm with stridor and destatting.\\n Flex bronch showed moderate granulation tissue in proximal trachea, and\\n trach tube was changed for malpositioning (). Trach was capped,\\n and pt went into brady/PEA arrest. Pt then had a rigid bronch and was\\n changed to a T-tube (). Pt is now in ICU for the management of\\n T-tube secretions. Pt has a PEG, but had been weaned off her TF at her\\n care facility, and was tolerating a soft diet. But TF are now\\n restarted, and pt unable to take po\\ns until S/S eval can be done with\\n PMV today. If pt is able to take po\\ns, TF\\ns might not be needed at\\n this time. Will follow results of PMV/speech/swallow eval.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1) Until pt can take po\\ns, rec TF goal of Fibersource @ 50cc/hr\\n (1440kcal, 64g protein) via PEG.\\n 2) S/S eval, advance diet as recommended by SLP.\\n 3) Monitor lytes, hydration.\\n Please page with ?\\ns #\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548002,\n \"text\": \"Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\\n fall with c2-4 fracture earlier this year admitted on due to\\n stridor and desaturations at her rehab facility in setting of placing\\n trach cap.\\n On , the patient underwent flexible bronchoscopy which revealed\\n TBM with trach malpositioned. Her trach was changed from Bovona to\\n Portex 6 mm cuffed with inner cannula.\\n On the evening of , the patient was doing well on the Thoracics\\n floor. At about 1817, the patient was noted to have bradycardia on\\n telemetry and the patient was noted to be pulseless. She was cyanotic\\n and apneic at that time. Her trach cap was uncapped and she was\\n suctioned with good result. She had about 1-2 minutes of chest\\n compressions and no medications and regained a good femoral pulse. BP\\n following this was in the 160s systolic. The patient was immediately\\n more alert but not answering questions. ABG during this time was\\n 7.29/64/290..\\n On arrival to the ICU, the patient is alert and answering questions\\n appropriately. She denies any pain. She denies any difficulty with her\\n breathing.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Received the pt on 100%CPAP with RR 20-30.LS rhonchi with diminished\\n base.Pt apneic frequently.\\n Action:\\n Put on MMV with 40%.Suctioned for thick yellow secretion.CXR revealed\\n atelectasis on LLL.\\n Response:\\n Saturating well on the current settings.\\n Plan:\\n Transition to trach collar in the am,Pt uses psm valve,?decannulation\\n given recent events.?c/o.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"ICU Attending Note\",\n \"row_id\": 547990,\n \"text\": \"TITLE:\\n Chart reviewed, pt examined, case discussed in detail with Dr. . I\\n agree with her note and in addition would add/emphasize:\\n 81F h/o Parkinson\\ns dz, recurrent PNA, s/p tracheostomy at ,\\n admitted from rehab after dev stridor and desat after placing cap\\n on trache. FOB on notable for tracheobroncheofmalacia. \\n trache changed. Post-proc on floor, brady to 40s noted on tele, pulse\\n lost\\n code blue called\\n CPR performed, pulse rapidly returned within\\n 1-2 minutes, suctioned with good result. Arrest presumed secondary to\\n plugging. Transferred to MICU for close observation / care s/p\\n arrest. Mental status rapidly improving. Close pulm toilet. Cont\\n PSV settings for now, TM trial in morning. Cycle enzymes.\\n Pt is critically ill.\\n Time spent: 35min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 547994,\n \"text\": \"Chief Complaint: respiratory distress, PEA arrest\\n HPI:\\n Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\\n fall with c2-4 fracture earlier this year admitted on due to\\n stridor and desaturations at her rehab facility in setting of placing\\n trach cap.\\n .\\n The patient was evaluated by neurosurgery on due to recent spinal\\n fusion and ? of rigid bronchoscopy. Based on her recent surgery, rigid\\n bronch is not indicated but the patient is apparently physically unable\\n to hyperextend her neck. On , the patient underwent flexible\\n bronchoscopy which revealed TBM with trach malpositioned. Her trach was\\n changed from Bovona to Portex 6 mm cuffed with inner cannula by Dr.\\n . She tolerated the procedure well with exception of atrial\\n tachyarrhythmia intermittently.\\n .\\n On the evening of , the patient was doing well on the Thoracics\\n floor. She was noted to be talking with her trach cap in place and had\\n her dinner. At about 1817, the patient was noted to have bradycardia on\\n telemetry monitoring. RN and MD personnel quickly went to the\\n bedside and the patient was noted to be pulseless. She was cyanotic and\\n apneic at that time. Her trach cap was uncapped and she was suctioned\\n with good result. She had about 1-2 minutes of chest compressions and\\n no medications and regained a good femoral pulse. BP following this was\\n in the 160s systolic. The patient was immediately more alert but not\\n answering questions. ABG during this time was 7.29/64/290.\\n .\\n On arrival to the ICU, the patient is alert and answering questions\\n appropriately. She denies any pain. She denies any difficulty with her\\n breathing.\\n Patient admitted from: \\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Meds at rehab:\\n acetylcysteine neb \\n albuterol neb q6h\\n calcium carbonate 650 mg (via peg)\\n carbidopa/levodopa 37.5/150 tid (give at 0630, 1100, and 1600)\\n carbodopa/levodopa 12.5/50 at 0830\\n carbidopa/levodopa 37.5/150 at 1400\\n vit d 1000 U daily\\n cyanocobalamin 1000 mcg daily\\n bisacodyl 10 mg daily prn\\n mag hydroxide 30 ml once daily prn\\n ambien 5 mg prn\\n miconazole powder prn\\n mupirocin to anterior neck \\n senna 17.2 mg at bedtime\\n omeprazole 20 mg \\n modafinil 50 mg (0800, 1400)\\n mirtazapine 30 mg at bedtime\\n atrovent neb q6h\\n ferrous sulfate 325 mg at bedtime (g tube)\\n entacapone 200 mg at 0630, 11, 1400, 1600 (with sinemet)\\n .\\n MEDS on transfer:\\n acetylcysteine 20% neb \\n calcium carbonate 500 (given via PEG)\\n vit d 800 U daily\\n cyanocobalamin 1000 mcg daily\\n ambien 5 mg qhs\\n colace 100 mg \\n omeprazole 20 mg \\n hep sc tid\\n sinemet 25/100, 1.5 tab tid\\n albuterol inhalers prn\\n Past medical history:\\n Family history:\\n Social History:\\n * Parkinson's disease\\n * Fall with C2-4 fracture in , s/p cervical fusion at \\n * Recurrent pneumonia, s/p trach after difficulty weaning from vent\\n after surgery\\n Occupation:\\n Drugs:\\n Tobacco: denies\\n Alcohol: denies\\n Other: Recently living at Rehab.\\n Review of systems:\\n Flowsheet Data as of 02:00 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 (98.2\\n HR: 64 (63 - 80) bpm\\n BP: 124/59(73) {80/43(52) - 137/68(85)} mmHg\\n RR: 13 (10 - 34) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 250 mL\\n 10 mL\\n PO:\\n TF:\\n IVF:\\n 250 mL\\n 10 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 250 mL\\n 10 mL\\n Respiratory\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: MMV/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 515 (103 - 515) mL\\n PS : 15 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 22 cmH2O\\n SpO2: 97%\\n ABG: ///34/\\n Ve: 11 L/min\\n Physical Examination\\n T: 98.6 BP: 134/61 HR: 78 RR: 20 O2 100% on PS 15/5, FiO2 100%\\n Gen: Pleasant elderly female in no distress\\n HEENT: Sclerae slightly pale, tongue moist and midline\\n NECK: supple, no lad, no thyromegaly\\n CV: RRR. normal S1, S2. no murmurs appreciated.\\n LUNGS: coarse breath sounds bilaterally, no wheezing\\n ABD: soft, PEG in place in LUQ, normoactive bowel sounds, nontender to\\n palpation\\n EXT: warm throughout, dp pulses 2+ bilaterally\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: alert, answering questions, hard of hearing in right ear, face\\n symmetric, tongue midline, pupils small but reactive bilaterally,\\n following commands (moving toes, grasping hand), moving all extremities\\n without difficulty, rhythmic tremor R > L hand and arm consistent with\\n h/o parkinson's\\n Labs / Radiology\\n 253\\n 10.5\\n 140\\n 0.6\\n 14\\n 34\\n 101\\n 3.7\\n 141\\n 31.1\\n 11.1\\n [image002.jpg]\\n Other labs: PT / PTT / INR://1.2, CK / CKMB / Troponin-T:29 / / < 0.01,\\n Lactic Acid:2.8, Ca++:9.4, Mg++:2.1, PO4:4.2\\n Fluid analysis / Other labs: ABG: 7.29/64/290\\n Imaging: Bronch (): superior glottis + edema, mucosal ridge seen\\n in anterior tracheal wall, just below cricoid + malacia at cervical\\n trachea, trach tube found Right lateral wall, distal trach/LMS with\\n malacia\\n .\\n CXR: No pneumothorax identified. Retrocardiac opacity may represent\\n left lower lobe atelectasis. Right basilar atelectasis also likely.\\n ECG: ekg: sinus rhythm at 70, normal axis, t wave flattening in v4-6,\\n III, avf, overall similar to prior from \\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection.\\n - npo for now\\n - positive pressure ventilation this evening with repeat ABG\\n - transition back to trach mask, hopefully by tomorrow AM\\n - continue to monitor closely and suction prn\\n - IP team to see tomorrow to decide dispo\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) at discretion of IP\\n team\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - ekg in the Am\\n - cycle cardiac enzymes\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\\n formulary.\\n - resume home mirtazapine\\n - resume home modafinil on transfer to Rehab\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thin liquids when back on trach collar/cap, replete lytes prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: pending overnight monitoring, tolerating trach mask\\n ICU Care\\n Nutrition:\\n Comments: npo for now until off ventilator\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n 18 Gauge - 08:35 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 547999,\n \"text\": \"Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\\n fall with c2-4 fracture earlier this year admitted on due to\\n stridor and desaturations at her rehab facility in setting of placing\\n trach cap.\\n On , the patient underwent flexible bronchoscopy which revealed\\n TBM with trach malpositioned. Her trach was changed from Bovona to\\n Portex 6 mm cuffed with inner cannula.\\n On the evening of , the patient was doing well on the Thoracics\\n floor. At about 1817, the patient was noted to have bradycardia on\\n telemetry and the patient was noted to be pulseless. She was cyanotic\\n and apneic at that time. Her trach cap was uncapped and she was\\n suctioned with good result. She had about 1-2 minutes of chest\\n compressions and no medications and regained a good femoral pulse. BP\\n following this was in the 160s systolic. The patient was immediately\\n more alert but not answering questions. ABG during this time was\\n 7.29/64/290..\\n On arrival to the ICU, the patient is alert and answering questions\\n appropriately. She denies any pain. She denies any difficulty with her\\n breathing.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548124,\n \"text\": \"Events: Off vent to track mask- tolerating weel. Placed on PMV and\\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\\n of thick yellow secretions- pt able to bring up secretions to RN\\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\\n overnight and transfer to Rehab in AM. Likely will return as\\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\\n Rehab- reviewing POC and events, daughter (HCP) and family.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Pt sating 95-100% on trach mask 40%, rec\\nd pt with PMV in, tolerating\\n well, A&Ox3- able to make needs known.\\n Action:\\n PMV taken out by respiratory for night, Close monitoring s/s\\n aspiration. Sxned x2 for sm-mod. Amounts of white thick sputum. Pt\\n able to raise most secretions on own, using yankuer by self.\\n Response:\\n Tolerating trach mask.\\n Plan:\\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\\n PRN. Plan to go to Rehab this AM.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548034,\n \"text\": \"Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\\n fall with c2-4 fracture earlier this year admitted on due to\\n stridor and desaturations at her rehab facility in setting of placing\\n trach cap.\\n On , the patient underwent flexible bronchoscopy which revealed\\n TBM with trach malpositioned. Her trach was changed from Bovona to\\n Portex 6 mm cuffed with inner cannula.\\n On the evening of , the patient was doing well on the Thoracics\\n floor. At about 1817, the patient was noted to have bradycardia on\\n telemetry and the patient was noted to be pulseless. She was cyanotic\\n and apneic at that time. Her trach cap was uncapped and she was\\n suctioned with good result. She had about 1-2 minutes of chest\\n compressions and no medications and regained a good femoral pulse. BP\\n following this was in the 160s systolic. The patient was immediately\\n more alert but not answering questions. ABG during this time was\\n 7.29/64/290..\\n On arrival to the ICU, the patient is alert and answering questions\\n appropriately. She denies any pain. She denies any difficulty with her\\n breathing.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Received the pt on 100%CPAP with RR 20-30.LS rhonchi with diminished\\n base.Pt apneic frequently.\\n Action:\\n Put on MMV with 40%.Suctioned for thick yellow secretion.CXR revealed\\n atelectasis on LLL.\\n Response:\\n Saturating well on the current settings.\\n Plan:\\n Transition to trach collar in the am,Pt uses psm valve,?decannulation\\n given recent events.?c/o.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548054,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 06:50 PM\\n -found PEA on floor, brief Chest compression, pulse returned after\\n suction of trach\\n -transfered to MICU, no further events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Entacapone\\n Modadinil\\n Mirtazapine\\n Carbidopa-levodopa\\n Albuterol\\n Chlorhexidine\\n Heparin SQ\\n Omeprazole\\n Colace\\n Bisacodyl\\n Tylenol\\n MOM\\n Cyanocobalamin\\n Vit D\\n Calcium carbonate\\n Albuterol\\n Mucomyst\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 64 (63 - 80) bpm\\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\\n RR: 18 (10 - 34) insp/min\\n SpO2: 100% (97-100)\\n Heart rhythm: SR (Sinus Rhythm)\\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\\n Total In:\\n 250 mL\\n 35 mL\\n PO:\\n TF:\\n IVF:\\n 250 mL\\n 35 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 250 mL\\n -116 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 387 (103 - 515) mL\\n PS : 10 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: ///29/\\n Ve: 6.7 L/min\\n Physical Examination\\n Gen: Pleasant elderly female in no distress\\n HEENT: Sclerae slightly pale, tongue moist and midline\\n NECK: supple, no lad, no thyromegaly\\n CV: RRR. normal S1, S2. no murmurs appreciated.\\n LUNGS: clear BS, no wheezing\\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\\n erythema., normoactive bowel sounds, nontender to palpation\\n EXT: warm throughout, dp pulses 2+ bilaterally\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: alert, answering questions, hard of hearing in right ear, face\\n symmetric, tongue midline, pupils small but reactive bilaterally,\\n following commands (moving toes, grasping hand), moving all extremities\\n without difficulty, rhythmic tremor R > L hand and arm consistent with\\n h/o parkinson's\\n Peripheral 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 241 K/uL\\n 10.2 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 30.0 %\\n 9.5 K/uL\\n [image002.jpg]\\n CXR: retrocardiac opacity likely LLL ateletasis\\n 04:15 AM\\n WBC\\n 9.5\\n Hct\\n 30.0\\n Plt\\n 241\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 107\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection.\\n - npo for now\\n - positive pressure ventilation this evening with repeat ABG\\n - transition back to trach mask, hopefully by tomorrow AM\\n - continue to monitor closely and suction prn\\n - IP team to see tomorrow to decide dispo\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) at discretion of IP\\n team\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - ekg in the Am\\n - cycle cardiac enzymes\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\\n formulary.\\n - resume home mirtazapine\\n - resume home modafinil on transfer to Rehab\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thin liquids when back on trach collar/cap, replete lytes prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: pending overnight monitoring, tolerating trach mask\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548055,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 06:50 PM\\n -found PEA on floor, brief Chest compression, pulse returned after\\n suction of trach\\n -transfered to MICU, no further events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Entacapone\\n Modadinil\\n Mirtazapine\\n Carbidopa-levodopa\\n Albuterol\\n Chlorhexidine\\n Heparin SQ\\n Omeprazole\\n Colace\\n Bisacodyl\\n Tylenol\\n MOM\\n Cyanocobalamin\\n Vit D\\n Calcium carbonate\\n Albuterol\\n Mucomyst\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 64 (63 - 80) bpm\\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\\n RR: 18 (10 - 34) insp/min\\n SpO2: 100% (97-100)\\n Heart rhythm: SR (Sinus Rhythm)\\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\\n Total In:\\n 250 mL\\n 35 mL\\n PO:\\n TF:\\n IVF:\\n 250 mL\\n 35 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 250 mL\\n -116 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 387 (103 - 515) mL\\n PS : 10 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: ///29/\\n Ve: 6.7 L/min\\n Physical Examination\\n Gen: Pleasant elderly female in no distress\\n HEENT: Sclerae slightly pale, tongue moist and midline\\n NECK: supple, no lad, no thyromegaly\\n CV: RRR. normal S1, S2. no murmurs appreciated.\\n LUNGS: clear BS, no wheezing\\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\\n erythema., normoactive bowel sounds, nontender to palpation\\n EXT: warm throughout, dp pulses 2+ bilaterally\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: alert, answering questions, hard of hearing in right ear, face\\n symmetric, tongue midline, pupils small but reactive bilaterally,\\n following commands (moving toes, grasping hand), moving all extremities\\n without difficulty, rhythmic tremor R > L hand and arm consistent with\\n h/o parkinson's\\n Peripheral 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 241 K/uL\\n 10.2 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 30.0 %\\n 9.5 K/uL\\n [image002.jpg]\\n CXR: retrocardiac opacity likely LLL ateletasis\\n 04:15 AM\\n WBC\\n 9.5\\n Hct\\n 30.0\\n Plt\\n 241\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 107\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection. CXR with LLL opacity consistant with resolving mucous\\n plugging\\n - npo for now, consider soft diet after stable on trach mask\\n - weaning off positive pressure ventilation am\\n - continue to monitor closely and suction prn\\n - IP team to see today to decide dispo\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) at discretion of IP\\n team\\n -CXR tomorrow to eval change in LLL opacity\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - ekg this am\\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet.\\n - resume home mirtazapine\\n - NF request for modafinil and entacapone\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thin liquids when back on trach collar/cap, replete lytes prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\\n Possible to floor today\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548060,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 06:50 PM\\n -found PEA on floor, brief Chest compression, pulse returned after\\n suction of trach\\n -transfered to MICU, no further events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Entacapone\\n Modadinil\\n Mirtazapine\\n Carbidopa-levodopa\\n Albuterol\\n Chlorhexidine\\n Heparin SQ\\n Omeprazole\\n Colace\\n Bisacodyl\\n Tylenol\\n MOM\\n Cyanocobalamin\\n Vit D\\n Calcium carbonate\\n Albuterol\\n Mucomyst\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 64 (63 - 80) bpm\\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\\n RR: 18 (10 - 34) insp/min\\n SpO2: 100% (97-100)\\n Heart rhythm: SR (Sinus Rhythm)\\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\\n Total In:\\n 250 mL\\n 35 mL\\n PO:\\n TF:\\n IVF:\\n 250 mL\\n 35 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 250 mL\\n -116 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 387 (103 - 515) mL\\n PS : 10 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: ///29/\\n Ve: 6.7 L/min\\n Physical Examination\\n Gen: Pleasant elderly female in no distress\\n HEENT: Sclerae slightly pale, tongue moist and midline\\n NECK: supple, no lad, no thyromegaly\\n CV: RRR. normal S1, S2. no murmurs appreciated.\\n LUNGS: clear BS, no wheezing\\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\\n erythema., normoactive bowel sounds, nontender to palpation\\n EXT: warm throughout, dp pulses 2+ bilaterally\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: alert, answering questions, hard of hearing in right ear, face\\n symmetric, tongue midline, pupils small but reactive bilaterally,\\n following commands (moving toes, grasping hand), moving all extremities\\n without difficulty, rhythmic tremor R > L hand and arm consistent with\\n h/o parkinson's\\n Peripheral 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 241 K/uL\\n 10.2 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 30.0 %\\n 9.5 K/uL\\n [image002.jpg]\\n CXR: retrocardiac opacity likely LLL ateletasis\\n 04:15 AM\\n WBC\\n 9.5\\n Hct\\n 30.0\\n Plt\\n 241\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 107\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection. CXR with LLL opacity consistant with resolving mucous\\n plugging\\n - npo for now, consider soft diet after stable on trach mask\\n - weaning off positive pressure ventilation am\\n - continue to monitor closely and suction prn\\n - IP team to see today to decide dispo\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) at discretion of IP\\n team\\n -CXR tomorrow to eval change in LLL opacity\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - ekg this am\\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet.\\n - resume home mirtazapine\\n - NF request for modafinil and entacapone\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thin liquids when back on trach collar/cap, replete lytes prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\\n Possible to floor today\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 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: 81 yo F with h/o Parkinson\\ns dz, recurrent\\n PNA, s/p tracheostomy at , admitted from rehab after\\n developing stridor and desaturations after placing cap on trach. FOB\\n on notable for tracheobroncheomalacia and malpositioning of\\n trache. \\n> trache changed. Post-proc on floor became brady to\\n 40s with pea arrest\\n code blue called\\n > CPR performed with pulse\\n returned within 1-2 minutes, suctioned with good result. Arrest\\n presumed secondary to mucus plugging. Transferred to MICU for close\\n observation / care s/p arrest. Remained on PP vent overnight.\\n Exam notable for Tm AF 98.8 BP 80/37-137/68 HR 64 (63-80) RR with sat\\n 97-100 on 40% PS 5/5. Awake and alert, following commands, sig\\n kyphosis, trach site clean, lungs CTA with decreased b/b BS, RR, peg\\n site without erythema, abd benign, baseline tremor and cogwheeling\\n Labs notable for WBC 9.5 (11)K, 30 HCT , 3.9K+ , 0.6Cr .\\n CXR: rotated, sig kyphosis, partial LLL collapse,\\n ECG--atrial ectopy and freq PACs, sinus rhythm, no acute ischemic\\n changes\\n ISSUES:\\n * s/p PEA arrest presumably from mucus plugging\\n * TBM\\n * Parkinson\\ns ds\\n Agree with plan to transition to trach mask with close monitoring.\\n Continue mucomyst, nebs, pulm toilet. Repeat cxr in am to monitor LLL\\n though no fever or wbc to suggest asp pna. IP service following. Given\\n significant TBM will likely require long term trach. Remains stable\\n from hemodynamic standpoint since PEA arrest.Neg CEs. Follow/replete\\n lytes given atrial ectopy on monitor. Continue Parkinson's regimen per\\n Rehab. Remainder of plan as outlined above.\\n Patient is critically ill, Once stable off PP on trach collar will\\n transfer to surgical floor.\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 01:45 PM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548118,\n \"text\": \"Events: Off vent to track mask- tolerating weel. Placed on PMV and\\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\\n of thick yellow secretions- pt able to bring up secretions to RN\\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\\n overnight and transfer to Rehab in AM. Likely will return as\\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\\n Rehab- reviewing POC and events, daughter (HCP) and family.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Tolerating being placed on trach mask then PMV\\n Action:\\n Close monitoring s/s aspiration\\n Response:\\n tolerating\\n Plan:\\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 548131,\n \"text\": \"TITLE: Resp Care Note, Pt remains on t-collar 40%. Instilled with\\n mucomyst and given MDI albuterol. Suctioned for thick tan plugs. Inner\\n cannula inn cuff inflated at this time.Needs inner cannula out during\\n suctioning. H20 filled all equipment present. Will cont to monitor resp\\n status.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 548091,\n \"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 Size:\\n Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 6.0mm\\n PMV: Yes\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Unassisted spontaneous breathing\\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:\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548187,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n URINE CULTURE - At 05:00 PM\\n cloudy urine\\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\\n cannot bronch to spinal fusion, can go to IP if looks good\\n - weaned off vent - sitting pretty on TM\\n - advanced to soft dysphagia/nektar thick liquids\\n - disimpacted for hard stool - may need more bowel meds\\n - desires to go back to rehab\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 06:10 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 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\\nC (96.8\\n HR: 62 (52 - 91) bpm\\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\\n RR: 23 (16 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 395 mL\\n 60 mL\\n PO:\\n TF:\\n IVF:\\n 35 mL\\n Blood products:\\n Total out:\\n 1,170 mL\\n 640 mL\\n Urine:\\n 1,170 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -776 mL\\n -580 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 171 (171 - 171) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 42\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SpO2: 98%\\n ABG: ///34/\\n Ve: 12.5 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 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Cr\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection. CXR with LLL opacity consistant with resolving mucous\\n plugging\\n - npo for now, consider soft diet after stable on trach mask\\n - weaned off ventilation, now on TM at 40%\\n - continue to monitor closely and suction prn\\n - IP team to see today to decide dispo\\n d/w IP team pt to go to floor\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) per IP team\\n -CXR tomorrow to eval change in LLL opacity\\n persistent LLL opacity,\\n c/w atelectasis, PA and lateral may be better to assess\\n -blood gas this AM to better assess pulmonary status in presence\\n of increased CO2\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - repeat EKG without any new changes\\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\\n entacapone (the last two ordered non-formulary)\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thick nectar liquids when back on trach collar/cap, replete lytes\\n prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548188,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n URINE CULTURE - At 05:00 PM\\n cloudy urine\\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\\n cannot bronch to spinal fusion, can go to IP if looks good\\n - weaned off vent - sitting pretty on TM\\n - advanced to soft dysphagia/nektar thick liquids\\n - disimpacted for hard stool - may need more bowel meds\\n - desires to go back to rehab\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 06:10 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 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\\nC (96.8\\n HR: 62 (52 - 91) bpm\\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\\n RR: 23 (16 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 395 mL\\n 60 mL\\n PO:\\n TF:\\n IVF:\\n 35 mL\\n Blood products:\\n Total out:\\n 1,170 mL\\n 640 mL\\n Urine:\\n 1,170 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -776 mL\\n -580 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 171 (171 - 171) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 42\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SpO2: 98%\\n ABG: ///34/\\n Ve: 12.5 L/min\\n Physical Examination\\n Gen: Pleasant elderly female in no distress\\n HEENT: Producing thin, nonpurulent sputum\\n CV: RRR. normal S1, S2\\n LUNGS: clear at apices, mild crackles at bases\\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\\n erythema., normoactive bowel sounds, nontender to palpation\\n EXT: warm throughout, dp pulses 2+ bilaterally\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: alert, answering questions, hard of hearing in right ear, masked\\n facies, rhythmic tremor R > L hand with pillrolling\\n Peripheral 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 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Cr\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection. CXR with LLL opacity consistant with resolving mucous\\n plugging\\n - npo for now, consider soft diet after stable on trach mask\\n - weaned off ventilation, now on TM at 40%\\n - continue to monitor closely and suction prn\\n - IP team to see today to decide dispo\\n d/w IP team pt to go to floor\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) per IP team\\n -CXR tomorrow to eval change in LLL opacity\\n persistent LLL opacity,\\n c/w atelectasis, PA and lateral may be better to assess\\n -blood gas this AM to better assess pulmonary status in presence\\n of increased CO2\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - repeat EKG without any new changes\\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\\n entacapone (the last two ordered non-formulary)\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thick nectar liquids when back on trach collar/cap, replete lytes\\n prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548202,\n \"text\": \"Events: Off vent to track mask- tolerating well. Placed on PMV and\\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\\n of thick yellow secretions- pt able to bring up secretions to RN\\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\\n overnight and transfer to Rehab in AM. Pt very anxious to go\\n back t o Rehab- reviewing POC and events, daughter (HCP) and\\n family. IP/surgery following - plan for flexible broncoscopy in AM for\\n re-eval for regarding ? T tube placement in house. C/O to floor.\\n Returning to Rehab pending results of broncoscopy.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Tolerating being placed on trach mask then PMV, large amount of oral\\n secretions-able to manage on own w/ suction, able to cough up secretios\\n to mouth, trach- mod amount thick yellow secretions\\n Action:\\n Close monitoring s/s aspiration\\n Response:\\n tolerating\\n Plan:\\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 548203,\n \"text\": \"Events: Occ suctioning sm amts of thick yellow secretions- pt able to\\n bring up secretions to RN able to easily suction out- occ deep\\n suctioning. Very anxious to go back t o Rehab- reviewing POC\\n and events, daughter (HCP) and family. IP/surgery following - plan for\\n flexible broncoscopy in AM for re-eval for regarding ? T tube placement\\n in house. C/O to floor. Returning to Rehab pending results of\\n broncoscopy.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Tolerating being placed on trach mask then PMV, large amount of oral\\n secretions-able to manage on own w/ suction, able to cough up\\n secretions to mouth, trach- mod amount thick yellow secretions\\n Action:\\n Close monitoring s/s aspiration\\n Response:\\n tolerating\\n Plan:\\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n AIRWAY OBSTRUCTION\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 71.4 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\\n spinal fusion,s/p trach following that.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:118\\n D:59\\n Temperature:\\n 98.1\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 28 insp/min\\n Heart Rate:\\n 65 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Trach mask\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 10 L/min\\n FiO2 set:\\n 40% %\\n 24h total in:\\n 420 mL\\n 24h total out:\\n 740 mL\\n Pertinent Lab Results:\\n Sodium:\\n 143 mEq/L\\n 02:57 AM\\n Potassium:\\n 3.7 mEq/L\\n 02:57 AM\\n Chloride:\\n 106 mEq/L\\n 02:57 AM\\n CO2:\\n 34 mEq/L\\n 02:57 AM\\n BUN:\\n 11 mg/dL\\n 02:57 AM\\n Creatinine:\\n 0.5 mg/dL\\n 02:57 AM\\n Glucose:\\n 83 mg/dL\\n 02:57 AM\\n Hematocrit:\\n 30.6 %\\n 02:57 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables: red and white shirt, white shoes, head phone to\\n increase hearing\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: MICU 6\\n Transferred to: 7\\n Date & time of Transfer: 12:00 AM\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 548205,\n \"text\": \"Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\\n fall with c2-4 fracture earlier this year admitted on due to\\n stridor and desaturations at her rehab facility in setting of placing\\n trach cap.\\n .\\n The patient was evaluated by neurosurgery on due to recent spinal\\n fusion and ? of rigid bronchoscopy. Based on her recent surgery, rigid\\n bronch is not indicated but the patient is apparently physically unable\\n to hyperextend her neck. On , the patient underwent flexible\\n bronchoscopy which revealed TBM with trach malpositioned. Her trach was\\n changed from Bovona to Portex 6 mm cuffed with inner cannula by Dr.\\n . She tolerated the procedure well with exception of atrial\\n tachyarrhythmia intermittently.\\n .\\n On the evening of , the patient was doing well on the Thoracics\\n floor. She was noted to be talking with her trach cap in place and had\\n her dinner. At about 1817, the patient was noted to have bradycardia on\\n telemetry monitoring. RN and MD personnel quickly went to the\\n bedside and the patient was noted to be pulseless. She was cyanotic and\\n apneic at that time. Her trach cap was uncapped and she was suctioned\\n with good result. She had about 1-2 minutes of chest compressions and\\n no medications and regained a good femoral pulse. BP following this was\\n in the 160s systolic. The patient was immediately more alert but not\\n answering questions. ABG during this time was 7.29/64/290.\\n Events: Occ suctioning sm amts of thick yellow secretions- pt able to\\n bring up secretions to RN able to easily suction out- occ deep\\n suctioning. Very anxious to go back t o Rehab- reviewing POC\\n and events, daughter (HCP) and family. IP/surgery following - plan for\\n flexible broncoscopy in AM for re-eval for regarding ? T tube placement\\n in house. C/O to floor. Returning to Rehab pending results of\\n broncoscopy.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Tolerating being placed on trach mask then PMV, large amount of oral\\n secretions-able to manage on own w/ suction, able to cough up\\n secretions to mouth, trach- mod amount thick yellow secretions\\n Action:\\n Close monitoring s/s aspiration\\n Response:\\n tolerating\\n Plan:\\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n AIRWAY OBSTRUCTION\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 71.4 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\\n spinal fusion,s/p trach following that.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:118\\n D:59\\n Temperature:\\n 98.1\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 28 insp/min\\n Heart Rate:\\n 65 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n Trach mask\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 10 L/min\\n FiO2 set:\\n 40% %\\n 24h total in:\\n 420 mL\\n 24h total out:\\n 740 mL\\n Pertinent Lab Results:\\n Sodium:\\n 143 mEq/L\\n 02:57 AM\\n Potassium:\\n 3.7 mEq/L\\n 02:57 AM\\n Chloride:\\n 106 mEq/L\\n 02:57 AM\\n CO2:\\n 34 mEq/L\\n 02:57 AM\\n BUN:\\n 11 mg/dL\\n 02:57 AM\\n Creatinine:\\n 0.5 mg/dL\\n 02:57 AM\\n Glucose:\\n 83 mg/dL\\n 02:57 AM\\n Hematocrit:\\n 30.6 %\\n 02:57 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables: red and white shirt, white shoes, head phone to\\n increase hearing\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: MICU 6\\n Transferred to: 7\\n Date & time of Transfer: 12:00 AM\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548093,\n \"text\": \"Events: Off vent to track mask- tolerating weel. Placed on PMV and\\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\\n of thick yellow secretions- pt able to bring up secretions to RN\\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\\n overnight and transfer to Rehab in AM. Likely will return as\\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\\n Rehab- reviewing POC and events, daughter (HCP) and family.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Tolerating being placed on trach mask then PMV\\n Action:\\n Close monitoring s/s aspiration\\n Response:\\n tolerating\\n Plan:\\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548191,\n \"text\": \"Events: Off vent to track mask- tolerating well. Placed on PMV and\\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\\n of thick yellow secretions- pt able to bring up secretions to RN\\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\\n overnight and transfer to Rehab in AM. Pt very anxious to go\\n back t o Rehab- reviewing POC and events, daughter (HCP) and\\n family.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Tolerating being placed on trach mask then PMV, large amount of oral\\n secretions-able to manage on own w/ suction, able to cough up secretios\\n to mouth, trach- mod amount thick yellow secretions\\n Action:\\n Close monitoring s/s aspiration\\n Response:\\n tolerating\\n Plan:\\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548192,\n \"text\": \"Events: Off vent to track mask- tolerating well. Placed on PMV and\\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\\n of thick yellow secretions- pt able to bring up secretions to RN\\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\\n overnight and transfer to Rehab in AM. Pt very anxious to go\\n back t o Rehab- reviewing POC and events, daughter (HCP) and\\n family. Plan to consult pt MD regarding ? T place\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Tolerating being placed on trach mask then PMV, large amount of oral\\n secretions-able to manage on own w/ suction, able to cough up secretios\\n to mouth, trach- mod amount thick yellow secretions\\n Action:\\n Close monitoring s/s aspiration\\n Response:\\n tolerating\\n Plan:\\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548193,\n \"text\": \"Events: Off vent to track mask- tolerating well. Placed on PMV and\\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\\n of thick yellow secretions- pt able to bring up secretions to RN\\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\\n overnight and transfer to Rehab in AM. Pt very anxious to go\\n back t o Rehab- reviewing POC and events, daughter (HCP) and\\n family. IP/surgery following - plan for flexible broncoscopy in AM for\\n re-eval for regarding ? T tube placement in house. C/O to floor.\\n Returning to Rehab pending results of broncoscopy.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Tolerating being placed on trach mask then PMV, large amount of oral\\n secretions-able to manage on own w/ suction, able to cough up secretios\\n to mouth, trach- mod amount thick yellow secretions\\n Action:\\n Close monitoring s/s aspiration\\n Response:\\n tolerating\\n Plan:\\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548194,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n URINE CULTURE - At 05:00 PM\\n cloudy urine\\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\\n cannot bronch to spinal fusion, can go to IP if looks good\\n - weaned off vent - sitting pretty on TM\\n - advanced to soft dysphagia/nektar thick liquids\\n - disimpacted for hard stool - may need more bowel meds\\n - desires to go back to rehab\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 06:10 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 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\\nC (96.8\\n HR: 62 (52 - 91) bpm\\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\\n RR: 23 (16 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 395 mL\\n 60 mL\\n PO:\\n TF:\\n IVF:\\n 35 mL\\n Blood products:\\n Total out:\\n 1,170 mL\\n 640 mL\\n Urine:\\n 1,170 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -776 mL\\n -580 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 171 (171 - 171) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 42\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SpO2: 98%\\n ABG: ///34/\\n Ve: 12.5 L/min\\n Physical Examination\\n Gen: Pleasant elderly female in no distress\\n HEENT: Producing thin, nonpurulent sputum\\n CV: RRR. normal S1, S2\\n LUNGS: clear at apices, mild crackles at bases\\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\\n erythema., normoactive bowel sounds, nontender to palpation\\n EXT: warm throughout, dp pulses 2+ bilaterally\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: alert, answering questions, hard of hearing in right ear, masked\\n facies, rhythmic tremor R > L hand with pillrolling\\n Peripheral 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 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Cr\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection. CXR with LLL opacity consistant with resolving mucous\\n plugging\\n - npo for now, consider soft diet after stable on trach mask\\n - weaned off ventilation, now on TM at 40%\\n - continue to monitor closely and suction prn\\n - IP team to see today to decide dispo\\n d/w IP team pt to go to floor\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) per IP team\\n -CXR tomorrow to eval change in LLL opacity\\n persistent LLL opacity,\\n c/w atelectasis, PA and lateral may be better to assess\\n -blood gas this AM to better assess pulmonary status in presence\\n of increased CO2\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - repeat EKG without any new changes\\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\\n entacapone (the last two ordered non-formulary)\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thick nectar liquids when back on trach collar/cap, replete lytes\\n prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 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: 81 yo F with h/o Parkinson\\ns dz, recurrent\\n PNA, s/p tracheostomy at , admitted from rehab after\\n developing stridor and desaturations after placing cap on trach. FOB\\n on notable for tracheobroncheomalacia and malpositioning of\\n trache. \\n> trache changed. Post-proc on floor became brady to\\n 40s with pea arrest\\nwith pulse returned within 1-2 minutes, suctioned\\n with good result. Arrest presumed secondary to mucus plugging.\\n Transferred to MICU for close observation / care s/p arrest.\\n Tolerating TM since yesterday. Diet advanced to prior.\\n Exam notable for Tm 97.8 BP 138/64 HR 62 RR 23 with sat 98% on\\n TM--40%. Awake and alert, following commands and speaking\\n appropriately, kyphoitc, trach site clean, lungs CTA with decreased b/b\\n BS, RR, abd benign, baseline tremor and cogwheeling\\n Labs notable for WBC 6.0, cr 0.5, serum CO2 34 (29).\\n CXR: rotated, sig kyphosis, underpenetrated\\nstable partial LLL\\n collapse\\n Active issues include:\\n * s/p PEA arrest, presumably from mucus plugging\\n * TBM\\n * Parkinson\\ns ds\\n Has tolerated trach mask X 24 hrs. Managing secretions well. Continue\\n mucomyst, nebs, pulm toilet, sx\\ning. CXR with stable partial LLL\\n collapse in setting of significant kyphosis, though clinically without\\n fever or leukcoytosis to suggest pna/tracheobronchitis. Secretions are\\n clear/nonpurulent. Tolerating prior diet without evidence of\\n aspiration. Given significant TBM will likely require long term trach.\\n Remains stable from hemodynamic standpoint since PEA arrest with less\\n ectopy on monitor. Serum CO2 is elevated today--may be from mild\\n contraction as put out sig urine. Is at risk for hypoventilation and\\n co2 retention given kyphosis and probable restrictive lung ds. Will\\n check abg to assess baseline CO2 but has remained very alert and\\n mentating appropriately. Would suggest monitoring of this at rehab.\\n Continue Parkinson's regimen. Remainder of plan as outlined above.\\n Stable for rehab transfer.\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 01:18 PM ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 548008,\n \"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 Tracheostomy tube:\\n Type: Standard\\n Manufacturer: Portex\\n Size: 6.0mm\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Plan\\n Next 24-48 hours:\\n Reason for continuing current ventilatory support:\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments: Pt remains on current vent settings. See vent flow sheet for\\n details. Pt rested on MMV overnight for periods of apnea. RSBI done on\\n 0 peep 5 ips 56. Pt awake and alert.Will consider weaning to t- collar\\n this AM.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548154,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n URINE CULTURE - At 05:00 PM\\n cloudy urine\\n - IP recs - wean as tol, repeat CXR ? of RLL PNA, hold off on abx,\\n cannot bronch to spinal fusion, can go to IP if looks good\\n - weaned off vent - sitting pretty on TM\\n - advanced to soft dysphagia/nektar thick liquids\\n - disimpacted for hard stool - may need more bowel meds\\n - desires to go back to rehab\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 06:10 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 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\\nC (96.8\\n HR: 62 (52 - 91) bpm\\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\\n RR: 23 (16 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 395 mL\\n 60 mL\\n PO:\\n TF:\\n IVF:\\n 35 mL\\n Blood products:\\n Total out:\\n 1,170 mL\\n 640 mL\\n Urine:\\n 1,170 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -776 mL\\n -580 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 171 (171 - 171) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 42\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SpO2: 98%\\n ABG: ///34/\\n Ve: 12.5 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 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Cr\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548155,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n URINE CULTURE - At 05:00 PM\\n cloudy urine\\n - IP recs - wean as tol, repeat CXR ? of RLL PNA, hold off on abx,\\n cannot bronch to spinal fusion, can go to IP if looks good\\n - weaned off vent - sitting pretty on TM\\n - advanced to soft dysphagia/nektar thick liquids\\n - disimpacted for hard stool - may need more bowel meds\\n - desires to go back to rehab\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 06:10 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 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\\nC (96.8\\n HR: 62 (52 - 91) bpm\\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\\n RR: 23 (16 - 32) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 395 mL\\n 60 mL\\n PO:\\n TF:\\n IVF:\\n 35 mL\\n Blood products:\\n Total out:\\n 1,170 mL\\n 640 mL\\n Urine:\\n 1,170 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -776 mL\\n -580 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 171 (171 - 171) mL\\n PS : 5 cmH2O\\n RR (Spontaneous): 42\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SpO2: 98%\\n ABG: ///34/\\n Ve: 12.5 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 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Cr\\n 0.6\\n 0.5\\n TropT\\n <0.01\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection. CXR with LLL opacity consistant with resolving mucous\\n plugging\\n - npo for now, consider soft diet after stable on trach mask\\n - weaning off positive pressure ventilation am\\n - continue to monitor closely and suction prn\\n - IP team to see today to decide dispo\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) at discretion of IP\\n team\\n -CXR tomorrow to eval change in LLL opacity\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - ekg this am\\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet.\\n - resume home mirtazapine\\n - NF request for modafinil and entacapone\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thin liquids when back on trach collar/cap, replete lytes prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\\n Possible to floor today\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548142,\n \"text\": \"Events: Off vent to track mask- tolerating weel. Placed on PMV and\\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\\n of thick yellow secretions- pt able to bring up secretions to RN\\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\\n overnight and transfer to Rehab in AM. Likely will return as\\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\\n Rehab- reviewing POC and events, daughter (HCP) and family.\\n .H/O airway obstruction, Central / Upper\\n Assessment:\\n Pt sating 95-100% on trach mask 40%, rec\\nd pt with PMV in, tolerating\\n well, A&Ox3- able to make needs known.\\n Action:\\n PMV taken out by respiratory for night, Close monitoring s/s\\n aspiration. Sxned x2 for sm-mod. Amounts of white thick sputum. Pt\\n able to raise most secretions on own, using yankuer by self.\\n Response:\\n Tolerating trach mask.\\n Plan:\\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\\n PRN. Plan to go to Rehab this AM.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548588,\n \"text\": \".H/O airway obstruction, Central / Upper\\n Assessment:\\n 02 sats 95-100% on 50% fi02 trache collar. LS w/ rhonch throughout.\\n Scant tan secretions noted.\\n Action:\\n Mucomyst nebs given Q 6. IV levaquin started. Sputum sample sent.\\n Response:\\n 02 sats 95-100% throughout the noc. No c/o sob. Pt able to expectorate\\n own scant, tan secretions.\\n Plan:\\n Continue pulmonary toilet. Q 6 hour mucomyst nebs. Follow up on results\\n of sputum sample sent.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 548579,\n \"text\": \".H/O airway obstruction, Central / Upper\\n Assessment:\\n Action:\\n Mucomyst nebs given Q 6. IV levaquin started. Sputum sample sent.\\n Response:\\n 02 sats 95-100% throughout the noc. No c/o sob. Pt able to expectorate\\n own scant, tan secretions.\\n Plan:\\n Continue pulmonary toilet. Q 6 hour mucomyst nebs. Follow up on results\\n of sputum sample sent.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-15 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 548580,\n \"text\": \"SICU\\n HPI:\\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\\n placed for concern of unstable C-spine. Admitted for\\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\\n rigid bronch concern of hyperextension) showed mod granulation\\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\\n trach. underwent trach change for malpositioned tube. That\\n night after capping trach, pt went to brady/PEA arrest thought to be\\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\\n T-tube secretions.\\n Chief complaint:\\n tracheal stenosis\\n PMHx:\\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\\n fusion at , Recurrent pneumonia\\n Current medications:\\n 24 Hour Events:\\n SPUTUM CULTURE - At 05:27 AM\\n NASAL SWAB - At 05:29 AM\\n CALLED OUT\\n Post operative day:\\n HD 6, POD 2 (T-tube)\\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Levofloxacin - 03:00 AM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 06:00 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37\\nC (98.6\\n T current: 36.7\\nC (98\\n HR: 68 (55 - 71) bpm\\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\\n RR: 22 (12 - 26) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 229 mL\\n PO:\\n Tube feeding:\\n 65 mL\\n IV Fluid:\\n 164 mL\\n Blood products:\\n Total out:\\n 880 mL\\n 1,480 mL\\n Urine:\\n 880 mL\\n 1,480 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -880 mL\\n -1,251 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n SPO2: 98%\\n ABG: ////\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n Moves all extremities, hard of hearing, able to communicate w/ writing.\\n Labs / Radiology\\n 243 K/uL\\n 10.2 g/dL\\n 83 mg/dL\\n 0.5 mg/dL\\n 34 mEq/L\\n 3.7 mEq/L\\n 11 mg/dL\\n 106 mEq/L\\n 143 mEq/L\\n 30.6 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:15 AM\\n 02:57 AM\\n 02:34 PM\\n WBC\\n 9.5\\n 6.0\\n Hct\\n 30.0\\n 30.6\\n Plt\\n 241\\n 243\\n Creatinine\\n 0.6\\n 0.5\\n Troponin T\\n <0.01\\n TCO2\\n 35\\n Glucose\\n 107\\n 83\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\\n placement.\\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\\n Modafinil, Mirtazapine\\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \\n will diuresis. t/c echo\\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\\n self suction.\\n Gastrointestinal / Abdomen: g-tube\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\\n Hematology: stable\\n Endocrine: RISS\\n Infectious Disease: levoquin for RLL infiltrate by team\\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\\n Wounds:\\n Imaging:\\n Fluids: KVO\\n Consults: Thoracic, Interventional Pulm\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 11:08 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548022,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 06:50 PM\\n -found PEA on floor, brief Chest compression, pulse returned after\\n suction of trach\\n -transfered to MICU, no further events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 64 (63 - 80) bpm\\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\\n RR: 18 (10 - 34) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 250 mL\\n 35 mL\\n PO:\\n TF:\\n IVF:\\n 250 mL\\n 35 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 250 mL\\n -116 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 387 (103 - 515) mL\\n PS : 10 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: ///29/\\n Ve: 6.7 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 241 K/uL\\n 10.2 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 30.0 %\\n 9.5 K/uL\\n [image002.jpg]\\n 04:15 AM\\n WBC\\n 9.5\\n Hct\\n 30.0\\n Plt\\n 241\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 107\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 548023,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 06:50 PM\\n -found PEA on floor, brief Chest compression, pulse returned after\\n suction of trach\\n -transfered to MICU, no further events\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:51 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 64 (63 - 80) bpm\\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\\n RR: 18 (10 - 34) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 250 mL\\n 35 mL\\n PO:\\n TF:\\n IVF:\\n 250 mL\\n 35 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 250 mL\\n -116 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 387 (103 - 515) mL\\n PS : 10 cmH2O\\n RR (Set): 10\\n RR (Spontaneous): 17\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 56\\n PIP: 15 cmH2O\\n SpO2: 100%\\n ABG: ///29/\\n Ve: 6.7 L/min\\n Physical Examination\\n Gen: Pleasant elderly female in no distress\\n HEENT: Sclerae slightly pale, tongue moist and midline\\n NECK: supple, no lad, no thyromegaly\\n CV: RRR. normal S1, S2. no murmurs appreciated.\\n LUNGS: coarse breath sounds bilaterally, no wheezing\\n ABD: soft, PEG in place in LUQ, normoactive bowel sounds, nontender to\\n palpation\\n EXT: warm throughout, dp pulses 2+ bilaterally\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: alert, answering questions, hard of hearing in right ear, face\\n symmetric, tongue midline, pupils small but reactive bilaterally,\\n following commands (moving toes, grasping hand), moving all extremities\\n without difficulty, rhythmic tremor R > L hand and arm consistent with\\n h/o parkinson's\\n Peripheral 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 241 K/uL\\n 10.2 g/dL\\n 107 mg/dL\\n 0.6 mg/dL\\n 29 mEq/L\\n 3.9 mEq/L\\n 14 mg/dL\\n 105 mEq/L\\n 140 mEq/L\\n 30.0 %\\n 9.5 K/uL\\n [image002.jpg]\\n 04:15 AM\\n WBC\\n 9.5\\n Hct\\n 30.0\\n Plt\\n 241\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 107\\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\\n admitted to MICU after PEA arrest on the floor.\\n .\\n # Respiratory distress: Patient was noted to be apneic on the floor\\n prior to PEA arrest. Likely related to mucous plugging but patient\\n reportedly had dinner so could be related to aspiration. Per notes from\\n Rehab was eating a soft diet there with thin liquids. Do not\\n feel that there is evidence of new pneumonia at this time (no WBC\\n elevation, no fever); will continue to monitor for signs/symptoms of\\n infection.\\n - npo for now\\n - positive pressure ventilation this evening with repeat ABG\\n - transition back to trach mask, hopefully by tomorrow AM\\n - continue to monitor closely and suction prn\\n - IP team to see tomorrow to decide dispo\\n - continue albuterol/atrovent nebs with mucomyst nebs\\n - further trach interventions (i.e., rigid bronch) at discretion of IP\\n team\\n .\\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\\n Telemetry monitoring during time of event appears to have artifact\\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\\n bradycardia. Artifact could represent chest compressions and no other\\n telemetry strips printed from time of event. Cardiac enzymes sent\\n peri-code negative and ekg is unchanged from prior.\\n - ekg in the Am\\n - cycle cardiac enzymes\\n - monitor respiratory status closely as above\\n .\\n # Osteoporosis: Continue calcium and vitamin D.\\n .\\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\\n formulary.\\n - resume home mirtazapine\\n - resume home modafinil on transfer to Rehab\\n .\\n # FEN: npo for now while on positive pressure ventilation, soft diet\\n with thin liquids when back on trach collar/cap, replete lytes prn\\n .\\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\\n .\\n # CODE: full code, confirmed with daughter\\n .\\n # COMM: with patient and daughter , \\n .\\n # DISP: pending overnight monitoring, tolerating trach mask\\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:35 PM\\n 20 Gauge - 02:46 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-11-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1051013,\n \"text\": \" 3:32 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change LLL\\n Admitting Diagnosis: AIRWAY OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with trach s/p PEA arrest after likely mucous plug. Fully\\n recoved. LLL opacity on previous CXR\\n REASON FOR THIS EXAMINATION:\\n interval change LLL\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest, .\\n\\n HISTORY: 81-year-old woman with tracheostomy, status post PEA arrest. Likely\\n mucous plug. Evaluate left lower lobe opacity.\\n\\n FINDINGS: Comparison is made to previous study from .\\n\\n There has been decrease in the amount of gas within the known hiatal hernia.\\n There remains cardiomegaly stable. There is improvement of the air\\n bronchograms within the left base; however, there remains consolidation in\\n this location. There are no signs for overt pulmonary edema. There has also\\n been improvement of the infiltrate at the right base.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-11-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1050857,\n \"text\": \" 7:49 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pneumothorax\\n Admitting Diagnosis: AIRWAY OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with\\n REASON FOR THIS EXAMINATION:\\n pneumothorax\\n ______________________________________________________________________________\\n WET READ: ARHb FRI 8:43 PM\\n No pneumothorax identified. Retrocardiac opacity may represent left lower lobe\\n atelectasis. Right basilar atelectasis also likely. D/ @\\n 20:40.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n CLINICAL INFORMATION: Pneumothorax.\\n\\n FINDINGS:\\n\\n There is a very large hiatal hernia which occupies the mid section of the\\n chest. There is large left lower lobe consolidation with air bronchograms and\\n a moderate left pleural effusion. These findings have increased since prior\\n study. There is also focal right lower lobe consolidation. Heart is\\n enlarged. Aorta is tortuous. Tracheostomy remains in the midline.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-11-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1051468,\n \"text\": \" 9:40 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pna\\n Admitting Diagnosis: AIRWAY OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with T-tube and rigid bronch yesterday, increased secretions\\n REASON FOR THIS EXAMINATION:\\n pna\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj TUE 12:21 PM\\n New right lower lobe opacity may represent aspiration or less likely\\n hemorrhage/edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 81-year-old female status post tracheal T-tube change and rigid\\n bronchoscopy on .\\n\\n PORTABLE AP CHEST: Comparison is made to . The cardiomediastinal\\n contours are stable. A new right lower lobe opacity is evident. Dense\\n consolidation versus atelectasis at the left lung base is unchanged. The\\n upper lungs are well aerated. Lucency projecting over the mid thoracic spine,\\n compatible with patient's known hiatal hernia appears similar to previous\\n studies.\\n\\n IMPRESSION: New dense opacity in the right lower lobe status post\\n bronchoscopy and tracheal T-tube change. The differential diagnosis includes\\n aspiration given recent procedure. Other diagnostic considerations include\\n hemorrhage or edema. Close interval followup is recommended.\\n\\n Findings were discussed with Dr. on the morning of by Dr.\\n over the telephone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-11-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1051469,\n \"text\": \", TSURG FA7A 9:40 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pna\\n Admitting Diagnosis: AIRWAY OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with T-tube and rigid bronch yesterday, increased secretions\\n REASON FOR THIS EXAMINATION:\\n pna\\n ______________________________________________________________________________\\n PFI REPORT\\n New right lower lobe opacity may represent aspiration or less likely\\n hemorrhage/edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2141-11-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1051625,\n \"text\": \" 7:36 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval for progressing ? PNA\\n Admitting Diagnosis: AIRWAY OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with purulent secretions\\n REASON FOR THIS EXAMINATION:\\n eval for progressing ? PNA\\n ______________________________________________________________________________\\n WET READ: KYg TUE 8:42 PM\\n PRELIMINARY REPORT: MULTIFOCAL BILATERAL OPACITIES WORRISOME FOR PNEUMONIA.\\n COMPARED TO THE PRIOR EXAM THERE IS SLIGLHTLY IMPROVED AERATION OF THE RIGHT\\n LUNG BASE. NO PNEUMOTHORAX. NOTE IS MADE OF CHANGES RELATED TO CERVICAL FUSION\\n AND LAMINECTOMY. \\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 7:49 P.M. \\n\\n HISTORY: Purulent secretions.\\n\\n IMPRESSION: AP chest compared to and 16:\\n\\n Severe bibasilar consolidation which developed between and has worsened on the right since , stable on the left since\\n though associated moderate left pleural effusion is slightly\\n smaller today than on . Moderate-to-severe cardiomegaly is stable.\\n Esophagus is distended above a large gastric hiatus hernia. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2141-11-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224169,\n \"text\": \"Sinus rhythm with occasional ventricular ectopy and occasional atrial ectopy.\\nNon-specific inferior ST-T wave changes. Compared to the previous tracing\\nof the limb lead voltage has diminished and ventricular ectopy has\\nappeared. Otherwise no diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2141-11-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224170,\n \"text\": \"Sinus rhythm. Frequent premature atrial contractions. Voltage criteria\\nfor left ventricular hypertrophy. Lateral ST-T wave abnormalities which are\\nnon-specific. Compared to the previous tracing of frequent atrial\\npremature beats are new. There are voltage criteria for left ventricular\\nhypertrophy which are new.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2141-11-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224171,\n \"text\": \"Sinus rhythm. Poor R wave progression. Non-specific low amplitude\\nT waves in the inferior and lateral leads. Compared to the previous tracing\\nof T wave flattening is more pronounced and the Q-T interval is\\nshorter.\\n\\n\"\n }\n]"}}},{"rowIdx":774,"cells":{"subject_id":{"kind":"number","value":27097,"string":"27,097"},"hadm_id":{"kind":"number","value":177588,"string":"177,588"},"target_text":{"kind":"string","value":"He was admitted to the Trauma service. Neurosurgery/Spine was consulted for his spine injuries which were non operative. He underwent MRI of Thoracic and Lumbar spine and was maintained on log roll precautions pending MRI outcome. He was fitted for TLSO brace and will need to wear this when out of bed. His pain is being controlled with Tylenol around the clock and prn Oxycodone. Follow up in clinic with Dr. in 6 weeks. Orthopedics was also consulted given his for his left clavicle fracture; this was also nonoperative. A sling was recommended; he is to remain non weight bearing on his left arm. Follow up with Dr. in 2 weeks. He did have an elevated blood pressure postoperatively; systolic BP was on high 160's, and was started on Lopressor.His systolic BP has been in 140's range since starting Lopressor. He was evaluated by Physical and Occupational therapy and was recommended for rehab following acute hospital stay."},"extractive_notes_summ":{"kind":"string","value":"The aorta is mildly tortuous, with atherosclerotic calcifications. Hypertension resloved after ativan given. A separate well-corticated ossification is seen at the superior aspect of the left acromioclavicular joint, which reflects old trauma. Mild anterior wedging of the T5 and T7 vertebral bodies. Sinus rhythmVentricular premature complexBorderline first degree A-V delayConsider left atrial abnormalityProminent precordial low QRS voltage - consider left ventricular hypertrophyalthough is nondiagnosticNo previous tracing available for comparison Comminuted, mildly displaced fracture of the distal clavicle. afebrile.Resp: on 4L NC, LS clear bilat, diminished in bases. Linear hypodense structures coursing adjacent to the largest lesion, may reflect a minimally dilated intrahepatic duct. mild bilateral neuroforaminal narrowing at these levels. Minimally displaced right transverse process fractures at L3 and L4. Pt continued with hypertension and slightly tachycardic (100's). Mild compression deformity of the T5 and T7 vertebral bodies, may be acute. There are multilevel degenerative changes, with a slight accentuation of the normal cervical lordosis. Nursing Noteevents: C-spine clearedNeuro: Pt. Remote trauma noted cephalad to the acromioclavicular joint. On delayed images, these subsequently demonstrate centripetal enhancement, suggestive of hemangiomas. The adenoma signal changes in compressions of T6-T10 and T12 are suggestive of mild acute compressions. Compression boots and SC Heparin for prophylaxis.RESP-Lung sounds clear with diminished bases R>L. MAE, LUE without full ROM d/t clavicle fx. Slight anterior wedging of T5 and T7 vertebral bodies, without associated hematoma or retropulsion. At L5-S1 level, disc degenerative changes are identified with mild bulging without spinal stenosis. Left distal clavicle fracture. There is also slight irregularity of the inferior endplate of the T6 vertebral body, which likely represents a degenerative/Schmorl's node. There is a mildly displaced fracture of the coracoid process of the scapula with slight inferior displacement of the coracoid. T/SICU NURSING PROGRESS NOTE*PLEASE SEE CAREVUE FOR EXACT DATA*SIGNIFICANT EVENTS: Pt noted for hypertension unrelated to pain. HCT stable Compression boots and SC Heparin.RESP-Lung sounds clear with diminished bases, 4L NC. The lungs are essentially clear except for right lower lobe opacity consistent with atelectasis. OOB as tolerated Dr. . afebrile.Resp: On 2L NC, LS diminished throughout. Left shoulder abrasion and ecchymosis. The humeral head is grossly in place. FINAL REPORT HISTORY: Status post MVA, Rule out bleed or fracture. Degenerative disc disease and mild bulging seen from L1 and S2-L4 L5 level. SBP 160-190-no parameters.Resp: 2L NC, BS diminished bilaterally.GI: +BS, soft abdomen non tender, non distended. Prolonged A-V conduction.Possible left ventricular hypertrophy. LUMBAR SPINE: TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of the (Over) 12:53 AM MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # Reason: assess soft tissue around fx Admitting Diagnosis: BLUNT TRAUMA FINAL REPORT (Cont) lumbar spine were acquired. In the visualized lower thoracic region, mild acute compression of T12 vertebra seen on the superior endplate, as seen on the thoracic spine MRI. Chronic compressions of T3-T5 vertebral bodies. Rule out fracture. Probable left shoulder joint effusion. Otherwise, paranasal sinuses and mastoid air cells are normally aerated. PORTABLE SUPINE AP CHEST, ON A TRAUMA BACKBOARD: Heart size is in the upper limits of normal. CT left shoulder done, MRI TLS done.N: A/O x3. FINDINGS: There is an oblique fracture through the distal diaphysis of the left clavicle with no definite intra-articular extension. There is a focal rounded hypodense lesion within the corona radiata on the left, which may represent a prior lacunar infarct. for brace.CV: HR as noted, BP WNL.Resp: on 3L NC, 1250 on IS. There are minimally displaced fractures of the right transverse process at L3 and L4. There is a comminuted fracture of the distal left clavicle. If TLS clear get OOB. small bulges and facet hypertrophy at L3/4, L4/5, L5/S1. Morphine PCA for pain- using appropriately. THORACIC SPINE: TECHNIQUE: T1, T2, and inversion recovery sagittal, and T2 axial images obtained. There is marrow edema seen in the inferior aspect of T6 with mild compression. The airways are patent to the subsegmental level. Logg roll precautions-awaiting MRI Thoracic and LS. T/SICU NURSING PROGRESS NOTENO SIGNIFICANT EVENTS TIHS SHIFT*REVIEW OF SYSTEMS*NEURO-Pt A&Ox3, able to MAE's with LUE slightly weaker due to injury. MG 1.7-2gr given. Compression boots and SC Heparin for prophylaxis.RESP-Lung sounds diminished, continues on 2L NC. Nursing NoteEvents: Pt. Nursing NoteEvents: Pt. TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast. There is no evidence of There is subtle increased signal is seen in the interspinous region at T5-6.07 T5-6 and T6 and inversion recovery images, which could be secondary to mild trauma to the interspinous ligament. Mild acute compressions of T6, T10 and T12 without spinal stenosis. Initial Chem 10 hemolyzed, labs repeated and WNL.INTEG-Skin tear noted to LUE and right knee, adaptic dressings intact. T/SICU NURSING PROGRESS NOTENO SIGNIFICANT EVENTS THIS SHIFTREVIEW OF SYSTEMS:NEURO-Pt A&Ox3, exam intact. NEOPS in to measure pt. Neuro checks Q1hr. Neuro checks Q1hr. Neuro checks Q1hr. Sinus rhythm with ventricular premature beats. A well-corticated bony fragment lies cephalad to the acromioclavicular joint and may be the result of more remote trauma. Additionally, there is minimal grade 1 retrolisthesis of C3 on C4 and C4 on C5. Subtle linear increased signal within the mid thoracic spinal cord represents an incidental slight prominence of central canal. SBP 140-190.Resp: BS diminished throughout."},"n_notes":{"kind":"number","value":20,"string":"20"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2112-05-08 00:00:00.000","description":"Report","row_id":1616501,"text":"Addendum\nHOB may be increased >30 degrees and pt. OOB as tolerated Dr. .\n"},{"category":"Nursing/other","chartdate":"2112-05-09 00:00:00.000","description":"Report","row_id":1616502,"text":"T/SICU NURSING PROGRESS NOTE\n\nNO SIGNIFICANT EVENTS THIS SHIFT\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt A&Ox3, exam intact. MAE's LUE weaker due to injury. Continues on Morphine PCA 0.5mg q6minutes with adequate pain control. Pt given Ambien as sleep aide and slept throughout majority of night.\n\nCV-NSR with occ PVC's rate 60-70's, NIBP with SBP raning 120-150's. PIVx2. HCT stable Compression boots and SC Heparin.\n\nRESP-Lung sounds clear with diminished bases, 4L NC. Using IS at 1500. Strong cough. No distress noted\n\nGI/GU-Abdomen soft with present bowel sounds. House diet. No BM, colace given. H2B\n\nENDO-RISS, no coverage required.\n\nID-Afebrile, no antibiotics ordered.\n\nINTEG-Skin tear and abrasion to LUE, right knee with laceration and adaptic dressing.\n\n nephew called and updated last night.\n\nPLAN-Continue to monitor for pain control, increase activity as ordered, encourage diet, coughing/deep breathing and IS use.\n"},{"category":"Nursing/other","chartdate":"2112-05-09 00:00:00.000","description":"Report","row_id":1616503,"text":"Nursing Note\nEvents: Pt. OOB to chair, fitted for TLSO brace today.\n\nNeuro: Pain well controlled with PCA. Pt. very anxoius to get OOB this am, able to move quite well with PCA. NEOPS in to measure pt. for brace.\n\nCV: HR as noted, BP WNL.\n\nResp: on 3L NC, 1250 on IS. LS clear bilat diminished in bases.\n\nGI/GU: House diet, aqueqaute UOP.\n\nSocial: No family contact overnight.\n\nPlan: Brace placement on Wed.\nPain control\nEncourage ambulation\nPt. support and encouragement.\n"},{"category":"Radiology","chartdate":"2112-05-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1014772,"text":" 5:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: trauma chest\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVC vs truck, ejected, +LOC, abdominal pain\n REASON FOR THIS EXAMINATION:\n trauma chest\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of a patient after trauma.\n\n Portable AP supine radiograph which was obtained on was brought\n to our review today on .\n\n The heart size is mildly enlarged but stable. The mediastinal contours are\n unremarkable. The lungs are essentially clear except for right lower lobe\n opacity consistent with atelectasis. Multiple rib fractures are noted in the\n right hemithorax. For more detailed description of the chest pathology please\n refer to torso CT obtained on at 5:49 p.m. and the corresponding\n report.\n\n"},{"category":"Radiology","chartdate":"2112-05-06 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":1014768,"text":" 5:35 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p MVA\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc FRI 6:54 PM\n No acute fx or malalignment. Multilevel degenerative changes.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old status post MVA. Rule out fracture.\n\n No prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images were obtained from the skull base to T1.\n Coronal and sagittal reformatted images were reviewed in conjunction with the\n axial.\n\n FINDINGS: There is no prevertebral soft tissue abnormality. No acute\n fracture or malalignment is identified. There are multilevel degenerative\n changes, with a slight accentuation of the normal cervical lordosis.\n Degenerative changes are most severe at C3-4 and C4-5, with loss of disc\n height space and slight bony proliferative changes. Additionally, there is\n minimal grade 1 retrolisthesis of C3 on C4 and C4 on C5. The central canal\n appears largely patent. Visualized lung apices reveal no evidence for\n pneumothorax.\n\n IMPRESSION:\n 1. No acute fracture or malalignment.\n 2. Multilevel degenerative changes.\n\n Findings entered into the emergency dashboard at the time of interpretation.\n\n"},{"category":"Radiology","chartdate":"2112-05-06 00:00:00.000","description":"CT PELVIS W/CONTRAST","row_id":1014770,"text":" 5:36 PM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: r/o injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p MVA\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc FRI 7:59 PM\n Multiple right sided rib fx with small hemothorax. Right transverse fx\n involving L3 and L4. Coracoid fx on the left with extension to the glenoid.\n Extensive soft tissue swelling and hematoma in the region of the left deltoid.\n Mild compression deformity of the T5 and T7 vertebral bodies, may be acute.\n D/w Dr. from surgery.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old status post MVA, rule out injury.\n\n No prior studies for comparison.\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis with the administration of IV contrast. Delayed images\n through the liver were also obtained. Coronal and sagittal reformatted images\n were viewed in conjunction with the axial.\n\n CT OF THE CHEST WITH IV CONTRAST: Mild atherosclerotic calcifications of the\n coronary arteries and aortic arch are seen. Otherwise, the heart,\n pericardium, and great vessels are unremarkable, without evidence of an acute\n injury. There are no pathologically enlarged mediastinal, hilar, or axillary\n lymphadenopathy.\n\n The lungs are clear without evidence of a focal contusion. There is a small\n amount of fluid within the right posterior pleural space in the region of\n multiple rib fractures, consistent with a small hemothorax. Within this\n hemothorax, there is a sliver of bone from an adjacent rib fracture. The\n airways are patent to the subsegmental level.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Within the right lobe of the liver, there\n is a large heterogeneous 5 cm predominantly hypodense lesion, and a smaller\n one measuring approximately 1.6 cm slightly cephalad. On delayed images,\n these subsequently demonstrate centripetal enhancement, suggestive of\n hemangiomas. Linear hypodense structures coursing adjacent to the largest\n lesion, may reflect a minimally dilated intrahepatic duct. There is no\n evidence of an acute injury in the liver. The kidneys, gallbladder, spleen,\n adrenal glands, and pancreas are unremarkable. Stomach and bowel are within\n normal limits. There is no free air, free fluid, or adenopathy. There are\n atherosclerotic calcifications of the abdominal aorta, with atheromatous\n plaque seen. There is no evidence of an acute aortic injury.\n\n CT OF THE PELVIS WITH IV CONTRAST: Foley catheter courses into the bladder.\n (Over)\n\n 5:36 PM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: r/o injury\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Prostate and rectum are unremarkable. There is no free fluid or adenopathy.\n\n OSSEOUS STRUCTURES: There are multiple minimally displaced right-sided rib\n fractures. Specifically, there is a fracture involving the posterior right\n fifth, sixth, seventh, and eighth ribs; the lateral right ninth, tenth, and\n eleventh ribs; and the posterior right twelfth rib.\n\n There are minimally displaced fractures of the right transverse process at L3\n and L4.\n\n There is a displaced fracture of the left coracoid process, and a bone\n fragment in the joint space, possibly from the glenoid. There is associated\n extensive soft tissue swelling and hematoma in the left upper extremity and\n around the deltoid. Within the soft tissues in the right posterior pelvis,\n subcutaneous stranding may also possibly represent an area of contusion.\n\n Mild anterior wedging of the T5 and T7 vertebral bodies. Although there is no\n associated hematoma or retropulsion of fragments into the central canal, these\n may represent acute compression fractures. There is also slight irregularity\n of the inferior endplate of the T6 vertebral body, which likely represents a\n degenerative/Schmorl's node.\n\n IMPRESSION:\n 1. Multiple right-sided rib fractures, with an associated small right\n hemothorax.\n\n 2. Left coracoid fracture, with possible involvement of the glenoid, and\n associated extensive soft tissue swelling and hematoma.\n\n 3. Minimally displaced right transverse process fractures at L3 and L4.\n\n 4. Slight anterior wedging of T5 and T7 vertebral bodies, without associated\n hematoma or retropulsion. These may represent an acute compression fracture.\n If clinically warranted, an MR may be obtained for confirmation.\n\n 5. Two rounded hypodense lesions within the liver, likely representing\n hemangiomas.\n\n Findings posted to the ED dashboard at the time of interpretation.\n\n"},{"category":"Radiology","chartdate":"2112-05-06 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1014767,"text":" 5:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed, fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p MVA\n REASON FOR THIS EXAMINATION:\n r/o bleed, fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc FRI 5:55 PM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post MVA, Rule out bleed or fracture.\n\n No prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, edema, mass effect,\n shift of normally midline structures, or acute major vascular territorial\n infarction. Periventricular white matter low attenuation is most consistent\n with chronic small vessel ischemic disease. There is a focal rounded\n hypodense lesion within the corona radiata on the left, which may represent a\n prior lacunar infarct. The ventricles and sulci are normal in caliber and\n configuration. No acute fractures are identified. Atherosclerotic\n calcification of the cavernous portions of the carotid arteries are seen\n bilaterally. There is mild mucosal thickening of the ethmoidal sinuses.\n Otherwise, paranasal sinuses and mastoid air cells are normally aerated.\n\n IMPRESSION: No acute intracranial process.\n\n Findings posted to the ED dashboard at the time of interpretation.\n\n\n"},{"category":"Radiology","chartdate":"2112-05-07 00:00:00.000","description":"MR THORACIC SPINE W/O CONTRAST","row_id":1014801,"text":" 12:53 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: assess soft tissue around fx\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVC, T5 & T7 end plate fx\n REASON FOR THIS EXAMINATION:\n assess soft tissue around fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KN SAT 4:07 AM\n MR - superior endplate fx's of T6,10, 12. no extension to posterior\n elements. no retropulsion, epidural hematoma or cord compression.\n\n MR - NO fx. small bulges and facet hypertrophy at L3/4, L4/5, L5/S1.\n mild bilateral neuroforaminal narrowing at these levels.\n\n , MD NIghtvision\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the thoracic and lumbar spine.\n\n CLINICAL INFORMATION: Patient with motor vehicle accident and T5-T7\n fractures, for further evaluation.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal, and T2 axial images\n obtained.\n\n FINDINGS: There are chronic compressions of T3-T4 and T5 vertebral bodies\n identified without any marrow edema. There is marrow edema seen in the\n inferior aspect of T6 with mild compression. Additionally, superior endplate\n of T10 and T2 demonstrate increased signal with mild compression. The adenoma\n signal changes in compressions of T6-T10 and T12 are suggestive of mild acute\n compressions. There is no retropulsion identified or spinal canal stenosis\n seen. There is no evidence of spinal cord compression or intraspinal hematoma\n identified. Subtle linear increased signal within the mid thoracic spinal\n cord represents an incidental slight prominence of central canal. There is no\n evidence of There is subtle increased signal is seen in the interspinous\n region at T5-6.07 T5-6 and T6 and inversion recovery images, which could be\n secondary to mild trauma to the interspinous ligament. However, there is no\n MRI evidence of disruption of the ligament idea identified.\n\n IMPRESSION:\n 1. Mild acute compressions of T6, T10 and T12 without spinal stenosis.\n Chronic compressions of T3-T5 vertebral bodies. No spinal stenosis or spinal\n cord compression. Other changes as described above.\n\n LUMBAR SPINE:\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of the\n (Over)\n\n 12:53 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: assess soft tissue around fx\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lumbar spine were acquired.\n\n FINDINGS: There is no evidence of marrow edema seen or fracture identified in\n the lumbar vertebral bodies or in the visualized upper sacrum. Degenerative\n disc disease and mild bulging seen from L1 and S2-L4 L5 level. At L5-S1\n level, disc degenerative changes are identified with mild bulging without\n spinal stenosis. There is no evidence of high-grade foraminal narrowing seen.\n\n In the visualized lower thoracic region, mild acute compression of T12\n vertebra seen on the superior endplate, as seen on the thoracic spine MRI.\n\n Mild decreased signal within the right side of L4 vertebra on T1- and T2-\n weighted images, is not confirmed on inversion recovery images could be due to\n an atypical hemangioma. This could also be due to heterogenous marrow signal.\n\n IMPRESSION: No evidence of compression fracture or marrow edema in the lumbar\n region. Degenerative changes.\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2112-05-07 00:00:00.000","description":"CT UP EXT W/O C","row_id":1014803,"text":" 1:28 AM\n CT UP EXT W/O C Clip # \n Reason: assess fx of shoulder\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with coracoid fx, ? glenoid fx\n REASON FOR THIS EXAMINATION:\n assess fx of shoulder\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE LEFT SHOULDER WITHOUT CONTRAST\n\n INDICATION: Evaluate for coracoid fracture or glenoid fracture.\n\n TECHNIQUE: CT scan of the left shoulder was performed without intravenous\n contrast. Images were acquired in the axial plane. Coronal and sagittal\n reformats were created and reviewed. No comparisons.\n\n FINDINGS: Numerous fractures are seen about the shoulder. There is a\n comminuted fracture of the distal left clavicle. There is a mildly displaced\n fracture of the coracoid process of the scapula with slight inferior\n displacement of the coracoid. Numerous fracture fragments are seen in\n association with the glenoid, including comminuted fracture of the posterior\n lip of the glenoid as well as a cortical fracture fragment seen in the\n superior aspect of the glenohumeral joint. No scapular body or humeral\n fracture is seen. The visualized left upper ribs are intact. Multilevel\n degenerative changes of the lower cervical spine are seen. Visualized portion\n of the left lung apex is clear. Hemorrhage and edema is seen tracking into\n the axilla, likely related to the fractures. A focal hematoma is seen within\n the subcutaneous soft tissues of the upper arm and there is contiguous edema\n and standing likely also related to the known fractures. There is a\n suggestion of a left shoulder joint effusion. A separate well-corticated\n ossification is seen at the superior aspect of the left acromioclavicular\n joint, which reflects old trauma.\n\n IMPRESSION:\n\n 1. Fracture of the coracoid process of the scapula with inferior displacement\n of the coracoid.\n\n 2. Comminuted, mildly displaced fracture of the distal clavicle.\n\n 3. Numerous fracture fragments adjacent to the glenoid, likely arising from\n the posterior and superior aspects of the glenoid rim.\n\n 4. No evidence of proximal humeral or scapular body fractures.\n\n 5. Extensive associated soft tissue stranding and focal hematoma in the\n subcutaneous soft tissues of the left upper arm. Probable left shoulder joint\n effusion.\n\n (Over)\n\n 1:28 AM\n CT UP EXT W/O C Clip # \n Reason: assess fx of shoulder\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Nursing/other","chartdate":"2112-05-10 00:00:00.000","description":"Report","row_id":1616504,"text":"T/SICU NURSING PROGRESS NOTE\n\nNO SIGNIFICANT EVENTS TIHS SHIFT\n\n*REVIEW OF SYSTEMS*\n\nNEURO-Pt A&Ox3, able to MAE's with LUE slightly weaker due to injury. Ambien given at 2100, pt slept for 3 hour periods throughout night. Denies pain at rest, c/o pain to right ribs with activity/turning which is relieved by Morphine PCA 0.5mg q6 minutes. Pt OOB to chair throughout day, fitted for TLSO brace yesterday (brace needed x6wks for ambulating).\n\nCV-NSR rate 60-80's with occ. PVC's. SBP ranging 130-160 and stable. New #18G PIV placed to right FA. HCT stable at 30.9. Compression boots and SC Heparin for prophylaxis.\n\nRESP-Lung sounds clear with diminished bases R>L. Continues on 4L NC sat mid to high 90's. Strong productive cough. Using IS at 1000-1250.\n\nGI/GU-Abdomen soft with present bowel sounds. Non tender to palpation. Tolerating regular diet. H2B. Indwelling foley catheter with adequate amounts of clear yellow UOP. Initial Chem 10 hemolyzed, labs repeated and WNL.\n\nINTEG-Skin tear noted to LUE and right knee, adaptic dressings intact. Left shoulder abrasion and ecchymosis. Sling to left arm for comfort.\n\nENDO-BS q12hours, no insulin coverage required.\n\nID-No issues, wbc's 8.6 and stable. No abx.\n\n nephew is spokesperson, called last night and updated on pts progress and poc. He or his wife will be in this afternoon, pt requested they bring his glasses.\n\nPLAN-?transfer to floor, monitor for pain, encourage IS use and coughing/deep breathing, oob to chair, awaiting arrival of tlso brace (pt fitted yesterday)\n"},{"category":"Nursing/other","chartdate":"2112-05-08 00:00:00.000","description":"Report","row_id":1616499,"text":"T/SICU NURSING PROGRESS NOTE\n\n*PLEASE SEE CAREVUE FOR EXACT DATA*\n\nSIGNIFICANT EVENTS: Pt noted for hypertension unrelated to pain. Spoke to Dr. (SBP 170's), Hydralizine given 10mg x2 doses with little effect. Pt continued with hypertension and slightly tachycardic (100's). Pt denied pain however reported that he was anxious because he thought he was going to die. He began speaking about his will and last rights. He reported he was unable to get enough oxygen to his lungs and that he \"would just close my eyes and it will be over\". Spoke to Dr and pt given Ativan 0.5mg x1 dose IV for anxiety. Continuing to monitor.\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt A&Ox3, MAE's. LUE slightly weaker due to injury. , strong cough and gag. +sensation throughout extremities. Please note episode listed above. Pt denies pain at rest, however reports pain to right ribs with turning/movement. Morphine PCA 0.5mg q6mintues tolerated well. HOB<30degrees, needs TLSO brace.\n\nCV-NSR rate 60-80's with occ PVC's. SBP ranging 130-170's, Hydralizine 10mg iv given x2 doses w/ little relief. Hypertension resloved after ativan given. PIVx2. Compression boots and SC Heparin for prophylaxis.\n\nRESP-Lung sounds diminished, continues on 2L NC. Attempted to weak off o2 and sats down to 92%. Using IS at 1250.\n\nGI-Abdomen soft with present bowel sounds. House diet as ordered. H2b\n\nGU-Indwelling foley catheter with adequate amounts of clear yellow uop. Lytes wnl.\n\nENDO-RISS without coverage required.\n\nID-No issues\n\nSOCIAL-No family contacts overnight.\n\nPLAN-Follow up with TLSO brace status, encourage diet and is use, monitor hemodynamics, montior for pain/anxiety issues and medicate as needed. ?transfer to floor if cleared by team.\n"},{"category":"Nursing/other","chartdate":"2112-05-08 00:00:00.000","description":"Report","row_id":1616500,"text":"Nursing Note\nEvents: Pt. ordered for TLSO brace. NEOPS unable to come until Tuesday d/t holiday.\n\nNeuro: Pt. remains on PCA, using only during movements. Pain controled well with PCA. MAE's, follows commands. Trauma team wants to keep HOB no higher than 30 degrees.\n Pt. describing dream he had last evening where he thought medical team was giving him his last rights. Pt. stating that the dream was so vivid and he thought the staff was out to get him and he was going to die. Pt. revealed that when he woke up this morning everything was suddenl\\y clear and he knew he was dreaming. Pt. asked for encouragement that he was going to survive and continue an active life.\n\nCV: HR 80-90's NSR with occasional PVC. BP WNL. Pt. afebrile.\n\nResp: on 4L NC, LS clear bilat, diminished in bases. Pt. acheiving 1250 on IS.\n\nGI/GU: on house diet, abd. benign, no stool. Foley in place draining clear yellow urine.\n\nEndo: No insulin given per RISS.\n\nSkin: Abrasions and skin tears as documented.\n\nSocial: Family called today, updated to POC.\n\nPlan:\nTLSO brace on Tues/Wed.\nGet pt. OOB\nPain control/ HOB<30 degrees\nPt. and family support\n"},{"category":"Nursing/other","chartdate":"2112-05-07 00:00:00.000","description":"Report","row_id":1616497,"text":"addendum admission Note\nEvents: Patient admitted(see admission note). CT left shoulder done, MRI TLS done.\n\nN: A/O x3. normal strengths LE upper extremities not able to lift and hold but can move on bed. Purposeful. PERRLA 3mm bilaterally and briskly reactive. Neuro checks Q1hr. Morphine PCA for pain- using appropriately. MG 1.7-2gr given. Pt on log roll precautions- J in place until TLS cleared. LR @60.\n\nCVS: NSR-70-80's with occasional- frequent PVC's. A febrile. SBP 140-190.\n\nResp: BS diminished throughout. Pt encouraged to CDB. 2L NC. Multip rib fx's see FHP for full injury list.\n\nGI: NPO except meds. +BS throughout. NO BM this shift.\n\nGU: voiding adequate amounts of clear yellow urine.\n\nEndo: covered per RISS- 148,166\n\nSkin: see carevue for specifics.\n\nPlan: Awaiting results of MRI and CT. ? D/c log roll and or J when results read. Encourage to CDB. If TLS clear get OOB. Pain Management- continue to educate about use of PCA. Neuro checks Q1hr.\n"},{"category":"Nursing/other","chartdate":"2112-05-07 00:00:00.000","description":"Report","row_id":1616498,"text":"Nursing Note\nevents: C-spine cleared\n\nNeuro: Pt. very pleasant, A&O x3, appropriate. MAE, LUE without full ROM d/t clavicle fx. , pt. follows commands, on Morphine PCA with good pain control. HOB up to 30 degrees, TLS brace ordered.\n\nCV: HR 60-70's NSR with frequent PVC's. BP WNL. Pt. afebrile.\n\nResp: On 2L NC, LS diminished throughout. IS encouraged, pt. up to 1500.\n\nGI/GU: Pt. on House diet, Abd. benign, no stool. Foley in place draining clear yellow urine.\n\nendo: Insulin given as noted.\n\nSkin: Abrasion and skin tears as documented, adaptics in place.\n\nPlan:\nTLS brace then OOB\nPain control\nencourage IS, CDB\n"},{"category":"Nursing/other","chartdate":"2112-05-06 00:00:00.000","description":"Report","row_id":1616496,"text":"admission\n85 y.o male s/p rollover MVC-pt hit from side. restrained driver. Initially didn't remember events at scene. Med flighted to . Now recalls all events- pt was restrained unbelted self and crawled out of car waited on side of road. Injuries Include: Multiple rib fractures right side, right side small hemothorax, Left transverse fracture L3-L4, Left coracoid fracture extending to glenoid. Left distal clavicle fracture. Skin abrasion to left shoulder, skin tear left lower arm, skin tear to right knee, and hematoma to left upper arm.\n\nNo PMH: no medications on admission.\n\nPast surgeries: hernia repair, surgery to left eye WWII after ? shrapnel got into eye from stove explosion.\n\nN: A/o X3. Neuro checks Q1hr. Follows commands pleasant. LUE able to move on bed but not able to lift and hold. All other extremities equal strength. PERRLA 3mm briskly reactive bilaterally. PCA morphine for pain. Logg roll precautions-awaiting MRI Thoracic and LS. Also awaiting CT left shoulder\n\nCVS: HR 70-80's NSR with occasional to frequent PVC's. SBP 160-190-no parameters.\n\nResp: 2L NC, BS diminished bilaterally.\n\nGI: +BS, soft abdomen non tender, non distended. NPO at this time\n\nGU: foley draining patent yellow urine.\n\nSocial: nephew and wife into visit. Nephew is spokesperson.\n\n"},{"category":"Radiology","chartdate":"2112-05-06 00:00:00.000","description":"L HUMERUS (AP & LAT) LEFT","row_id":1014773,"text":" 6:05 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT; HUMERUS (AP & LAT) LEFTClip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVC vs truck, ejected, +LOC, abdominal pain\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n LEFT SHOULDER THREE VIEWS LEFT HUMERUS TWO VIEWS AT 18:03 HOURS\n\n HISTORY: Motor vehicle collision post-ejection.\n\n COMPARISON: CT of the torso acquired earlier same day.\n\n FINDINGS: There is an oblique fracture through the distal diaphysis of the\n left clavicle with no definite intra-articular extension. A well-corticated\n bony fragment lies cephalad to the acromioclavicular joint and may be the\n result of more remote trauma. The humeral head is grossly in place. Please\n note orthogonal views such as scapular, Y or axillary were not obtained. There\n are multiple bony fragments retracted at the level of the proximal diaphysis\n of the humerus. The elbow joint is grossly appropriately aligned.\n\n IMPRESSION: Oblique fracture of the distal clavicle with no significant\n displacement or distraction. Remote trauma noted cephalad to the\n acromioclavicular joint. No definite dislocation is seen although for\n confirmatory evidence consider orthogonal view. Bony fragments seen in the\n medial aspect of the arm have likely avulsed from the coracoid process or\n possibly the glenoid.\n\n\n"},{"category":"Radiology","chartdate":"2112-05-06 00:00:00.000","description":"TRAUMA #3 (PORT CHEST ONLY)","row_id":1014761,"text":" 4:59 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n No prior studies for comparison.\n\n PORTABLE SUPINE AP CHEST, ON A TRAUMA BACKBOARD: Heart size is in the upper\n limits of normal. The aorta is mildly tortuous, with atherosclerotic\n calcifications. Prominence of the right upper mediastinum likely reflects\n vascular shadows. No focal pulmonary consolidation is identified. There is\n no evidence of pneumothorax or pleural effusion. There are multiple mildly\n displaced right rib fractures, specifically the posterior aspect of the 5-8th\n ribs.\n\n IMPRESSION: Multiple mildly displaced right rib fractures. No clear evidence\n of a pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2112-05-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1015118,"text":" 9:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with rib fractures\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rib fractures, to evaluate for change.\n\n FINDINGS: In comparison with study of , there has been development of\n some atelectatic changes at the left base. Rib fractures again seen but no\n evidence of pneumothorax.\n\n\n"},{"category":"ECG","chartdate":"2112-05-06 00:00:00.000","description":"Report","row_id":213951,"text":"Sinus rhythm\nVentricular premature complex\nBorderline first degree A-V delay\nConsider left atrial abnormality\nProminent precordial low QRS voltage - consider left ventricular hypertrophy\nalthough is nondiagnostic\nNo previous tracing available for comparison\n\n"},{"category":"ECG","chartdate":"2112-05-06 00:00:00.000","description":"Report","row_id":213952,"text":"Sinus rhythm with ventricular premature beats. Prolonged A-V conduction.\nPossible left ventricular hypertrophy. No previous tracing availa comparison.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616501,\n \"text\": \"Addendum\\nHOB may be increased >30 degrees and pt. OOB as tolerated Dr. .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616502,\n \"text\": \"T/SICU NURSING PROGRESS NOTE\\n\\nNO SIGNIFICANT EVENTS THIS SHIFT\\n\\nREVIEW OF SYSTEMS:\\n\\nNEURO-Pt A&Ox3, exam intact. MAE's LUE weaker due to injury. Continues on Morphine PCA 0.5mg q6minutes with adequate pain control. Pt given Ambien as sleep aide and slept throughout majority of night.\\n\\nCV-NSR with occ PVC's rate 60-70's, NIBP with SBP raning 120-150's. PIVx2. HCT stable Compression boots and SC Heparin.\\n\\nRESP-Lung sounds clear with diminished bases, 4L NC. Using IS at 1500. Strong cough. No distress noted\\n\\nGI/GU-Abdomen soft with present bowel sounds. House diet. No BM, colace given. H2B\\n\\nENDO-RISS, no coverage required.\\n\\nID-Afebrile, no antibiotics ordered.\\n\\nINTEG-Skin tear and abrasion to LUE, right knee with laceration and adaptic dressing.\\n\\n nephew called and updated last night.\\n\\nPLAN-Continue to monitor for pain control, increase activity as ordered, encourage diet, coughing/deep breathing and IS use.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616503,\n \"text\": \"Nursing Note\\nEvents: Pt. OOB to chair, fitted for TLSO brace today.\\n\\nNeuro: Pain well controlled with PCA. Pt. very anxoius to get OOB this am, able to move quite well with PCA. NEOPS in to measure pt. for brace.\\n\\nCV: HR as noted, BP WNL.\\n\\nResp: on 3L NC, 1250 on IS. LS clear bilat diminished in bases.\\n\\nGI/GU: House diet, aqueqaute UOP.\\n\\nSocial: No family contact overnight.\\n\\nPlan: Brace placement on Wed.\\nPain control\\nEncourage ambulation\\nPt. support and encouragement.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1014772,\n \"text\": \" 5:58 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: trauma chest\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man s/p MVC vs truck, ejected, +LOC, abdominal pain\\n REASON FOR THIS EXAMINATION:\\n trauma chest\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of a patient after trauma.\\n\\n Portable AP supine radiograph which was obtained on was brought\\n to our review today on .\\n\\n The heart size is mildly enlarged but stable. The mediastinal contours are\\n unremarkable. The lungs are essentially clear except for right lower lobe\\n opacity consistent with atelectasis. Multiple rib fractures are noted in the\\n right hemithorax. For more detailed description of the chest pathology please\\n refer to torso CT obtained on at 5:49 p.m. and the corresponding\\n report.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 1014768,\n \"text\": \" 5:35 PM\\n CT C-SPINE W/O CONTRAST Clip # \\n Reason: r/o fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n s/p MVA\\n REASON FOR THIS EXAMINATION:\\n r/o fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JXKc FRI 6:54 PM\\n No acute fx or malalignment. Multilevel degenerative changes.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 85-year-old status post MVA. Rule out fracture.\\n\\n No prior studies for comparison.\\n\\n TECHNIQUE: Contiguous axial images were obtained from the skull base to T1.\\n Coronal and sagittal reformatted images were reviewed in conjunction with the\\n axial.\\n\\n FINDINGS: There is no prevertebral soft tissue abnormality. No acute\\n fracture or malalignment is identified. There are multilevel degenerative\\n changes, with a slight accentuation of the normal cervical lordosis.\\n Degenerative changes are most severe at C3-4 and C4-5, with loss of disc\\n height space and slight bony proliferative changes. Additionally, there is\\n minimal grade 1 retrolisthesis of C3 on C4 and C4 on C5. The central canal\\n appears largely patent. Visualized lung apices reveal no evidence for\\n pneumothorax.\\n\\n IMPRESSION:\\n 1. No acute fracture or malalignment.\\n 2. Multilevel degenerative changes.\\n\\n Findings entered into the emergency dashboard at the time of interpretation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"CT PELVIS W/CONTRAST\",\n \"row_id\": 1014770,\n \"text\": \" 5:36 PM\\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT CHEST W/CONTRAST\\n Reason: r/o injury\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n s/p MVA\\n REASON FOR THIS EXAMINATION:\\n r/o injury\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JXKc FRI 7:59 PM\\n Multiple right sided rib fx with small hemothorax. Right transverse fx\\n involving L3 and L4. Coracoid fx on the left with extension to the glenoid.\\n Extensive soft tissue swelling and hematoma in the region of the left deltoid.\\n Mild compression deformity of the T5 and T7 vertebral bodies, may be acute.\\n D/w Dr. from surgery.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 85-year-old status post MVA, rule out injury.\\n\\n No prior studies for comparison.\\n\\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\\n symphysis pubis with the administration of IV contrast. Delayed images\\n through the liver were also obtained. Coronal and sagittal reformatted images\\n were viewed in conjunction with the axial.\\n\\n CT OF THE CHEST WITH IV CONTRAST: Mild atherosclerotic calcifications of the\\n coronary arteries and aortic arch are seen. Otherwise, the heart,\\n pericardium, and great vessels are unremarkable, without evidence of an acute\\n injury. There are no pathologically enlarged mediastinal, hilar, or axillary\\n lymphadenopathy.\\n\\n The lungs are clear without evidence of a focal contusion. There is a small\\n amount of fluid within the right posterior pleural space in the region of\\n multiple rib fractures, consistent with a small hemothorax. Within this\\n hemothorax, there is a sliver of bone from an adjacent rib fracture. The\\n airways are patent to the subsegmental level.\\n\\n CT OF THE ABDOMEN WITH IV CONTRAST: Within the right lobe of the liver, there\\n is a large heterogeneous 5 cm predominantly hypodense lesion, and a smaller\\n one measuring approximately 1.6 cm slightly cephalad. On delayed images,\\n these subsequently demonstrate centripetal enhancement, suggestive of\\n hemangiomas. Linear hypodense structures coursing adjacent to the largest\\n lesion, may reflect a minimally dilated intrahepatic duct. There is no\\n evidence of an acute injury in the liver. The kidneys, gallbladder, spleen,\\n adrenal glands, and pancreas are unremarkable. Stomach and bowel are within\\n normal limits. There is no free air, free fluid, or adenopathy. There are\\n atherosclerotic calcifications of the abdominal aorta, with atheromatous\\n plaque seen. There is no evidence of an acute aortic injury.\\n\\n CT OF THE PELVIS WITH IV CONTRAST: Foley catheter courses into the bladder.\\n (Over)\\n\\n 5:36 PM\\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT CHEST W/CONTRAST\\n Reason: r/o injury\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Prostate and rectum are unremarkable. There is no free fluid or adenopathy.\\n\\n OSSEOUS STRUCTURES: There are multiple minimally displaced right-sided rib\\n fractures. Specifically, there is a fracture involving the posterior right\\n fifth, sixth, seventh, and eighth ribs; the lateral right ninth, tenth, and\\n eleventh ribs; and the posterior right twelfth rib.\\n\\n There are minimally displaced fractures of the right transverse process at L3\\n and L4.\\n\\n There is a displaced fracture of the left coracoid process, and a bone\\n fragment in the joint space, possibly from the glenoid. There is associated\\n extensive soft tissue swelling and hematoma in the left upper extremity and\\n around the deltoid. Within the soft tissues in the right posterior pelvis,\\n subcutaneous stranding may also possibly represent an area of contusion.\\n\\n Mild anterior wedging of the T5 and T7 vertebral bodies. Although there is no\\n associated hematoma or retropulsion of fragments into the central canal, these\\n may represent acute compression fractures. There is also slight irregularity\\n of the inferior endplate of the T6 vertebral body, which likely represents a\\n degenerative/Schmorl's node.\\n\\n IMPRESSION:\\n 1. Multiple right-sided rib fractures, with an associated small right\\n hemothorax.\\n\\n 2. Left coracoid fracture, with possible involvement of the glenoid, and\\n associated extensive soft tissue swelling and hematoma.\\n\\n 3. Minimally displaced right transverse process fractures at L3 and L4.\\n\\n 4. Slight anterior wedging of T5 and T7 vertebral bodies, without associated\\n hematoma or retropulsion. These may represent an acute compression fracture.\\n If clinically warranted, an MR may be obtained for confirmation.\\n\\n 5. Two rounded hypodense lesions within the liver, likely representing\\n hemangiomas.\\n\\n Findings posted to the ED dashboard at the time of interpretation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1014767,\n \"text\": \" 5:35 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o bleed, fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n s/p MVA\\n REASON FOR THIS EXAMINATION:\\n r/o bleed, fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JXKc FRI 5:55 PM\\n No acute intracranial process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post MVA, Rule out bleed or fracture.\\n\\n No prior studies for comparison.\\n\\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\\n contrast.\\n\\n FINDINGS: There is no intra- or extra-axial hemorrhage, edema, mass effect,\\n shift of normally midline structures, or acute major vascular territorial\\n infarction. Periventricular white matter low attenuation is most consistent\\n with chronic small vessel ischemic disease. There is a focal rounded\\n hypodense lesion within the corona radiata on the left, which may represent a\\n prior lacunar infarct. The ventricles and sulci are normal in caliber and\\n configuration. No acute fractures are identified. Atherosclerotic\\n calcification of the cavernous portions of the carotid arteries are seen\\n bilaterally. There is mild mucosal thickening of the ethmoidal sinuses.\\n Otherwise, paranasal sinuses and mastoid air cells are normally aerated.\\n\\n IMPRESSION: No acute intracranial process.\\n\\n Findings posted to the ED dashboard at the time of interpretation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-07 00:00:00.000\",\n \"description\": \"MR THORACIC SPINE W/O CONTRAST\",\n \"row_id\": 1014801,\n \"text\": \" 12:53 AM\\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \\n Reason: assess soft tissue around fx\\n Admitting Diagnosis: BLUNT TRAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man s/p MVC, T5 & T7 end plate fx\\n REASON FOR THIS EXAMINATION:\\n assess soft tissue around fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KN SAT 4:07 AM\\n MR - superior endplate fx's of T6,10, 12. no extension to posterior\\n elements. no retropulsion, epidural hematoma or cord compression.\\n\\n MR - NO fx. small bulges and facet hypertrophy at L3/4, L4/5, L5/S1.\\n mild bilateral neuroforaminal narrowing at these levels.\\n\\n , MD NIghtvision\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRI of the thoracic and lumbar spine.\\n\\n CLINICAL INFORMATION: Patient with motor vehicle accident and T5-T7\\n fractures, for further evaluation.\\n\\n THORACIC SPINE:\\n\\n TECHNIQUE: T1, T2, and inversion recovery sagittal, and T2 axial images\\n obtained.\\n\\n FINDINGS: There are chronic compressions of T3-T4 and T5 vertebral bodies\\n identified without any marrow edema. There is marrow edema seen in the\\n inferior aspect of T6 with mild compression. Additionally, superior endplate\\n of T10 and T2 demonstrate increased signal with mild compression. The adenoma\\n signal changes in compressions of T6-T10 and T12 are suggestive of mild acute\\n compressions. There is no retropulsion identified or spinal canal stenosis\\n seen. There is no evidence of spinal cord compression or intraspinal hematoma\\n identified. Subtle linear increased signal within the mid thoracic spinal\\n cord represents an incidental slight prominence of central canal. There is no\\n evidence of There is subtle increased signal is seen in the interspinous\\n region at T5-6.07 T5-6 and T6 and inversion recovery images, which could be\\n secondary to mild trauma to the interspinous ligament. However, there is no\\n MRI evidence of disruption of the ligament idea identified.\\n\\n IMPRESSION:\\n 1. Mild acute compressions of T6, T10 and T12 without spinal stenosis.\\n Chronic compressions of T3-T5 vertebral bodies. No spinal stenosis or spinal\\n cord compression. Other changes as described above.\\n\\n LUMBAR SPINE:\\n\\n TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of the\\n (Over)\\n\\n 12:53 AM\\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \\n Reason: assess soft tissue around fx\\n Admitting Diagnosis: BLUNT TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n lumbar spine were acquired.\\n\\n FINDINGS: There is no evidence of marrow edema seen or fracture identified in\\n the lumbar vertebral bodies or in the visualized upper sacrum. Degenerative\\n disc disease and mild bulging seen from L1 and S2-L4 L5 level. At L5-S1\\n level, disc degenerative changes are identified with mild bulging without\\n spinal stenosis. There is no evidence of high-grade foraminal narrowing seen.\\n\\n In the visualized lower thoracic region, mild acute compression of T12\\n vertebra seen on the superior endplate, as seen on the thoracic spine MRI.\\n\\n Mild decreased signal within the right side of L4 vertebra on T1- and T2-\\n weighted images, is not confirmed on inversion recovery images could be due to\\n an atypical hemangioma. This could also be due to heterogenous marrow signal.\\n\\n IMPRESSION: No evidence of compression fracture or marrow edema in the lumbar\\n region. Degenerative changes.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-07 00:00:00.000\",\n \"description\": \"CT UP EXT W/O C\",\n \"row_id\": 1014803,\n \"text\": \" 1:28 AM\\n CT UP EXT W/O C Clip # \\n Reason: assess fx of shoulder\\n Admitting Diagnosis: BLUNT TRAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with coracoid fx, ? glenoid fx\\n REASON FOR THIS EXAMINATION:\\n assess fx of shoulder\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT SCAN OF THE LEFT SHOULDER WITHOUT CONTRAST\\n\\n INDICATION: Evaluate for coracoid fracture or glenoid fracture.\\n\\n TECHNIQUE: CT scan of the left shoulder was performed without intravenous\\n contrast. Images were acquired in the axial plane. Coronal and sagittal\\n reformats were created and reviewed. No comparisons.\\n\\n FINDINGS: Numerous fractures are seen about the shoulder. There is a\\n comminuted fracture of the distal left clavicle. There is a mildly displaced\\n fracture of the coracoid process of the scapula with slight inferior\\n displacement of the coracoid. Numerous fracture fragments are seen in\\n association with the glenoid, including comminuted fracture of the posterior\\n lip of the glenoid as well as a cortical fracture fragment seen in the\\n superior aspect of the glenohumeral joint. No scapular body or humeral\\n fracture is seen. The visualized left upper ribs are intact. Multilevel\\n degenerative changes of the lower cervical spine are seen. Visualized portion\\n of the left lung apex is clear. Hemorrhage and edema is seen tracking into\\n the axilla, likely related to the fractures. A focal hematoma is seen within\\n the subcutaneous soft tissues of the upper arm and there is contiguous edema\\n and standing likely also related to the known fractures. There is a\\n suggestion of a left shoulder joint effusion. A separate well-corticated\\n ossification is seen at the superior aspect of the left acromioclavicular\\n joint, which reflects old trauma.\\n\\n IMPRESSION:\\n\\n 1. Fracture of the coracoid process of the scapula with inferior displacement\\n of the coracoid.\\n\\n 2. Comminuted, mildly displaced fracture of the distal clavicle.\\n\\n 3. Numerous fracture fragments adjacent to the glenoid, likely arising from\\n the posterior and superior aspects of the glenoid rim.\\n\\n 4. No evidence of proximal humeral or scapular body fractures.\\n\\n 5. Extensive associated soft tissue stranding and focal hematoma in the\\n subcutaneous soft tissues of the left upper arm. Probable left shoulder joint\\n effusion.\\n\\n (Over)\\n\\n 1:28 AM\\n CT UP EXT W/O C Clip # \\n Reason: assess fx of shoulder\\n Admitting Diagnosis: BLUNT TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616504,\n \"text\": \"T/SICU NURSING PROGRESS NOTE\\n\\nNO SIGNIFICANT EVENTS TIHS SHIFT\\n\\n*REVIEW OF SYSTEMS*\\n\\nNEURO-Pt A&Ox3, able to MAE's with LUE slightly weaker due to injury. Ambien given at 2100, pt slept for 3 hour periods throughout night. Denies pain at rest, c/o pain to right ribs with activity/turning which is relieved by Morphine PCA 0.5mg q6 minutes. Pt OOB to chair throughout day, fitted for TLSO brace yesterday (brace needed x6wks for ambulating).\\n\\nCV-NSR rate 60-80's with occ. PVC's. SBP ranging 130-160 and stable. New #18G PIV placed to right FA. HCT stable at 30.9. Compression boots and SC Heparin for prophylaxis.\\n\\nRESP-Lung sounds clear with diminished bases R>L. Continues on 4L NC sat mid to high 90's. Strong productive cough. Using IS at 1000-1250.\\n\\nGI/GU-Abdomen soft with present bowel sounds. Non tender to palpation. Tolerating regular diet. H2B. Indwelling foley catheter with adequate amounts of clear yellow UOP. Initial Chem 10 hemolyzed, labs repeated and WNL.\\n\\nINTEG-Skin tear noted to LUE and right knee, adaptic dressings intact. Left shoulder abrasion and ecchymosis. Sling to left arm for comfort.\\n\\nENDO-BS q12hours, no insulin coverage required.\\n\\nID-No issues, wbc's 8.6 and stable. No abx.\\n\\n nephew is spokesperson, called last night and updated on pts progress and poc. He or his wife will be in this afternoon, pt requested they bring his glasses.\\n\\nPLAN-?transfer to floor, monitor for pain, encourage IS use and coughing/deep breathing, oob to chair, awaiting arrival of tlso brace (pt fitted yesterday)\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616499,\n \"text\": \"T/SICU NURSING PROGRESS NOTE\\n\\n*PLEASE SEE CAREVUE FOR EXACT DATA*\\n\\nSIGNIFICANT EVENTS: Pt noted for hypertension unrelated to pain. Spoke to Dr. (SBP 170's), Hydralizine given 10mg x2 doses with little effect. Pt continued with hypertension and slightly tachycardic (100's). Pt denied pain however reported that he was anxious because he thought he was going to die. He began speaking about his will and last rights. He reported he was unable to get enough oxygen to his lungs and that he \\\"would just close my eyes and it will be over\\\". Spoke to Dr and pt given Ativan 0.5mg x1 dose IV for anxiety. Continuing to monitor.\\n\\nREVIEW OF SYSTEMS:\\n\\nNEURO-Pt A&Ox3, MAE's. LUE slightly weaker due to injury. , strong cough and gag. +sensation throughout extremities. Please note episode listed above. Pt denies pain at rest, however reports pain to right ribs with turning/movement. Morphine PCA 0.5mg q6mintues tolerated well. HOB<30degrees, needs TLSO brace.\\n\\nCV-NSR rate 60-80's with occ PVC's. SBP ranging 130-170's, Hydralizine 10mg iv given x2 doses w/ little relief. Hypertension resloved after ativan given. PIVx2. Compression boots and SC Heparin for prophylaxis.\\n\\nRESP-Lung sounds diminished, continues on 2L NC. Attempted to weak off o2 and sats down to 92%. Using IS at 1250.\\n\\nGI-Abdomen soft with present bowel sounds. House diet as ordered. H2b\\n\\nGU-Indwelling foley catheter with adequate amounts of clear yellow uop. Lytes wnl.\\n\\nENDO-RISS without coverage required.\\n\\nID-No issues\\n\\nSOCIAL-No family contacts overnight.\\n\\nPLAN-Follow up with TLSO brace status, encourage diet and is use, monitor hemodynamics, montior for pain/anxiety issues and medicate as needed. ?transfer to floor if cleared by team.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616500,\n \"text\": \"Nursing Note\\nEvents: Pt. ordered for TLSO brace. NEOPS unable to come until Tuesday d/t holiday.\\n\\nNeuro: Pt. remains on PCA, using only during movements. Pain controled well with PCA. MAE's, follows commands. Trauma team wants to keep HOB no higher than 30 degrees.\\n Pt. describing dream he had last evening where he thought medical team was giving him his last rights. Pt. stating that the dream was so vivid and he thought the staff was out to get him and he was going to die. Pt. revealed that when he woke up this morning everything was suddenl\\\\y clear and he knew he was dreaming. Pt. asked for encouragement that he was going to survive and continue an active life.\\n\\nCV: HR 80-90's NSR with occasional PVC. BP WNL. Pt. afebrile.\\n\\nResp: on 4L NC, LS clear bilat, diminished in bases. Pt. acheiving 1250 on IS.\\n\\nGI/GU: on house diet, abd. benign, no stool. Foley in place draining clear yellow urine.\\n\\nEndo: No insulin given per RISS.\\n\\nSkin: Abrasions and skin tears as documented.\\n\\nSocial: Family called today, updated to POC.\\n\\nPlan:\\nTLSO brace on Tues/Wed.\\nGet pt. OOB\\nPain control/ HOB<30 degrees\\nPt. and family support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616497,\n \"text\": \"addendum admission Note\\nEvents: Patient admitted(see admission note). CT left shoulder done, MRI TLS done.\\n\\nN: A/O x3. normal strengths LE upper extremities not able to lift and hold but can move on bed. Purposeful. PERRLA 3mm bilaterally and briskly reactive. Neuro checks Q1hr. Morphine PCA for pain- using appropriately. MG 1.7-2gr given. Pt on log roll precautions- J in place until TLS cleared. LR @60.\\n\\nCVS: NSR-70-80's with occasional- frequent PVC's. A febrile. SBP 140-190.\\n\\nResp: BS diminished throughout. Pt encouraged to CDB. 2L NC. Multip rib fx's see FHP for full injury list.\\n\\nGI: NPO except meds. +BS throughout. NO BM this shift.\\n\\nGU: voiding adequate amounts of clear yellow urine.\\n\\nEndo: covered per RISS- 148,166\\n\\nSkin: see carevue for specifics.\\n\\nPlan: Awaiting results of MRI and CT. ? D/c log roll and or J when results read. Encourage to CDB. If TLS clear get OOB. Pain Management- continue to educate about use of PCA. Neuro checks Q1hr.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616498,\n \"text\": \"Nursing Note\\nevents: C-spine cleared\\n\\nNeuro: Pt. very pleasant, A&O x3, appropriate. MAE, LUE without full ROM d/t clavicle fx. , pt. follows commands, on Morphine PCA with good pain control. HOB up to 30 degrees, TLS brace ordered.\\n\\nCV: HR 60-70's NSR with frequent PVC's. BP WNL. Pt. afebrile.\\n\\nResp: On 2L NC, LS diminished throughout. IS encouraged, pt. up to 1500.\\n\\nGI/GU: Pt. on House diet, Abd. benign, no stool. Foley in place draining clear yellow urine.\\n\\nendo: Insulin given as noted.\\n\\nSkin: Abrasion and skin tears as documented, adaptics in place.\\n\\nPlan:\\nTLS brace then OOB\\nPain control\\nencourage IS, CDB\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1616496,\n \"text\": \"admission\\n85 y.o male s/p rollover MVC-pt hit from side. restrained driver. Initially didn't remember events at scene. Med flighted to . Now recalls all events- pt was restrained unbelted self and crawled out of car waited on side of road. Injuries Include: Multiple rib fractures right side, right side small hemothorax, Left transverse fracture L3-L4, Left coracoid fracture extending to glenoid. Left distal clavicle fracture. Skin abrasion to left shoulder, skin tear left lower arm, skin tear to right knee, and hematoma to left upper arm.\\n\\nNo PMH: no medications on admission.\\n\\nPast surgeries: hernia repair, surgery to left eye WWII after ? shrapnel got into eye from stove explosion.\\n\\nN: A/o X3. Neuro checks Q1hr. Follows commands pleasant. LUE able to move on bed but not able to lift and hold. All other extremities equal strength. PERRLA 3mm briskly reactive bilaterally. PCA morphine for pain. Logg roll precautions-awaiting MRI Thoracic and LS. Also awaiting CT left shoulder\\n\\nCVS: HR 70-80's NSR with occasional to frequent PVC's. SBP 160-190-no parameters.\\n\\nResp: 2L NC, BS diminished bilaterally.\\n\\nGI: +BS, soft abdomen non tender, non distended. NPO at this time\\n\\nGU: foley draining patent yellow urine.\\n\\nSocial: nephew and wife into visit. Nephew is spokesperson.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"L HUMERUS (AP & LAT) LEFT\",\n \"row_id\": 1014773,\n \"text\": \" 6:05 PM\\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT; HUMERUS (AP & LAT) LEFTClip # \\n Reason: r/o fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man s/p MVC vs truck, ejected, +LOC, abdominal pain\\n REASON FOR THIS EXAMINATION:\\n r/o fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n LEFT SHOULDER THREE VIEWS LEFT HUMERUS TWO VIEWS AT 18:03 HOURS\\n\\n HISTORY: Motor vehicle collision post-ejection.\\n\\n COMPARISON: CT of the torso acquired earlier same day.\\n\\n FINDINGS: There is an oblique fracture through the distal diaphysis of the\\n left clavicle with no definite intra-articular extension. A well-corticated\\n bony fragment lies cephalad to the acromioclavicular joint and may be the\\n result of more remote trauma. The humeral head is grossly in place. Please\\n note orthogonal views such as scapular, Y or axillary were not obtained. There\\n are multiple bony fragments retracted at the level of the proximal diaphysis\\n of the humerus. The elbow joint is grossly appropriately aligned.\\n\\n IMPRESSION: Oblique fracture of the distal clavicle with no significant\\n displacement or distraction. Remote trauma noted cephalad to the\\n acromioclavicular joint. No definite dislocation is seen although for\\n confirmatory evidence consider orthogonal view. Bony fragments seen in the\\n medial aspect of the arm have likely avulsed from the coracoid process or\\n possibly the glenoid.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"TRAUMA #3 (PORT CHEST ONLY)\",\n \"row_id\": 1014761,\n \"text\": \" 4:59 PM\\n TRAUMA #3 (PORT CHEST ONLY) Clip # \\n Reason: TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Trauma.\\n\\n No prior studies for comparison.\\n\\n PORTABLE SUPINE AP CHEST, ON A TRAUMA BACKBOARD: Heart size is in the upper\\n limits of normal. The aorta is mildly tortuous, with atherosclerotic\\n calcifications. Prominence of the right upper mediastinum likely reflects\\n vascular shadows. No focal pulmonary consolidation is identified. There is\\n no evidence of pneumothorax or pleural effusion. There are multiple mildly\\n displaced right rib fractures, specifically the posterior aspect of the 5-8th\\n ribs.\\n\\n IMPRESSION: Multiple mildly displaced right rib fractures. No clear evidence\\n of a pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2112-05-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1015118,\n \"text\": \" 9:30 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change?\\n Admitting Diagnosis: BLUNT TRAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with rib fractures\\n REASON FOR THIS EXAMINATION:\\n interval change?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Rib fractures, to evaluate for change.\\n\\n FINDINGS: In comparison with study of , there has been development of\\n some atelectatic changes at the left base. Rib fractures again seen but no\\n evidence of pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 213951,\n \"text\": \"Sinus rhythm\\nVentricular premature complex\\nBorderline first degree A-V delay\\nConsider left atrial abnormality\\nProminent precordial low QRS voltage - consider left ventricular hypertrophy\\nalthough is nondiagnostic\\nNo previous tracing available for comparison\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2112-05-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 213952,\n \"text\": \"Sinus rhythm with ventricular premature beats. Prolonged A-V conduction.\\nPossible left ventricular hypertrophy. No previous tracing availa comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":775,"cells":{"subject_id":{"kind":"number","value":17592,"string":"17,592"},"hadm_id":{"kind":"number","value":182639,"string":"182,639"},"target_text":{"kind":"string","value":"He was admitted to the Trauma Service. Orthopedics was consulted because of his femur fracture; he was taken to the operating room for repair of his perineal laceration and ORIF of left femur. Postoperatively there were some pain control issues; he initially required PCA Dilaudid with same fro breakthrough pain. he was eventually changed to oral Dilaudid which has been effective in controlling his pain. Plastic Surgery was consulted because of ear and nasal lacerations; these were sutured in the ED, his nose required packing with Xeroform gauze, this was later removed. It was also noted that he had a right brachial plexus injury; Plastic surgery was consulted for this as well. Physical and Occupational therapy were consulted; there were some balance issues initially, but then he was later cleared for discharge to home. He is being discharged to home and will continue on Lovenox injections until follow up with Orthopedics. He will also need to follow up with Trauma Surgery nd Plastic Surgery in 2 weeks."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: No definite fracture, although evaluation of the left lower extremity is markedly limited due to overlying external fixation device. No definite mucosal injury is identified and contrast is noted in the more proximal aspects of the urethra. FINDINGS: Trauma back board artifact obscures portions of the chest and pelvis. secreations minimal.Plan: Wean to extubate. No bony trauma to the pelvis, although linear lucencies in the region of the scrotum suggest soft tissue injury. Minimal movement of LE's noted yet left leg in traction splint on admission. IMPRESSION: Evaluation with no obvious shoulder injury identified. Backside not visualized at this time, Perineum w/ laceration to be washed out and repaired in OR. IMPRESSION: Limited nonfluroscopic retrograde urethrogram done portably in the trauma bay. t/fer'd here for futher managment of injuries.Injuries include left. Please note, not mentioned above, there are extensive linear lucencies in the region of the perineum likely related to laceration seen intially on the scout radiograph. This is a smooth concentric extrinsic compression. RIGHT TIB-FIB: There is soft tissue defect overlying the right lateral lower extremity. This obscures portions of the sacrum and pelvis. There is, however, marked narrowing of approximately 1.7 cm in length in the region of the membranous and proximal bulbous urethra. LEFT TIB-FIB: Evaluation is markedly limited due to overlying external fixation device. The Foley catheter was withdrawn. FINDINGS: At described on multiple prior examinations, there is contrast filling the bladder which obscures the sacrum and portions of the pelvis. The regional soft tissues are unremarkable. IMPRESSION: Comminuted mid diaphyseal left femur fracture. Of note, the patient has contrast within the bladder from an outside CT scan, which obscures the base of the bladder and the most proximal urethra. TECHNIQUE: A portable retrograde urethrogram was performed. Within that limitation, the pelvis is intact. Again, the knee joint is grossly aligned, however there is marked low position of the patella. INDICATION: Status post trauma. Please note posterior dislocations may not be evident on AP views. The mediastinum is unremarkable and stable. This would correspond to a type 1 urethral injury. There is no orthogonal projection as the patient is intubated. Within these limited views, there is no obvious fracture. The iliac crests have been excluded from view. No LOC at scene,TLS cleared. These demonstrate intramedullary rod fixation of a comminuted fracture of the mid left femoral diaphysis. No definite fracture is seen. O2 sats 99-100% on 100%.GI- abd firm yet not distended, bowel sounds present, small amt brown aspirate via OGT, Pt started on famotidine.GU- 16 French Coude cath foley placed at bedside w/o difficulty. BP 130-160/85-95, left radial a-line placed just prior to OR. Soft tissue defect overlying the right calf. Evaluation is suboptimal secondary to portable technique. There is slight posterior displacement and anterior angulation of the distal fracture fragment. There is, however concentric extrinsic compression in the region of the membranous and proximal bulbar urethra resulting in marked narrowing. Intubated in our ED for in preparation for OR.BS:clear equal bilat. Nasogastric tube ends in the stomach. There is no obvious mucosal disruption. The cardiac silhouette is within normal limits for size. Bilateral femoral heads are appropriately located. There are linear lucencies in the region overlying the scrotum. HISTORY: Status post intubation. External fixation device is noted over the proximal left femur. Pt w/ palpable pulses in LE's + bilaterally, feet pale and cool yet brisk cap refill. The mediastinum is unremarkable. No gross dislocation is evident. Grossly, the pelvis and sacrum are intact. No effusion or pneumothorax is evident. No effusion or pneumothorax is evident. The descending thoracic aorta is well defined. Resp CarePt. pt fully vented, ETT advanced 3cm as high per postextubation x-ray, repeat x-ray w/ tube in good position, breath sounds clear bilaterally, slightly diminished at right base. No definite disruption is identified. PT as per ortho, GI ADT. Question quadriceps rupture. IMPRESSION: No radiographic evidence of traumatic injury to the chest. The coracoclavicular interval is appropriate. Cardiac function should be assessed to exclude pericardial effusion and cardiac injury. FINDINGS: This is a limited examination as dynamic evaluation under fluoroscopy could not be performed due to patient condition. If clinically feasible, consider orthogonal views such scapular Y or axillary. Please note absolute integrity of the urethra to the bladder is not possible given the presence of contrast material already in the bladder from an outside hospital CT scan. No pneumothorax, pleural effusion, or mediastinal widening. There is contrast within the bladder from the outside facility CT scan. The femoral heads are appropriately located. There is no osseous erosion or joint space narrowing. The patient was not stable enough to be transported to the fluoroscopy suite. There is no gross dislocation. Left ear repaired by plastics in EW as well. Of note, there was a strong gush of contrast material and a postvoid radiograph was obtained. No prior comparisons. No immediate hardware-related complication is seen. No displaced fractures are seen. The penis was repositioned and additional radiograph was obtained to attempt to obtain a different level of obliquity. 4:14 AM FEMUR (AP & LAT) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # Reason: S/P TRAUMA FRACTURE FEMUR Admitting Diagnosis: BLUNT TRAUMA FINAL REPORT LEFT FEMUR, EIGHT VIEWS. femur fx, 8cm perineal lac and partial left ear amputation. Please evaluate for fracture. Pt w/ no PMHx, no meds, Pt does smoke one PPD, drinks occaisionally. Please note that the film was overexposed such that the right knee is grossly difficult to evaluate on lateral view. No fracture is seen. FINDINGS: The endotracheal tube is high at approximately 7 cm from the carina."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2121-06-09 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":960058,"text":" 6:13 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: 5\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AND AP PELVIS, , AT 1800 HOURS.\n\n HISTORY: Trauma.\n\n COMPARISON: None.\n\n FINDINGS: Trauma back board artifact obscures portions of the chest and\n pelvis. Lungs are clear. The mediastinum is unremarkable. The descending\n thoracic aorta is well defined. The cardiac silhouette is within normal\n limits for size. No effusion or pneumothorax is evident. No displaced\n fractures are seen. The iliac crests have been excluded from view. There is\n contrast within the bladder from the outside facility CT scan. This obscures\n portions of the sacrum and pelvis. Within that limitation, the pelvis is\n intact. The femoral heads are appropriately located. There are linear\n lucencies in the region overlying the scrotum. External fixation device is\n noted over the proximal left femur.\n\n IMPRESSION: No radiographic evidence of traumatic injury to the chest. No\n bony trauma to the pelvis, although linear lucencies in the region of the\n scrotum suggest soft tissue injury.\n\n"},{"category":"Radiology","chartdate":"2121-06-09 00:00:00.000","description":"BILAT HIPS (AP,LAT & AP PELVIS)","row_id":960076,"text":" 7:25 PM\n BILAT HIPS (AP,LAT & AP PELVIS); FEMUR (AP & LAT) BILAT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS, TWO VIEWS RIGHT FEMUR, TWO VIEWS LEFT FEMUR, AT 19:46\n HOURS.\n\n HISTORY: Motor vehicle collision.\n\n COMPARISON: None.\n\n FINDINGS: At described on multiple prior examinations, there is contrast\n filling the bladder which obscures the sacrum and portions of the pelvis.\n There is also high attenuation foci within the region of the perineum, likely\n related to recent retrograde urethrogram. Grossly, the pelvis and sacrum are\n intact. Bilateral femoral heads are appropriately located.\n\n The proximal two thirds of the femur are noted on AP view and the distal two\n thirds are noted on lateral view. Within these limited views, there is no\n obvious fracture. Please note that the film was overexposed such that the\n right knee is grossly difficult to evaluate on lateral view.\n\n There is an external fixation device on the left leg. There is a comminuted\n fracture with a large butterfly fragment medially of the mid diaphysis of the\n left femur. There is slight posterior displacement and anterior angulation of\n the distal fracture fragment. Again, the knee joint is grossly aligned,\n however there is marked low position of the patella. Question quadriceps\n rupture.\n\n IMPRESSION: Comminuted mid diaphyseal left femur fracture. Evaluation is\n suboptimal secondary to portable technique.\n\n\n"},{"category":"Radiology","chartdate":"2121-06-09 00:00:00.000","description":"R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT","row_id":960074,"text":" 7:24 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE TWO VIEWS OF THE RIGHT SHOULDER, , AT 20:04 HOURS.\n\n HISTORY: Status post motor vehicle collision.\n\n COMPARISON: None.\n\n FINDINGS: AP, internal and external rotation views remained available for\n review. There is no orthogonal projection as the patient is intubated. No\n gross dislocation is evident. No fracture is seen. The AC joint is\n approximately 8 mm wide which is within the wide range of normal. The\n coracoclavicular interval is appropriate. The regional soft tissues are\n unremarkable. The visualized adjacent lung is clear.\n\n IMPRESSION: Evaluation with no obvious shoulder injury identified. Please\n note posterior dislocations may not be evident on AP views. If clinically\n feasible, consider orthogonal views such scapular Y or axillary.\n\n\n"},{"category":"Radiology","chartdate":"2121-06-09 00:00:00.000","description":"B TIB/FIB (AP & LAT) BILAT","row_id":960075,"text":" 7:24 PM\n TIB/FIB (AP & LAT) BILAT; ANKLE (AP, MORTISE & LAT) BILAT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old male status post MVC. Please evaluate for fracture.\n\n FINDINGS: Total of eight radiographs comprising multiple views of the\n bilateral tibia and fibula were reviewed. No prior comparisons.\n\n RIGHT TIB-FIB: There is soft tissue defect overlying the right lateral lower\n extremity. There is no fracture or dislocation. There is no osseous erosion\n or joint space narrowing. There is no soft tissue calcification or radiopaque\n foreign object.\n\n LEFT TIB-FIB: Evaluation is markedly limited due to overlying external\n fixation device. No definite fracture is seen. There is no gross\n dislocation. There is no soft tissue calcification or radiopaque foreign\n object.\n\n IMPRESSION: No definite fracture, although evaluation of the left lower\n extremity is markedly limited due to overlying external fixation device. Soft\n tissue defect overlying the right calf.\n\n\n"},{"category":"Radiology","chartdate":"2121-06-10 00:00:00.000","description":"L FEMUR (AP & LAT) LEFT","row_id":960114,"text":" 4:14 AM\n FEMUR (AP & LAT) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \n Reason: S/P TRAUMA FRACTURE FEMUR\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FEMUR, EIGHT VIEWS.\n\n INDICATION: Status post trauma.\n\n FINDINGS: Comparison to . A series of eight intraoperative\n radiographs of the left femur were obtained without a radiologist present.\n These demonstrate intramedullary rod fixation of a comminuted fracture of the\n mid left femoral diaphysis. No immediate hardware-related complication is\n seen. Please refer to operative report for full details.\n\n"},{"category":"Radiology","chartdate":"2121-06-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":960091,"text":" 9:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with s/p MVC, intubated in ED. check placement\n\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:56 p.m. on \n\n HISTORY: Motor vehicle accident.\n\n IMPRESSION: AP chest compared to at 6:51 p.m.:\n\n ET tube has been advanced to standard placement, tip approximately 4 cm from\n the carina. Lungs are low in volume but clear. No pneumothorax, pleural\n effusion, or mediastinal widening. Nasogastric tube ends in the stomach.\n Heart, though not clearly enlarged, is somewhat larger than expected for a\n young patient, perhaps exaggerated by low lung volumes and supine positioning.\n Cardiac function should be assessed to exclude pericardial effusion and\n cardiac injury.\n\n Dr. was paged to report these findings, at the time of dictation.\n\n\n"},{"category":"Radiology","chartdate":"2121-06-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":960067,"text":" 6:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with s/p MVC, intubated in ED. check placement\n REASON FOR THIS EXAMINATION:\n check ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, , 1851 HOURS.\n\n HISTORY: Status post intubation.\n\n COMPARISON: Earlier same day.\n\n FINDINGS: The endotracheal tube is high at approximately 7 cm from the\n carina. A nasogastric tube is well positioned, coiled within the gastric\n body. The lungs remain clear. The mediastinum is unremarkable and stable.\n No effusion or pneumothorax is evident.\n\n IMPRESSION: Endotracheal tube is high at approximately 7 cm from the carina.\n Advance 3 cm for optimal placement.\n\n\n"},{"category":"Radiology","chartdate":"2121-06-09 00:00:00.000","description":"RETRO UROGRAM (74450,51610)","row_id":960068,"text":" 6:53 PM\n RETRO UROGRAM (,) Clip # \n Reason: eval for Floey placement, urethral injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for Floey placement, urethral injury\n ______________________________________________________________________________\n FINAL REPORT\n RETROGRADE URETHROGRAM, AT 18:52 HOURS.\n\n HISTORY: Perineal trauma.\n\n TECHNIQUE: A portable retrograde urethrogram was performed. The patient was\n not stable enough to be transported to the fluoroscopy suite. A scout\n radiograph was obtained. Of note, the patient has contrast within the bladder\n from an outside CT scan, which obscures the base of the bladder and the most\n proximal urethra. Using sterile technique, a Foley catheter was introduced\n into the distal tip of the penis and approximately 3 cc of water expanded the\n balloon within the fossa navicularis. Approximately 20 cc of Conray contrast\n material was injected and the radiograph was taken with the tube obliqued to\n approximately 45 degrees. The penis was repositioned and additional\n radiograph was obtained to attempt to obtain a different level of obliquity.\n The Foley catheter was withdrawn. Of note, there was a strong gush of\n contrast material and a postvoid radiograph was obtained.\n\n FINDINGS: This is a limited examination as dynamic evaluation under\n fluoroscopy could not be performed due to patient condition. No definite\n mucosal injury is identified and contrast is noted in the more proximal\n aspects of the urethra. There is, however, marked narrowing of approximately\n 1.7 cm in length in the region of the membranous and proximal bulbous urethra.\n This is a smooth concentric extrinsic compression. No definite disruption is\n identified.\n\n Please note, not mentioned above, there are extensive linear lucencies in the\n region of the perineum likely related to laceration seen intially on the\n scout radiograph.\n\n IMPRESSION: Limited nonfluroscopic retrograde urethrogram done portably in\n the trauma bay. There is no obvious mucosal disruption. There is, however\n concentric extrinsic compression in the region of the membranous and proximal\n bulbar urethra resulting in marked narrowing. This would correspond to a type\n 1 urethral injury. Please note absolute integrity of the urethra to the\n bladder is not possible given the presence of contrast material already in the\n bladder from an outside hospital CT scan.\n\n"},{"category":"Nursing/other","chartdate":"2121-06-10 00:00:00.000","description":"Report","row_id":1493432,"text":"TSICU Nsg Admit Note\n Pt is a 24y/o male s/p rollover MVC. Pt unrestrained, tox screen negative, no LOC at the scene and awake and alert x's 3 at the OSH (). Pt medflighted to for further tx. Injuries include left femur fx, 8cm perineal laceration from scrotum to anus, left partial ear amputaion, small nose lac, right lower leg laceration. Pt intubated in EW on arrival and plan for OR. Pt admitted to TSICU till OR ready. Left ear repaired by plastics in EW as well.\n Pt w/ no PMHx, no meds, Pt does smoke one PPD, drinks occaisionally. Pt taken to OR at 11pm on for repair of left femur fx and repair of perineal laceration.\n\nReview of systems:\n\n pt sedated and intubated on propofol at 70mcgs/kg/min, receiving fentanyl 50-100mcgs q 2hrs for pain, when light pt moving upperextremities purposefully yet not following commands, agitated and attempting to sit up in bed. Minimal movement of LE's noted yet left leg in traction splint on admission. Pt placed in J collar from stiff neck collar, TLS cleared by team.\n\n pt in sinus, initially tachy w/ rate > 100, slowed after pain med to 85-95, no ectopy. BP 130-160/85-95, left radial a-line placed just prior to OR. Pt w/ palpable pulses in LE's + bilaterally, feet pale and cool yet brisk cap refill.\n\n pt fully vented, ETT advanced 3cm as high per postextubation x-ray, repeat x-ray w/ tube in good position, breath sounds clear bilaterally, slightly diminished at right base. O2 sats 99-100% on 100%.\n\nGI- abd firm yet not distended, bowel sounds present, small amt brown aspirate via OGT, Pt started on famotidine.\n\nGU- 16 French Coude cath foley placed at bedside w/o difficulty. 500cc's amber urine emptied prior to OR.\n\nID- temp on admission 99.1, pt written for cefazolen, had received vanco, cefazolen and flagyl preadmission.\n\n pt written for sliding scale, BS at midnight 129 yet pt in OR at the time.\n\n pt w/ multiple abrasions on face above right eye, left neck w/ abrasions, right lower leg w/ open gash to be washed out in the OR and sutured, left ear sutured and suture on small lac under nose w/ xeroform gauze as packing. Backside not visualized at this time, Perineum w/ laceration to be washed out and repaired in OR.\n\n pt's parents in to visit, they report that patient had been at his grandmother's funeral earlier in the day and had gone out to do an errand and had reportedly fallen asleep at the wheel.\n\nA/P- neuro stable, pain management as ordered, CV stable follow hcts , resp- wean and extubate post-op w/ post op pulmonary hygeine. PT as per ortho, GI ADT.\n"},{"category":"Nursing/other","chartdate":"2121-06-10 00:00:00.000","description":"Report","row_id":1493433,"text":"Resp Care\nPt. is a 23 yom t/fer via s/p MVC rollover/unrestrained. No LOC at scene,TLS cleared. t/fer'd here for futher managment of injuries.Injuries include left. femur fx, 8cm perineal lac and partial left ear amputation. Intubated in our ED for in preparation for OR.\nBS:clear equal bilat. secreations minimal.\nPlan: Wean to extubate.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-09 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 960058,\n \"text\": \" 6:13 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: 5\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST AND AP PELVIS, , AT 1800 HOURS.\\n\\n HISTORY: Trauma.\\n\\n COMPARISON: None.\\n\\n FINDINGS: Trauma back board artifact obscures portions of the chest and\\n pelvis. Lungs are clear. The mediastinum is unremarkable. The descending\\n thoracic aorta is well defined. The cardiac silhouette is within normal\\n limits for size. No effusion or pneumothorax is evident. No displaced\\n fractures are seen. The iliac crests have been excluded from view. There is\\n contrast within the bladder from the outside facility CT scan. This obscures\\n portions of the sacrum and pelvis. Within that limitation, the pelvis is\\n intact. The femoral heads are appropriately located. There are linear\\n lucencies in the region overlying the scrotum. External fixation device is\\n noted over the proximal left femur.\\n\\n IMPRESSION: No radiographic evidence of traumatic injury to the chest. No\\n bony trauma to the pelvis, although linear lucencies in the region of the\\n scrotum suggest soft tissue injury.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-09 00:00:00.000\",\n \"description\": \"BILAT HIPS (AP,LAT & AP PELVIS)\",\n \"row_id\": 960076,\n \"text\": \" 7:25 PM\\n BILAT HIPS (AP,LAT & AP PELVIS); FEMUR (AP & LAT) BILAT Clip # \\n Reason: eval for fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man s/p mvc\\n REASON FOR THIS EXAMINATION:\\n eval for fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PELVIS, TWO VIEWS RIGHT FEMUR, TWO VIEWS LEFT FEMUR, AT 19:46\\n HOURS.\\n\\n HISTORY: Motor vehicle collision.\\n\\n COMPARISON: None.\\n\\n FINDINGS: At described on multiple prior examinations, there is contrast\\n filling the bladder which obscures the sacrum and portions of the pelvis.\\n There is also high attenuation foci within the region of the perineum, likely\\n related to recent retrograde urethrogram. Grossly, the pelvis and sacrum are\\n intact. Bilateral femoral heads are appropriately located.\\n\\n The proximal two thirds of the femur are noted on AP view and the distal two\\n thirds are noted on lateral view. Within these limited views, there is no\\n obvious fracture. Please note that the film was overexposed such that the\\n right knee is grossly difficult to evaluate on lateral view.\\n\\n There is an external fixation device on the left leg. There is a comminuted\\n fracture with a large butterfly fragment medially of the mid diaphysis of the\\n left femur. There is slight posterior displacement and anterior angulation of\\n the distal fracture fragment. Again, the knee joint is grossly aligned,\\n however there is marked low position of the patella. Question quadriceps\\n rupture.\\n\\n IMPRESSION: Comminuted mid diaphyseal left femur fracture. Evaluation is\\n suboptimal secondary to portable technique.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-09 00:00:00.000\",\n \"description\": \"R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT\",\n \"row_id\": 960074,\n \"text\": \" 7:24 PM\\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \\n Reason: eval for fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man s/p mvc\\n REASON FOR THIS EXAMINATION:\\n eval for fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE TWO VIEWS OF THE RIGHT SHOULDER, , AT 20:04 HOURS.\\n\\n HISTORY: Status post motor vehicle collision.\\n\\n COMPARISON: None.\\n\\n FINDINGS: AP, internal and external rotation views remained available for\\n review. There is no orthogonal projection as the patient is intubated. No\\n gross dislocation is evident. No fracture is seen. The AC joint is\\n approximately 8 mm wide which is within the wide range of normal. The\\n coracoclavicular interval is appropriate. The regional soft tissues are\\n unremarkable. The visualized adjacent lung is clear.\\n\\n IMPRESSION: Evaluation with no obvious shoulder injury identified. Please\\n note posterior dislocations may not be evident on AP views. If clinically\\n feasible, consider orthogonal views such scapular Y or axillary.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-09 00:00:00.000\",\n \"description\": \"B TIB/FIB (AP & LAT) BILAT\",\n \"row_id\": 960075,\n \"text\": \" 7:24 PM\\n TIB/FIB (AP & LAT) BILAT; ANKLE (AP, MORTISE & LAT) BILAT Clip # \\n Reason: eval for fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man s/p mvc\\n REASON FOR THIS EXAMINATION:\\n eval for fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 23-year-old male status post MVC. Please evaluate for fracture.\\n\\n FINDINGS: Total of eight radiographs comprising multiple views of the\\n bilateral tibia and fibula were reviewed. No prior comparisons.\\n\\n RIGHT TIB-FIB: There is soft tissue defect overlying the right lateral lower\\n extremity. There is no fracture or dislocation. There is no osseous erosion\\n or joint space narrowing. There is no soft tissue calcification or radiopaque\\n foreign object.\\n\\n LEFT TIB-FIB: Evaluation is markedly limited due to overlying external\\n fixation device. No definite fracture is seen. There is no gross\\n dislocation. There is no soft tissue calcification or radiopaque foreign\\n object.\\n\\n IMPRESSION: No definite fracture, although evaluation of the left lower\\n extremity is markedly limited due to overlying external fixation device. Soft\\n tissue defect overlying the right calf.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-10 00:00:00.000\",\n \"description\": \"L FEMUR (AP & LAT) LEFT\",\n \"row_id\": 960114,\n \"text\": \" 4:14 AM\\n FEMUR (AP & LAT) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \\n Reason: S/P TRAUMA FRACTURE FEMUR\\n Admitting Diagnosis: BLUNT TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n LEFT FEMUR, EIGHT VIEWS.\\n\\n INDICATION: Status post trauma.\\n\\n FINDINGS: Comparison to . A series of eight intraoperative\\n radiographs of the left femur were obtained without a radiologist present.\\n These demonstrate intramedullary rod fixation of a comminuted fracture of the\\n mid left femoral diaphysis. No immediate hardware-related complication is\\n seen. Please refer to operative report for full details.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 960091,\n \"text\": \" 9:46 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: ETT placement\\n Admitting Diagnosis: BLUNT TRAUMA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with s/p MVC, intubated in ED. check placement\\n\\n REASON FOR THIS EXAMINATION:\\n ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 9:56 p.m. on \\n\\n HISTORY: Motor vehicle accident.\\n\\n IMPRESSION: AP chest compared to at 6:51 p.m.:\\n\\n ET tube has been advanced to standard placement, tip approximately 4 cm from\\n the carina. Lungs are low in volume but clear. No pneumothorax, pleural\\n effusion, or mediastinal widening. Nasogastric tube ends in the stomach.\\n Heart, though not clearly enlarged, is somewhat larger than expected for a\\n young patient, perhaps exaggerated by low lung volumes and supine positioning.\\n Cardiac function should be assessed to exclude pericardial effusion and\\n cardiac injury.\\n\\n Dr. was paged to report these findings, at the time of dictation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 960067,\n \"text\": \" 6:50 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: check ETT placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man with s/p MVC, intubated in ED. check placement\\n REASON FOR THIS EXAMINATION:\\n check ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP PORTABLE CHEST, , 1851 HOURS.\\n\\n HISTORY: Status post intubation.\\n\\n COMPARISON: Earlier same day.\\n\\n FINDINGS: The endotracheal tube is high at approximately 7 cm from the\\n carina. A nasogastric tube is well positioned, coiled within the gastric\\n body. The lungs remain clear. The mediastinum is unremarkable and stable.\\n No effusion or pneumothorax is evident.\\n\\n IMPRESSION: Endotracheal tube is high at approximately 7 cm from the carina.\\n Advance 3 cm for optimal placement.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2121-06-09 00:00:00.000\",\n \"description\": \"RETRO UROGRAM (74450,51610)\",\n \"row_id\": 960068,\n \"text\": \" 6:53 PM\\n RETRO UROGRAM (,) Clip # \\n Reason: eval for Floey placement, urethral injury\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 23 year old man s/p mvc\\n REASON FOR THIS EXAMINATION:\\n eval for Floey placement, urethral injury\\n ______________________________________________________________________________\\n FINAL REPORT\\n RETROGRADE URETHROGRAM, AT 18:52 HOURS.\\n\\n HISTORY: Perineal trauma.\\n\\n TECHNIQUE: A portable retrograde urethrogram was performed. The patient was\\n not stable enough to be transported to the fluoroscopy suite. A scout\\n radiograph was obtained. Of note, the patient has contrast within the bladder\\n from an outside CT scan, which obscures the base of the bladder and the most\\n proximal urethra. Using sterile technique, a Foley catheter was introduced\\n into the distal tip of the penis and approximately 3 cc of water expanded the\\n balloon within the fossa navicularis. Approximately 20 cc of Conray contrast\\n material was injected and the radiograph was taken with the tube obliqued to\\n approximately 45 degrees. The penis was repositioned and additional\\n radiograph was obtained to attempt to obtain a different level of obliquity.\\n The Foley catheter was withdrawn. Of note, there was a strong gush of\\n contrast material and a postvoid radiograph was obtained.\\n\\n FINDINGS: This is a limited examination as dynamic evaluation under\\n fluoroscopy could not be performed due to patient condition. No definite\\n mucosal injury is identified and contrast is noted in the more proximal\\n aspects of the urethra. There is, however, marked narrowing of approximately\\n 1.7 cm in length in the region of the membranous and proximal bulbous urethra.\\n This is a smooth concentric extrinsic compression. No definite disruption is\\n identified.\\n\\n Please note, not mentioned above, there are extensive linear lucencies in the\\n region of the perineum likely related to laceration seen intially on the\\n scout radiograph.\\n\\n IMPRESSION: Limited nonfluroscopic retrograde urethrogram done portably in\\n the trauma bay. There is no obvious mucosal disruption. There is, however\\n concentric extrinsic compression in the region of the membranous and proximal\\n bulbar urethra resulting in marked narrowing. This would correspond to a type\\n 1 urethral injury. Please note absolute integrity of the urethra to the\\n bladder is not possible given the presence of contrast material already in the\\n bladder from an outside hospital CT scan.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1493432,\n \"text\": \"TSICU Nsg Admit Note\\n Pt is a 24y/o male s/p rollover MVC. Pt unrestrained, tox screen negative, no LOC at the scene and awake and alert x's 3 at the OSH (). Pt medflighted to for further tx. Injuries include left femur fx, 8cm perineal laceration from scrotum to anus, left partial ear amputaion, small nose lac, right lower leg laceration. Pt intubated in EW on arrival and plan for OR. Pt admitted to TSICU till OR ready. Left ear repaired by plastics in EW as well.\\n Pt w/ no PMHx, no meds, Pt does smoke one PPD, drinks occaisionally. Pt taken to OR at 11pm on for repair of left femur fx and repair of perineal laceration.\\n\\nReview of systems:\\n\\n pt sedated and intubated on propofol at 70mcgs/kg/min, receiving fentanyl 50-100mcgs q 2hrs for pain, when light pt moving upperextremities purposefully yet not following commands, agitated and attempting to sit up in bed. Minimal movement of LE's noted yet left leg in traction splint on admission. Pt placed in J collar from stiff neck collar, TLS cleared by team.\\n\\n pt in sinus, initially tachy w/ rate > 100, slowed after pain med to 85-95, no ectopy. BP 130-160/85-95, left radial a-line placed just prior to OR. Pt w/ palpable pulses in LE's + bilaterally, feet pale and cool yet brisk cap refill.\\n\\n pt fully vented, ETT advanced 3cm as high per postextubation x-ray, repeat x-ray w/ tube in good position, breath sounds clear bilaterally, slightly diminished at right base. O2 sats 99-100% on 100%.\\n\\nGI- abd firm yet not distended, bowel sounds present, small amt brown aspirate via OGT, Pt started on famotidine.\\n\\nGU- 16 French Coude cath foley placed at bedside w/o difficulty. 500cc's amber urine emptied prior to OR.\\n\\nID- temp on admission 99.1, pt written for cefazolen, had received vanco, cefazolen and flagyl preadmission.\\n\\n pt written for sliding scale, BS at midnight 129 yet pt in OR at the time.\\n\\n pt w/ multiple abrasions on face above right eye, left neck w/ abrasions, right lower leg w/ open gash to be washed out in the OR and sutured, left ear sutured and suture on small lac under nose w/ xeroform gauze as packing. Backside not visualized at this time, Perineum w/ laceration to be washed out and repaired in OR.\\n\\n pt's parents in to visit, they report that patient had been at his grandmother's funeral earlier in the day and had gone out to do an errand and had reportedly fallen asleep at the wheel.\\n\\nA/P- neuro stable, pain management as ordered, CV stable follow hcts , resp- wean and extubate post-op w/ post op pulmonary hygeine. PT as per ortho, GI ADT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2121-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1493433,\n \"text\": \"Resp Care\\nPt. is a 23 yom t/fer via s/p MVC rollover/unrestrained. No LOC at scene,TLS cleared. t/fer'd here for futher managment of injuries.Injuries include left. femur fx, 8cm perineal lac and partial left ear amputation. Intubated in our ED for in preparation for OR.\\nBS:clear equal bilat. secreations minimal.\\nPlan: Wean to extubate.\\n\"\n }\n]"}}},{"rowIdx":776,"cells":{"subject_id":{"kind":"number","value":29141,"string":"29,141"},"hadm_id":{"kind":"number","value":172116,"string":"172,116"},"target_text":{"kind":"string","value":"# Respiratory distress/COPD: The patient presented in hypercarbic respiratory failure, with a pCO2 in the 80s. A chest X-ray at the outside hospital was read as possible CHF or pneumonia. He was treated for both diagnoses, and given lasix 40mg IV, 60mg of prednisone, Combivent nebs, and ceftriaxone. . A repeat CXR at was questionable for CHF and there was no focal infiltrate. His report of green sputum was thought to represent a COPD flare. Antibiotic coverage was changed to azithromycin, which he completed a 5 day course. He was also given systemic steroids, which were tapered to 20 mg prednisone prior to discharge. His regimen of inhaled medications were optimized with long-acting beta-agonists, anticholinergics, and steroids. . # CHF - The patient has a h/o CHF w/ a dilated left atrium and EF of 50%. A CXR at the OSH was reported as heart failure. The patient was diuresed with 40mg IV lasix. In the ED here, he received a second dose of 40mg IV Lasix. However, on admission to the MICU his creatinine was noted to have increased to 1.3, and his home lasix and spironolactone were held. After he clinically stabilized on the floor, he received IV lasix 80mg for four days for bibasilar crackles and lower extremity edema. He was continued on beta-blocker and ACE inhibitor, and transitioned back to his home PO Lasix prior to discharge. . # Atrial fibrillation/flutter: The patient has a known history of AF on bisoprolol 2.5mg qday. However, in the setting of his acute respiratory illness, his HR rose to the 130's-140's. He received additional beta blockade with 5mg of Lopressor IV, but with little effect. He responded well to IV diltiazem, and was started on PO Diltiazem 30mg QID. This was titrated up and converted to 240mg of long-acting Diltiazem with good effect. His HR was in the 70-80s at discharge. He will need to follow up with his cardiologist to evaluate the effect of the medication, as there is the possibility that as the CHF resolves less rate control will be needed. At , his INR was 1.6, and he was continued on his home dose of coumadin. However, his INR became supratherapeutic during his hospitalization, presumed due to concomitant antibiotic therapy. He was discharged on 3mg of Coumadin daily. . # Acute Renal Failure: The patient was noted to be in acute renal failure with a creatinine of 1.3 on admission after receiving 2 of IV lasix. Both Lasix and spironolactone were held because prerenal azotemia was suspected. The patient received gentle IV hydration and his creatinine normalized to 0.9. As noted above, he received several of IV lasix after he clinically stabilized on the floor, for bibasilar crackles and lower extremity edema. He was transitioned back to his home lasix and spironolactone prior to discharge. . # CAD: An EKG was performed and did not show active ischemia. Cardiac enzymes were sent and were negative X3. The patient was continued on aspirin, statin, lopressor, and lisinopril. . # Neuropathy. This was not an active issue, and the patient was continued on his home dose of fentanyl patch, gabapentin, and percocet. . # Depression: This was not an active issue. The patient was continued on his home sertraline . # FEN: The patient was placed on a cardiac/heart healthy diet."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: PA and lateral chest compared to and 9: Vascular congestion and cardiomegaly are borderline unchanged since . Atrial flutterModest nonspecific intraventricular conduction delayConsider prior inferior myocardial infarction although is nondiagnosticModest nonspecific ST-T wave changesSince previous tracing of , sinus rhythm absent Lung volumes remain low, particular on the right where there is relative elevation of the lung base, with disparity more pronounced now than it was in , probably due to progressive diaphragmatic eventration. Bibasal linear opacities are unchanged, most likely representing atelectasis. Atrial flutterModest nonspecific intraventricular conduction delayConsider prior inferior myocardial infarction although is nondiagnosticModest nonspecific ST-T wave changesSince previous tracing of the same date, no significant change FINDINGS: There are low lung volumes. Since previous tracingof the ventricular response has decreased. The overall lung volumes remain low. HISTORY: Respiratory distress. Abd soft, obese, + stool x 1. HR 100-130s aflutter with variable block. Regular narrow complex rhythm. There is persistent elevation of the right hemidiaphragm. IMPRESSION: No acute cardiopulmonary process. Respiratory Care NotePt given Atrovent neb at 12noon. Probable atrial flutterwhich is not counterclockwise in configuration. Portable AP chest radiograph compared to . LS coarse t/o, expectorated yellow/green sputum x1 this shift. Pt has a congested cough. The cardiomediastinal and hilar contours are stable. No sizable pleural effusion is noted. Secretions swallowed. There is right lower lobe atelectasis. Sputum spec sent. Baseline artifact. Linear area of scarring is seen in the right upper lobe. The heart size is moderately enlarged but stable. FINAL REPORT PA AND LATERAL CHEST ON HISTORY: COPD, CHF, look for vascular congestion. REASON FOR THIS EXAMINATION: assess for vascular congestion progression. NBP WNL. Nursing Progress Note 0700-1900Please see carevue and FHP for additional data.Dispo: FULL codeAllergies: NeosporinAccess: 1 pivPt alert, avioding orientation questions, needy at times, carries on coversation appropriately. 12:10 PM CHEST (PA & LAT) PORT Clip # Reason: assess for vascular congestion progression. Called out to floor. There is no pleural effusion. There are no consolidations or effusions. last pm. There is no pneumothorax. There is no evidence of congestive heart failure. Remains on 3L nc, with sats 95%, will desat with exertion, but recovers quickly. Foley secure and patent draining adequate amounts of urine. 3:23 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change Admitting Diagnosis: CONGESTIVE HEART FAILURE MEDICAL CONDITION: 74 year old man with COPD, SOB REASON FOR THIS EXAMINATION: please eval for interval change FINAL REPORT REASON FOR EXAMINATION: Shortness of breath. c/o floormonitor resp status/vitals/MAP > 60update with pt and family Rec'd 5mg lopressor x 1 for HR 130s, restarted on home BP medication. 74 y/o male with PMH of COPD (steroid ddependent and on Home O2),CHF,A-Fib on Coumadin,Neuropathy with chronic pain,Ca Lungs diagnosed 5 yrs ago s/P resection of rt lung,Depression... was found unresposive at home,wife called EMS and transferred to tried to intubate,gag was and positive and pt woke up Lasix,nebs,steroids and ceftriaxone was given Pt was transferred to ED and at 2300 pt was transferred in MICU for further management because pt had increased confusion yesterday.On admission to MICU pt is coherent Alert and oriented X 3,follows all commands,moves all extrimities C/O pain all over body percocet given with good relief.Denies any SOB or CP.In A-Fib on coumadin EKG obtained on admission,blood work up done NBP dropped to 80's on admission NS 500 ml bolused with good effect.HR 80-100,NBP 90-110/30-50.Extrimities has pitting edema,Pedal pulses are doppled.For access one PIV on lt hand.Multiple ecchymotic areas all over the body.RR 16-25 breathing efforts are normal,LS are coarse throughout,expectorating thick yellow sputum,c/s sent.O2 sats are maintained 94-96% on NC 2L.Abdomen obese positive bowel sounds,had liquids orally.No bowel movement at this shift.voiding adequate amts of clear urineNo contact from family at this shiftPLAN; ? 1:23 PM CHEST (PORTABLE AP) Clip # Reason: eval for chf/infiltrate MEDICAL CONDITION: 74 year old man with resp distress REASON FOR THIS EXAMINATION: eval for chf/infiltrate FINAL REPORT CHEST PORTABLE AP COMPARISON: ."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2163-12-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":985960,"text":" 3:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with COPD, SOB\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath.\n\n Portable AP chest radiograph compared to .\n\n The heart size is moderately enlarged but stable. There is no evidence of\n congestive heart failure. Bibasal linear opacities are unchanged, most likely\n representing atelectasis. No sizable pleural effusion is noted. The overall\n lung volumes remain low.\n\n\n"},{"category":"Radiology","chartdate":"2163-12-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":985901,"text":" 1:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf/infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n eval for chf/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMPARISON: .\n\n HISTORY: Respiratory distress.\n\n FINDINGS: There are low lung volumes. There is persistent elevation of the\n right hemidiaphragm. There are no consolidations or effusions. There is no\n pneumothorax. Linear area of scarring is seen in the right upper lobe. There\n is right lower lobe atelectasis. The cardiomediastinal and hilar contours are\n stable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2163-12-18 00:00:00.000","description":"P CHEST (PA & LAT) PORT","row_id":986265,"text":" 12:10 PM\n CHEST (PA & LAT) PORT Clip # \n Reason: assess for vascular congestion progression.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with copd exacerbation, chf.\n REASON FOR THIS EXAMINATION:\n assess for vascular congestion progression.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: COPD, CHF, look for vascular congestion.\n\n IMPRESSION: PA and lateral chest compared to and 9:\n\n Vascular congestion and cardiomegaly are borderline unchanged since . There is no pleural effusion. Lung volumes remain low, particular on the\n right where there is relative elevation of the lung base, with disparity more\n pronounced now than it was in , probably due to progressive diaphragmatic\n eventration.\n\n"},{"category":"Nursing/other","chartdate":"2163-12-16 00:00:00.000","description":"Report","row_id":1640109,"text":"Nursing Progress Note 0700-1900\nPlease see carevue and FHP for additional data.\n\nDispo: FULL code\nAllergies: Neosporin\nAccess: 1 piv\n\nPt alert, avioding orientation questions, needy at times, carries on coversation appropriately. HR 100-130s aflutter with variable block. Rec'd 5mg lopressor x 1 for HR 130s, restarted on home BP medication. NBP WNL. Remains on 3L nc, with sats 95%, will desat with exertion, but recovers quickly. LS coarse t/o, expectorated yellow/green sputum x1 this shift. Sputum spec sent. last pm. Abd soft, obese, + stool x 1. Foley secure and patent draining adequate amounts of urine. Called out to floor.\n"},{"category":"Nursing/other","chartdate":"2163-12-16 00:00:00.000","description":"Report","row_id":1640110,"text":"Respiratory Care Note\nPt given Atrovent neb at 12noon. Pt has a congested cough. Secretions swallowed.\n"},{"category":"Nursing/other","chartdate":"2163-12-16 00:00:00.000","description":"Report","row_id":1640108,"text":"74 y/o male with PMH of COPD (steroid ddependent and on Home O2),CHF,A-Fib on Coumadin,Neuropathy with chronic pain,Ca Lungs diagnosed 5 yrs ago s/P resection of rt lung,Depression... was found unresposive at home,wife called EMS and transferred to tried to intubate,gag was and positive and pt woke up Lasix,nebs,steroids and ceftriaxone was given Pt was transferred to ED and at 2300 pt was transferred in MICU for further management because pt had increased confusion yesterday.\n\nOn admission to MICU pt is coherent Alert and oriented X 3,follows all commands,moves all extrimities C/O pain all over body percocet given with good relief.Denies any SOB or CP.\n\nIn A-Fib on coumadin EKG obtained on admission,blood work up done NBP dropped to 80's on admission NS 500 ml bolused with good effect.HR 80-100,NBP 90-110/30-50.Extrimities has pitting edema,Pedal pulses are doppled.For access one PIV on lt hand.Multiple ecchymotic areas all over the body.\n\nRR 16-25 breathing efforts are normal,LS are coarse throughout,expectorating thick yellow sputum,c/s sent.O2 sats are maintained 94-96% on NC 2L.\n\nAbdomen obese positive bowel sounds,had liquids orally.No bowel movement at this shift.\n\nvoiding adequate amts of clear urine\n\nNo contact from family at this shift\n\nPLAN; ? c/o floor\nmonitor resp status/vitals/MAP > 60\nupdate with pt and family\n\n\n"},{"category":"ECG","chartdate":"2163-12-19 00:00:00.000","description":"Report","row_id":287790,"text":"Baseline artifact. Regular narrow complex rhythm. Probable atrial flutter\nwhich is not counterclockwise in configuration. Since previous tracing\nof the ventricular response has decreased.\n\n"},{"category":"ECG","chartdate":"2163-12-17 00:00:00.000","description":"Report","row_id":287791,"text":"Atrial flutter\nModest nonspecific intraventricular conduction delay\nConsider prior inferior myocardial infarction although is nondiagnostic\nModest nonspecific ST-T wave changes\nSince previous tracing of the same date, no significant change\n\n"},{"category":"ECG","chartdate":"2163-12-17 00:00:00.000","description":"Report","row_id":287792,"text":"Atrial flutter\nModest nonspecific intraventricular conduction delay\nConsider prior inferior myocardial infarction although is nondiagnostic\nModest nonspecific ST-T wave changes\nSince previous tracing of , sinus rhythm absent\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2163-12-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 985960,\n \"text\": \" 3:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for interval change\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with COPD, SOB\\n REASON FOR THIS EXAMINATION:\\n please eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Shortness of breath.\\n\\n Portable AP chest radiograph compared to .\\n\\n The heart size is moderately enlarged but stable. There is no evidence of\\n congestive heart failure. Bibasal linear opacities are unchanged, most likely\\n representing atelectasis. No sizable pleural effusion is noted. The overall\\n lung volumes remain low.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2163-12-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 985901,\n \"text\": \" 1:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for chf/infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with resp distress\\n REASON FOR THIS EXAMINATION:\\n eval for chf/infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PORTABLE AP\\n\\n COMPARISON: .\\n\\n HISTORY: Respiratory distress.\\n\\n FINDINGS: There are low lung volumes. There is persistent elevation of the\\n right hemidiaphragm. There are no consolidations or effusions. There is no\\n pneumothorax. Linear area of scarring is seen in the right upper lobe. There\\n is right lower lobe atelectasis. The cardiomediastinal and hilar contours are\\n stable.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2163-12-18 00:00:00.000\",\n \"description\": \"P CHEST (PA & LAT) PORT\",\n \"row_id\": 986265,\n \"text\": \" 12:10 PM\\n CHEST (PA & LAT) PORT Clip # \\n Reason: assess for vascular congestion progression.\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with copd exacerbation, chf.\\n REASON FOR THIS EXAMINATION:\\n assess for vascular congestion progression.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST ON \\n\\n HISTORY: COPD, CHF, look for vascular congestion.\\n\\n IMPRESSION: PA and lateral chest compared to and 9:\\n\\n Vascular congestion and cardiomegaly are borderline unchanged since . There is no pleural effusion. Lung volumes remain low, particular on the\\n right where there is relative elevation of the lung base, with disparity more\\n pronounced now than it was in , probably due to progressive diaphragmatic\\n eventration.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2163-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1640109,\n \"text\": \"Nursing Progress Note 0700-1900\\nPlease see carevue and FHP for additional data.\\n\\nDispo: FULL code\\nAllergies: Neosporin\\nAccess: 1 piv\\n\\nPt alert, avioding orientation questions, needy at times, carries on coversation appropriately. HR 100-130s aflutter with variable block. Rec'd 5mg lopressor x 1 for HR 130s, restarted on home BP medication. NBP WNL. Remains on 3L nc, with sats 95%, will desat with exertion, but recovers quickly. LS coarse t/o, expectorated yellow/green sputum x1 this shift. Sputum spec sent. last pm. Abd soft, obese, + stool x 1. Foley secure and patent draining adequate amounts of urine. Called out to floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2163-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1640110,\n \"text\": \"Respiratory Care Note\\nPt given Atrovent neb at 12noon. Pt has a congested cough. Secretions swallowed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2163-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1640108,\n \"text\": \"74 y/o male with PMH of COPD (steroid ddependent and on Home O2),CHF,A-Fib on Coumadin,Neuropathy with chronic pain,Ca Lungs diagnosed 5 yrs ago s/P resection of rt lung,Depression... was found unresposive at home,wife called EMS and transferred to tried to intubate,gag was and positive and pt woke up Lasix,nebs,steroids and ceftriaxone was given Pt was transferred to ED and at 2300 pt was transferred in MICU for further management because pt had increased confusion yesterday.\\n\\nOn admission to MICU pt is coherent Alert and oriented X 3,follows all commands,moves all extrimities C/O pain all over body percocet given with good relief.Denies any SOB or CP.\\n\\nIn A-Fib on coumadin EKG obtained on admission,blood work up done NBP dropped to 80's on admission NS 500 ml bolused with good effect.HR 80-100,NBP 90-110/30-50.Extrimities has pitting edema,Pedal pulses are doppled.For access one PIV on lt hand.Multiple ecchymotic areas all over the body.\\n\\nRR 16-25 breathing efforts are normal,LS are coarse throughout,expectorating thick yellow sputum,c/s sent.O2 sats are maintained 94-96% on NC 2L.\\n\\nAbdomen obese positive bowel sounds,had liquids orally.No bowel movement at this shift.\\n\\nvoiding adequate amts of clear urine\\n\\nNo contact from family at this shift\\n\\nPLAN; ? c/o floor\\nmonitor resp status/vitals/MAP > 60\\nupdate with pt and family\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2163-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 287790,\n \"text\": \"Baseline artifact. Regular narrow complex rhythm. Probable atrial flutter\\nwhich is not counterclockwise in configuration. Since previous tracing\\nof the ventricular response has decreased.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2163-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 287791,\n \"text\": \"Atrial flutter\\nModest nonspecific intraventricular conduction delay\\nConsider prior inferior myocardial infarction although is nondiagnostic\\nModest nonspecific ST-T wave changes\\nSince previous tracing of the same date, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2163-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 287792,\n \"text\": \"Atrial flutter\\nModest nonspecific intraventricular conduction delay\\nConsider prior inferior myocardial infarction although is nondiagnostic\\nModest nonspecific ST-T wave changes\\nSince previous tracing of , sinus rhythm absent\\n\\n\"\n }\n]"}}},{"rowIdx":777,"cells":{"subject_id":{"kind":"number","value":14311,"string":"14,311"},"hadm_id":{"kind":"number","value":198441,"string":"198,441"},"target_text":{"kind":"string","value":"The pt was transferred from the ERCP suite to the ICU for close monitoring. A NGT, Foley, amd R CVL was placed. CT abdomen upon admission read the following: Large amount of free air within the peritoneum and in the porta hepatis region. ? duodenal perforation. No extravasation. Large amount of ascites tracking into the pelvis. Diverticulosis without diverticulitis. Bibasilar atelectasis. Clinically, the pt looked well and denied abdominal pain. Pt was hemodynamincally stable w/ O2 sats of 96% on RA. Abdominal exam was significant only for mild distention, NT, no R/G. See admission labs/PE. The pt was administered IVF, kept NPO, and started on Zosyn. HD1, the pt required 1 L bolus for decreasing urine output with a good response. The pt recieved 2 U PRBC and recieved prn hydralazine for hypertension. NGT was DC'd on HD 3 and the pt was kept NPO. On HD4, the pt was overall much improved. She was started on lopressor despite her hx of mild asthma and tolerated it well. Her HR and blood pressure was better controlled and the pt was ultimately DC'd on lopressor. The pt was started on clears and transferred to the floor. The pt tolerated clears without problems and was advanced to a regular diet on HD 6. Upon DC, the pt was passing flatus and voiding on her own. She was passing flatus and having bowel movements. She was afebrile with stable vital signs. Her PE was unremarkable. Please see DC labs. Her WBC was nl and LFT's were steadily trending down. The pt was DC's w/ VNA for umbilical dressing changes (pre admission) and PT on 7 days of PO levofloxacin."},"extractive_notes_summ":{"kind":"string","value":"responsive to one albuterol neb. neuro intact.CV: afebrile, HR cont. pt denies c/o nausea. CT ABODMEN W/O CONTRAST: Bibasilar atelectasis is seen. hct stable. Abd is softly distended with + hypoactive BS. peripheral pulses intact x 4 afebrile sys bp 140-190 with stim. abg on nasal cannula: 7.46/36/99/26/1. Pulm: As stated above. K/mg/ca repleted this am. BT hypoactive. amt.SKIN: intact, small drsg and intact.PAIN: deniesACCESS: multilumen catheter in place, artline dampened, will dc this am.PLAN: cont. NGT to LIWS. CV: Afebrile. Pt in NSR but with ventricular bigeminy/frequent ectopy. PT RECIEVED WITH VS STABLE. slightly hem positive. GU: Foley to gravity. GU: Foley to gravity. abd drsg and . bruised around abd.ACCESS: art line /right subclavian placed. Noted to MD. PERL.CV: HT sys. Coronal and sagittal reformatted images were obtained. GI: Pt strictly NPO. UOP as above. CVP 10-12.RESP: clear bil. assess or resp status. Free fluid is seen tracking into the pelvis. receiving abx as ordered. in vent bigem. Lungs essentially clear, but diminished bases. and postitioning. GU urine drk min. pulmonary toilet with freq. Endo: FS consistantly < 110. no runs Vtach, sys 110-160, cont. ogt to lis with bilious, trace+ drainage. remains npo. FOR VITAL SIGNS. murmur, sinus tach with vent. pt. PT. verified placement by xray. CT PELVIS W/ IV CONTRAST A Foley catheter remains in place. prob. Lungs diminished but clear. An NG tube remains in place. Amber/clear. Non tender to palpation. CXR clear without sx of failure. remain NPO, low suction to ng. wbc slightly elevated today (up to 14 from 12.2).access-> left radial a-line has a very slugglish blood return and tracing is positional. Abd soft distended with absent bowel sounds. sys. denies nausea, no BT. NPN Addendum 0630Pt. Pt in NSR, frequent ventricular ectopy. 3) Diverticulosis without diverticulitis. IMPRESSION 1. amb with standby assist, oriented and calm. IV metoprolol for rate control and bp. remains drk.SKIN: no issues. CT abd without contrast early pm then return for IV and ng contrast early am.GU: urine drk. returns bilious. Coronal and sagittal reformatted images confirm these findings. she is up oob to chair and doing quite well so far.review of systemsrespiratory-> lung sounds are course w/diminished breath sounds bibasilarly. Plan is to c/o pt tommorrow if she remains stable. This was discussed with Dr. . xray did verify.SOCIAL: pt. since mn, the pt has maintained an even fluid balance but is ~1.7 liters tfb positive for her los.id-> tmax 100.6 rectally. There is a biliary stent in place. md did pull back slightly for optimum postitioning. A biliary stent remains in place. Updated by Dr. today. upper, coarse at bases. GI: Pt remains strictly NPO. -bm .gu-> uop >30cc/hr. TECHNIQUE: CT abdomen and pelvis without oral or IV contrast. No c/o pain. Now post op from laparoscopic cholecystectomy and ERCP with increasing jaundice, free air on plain film. Lytes replaced this am--f/u lytes wnl except K+ =3.9--repleted with 20 meq kcl IV. There is a persistent amount of free air and ascites within the abdomen. Contrast is seen within the ascending and transverse colon from a prior contrast enhanced study. Tube patent--flushed by surgery. pulm toilet, transfer to floor today, encourage amb. emotional support and information to pt. BM at 0400 soft to formed brown. sbp ranging 120-160's. Free air is seen throughout the abdomen including within the porta hepatis region. This is most likely due to a duodenal perforation. central line pulled back 2 cm by md . There is a ventral abdominal hernia containing free air and a loop of large bowel. cough non productive.GI: abd distended firm to soft with ngt to low intermittant suction. Mucous membranes dry. Sinus tachycardiaFrequent multiform PVCsRV conduction delayPossible left atrial abnormalityProbable old inferior infarctPossible anterior infarct - age undeterminedNo previous tracing Last ABG sl alkalotic with P02 in 70's. bigem., occasional runs of three mulitfocal pvc, denies cp. Pt often in bigeminy. will refer. EKG DONE AND EXAMINED BY DR . amber urine minimal until fluid bolus x 2. Skin: INtact. Sinus tachycardiaFrequent multiform PVCsRV conduction delayInferior infarct - age undeterminedPossible old anteroseptal myocardial infarctionSince previous tracing of , no significant change A large amount of free fluid tracts into the pelvis. (Over) 2:27 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: PAIN S/P ERCP. Pt remains NPO X 1 more day. No pain with palpation. 2:27 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: PAIN S/P ERCP. This is likely due to a duodenal perforation. Pt showing good technique with IS. pt has been using the incentive spirometer since getting oob.cardiac-> hr 90-110's, vent bigemy/trigemy. UOp excellent 80-200 cc/hr. IN TO SEEPT AND ARRANGED FOR TRANSFER TO MICUA FOR POSS NEED FOR FINDING OF FREE AIR IN ABD. she did well getting oob to the chair w/minimal 2 person assist.gi-> abd is soft, distended w/absent bs. The patient is status-post cholecystectomy. There are numerous diverticula without diverticulitis within the sigmoid colon. PT C/O CHEST PRESS NON RADIATING AT 1745. 2. Pt able to stand/pivot to chair with 1 minimal assist. Pt able to assist with turning. Abdomen remains soft/non tender. Team considering fluids. OOBTC X 2, walking in place and frequent use of IS. earlier. MICU NPN 0700-: Overall pt had an excellent day. Scattered diverticula are seen within the sigmoid without evidence of diverticulitis. Minimal output. Neuro: Alert and oriented. CT ABDOMEN W/ IV CONTRAST There are persistent atelectatic changes at the lung bases."},"n_notes":{"kind":"number","value":12,"string":"12"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2107-10-22 00:00:00.000","description":"CT PELVIS W/CONTRAST","row_id":844323,"text":" 2:27 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: PAIN S/P ERCP.?PERF\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\n Field of view: 45 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with possible perforation after ERCP for jaundice after lap\n chole\n REASON FOR THIS EXAMINATION:\n po and iv contrast looking for duodenal perf\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old with perforation post ERCP, assess for extravasation\n of contrast.\n\n TECHNIQUE: CT of the abdomen and pelvis with IV and oral contrast. 150 cc of\n Optiray were used for this examination due to history of debility. Coronal\n and sagittal reformatted images were obtained.\n\n COMPARISON: Comparison is made to noncontrast study performed 3 hrs. earlier.\n\n CT ABDOMEN W/ IV CONTRAST\n\n There are persistent atelectatic changes at the lung bases. There is a hypo-\n density in the left lobe of the liver, which is incompletely visualized, but\n likely represents a hemangioma. The liver is otherwise unremarkable. The\n spleen, pancreas, adrenals, and kidneys are normal in appearance. The patient\n is post-Billroth II with a gastrojejunostomy and jejuno-jejunostomy. An NG\n tube remains in place. No extravasation of oral contrast is seen from loops\n of small bowel. A biliary stent remains in place. The patient is status-post\n cholecystectomy. There is a persistent large amount of free air and ascites\n within the abdomen. There is a ventral abdominal hernia containing free air\n and a loop of large bowel. In addition, there appears to be added loops of\n small bowel adjacent to the hernia with a smaller hernia sac containing small\n bowel. Several small lymph nodes are seen throughout the abdomen.\n\n CT PELVIS W/ IV CONTRAST\n\n A Foley catheter remains in place. Scattered diverticula are seen within the\n sigmoid without evidence of diverticulitis. A large amount of free fluid\n tracts into the pelvis.\n\n Coronal and sagittal reformatted images confirm these findings.\n\n IMPRESSION\n\n 1. No evidence of contrast extravasation.\n\n 2. There is a persistent amount of free air and ascites within the abdomen.\n This is likely due to a duodenal perforation.\n (Over)\n\n 2:27 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: PAIN S/P ERCP.?PERF\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\n Field of view: 45 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The findings were discussed with Dr. .\n\n"},{"category":"Radiology","chartdate":"2107-10-21 00:00:00.000","description":"CT PELVIS W/O CONTRAST","row_id":844317,"text":" 10:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ?perf there was free air on X-ray of chest\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\n Field of view: 45\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with possible perforation afetr ERCP for jaundice after lap\n chole\n REASON FOR THIS EXAMINATION:\n ?perf there was free air on X-ray of chest\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72 year old with histor of Billroth II for peptic ulcer disease.\n Now post op from laparoscopic cholecystectomy and ERCP with increasing\n jaundice, free air on plain film.\n\n TECHNIQUE: CT abdomen and pelvis without oral or IV contrast.\n\n No prior studies for comparison.\n\n CT ABODMEN W/O CONTRAST:\n Bibasilar atelectasis is seen. No pleural effusions. The heart is somewhat\n enlarged. An NG tube is present with its tip coiled within the stomach. The\n patient is post Billroth II with a gastrojejunostomy. Clips are seen in the\n gallbladder fossa from prior cholecystectomy. There is a biliary stent in\n place. Free air is seen throughout the abdomen including within the porta\n hepatis region. The liver, spleen, pancreas, adrenals, and kidneys are\n unremarkable. There is a ventral hernia containing large bowel. Contrast is\n seen within the ascending and transverse colon from a prior contrast enhanced\n study. The descending colon is collapsed. The intraabdominal small bowel is\n unremarkable. Ascites is seen throughout the abdomen tracking into the\n pelvis. There is no pathologic lymphadenopathy within the abdomen.\n\n CT PELVIS W/O IV CONTRAST:\n A Foley catheter is seen within the bladder which is collapsed. Free fluid is\n seen tracking into the pelvis. There are numerous diverticula without\n diverticulitis within the sigmoid colon. There is no lymphadenopathy within\n the pelvis.\n\n The osseous structures demonstrate degenerative changes throughout the lower\n thoracic and lumbar spine.\n\n IMPRESSION:\n 1) Large amount of free air within the peritoneum and in the porta hepatis\n region. This is most likely due to a duodenal perforation. This was discussed\n with Dr. .\n\n 2) Large amount of ascites tracking into the pelvis.\n\n 3) Diverticulosis without diverticulitis.\n\n (Over)\n\n 10:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ?perf there was free air on X-ray of chest\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\n Field of view: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4) Bibasilar atelectasis.\n\n"},{"category":"ECG","chartdate":"2107-10-21 00:00:00.000","description":"Report","row_id":297373,"text":"Sinus tachycardia\nFrequent multiform PVCs\nRV conduction delay\nPossible left atrial abnormality\nProbable old inferior infarct\nPossible anterior infarct - age undetermined\nNo previous tracing\n\n"},{"category":"ECG","chartdate":"2107-10-21 00:00:00.000","description":"Report","row_id":297374,"text":"Sinus tachycardia\nFrequent multiform PVCs\nRV conduction delay\nInferior infarct - age undetermined\nPossible old anteroseptal myocardial infarction\nSince previous tracing of , no significant change\n\n"},{"category":"Nursing/other","chartdate":"2107-10-23 00:00:00.000","description":"Report","row_id":1449242,"text":"pmicu 7p-7a\n\n\n pt slept poorly, c/o feeling \"stiff\" from being in bed for more than a week. she was intermittently restless and anxious but responded well to verbal reassurance/family presence. although acutely tachypneic w/turning, she was eventually weaned to 6l via cannula and has been maintaining sats >95%. she is up oob to chair and doing quite well so far.\n\nreview of systems\n\nrespiratory-> lung sounds are course w/diminished breath sounds bibasilarly. rr 20's, intermittently tachypneic w/exertion but appears more comfortable sitting up in the chair. abg on nasal cannula: 7.46/\n36/99/26/1. pt has been using the incentive spirometer since getting oob.\n\ncardiac-> hr 90-110's, vent bigemy/trigemy. sbp ranging 120-160's. as discussed w/the surgical resident this morning, iv lopressor did little to lower the pt's hr and reduce her blood pressure; however, she did respond to a total of 20mg iv hydralazine given in 10mg increments. she was repleted w/ca gluconate and magnesium sulfate this morning.\n\nneuro-> a&o x3 and able to participate in her care. she did well getting oob to the chair w/minimal 2 person assist.\n\ngi-> abd is soft, distended w/absent bs. remains npo. ogt to lis with bilious, trace+ drainage. hct stable. pt denies c/o nausea. -bm .\n\ngu-> uop >30cc/hr. since mn, the pt has maintained an even fluid balance but is ~1.7 liters tfb positive for her los.\n\nid-> tmax 100.6 rectally. receiving abx as ordered. wbc slightly elevated today (up to 14 from 12.2).\n\naccess-> left radial a-line has a very slugglish blood return and tracing is positional. right sc triple lumen central line is patent and intact.\n\nsocial-> pt's dtr stayed in the waiting area and was updated on her condition.\n"},{"category":"Nursing/other","chartdate":"2107-10-23 00:00:00.000","description":"Report","row_id":1449243,"text":"MICU NPN 0700-:\n\n Overall pt had an excellent day. OOBTC X 2, walking in place and frequent use of IS. Abd remains benign with no s/sx of peritonitis. NGT removed by Green Surgery. Pt remains NPO X 1 more day. Plan is to c/o pt tommorrow if she remains stable.\n\n Neuro: Alert and oriented X 3, pleasant, cooperative and conversant. Pt able to stand/pivot to chair with 1 minimal assist. No c/o pain.\n\n CV: Afebrile. Pt in NSR, frequent ventricular ectopy. Pt often in bigeminy. BP stable and lopressor increased to 10 mg IV q 6 hours. K/mg/ca repleted this am. Mucous membranes dry. CVP 4-8 with UOP dropping to 30-80 cc/hr. Concentrated/dark urine. Team considering fluids.\n\n Pulm: Pt remains on 6 L NP with sats 95-98%. Lungs essentially clear, but diminished bases. Pt showing good technique with IS. No cough.\n\n GI: Pt remains strictly NPO. She swishes/spits ice water frequently for comfort. Abd is softly distended with + hypoactive BS. Non tender to palpation.\n\n GU: Foley to gravity. UOP as above.\n\n Endo: FS consistantly < 110.\n\n Skin: INtact.\n\n Family: At bedside continuously. Updated by Dr. today.\n"},{"category":"Nursing/other","chartdate":"2107-10-22 00:00:00.000","description":"Report","row_id":1449240,"text":"NPN Addendum 0630\nPt. noted to have 5 beat run Vtach, asymptomatic, no change in VS. Noted to MD. Magnesium, Calcium gluconate and potassium as ordered.\n\nrepeat hct 25.2, reported to md. no orders received.\n"},{"category":"Nursing/other","chartdate":"2107-10-22 00:00:00.000","description":"Report","row_id":1449241,"text":"MICU NPN 0700-:\n\n Events: Pt recieved 2 u prbc with hct bump from 25 to 30. Resp status has continued to worsen today with 02 requirements increasing from 4 L NP to 70% high flow neb. CXR clear without sx of failure. Abdomen remains soft/non tender. Lactate 1.0--surgery is following closely, but do not plan on taking her to OR unless she starts showing signs of worsening sepsis.\n\n Neuro: Alert and oriented. Increasing mild agitation with resp distress during the afternoon. Pt able to assist with turning.\n\n CV: Pt developed low grade temp today during blood transfusion to 100.0, but temperature change was less than 2 degrees. No other s/sx of reaction. Pt in NSR but with ventricular bigeminy/frequent ectopy. PT hypertensive to 170's this afternoon--she was given 10 mg IV hydralazine X 3 and pressure now in 130's. Lytes replaced this am--f/u lytes wnl except K+ =3.9--repleted with 20 meq kcl IV.\n\n Pulm: As stated above. Pt currently on 70% high flow neb with sats 98%. Last ABG sl alkalotic with P02 in 70's. Lungs diminished but clear. No wheezes.\n\n GI: Pt strictly NPO. NGT to LIWS. Minimal output. Tube patent--flushed by surgery. Abd soft distended with absent bowel sounds. No pain with palpation.\n\n GU: Foley to gravity. UOp excellent 80-200 cc/hr. Amber/clear. Team considering lasix, but UOP is brisk.\n\n Skin: Pt has open area from cholecystectomy incision--wtd dressing change done by surgery. Plan to change dressing .\n"},{"category":"Nursing/other","chartdate":"2107-10-21 00:00:00.000","description":"Report","row_id":1449238,"text":"PT RECIEVED WITH VS STABLE. SEE AND ADMIT NOTE.\nRESP: PT WAS 100% SAT ON NRB 12 LITERS AND PROGRESSED TO HUMIDIFIED MASK NAT 10 LITERS. IN TO SEEPT AND ARRANGED FOR TRANSFER TO MICUA FOR POSS NEED FOR FINDING OF FREE AIR IN ABD. PT WAS IS AND OUT OF VENT BIGEMENY THE ENTIRE TIME IN FIN MICU. PT C/O CHEST PRESS NON RADIATING AT 1745. EKG DONE AND EXAMINED BY DR . NO CHANGES OR ACUTE PROBLEMS NOTED PER TEAM AND PT WAS THEN TRANSFERED VIA AMBULANCE TO MICU_A. REPORT GIVEN TO NURSE BY THIS NURSE. FOR VITAL SIGNS.\n"},{"category":"Nursing/other","chartdate":"2107-10-22 00:00:00.000","description":"Report","row_id":1449239,"text":"NPN 1900-0730\nNEURO: MAE, follow commands, easily anxious, able to calm with reassurance. PERL.\n\nCV: HT sys. murmur, sinus tach with vent. bigem., occasional runs of three mulitfocal pvc, denies cp. peripheral pulses intact x 4 afebrile sys bp 140-190 with stim. amber urine minimal until fluid bolus x 2. CVP 10-12.\n\nRESP: clear bil. upper, coarse at bases. Initially on 40% mask and able to wean to nc.sats 90's 2-4 liters, did desat into 80's when flat for CT and began to wheeze. responsive to one albuterol neb. and postitioning. sats return to 90's. cough non productive.\n\nGI: abd distended firm to soft with ngt to low intermittant suction. returns bilious. verified placement by xray. md did pull back slightly for optimum postitioning. denies nausea, no BT. BM at 0400 soft to formed brown. abd drsg and . CT abd without contrast early pm then return for IV and ng contrast early am.\n\nGU: urine drk. min output early in shift until fluid bolus x 2 then 100cc hr. remains drk.\n\nSKIN: no issues. bruised around abd.\n\nACCESS: art line /right subclavian placed. central line pulled back 2 cm by md . xray did verify.\n\nSOCIAL: pt. very anxious but cooperative. family at bedside. dtr to spend night in hospital for assist. pt. does speak english but feels more comfortable with italian with family.\n\nPLAN: Careful monitoring of GI status. remain NPO, low suction to ng. IVF for rehydration, antibiotics. emotional support for pt and family. pulmonary toilet with freq. assess or resp status. Respond to abnormal labs, vs.\n"},{"category":"Nursing/other","chartdate":"2107-10-24 00:00:00.000","description":"Report","row_id":1449244,"text":"1900-0700 NPN\nNEURO: pt. up in chair most pm. amb with standby assist, oriented and calm. neuro intact.\n\nCV: afebrile, HR cont. in vent bigem. no runs Vtach, sys 110-160, cont. IV metoprolol for rate control and bp. sys. murmur\n\nRESP: on 3 liter nc, sats high90's, cough non productive, uses IS to 1000cc with little prompting.\n\nGU/GI: soft, rounded, passed liquid brown stool mod amt. slightly hem positive. no nausea, tol sips water. BT hypoactive. GU urine drk min. amt.\n\nSKIN: intact, small drsg and intact.\n\nPAIN: denies\n\nACCESS: multilumen catheter in place, artline dampened, will dc this am.\n\nPLAN: cont. pulm toilet, transfer to floor today, encourage amb. prob. progress in diet. emotional support and information to pt. and family. PT. would like social service to see regarding visiting nurse at home on dc for followup and Physical therapy. will refer.\n\n\n"},{"category":"Nursing/other","chartdate":"2107-10-24 00:00:00.000","description":"Report","row_id":1449245,"text":"See transfer note.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-22 00:00:00.000\",\n \"description\": \"CT PELVIS W/CONTRAST\",\n \"row_id\": 844323,\n \"text\": \" 2:27 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\\n Reason: PAIN S/P ERCP.?PERF\\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\\n Field of view: 45 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with possible perforation after ERCP for jaundice after lap\\n chole\\n REASON FOR THIS EXAMINATION:\\n po and iv contrast looking for duodenal perf\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old with perforation post ERCP, assess for extravasation\\n of contrast.\\n\\n TECHNIQUE: CT of the abdomen and pelvis with IV and oral contrast. 150 cc of\\n Optiray were used for this examination due to history of debility. Coronal\\n and sagittal reformatted images were obtained.\\n\\n COMPARISON: Comparison is made to noncontrast study performed 3 hrs. earlier.\\n\\n CT ABDOMEN W/ IV CONTRAST\\n\\n There are persistent atelectatic changes at the lung bases. There is a hypo-\\n density in the left lobe of the liver, which is incompletely visualized, but\\n likely represents a hemangioma. The liver is otherwise unremarkable. The\\n spleen, pancreas, adrenals, and kidneys are normal in appearance. The patient\\n is post-Billroth II with a gastrojejunostomy and jejuno-jejunostomy. An NG\\n tube remains in place. No extravasation of oral contrast is seen from loops\\n of small bowel. A biliary stent remains in place. The patient is status-post\\n cholecystectomy. There is a persistent large amount of free air and ascites\\n within the abdomen. There is a ventral abdominal hernia containing free air\\n and a loop of large bowel. In addition, there appears to be added loops of\\n small bowel adjacent to the hernia with a smaller hernia sac containing small\\n bowel. Several small lymph nodes are seen throughout the abdomen.\\n\\n CT PELVIS W/ IV CONTRAST\\n\\n A Foley catheter remains in place. Scattered diverticula are seen within the\\n sigmoid without evidence of diverticulitis. A large amount of free fluid\\n tracts into the pelvis.\\n\\n Coronal and sagittal reformatted images confirm these findings.\\n\\n IMPRESSION\\n\\n 1. No evidence of contrast extravasation.\\n\\n 2. There is a persistent amount of free air and ascites within the abdomen.\\n This is likely due to a duodenal perforation.\\n (Over)\\n\\n 2:27 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\\n Reason: PAIN S/P ERCP.?PERF\\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\\n Field of view: 45 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n The findings were discussed with Dr. .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-21 00:00:00.000\",\n \"description\": \"CT PELVIS W/O CONTRAST\",\n \"row_id\": 844317,\n \"text\": \" 10:38 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: ?perf there was free air on X-ray of chest\\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\\n Field of view: 45\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with possible perforation afetr ERCP for jaundice after lap\\n chole\\n REASON FOR THIS EXAMINATION:\\n ?perf there was free air on X-ray of chest\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72 year old with histor of Billroth II for peptic ulcer disease.\\n Now post op from laparoscopic cholecystectomy and ERCP with increasing\\n jaundice, free air on plain film.\\n\\n TECHNIQUE: CT abdomen and pelvis without oral or IV contrast.\\n\\n No prior studies for comparison.\\n\\n CT ABODMEN W/O CONTRAST:\\n Bibasilar atelectasis is seen. No pleural effusions. The heart is somewhat\\n enlarged. An NG tube is present with its tip coiled within the stomach. The\\n patient is post Billroth II with a gastrojejunostomy. Clips are seen in the\\n gallbladder fossa from prior cholecystectomy. There is a biliary stent in\\n place. Free air is seen throughout the abdomen including within the porta\\n hepatis region. The liver, spleen, pancreas, adrenals, and kidneys are\\n unremarkable. There is a ventral hernia containing large bowel. Contrast is\\n seen within the ascending and transverse colon from a prior contrast enhanced\\n study. The descending colon is collapsed. The intraabdominal small bowel is\\n unremarkable. Ascites is seen throughout the abdomen tracking into the\\n pelvis. There is no pathologic lymphadenopathy within the abdomen.\\n\\n CT PELVIS W/O IV CONTRAST:\\n A Foley catheter is seen within the bladder which is collapsed. Free fluid is\\n seen tracking into the pelvis. There are numerous diverticula without\\n diverticulitis within the sigmoid colon. There is no lymphadenopathy within\\n the pelvis.\\n\\n The osseous structures demonstrate degenerative changes throughout the lower\\n thoracic and lumbar spine.\\n\\n IMPRESSION:\\n 1) Large amount of free air within the peritoneum and in the porta hepatis\\n region. This is most likely due to a duodenal perforation. This was discussed\\n with Dr. .\\n\\n 2) Large amount of ascites tracking into the pelvis.\\n\\n 3) Diverticulosis without diverticulitis.\\n\\n (Over)\\n\\n 10:38 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: ?perf there was free air on X-ray of chest\\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\\n Field of view: 45\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 4) Bibasilar atelectasis.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 297373,\n \"text\": \"Sinus tachycardia\\nFrequent multiform PVCs\\nRV conduction delay\\nPossible left atrial abnormality\\nProbable old inferior infarct\\nPossible anterior infarct - age undetermined\\nNo previous tracing\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 297374,\n \"text\": \"Sinus tachycardia\\nFrequent multiform PVCs\\nRV conduction delay\\nInferior infarct - age undetermined\\nPossible old anteroseptal myocardial infarction\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1449242,\n \"text\": \"pmicu 7p-7a\\n\\n\\n pt slept poorly, c/o feeling \\\"stiff\\\" from being in bed for more than a week. she was intermittently restless and anxious but responded well to verbal reassurance/family presence. although acutely tachypneic w/turning, she was eventually weaned to 6l via cannula and has been maintaining sats >95%. she is up oob to chair and doing quite well so far.\\n\\nreview of systems\\n\\nrespiratory-> lung sounds are course w/diminished breath sounds bibasilarly. rr 20's, intermittently tachypneic w/exertion but appears more comfortable sitting up in the chair. abg on nasal cannula: 7.46/\\n36/99/26/1. pt has been using the incentive spirometer since getting oob.\\n\\ncardiac-> hr 90-110's, vent bigemy/trigemy. sbp ranging 120-160's. as discussed w/the surgical resident this morning, iv lopressor did little to lower the pt's hr and reduce her blood pressure; however, she did respond to a total of 20mg iv hydralazine given in 10mg increments. she was repleted w/ca gluconate and magnesium sulfate this morning.\\n\\nneuro-> a&o x3 and able to participate in her care. she did well getting oob to the chair w/minimal 2 person assist.\\n\\ngi-> abd is soft, distended w/absent bs. remains npo. ogt to lis with bilious, trace+ drainage. hct stable. pt denies c/o nausea. -bm .\\n\\ngu-> uop >30cc/hr. since mn, the pt has maintained an even fluid balance but is ~1.7 liters tfb positive for her los.\\n\\nid-> tmax 100.6 rectally. receiving abx as ordered. wbc slightly elevated today (up to 14 from 12.2).\\n\\naccess-> left radial a-line has a very slugglish blood return and tracing is positional. right sc triple lumen central line is patent and intact.\\n\\nsocial-> pt's dtr stayed in the waiting area and was updated on her condition.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1449243,\n \"text\": \"MICU NPN 0700-:\\n\\n Overall pt had an excellent day. OOBTC X 2, walking in place and frequent use of IS. Abd remains benign with no s/sx of peritonitis. NGT removed by Green Surgery. Pt remains NPO X 1 more day. Plan is to c/o pt tommorrow if she remains stable.\\n\\n Neuro: Alert and oriented X 3, pleasant, cooperative and conversant. Pt able to stand/pivot to chair with 1 minimal assist. No c/o pain.\\n\\n CV: Afebrile. Pt in NSR, frequent ventricular ectopy. Pt often in bigeminy. BP stable and lopressor increased to 10 mg IV q 6 hours. K/mg/ca repleted this am. Mucous membranes dry. CVP 4-8 with UOP dropping to 30-80 cc/hr. Concentrated/dark urine. Team considering fluids.\\n\\n Pulm: Pt remains on 6 L NP with sats 95-98%. Lungs essentially clear, but diminished bases. Pt showing good technique with IS. No cough.\\n\\n GI: Pt remains strictly NPO. She swishes/spits ice water frequently for comfort. Abd is softly distended with + hypoactive BS. Non tender to palpation.\\n\\n GU: Foley to gravity. UOP as above.\\n\\n Endo: FS consistantly < 110.\\n\\n Skin: INtact.\\n\\n Family: At bedside continuously. Updated by Dr. today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1449240,\n \"text\": \"NPN Addendum 0630\\nPt. noted to have 5 beat run Vtach, asymptomatic, no change in VS. Noted to MD. Magnesium, Calcium gluconate and potassium as ordered.\\n\\nrepeat hct 25.2, reported to md. no orders received.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1449241,\n \"text\": \"MICU NPN 0700-:\\n\\n Events: Pt recieved 2 u prbc with hct bump from 25 to 30. Resp status has continued to worsen today with 02 requirements increasing from 4 L NP to 70% high flow neb. CXR clear without sx of failure. Abdomen remains soft/non tender. Lactate 1.0--surgery is following closely, but do not plan on taking her to OR unless she starts showing signs of worsening sepsis.\\n\\n Neuro: Alert and oriented. Increasing mild agitation with resp distress during the afternoon. Pt able to assist with turning.\\n\\n CV: Pt developed low grade temp today during blood transfusion to 100.0, but temperature change was less than 2 degrees. No other s/sx of reaction. Pt in NSR but with ventricular bigeminy/frequent ectopy. PT hypertensive to 170's this afternoon--she was given 10 mg IV hydralazine X 3 and pressure now in 130's. Lytes replaced this am--f/u lytes wnl except K+ =3.9--repleted with 20 meq kcl IV.\\n\\n Pulm: As stated above. Pt currently on 70% high flow neb with sats 98%. Last ABG sl alkalotic with P02 in 70's. Lungs diminished but clear. No wheezes.\\n\\n GI: Pt strictly NPO. NGT to LIWS. Minimal output. Tube patent--flushed by surgery. Abd soft distended with absent bowel sounds. No pain with palpation.\\n\\n GU: Foley to gravity. UOp excellent 80-200 cc/hr. Amber/clear. Team considering lasix, but UOP is brisk.\\n\\n Skin: Pt has open area from cholecystectomy incision--wtd dressing change done by surgery. Plan to change dressing .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1449238,\n \"text\": \"PT RECIEVED WITH VS STABLE. SEE AND ADMIT NOTE.\\nRESP: PT WAS 100% SAT ON NRB 12 LITERS AND PROGRESSED TO HUMIDIFIED MASK NAT 10 LITERS. IN TO SEEPT AND ARRANGED FOR TRANSFER TO MICUA FOR POSS NEED FOR FINDING OF FREE AIR IN ABD. PT WAS IS AND OUT OF VENT BIGEMENY THE ENTIRE TIME IN FIN MICU. PT C/O CHEST PRESS NON RADIATING AT 1745. EKG DONE AND EXAMINED BY DR . NO CHANGES OR ACUTE PROBLEMS NOTED PER TEAM AND PT WAS THEN TRANSFERED VIA AMBULANCE TO MICU_A. REPORT GIVEN TO NURSE BY THIS NURSE. FOR VITAL SIGNS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1449239,\n \"text\": \"NPN 1900-0730\\nNEURO: MAE, follow commands, easily anxious, able to calm with reassurance. PERL.\\n\\nCV: HT sys. murmur, sinus tach with vent. bigem., occasional runs of three mulitfocal pvc, denies cp. peripheral pulses intact x 4 afebrile sys bp 140-190 with stim. amber urine minimal until fluid bolus x 2. CVP 10-12.\\n\\nRESP: clear bil. upper, coarse at bases. Initially on 40% mask and able to wean to nc.sats 90's 2-4 liters, did desat into 80's when flat for CT and began to wheeze. responsive to one albuterol neb. and postitioning. sats return to 90's. cough non productive.\\n\\nGI: abd distended firm to soft with ngt to low intermittant suction. returns bilious. verified placement by xray. md did pull back slightly for optimum postitioning. denies nausea, no BT. BM at 0400 soft to formed brown. abd drsg and . CT abd without contrast early pm then return for IV and ng contrast early am.\\n\\nGU: urine drk. min output early in shift until fluid bolus x 2 then 100cc hr. remains drk.\\n\\nSKIN: no issues. bruised around abd.\\n\\nACCESS: art line /right subclavian placed. central line pulled back 2 cm by md . xray did verify.\\n\\nSOCIAL: pt. very anxious but cooperative. family at bedside. dtr to spend night in hospital for assist. pt. does speak english but feels more comfortable with italian with family.\\n\\nPLAN: Careful monitoring of GI status. remain NPO, low suction to ng. IVF for rehydration, antibiotics. emotional support for pt and family. pulmonary toilet with freq. assess or resp status. Respond to abnormal labs, vs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1449244,\n \"text\": \"1900-0700 NPN\\nNEURO: pt. up in chair most pm. amb with standby assist, oriented and calm. neuro intact.\\n\\nCV: afebrile, HR cont. in vent bigem. no runs Vtach, sys 110-160, cont. IV metoprolol for rate control and bp. sys. murmur\\n\\nRESP: on 3 liter nc, sats high90's, cough non productive, uses IS to 1000cc with little prompting.\\n\\nGU/GI: soft, rounded, passed liquid brown stool mod amt. slightly hem positive. no nausea, tol sips water. BT hypoactive. GU urine drk min. amt.\\n\\nSKIN: intact, small drsg and intact.\\n\\nPAIN: denies\\n\\nACCESS: multilumen catheter in place, artline dampened, will dc this am.\\n\\nPLAN: cont. pulm toilet, transfer to floor today, encourage amb. prob. progress in diet. emotional support and information to pt. and family. PT. would like social service to see regarding visiting nurse at home on dc for followup and Physical therapy. will refer.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1449245,\n \"text\": \"See transfer note.\\n\"\n }\n]"}}},{"rowIdx":778,"cells":{"subject_id":{"kind":"number","value":83981,"string":"83,981"},"hadm_id":{"kind":"number","value":147314,"string":"147,314"},"target_text":{"kind":"string","value":"45 yo M presented worsening shortness of breath over the past several months and was at preparing for sinus surgery and had a syncopal event,coded briefly. Transferred to . Patient was found to have severe mitral regurgitation with a flailed valve leaflet. In the ER he vasovagaled after blood was drawn and had 9 second asystole. He was intubated and had a swan placed and was found to have a low CI (1.7). Patient had aortic balloon pump placed because of low cardiac output and impaired forward flow. Balloon pump (1:1) to which he responded well; post-IABP CI was 2.6. We felt his mitral regurg was likely chronic given the progression of his EKG changes since (increasing RVH, new RAD), his elevated PA pressures without florid pulmonary edema, and the gradual worsening of his symptoms, which were previously attributed to sinusitis alone. Echo showed myxomatous mitral valve. While he was here we gave him lasix to diurese him. He had a temp max of 100.6 which we thought could be a pneumonitis from intubation causing gastric contents to irritate his lungs and cause a fever. CXR showed no PNA but we treated him for possible aspiration pneumonia because he was at high aspiration risk because he was intubated. We started him on vancomycin and zosyn. He was on a heparin drip because he was on the balloon pump. On pt was taken to the OR and underwent MV repair with #32 ring resection of P2. He arrived from OR fully vented on pressor and inotropes. His first night post-op he had significant rise in his pulmonary artery pressures and was hypotensive. TTE/TEE showed significant RV and LV dysfunction. He remained intubated, sedated and on pressors and inotropes for several days. All gtts were weaned off slowly. He developed post-op afib and was started on amiodarone. After a few days her returned to sinus rhythm. His sedation was weaned off and he eventually extubated on POD #4. On night of POD#3 he had 2min seizure that was treated with propofol and ativan. Neurology was consulted, head CT and MRI unremarkable. No further seizure activity was noted. He initially was confused with generalized weakness, greater left sided weakness noted. Pain meds were adjusted and he was seen by the Psych service for his depression and Wellbutrin was increased. He was thrombocytopenic while IABP was in this had since resolved and he was started on anticoagulation for his a-fib. He was febrile consistently in the first few days post-op and sputum culture was positive for PANTOEA SPECIES. His antibiotics were adjusted and he was treated with a course of meropenem at the recommendations of ID. On POD #5 the patient transferred to the floor. He developed intermittant atrial fibrillation and his lopressor was increased and he was started on amiodarone and coumadin. he did convert to sinus rhythm and will continue on coumadin therapy upon discharge. Chest tubes and pacing wires were removed without incident. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #9 the patient was ambulating independently, the sternal wound was healing with scant serosanguinous drainage from the distal and he was placed on Keflex. He was also note to have folliculitis over his anterior chest. Pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions."},"extractive_notes_summ":{"kind":"string","value":"Mild [1+] TR.PERICARDIUM: Very small pericardial effusion.GENERAL COMMENTS: Informed consent was obtained. The end-diastolic PR velocity isincreased c/w PA diastolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. Abnormal septalmotion/position.AORTIC VALVE: No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Right perihilar opacity most likely represents a combination of atelectasis, with potentially minimal edema. At least moderatepulmonary artery systolic hypertension. Mild to moderate [+] TR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads orelectrodes. Abnormal septal motion/position consistent with RVpressure/volume overload.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The right ventricle appears mildlyhypokinetic on the current echocardiogram. Moderately dilated LV cavity.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). There is moderate pulmonary artery systolichypertension. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. Echocardiographic signs of tamponade may be absent in the presenceof elevated right sided pressures.Conclusions:The left atrium and right atrium are markedly dilated. Normalappearing coronary sinus.POSTBYPASS: Normally functioning MV repair with ring and neochord to anteriorleaflet. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is a small circumferential pericardialeffusion located predominantly along the infero-lateral wall and right atrium(small-moderate along the RA) . No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Overallleft ventricular systolic function is mildly depressed There is abnormalsystolic septal motion/position consistent with right ventricular pressureoverload. The right ventricular cavity ismoderately dilated with mild global free wall hypokinesis. No PS.Physiologic PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: Informed consent was obtained. The ascending,transverse and descending thoracic aorta are normal in diameter and free ofatherosclerotic plaque with IABP distal to arch about 2-3cm.. right chest tube and mediasinal drains removed. No VSD.RIGHT VENTRICLE: Moderately dilated RV cavity. There is no evidence of tamponade.Echocardiographic signs of tamponade may be absent in the presence of elevatedright sided pressures.IMPRESSION: Moderately dilated left ventricular cavity with hyperdynamic leftventricular function and severe mitral regurgitation secondary to a flailposterior mitral leaflet and thorn mitral valve chordae. Severe (4+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Right ventricular functionappears depressed. Moderate [2+]tricuspid regurgitation is seen. There is abnormalseptal motion/position consistent with right ventricular pressure/volumeoverload. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS. Mildthickening of mitral valve chordae. There ismoderate pulmonary artery systolic hypertension (RA pressure not estimated asthe patient is intubated). ]TRICUSPID VALVE: Normal tricuspid valve leaflets. Well-seated mitral annular ring with normal gradient. Non-specific ST segment flattening in theprecordial leads. Normal intracranial flow voids are present. Left atrial abnormality is no longer apparent.QRS morphology is much more fractionated in lead V1. Left atrialabnormality, incomplete right bundle-branch block, right ventricularhypertrophy, right axis deviation are unchanged. Stability of the retrocardiac opacity that could be atelectasis. Non-specific ST segment flattening persists in the limb leads.Computed Q-T interval is normal. Left atrial abnormality, right axis deviation,right ventricular hypertrophy, and incomplete right bundle-branch block patternare unchanged. There is increasing obscuration of the right hemidiaphragm and less prominent on the left concerning for bilateral effusions. Mild bilateral pleural effusions. FINDINGS: Position of endotracheal tube and right-sided Swan-Ganz is unchanged. T wave inversions are nolonger present in leads V3-V5, replaced with more non-specific repolarizationabnormalities. Left atrial abnormality. Right ventricular hypertrophy withST segment changes suggestive of right ventricular strain. Right axis deviation and rightventricular hypertrophy. Right axis deviation. Right axis deviation. Mild bilateral pleural effusions are unchanged. Right ventricular hypertrophy, rightaxis deviation, non-specific ST segment flattening in the limb leads persist.Precordial electrode placement is clearly different, with concomitant extensionof T wave inversions from lead V2 now into lead V3. Retrocardiac opacities consistent with atelectasis are unchanged. Moderate-to-severe enlargement of the cardiac silhouette is stable, is possible that there is pericardial effusion. RSR' pattern is no longerpresent in lead V2 with deep T wave inversions. Non-specific ST segment abnormalities in the limb leads aremore prominent. However, prioranterior myocardial ischemia cannot be excluded. Mild mucosal thickening in the mastoids, ethmoids, and left maxillary sinus retention cyst. Also, possible posteriormyocardial infarction. Sinus bradycardia. Compared to the previous tracing precordial electrode placementis clearly different. Compared to the previous tracing from the same dateQRS morphology in lead V1 is different. Consider myocardial ischemia.TRACING #2 Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. The patient with moderate to important cardiomegaly and mitral valve repair. Sinus tachycardia. TECHNIQUE: Sagittal T1, axial FLAIR, T2, susceptibility, and diffusion-weighted images were obtained. Incomplete rightbundle-branch block pattern. IMPRESSION: The ET tube has been removed and the lung volumes are thus low. FINDINGS: There is mucosal thickening involving the bilateral mastoid air cells, the ethmoids, and a small retention cyst in the left maxillary sinus. The basal cisterns appear patent, and there is preservation of -white differentiation. An ongoing anteroseptal ischemic processcannot be excluded. An endotracheal tube is seen. Right-sided Swan-Ganz ends in the right pulmonary artery. There is mild vascukar congestion with no overt edema. The ET tube has been removed and the lung volumes are low. Bilateral patchy lung opacifications, likely represent atelectasis and crowding of pulmonary vasculature secondary to low volumes. Prolonged Q-T interval.Compared to the previous tracing of ST-T wave changes, particularly inleads V1-V4, have improved and the rhythm is no longer sinus.TRACING #1 ET tube is in standard position. The normally midline structures are midline. T wave inversions are somewhat deeper in leads V3-V4 extendingnow to lead V5, although precordial electrode placement is clearly different.Non-specific ST segment flattening in lead V6."},"n_notes":{"kind":"number","value":29,"string":"29"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2109-08-28 00:00:00.000","description":"Report","row_id":65057,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P MV repair .\nHeight: (in) 71\nWeight (lb): 244\nBSA (m2): 2.30 m2\nBP (mm Hg): 135/62\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mitral valve annuloplasty ring. Well-seated mitral annular ring\nwith normal gradient. No MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate\n[2+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. The end-diastolic PR velocity is\nincreased c/w PA diastolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\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. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is mildly dilated. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is preserved (LVEF>50%).\nThere is no ventricular septal defect. The right ventricular cavity is\nmoderately dilated with mild global free wall hypokinesis. There is abnormal\nseptal motion/position consistent with right ventricular pressure/volume\noverload. 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. A mitral valve annuloplasty ring is present. The mitral\nannular ring appears well seated with normal gradient. No mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. The end-diastolic pulmonic regurgitation velocity is increased\nsuggesting pulmonary artery diastolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , no clear\nchange.;\n\n\n"},{"category":"Echo","chartdate":"2109-08-24 00:00:00.000","description":"Report","row_id":65058,"text":"PATIENT/TEST INFORMATION:\nIndication: S/p MV repair for ruptured chordae (P2).Hypotension and increased pulmonary pressures on pressors.\nHeight: (in) 71\nWeight (lb): 239\nBSA (m2): 2.28 m2\nBP (mm Hg): 90/40\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 02:53\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: Mild global LV hypokinesis. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: RV not well seen. RV function depressed. Abnormal systolic\nseptal motion/position consistent with RV pressure overload. Abnormal septal\nmotion/position.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. Well-seated mitral annular ring with normal gradient. Mild\nthickening of mitral valve chordae. Trivial MR. [Due to acoustic shadowing,\nthe severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality - body habitus. Suboptimal image quality\n- ventilator. Suboptimal image quality - patient unable to cooperate. If\nclinically indicated, a transesophageal echocardiographic examination is\nrecommended. Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThere is mild global left ventricular hypokinesis (LVEF = 40-45 %). Overall\nleft ventricular systolic function is mildly depressed There is abnormal\nsystolic septal motion/position consistent with right ventricular pressure\noverload. There is abnormal septal motion/position. Right ventricular function\nappears depressed. No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. A mitral valve annuloplasty ring is present. The mitral\nannular ring appears well seated with normal gradient. Trivial mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] There is a\ntrivial/physiologic pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of ,\nleft ventricular systolic function has declined. Mitral annuloplasty ring is\npresent with only trivial regurgitation. Ring is well-seated with normal\ntransvalvular gradient. Pulmonary artery pressures were not assessed.\nPericardial effusion has resolved. A pacing wire is identified and there is\nmore tricuspid regurgitation.\n\n\n"},{"category":"Echo","chartdate":"2109-08-23 00:00:00.000","description":"Report","row_id":65059,"text":"PATIENT/TEST INFORMATION:\nIndication: Mitral valve disease.\nStatus: Inpatient\nDate/Time: at 09:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Moderately dilated LV cavity.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Torn mitral chordae. Severe (4+) 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: Small pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations.\n\nConclusions:\nPREBYASS: SEVERE MR from P2 flail and leaflet with anteriorly directed MR jet\nwith coanda effect, with LA and LV dilation from LV volume overload from MR\notherwise essentially normal exam.Torn mitral chordae are present. Severe (4+)\nmitral regurgitation is seen.Preserved LV systolic function with LVEF > 55%,\nno segmental wall motion abnormalities. Other valves are normal Balloon pump\nin good position. Intact interatrial septum. As expected with severe MR, no\nclot in the LAA . The left atrium is moderately dilated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is moderately dilated.\nRight ventricular chamber size and free wall motion are normal. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque with IABP distal to arch about 2-3cm.. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis or aortic regurgitation. There is a small pericardial\neffusion. Diastolic function appears to be normal with e' >10 cm/sec. Normal\nappearing coronary sinus.\n\nPOSTBYPASS: Normally functioning MV repair with ring and neochord to anterior\nleaflet. No sig MR . , otherwise unchanged\n\n\n"},{"category":"Echo","chartdate":"2109-08-22 00:00:00.000","description":"Report","row_id":65060,"text":"PATIENT/TEST INFORMATION:\nIndication: Severe mitral regurgitation, preoperative assessment\nHeight: (in) 71\nWeight (lb): 237\nBSA (m2): 2.27 m2\nBP (mm Hg): 97/48\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 10:57\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: No atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Partial mitral leaflet flail. Mitral leaflets fail to fully\ncoapt. Eccentric MR jet. Severe (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPERICARDIUM: Very small pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). No glycopyrrolate was\nadministered. No TEE related complications.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis or aortic regurgitation. There is posterior mitral leaflet\nflail. An eccentric, anteriorly directed jet of severe (4+) mitral\nregurgitation is seen. There is a small circumferential pericardial effusion.\n\nIMPRESSION: Myxomatous mitral valve disease with flail posterior mitral\nleaflet. Severe mitral regurgitation. No evidence of papillary muscle rupture,\nregional LV dysfunction, or endocarditis.\n\n\n"},{"category":"Echo","chartdate":"2109-08-21 00:00:00.000","description":"Report","row_id":65061,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease.\nHeight: (in) 71\nWeight (lb): 200\nBSA (m2): 2.11 m2\nBP (mm Hg): 119/66\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 16:30\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. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\nHyperdynamic LVEF >75%. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Partial mitral leaflet\nflail. Torn mitral chordae. Severe (4+) 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: Small pericardial effusion. No echocardiographic signs of\ntamponade. Sustained RA diastolic collapse, c/w low filling pressures or early\ntamponade. Echocardiographic signs of tamponade may be absent in the presence\nof elevated right sided pressures.\n\nConclusions:\nThe left atrium and right atrium are markedly dilated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is moderately dilated.\nLeft ventricular systolic function is hyperdynamic (EF>75%). Right ventricular\nchamber size is normal. with mild global free wall hypokinesis. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis or aortic regurgitation. The mitral valve leaflets are\nmildly thickened. There is posterior mitral leaflet flail (P2 scallop) with\ntorn mitral chordae. Severe (4+) mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension (RA pressure not estimated as\nthe patient is intubated). There is a small circumferential pericardial\neffusion located predominantly along the infero-lateral wall and right atrium\n(small-moderate along the RA) . There is no evidence of tamponade.\nEchocardiographic signs of tamponade may be absent in the presence of elevated\nright sided pressures.\n\nIMPRESSION: Moderately dilated left ventricular cavity with hyperdynamic left\nventricular function and severe mitral regurgitation secondary to a flail\nposterior mitral leaflet and thorn mitral valve chordae. At least moderate\npulmonary artery systolic hypertension. Small circumferential pericardial\neffusion with no evidence of tamponade.\n\nCompared with the earlier echocardiographic study dated (images\nunavailable for review), the pericardial effusion is more prominent although\nstill not hemodynamically significant. The right ventricle appears mildly\nhypokinetic on the current echocardiogram. Other findings are similar.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-25 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1248124,"text":" 4:38 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check swan placement\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man\n REASON FOR THIS EXAMINATION:\n check swan placement\n ______________________________________________________________________________\n WET READ: MDAg SUN 6:51 PM\n ETT ends 7.7cm above carina and could be advanced for better seating. NGT ends\n in the distal esophagus. Swan ganx ends in proximal right main pulmonary\n artery. right chest tube and mediasinal drains removed. intra-aortic balloon\n pump unchanged in position.\n -MAgarwal d/ by phone 6:50pm .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Swan placement.\n\n FINDINGS: In comparison with the earlier study of this date, the Swan-Ganz\n catheter tip lies well into the right pulmonary artery. Nasogastric tube has\n been pulled back so that the tip is in the region of the esophagogastric\n junction. The right chest tube has been removed and there is no pneumothorax.\n IABP is unchanged in position.\n\n Left hemidiaphragm is again not well seen, suggesting substantial volume loss\n in the left lower lobe.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1247997,"text":" 10:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulmonary edema\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with MVR, pulm HTN\n REASON FOR THIS EXAMINATION:\n eval for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with mitral valve\n replacement and pulmonary hypertension.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Tubes and lines are in unchanged position. The right chest tube is in place.\n Left retrocardiac opacity is slightly more pronounced than on the prior study.\n Left infrahilar opacity has minimally improved. No pneumothorax is seen. No\n interval development of pulmonary edema is demonstrated.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1248159,"text":" 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval line placement\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: In comparison with the study of , the IABP has been removed.\n The tip of the Swan-Ganz catheter is in the right pulmonary artery.\n Nasogastric tube extends to the body of the stomach with the side hole in the\n region of the esophagogastric junction.\n\n Continued low lung volumes with enlargement of the cardiac silhouette.\n Retrocardiac opacification is consistent with volume loss in the left lower\n lobe.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1247722,"text":" 9:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Confirm position of swan and balloon pump\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with chordae tendinae rupture now with Swan and IABP\n REASON FOR THIS EXAMINATION:\n Confirm position of swan and balloon pump\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Swan-Ganz catheter, aortic balloon pump.\n\n COMPARISON: , 4:08 p.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects approximately 3 cm above\n the carina. The course and the tip of the Swan-Ganz catheter is unremarkable,\n but the catheter should be pulled back by approximately 2 cm, as the tip\n projects over the rather distal parts of the right pulmonary artery. Moderate\n pulmonary edema is unchanged, moderate-to-severe cardiomegaly. No pleural\n effusions.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1248085,"text":" 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p MV repair w/continued inotropic requirement r/o effusion\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p MV repair w/continued inotropic requirement r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after mitral valve repair\n with continued inotropic requirement.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n As compared to the prior study, there is impression of increased cardiac\n silhouette that might reflect pericardial effusion, correlation with\n echocardiography is required. Swan-Ganz catheter tip is at the level of the\n right ventricle outflow tract. Intra-aortic balloon pump is approximately 3.3\n cm below the roof of the aortic arch. The replaced mitral valve is in place\n as well as the right chest tube. No pulmonary edema or substantial increase\n in pleural effusions or no pneumothorax is seen.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1247829,"text":" 4:35 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please assess for O/G tube\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with severe mitral regurg with baloon pump, intubated, please\n assess for OG tube\n REASON FOR THIS EXAMINATION:\n please assess for O/G tube\n ______________________________________________________________________________\n WET READ: 6:02 PM\n OG tube could be advanced by 1-2 cm to ensure that the sideport is beyond the\n GE junction. Swan-Ganz catheter has been removed. IABP tip terminates over\n the left 2nd rib anteriorly. Study is otherwise unchanged. T. Pinar\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess NG tube.\n\n Comparison is made with prior study performed five hours earlier.\n\n NG tube tip is in the stomach but the side port is just distal to the EG\n junction. It can be advanced couple of centimeters. Enlargement of the\n cardiac silhouette is stable. There is mild vascular congestion. No\n pulmonary edema and no pleural effusion. ET tube is in standard position.\n Intra-aortic balloon is in unchanged position. It could be withdrawn 1.5 cm\n for more standard position.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-23 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1247920,"text":" 11:53 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: cardiac srugery fast t rack. eval for ptx, effusions. c\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with s/p MV Repair\n REASON FOR THIS EXAMINATION:\n cardiac srugery fast t rack. eval for ptx, effusions. is the\n CVICU provider page him if there is concern\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after mitral valve repair.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The ET tube tip is 6 cm above the carina. The Swan-Ganz catheter tip is at\n the level of the right ventricular outflow tract. Mediastinal drains, right\n chest tube and replaced mitral valve are in place, in expected positions.\n There is no pneumothorax or appreciable pleural effusion. The\n cardiomediastinal silhouette is stable. The intra-aortic balloon tip is\n approximately 2.5 cm below the roof of the aorta.\n\n Right perihilar opacity most likely represents a combination of atelectasis,\n with potentially minimal edema.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1247736,"text":" 5:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line & OG placement, ? stable pulmonary congestion\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with pulmonary congestion, IABP, Swan, ETT, OG tube\n REASON FOR THIS EXAMINATION:\n line & OG placement, ? stable pulmonary congestion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pulmonary congestion, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, monitoring and support\n devices are constant. A Swan-Ganz catheter is located very distally, it\n should be pulled back, as already noted in the previous report.\n\n Marked cardiomegaly with evidence of mild-to-moderate pulmonary edema.\n Retrocardiac atelectasis. No evidence of pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1247693,"text":" 4:03 PM\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \n -76 BY SAME PHYSICIAN\n : s/p intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 45M with arrest\n REASON FOR THIS EXAMINATION:\n s/p intubation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Status post intubation after arrest.\n\n COMPARISONS: None available.\n\n TECHNIQUE: Chest, portable AP supine.\n\n FINDINGS: The patient is intubated. The endotracheal tube terminates at the\n thoracic inlet approximately 7 cm above the carina. Advancing the tube by\n approximately 3 cm could be considered for more optimal positioning. The\n heart is moderate to severely enlarged with a globular configuration.\n Perihilar fullness suggests mild vascular congestion but otherwise the lungs\n appear clear. Although the left costophrenic sulcus is not entirely included,\n there is no definite pleural effusion. There is no pneumothorax.\n\n IMPRESSION:\n\n 1. Striking cardiomegaly; true cardiac enlargement or the possibility of a\n pericardial effusion, or perhaps both, could be considered.\n\n 2. Prominent main pulmonary artery contour.\n\n 3. Findings suggesting mild vascular congestion.\n\n 4. Status post endotracheal intubation, with relatively high lying\n endotracheal tube, which could be advanced by approximately 3 cm for more\n optimal positioning, if clinically indicated.\n\n"},{"category":"Radiology","chartdate":"2109-08-30 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1248788,"text":" 7:10 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p mvr\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n WET READ: OXZa FRI 8:36 PM\n interval removal of esophageal catheter. lung volumes remain low however there\n is improved aeration at bases and decreased effusions.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST X-RAY \n\n COMPARISON: radiograph as well as earlier radiograph dating\n back to .\n\n FINDINGS: The patient is status post median sternotomy and mitral valve\n replacement procedure. Cardiac silhouette is markedly enlarged but stable in\n size. Improved pulmonary vascular congestion and decrease in size of pleural\n effusions with residual small to moderate right and small left effusions\n remaining. Marked improvement in bibasilar atelectasis.\n\n IMPRESSION: Improving bibasilar atelectasis and effusions.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1247793,"text":" 12:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OG tube placement\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cardiogenic shock and baloon pump, OG tube was placed\n please evaluate\n REASON FOR THIS EXAMINATION:\n OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Catheter check, evaluate balloon pump and also OJ tube.\n\n Comparison is made with prior study performed six hours earlier.\n\n NG tube is no longer visualized. ET tube is in standard position. Swan-Ganz\n catheter tip is too distal in the right pulmonary artery, it should be\n withdrawn at least 4 cm for more standard position. Moderate-to-severe\n enlargement of the cardiac silhouette is stable, is possible that there is\n pericardial effusion. There is no evidence of pneumothorax or pleural\n effusion. Retrocardiac opacities consistent with atelectasis are unchanged.\n Intra-aortic balloon pump tip is 3.1 cm above the left main bronchus, can be\n withdrawn 1 cm. When compared to prior study performed a day earlier, the\n intra-aortic balloon pump was more distally located in appropriate position.\n There is mild vascukar congestion with no overt edema.\n\n\n\n"},{"category":"Radiology","chartdate":"2109-08-29 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":1248561,"text":" 12:24 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for evidence of bleeding in patient w left sided weakne\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n eval for evidence of bleeding in patient w left sided weakness who needs\n coumadin for afib. NEEDS COUMADIN, WHICH IS BEING HELD FOR MR.\n contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE HEAD\n\n CLINICAL INFORMATION: 45-year-old man status post mitral valve replacement.\n Evaluate for evidence of bleeding in patient with left-sided weakness.\n\n COMPARISON: None.\n\n TECHNIQUE: Sagittal T1, axial FLAIR, T2, susceptibility, and\n diffusion-weighted images were obtained.\n\n FINDINGS: There is mucosal thickening involving the bilateral mastoid air\n cells, the ethmoids, and a small retention cyst in the left maxillary sinus.\n There is no focal signal abnormality within the brain parenchyma, no evidence\n of hemorrhage, and no evidence of slow diffusion. The ventricles, sulci,\n subarachnoid spaces are normal in size and configuration. Normal intracranial\n flow voids are present.\n\n IMPRESSION:\n 1. No acute intracranial abnormality. No evidence of hemorrhage.\n 2. Mild mucosal thickening in the mastoids, ethmoids, and left maxillary\n sinus retention cyst.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-26 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1248169,"text":" 8:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ischemic vs.hemorrhagic event\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with s/p MVr\n REASON FOR THIS EXAMINATION:\n ischemic vs.hemorrhagic event\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n INDICATION: Ischemic versus hemorrhagic event.\n\n TECHNIQUE: MDCT continuous axial images were acquired through the brain at a\n slice thickness of 5 mm without administration of IV contrast.\n\n COMPARISON: None.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or\n infarction. The ventricles and sulci are normal in size and configuration.\n The basal cisterns appear patent, and there is preservation of -white\n differentiation. The normally midline structures are midline.\n\n There is opacification of many ethmoid air cells. Mucosal thickening is also\n seen in the maxillary sinuses and the sphenoid sinus. The left maxillary\n sinus is notable for a mucus retention cyst. An endotracheal tube is seen.\n Mucosal thickening in the - and oro-pharyngeal area is consistent with\n intubation.\n\n No bony abnormality is seen. The mastoid air cells and middle ear cavities\n are clear. The globes are unremarkable.\n\n IMPRESSION: No evidence of acute hemorrhage, edema. No significant\n abnormalities on head CT.\n\n COMMENT: These findings were communicated by telephone by Dr. \n to Ms. , PA (cardiac surgery) at 10:58 a.m. on .\n\n"},{"category":"Radiology","chartdate":"2109-08-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1248315,"text":" 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with s/p MVr\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man status post mitral valve replacement,? pneumonia.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST RADIOGRAPH.\n\n FINDINGS: Position of endotracheal tube and right-sided Swan-Ganz is\n unchanged. NG tube projects over the stomach. Sternotomy wires and outline\n of artificial mitral valve noted. Heart is moderately enlarged as before.\n Mild bilateral pleural effusions are unchanged. Bilateral patchy lung\n opacifications, likely represent atelectasis and crowding of pulmonary\n vasculature secondary to low volumes. No focal areas of consolidation to\n suggest pneumonia. No pneumothorax.\n\n IMPRESSION:\n No significant changes compared to the prior study.\n\n"},{"category":"Radiology","chartdate":"2109-08-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1248440,"text":" 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p MV repair w/continued hypoxia r/o effusion\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p MV repair w/continued hypoxia r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE\n\n INDICATION: 45-year-old man with status post MV repair, continued hypoxia,\n rule out effusion.\n\n Comparison is made to prior examination of . There is cardiomegaly.\n This is unchanged. The ET tube has been removed and the lung volumes are low.\n There is increasing obscuration of the right hemidiaphragm and less prominent\n on the left concerning for bilateral effusions. An NG tube is identified with\n its tip in the stomach. Crowding of the vasculature may also represent low\n lung volumes.\n\n IMPRESSION: The ET tube has been removed and the lung volumes are thus low.\n Obscuration of the hemidiaphragm bilaterally may be due to atelectasis is\n worsening compared to prior examination. There could be some element of\n bilateral pleural effusions as well. A lateral film or ultrasound could\n evaluate the extent of the size of pleural effusions bilaterally.\n\n\n"},{"category":"Radiology","chartdate":"2109-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1248203,"text":" 11:48 AM\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \n -76 BY SAME PHYSICIAN\n : *low film check DHT placement\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with s/p MVr\n REASON FOR THIS EXAMINATION:\n *low film check DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: Patient with mitral valve repair, assess Dobhoff placement.\n\n COMPARISON: at 7:59 a.m.\n\n FINDINGS:\n\n The first film shows a Dobhoff tube that is going to mid esophagus and going\n back up where we cannot see the tip of the tube and the second film shows an\n adequate placement of Dobhoff in the stomach. Right-sided Swan-Ganz ends in\n the right pulmonary artery. ET tube ends at 5.3 cm above carina. NG tube is\n in adequate position. The patient with moderate to important cardiomegaly and\n mitral valve repair. Stability of the retrocardiac opacity that could be\n atelectasis. Mild bilateral pleural effusions.\n\n CONCLUSION:\n\n The tubes and lines are in adequate position.\n\n"},{"category":"ECG","chartdate":"2109-08-26 00:00:00.000","description":"Report","row_id":131183,"text":"Baseline artifact. Sinus tachycardia. Compared to the previous tracing the\nrate is faster, the rhythm is sinus, and ST-T wave changes are more\nsignificant. Consider myocardial ischemia.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2109-08-21 00:00:00.000","description":"Report","row_id":131237,"text":"Sinus rhythm. Compared to the previous tracing the rate has increased and is\nno longer bradycardic. Q-T interval remains prolonged. Left atrial\nabnormality, incomplete right bundle-branch block, right ventricular\nhypertrophy, right axis deviation are unchanged. RSR' pattern is more apparent\nin lead V2. T wave inversions persist in leads V3-V4 but are slightly less in\nlead V5. An ongoing anterolateral ischemic process cannot be excluded.\nClinical correlation is suggested.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2109-08-21 00:00:00.000","description":"Report","row_id":131238,"text":"Baseline artifact. Sinus bradycardia. Compared to the previous tracing from\nthe same date the rate is much slower and now bradycardic. Computed\nQ-T interval is prolonged. Left atrial abnormality, right axis deviation,\nright ventricular hypertrophy, and incomplete right bundle-branch block pattern\nare unchanged. Non-specific ST segment abnormalities in the limb leads are\nmore prominent. T wave inversions are somewhat deeper in leads V3-V4 extending\nnow to lead V5, although precordial electrode placement is clearly different.\nNon-specific ST segment flattening in lead V6. An ongoing anterolateral\nischemic process cannot be excluded. Clinical correlation is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2109-08-26 00:00:00.000","description":"Report","row_id":131184,"text":"Accelerated junctional rhythm. Right axis deviation. Prolonged Q-T interval.\nCompared to the previous tracing of ST-T wave changes, particularly in\nleads V1-V4, have improved and the rhythm is no longer sinus.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2109-08-23 00:00:00.000","description":"Report","row_id":131185,"text":"Sinus rhythm. Right axis deviation. Right ventricular hypertrophy with\nST segment changes suggestive of right ventricular strain. However, prior\nanterior myocardial ischemia cannot be excluded. Also, possible posterior\nmyocardial infarction. Compared to the previous tracing of the\nfindings are similar. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2109-08-22 00:00:00.000","description":"Report","row_id":131236,"text":"Sinus rhythm. Compared to the previous tracing precordial electrode placement\nis clearly different. Left atrial abnormality is no longer apparent.\nQRS morphology is much more fractionated in lead V1. RSR' pattern is no longer\npresent in lead V2 with deep T wave inversions. T wave inversions are no\nlonger present in leads V3-V5, replaced with more non-specific repolarization\nabnormalities. Non-specific ST segment flattening persists in the limb leads.\nComputed Q-T interval is normal. An ongoing anteroseptal ischemic process\ncannot be excluded. Clinical correlation is suggested.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2109-08-21 00:00:00.000","description":"Report","row_id":131239,"text":"Localized baseline artifact. Sinus rhythm. Right axis deviation and right\nventricular hypertrophy. Left atrial abnormality. Incomplete right\nbundle-branch block pattern. Non-specific ST segment flattening in the\nprecordial leads. T wave inversions in leads V1-V4 may be ischemic in origin.\nNo previous tracing available for comparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2109-08-22 00:00:00.000","description":"Report","row_id":131186,"text":"Sinus rhythm. Compared to the previous tracing from the same date\nQRS morphology in lead V1 is different. Right ventricular hypertrophy, right\naxis deviation, non-specific ST segment flattening in the limb leads persist.\nPrecordial electrode placement is clearly different, with concomitant extension\nof T wave inversions from lead V2 now into lead V3. An ongoing anteroseptal\nischemic process cannot be excluded. Clinical correlation is suggested.\nTRACING #5\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2109-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 65057,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. S/P MV repair .\\nHeight: (in) 71\\nWeight (lb): 244\\nBSA (m2): 2.30 m2\\nBP (mm Hg): 135/62\\nHR (bpm): 70\\nStatus: Inpatient\\nDate/Time: at 11:57\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial\\nseptum. No ASD by 2D or color Doppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Suboptimal\\ntechnical quality, a focal LV wall motion abnormality cannot be fully\\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\\nhypokinesis. Abnormal septal motion/position consistent with RV\\npressure/volume overload.\\n\\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\\n\\nMITRAL VALVE: Mitral valve annuloplasty ring. Well-seated mitral annular ring\\nwith normal gradient. No MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate\\n[2+] TR. Moderate PA systolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS. The end-diastolic PR velocity is\\nincreased c/w PA diastolic hypertension.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\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. Left ventricular wall\\nthicknesses are normal. The left ventricular cavity is mildly dilated. Due to\\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\\nexcluded. Overall left ventricular systolic function is preserved (LVEF>50%).\\nThere is no ventricular septal defect. The right ventricular cavity is\\nmoderately dilated with mild global free wall hypokinesis. There is abnormal\\nseptal motion/position consistent with right ventricular pressure/volume\\noverload. 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. A mitral valve annuloplasty ring is present. The mitral\\nannular ring appears well seated with normal gradient. No mitral regurgitation\\nis seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+]\\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\\nhypertension. The end-diastolic pulmonic regurgitation velocity is increased\\nsuggesting pulmonary artery diastolic hypertension. There is no pericardial\\neffusion.\\n\\nCompared with the prior study (images reviewed) of , no clear\\nchange.;\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2109-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 65058,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: S/p MV repair for ruptured chordae (P2).Hypotension and increased pulmonary pressures on pressors.\\nHeight: (in) 71\\nWeight (lb): 239\\nBSA (m2): 2.28 m2\\nBP (mm Hg): 90/40\\nHR (bpm): 92\\nStatus: Inpatient\\nDate/Time: at 02:53\\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: Mild global LV hypokinesis. Mildly depressed LVEF.\\n\\nRIGHT VENTRICLE: RV not well seen. RV function depressed. Abnormal systolic\\nseptal motion/position consistent with RV pressure overload. Abnormal septal\\nmotion/position.\\n\\nAORTIC VALVE: No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve\\nannuloplasty ring. Well-seated mitral annular ring with normal gradient. Mild\\nthickening of mitral valve chordae. Trivial MR. [Due to acoustic shadowing,\\nthe severity of MR may be significantly UNDERestimated.]\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\\nelectrodes. Suboptimal image quality - body habitus. Suboptimal image quality\\n- ventilator. Suboptimal image quality - patient unable to cooperate. If\\nclinically indicated, a transesophageal echocardiographic examination is\\nrecommended. Emergency study performed by the cardiology fellow on call.\\n\\nConclusions:\\nThere is mild global left ventricular hypokinesis (LVEF = 40-45 %). Overall\\nleft ventricular systolic function is mildly depressed There is abnormal\\nsystolic septal motion/position consistent with right ventricular pressure\\noverload. There is abnormal septal motion/position. Right ventricular function\\nappears depressed. No aortic regurgitation is seen. The mitral valve leaflets\\nare mildly thickened. A mitral valve annuloplasty ring is present. The mitral\\nannular ring appears well seated with normal gradient. Trivial mitral\\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\\nregurgitation may be significantly UNDERestimated.] There is a\\ntrivial/physiologic pericardial effusion.\\n\\nCompared with the findings of the prior study (images reviewed) of ,\\nleft ventricular systolic function has declined. Mitral annuloplasty ring is\\npresent with only trivial regurgitation. Ring is well-seated with normal\\ntransvalvular gradient. Pulmonary artery pressures were not assessed.\\nPericardial effusion has resolved. A pacing wire is identified and there is\\nmore tricuspid regurgitation.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2109-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 65059,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Mitral valve disease.\\nStatus: Inpatient\\nDate/Time: at 09:41\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Moderate LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum.\\n\\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\\nimages. Normal LV wall thickness. Moderately dilated LV cavity.\\n\\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\\natherosclerotic plaque.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Torn mitral chordae. Severe (4+) 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: Small pericardial effusion.\\n\\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\\nlocation listed above. I certify I was present in compliance with HCFA\\nregulations.\\n\\nConclusions:\\nPREBYASS: SEVERE MR from P2 flail and leaflet with anteriorly directed MR jet\\nwith coanda effect, with LA and LV dilation from LV volume overload from MR\\notherwise essentially normal exam.Torn mitral chordae are present. Severe (4+)\\nmitral regurgitation is seen.Preserved LV systolic function with LVEF > 55%,\\nno segmental wall motion abnormalities. Other valves are normal Balloon pump\\nin good position. Intact interatrial septum. As expected with severe MR, no\\nclot in the LAA . The left atrium is moderately dilated. Left ventricular wall\\nthicknesses are normal. The left ventricular cavity is moderately dilated.\\nRight ventricular chamber size and free wall motion are normal. The ascending,\\ntransverse and descending thoracic aorta are normal in diameter and free of\\natherosclerotic plaque with IABP distal to arch about 2-3cm.. The aortic valve\\nleaflets (3) appear structurally normal with good leaflet excursion and no\\naortic stenosis or aortic regurgitation. There is a small pericardial\\neffusion. Diastolic function appears to be normal with e' >10 cm/sec. Normal\\nappearing coronary sinus.\\n\\nPOSTBYPASS: Normally functioning MV repair with ring and neochord to anterior\\nleaflet. No sig MR . , otherwise unchanged\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2109-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 65060,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Severe mitral regurgitation, preoperative assessment\\nHeight: (in) 71\\nWeight (lb): 237\\nBSA (m2): 2.27 m2\\nBP (mm Hg): 97/48\\nHR (bpm): 87\\nStatus: Inpatient\\nDate/Time: at 10:57\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\\n(>55%).\\n\\nRIGHT VENTRICLE: Normal RV systolic function.\\n\\nAORTA: No atheroma in descending aorta.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Partial mitral leaflet flail. Mitral leaflets fail to fully\\ncoapt. Eccentric MR jet. Severe (4+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\\n\\nPERICARDIUM: Very small pericardial effusion.\\n\\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\\nlocation listed above. I certify I was present in compliance with HCFA\\nregulations. The patient was monitored by a nurse throughout the\\nprocedure. The patient was monitored by a nurse throughout the\\nprocedure. The patient was sedated for the TEE. Medications and dosages are\\nlisted above (see Test Information section). No glycopyrrolate was\\nadministered. No TEE related complications.\\n\\nConclusions:\\nOverall left ventricular systolic function is normal (LVEF>55%). The aortic\\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\\nno aortic stenosis or aortic regurgitation. There is posterior mitral leaflet\\nflail. An eccentric, anteriorly directed jet of severe (4+) mitral\\nregurgitation is seen. There is a small circumferential pericardial effusion.\\n\\nIMPRESSION: Myxomatous mitral valve disease with flail posterior mitral\\nleaflet. Severe mitral regurgitation. No evidence of papillary muscle rupture,\\nregional LV dysfunction, or endocarditis.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2109-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 65061,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Mitral valve disease.\\nHeight: (in) 71\\nWeight (lb): 200\\nBSA (m2): 2.11 m2\\nBP (mm Hg): 119/66\\nHR (bpm): 104\\nStatus: Inpatient\\nDate/Time: at 16:30\\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. Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\\nHyperdynamic LVEF >75%. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\\n\\nAORTA: Normal aortic diameter at the sinus level.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Partial mitral leaflet\\nflail. Torn mitral chordae. Severe (4+) 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: Small pericardial effusion. No echocardiographic signs of\\ntamponade. Sustained RA diastolic collapse, c/w low filling pressures or early\\ntamponade. Echocardiographic signs of tamponade may be absent in the presence\\nof elevated right sided pressures.\\n\\nConclusions:\\nThe left atrium and right atrium are markedly dilated. Left ventricular wall\\nthicknesses are normal. The left ventricular cavity is moderately dilated.\\nLeft ventricular systolic function is hyperdynamic (EF>75%). Right ventricular\\nchamber size is normal. with mild global free wall hypokinesis. The aortic\\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\\nno aortic stenosis or aortic regurgitation. The mitral valve leaflets are\\nmildly thickened. There is posterior mitral leaflet flail (P2 scallop) with\\ntorn mitral chordae. Severe (4+) mitral regurgitation is seen. There is\\nmoderate pulmonary artery systolic hypertension (RA pressure not estimated as\\nthe patient is intubated). There is a small circumferential pericardial\\neffusion located predominantly along the infero-lateral wall and right atrium\\n(small-moderate along the RA) . There is no evidence of tamponade.\\nEchocardiographic signs of tamponade may be absent in the presence of elevated\\nright sided pressures.\\n\\nIMPRESSION: Moderately dilated left ventricular cavity with hyperdynamic left\\nventricular function and severe mitral regurgitation secondary to a flail\\nposterior mitral leaflet and thorn mitral valve chordae. At least moderate\\npulmonary artery systolic hypertension. Small circumferential pericardial\\neffusion with no evidence of tamponade.\\n\\nCompared with the earlier echocardiographic study dated (images\\nunavailable for review), the pericardial effusion is more prominent although\\nstill not hemodynamically significant. The right ventricle appears mildly\\nhypokinetic on the current echocardiogram. Other findings are similar.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-25 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1248124,\n \"text\": \" 4:38 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: check swan placement\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man\\n REASON FOR THIS EXAMINATION:\\n check swan placement\\n ______________________________________________________________________________\\n WET READ: MDAg SUN 6:51 PM\\n ETT ends 7.7cm above carina and could be advanced for better seating. NGT ends\\n in the distal esophagus. Swan ganx ends in proximal right main pulmonary\\n artery. right chest tube and mediasinal drains removed. intra-aortic balloon\\n pump unchanged in position.\\n -MAgarwal d/ by phone 6:50pm .\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Swan placement.\\n\\n FINDINGS: In comparison with the earlier study of this date, the Swan-Ganz\\n catheter tip lies well into the right pulmonary artery. Nasogastric tube has\\n been pulled back so that the tip is in the region of the esophagogastric\\n junction. The right chest tube has been removed and there is no pneumothorax.\\n IABP is unchanged in position.\\n\\n Left hemidiaphragm is again not well seen, suggesting substantial volume loss\\n in the left lower lobe.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1247997,\n \"text\": \" 10:28 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for pulmonary edema\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with MVR, pulm HTN\\n REASON FOR THIS EXAMINATION:\\n eval for pulmonary edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the patient with mitral valve\\n replacement and pulmonary hypertension.\\n\\n Portable AP radiograph of the chest was reviewed in comparison to .\\n\\n Tubes and lines are in unchanged position. The right chest tube is in place.\\n Left retrocardiac opacity is slightly more pronounced than on the prior study.\\n Left infrahilar opacity has minimally improved. No pneumothorax is seen. No\\n interval development of pulmonary edema is demonstrated.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1248159,\n \"text\": \" 7:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval line placement\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man\\n REASON FOR THIS EXAMINATION:\\n eval line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Line placement.\\n\\n FINDINGS: In comparison with the study of , the IABP has been removed.\\n The tip of the Swan-Ganz catheter is in the right pulmonary artery.\\n Nasogastric tube extends to the body of the stomach with the side hole in the\\n region of the esophagogastric junction.\\n\\n Continued low lung volumes with enlargement of the cardiac silhouette.\\n Retrocardiac opacification is consistent with volume loss in the left lower\\n lobe.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1247722,\n \"text\": \" 9:45 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: Confirm position of swan and balloon pump\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with chordae tendinae rupture now with Swan and IABP\\n REASON FOR THIS EXAMINATION:\\n Confirm position of swan and balloon pump\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Swan-Ganz catheter, aortic balloon pump.\\n\\n COMPARISON: , 4:08 p.m.\\n\\n FINDINGS: As compared to the previous radiograph, the patient has been\\n intubated. The tip of the endotracheal tube projects approximately 3 cm above\\n the carina. The course and the tip of the Swan-Ganz catheter is unremarkable,\\n but the catheter should be pulled back by approximately 2 cm, as the tip\\n projects over the rather distal parts of the right pulmonary artery. Moderate\\n pulmonary edema is unchanged, moderate-to-severe cardiomegaly. No pleural\\n effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1248085,\n \"text\": \" 8:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p MV repair w/continued inotropic requirement r/o effusion\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with as above\\n REASON FOR THIS EXAMINATION:\\n s/p MV repair w/continued inotropic requirement r/o effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the patient after mitral valve repair\\n with continued inotropic requirement.\\n\\n Portable AP radiograph of the chest was reviewed in comparison to .\\n\\n As compared to the prior study, there is impression of increased cardiac\\n silhouette that might reflect pericardial effusion, correlation with\\n echocardiography is required. Swan-Ganz catheter tip is at the level of the\\n right ventricle outflow tract. Intra-aortic balloon pump is approximately 3.3\\n cm below the roof of the aortic arch. The replaced mitral valve is in place\\n as well as the right chest tube. No pulmonary edema or substantial increase\\n in pleural effusions or no pneumothorax is seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1247829,\n \"text\": \" 4:35 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please assess for O/G tube\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with severe mitral regurg with baloon pump, intubated, please\\n assess for OG tube\\n REASON FOR THIS EXAMINATION:\\n please assess for O/G tube\\n ______________________________________________________________________________\\n WET READ: 6:02 PM\\n OG tube could be advanced by 1-2 cm to ensure that the sideport is beyond the\\n GE junction. Swan-Ganz catheter has been removed. IABP tip terminates over\\n the left 2nd rib anteriorly. Study is otherwise unchanged. T. Pinar\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Assess NG tube.\\n\\n Comparison is made with prior study performed five hours earlier.\\n\\n NG tube tip is in the stomach but the side port is just distal to the EG\\n junction. It can be advanced couple of centimeters. Enlargement of the\\n cardiac silhouette is stable. There is mild vascular congestion. No\\n pulmonary edema and no pleural effusion. ET tube is in standard position.\\n Intra-aortic balloon is in unchanged position. It could be withdrawn 1.5 cm\\n for more standard position.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-23 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1247920,\n \"text\": \" 11:53 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: cardiac srugery fast t rack. eval for ptx, effusions. c\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with s/p MV Repair\\n REASON FOR THIS EXAMINATION:\\n cardiac srugery fast t rack. eval for ptx, effusions. is the\\n CVICU provider page him if there is concern\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the patient after mitral valve repair.\\n\\n Portable AP radiograph of the chest was reviewed in comparison to .\\n\\n The ET tube tip is 6 cm above the carina. The Swan-Ganz catheter tip is at\\n the level of the right ventricular outflow tract. Mediastinal drains, right\\n chest tube and replaced mitral valve are in place, in expected positions.\\n There is no pneumothorax or appreciable pleural effusion. The\\n cardiomediastinal silhouette is stable. The intra-aortic balloon tip is\\n approximately 2.5 cm below the roof of the aorta.\\n\\n Right perihilar opacity most likely represents a combination of atelectasis,\\n with potentially minimal edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1247736,\n \"text\": \" 5:45 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: line & OG placement, ? stable pulmonary congestion\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with pulmonary congestion, IABP, Swan, ETT, OG tube\\n REASON FOR THIS EXAMINATION:\\n line & OG placement, ? stable pulmonary congestion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Pulmonary congestion, evaluation.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, monitoring and support\\n devices are constant. A Swan-Ganz catheter is located very distally, it\\n should be pulled back, as already noted in the previous report.\\n\\n Marked cardiomegaly with evidence of mild-to-moderate pulmonary edema.\\n Retrocardiac atelectasis. No evidence of pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1247693,\n \"text\": \" 4:03 PM\\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \\n -76 BY SAME PHYSICIAN\\n : s/p intubation\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 45M with arrest\\n REASON FOR THIS EXAMINATION:\\n s/p intubation\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n HISTORY: Status post intubation after arrest.\\n\\n COMPARISONS: None available.\\n\\n TECHNIQUE: Chest, portable AP supine.\\n\\n FINDINGS: The patient is intubated. The endotracheal tube terminates at the\\n thoracic inlet approximately 7 cm above the carina. Advancing the tube by\\n approximately 3 cm could be considered for more optimal positioning. The\\n heart is moderate to severely enlarged with a globular configuration.\\n Perihilar fullness suggests mild vascular congestion but otherwise the lungs\\n appear clear. Although the left costophrenic sulcus is not entirely included,\\n there is no definite pleural effusion. There is no pneumothorax.\\n\\n IMPRESSION:\\n\\n 1. Striking cardiomegaly; true cardiac enlargement or the possibility of a\\n pericardial effusion, or perhaps both, could be considered.\\n\\n 2. Prominent main pulmonary artery contour.\\n\\n 3. Findings suggesting mild vascular congestion.\\n\\n 4. Status post endotracheal intubation, with relatively high lying\\n endotracheal tube, which could be advanced by approximately 3 cm for more\\n optimal positioning, if clinically indicated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-30 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1248788,\n \"text\": \" 7:10 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for effusion\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man s/p mvr\\n REASON FOR THIS EXAMINATION:\\n eval for effusion\\n ______________________________________________________________________________\\n WET READ: OXZa FRI 8:36 PM\\n interval removal of esophageal catheter. lung volumes remain low however there\\n is improved aeration at bases and decreased effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL CHEST X-RAY \\n\\n COMPARISON: radiograph as well as earlier radiograph dating\\n back to .\\n\\n FINDINGS: The patient is status post median sternotomy and mitral valve\\n replacement procedure. Cardiac silhouette is markedly enlarged but stable in\\n size. Improved pulmonary vascular congestion and decrease in size of pleural\\n effusions with residual small to moderate right and small left effusions\\n remaining. Marked improvement in bibasilar atelectasis.\\n\\n IMPRESSION: Improving bibasilar atelectasis and effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1247793,\n \"text\": \" 12:31 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: OG tube placement\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with cardiogenic shock and baloon pump, OG tube was placed\\n please evaluate\\n REASON FOR THIS EXAMINATION:\\n OG tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE FRONTAL VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Catheter check, evaluate balloon pump and also OJ tube.\\n\\n Comparison is made with prior study performed six hours earlier.\\n\\n NG tube is no longer visualized. ET tube is in standard position. Swan-Ganz\\n catheter tip is too distal in the right pulmonary artery, it should be\\n withdrawn at least 4 cm for more standard position. Moderate-to-severe\\n enlargement of the cardiac silhouette is stable, is possible that there is\\n pericardial effusion. There is no evidence of pneumothorax or pleural\\n effusion. Retrocardiac opacities consistent with atelectasis are unchanged.\\n Intra-aortic balloon pump tip is 3.1 cm above the left main bronchus, can be\\n withdrawn 1 cm. When compared to prior study performed a day earlier, the\\n intra-aortic balloon pump was more distally located in appropriate position.\\n There is mild vascukar congestion with no overt edema.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-29 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 1248561,\n \"text\": \" 12:24 AM\\n MR HEAD W/O CONTRAST Clip # \\n Reason: eval for evidence of bleeding in patient w left sided weakne\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man s/p MVR\\n REASON FOR THIS EXAMINATION:\\n eval for evidence of bleeding in patient w left sided weakness who needs\\n coumadin for afib. NEEDS COUMADIN, WHICH IS BEING HELD FOR MR.\\n contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n MRI OF THE HEAD\\n\\n CLINICAL INFORMATION: 45-year-old man status post mitral valve replacement.\\n Evaluate for evidence of bleeding in patient with left-sided weakness.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Sagittal T1, axial FLAIR, T2, susceptibility, and\\n diffusion-weighted images were obtained.\\n\\n FINDINGS: There is mucosal thickening involving the bilateral mastoid air\\n cells, the ethmoids, and a small retention cyst in the left maxillary sinus.\\n There is no focal signal abnormality within the brain parenchyma, no evidence\\n of hemorrhage, and no evidence of slow diffusion. The ventricles, sulci,\\n subarachnoid spaces are normal in size and configuration. Normal intracranial\\n flow voids are present.\\n\\n IMPRESSION:\\n 1. No acute intracranial abnormality. No evidence of hemorrhage.\\n 2. Mild mucosal thickening in the mastoids, ethmoids, and left maxillary\\n sinus retention cyst.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-26 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1248169,\n \"text\": \" 8:16 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ischemic vs.hemorrhagic event\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with s/p MVr\\n REASON FOR THIS EXAMINATION:\\n ischemic vs.hemorrhagic event\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT HEAD WITHOUT CONTRAST\\n\\n INDICATION: Ischemic versus hemorrhagic event.\\n\\n TECHNIQUE: MDCT continuous axial images were acquired through the brain at a\\n slice thickness of 5 mm without administration of IV contrast.\\n\\n COMPARISON: None.\\n\\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or\\n infarction. The ventricles and sulci are normal in size and configuration.\\n The basal cisterns appear patent, and there is preservation of -white\\n differentiation. The normally midline structures are midline.\\n\\n There is opacification of many ethmoid air cells. Mucosal thickening is also\\n seen in the maxillary sinuses and the sphenoid sinus. The left maxillary\\n sinus is notable for a mucus retention cyst. An endotracheal tube is seen.\\n Mucosal thickening in the - and oro-pharyngeal area is consistent with\\n intubation.\\n\\n No bony abnormality is seen. The mastoid air cells and middle ear cavities\\n are clear. The globes are unremarkable.\\n\\n IMPRESSION: No evidence of acute hemorrhage, edema. No significant\\n abnormalities on head CT.\\n\\n COMMENT: These findings were communicated by telephone by Dr. \\n to Ms. , PA (cardiac surgery) at 10:58 a.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1248315,\n \"text\": \" 7:58 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?PNA\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with s/p MVr\\n REASON FOR THIS EXAMINATION:\\n ?PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 45-year-old man status post mitral valve replacement,? pneumonia.\\n\\n COMPARISON: .\\n\\n AP UPRIGHT CHEST RADIOGRAPH.\\n\\n FINDINGS: Position of endotracheal tube and right-sided Swan-Ganz is\\n unchanged. NG tube projects over the stomach. Sternotomy wires and outline\\n of artificial mitral valve noted. Heart is moderately enlarged as before.\\n Mild bilateral pleural effusions are unchanged. Bilateral patchy lung\\n opacifications, likely represent atelectasis and crowding of pulmonary\\n vasculature secondary to low volumes. No focal areas of consolidation to\\n suggest pneumonia. No pneumothorax.\\n\\n IMPRESSION:\\n No significant changes compared to the prior study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1248440,\n \"text\": \" 7:32 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p MV repair w/continued hypoxia r/o effusion\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with as above\\n REASON FOR THIS EXAMINATION:\\n s/p MV repair w/continued hypoxia r/o effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, PORTABLE\\n\\n INDICATION: 45-year-old man with status post MV repair, continued hypoxia,\\n rule out effusion.\\n\\n Comparison is made to prior examination of . There is cardiomegaly.\\n This is unchanged. The ET tube has been removed and the lung volumes are low.\\n There is increasing obscuration of the right hemidiaphragm and less prominent\\n on the left concerning for bilateral effusions. An NG tube is identified with\\n its tip in the stomach. Crowding of the vasculature may also represent low\\n lung volumes.\\n\\n IMPRESSION: The ET tube has been removed and the lung volumes are thus low.\\n Obscuration of the hemidiaphragm bilaterally may be due to atelectasis is\\n worsening compared to prior examination. There could be some element of\\n bilateral pleural effusions as well. A lateral film or ultrasound could\\n evaluate the extent of the size of pleural effusions bilaterally.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1248203,\n \"text\": \" 11:48 AM\\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \\n -76 BY SAME PHYSICIAN\\n : *low film check DHT placement\\n Admitting Diagnosis: CHORDAE RUPTURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 45 year old man with s/p MVr\\n REASON FOR THIS EXAMINATION:\\n *low film check DHT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE AP CHEST X-RAY\\n\\n INDICATION: Patient with mitral valve repair, assess Dobhoff placement.\\n\\n COMPARISON: at 7:59 a.m.\\n\\n FINDINGS:\\n\\n The first film shows a Dobhoff tube that is going to mid esophagus and going\\n back up where we cannot see the tip of the tube and the second film shows an\\n adequate placement of Dobhoff in the stomach. Right-sided Swan-Ganz ends in\\n the right pulmonary artery. ET tube ends at 5.3 cm above carina. NG tube is\\n in adequate position. The patient with moderate to important cardiomegaly and\\n mitral valve repair. Stability of the retrocardiac opacity that could be\\n atelectasis. Mild bilateral pleural effusions.\\n\\n CONCLUSION:\\n\\n The tubes and lines are in adequate position.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 131183,\n \"text\": \"Baseline artifact. Sinus tachycardia. Compared to the previous tracing the\\nrate is faster, the rhythm is sinus, and ST-T wave changes are more\\nsignificant. Consider myocardial ischemia.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 131237,\n \"text\": \"Sinus rhythm. Compared to the previous tracing the rate has increased and is\\nno longer bradycardic. Q-T interval remains prolonged. Left atrial\\nabnormality, incomplete right bundle-branch block, right ventricular\\nhypertrophy, right axis deviation are unchanged. RSR' pattern is more apparent\\nin lead V2. T wave inversions persist in leads V3-V4 but are slightly less in\\nlead V5. An ongoing anterolateral ischemic process cannot be excluded.\\nClinical correlation is suggested.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 131238,\n \"text\": \"Baseline artifact. Sinus bradycardia. Compared to the previous tracing from\\nthe same date the rate is much slower and now bradycardic. Computed\\nQ-T interval is prolonged. Left atrial abnormality, right axis deviation,\\nright ventricular hypertrophy, and incomplete right bundle-branch block pattern\\nare unchanged. Non-specific ST segment abnormalities in the limb leads are\\nmore prominent. T wave inversions are somewhat deeper in leads V3-V4 extending\\nnow to lead V5, although precordial electrode placement is clearly different.\\nNon-specific ST segment flattening in lead V6. An ongoing anterolateral\\nischemic process cannot be excluded. Clinical correlation is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 131184,\n \"text\": \"Accelerated junctional rhythm. Right axis deviation. Prolonged Q-T interval.\\nCompared to the previous tracing of ST-T wave changes, particularly in\\nleads V1-V4, have improved and the rhythm is no longer sinus.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 131185,\n \"text\": \"Sinus rhythm. Right axis deviation. Right ventricular hypertrophy with\\nST segment changes suggestive of right ventricular strain. However, prior\\nanterior myocardial ischemia cannot be excluded. Also, possible posterior\\nmyocardial infarction. Compared to the previous tracing of the\\nfindings are similar. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 131236,\n \"text\": \"Sinus rhythm. Compared to the previous tracing precordial electrode placement\\nis clearly different. Left atrial abnormality is no longer apparent.\\nQRS morphology is much more fractionated in lead V1. RSR' pattern is no longer\\npresent in lead V2 with deep T wave inversions. T wave inversions are no\\nlonger present in leads V3-V5, replaced with more non-specific repolarization\\nabnormalities. Non-specific ST segment flattening persists in the limb leads.\\nComputed Q-T interval is normal. An ongoing anteroseptal ischemic process\\ncannot be excluded. Clinical correlation is suggested.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-08-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 131239,\n \"text\": \"Localized baseline artifact. Sinus rhythm. Right axis deviation and right\\nventricular hypertrophy. Left atrial abnormality. Incomplete right\\nbundle-branch block pattern. Non-specific ST segment flattening in the\\nprecordial leads. T wave inversions in leads V1-V4 may be ischemic in origin.\\nNo previous tracing available for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 131186,\n \"text\": \"Sinus rhythm. Compared to the previous tracing from the same date\\nQRS morphology in lead V1 is different. Right ventricular hypertrophy, right\\naxis deviation, non-specific ST segment flattening in the limb leads persist.\\nPrecordial electrode placement is clearly different, with concomitant extension\\nof T wave inversions from lead V2 now into lead V3. An ongoing anteroseptal\\nischemic process cannot be excluded. Clinical correlation is suggested.\\nTRACING #5\\n\\n\"\n }\n]"}}},{"rowIdx":779,"cells":{"subject_id":{"kind":"number","value":25030,"string":"25,030"},"hadm_id":{"kind":"number","value":128473,"string":"128,473"},"target_text":{"kind":"string","value":"1. E. coli bacteremia. 39 yo W with h/o ESRD, DMI, HTN, CVA, multiple line infections who was admitted to general medicine service with fevers and c/o tenderness at the right subclavian catheter site. Blood cultures grew E. coli in bottles from and then in bottles on . The patient was initially covered broadly with Vancomycin and Zosyn. When culture and sensitivity results returned Vancomycin was discontinued and then Zosyn was changed to Levaquin. Initially right subclavian line was not removed per Nephrology request because the patient has very difficult access. However, after the work up of potential sources of infection was unrevealing, the R subclavian line was removed on and the tip culture grew E coli and Citrobacter. Temporary femoral line placed for HD. Overnight of , patient spike to 105, became tachy to 140's, WBC went up to 37 and cooling blanket started on floor. She received IV lopressor, tylenol on floor, then became hypothermic to 91 w/ sbp 70's and was tranferred to MICU for hypotension. She was given fluids, one dose of Gentamycin was given and Levaquin was changed back to Zosyn. She required Dopa briefly but was quickly weaned off pressors. She remained hemodynamically stable. The patient was transferred back to the general floor on . She defervesced and her leukocytosis quickly resolved. The patient was doing well and being screened for transfer back to . She underwent permanent hemodialysis line placement by IR on . She had a new fever of 102 later that day and was changed from Levaquin back to Zosyn. On she was started on higher dose of Levaquin with good effect. She is to complete a 2 week course of levoquin. 2. DM, Type I. The patient was continued on glargine and ISS for tight glycemic control. 3. Pulmonary nodules on CT chest. Per discussion with radiology these are new and were not seen on CT back in . The appearance was not specific but consistent with infectious etiology. The patient had no pulmonary complaints. Follow up CT to assess for resolution/interval change was recommended. She also has significant adenopathy on past CTs and exam. Workup has been limited thus far secondary to chronic infection. Her low grade fevers may be attributed to this adenopathy as she is clinically without infection. 4. HTN. Continued Lisinopril, metoprolol. Amlodipine was discontinued to maximize cardiac regimen. Blood pressure medications were briefly held while she was hypotensive. 5. Hypercholesterolemia. Lipitor was continued. 6. ESRD secondary to DM s/p failed transplant. HD treatments and renal medications were continues per nephrology 8. Elevated LFTs. Abdominal CT with liver hemangiomas. Bili normal. Patient on lipitor. Hepatitis serologies negative. Monitor. Elevated alk phos and ggt. PTH sent. 9. Left shoulder pain. The patient developed left shoulder pain in left sternoclavicular area. CT was done to evaluate this further and showed no abnormalities. It was thought to be secondary do DJD. 10. Cardiomypathy. EF ~25-30%. The patient had a normal EF in . Given significant decline in EF, the patient should have a follow up echo when she is recovered from acute event. If repeat echo is still with decreased EF, further work up may be indicated. The patient was continued on ASA, beta-blocker, lisinopril, lipitor."},"extractive_notes_summ":{"kind":"string","value":"Stable retroperitoneal lymphadenopathy. Bulky left axillary and mediastinal lymphadenopathy, notably in the prevascular, AP window, pretracheal, precarinal, and subcarinal regions is demonstrated, and that was also described on the prior CT report of . The right common femoral vein was found to be patent and compressible by ultrasound. Also seen is the retroperitoneal mass which appears to splay the celiac axis, and is unchanged. IMPRESSION: Aspiration of tiny anterior abdominal wall fluid collection, which appears to be a hematoma. Under fluoroscopic guidance, a 0.035 Amplatz wire was advanced through the indwelling catheter lumen into the inferior vena cava. Mild (1+) mitral regurgitation is seen. Tunneled right subclavian dialysis catheter removal was performed by Dr. , Dr. , and Dr. . The tip of the catheter is present in the inferior vena cava. Able to tolerate hemodialysis today. CT OF THE ABDOMEN WITH IV CONTRAST: There is minor atelectasis at both lung bases. FINDINGS: A fluoroscopic spot image of the abdomen was obtained at the termination of the procedure, demonstrating the catheter tip to be present within the inferior vena cava. also with lymphadenopathy. Successful removal of a tunneled right subclavian dialysis catheter. Vanco and Gentamycin dc'd.A&P: Resolution of hypotension d/t sepsis with fluids and transient dopa. Sinus rhythmProbable inferior infarct, age indeterminate - possibly acuteAnterolateral ST-T wave abnormalities - Cannot exclude in part ischemiaClinical correlation is suggestedSince previous tracing of , ST-T wave abnormalities less prominent andL-R arm lead now in normal position As previously identified on ultrasound (), there is a 21 x 95 mm complex fluid collection in the anterior aspect of the liver, which is probably unchanged. It has peripheral puddling, and is most likely a hemangioma. Infected tunneled right subclavian dialysis catheter. There is focal calcification of thenon-coronary cusp. An appropriate catheter exit site was chosen in the right groin. Procedure done by radiologist:Limited ultrasound over the anterior abdominal wall, just to the right of midline showed a small fluid collection measuring 1.6 x 3 x 0.6 cm. A 0.018 guidewire was advanced through the needle into the IVC under fluoroscopic guidance. FINAL REPORT HISTORY: Sepsis, anterior abdominal wall fluid collection. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 60Weight (lb): 100BSA (m2): 1.39 m2BP (mm Hg): 103/57HR (bpm): 87Status: InpatientDate/Time: at 15:22Test: Portable TEE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA. FINDINGS: CT OF THE CHEST WITHOUT IV CONTRAST: Examination of the osseous structures demonstrate very mild irregularity along the articular surface of both clavicular heads, which appears somewhat symmetric, with appearances typically seen with degenerative joint disease. Diffuse non-specific ST-T wave abnormalities.Clinical correlation is suggested. possible hemodialysis . Normal interatrial septum. Remains on Zosyn Q 12hrs and 1 x dose of gentamycin.Endo: Cortstim test done. Possible old inferior wall myocardial infarction.Anterolateral ST-T wave abnormalities - cannot rule out myocardial ischemia.Clinical correlation is suggested. Her right groin, including the indwelling temporary dialysis catheter, was prepped and draped in the standard sterile fashion. Stable chest radiographic findings with cardiomegaly and prominent mediastinal contour. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. There are simple atheroma in the descending thoracic aorta.There are three aortic valve leaflets. CT OF THE PELVIS WITH IV CONTRAST: There is thickening of the rectal wall, which may represent edema. After the Amplatz wire was removed, the new 14.5-French catheter was advanced through the peel-away sheath into the inferior vena cava. There is moderate global right ventricular freewall hypokinesis. A final fluoroscopic abdominal radiograph was obtained, documenting the catheter tip in the IVC. PT WAS TREATED WITH IVF WIDE OPEN AND STARTED ON DOPA 5MCG WITH NEW IV INSERTED.ON ARRIVAL, 1 LITER IVF HAD INFUSED AND DOPA WAS AT 5MCG- BP ON ARRIVAL- 95/60 AND HR- 70 SR. TECHNIQUE: MDCT-acquired images of the chest were obtained before and after the administration of IV contrast. Moderate global LV hypokinesis.RIGHT VENTRICLE: Normal RV chamber size. Attention was then turned to the patient's tunneled right subclavian dialysis catheter. Limited images of the upper abdomen demonstrate extensive vascular calcifications. TECHNIQUE: Axial CT images of the upper chest were performed, which included thin-collimation slices and coronal and sagittal reformatted images. REASON FOR THIS EXAMINATION: placement of temporary dialysis femoral catheter FINAL REPORT HISTORY: Endstage renal disease requiring hemodialysis. 1% lidocaine was used for local anesthesia. The catheter was flushed, capped, and heplocked. Pressure was applied at the venous entry site until hemostasis was achieved. REASON FOR THIS EXAMINATION: aspiration of anterior abdominal wall fluid collection under US guidance. Clinical correlation is suggested.TRACING #1 There is moderate globalleft ventricular hypokinesis. The patient was sedated forthe TEE. Note is made of marked left axillary lymphadenopathy, associated with adenopathy including lymph nodes predominantly in the prevascular space and the AP window. Since the previous tracing of sinustachycardia is absent. Reversed L-R arm leadSinus rhythmConsider left atrial abnormalityProbable inferior myocardial infarction with ST-T wave configuration suggestsacute processPrecordial/anterior ST-T wave abnormalities - suggests ischemiaClinical correlation is suggestedSince previous tracing of , inferior myocardial infarction suggested,further ST-T wave abnormalities present and L-R arm lead reversed A tiny hypervascular focus measuring 6 mm is seen near the gallbladder fossa on the same slice (series 2 image 30). Note is made of coronary artery and aortic mural calcifications. The venous puncture site in the right groin was then closed with an absorbable 2-0 Vicryl suture, followed by a dry sterile dressing. Compared to the previous tracing of the patient is significantly tachycardic. Subtle low density lesion in the right anterior abdominal/pelvic wall, which is new since the last examination, and may represent an abscess. Pt recieved at total of 2250cc IV fluids to maintain MAP >60 and wean Dopamine to off."},"n_notes":{"kind":"number","value":17,"string":"17"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2117-07-22 00:00:00.000","description":"Report","row_id":1588800,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P FEVER/HYPOTENSION\n\nS- \" CAN I HAVE SOME MORE TOAST?\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE. HR- 88-90 ST, NO VEA- BP- 118/77-109/56 VIA DYNAMAP.\nNO FURTHER PRESSORS OR FLUID BOLUSES.\n\n PT 96 PO- 97.8 RECTAL.\nREMAINS ON ZOSYN AS ORDERED AND DOSING VANCO/GENT AS NEEDED PER RENAL FX.\nSPECIMENS PENDING\nSENT STOOL FOR R/O CDIFF AS WELL.\n\nGU- ANURIC- AWAITING DIALYSIS TODAY\nAM LABS PENDING.\nS/P K EX FOR K- 5.3 EVES.\n\nGI- TAKING TOAST AND LIQUIDS FOR NUTRITION- APPEARS HUNGRY, ASKING FOR MORE- AFTER 2ND ROUND OF PT HAD LARGE AMT LOOSE LIX STOOL\nG (-)- SENT FOR CULTURE- ALSO ON REGLAN- HOLDING COLACE.\nSS REG INSULIN AND DAILY FIXED GLARGINE DOSE.\n\n PT A AND O X 3- SLEEPING MUCH OF SHIFT\nASKING APPROPRIATE QUESTIONS.\nAPPEARS COMFORTABLE.\nNO FAMILY CALLS THIS SHIFT.\n\nLINES- BILATERAL PERIPHERAL IV'S AND RT FEMORAL QUENTIN- REQUIRES REMINDING ABOUT NOT BENDING RT LEG AND SITTING UP AT 45 DEGREES.\n\nA/ PT WITH FEVER/HYPOTENSION CURRENTLY AFEBRILE AND HEMODYNAMICALLY STABLE.\nPLAN FOR DIALYSIS TODAY\nCONTINUE ANTIBX AS ORDERED.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE\nC/O TO FLOOR IF REMAINS HEMODYNAMICALLY STABLE.\nSS REG INSULIN/AWAIT CULTURES.\n\n"},{"category":"Nursing/other","chartdate":"2117-07-22 00:00:00.000","description":"Report","row_id":1588801,"text":"Nursing Progress Note\n\nS: \"Am I going home today?\"\n\nO: Please see flow sheet for objective data. >100. Tolerated hemodialysis run well. 3 liters removed. BS slightly ^ today. Recieved full dose off lantis this am with SS coverage. Steriods dc'd after 6am dose. Tolerating diet well after hemo. T 96-97.4 po. WBC down to 9,000. Temp Quinton remains in R fem. Lungs are diminshed at bases. Conts on Zosyn Q 12. Vanco and Gentamycin dc'd.\n\nA&P: Resolution of hypotension d/t sepsis with fluids and transient dopa. Able to tolerate hemodialysis today. to monitor lytes. ? source for long term access.\n"},{"category":"Nursing/other","chartdate":"2117-07-21 00:00:00.000","description":"Report","row_id":1588798,"text":"CCU NSG ACCEPTANCE NOTE 6:15A\n\nS- LETHARGIC\n\n PT ARRIVED FROM CC7 AFTER DROPPING TEMP TO 90 PO AND BP TO 60/40 AFTER A LATE EVE TEMP SPIKE/RECULTURE. PT WAS TREATED WITH IVF WIDE OPEN AND STARTED ON DOPA 5MCG WITH NEW IV INSERTED.\nON ARRIVAL, 1 LITER IVF HAD INFUSED AND DOPA WAS AT 5MCG- BP ON ARRIVAL- 95/60 AND HR- 70 SR. GIVEN STAT DOSE GENT 50 MG AND AN ADDITIONAL 500CC IVF. PT IS RESPONSIVE TO CONVERSATION BUT IS LETHARGIC, DENIES PAIN.\nSTAT LABS FROM CC7 PENDING, TO INSERT CENTRAL ACCESS AND ? ALINE CURRENTLY.\n\nA/ PT WITH EXTENSIVE MEDICAL HX/RENAL FX/ESRD/VRE/MRSA CURRENTLY ADMITTED TO CCU FOR HYPOTENSION/SEPSIS\n\nPLAN- LINE INSERTION, BAIR HUGGER, 500CC MORE IVF AND ANTIBX AS ORDERED. CONTINUE TO FOLLOW SPECIMENS/MONITOR HEMODYNAMICS AND KEEP MAPS > 60. KEEP PT AND FAMILY AWARE OF PLAN OF CARE.\n"},{"category":"Nursing/other","chartdate":"2117-07-21 00:00:00.000","description":"Report","row_id":1588799,"text":"Nursing Progress Note\n\nS\" \" I'm so hot.\"\n\nO: Please see flow sheet for objective data. Tele sinus rhythm. Pt recieved at total of 2250cc IV fluids to maintain MAP >60 and wean Dopamine to off. Presently dopamine remains off. TEE done, did not show any evidence of vegatation or endocarditis. EF approx 35%.\n\nResp: Lungs diminshed throughout the bases. O2 sat 93-98%.\n\nNeuro: Pt lethargic throughout the day. Pt did receive versed .5mg & fentanyl 25mcgs for TEE which she tolerated well.Easily arousable to verbal stimulation. Seems to be aware of what's happening.\n\nGU/GI: Pt NPO for most of the day for TEE. Tolerating diet well this pm. Abd is soft with bowel sounds present. Pt does not void. Hemodialysis held off today. K 5.6 repeat pending.\n\nID: Temp 94-96 po. Bear hugger removed early this am when pt c/o being too hot and temp had started to come up. Placed back on blanket after temp remained down. Off at present. WBC 27,000 this am. Dose of vancomycin held today d/t vancomycin level of 21.3. Remains on Zosyn Q 12hrs and 1 x dose of gentamycin.\n\nEndo: Cortstim test done. Started on Decadron 10mg IV Q 8. given half dose of Glargine at 12n d/t NPO. BS in better control with SS.\n\nAccess: Pt has R fem Quinton. Pt has no other site for central access so central line not placed.\n\nA&P: Pt able to wean off dopamine throughout the day. to monitor hemodynamics. to monitor K. ? possible hemodialysis . with POC.\n"},{"category":"Radiology","chartdate":"2117-07-26 00:00:00.000","description":"DISTINCT PROCEDURAL SERVICE","row_id":870747,"text":" 6:51 PM\n CHEST (PA & LAT); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate for metastatic lesion, evidence of joint infection\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with IDDM, ESRD, with E.coli sepsis, now w/ shoulder pain.\n also with lymphadenopathy. evaluate for evidence of metastatic lestion or joint\n space infection\n REASON FOR THIS EXAMINATION:\n evaluate for metastatic lesion, evidence of joint infection\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Evaluate for metastatic lesion or joint infection.\n\n The cardiac silhouette is enlarged but stable. There is stable widening of\n the mediastinum. The pulmonary vascularity is normal, and the lungs appear\n grossly clear allowing for low lung volumes. No pleural effusions are\n identified. Surgical clips are seen in the left paratracheal region.\n\n IMPRESSION:\n 1. Stable chest radiographic findings with cardiomegaly and prominent\n mediastinal contour. The latter is likely related to lymphadenopathy.\n 2. No evidence of pulmonary nodules or masses.\n\n\n"},{"category":"Radiology","chartdate":"2117-07-26 00:00:00.000","description":"UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD","row_id":870659,"text":" 7:15 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: placement of a new permanent line for dialysis\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ********************************* CPT Codes ********************************\n * TUNNELED W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUOR GUID PLCT/REPLCT/REMOVE C1750 CATH,HEMO/PERTI DIALYSIS LONG *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with ESRD on HD whose R sublclavian tunneled line was\n infected and recently d/c'd needs new permanent dialysis access.\n\n REASON FOR THIS EXAMINATION:\n placement of a new permanent line for dialysis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old female with end-stage renal disease and multiple line\n infections who presents with an indwelling temporary right groin catheter. The\n patient now needs placement of a tunneled dialysis catheter.\n\n PHYSICIANS: The procedure was performed by Dr. , Dr. \n , and Dr. . Dr. , the staff\n radiologist, was present and supervising throughout.\n\n PROCEDURE: After the risks and benefits of the procedure were discussed with\n the patient and informed consent was obtained, the patient was placed supine\n on the angiography table. Her right groin, including the indwelling temporary\n dialysis catheter, was prepped and draped in the standard sterile fashion. The\n skin and subcutaneous tissues in the right groin were anesthetized thoroughly\n with 1% lidocaine. Under fluoroscopic guidance, a 0.035 Amplatz wire was\n advanced through the indwelling catheter lumen into the inferior vena cava.\n Our attention was then turned to creation of the subcutaneous tunnel.\n\n An appropriate catheter exit site was chosen in the right groin. A small skin\n incision was created using a #11 blade scalpel. A subcutaneous tunnel was then\n created using blunt dissection with the assistance of a hemostat device. A new\n 14.5-French tunneled dual lumen hemodialysis catheter was then advanced\n through the subcutaneous tunnel to the venous puncture site in the right\n groin. The existing catheter was then removed and a 15-French peel-away sheath\n was advanced over the Amplatz wire into the right femoral vein. After the\n Amplatz wire was removed, the new 14.5-French catheter was advanced through\n the peel-away sheath into the inferior vena cava. The peel-away sheath was\n removed. The catheter was flushed, capped, and heplocked. It was secured to\n the skin using 2-0 silk sutures. The venous puncture site in the right groin\n was then closed with an absorbable 2-0 Vicryl suture, followed by a dry\n sterile dressing.\n\n FINDINGS: A fluoroscopic spot image of the abdomen was obtained at the\n termination of the procedure, demonstrating the catheter tip to be present\n within the inferior vena cava.\n\n COMPLICATIONS: None.\n (Over)\n\n 7:15 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: placement of a new permanent line for dialysis\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MEDICATIONS: 1% lidocaine SQ. Totals of 0.5 mg of Versed and 50 mcg of\n fentanyl were administered in intermittent doses with continuous monitoring of\n vital signs by the nursing staff.\n\n IMPRESSION: Successful replacement of a 14.5-French temporary catheter for a\n new 14.5-French, 32-cm long tunneled dual lumen hemodialysis catheter over a\n guidewire via the right common femoral vein. The catheter tip to cuff length\n measures 27 cm. The tip of the catheter is present in the inferior vena cava.\n The catheter is ready for immediate use.\n\n"},{"category":"Radiology","chartdate":"2117-07-27 00:00:00.000","description":"CT RECONSTRUCTION","row_id":870861,"text":" 4:24 PM\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \n Reason: please evaluate for soft tissue infectious process, evidence\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with E coli bacteremia now with pain in left sternoclavicular\n joint area.\n REASON FOR THIS EXAMINATION:\n please evaluate for soft tissue infectious process, evidence of osteomyelitis\n in the left sternoclaricular area.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: E. coli bacteremia with pain in the left sternoclavicular joint\n area. Evaluate for evidence of osteomyelitis or other infectious processes.\n\n TECHNIQUE: Axial CT images of the upper chest were performed, which included\n thin-collimation slices and coronal and sagittal reformatted images.\n Comparison is also made to CT examination of the chest performed . No\n post-contrast images could be obtained due to the limited IV access.\n\n FINDINGS:\n CT OF THE CHEST WITHOUT IV CONTRAST: Examination of the osseous structures\n demonstrate very mild irregularity along the articular surface of both\n clavicular heads, which appears somewhat symmetric, with appearances typically\n seen with degenerative joint disease. There are no associated effusions or\n other fluid collections. Without IV contrast, we cannot assess for\n enhancement.\n\n Metallic clip is seen just anterior to the inferior aspect of the left\n thyroid.\n\n Note is made of marked left axillary lymphadenopathy, associated with\n adenopathy including lymph nodes predominantly in the prevascular space and\n the AP window. Visualized aspects of the heart appear markedly enlarged, with\n marked vascular calcifications including the coronary arteries.\n\n Examination of the lungs demonstrate changes related to tracheobronchomalacia,\n particularly at the level of the carina and left main stem bronchus. In\n addition, there is a stable dominant nodule in the right upper lobe anteriorly\n which measures approximately 1 cm in size and is unchanged since the\n comparison. Multiple other tiny nodular pulmonary opacities are also\n appreciated, also stable.\n\n Examination of coronally and sagittally reformatted images of the\n sternoclavicular joints was also reviewed, not demonstrating frank destructive\n changes or evidence of effusion/abscess at the joints.\n\n IMPRESSION:\n\n 2) Very mild irregularity of both sternoclavicular joints, without significant\n difference in severity between the left and right side, has appearances most\n (Over)\n\n 4:24 PM\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \n Reason: please evaluate for soft tissue infectious process, evidence\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n often seen in the setting of mild degenerative changes. While osteomyelitis\n cannot be excluded, no complication of osteomyelitis such as adjacent abscess\n or fluid collection is evident.\n\n"},{"category":"Echo","chartdate":"2117-07-21 00:00:00.000","description":"Report","row_id":100302,"text":"PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 60\nWeight (lb): 100\nBSA (m2): 1.39 m2\nBP (mm Hg): 103/57\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 15:22\nTest: Portable TEE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Normal interatrial septum. No ASD\nby 2D or color Doppler.\n\nLEFT VENTRICLE: Symmetric LVH. Moderate global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTA: No atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No masses or vegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or\nvegetation on mitral valve. No mitral valve abscess. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. No abscess of tricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. No 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 sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. No TEE\nrelated complications. 0.2 mg of IV glycopyrrolate was given as an\nantisialogogue prior to TEE probe insertion. The patient appears to be in\nsinus rhythm. The house officer caring for the patient was notified of the\nresults by text page.\n\nConclusions:\nThe left atrium is dilated. There is symmetric LVH. There is moderate global\nleft ventricular hypokinesis. There is moderate global right ventricular free\nwall hypokinesis. There are simple atheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. There is focal calcification of the\nnon-coronary cusp. No masses or vegetations are seen on the aortic valve.\nTrace aortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. There is a 2-3 mm calcified mobile echodensity attached to the tip\nof the anterior mitral leaflet seen on ventricular side of the valve, which\nlikely represents a torn chordae (present on prior TEE from , see below).\nNo discrete mass or vegetation is seen on the mitral valve. No mitral valve\nabscess is seen. Mild (1+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is no abscess of the tricuspid valve. No\nvegetation/mass is seen on the pulmonic valve. There is no pericardial\neffusion.\nCompared with the findings of the prior study (tape reviewed) of ,\nbiventricular systolic dysfunction is now present. The degree of valvular\ndisease is unchanged.\n\nImpression: no echocardiographic evidence of endocarditis.\n\n\n"},{"category":"Radiology","chartdate":"2117-07-18 00:00:00.000","description":"CT PELVIS W/CONTRAST","row_id":869724,"text":" 10:01 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: rule out abscess/evaluate for source of infection\n Admitting Diagnosis: FEVER-LINE SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with ESRD on HD with Gram negative rod bacteremia and mild\n abdominal tenderness\n REASON FOR THIS EXAMINATION:\n rule out abscess/evaluate for source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old woman with end-stage renal disease, bacteremia.\n Evaluate for possible abscess.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the lung\n bases to the pubic symphysis after administration of oral and IV contrast.\n\n COMPARISON: CT scan.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is minor atelectasis at both lung\n bases. A previously identified low density lesion within the right lobe of\n the liver measures 19 x 17 mm. It has peripheral puddling, and is most likely\n a hemangioma. A tiny hypervascular focus measuring 6 mm is seen near the\n gallbladder fossa on the same slice (series 2 image 30). Another\n hypervascular focus, 9 x 8 mm, is seen in the left lobe of the liver (junction\n of 4a and 4b). No other lesions are seen in the liver. There is a gallstone,\n without evidence of cholecystitis. The pancreas is atrophic. Native kidneys\n are shrunken; there are heavy calcifications within the renal arteries,\n superior mesenteric artery, and celiac axis. The spleen is unremarkable. The\n adrenals are unchanged. The stomach is within normal limits. As previously\n identified on ultrasound (), there is a 21 x 95 mm complex fluid\n collection in the anterior aspect of the liver, which is probably unchanged.\n Also seen is the retroperitoneal mass which appears to splay the celiac axis,\n and is unchanged. A small amount of free fluid is seen in the abdomen. Again,\n as noted, there are extensive vascular calcifications throughout the abdominal\n vasculature.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is thickening of the rectal wall,\n which may represent edema. The remainder of the bowel loops are unremarkable.\n Again seen in the right lower quadrant is a heavily calcified rejected\n transplant kidney. No lymphadenopathy is definitively identified in the\n pelvis. However, in the right anterior rectus sheath, there is a 16 x 42 mm\n low density lesion. A small amount of free fluid is seen in the pelvis. As\n previously noted, there are heavy vascular calcifications throughout all\n pelvic vessels.\n\n Osseous structures are remarkable for renal osteodystrophy disease.\n\n IMPRESSION:\n (Over)\n\n 10:01 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: rule out abscess/evaluate for source of infection\n Admitting Diagnosis: FEVER-LINE SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Subtle low density lesion in the right anterior abdominal/pelvic wall,\n which is new since the last examination, and may represent an abscess.\n Ultrasound may be useful for further characterization.\n 2. Thickening/edema of the rectal wall, which may represent proctitis.\n Correlation with physical exam may be useful in excluding this as a source of\n bacteremia.\n 3. Hemangioma in liver. Two hypervascular foci in liver on this single-\n contrast study; ultrasound or MRI may be useful for further characterization,\n if clinically indicated.\n 4. Stable retroperitoneal lymphadenopathy.\n 5. Stable appearance of complex fluid collection in anterior aspect of liver.\n 6. Heavily calcified abdominal vasculature as previously identified, probably\n due to end-stage renal disease.\n\n\n"},{"category":"Radiology","chartdate":"2117-07-16 00:00:00.000","description":"CT 100CC NON IONIC CONTRAST","row_id":869547,"text":" 2:49 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with pleuritic R chest pain, low grade fever.\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl FRI 3:41 PM\n NO evidence of PE.\n multifocal vague, small nonspecific lung opacities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pleuritic right chest pain and low-grade fever, rule out PE.\n\n No CT is available for comparison on PACs.\n\n TECHNIQUE: MDCT-acquired images of the chest were obtained before and after\n the administration of IV contrast.\n\n CT OF THE CHEST WITH IV CONTRAST: There are no filling defects within the\n pulmonary arterial system to suggest PE. The great vessels are unremarkable.\n Note is made of coronary artery and aortic mural calcifications. There are\n extensive calcifications within the abdominal vasculature as well. Lung\n windows demonstrate several patchy nonspecific opacities in the right upper\n lobe (series 3, image 87), right lower lobe (series 3, image 51), and left\n lower lobe (series 3, image 24). No images were available for comparison.\n There is a 3.5 mm nodular density near the left major fissure in the left\n lower lobe (series 3, image 52). An additional tiny pleural-based density is\n also seen in the lingula (series 3, image 68). Bulky left axillary and\n mediastinal lymphadenopathy, notably in the prevascular, AP window,\n pretracheal, precarinal, and subcarinal regions is demonstrated, and that was\n also described on the prior CT report of .\n\n Limited images of the upper abdomen demonstrate extensive vascular\n calcifications.\n\n Bone windows demonstrate no suspicious lytic or sclerotic foci.\n\n IMPRESSION:\n 1) No evidence of PE.\n 2) Multifocal, nonspecific, vague small patchy opacities with a tiny nodular\n density in the left lower lobe. No comparison studies are currently available\n on PACs for comparison.\n 3) Extensive atherosclerotic disease.\n (Over)\n\n 2:49 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2117-07-20 00:00:00.000","description":"GUIDANCE CYST OR RENAL ANY LOC US","row_id":870015,"text":" 2:22 PM\n US SIMPLE/SING ABSC/CYST DRAIN/INCISION; GUIDANCE CYST OR RENAL ANY LOC USClip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: aspiration of anterior abdominal wall fluid collection under\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with ESRD, E coli bacteremia with aterior abdominal wall\n fluid collection.\n REASON FOR THIS EXAMINATION:\n aspiration of anterior abdominal wall fluid collection under US guidance.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis, anterior abdominal wall fluid collection.\n\n Procedure done by radiologist:Limited ultrasound over the anterior abdominal\n wall, just to the right of midline showed a small fluid collection measuring\n 1.6 x 3 x 0.6 cm. The risks and benefits were explained to the patient and\n informed consent was obtained. A preprocedure timeout was performed regarding\n the patient's name and procedure. The area was prepped and draped in a\n sterile fashion. 1% lidocaine was used for local anesthesia. Using\n ultrasonographic guidance, an 18-gauge spinal needle was inserted into this\n collection and approximately 2 mL of blood-tinged fluid was aspirated. This\n was sent for Gram stain and culture. No more fluid was able to be aspirated.\n\n Dr. , the attending radiologist, was present and supervised the\n entire procedure. There were no immediate post-procedure complications.\n\n IMPRESSION: Aspiration of tiny anterior abdominal wall fluid collection,\n which appears to be a hematoma. This fluid was sent for Gram stain and\n culture.\n\n"},{"category":"Radiology","chartdate":"2117-07-20 00:00:00.000","description":"TUNNELED CENTRAL W/O PORT","row_id":870029,"text":" 3:42 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: placement of temporary dialysis femoral catheter\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED TUNNELED CENTRAL W/O PORT *\n * -51 MULTI-PROCEDURE SAME DAY FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with ESRD on HD with E coli bacteremia.\n\n REASON FOR THIS EXAMINATION:\n placement of temporary dialysis femoral catheter\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Endstage renal disease requiring hemodialysis. Infected tunneled\n right subclavian dialysis catheter.\n\n PHYSICIANS: Temporary dialysis catheter placement was performed by Dr. \n and Dr. . Tunneled right subclavian dialysis catheter\n removal was performed by Dr. , Dr. , and Dr. \n . The attending physician, . , was present and supervising.\n\n CONSENT: After the risks and benefits of the procedure were discussed with\n the patient, written informed consent was obtained.\n\n PROCEDURE/FINDINGS: The patient was placed supine on the procedure table. The\n right common femoral vein was found to be patent and compressible by\n ultrasound. The right groin was prepped and draped in a standard sterile\n fashion. 1% lidocaine was administered to the skin and subcutaneous tissues\n over the right femoral vein for local anesthesia. The right common femoral\n vein was accessed by a 21-gauge needle under ultrasound guidance. A 0.018\n guidewire was advanced through the needle into the IVC under fluoroscopic\n guidance. The needle was exchanged for a 4-French micropuncture sheath. The\n guidewire was exchanged for wire, which was advanced into the IVC\n under fluoroscopic guidance. The venous access site was widened by a scalpel.\n It was then sequentially dilated by 12 and 14-French dilators. The last\n dilator was exchanged for a 20 cm, 14.5-French dual lumen dialysis catheter,\n which was advanced into the IVC under fluoroscopic guidance. A final\n fluoroscopic abdominal radiograph was obtained, documenting the catheter tip\n in the IVC. The catheter was flushed and capped with extension tubing. It\n was sutured with two 2-0 nylon sutures. A dry dressing was applied. The\n catheter was hep-locked. The catheter is ready for use.\n\n Attention was then turned to the patient's tunneled right subclavian dialysis\n catheter. The catheter hub sutures and the tunnel exit site sutures were cut.\n The catheter was easily removed from the tunnel. Pressure was applied at the\n venous entry site until hemostasis was achieved. A dressing was applied at\n the tunnel exit site. The catheter tip was cut and sent for culture.\n\n COMPLICATIONS: No immediate complications.\n (Over)\n\n 3:42 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: placement of temporary dialysis femoral catheter\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MEDICATIONS: Versed IV, fentanyl IV, and 1% lidocaine subq were administered\n by a registered nurse who was monitoring the patient throughout the procedure.\n Please refer to the nursing records for dosages.\n\n IMPRESSION:\n 1. Successful placement of a 20 cm, 14.5-French dual lumen temporary dialysis\n catheter via the right common femoral vein, with tip in the IVC, ready for\n use.\n 2. Successful removal of a tunneled right subclavian dialysis catheter.\n Catheter tip was sent for culture.\n\n"},{"category":"ECG","chartdate":"2117-07-17 00:00:00.000","description":"Report","row_id":276744,"text":"Reversed L-R arm lead\nSinus rhythm\nConsider left atrial abnormality\nProbable inferior myocardial infarction with ST-T wave configuration suggests\nacute process\nPrecordial/anterior ST-T wave abnormalities - suggests ischemia\nClinical correlation is suggested\nSince previous tracing of , inferior myocardial infarction suggested,\nfurther ST-T wave abnormalities present and L-R arm lead reversed\n\n"},{"category":"ECG","chartdate":"2117-07-24 00:00:00.000","description":"Report","row_id":276740,"text":"Sinus rhythm. Rightward axis is non-specific. Consider prior inferior wall\nmyocardial infarction, although is non-diagnostic. Low precordial lead\nQRS voltage is non-specific. Diffuse non-specific ST-T wave abnormalities.\nClinical correlation is suggested. Since the previous tracing of sinus\ntachycardia is absent.\n\n"},{"category":"ECG","chartdate":"2117-07-19 00:00:00.000","description":"Report","row_id":276741,"text":"Sinus tachycardia. Compared to tracing #1 the heart rate is slightly slower.\nAnterolateral ST-T wave abnormalities persist. Clinical correlation is\nsuggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2117-07-19 00:00:00.000","description":"Report","row_id":276742,"text":"Sinus tachycardia. Possible old inferior wall myocardial infarction.\nAnterolateral ST-T wave abnormalities - cannot rule out myocardial ischemia.\nClinical correlation is suggested. Compared to the previous tracing of \nthe patient is significantly tachycardic. Anterolateral ST-T wve abnormalities\npersist. Clinical correlation is suggested.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2117-07-18 00:00:00.000","description":"Report","row_id":276743,"text":"Sinus rhythm\nProbable inferior infarct, age indeterminate - possibly acute\nAnterolateral ST-T wave abnormalities - Cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , ST-T wave abnormalities less prominent and\nL-R arm lead now in normal position\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1588800,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P FEVER/HYPOTENSION\\n\\nS- \\\" CAN I HAVE SOME MORE TOAST?\\\"\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\n PT REMAINS HEMODYNAMICALLY STABLE. HR- 88-90 ST, NO VEA- BP- 118/77-109/56 VIA DYNAMAP.\\nNO FURTHER PRESSORS OR FLUID BOLUSES.\\n\\n PT 96 PO- 97.8 RECTAL.\\nREMAINS ON ZOSYN AS ORDERED AND DOSING VANCO/GENT AS NEEDED PER RENAL FX.\\nSPECIMENS PENDING\\nSENT STOOL FOR R/O CDIFF AS WELL.\\n\\nGU- ANURIC- AWAITING DIALYSIS TODAY\\nAM LABS PENDING.\\nS/P K EX FOR K- 5.3 EVES.\\n\\nGI- TAKING TOAST AND LIQUIDS FOR NUTRITION- APPEARS HUNGRY, ASKING FOR MORE- AFTER 2ND ROUND OF PT HAD LARGE AMT LOOSE LIX STOOL\\nG (-)- SENT FOR CULTURE- ALSO ON REGLAN- HOLDING COLACE.\\nSS REG INSULIN AND DAILY FIXED GLARGINE DOSE.\\n\\n PT A AND O X 3- SLEEPING MUCH OF SHIFT\\nASKING APPROPRIATE QUESTIONS.\\nAPPEARS COMFORTABLE.\\nNO FAMILY CALLS THIS SHIFT.\\n\\nLINES- BILATERAL PERIPHERAL IV'S AND RT FEMORAL QUENTIN- REQUIRES REMINDING ABOUT NOT BENDING RT LEG AND SITTING UP AT 45 DEGREES.\\n\\nA/ PT WITH FEVER/HYPOTENSION CURRENTLY AFEBRILE AND HEMODYNAMICALLY STABLE.\\nPLAN FOR DIALYSIS TODAY\\nCONTINUE ANTIBX AS ORDERED.\\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE\\nC/O TO FLOOR IF REMAINS HEMODYNAMICALLY STABLE.\\nSS REG INSULIN/AWAIT CULTURES.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1588801,\n \"text\": \"Nursing Progress Note\\n\\nS: \\\"Am I going home today?\\\"\\n\\nO: Please see flow sheet for objective data. >100. Tolerated hemodialysis run well. 3 liters removed. BS slightly ^ today. Recieved full dose off lantis this am with SS coverage. Steriods dc'd after 6am dose. Tolerating diet well after hemo. T 96-97.4 po. WBC down to 9,000. Temp Quinton remains in R fem. Lungs are diminshed at bases. Conts on Zosyn Q 12. Vanco and Gentamycin dc'd.\\n\\nA&P: Resolution of hypotension d/t sepsis with fluids and transient dopa. Able to tolerate hemodialysis today. to monitor lytes. ? source for long term access.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1588798,\n \"text\": \"CCU NSG ACCEPTANCE NOTE 6:15A\\n\\nS- LETHARGIC\\n\\n PT ARRIVED FROM CC7 AFTER DROPPING TEMP TO 90 PO AND BP TO 60/40 AFTER A LATE EVE TEMP SPIKE/RECULTURE. PT WAS TREATED WITH IVF WIDE OPEN AND STARTED ON DOPA 5MCG WITH NEW IV INSERTED.\\nON ARRIVAL, 1 LITER IVF HAD INFUSED AND DOPA WAS AT 5MCG- BP ON ARRIVAL- 95/60 AND HR- 70 SR. GIVEN STAT DOSE GENT 50 MG AND AN ADDITIONAL 500CC IVF. PT IS RESPONSIVE TO CONVERSATION BUT IS LETHARGIC, DENIES PAIN.\\nSTAT LABS FROM CC7 PENDING, TO INSERT CENTRAL ACCESS AND ? ALINE CURRENTLY.\\n\\nA/ PT WITH EXTENSIVE MEDICAL HX/RENAL FX/ESRD/VRE/MRSA CURRENTLY ADMITTED TO CCU FOR HYPOTENSION/SEPSIS\\n\\nPLAN- LINE INSERTION, BAIR HUGGER, 500CC MORE IVF AND ANTIBX AS ORDERED. CONTINUE TO FOLLOW SPECIMENS/MONITOR HEMODYNAMICS AND KEEP MAPS > 60. KEEP PT AND FAMILY AWARE OF PLAN OF CARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1588799,\n \"text\": \"Nursing Progress Note\\n\\nS\\\" \\\" I'm so hot.\\\"\\n\\nO: Please see flow sheet for objective data. Tele sinus rhythm. Pt recieved at total of 2250cc IV fluids to maintain MAP >60 and wean Dopamine to off. Presently dopamine remains off. TEE done, did not show any evidence of vegatation or endocarditis. EF approx 35%.\\n\\nResp: Lungs diminshed throughout the bases. O2 sat 93-98%.\\n\\nNeuro: Pt lethargic throughout the day. Pt did receive versed .5mg & fentanyl 25mcgs for TEE which she tolerated well.Easily arousable to verbal stimulation. Seems to be aware of what's happening.\\n\\nGU/GI: Pt NPO for most of the day for TEE. Tolerating diet well this pm. Abd is soft with bowel sounds present. Pt does not void. Hemodialysis held off today. K 5.6 repeat pending.\\n\\nID: Temp 94-96 po. Bear hugger removed early this am when pt c/o being too hot and temp had started to come up. Placed back on blanket after temp remained down. Off at present. WBC 27,000 this am. Dose of vancomycin held today d/t vancomycin level of 21.3. Remains on Zosyn Q 12hrs and 1 x dose of gentamycin.\\n\\nEndo: Cortstim test done. Started on Decadron 10mg IV Q 8. given half dose of Glargine at 12n d/t NPO. BS in better control with SS.\\n\\nAccess: Pt has R fem Quinton. Pt has no other site for central access so central line not placed.\\n\\nA&P: Pt able to wean off dopamine throughout the day. to monitor hemodynamics. to monitor K. ? possible hemodialysis . with POC.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-07-26 00:00:00.000\",\n \"description\": \"DISTINCT PROCEDURAL SERVICE\",\n \"row_id\": 870747,\n \"text\": \" 6:51 PM\\n CHEST (PA & LAT); -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: evaluate for metastatic lesion, evidence of joint infection\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old woman with IDDM, ESRD, with E.coli sepsis, now w/ shoulder pain.\\n also with lymphadenopathy. evaluate for evidence of metastatic lestion or joint\\n space infection\\n REASON FOR THIS EXAMINATION:\\n evaluate for metastatic lesion, evidence of joint infection\\n ______________________________________________________________________________\\n FINAL REPORT\\n COMPARISON: .\\n\\n INDICATION: Evaluate for metastatic lesion or joint infection.\\n\\n The cardiac silhouette is enlarged but stable. There is stable widening of\\n the mediastinum. The pulmonary vascularity is normal, and the lungs appear\\n grossly clear allowing for low lung volumes. No pleural effusions are\\n identified. Surgical clips are seen in the left paratracheal region.\\n\\n IMPRESSION:\\n 1. Stable chest radiographic findings with cardiomegaly and prominent\\n mediastinal contour. The latter is likely related to lymphadenopathy.\\n 2. No evidence of pulmonary nodules or masses.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-07-26 00:00:00.000\",\n \"description\": \"UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD\",\n \"row_id\": 870659,\n \"text\": \" 7:15 AM\\n TUNNEDLED DIALYSIS CATH PLACE Clip # \\n Reason: placement of a new permanent line for dialysis\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n ********************************* CPT Codes ********************************\\n * TUNNELED W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\\n * FLUOR GUID PLCT/REPLCT/REMOVE C1750 CATH,HEMO/PERTI DIALYSIS LONG *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old woman with ESRD on HD whose R sublclavian tunneled line was\\n infected and recently d/c'd needs new permanent dialysis access.\\n\\n REASON FOR THIS EXAMINATION:\\n placement of a new permanent line for dialysis\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 39-year-old female with end-stage renal disease and multiple line\\n infections who presents with an indwelling temporary right groin catheter. The\\n patient now needs placement of a tunneled dialysis catheter.\\n\\n PHYSICIANS: The procedure was performed by Dr. , Dr. \\n , and Dr. . Dr. , the staff\\n radiologist, was present and supervising throughout.\\n\\n PROCEDURE: After the risks and benefits of the procedure were discussed with\\n the patient and informed consent was obtained, the patient was placed supine\\n on the angiography table. Her right groin, including the indwelling temporary\\n dialysis catheter, was prepped and draped in the standard sterile fashion. The\\n skin and subcutaneous tissues in the right groin were anesthetized thoroughly\\n with 1% lidocaine. Under fluoroscopic guidance, a 0.035 Amplatz wire was\\n advanced through the indwelling catheter lumen into the inferior vena cava.\\n Our attention was then turned to creation of the subcutaneous tunnel.\\n\\n An appropriate catheter exit site was chosen in the right groin. A small skin\\n incision was created using a #11 blade scalpel. A subcutaneous tunnel was then\\n created using blunt dissection with the assistance of a hemostat device. A new\\n 14.5-French tunneled dual lumen hemodialysis catheter was then advanced\\n through the subcutaneous tunnel to the venous puncture site in the right\\n groin. The existing catheter was then removed and a 15-French peel-away sheath\\n was advanced over the Amplatz wire into the right femoral vein. After the\\n Amplatz wire was removed, the new 14.5-French catheter was advanced through\\n the peel-away sheath into the inferior vena cava. The peel-away sheath was\\n removed. The catheter was flushed, capped, and heplocked. It was secured to\\n the skin using 2-0 silk sutures. The venous puncture site in the right groin\\n was then closed with an absorbable 2-0 Vicryl suture, followed by a dry\\n sterile dressing.\\n\\n FINDINGS: A fluoroscopic spot image of the abdomen was obtained at the\\n termination of the procedure, demonstrating the catheter tip to be present\\n within the inferior vena cava.\\n\\n COMPLICATIONS: None.\\n (Over)\\n\\n 7:15 AM\\n TUNNEDLED DIALYSIS CATH PLACE Clip # \\n Reason: placement of a new permanent line for dialysis\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n MEDICATIONS: 1% lidocaine SQ. Totals of 0.5 mg of Versed and 50 mcg of\\n fentanyl were administered in intermittent doses with continuous monitoring of\\n vital signs by the nursing staff.\\n\\n IMPRESSION: Successful replacement of a 14.5-French temporary catheter for a\\n new 14.5-French, 32-cm long tunneled dual lumen hemodialysis catheter over a\\n guidewire via the right common femoral vein. The catheter tip to cuff length\\n measures 27 cm. The tip of the catheter is present in the inferior vena cava.\\n The catheter is ready for immediate use.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-07-27 00:00:00.000\",\n \"description\": \"CT RECONSTRUCTION\",\n \"row_id\": 870861,\n \"text\": \" 4:24 PM\\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \\n Reason: please evaluate for soft tissue infectious process, evidence\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old woman with E coli bacteremia now with pain in left sternoclavicular\\n joint area.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for soft tissue infectious process, evidence of osteomyelitis\\n in the left sternoclaricular area.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: E. coli bacteremia with pain in the left sternoclavicular joint\\n area. Evaluate for evidence of osteomyelitis or other infectious processes.\\n\\n TECHNIQUE: Axial CT images of the upper chest were performed, which included\\n thin-collimation slices and coronal and sagittal reformatted images.\\n Comparison is also made to CT examination of the chest performed . No\\n post-contrast images could be obtained due to the limited IV access.\\n\\n FINDINGS:\\n CT OF THE CHEST WITHOUT IV CONTRAST: Examination of the osseous structures\\n demonstrate very mild irregularity along the articular surface of both\\n clavicular heads, which appears somewhat symmetric, with appearances typically\\n seen with degenerative joint disease. There are no associated effusions or\\n other fluid collections. Without IV contrast, we cannot assess for\\n enhancement.\\n\\n Metallic clip is seen just anterior to the inferior aspect of the left\\n thyroid.\\n\\n Note is made of marked left axillary lymphadenopathy, associated with\\n adenopathy including lymph nodes predominantly in the prevascular space and\\n the AP window. Visualized aspects of the heart appear markedly enlarged, with\\n marked vascular calcifications including the coronary arteries.\\n\\n Examination of the lungs demonstrate changes related to tracheobronchomalacia,\\n particularly at the level of the carina and left main stem bronchus. In\\n addition, there is a stable dominant nodule in the right upper lobe anteriorly\\n which measures approximately 1 cm in size and is unchanged since the\\n comparison. Multiple other tiny nodular pulmonary opacities are also\\n appreciated, also stable.\\n\\n Examination of coronally and sagittally reformatted images of the\\n sternoclavicular joints was also reviewed, not demonstrating frank destructive\\n changes or evidence of effusion/abscess at the joints.\\n\\n IMPRESSION:\\n\\n 2) Very mild irregularity of both sternoclavicular joints, without significant\\n difference in severity between the left and right side, has appearances most\\n (Over)\\n\\n 4:24 PM\\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \\n Reason: please evaluate for soft tissue infectious process, evidence\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n often seen in the setting of mild degenerative changes. While osteomyelitis\\n cannot be excluded, no complication of osteomyelitis such as adjacent abscess\\n or fluid collection is evident.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2117-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 100302,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Endocarditis.\\nHeight: (in) 60\\nWeight (lb): 100\\nBSA (m2): 1.39 m2\\nBP (mm Hg): 103/57\\nHR (bpm): 87\\nStatus: Inpatient\\nDate/Time: at 15:22\\nTest: Portable TEE (Complete)\\nDoppler: Full doppler and color doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\\nLA/LAA or the RA/RAA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Normal interatrial septum. No ASD\\nby 2D or color Doppler.\\n\\nLEFT VENTRICLE: Symmetric LVH. Moderate global LV hypokinesis.\\n\\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\\nhypokinesis.\\n\\nAORTA: No atheroma in aortic arch. Simple atheroma in descending aorta.\\n\\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\\nleaflets. No masses or vegetations on aortic valve. Trace AR.\\n\\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or\\nvegetation on mitral valve. No mitral valve abscess. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\\nvegetation on tricuspid valve. No abscess of tricuspid valve. Mild [1+] TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\\nvegetation/mass on pulmonic valve. No 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 sedated for\\nthe TEE. Medications and dosages are listed above (see Test Information\\nsection). Local anesthesia was provided by benzocaine topical spray. No TEE\\nrelated complications. 0.2 mg of IV glycopyrrolate was given as an\\nantisialogogue prior to TEE probe insertion. The patient appears to be in\\nsinus rhythm. The house officer caring for the patient was notified of the\\nresults by text page.\\n\\nConclusions:\\nThe left atrium is dilated. There is symmetric LVH. There is moderate global\\nleft ventricular hypokinesis. There is moderate global right ventricular free\\nwall hypokinesis. There are simple atheroma in the descending thoracic aorta.\\nThere are three aortic valve leaflets. There is focal calcification of the\\nnon-coronary cusp. No masses or vegetations are seen on the aortic valve.\\nTrace aortic regurgitation is seen. The mitral valve leaflets are moderately\\nthickened. There is a 2-3 mm calcified mobile echodensity attached to the tip\\nof the anterior mitral leaflet seen on ventricular side of the valve, which\\nlikely represents a torn chordae (present on prior TEE from , see below).\\nNo discrete mass or vegetation is seen on the mitral valve. No mitral valve\\nabscess is seen. Mild (1+) mitral regurgitation is seen. The tricuspid valve\\nleaflets are mildly thickened. There is no abscess of the tricuspid valve. No\\nvegetation/mass is seen on the pulmonic valve. There is no pericardial\\neffusion.\\nCompared with the findings of the prior study (tape reviewed) of ,\\nbiventricular systolic dysfunction is now present. The degree of valvular\\ndisease is unchanged.\\n\\nImpression: no echocardiographic evidence of endocarditis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-07-18 00:00:00.000\",\n \"description\": \"CT PELVIS W/CONTRAST\",\n \"row_id\": 869724,\n \"text\": \" 10:01 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 100CC NON IONIC CONTRAST\\n Reason: rule out abscess/evaluate for source of infection\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n Field of view: 36 Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old woman with ESRD on HD with Gram negative rod bacteremia and mild\\n abdominal tenderness\\n REASON FOR THIS EXAMINATION:\\n rule out abscess/evaluate for source of infection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 39-year-old woman with end-stage renal disease, bacteremia.\\n Evaluate for possible abscess.\\n\\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the lung\\n bases to the pubic symphysis after administration of oral and IV contrast.\\n\\n COMPARISON: CT scan.\\n\\n CT OF THE ABDOMEN WITH IV CONTRAST: There is minor atelectasis at both lung\\n bases. A previously identified low density lesion within the right lobe of\\n the liver measures 19 x 17 mm. It has peripheral puddling, and is most likely\\n a hemangioma. A tiny hypervascular focus measuring 6 mm is seen near the\\n gallbladder fossa on the same slice (series 2 image 30). Another\\n hypervascular focus, 9 x 8 mm, is seen in the left lobe of the liver (junction\\n of 4a and 4b). No other lesions are seen in the liver. There is a gallstone,\\n without evidence of cholecystitis. The pancreas is atrophic. Native kidneys\\n are shrunken; there are heavy calcifications within the renal arteries,\\n superior mesenteric artery, and celiac axis. The spleen is unremarkable. The\\n adrenals are unchanged. The stomach is within normal limits. As previously\\n identified on ultrasound (), there is a 21 x 95 mm complex fluid\\n collection in the anterior aspect of the liver, which is probably unchanged.\\n Also seen is the retroperitoneal mass which appears to splay the celiac axis,\\n and is unchanged. A small amount of free fluid is seen in the abdomen. Again,\\n as noted, there are extensive vascular calcifications throughout the abdominal\\n vasculature.\\n\\n CT OF THE PELVIS WITH IV CONTRAST: There is thickening of the rectal wall,\\n which may represent edema. The remainder of the bowel loops are unremarkable.\\n Again seen in the right lower quadrant is a heavily calcified rejected\\n transplant kidney. No lymphadenopathy is definitively identified in the\\n pelvis. However, in the right anterior rectus sheath, there is a 16 x 42 mm\\n low density lesion. A small amount of free fluid is seen in the pelvis. As\\n previously noted, there are heavy vascular calcifications throughout all\\n pelvic vessels.\\n\\n Osseous structures are remarkable for renal osteodystrophy disease.\\n\\n IMPRESSION:\\n (Over)\\n\\n 10:01 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 100CC NON IONIC CONTRAST\\n Reason: rule out abscess/evaluate for source of infection\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n Field of view: 36 Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 1. Subtle low density lesion in the right anterior abdominal/pelvic wall,\\n which is new since the last examination, and may represent an abscess.\\n Ultrasound may be useful for further characterization.\\n 2. Thickening/edema of the rectal wall, which may represent proctitis.\\n Correlation with physical exam may be useful in excluding this as a source of\\n bacteremia.\\n 3. Hemangioma in liver. Two hypervascular foci in liver on this single-\\n contrast study; ultrasound or MRI may be useful for further characterization,\\n if clinically indicated.\\n 4. Stable retroperitoneal lymphadenopathy.\\n 5. Stable appearance of complex fluid collection in anterior aspect of liver.\\n 6. Heavily calcified abdominal vasculature as previously identified, probably\\n due to end-stage renal disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-07-16 00:00:00.000\",\n \"description\": \"CT 100CC NON IONIC CONTRAST\",\n \"row_id\": 869547,\n \"text\": \" 2:49 PM\\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \\n Reason: r/o PE\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old woman with pleuritic R chest pain, low grade fever.\\n REASON FOR THIS EXAMINATION:\\n r/o PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JJMl FRI 3:41 PM\\n NO evidence of PE.\\n multifocal vague, small nonspecific lung opacities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Pleuritic right chest pain and low-grade fever, rule out PE.\\n\\n No CT is available for comparison on PACs.\\n\\n TECHNIQUE: MDCT-acquired images of the chest were obtained before and after\\n the administration of IV contrast.\\n\\n CT OF THE CHEST WITH IV CONTRAST: There are no filling defects within the\\n pulmonary arterial system to suggest PE. The great vessels are unremarkable.\\n Note is made of coronary artery and aortic mural calcifications. There are\\n extensive calcifications within the abdominal vasculature as well. Lung\\n windows demonstrate several patchy nonspecific opacities in the right upper\\n lobe (series 3, image 87), right lower lobe (series 3, image 51), and left\\n lower lobe (series 3, image 24). No images were available for comparison.\\n There is a 3.5 mm nodular density near the left major fissure in the left\\n lower lobe (series 3, image 52). An additional tiny pleural-based density is\\n also seen in the lingula (series 3, image 68). Bulky left axillary and\\n mediastinal lymphadenopathy, notably in the prevascular, AP window,\\n pretracheal, precarinal, and subcarinal regions is demonstrated, and that was\\n also described on the prior CT report of .\\n\\n Limited images of the upper abdomen demonstrate extensive vascular\\n calcifications.\\n\\n Bone windows demonstrate no suspicious lytic or sclerotic foci.\\n\\n IMPRESSION:\\n 1) No evidence of PE.\\n 2) Multifocal, nonspecific, vague small patchy opacities with a tiny nodular\\n density in the left lower lobe. No comparison studies are currently available\\n on PACs for comparison.\\n 3) Extensive atherosclerotic disease.\\n (Over)\\n\\n 2:49 PM\\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \\n Reason: r/o PE\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-07-20 00:00:00.000\",\n \"description\": \"GUIDANCE CYST OR RENAL ANY LOC US\",\n \"row_id\": 870015,\n \"text\": \" 2:22 PM\\n US SIMPLE/SING ABSC/CYST DRAIN/INCISION; GUIDANCE CYST OR RENAL ANY LOC USClip # \\n -59 DISTINCT PROCEDURAL SERVICE\\n Reason: aspiration of anterior abdominal wall fluid collection under\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old woman with ESRD, E coli bacteremia with aterior abdominal wall\\n fluid collection.\\n REASON FOR THIS EXAMINATION:\\n aspiration of anterior abdominal wall fluid collection under US guidance.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Sepsis, anterior abdominal wall fluid collection.\\n\\n Procedure done by radiologist:Limited ultrasound over the anterior abdominal\\n wall, just to the right of midline showed a small fluid collection measuring\\n 1.6 x 3 x 0.6 cm. The risks and benefits were explained to the patient and\\n informed consent was obtained. A preprocedure timeout was performed regarding\\n the patient's name and procedure. The area was prepped and draped in a\\n sterile fashion. 1% lidocaine was used for local anesthesia. Using\\n ultrasonographic guidance, an 18-gauge spinal needle was inserted into this\\n collection and approximately 2 mL of blood-tinged fluid was aspirated. This\\n was sent for Gram stain and culture. No more fluid was able to be aspirated.\\n\\n Dr. , the attending radiologist, was present and supervised the\\n entire procedure. There were no immediate post-procedure complications.\\n\\n IMPRESSION: Aspiration of tiny anterior abdominal wall fluid collection,\\n which appears to be a hematoma. This fluid was sent for Gram stain and\\n culture.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-07-20 00:00:00.000\",\n \"description\": \"TUNNELED CENTRAL W/O PORT\",\n \"row_id\": 870029,\n \"text\": \" 3:42 PM\\n TEMP DIALYSIS LINE PLCT Clip # \\n Reason: placement of temporary dialysis femoral catheter\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n ********************************* CPT Codes ********************************\\n * NON-TUNNELED TUNNELED CENTRAL W/O PORT *\\n * -51 MULTI-PROCEDURE SAME DAY FLUOR GUID PLCT/REPLCT/REMOVE *\\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 39 year old woman with ESRD on HD with E coli bacteremia.\\n\\n REASON FOR THIS EXAMINATION:\\n placement of temporary dialysis femoral catheter\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Endstage renal disease requiring hemodialysis. Infected tunneled\\n right subclavian dialysis catheter.\\n\\n PHYSICIANS: Temporary dialysis catheter placement was performed by Dr. \\n and Dr. . Tunneled right subclavian dialysis catheter\\n removal was performed by Dr. , Dr. , and Dr. \\n . The attending physician, . , was present and supervising.\\n\\n CONSENT: After the risks and benefits of the procedure were discussed with\\n the patient, written informed consent was obtained.\\n\\n PROCEDURE/FINDINGS: The patient was placed supine on the procedure table. The\\n right common femoral vein was found to be patent and compressible by\\n ultrasound. The right groin was prepped and draped in a standard sterile\\n fashion. 1% lidocaine was administered to the skin and subcutaneous tissues\\n over the right femoral vein for local anesthesia. The right common femoral\\n vein was accessed by a 21-gauge needle under ultrasound guidance. A 0.018\\n guidewire was advanced through the needle into the IVC under fluoroscopic\\n guidance. The needle was exchanged for a 4-French micropuncture sheath. The\\n guidewire was exchanged for wire, which was advanced into the IVC\\n under fluoroscopic guidance. The venous access site was widened by a scalpel.\\n It was then sequentially dilated by 12 and 14-French dilators. The last\\n dilator was exchanged for a 20 cm, 14.5-French dual lumen dialysis catheter,\\n which was advanced into the IVC under fluoroscopic guidance. A final\\n fluoroscopic abdominal radiograph was obtained, documenting the catheter tip\\n in the IVC. The catheter was flushed and capped with extension tubing. It\\n was sutured with two 2-0 nylon sutures. A dry dressing was applied. The\\n catheter was hep-locked. The catheter is ready for use.\\n\\n Attention was then turned to the patient's tunneled right subclavian dialysis\\n catheter. The catheter hub sutures and the tunnel exit site sutures were cut.\\n The catheter was easily removed from the tunnel. Pressure was applied at the\\n venous entry site until hemostasis was achieved. A dressing was applied at\\n the tunnel exit site. The catheter tip was cut and sent for culture.\\n\\n COMPLICATIONS: No immediate complications.\\n (Over)\\n\\n 3:42 PM\\n TEMP DIALYSIS LINE PLCT Clip # \\n Reason: placement of temporary dialysis femoral catheter\\n Admitting Diagnosis: FEVER-LINE SEPSIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n MEDICATIONS: Versed IV, fentanyl IV, and 1% lidocaine subq were administered\\n by a registered nurse who was monitoring the patient throughout the procedure.\\n Please refer to the nursing records for dosages.\\n\\n IMPRESSION:\\n 1. Successful placement of a 20 cm, 14.5-French dual lumen temporary dialysis\\n catheter via the right common femoral vein, with tip in the IVC, ready for\\n use.\\n 2. Successful removal of a tunneled right subclavian dialysis catheter.\\n Catheter tip was sent for culture.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276744,\n \"text\": \"Reversed L-R arm lead\\nSinus rhythm\\nConsider left atrial abnormality\\nProbable inferior myocardial infarction with ST-T wave configuration suggests\\nacute process\\nPrecordial/anterior ST-T wave abnormalities - suggests ischemia\\nClinical correlation is suggested\\nSince previous tracing of , inferior myocardial infarction suggested,\\nfurther ST-T wave abnormalities present and L-R arm lead reversed\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276740,\n \"text\": \"Sinus rhythm. Rightward axis is non-specific. Consider prior inferior wall\\nmyocardial infarction, although is non-diagnostic. Low precordial lead\\nQRS voltage is non-specific. Diffuse non-specific ST-T wave abnormalities.\\nClinical correlation is suggested. Since the previous tracing of sinus\\ntachycardia is absent.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276741,\n \"text\": \"Sinus tachycardia. Compared to tracing #1 the heart rate is slightly slower.\\nAnterolateral ST-T wave abnormalities persist. Clinical correlation is\\nsuggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276742,\n \"text\": \"Sinus tachycardia. Possible old inferior wall myocardial infarction.\\nAnterolateral ST-T wave abnormalities - cannot rule out myocardial ischemia.\\nClinical correlation is suggested. Compared to the previous tracing of \\nthe patient is significantly tachycardic. Anterolateral ST-T wve abnormalities\\npersist. Clinical correlation is suggested.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 276743,\n \"text\": \"Sinus rhythm\\nProbable inferior infarct, age indeterminate - possibly acute\\nAnterolateral ST-T wave abnormalities - Cannot exclude in part ischemia\\nClinical correlation is suggested\\nSince previous tracing of , ST-T wave abnormalities less prominent and\\nL-R arm lead now in normal position\\n\\n\"\n }\n]"}}},{"rowIdx":780,"cells":{"subject_id":{"kind":"number","value":23483,"string":"23,483"},"hadm_id":{"kind":"number","value":158887,"string":"158,887"},"target_text":{"kind":"string","value":"59 yo F with h/o severe NICM EF 15-20%, severe MR, CAD s/p MI, mild 2v-d in ', biV/ICD in 7/. Pt now presents with dig toxicity and ICD shocks. . 1. rhythym: The pt was admitted to the Cardiac Intensive care unit, given the history of v-fib arrest with loss of pulse and unresponsiveness in the ambulance to the hospital. The electrophysiology team was called to evaluate the pacemaker/ICD and found that the device was functioning according to its programmed parameters, sensing fast Vfib/Vtach. However, the ICD was unable to detect slow VT, which the pt was experiencing in the setting of digoxin toxicity. The device was reprogrammed to sense lower rates of VT. On , the pt was taken to the EP lab for generator change since the battery was low. This operation proceeded without complications. The unstable rhythm occured in the setting of digoxin toxicity in acute renal failure. Digoxin was stopped, with the plan to not restart given the history of prior episodes of dig toxicity. The pt was noted to have a hematoma around the device, on the day prior to discharge. This was evaluated by the EP team, found to be stable. Should be followed up at rehab. . 2. CHF: Primarily secondary to valvular dz with 4+ MR, CAD s/p MI and CABG (SVG--> LAD), Pt was euvolemic most of the hospital stay. After the EP lab operation, the pt was found to be volume overloaded and diuresed with lasix over the following several days, returned to . Pt did not appear to tolerate ACE or well with creatinine , plan is to continue Imdur/hydral. Pt will be continued on aldactone, Imdur/Hydral, lasix 120 PO Bid. . 3. CAD: No active ischemia during the hospitalization. Pt has chronic CP symtoms, likely not anginal. Pt had LAD dissection 20 y ago, CABG SVG to LAD, last cath shows occ SVG, but otherwise mild 2V disease. Pt will be continued on ASA, statin . 3. Chronic back pain: The pt's PCP, . recommended high doses of pain medicines, given the patient's poor overal prognosis with severe CHF. The plan was to help provide as much comfort for the patient as possible. The patient agreed with this plan. Pt was started on a regimen of fentanyl patch, morphine IR, and valium. . 4. Weakness/deconditioning: Pt will get further conditioning at rehab. . 5. ARF: Resolved. cr bumped to 1.6 from baseline cr. 0.7 secondary to pre-renal state. . 5. Paroxysm a-fib: Pt was in paced rhythm during hospitalization. The a-fib was not an acute issue. Continue amio, was loaded with 200 for 2 weeks, then started 200 daily. Continue coumadin 3 mg HS, being discharged on lovenox bridge. . 6. hypothyroid: on levoxyl . 7. diarrhea: resolved"},"extractive_notes_summ":{"kind":"string","value":"Pt to on , pacer interogated, pacer in need of battery/generator change, generator change on , please see careview for VS and additional data.CV: Pt AV paced HR 70 DDD mode, NBP 103-130/66-80, pt down to EP during previous shift for generator change, dsd over site, scant amt of bld noted on dsg, betadyne noted, dsg unchanged throghout shift. dorsal/tibial pulses palp.Resp- c/o SOB since procedure on Mon. Admitted for GI distress, N/V, dig tox, and episodes of VF/VT relieved by ICD. ACE and lasix stopped.O: For complete VS see CCU flow sheet.ID: Pt remains afebrile. Heparin/coumadin to be started later this am, check with CCU Team/HO.Resp: Pt LS clear at apices with fine crackles noted bilateral bases. Per CCU Team, pt fluid goal of even, per Dr. , gentle hydration through PO fluids.ID: Pt afebrile.Skin: Pt skin with some brusing/ecchymosis on legs, pt with sm 1cm x1cm pressure sore/ulceration on R buttock cheek, duoderm applied.Social: Pt (whom pt states and states is HCP-no form in chart- asked by Dr. to bring in copy of form), called and spoke with RN x 3 this am. Upon arriving AICD was reprogramed to shock at lower HR.SHe has had no further episodes of VT. Captopril with rising creatine is supposed to be the source of dig toxicity.CV: Pt has been pain free. Nursing Progress Note 7am-7pmS: The pain in my back radiates down my legs and they feel numb.O: Please see carevue for complete objective data.CV-HR=80 AV paced, no ectopy. Medicated with prn Percocet, backrubs and frequent position changes. Am labs sent-> Hct 31, K 4.8, Na 131, PTT 63.7, INR 1.9-> Dr. aware.Resp: Pt LS clear at apices to crackles at bases, pt RR teens to mid 20's with exertion, O2 sats 98-100% on 3 L n.c. Pt SOB with movement/turning, pt RR decreases to teens with rest.GI/GU: Pt abd soft, +BS x 4, no stool this shift, pt NPO after midnoc for planned ICD battery change this am. Pt voiding via bedpan, pt with poor u/o-Dr. aware, see flowsheet. \"O: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 80 AVpaced, rare PVC noted. \"O- see flowsheet for all objective data.cv- Tele: AV paced rhythm- rate 80- b/p 100-108/63-78- dig level 4.1 this am- Hct 30.6- K 3.6 KCL 40meq given- Mg 1.9 Mg sulfate 1gm given-heparin gtt @ 700u/hr- PTT 63.6- plan is for battery change tomorrow.resp- In O2 2L via NC- lung sounds with bibasilar crackles- RR 18-22- very SOB with exertion- SPO2 97-99%- sats drop to 91% on room air.neuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.gi- abd soft (+) bowel sounds- taking Po fair- c/o nausea this afternoon- tylenol held @ 1600 due to nausea- no BM today- LFT's added to am labs- results pending- NPO after 12am for EP lab.gu- voiding conc amber colored urine- incontinent lg amt of urine while napping- U/O essentially = today- BUN 35 Crea 1.4comfort- c/o severe back pain with movement- morphine sulfate 15mg Po q12hr & tylenol 1000mg Po q8hr working well controlling pain overall- back care given PRN.A- Pre-op for battery change tomorrow- seen by anesthesia this am.P- monitor vs, lung sounds, I&O and labs- ? \"O: Please see carevue for complete objective data.CV- S/P generator change, AV paced, HR-70, BP 108-125/56-87. CCU NGS NOTE: ALT IN CV/SP PACER GENERATOR REVISIONS: \"That was long\"O: For complete VS see CCU flow sheet. \"O: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 80, initially vpaced, AVpaced most of the night. RR-16-21, regular, and LS clear with diminished bases.GI/GU- BS present and abd soft. REstrart morphine SR as needed. She has been able to sleep.A: Stable/awaiting replacement of pacer generated.P: Shut off heparin at 4am . THek wrote to start coumadin in am.RESP: She is sating 100% on 4L NP, but drops to high 80s on RA. states she has had PTA.Neuro: Pt. Duoderm from previous shift intact on buttocks from pressure sore, Pt. ICD FIRED \" AFTER 1 TO 1.5 MINUTES\" AND PT BACK IN PACED AND ALERT/ORIENTED. REPEAT EPISODE IN ER ABOUT 1-1.5 HOUR LATER WITH THE SAME PT \"FINE\" ONCE RESTORED WITH OWN ICD FIRING.DECIDED TO TRANSFER TO CCU.PT 3:30A- BY REPORT OF PT HAD VT ARREST AGAIN IN AMBULANCE AND WAS SHOCKED/DEFIB WITH 120 J BY PARAMEDICS AND RESTORED TO PACED WITHOUT LOC OR NEED FOR AMBU/CPR.TO CCU VSS. Started Hydralazine, tolerating well. SHe has multiple eccymotic areas.MS/COMFORT: Pt was quite groggy upon returning. Pt with c/o back/leg pain out of 1 to 10 pain scale, percocet given with minimal relief. Pt bladder slightly firm, pt denies pain with palpation, denies difficulty voiding, Dr. aware, obtain U&A when pt voids this eve. \"O: Please see careview for VS and additional data.CV: Pt HR 60 AVpaced, NBP 111-136/61-81, bilateral pedal and radial pulses palp. Pt voided x 3 via bedpan. Pt MAE, pt moves bilateral LE minimally, + sensation. PT PUT ON /DEFIB CURRENTLY.INR CURRENTLY 1.5- TO DISCUSS STARTING HEPARIN TO KEEP THERAPEUTIC IN LOW EF STATE, NO COUMADIN IN CASE OF NEED FOR INVASIVE PROCEDURE THIS AM.CPK THIS AM (-) AS WELL. Pt remains on 1L nc.GI/GU- No BM, BS present x 4, abd soft. She has usual discomfort with position changes, but appears comfortable when lying still.A: Successful generator replacement/DTVP: Monitor urine output closely. Pt bilateral pedal pulses palp, pt with bilateral LE edema +. gave scheduled and PRN pain meds and repositioned. O2 stopped after rounds and sats remained 92 and above. Pt LS clear at apices to coarse at bases this am, pt LS clear this afternoon.Neuro: Pt alert and oriented x 3-> pt has some difficulty recalling exact date, but aware of Month, year and Day. Stitches on scalp due to fall, clean and intact.Neuro- hx of depression, taking zoloft and ativan."},"n_notes":{"kind":"number","value":20,"string":"20"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2166-09-05 00:00:00.000","description":"Report","row_id":1569280,"text":"CCU NSG PROGRESS NOTE/ACCEPTANCE NOTE 3:30-7A/ VT\n\n\nS- \" MY BACK IS REALLY HURTING..BEFORE I FELL DOWN AT HOME, IT'S BEEN HURTING, MAYBE - I DON'T REMEMBER.. I ONLY GOT HOME A COUPLE OF WEEKS AGO...\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\nSEE NSG FHPA AND CCU TEAM NOTES FOR DETAILS R/T HPI/PMH.\n\nTHIS IS A 60 YR OLD PT WITH EXTENSIVE PMH MOST SIG FOR CM, CRI, CHF/CAD WHO WAS FOUND FALLEN AT HOME BY VNA AND BROUGHT TO ER FOR HEAD LACERATION WHICH WAS STITCHED/STAPLED- SHE WAS SENT TO CT WHICH WAS (-) FOR BLEED BY REPORT. ON ROUTE TO STEP DOWN FLOOR AROUND MN, HAD WITNESSED ARREST- GASPED, LOC AND REQUIRED CPR/AMBU. ICD FIRED \" AFTER 1 TO 1.5 MINUTES\" AND PT BACK IN PACED AND ALERT/ORIENTED. REPEAT EPISODE IN ER ABOUT 1-1.5 HOUR LATER WITH THE SAME PT \"FINE\" ONCE RESTORED WITH OWN ICD FIRING.\nDECIDED TO TRANSFER TO CCU.\n\nPT 3:30A- BY REPORT OF PT HAD VT ARREST AGAIN IN AMBULANCE AND WAS SHOCKED/DEFIB WITH 120 J BY PARAMEDICS AND RESTORED TO PACED WITHOUT LOC OR NEED FOR AMBU/CPR.\nTO CCU VSS.\n\n PT WITH V PACING- 80'S, INFREQ VEA NOTED. ALL LYTES CHECKED ON ARRIVAL -WNL.K- 4.4, MG-1.9,FREE CA- 1.15.\nBP- 106/72- 119/62 VIA DYNAMAP.\n12L EKG OBTAINED- 100% PACED.\nEP FELLOW CALLED AND IS CURRENTLY REVIEWING PT CASE AND TO INTEROGATE PACER/ICD. PT PUT ON /DEFIB CURRENTLY.\nINR CURRENTLY 1.5- TO DISCUSS STARTING HEPARIN TO KEEP THERAPEUTIC IN LOW EF STATE, NO COUMADIN IN CASE OF NEED FOR INVASIVE PROCEDURE THIS AM.\nCPK THIS AM (-) AS WELL.\n\n PT ARRIVED ON 100% NR- WEANED TO 40% FACE TENT- O2 SATS >97%\nCOMFORTABLE- BASE CX LEFT/RT.\nNO ISSUES CURRENTLY\n\nID- AFEBRILE\n\nGU- NO FOLEY CATH CURRENTLY. VOIDED 50CC X 1.\nAM CREATININE 1.6 UP FROM 0.7.\nRECEIVED 500CC NS AT OSH.\n\nGI- NO N/V CURRENTLY- STATES HAS NOT BEEN WELL FOR PAST SEVERAL DAYS.\n(+) DIG TOXIC. (+) BOWEL SOUNDS.\n\nMS-PT ALERT , ORIENTED, DIFFICULT TO FOLLOW HISTORY/STORY AT TIMES.\nSTATES SHE HAS NO SOB, WANTING PAIN MED FOR \"BACK PAIN\" - REPOSITIONED AND ATTEMPTED BACK RUB , ETC.\nRECEIVING 0.5 MSO4- SLEEPING CURRENTLY\n\nSTATES HEALTH CARE PROXY- - PH- \n\nLINES- #22 RT HAND IV ACCESS.\n\nA/ PT ADMITTED TO CCU FOR W/U OF POSSIBLE ICD MALFUNCTION/DELAY AND S/P SEVERAL EPISODES PRESUMED VT\n\nCONTINUE TO MONITOR PT , ON STANDBY.\nAWAIT PACER/ICD INTEROGATION AND PLAN FROM EP FELLOW.\nTO RESTART HEPARIN AND CV MEDS THIS AM.\nFOLLOW RENAL FX ? WET/DRY AND POSSIBLE NEED FOR MORE IVF.\nWEAN TENT TO NP AS ABLE THIS AM.\nCONTINUE TO PROVIDE INFO FOR PT, PLAN OF CARE AS WELL AS COMFORT/MEDS AS NEEDED. CALL TO TO OBTAIN CT REPORT.\nHOLD DIG.\n\n"},{"category":"Nursing/other","chartdate":"2166-09-05 00:00:00.000","description":"Report","row_id":1569281,"text":"CCU NPN 7a-7p\nS: \"My back and legs really hurt...the pain is always kinda there.\"\n\nO: Please see careview admission note and flowsheet for VS and additional data.\n\n\nCV: Pt HR 80 v paced, Dr. from EP up to interrogate pacer this am, see note in chart, plan for pt to have ICD battery change on Monday. NBP 97-117/62-72, MAPs>74. Pt bilateral pedal pulses palp, pt with bilateral LE edema +. No VT this shift. Pt started on heparin gtt at 900 units/hr, PTT subtherapeutic at 41, Heparin gtt increased to 1000 units/hr at 1650, PTT to be drawn this eve. Pt CK (CPK) 29 (was 33), troponin 0.06 (was 0.08). Dr. in to speak with pt regarding code status, per Dr. and order pt is but otherwise full code.\n\nResp: Received pt on face tent 40% with rr teens, O2 sats 100%-> pt weaned to 2L n.c with RR 16-23 (in 20's with pt c/o pain and after movement/turning in bed), O2 sats 99-100%. Pt denies SOB, appears comfortable at rest. Pt LS clear at apices to coarse at bases this am, pt LS clear this afternoon.\n\nNeuro: Pt alert and oriented x 3-> pt has some difficulty recalling exact date, but aware of Month, year and Day. Pt pleasant cooperative with care. Pt asking appropriate questions regarding care. Pt MAE, follows commands, appears to have good strength bilateral , pt moves bilateral slightly with difficulty, pt states d/t pain, pt able to wiggle toes, bend knees slightly,+sensation. Pt with c/o back/leg pain out of 1 to 10 pain scale, percocet given with minimal relief. Pt to L and T spine Xray this afternoon, results pending. Pt dozing intermittently, engaging in conversation at times.\n\nGI/GU: Pt abd soft, + BS x 4, no stool this shift, pt NPO this am-> changed to heart healthy diet with 1500 mL fluid restriction, pt ate some of dinner, pt compliant with fluid restriction, pt denies nausea. Pt voided x 3 via bedpan. Pt bladder slightly firm, pt denies pain with palpation, denies difficulty voiding, Dr. aware, obtain U&A when pt voids this eve. Per CCU Team, pt fluid goal of even, per Dr. , gentle hydration through PO fluids.\n\nID: Pt afebrile.\n\nSkin: Pt skin with some brusing/ecchymosis on legs, pt with sm 1cm x1cm pressure sore/ulceration on R buttock cheek, duoderm applied.\n\nSocial: Pt (whom pt states and states is HCP-no form in chart- asked by Dr. to bring in copy of form), called and spoke with RN x 3 this am. Pt changed prior code status (per HCP , pt had previous documented wishes DNR/DNI) pt verbalized wishes to have CPR/external defibrillation but does not wish to be intubted per Dr. . Pt brother called and spoke with pt this afternoon.\n\nA/P: 59 y/o female pacer/ICD interrogated, pt code status DNI but otherwise full code, pacer to T&L spine Xray this afternoon. As discussed per CCU Team rounds, continue to monitor pt hemodyanmics, rhythm, cont to monitor pt resp status-fluid I & O's, ? obtain U&A this eve, cont to follow. Continue to monitor PTT, lytes. Continue to p\n"},{"category":"Nursing/other","chartdate":"2166-09-05 00:00:00.000","description":"Report","row_id":1569282,"text":"CCU NPN 7a-7p\n(Continued)\nrovide emotional support to pt and family.\n\n\n"},{"category":"Nursing/other","chartdate":"2166-09-06 00:00:00.000","description":"Report","row_id":1569283,"text":"ccu npn 7p-7a\nS:\"I've had this back and leg pain for more than 2 weeks, I think its from being in a hospital bed for so long.\"\nO: Please see carevue for VS and objective data\nCVS: Hemodynamically stable with HR 80, initially vpaced, AVpaced most of the night. Isolated PVC's noted. BP ranges 90's-111/50-70. IV Heparin at 1000 units/hour, PTT 92.2.\nResp: Sats 97-100% on 2L n/c. Lungs clear to diminished bases with fine rales in left base. Pt. denies SOB.\nID: Afebrile\nGI:GU: Taking po's, no N/V. Abdomen soft with active bowel sounds, no stool this shift. Voiding qs clear, yellow urine via bedpan. U/A sent as urine has strong odor. pnd results. Total I/O approx. even for day.\nSkin: Head s/p laceration from fall at home PTA, D/I with 4 staples. No drainage or bleeding noted. Duoderm from previous shift intact on buttocks from pressure sore, Pt. states she has had PTA.\nNeuro: Pt. A/A/0X3, able to state name, place and time and events leading up to hospitalization including her Pmhx. Pleasant and cooperative. Conversing easily with RN, appreciative of care. Continues with moderate to severe back and leg pain, which she states she has had for 2 weeks which she attributes to prolonged bedrest. Awaiting results of xrays taken previous shift. Medicated with prn Percocet, backrubs and frequent position changes. Slept at short intervals after 5mg po Ambien. CCU MDs, Dr. , spoke to , earlier this eve.\nA: Hemodynamically stable, NO NSVT, VT/VFIB\nP: Cont. to monitor hemodynamics, monitor rhythm, maintain IV Heparin, follow up with am labs. Repeat Dig.level. Follow up with U/A, XRAY results. Prn Perocet. Comfort and emotional support to Pt. and family\n"},{"category":"Nursing/other","chartdate":"2166-09-09 00:00:00.000","description":"Report","row_id":1569289,"text":"CCU NPN 7p-7a\nS: My back really hurts when I move.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 60 AVpaced, NBP 111-136/61-81, bilateral pedal and radial pulses palp. Received pt on Heparin gtt 900 units/hr, Heparin gtt dc'd at 0400 for ICD battery change/generator change this am. Am labs sent-> Hct 31, K 4.8, Na 131, PTT 63.7, INR 1.9-> Dr. aware.\n\nResp: Pt LS clear at apices to crackles at bases, pt RR teens to mid 20's with exertion, O2 sats 98-100% on 3 L n.c. Pt SOB with movement/turning, pt RR decreases to teens with rest.\n\nGI/GU: Pt abd soft, +BS x 4, no stool this shift, pt NPO after midnoc for planned ICD battery change this am. Pt voiding via bedpan, pt with poor u/o-Dr. aware, see flowsheet. Pt +753 cc at midnoc, +.7 cc LOS. AM BUN 32, creat 1.2.\n\nNeuro: Pt alert and oriented x 3, pleasant and cooperative with care, pt conversing appropriately. Pt with c/o back pain, pain increased with movement, pt repositioned and PO morphine sulfate and tylenol given as ordered with some relief. Pt took 5 mg ambien for sleep with good effect.\n\nID: Pt afebrile, WBC 9.4.\n\nSkin: pt with mult areas of brusing/ecchymosis noted, duoderm intact on coccyx, site not visualized. Pt staples on head CDI.\n\nSocial: Pt received several phone calls overnoc.\n\nA/P: 54 y/o female awaiting ICD battery change/generator replacement in EP today, remains hemodynamically stable overnoc. Continue to monitor pt hemodynamics, cont to monitor pt resp status, u/o lytes-cont to update CCU Team. Conntinue to provide emotional support to pt. Awaiting further plan of care from CCU Team.\n"},{"category":"Nursing/other","chartdate":"2166-09-09 00:00:00.000","description":"Report","row_id":1569290,"text":"CCU NGS NOTE: ALT IN CV/SP PACER GENERATOR REVISION\nS: \"That was long\"\nO: For complete VS see CCU flow sheet. This 59y old woman with long hx of cardiomypathy with -v pacer with AICD was admitted to OSH after a fall at home. She was found to be dig toxic and had 2 episodes of VF which were not shocked until they converted to VF. She received digibind and was transfered to . She was shocked by EMTs in route for more VT. Upon arriving AICD was reprogramed to shock at lower HR.\nSHe has had no further episodes of VT. Captopril with rising creatine is supposed to be the source of dig toxicity.\nCV: Pt has been pain free. She went to EP today at 1030 for generator replace. THey put in temporary wire in preparation for change. All present caridac wires were in good operating condition so only generator was changed. HR on pacer was increased from 60 to 70 in DDD mode. She has therapies for VF, fast and slow VT. She received 1gm kefzol at 2pm and will cont that Q8. She received 2.5 of versed and 75 fentanyl. Pacing wire was removed from groin and she returned to CCU at 1630. HR now 70 AV paced with BP in 1-teens to 120/60. Her groin has very slight ooze, all pulses palpable. Dressing on L chest is dry and in tact. Heparin was d/c at 4am and as per EP should not be restarted until am. THek wrote to start coumadin in am.\nRESP: She is sating 100% on 4L NP, but drops to high 80s on RA. Decreased BS at bases.\nGI: Was NPO until she returned and ate fair dinner.\nRENAL: She voided in BP which spilled mod amt prior to leaving. She has not voided since. She tried upon returning but was unable to. Will try again\nSKIN: She has 2 very small skin tears on either side of coccyx. Duoderm replaced today. They seem to be healing. SHe has multiple eccymotic areas.\nMS/COMFORT: Pt was quite groggy upon returning. She had not received usual morphine SR 15mg at noon. She did get tylenol and percocette at 1730. She has usual discomfort with position changes, but appears comfortable when lying still.\nA: Successful generator replacement/DTV\nP: Monitor urine output closely. SHe is ~2 liters pos LOS. She has not received her usual lasix 100mg since admit so monitor resp status closely. REstrart morphine SR as needed. Do not restart anticoagulation until am.\n"},{"category":"Nursing/other","chartdate":"2166-09-10 00:00:00.000","description":"Report","row_id":1569291,"text":"CCU NPN 7p-7a\nS: \"Is it time for more pain medicine...when will this pain get better?\"\n\nO: 54 y/o female with cardiomyopathy, EF 15-20%, PAF, see admit note for additional hx, pt with -v pacer/AICD who fell at home and was admitted to OSH. While at OSH,head CT neg for bleed, pt found to be dig toxic, rec'd digibind, pt into VT/VF x 2 while at OSH-pt requiring CPR, ICD fired after approx 1.5 mins, VS restored, pt in ambulance to , pt into VT, shocked/defib and rhythm restored. Pt to on , pacer interogated, pacer in need of battery/generator change, generator change on , please see careview for VS and additional data.\n\nCV: Pt AV paced HR 70 DDD mode, NBP 103-130/66-80, pt down to EP during previous shift for generator change, dsd over site, scant amt of bld noted on dsg, betadyne noted, dsg unchanged throghout shift. R groin site CDI, area soft, no hematoma noted. Pt bilateral radial and pedal pulses palp, bilateral feet and hands cool. Am labs to be drawn. Heparin/coumadin to be started later this am, check with CCU Team/HO.\n\nResp: Pt LS clear at apices with fine crackles noted bilateral bases. Pt RR teens to 20's, pt SOB/RR increasing with movement/turning, RR teens at rest, O2 sats 95-100% on 2 L n.c.\n\nNeuro: Pt alert and oriented x 3, pt pleasant and cooperative with care, pt conversing and appropriate questions regarding care. Pt MAE, pt moves bilateral LE minimally, + sensation. Pt with c/o back/leg pain, PO morphine sulfate SR 15 mg and acetaminophen 1000 mg given, pt position change with some relief. Pt with some c/o discomfort when moving L arm-pt reminded not to move left arm.\n\nID: Pt afebrile, pt cont on Keflex 500 mg Q6 H for 7 days.\n\nGI/GU: Pt abd soft, + BS x 4, no stool this shift. Pt voiding via bedpan, approx 230 cc of measured u/o from -0300, pt with lg amt spilled x 1 and sm amt spilled x 1. Pt +730 cc at midnoc, +2689.7 cc LOS. AM BUN and creat to be drawn.\n\nSocial: Pt received one phone call last eve.\n\nA/P: 54 y/o female hemodynamically stable s/p battery/generator change biv pacer/ICD. Continue to monitor pt hemodynamics, rhythm, pacer site and groin site, start PO warfarin/? heparin-check with HO. Continue to monitor pt resp status, fluid status, u/o-pt has not rec'd home lasix dose since admission. Continue to monitor pt temps, lytes. Continue to provide emotional support to pt, awaiting further plan of care from CCU Team.\n"},{"category":"Nursing/other","chartdate":"2166-09-10 00:00:00.000","description":"Report","row_id":1569292,"text":"Nursing Progress Note 7am-7pm\nS: \"Even if they say I have to move today, I don't think I am going to!\"\n\nO: Please see carevue for complete objective data.\n\nCV- S/P generator change, AV paced, HR-70, BP 108-125/56-87. started Heparin drip at 0945, then dc'd hep drip at 1100. Set to start coumadin tonight. dorsal/tibial pulses palp.\n\nResp- c/o SOB since procedure on Mon. Sats-98% and higher on 2L nc, 92% and up on Room air. RR-16-21, regular, and LS clear with diminished bases.\n\nGI/GU- BS present and abd soft. No BM this shift. Gave lasix 100 mg to diurese, but diff to evaluate progress b/c of ocas. incontinence of urine. I&O's not exact due to leaks. ~ -120.0 for the shift\n\nNeuro-continuing pain throughout back and legs. gave scheduled and PRN pain meds and repositioned. Some relief achieved but not much. increasing negative attitude about recovery, (i.e. not wanting rehab, depressed about amount of pain.) Cooperative and A&O x 3.\n\nID-Afebrile, Keflex 500mg QID for 7 days\n\nSkin- 4 staples in scalp. CD&I, not s/s of infection or drainage. R femoral dressing clean and dry, no sign of hemotoma. LUQ dressing soaked with betadine, cov'd with gauze and transparent dressing. Coccyx area red, washed with soap and H2O, frequent turns.\n\n friend visit and brother call.\n\nA/P: 54yo female with cardiomyopathy s/p ICD generator change . Monitor hemodynamics, frequent position changes to prevent skin impairments. Manage Pain with meds and alternative options.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2166-09-07 00:00:00.000","description":"Report","row_id":1569286,"text":"CCU Progress Note:\n\nS- \"I feel sick to my stomach!\"\n\nO- see flowsheet for all objective data.\n\ncv- Tele: AV paced rhythm- rate 80- b/p 100-108/63-78- dig level 4.1 this am- Hct 30.6- K 3.6 KCL 40meq given- Mg 1.9 Mg sulfate 1gm given-\nheparin gtt @ 700u/hr- PTT 63.6- plan is for battery change tomorrow.\n\nresp- In O2 2L via NC- lung sounds with bibasilar crackles- RR 18-22- very SOB with exertion- SPO2 97-99%- sats drop to 91% on room air.\n\nneuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.\n\ngi- abd soft (+) bowel sounds- taking Po fair- c/o nausea this afternoon- tylenol held @ 1600 due to nausea- no BM today- LFT's added to am labs- results pending- NPO after 12am for EP lab.\n\ngu- voiding conc amber colored urine- incontinent lg amt of urine while napping- U/O essentially = today- BUN 35 Crea 1.4\n\ncomfort- c/o severe back pain with movement- morphine sulfate 15mg Po q12hr & tylenol 1000mg Po q8hr working well controlling pain overall- back care given PRN.\n\nA- Pre-op for battery change tomorrow- seen by anesthesia this am.\n\nP- monitor vs, lung sounds, I&O and labs- ? heparin gtt INR needs to be < 1.8 in am- offer emotional support to Pt & family- keep them updated on plan of care.\n\naddendum: Pt c/o of CP @ 1800- on pain scale- EKG done- paced rhythm- Ntg Sl X2 given with total relief of pain- vss.\n\n\n"},{"category":"Nursing/other","chartdate":"2166-09-08 00:00:00.000","description":"Report","row_id":1569287,"text":"CCU NURSING PROGRESS NOTE\nS:\"MY BACK IS SORE\"\nO:PT END STAGE HEART FAILURE, ICD BATTERY REPLACEMENT ON HOLD. PT W/ SEVERE DYSPNEA ON EXERTION. SATS REMAIN >95%. LUNGS W/ BIB CRACKLES. EXTREMITIES COLD AND MOTTLED, NOW COOL AND W/SLT COLOR IMPROVEMENT.\nPT W/ A GREY HUE TO GENERAL COLORING. NAUSEA ON AND OFF THROUGH THE NOC. TOL LIQ AND MEDS. VOIDING ON BED PAN. PT RECEIVED ATIVAN FOR ANXIETY W/ GOOD EFFECT. AMBIEN FOR SLEEP W/ SOME EFFECT.\nA/P:PT PRESENTLY FULL CODE, DISCUSS FINAL CODE STATUS IF PT WILL NOTE BE GOING TO EP LAB. SEE FLOW SHEET FOR ADDITIONAL INFORMATION.\n"},{"category":"Nursing/other","chartdate":"2166-09-08 00:00:00.000","description":"Report","row_id":1569288,"text":"CCU NSG NOTE: ALT IN CV:CARDIOMYOPATHY/SP VF ARREST\nS: \"I'd rather go tomorrow. I'm now hungry for the first time\"\nTHis 59y old woman with hx of cardiomyopathy with EF ~15% with -V pacer and AICD was transfered from OSH .She went after fall at home with dig toxicity and increasing creatinine. She received 4 vials of digibind after VF arrest and slow response from AICD. ONce arriving here AICD reprogramed to shock at lower rate. ACE and lasix stopped.\nO: For complete VS see CCU flow sheet.\nID: Pt remains afebrile. UA neg for infection.\nCV: No episodes of chest discomfort today. She remains AV paced at a rate of 60s. No ectopy seen. EP should increase her hr, but have not yet done it. It was decided to change her generator tomorrow. Dig, lasix and ace continue to be held. Hydralizine was increased to 20mg . AM Ptt was subtheraputic and she was bolused with 1000u and drip increased to 900u/hr. Repeat PTT theraputic at 67.9. Heparin should be stopped at 4am in preparation for pacer generator change tomorrow. Trial was lying flat on usual analgesic-nothing aditional was successful. She had no sob lying flat.\nRESP: Pt has BBR. She had no C/O of dyspnea. She is sating 98-100% on 3.5 L NP.\nGI: THough c/o of baseline mild nausea she ate well at lunch and dinner. No BM.\nRENAL: Creatinine continues to decrease to 1.2 today. Urine output is poor and urine appears very consentrated. She is considered to be uvolemic at this point. She is ~700cc pos for the day. and 1900cc pos LOS.\nSKIN: She has multiple eccomotic areas on her arms and legs. She has two small stage one skin tears to left and right of coccyx. Thin duoderm applied.\nCOMFORT: Pt conts on standing MS SR 15mg and 1000mg tylenol Q 8 and occasional percocette which is giving fair relief. She appears comfortable if not being moved. She has been able to sleep.\nA: Stable/awaiting replacement of pacer generated.\nP: Shut off heparin at 4am . Continue with standing back pain regimine. Monitor for heart failure. Keep careful I & O.\n"},{"category":"Nursing/other","chartdate":"2166-09-06 00:00:00.000","description":"Report","row_id":1569284,"text":"Nursing Progress Note 7am-7pm\nS: The pain in my back radiates down my legs and they feel numb.\n\nO: Please see carevue for complete objective data.\n\nCV-HR=80 AV paced, no ectopy. BP-100-110/69-73. Started Hydralazine, tolerating well. PTT-113.9, reduced heparin to 900 units/hour. EP requesting a goal PTT of 60-80 on heparin. PTT redrawn at 1630, results pending. Scheduled for ICD battery change on \n\nRESP- RR=14-22, varies on pain level and activity. Lungs clear with bilateral base crackles. O2 stopped after rounds and sats remained 92 and above. After CT scan sats dropped to high 80's. Gave O2 2L via nc and sats increased to high 90's. Pt remains on 1L nc.\n\nGI/GU- No BM, BS present x 4, abd soft. Voiding dark yellow urine via bedpan. Foley cath is not appropriate d/t pending procedure on Mon. Voided only 95cc for this shift. + 1.1L DC'd 1500cc restrictive diet. Gave 250 NS bolus for potential of being dry. Need UA on next void.\n\nSkin- PIV 22G in left hand, WNL. Impaired skin on coccyx area. Cov'd with duoderm, CD&I. Stitches on scalp due to fall, clean and intact.\n\nNeuro- hx of depression, taking zoloft and ativan. No s/s of confusion. A&O x3. Radiating pain from back down the legs. Legs are tingling and numb and has difficulty moving legs. Had pain consult and new meds prescribed. Heating pad applied to back, and pt expressed relief. CT scan done to locate pain source.\n\nSocial- very pleasant and cooperative. 2 nieces came to visitand made phone calls.\n\nA/P: 59 yo female with end satge cardiomyopathy, EF 15-20%, s/p CABG and MI with LAD dissection. Admitted for GI distress, N/V, dig tox, and episodes of VF/VT relieved by ICD. ICD reprogrammed and set for generator replacement on mon .\n\nMonitor VS and lab values to adjust heparin according to goal PTT 60-80. Attempt to wean off O2, keeping sats above 93%. Assess and manage pain with appropriate therapies.\n"},{"category":"Nursing/other","chartdate":"2166-09-07 00:00:00.000","description":"Report","row_id":1569285,"text":"ccu npn 7p-7a\nS:\"I'm tired tonight.\"\nO: Please see carevue for VS and objective data\nCVS: Hemodynamically stable with HR 80 AVpaced, rare PVC noted. BP ranges 100-117/50-70, tolerating po Hydralazine. IV Heparin at 800u/hour with repeat PTT 81.7, decreased to 700u/hour at 0000, to have PTT/PT, INR with am labs.\nResp; Sats 95-99% on 2l n/c. Lungs clear, diminished right base, left with fine rales.\nGI:GU: Taking po's, no N/V. Abdomen soft with active bowel sounds, no stool this shift. Voiding qs clear, yellow urine via bedpan. Urine lytes sent as ordered, pnd. Total I/O remains positive.\nID: afebrile\nNeuro: Pt. A/A/0x3, pleasant and cooperative, appreciative of care. Conts with back and leg pain, slightly improved with heating pad prn, Morphine sulfate SR 15mg q12hours and tylenol 1000mg po q 8hours. Given backrub and frequent repositioned. Slept well at intervals.\nA: Hemodynamically stable, no sign. vea noted, awaiting battery change by EP.\nP: Cont to monitor hemodynamics, rhythm, maintain IV Heparin with goal PTT 60-80, follow up with am labs. Plan for battery change with EP. Cont to assess Pt's response to pain management. Comfort and emotional support to Pt. and family.\n"},{"category":"ECG","chartdate":"2166-09-10 00:00:00.000","description":"Report","row_id":283830,"text":"A-V paced rhythm. Since the previous tracing of no significant change.\n\n"},{"category":"ECG","chartdate":"2166-09-07 00:00:00.000","description":"Report","row_id":283831,"text":"A-V paced rhythm\nPacemaker rhythm - no further analysis\nSince previous tracing, no significant change\n\n"},{"category":"ECG","chartdate":"2166-09-09 00:00:00.000","description":"Report","row_id":283832,"text":"A-V sequential paced rhythm\nNo change from previous\n\n"},{"category":"ECG","chartdate":"2166-09-08 00:00:00.000","description":"Report","row_id":283833,"text":"A-V paced rhythm. Since the previous tracing of no significant change.\n\n"},{"category":"ECG","chartdate":"2166-09-06 00:00:00.000","description":"Report","row_id":283834,"text":"A-V sequential paced rhythm\nCompared to previous tracing, no change\n\n"},{"category":"ECG","chartdate":"2166-09-07 00:00:00.000","description":"Report","row_id":283835,"text":"A-V sequential paced rhythm\nSince previous tracing, no significant change\n\n"},{"category":"ECG","chartdate":"2166-09-05 00:00:00.000","description":"Report","row_id":283836,"text":"A-V sequentially paced rhythm, new compared to the previous tracing of .\nOtherwise, no diagnostic interim change.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569280,\n \"text\": \"CCU NSG PROGRESS NOTE/ACCEPTANCE NOTE 3:30-7A/ VT\\n\\n\\nS- \\\" MY BACK IS REALLY HURTING..BEFORE I FELL DOWN AT HOME, IT'S BEEN HURTING, MAYBE - I DON'T REMEMBER.. I ONLY GOT HOME A COUPLE OF WEEKS AGO...\\\"\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\nSEE NSG FHPA AND CCU TEAM NOTES FOR DETAILS R/T HPI/PMH.\\n\\nTHIS IS A 60 YR OLD PT WITH EXTENSIVE PMH MOST SIG FOR CM, CRI, CHF/CAD WHO WAS FOUND FALLEN AT HOME BY VNA AND BROUGHT TO ER FOR HEAD LACERATION WHICH WAS STITCHED/STAPLED- SHE WAS SENT TO CT WHICH WAS (-) FOR BLEED BY REPORT. ON ROUTE TO STEP DOWN FLOOR AROUND MN, HAD WITNESSED ARREST- GASPED, LOC AND REQUIRED CPR/AMBU. ICD FIRED \\\" AFTER 1 TO 1.5 MINUTES\\\" AND PT BACK IN PACED AND ALERT/ORIENTED. REPEAT EPISODE IN ER ABOUT 1-1.5 HOUR LATER WITH THE SAME PT \\\"FINE\\\" ONCE RESTORED WITH OWN ICD FIRING.\\nDECIDED TO TRANSFER TO CCU.\\n\\nPT 3:30A- BY REPORT OF PT HAD VT ARREST AGAIN IN AMBULANCE AND WAS SHOCKED/DEFIB WITH 120 J BY PARAMEDICS AND RESTORED TO PACED WITHOUT LOC OR NEED FOR AMBU/CPR.\\nTO CCU VSS.\\n\\n PT WITH V PACING- 80'S, INFREQ VEA NOTED. ALL LYTES CHECKED ON ARRIVAL -WNL.K- 4.4, MG-1.9,FREE CA- 1.15.\\nBP- 106/72- 119/62 VIA DYNAMAP.\\n12L EKG OBTAINED- 100% PACED.\\nEP FELLOW CALLED AND IS CURRENTLY REVIEWING PT CASE AND TO INTEROGATE PACER/ICD. PT PUT ON /DEFIB CURRENTLY.\\nINR CURRENTLY 1.5- TO DISCUSS STARTING HEPARIN TO KEEP THERAPEUTIC IN LOW EF STATE, NO COUMADIN IN CASE OF NEED FOR INVASIVE PROCEDURE THIS AM.\\nCPK THIS AM (-) AS WELL.\\n\\n PT ARRIVED ON 100% NR- WEANED TO 40% FACE TENT- O2 SATS >97%\\nCOMFORTABLE- BASE CX LEFT/RT.\\nNO ISSUES CURRENTLY\\n\\nID- AFEBRILE\\n\\nGU- NO FOLEY CATH CURRENTLY. VOIDED 50CC X 1.\\nAM CREATININE 1.6 UP FROM 0.7.\\nRECEIVED 500CC NS AT OSH.\\n\\nGI- NO N/V CURRENTLY- STATES HAS NOT BEEN WELL FOR PAST SEVERAL DAYS.\\n(+) DIG TOXIC. (+) BOWEL SOUNDS.\\n\\nMS-PT ALERT , ORIENTED, DIFFICULT TO FOLLOW HISTORY/STORY AT TIMES.\\nSTATES SHE HAS NO SOB, WANTING PAIN MED FOR \\\"BACK PAIN\\\" - REPOSITIONED AND ATTEMPTED BACK RUB , ETC.\\nRECEIVING 0.5 MSO4- SLEEPING CURRENTLY\\n\\nSTATES HEALTH CARE PROXY- - PH- \\n\\nLINES- #22 RT HAND IV ACCESS.\\n\\nA/ PT ADMITTED TO CCU FOR W/U OF POSSIBLE ICD MALFUNCTION/DELAY AND S/P SEVERAL EPISODES PRESUMED VT\\n\\nCONTINUE TO MONITOR PT , ON STANDBY.\\nAWAIT PACER/ICD INTEROGATION AND PLAN FROM EP FELLOW.\\nTO RESTART HEPARIN AND CV MEDS THIS AM.\\nFOLLOW RENAL FX ? WET/DRY AND POSSIBLE NEED FOR MORE IVF.\\nWEAN TENT TO NP AS ABLE THIS AM.\\nCONTINUE TO PROVIDE INFO FOR PT, PLAN OF CARE AS WELL AS COMFORT/MEDS AS NEEDED. CALL TO TO OBTAIN CT REPORT.\\nHOLD DIG.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569281,\n \"text\": \"CCU NPN 7a-7p\\nS: \\\"My back and legs really hurt...the pain is always kinda there.\\\"\\n\\nO: Please see careview admission note and flowsheet for VS and additional data.\\n\\n\\nCV: Pt HR 80 v paced, Dr. from EP up to interrogate pacer this am, see note in chart, plan for pt to have ICD battery change on Monday. NBP 97-117/62-72, MAPs>74. Pt bilateral pedal pulses palp, pt with bilateral LE edema +. No VT this shift. Pt started on heparin gtt at 900 units/hr, PTT subtherapeutic at 41, Heparin gtt increased to 1000 units/hr at 1650, PTT to be drawn this eve. Pt CK (CPK) 29 (was 33), troponin 0.06 (was 0.08). Dr. in to speak with pt regarding code status, per Dr. and order pt is but otherwise full code.\\n\\nResp: Received pt on face tent 40% with rr teens, O2 sats 100%-> pt weaned to 2L n.c with RR 16-23 (in 20's with pt c/o pain and after movement/turning in bed), O2 sats 99-100%. Pt denies SOB, appears comfortable at rest. Pt LS clear at apices to coarse at bases this am, pt LS clear this afternoon.\\n\\nNeuro: Pt alert and oriented x 3-> pt has some difficulty recalling exact date, but aware of Month, year and Day. Pt pleasant cooperative with care. Pt asking appropriate questions regarding care. Pt MAE, follows commands, appears to have good strength bilateral , pt moves bilateral slightly with difficulty, pt states d/t pain, pt able to wiggle toes, bend knees slightly,+sensation. Pt with c/o back/leg pain out of 1 to 10 pain scale, percocet given with minimal relief. Pt to L and T spine Xray this afternoon, results pending. Pt dozing intermittently, engaging in conversation at times.\\n\\nGI/GU: Pt abd soft, + BS x 4, no stool this shift, pt NPO this am-> changed to heart healthy diet with 1500 mL fluid restriction, pt ate some of dinner, pt compliant with fluid restriction, pt denies nausea. Pt voided x 3 via bedpan. Pt bladder slightly firm, pt denies pain with palpation, denies difficulty voiding, Dr. aware, obtain U&A when pt voids this eve. Per CCU Team, pt fluid goal of even, per Dr. , gentle hydration through PO fluids.\\n\\nID: Pt afebrile.\\n\\nSkin: Pt skin with some brusing/ecchymosis on legs, pt with sm 1cm x1cm pressure sore/ulceration on R buttock cheek, duoderm applied.\\n\\nSocial: Pt (whom pt states and states is HCP-no form in chart- asked by Dr. to bring in copy of form), called and spoke with RN x 3 this am. Pt changed prior code status (per HCP , pt had previous documented wishes DNR/DNI) pt verbalized wishes to have CPR/external defibrillation but does not wish to be intubted per Dr. . Pt brother called and spoke with pt this afternoon.\\n\\nA/P: 59 y/o female pacer/ICD interrogated, pt code status DNI but otherwise full code, pacer to T&L spine Xray this afternoon. As discussed per CCU Team rounds, continue to monitor pt hemodyanmics, rhythm, cont to monitor pt resp status-fluid I & O's, ? obtain U&A this eve, cont to follow. Continue to monitor PTT, lytes. Continue to p\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569282,\n \"text\": \"CCU NPN 7a-7p\\n(Continued)\\nrovide emotional support to pt and family.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569283,\n \"text\": \"ccu npn 7p-7a\\nS:\\\"I've had this back and leg pain for more than 2 weeks, I think its from being in a hospital bed for so long.\\\"\\nO: Please see carevue for VS and objective data\\nCVS: Hemodynamically stable with HR 80, initially vpaced, AVpaced most of the night. Isolated PVC's noted. BP ranges 90's-111/50-70. IV Heparin at 1000 units/hour, PTT 92.2.\\nResp: Sats 97-100% on 2L n/c. Lungs clear to diminished bases with fine rales in left base. Pt. denies SOB.\\nID: Afebrile\\nGI:GU: Taking po's, no N/V. Abdomen soft with active bowel sounds, no stool this shift. Voiding qs clear, yellow urine via bedpan. U/A sent as urine has strong odor. pnd results. Total I/O approx. even for day.\\nSkin: Head s/p laceration from fall at home PTA, D/I with 4 staples. No drainage or bleeding noted. Duoderm from previous shift intact on buttocks from pressure sore, Pt. states she has had PTA.\\nNeuro: Pt. A/A/0X3, able to state name, place and time and events leading up to hospitalization including her Pmhx. Pleasant and cooperative. Conversing easily with RN, appreciative of care. Continues with moderate to severe back and leg pain, which she states she has had for 2 weeks which she attributes to prolonged bedrest. Awaiting results of xrays taken previous shift. Medicated with prn Percocet, backrubs and frequent position changes. Slept at short intervals after 5mg po Ambien. CCU MDs, Dr. , spoke to , earlier this eve.\\nA: Hemodynamically stable, NO NSVT, VT/VFIB\\nP: Cont. to monitor hemodynamics, monitor rhythm, maintain IV Heparin, follow up with am labs. Repeat Dig.level. Follow up with U/A, XRAY results. Prn Perocet. Comfort and emotional support to Pt. and family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569289,\n \"text\": \"CCU NPN 7p-7a\\nS: My back really hurts when I move.\\\"\\n\\nO: Please see careview for VS and additional data.\\n\\nCV: Pt HR 60 AVpaced, NBP 111-136/61-81, bilateral pedal and radial pulses palp. Received pt on Heparin gtt 900 units/hr, Heparin gtt dc'd at 0400 for ICD battery change/generator change this am. Am labs sent-> Hct 31, K 4.8, Na 131, PTT 63.7, INR 1.9-> Dr. aware.\\n\\nResp: Pt LS clear at apices to crackles at bases, pt RR teens to mid 20's with exertion, O2 sats 98-100% on 3 L n.c. Pt SOB with movement/turning, pt RR decreases to teens with rest.\\n\\nGI/GU: Pt abd soft, +BS x 4, no stool this shift, pt NPO after midnoc for planned ICD battery change this am. Pt voiding via bedpan, pt with poor u/o-Dr. aware, see flowsheet. Pt +753 cc at midnoc, +.7 cc LOS. AM BUN 32, creat 1.2.\\n\\nNeuro: Pt alert and oriented x 3, pleasant and cooperative with care, pt conversing appropriately. Pt with c/o back pain, pain increased with movement, pt repositioned and PO morphine sulfate and tylenol given as ordered with some relief. Pt took 5 mg ambien for sleep with good effect.\\n\\nID: Pt afebrile, WBC 9.4.\\n\\nSkin: pt with mult areas of brusing/ecchymosis noted, duoderm intact on coccyx, site not visualized. Pt staples on head CDI.\\n\\nSocial: Pt received several phone calls overnoc.\\n\\nA/P: 54 y/o female awaiting ICD battery change/generator replacement in EP today, remains hemodynamically stable overnoc. Continue to monitor pt hemodynamics, cont to monitor pt resp status, u/o lytes-cont to update CCU Team. Conntinue to provide emotional support to pt. Awaiting further plan of care from CCU Team.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569290,\n \"text\": \"CCU NGS NOTE: ALT IN CV/SP PACER GENERATOR REVISION\\nS: \\\"That was long\\\"\\nO: For complete VS see CCU flow sheet. This 59y old woman with long hx of cardiomypathy with -v pacer with AICD was admitted to OSH after a fall at home. She was found to be dig toxic and had 2 episodes of VF which were not shocked until they converted to VF. She received digibind and was transfered to . She was shocked by EMTs in route for more VT. Upon arriving AICD was reprogramed to shock at lower HR.\\nSHe has had no further episodes of VT. Captopril with rising creatine is supposed to be the source of dig toxicity.\\nCV: Pt has been pain free. She went to EP today at 1030 for generator replace. THey put in temporary wire in preparation for change. All present caridac wires were in good operating condition so only generator was changed. HR on pacer was increased from 60 to 70 in DDD mode. She has therapies for VF, fast and slow VT. She received 1gm kefzol at 2pm and will cont that Q8. She received 2.5 of versed and 75 fentanyl. Pacing wire was removed from groin and she returned to CCU at 1630. HR now 70 AV paced with BP in 1-teens to 120/60. Her groin has very slight ooze, all pulses palpable. Dressing on L chest is dry and in tact. Heparin was d/c at 4am and as per EP should not be restarted until am. THek wrote to start coumadin in am.\\nRESP: She is sating 100% on 4L NP, but drops to high 80s on RA. Decreased BS at bases.\\nGI: Was NPO until she returned and ate fair dinner.\\nRENAL: She voided in BP which spilled mod amt prior to leaving. She has not voided since. She tried upon returning but was unable to. Will try again\\nSKIN: She has 2 very small skin tears on either side of coccyx. Duoderm replaced today. They seem to be healing. SHe has multiple eccymotic areas.\\nMS/COMFORT: Pt was quite groggy upon returning. She had not received usual morphine SR 15mg at noon. She did get tylenol and percocette at 1730. She has usual discomfort with position changes, but appears comfortable when lying still.\\nA: Successful generator replacement/DTV\\nP: Monitor urine output closely. SHe is ~2 liters pos LOS. She has not received her usual lasix 100mg since admit so monitor resp status closely. REstrart morphine SR as needed. Do not restart anticoagulation until am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569291,\n \"text\": \"CCU NPN 7p-7a\\nS: \\\"Is it time for more pain medicine...when will this pain get better?\\\"\\n\\nO: 54 y/o female with cardiomyopathy, EF 15-20%, PAF, see admit note for additional hx, pt with -v pacer/AICD who fell at home and was admitted to OSH. While at OSH,head CT neg for bleed, pt found to be dig toxic, rec'd digibind, pt into VT/VF x 2 while at OSH-pt requiring CPR, ICD fired after approx 1.5 mins, VS restored, pt in ambulance to , pt into VT, shocked/defib and rhythm restored. Pt to on , pacer interogated, pacer in need of battery/generator change, generator change on , please see careview for VS and additional data.\\n\\nCV: Pt AV paced HR 70 DDD mode, NBP 103-130/66-80, pt down to EP during previous shift for generator change, dsd over site, scant amt of bld noted on dsg, betadyne noted, dsg unchanged throghout shift. R groin site CDI, area soft, no hematoma noted. Pt bilateral radial and pedal pulses palp, bilateral feet and hands cool. Am labs to be drawn. Heparin/coumadin to be started later this am, check with CCU Team/HO.\\n\\nResp: Pt LS clear at apices with fine crackles noted bilateral bases. Pt RR teens to 20's, pt SOB/RR increasing with movement/turning, RR teens at rest, O2 sats 95-100% on 2 L n.c.\\n\\nNeuro: Pt alert and oriented x 3, pt pleasant and cooperative with care, pt conversing and appropriate questions regarding care. Pt MAE, pt moves bilateral LE minimally, + sensation. Pt with c/o back/leg pain, PO morphine sulfate SR 15 mg and acetaminophen 1000 mg given, pt position change with some relief. Pt with some c/o discomfort when moving L arm-pt reminded not to move left arm.\\n\\nID: Pt afebrile, pt cont on Keflex 500 mg Q6 H for 7 days.\\n\\nGI/GU: Pt abd soft, + BS x 4, no stool this shift. Pt voiding via bedpan, approx 230 cc of measured u/o from -0300, pt with lg amt spilled x 1 and sm amt spilled x 1. Pt +730 cc at midnoc, +2689.7 cc LOS. AM BUN and creat to be drawn.\\n\\nSocial: Pt received one phone call last eve.\\n\\nA/P: 54 y/o female hemodynamically stable s/p battery/generator change biv pacer/ICD. Continue to monitor pt hemodynamics, rhythm, pacer site and groin site, start PO warfarin/? heparin-check with HO. Continue to monitor pt resp status, fluid status, u/o-pt has not rec'd home lasix dose since admission. Continue to monitor pt temps, lytes. Continue to provide emotional support to pt, awaiting further plan of care from CCU Team.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569292,\n \"text\": \"Nursing Progress Note 7am-7pm\\nS: \\\"Even if they say I have to move today, I don't think I am going to!\\\"\\n\\nO: Please see carevue for complete objective data.\\n\\nCV- S/P generator change, AV paced, HR-70, BP 108-125/56-87. started Heparin drip at 0945, then dc'd hep drip at 1100. Set to start coumadin tonight. dorsal/tibial pulses palp.\\n\\nResp- c/o SOB since procedure on Mon. Sats-98% and higher on 2L nc, 92% and up on Room air. RR-16-21, regular, and LS clear with diminished bases.\\n\\nGI/GU- BS present and abd soft. No BM this shift. Gave lasix 100 mg to diurese, but diff to evaluate progress b/c of ocas. incontinence of urine. I&O's not exact due to leaks. ~ -120.0 for the shift\\n\\nNeuro-continuing pain throughout back and legs. gave scheduled and PRN pain meds and repositioned. Some relief achieved but not much. increasing negative attitude about recovery, (i.e. not wanting rehab, depressed about amount of pain.) Cooperative and A&O x 3.\\n\\nID-Afebrile, Keflex 500mg QID for 7 days\\n\\nSkin- 4 staples in scalp. CD&I, not s/s of infection or drainage. R femoral dressing clean and dry, no sign of hemotoma. LUQ dressing soaked with betadine, cov'd with gauze and transparent dressing. Coccyx area red, washed with soap and H2O, frequent turns.\\n\\n friend visit and brother call.\\n\\nA/P: 54yo female with cardiomyopathy s/p ICD generator change . Monitor hemodynamics, frequent position changes to prevent skin impairments. Manage Pain with meds and alternative options.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569286,\n \"text\": \"CCU Progress Note:\\n\\nS- \\\"I feel sick to my stomach!\\\"\\n\\nO- see flowsheet for all objective data.\\n\\ncv- Tele: AV paced rhythm- rate 80- b/p 100-108/63-78- dig level 4.1 this am- Hct 30.6- K 3.6 KCL 40meq given- Mg 1.9 Mg sulfate 1gm given-\\nheparin gtt @ 700u/hr- PTT 63.6- plan is for battery change tomorrow.\\n\\nresp- In O2 2L via NC- lung sounds with bibasilar crackles- RR 18-22- very SOB with exertion- SPO2 97-99%- sats drop to 91% on room air.\\n\\nneuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.\\n\\ngi- abd soft (+) bowel sounds- taking Po fair- c/o nausea this afternoon- tylenol held @ 1600 due to nausea- no BM today- LFT's added to am labs- results pending- NPO after 12am for EP lab.\\n\\ngu- voiding conc amber colored urine- incontinent lg amt of urine while napping- U/O essentially = today- BUN 35 Crea 1.4\\n\\ncomfort- c/o severe back pain with movement- morphine sulfate 15mg Po q12hr & tylenol 1000mg Po q8hr working well controlling pain overall- back care given PRN.\\n\\nA- Pre-op for battery change tomorrow- seen by anesthesia this am.\\n\\nP- monitor vs, lung sounds, I&O and labs- ? heparin gtt INR needs to be < 1.8 in am- offer emotional support to Pt & family- keep them updated on plan of care.\\n\\naddendum: Pt c/o of CP @ 1800- on pain scale- EKG done- paced rhythm- Ntg Sl X2 given with total relief of pain- vss.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569287,\n \"text\": \"CCU NURSING PROGRESS NOTE\\nS:\\\"MY BACK IS SORE\\\"\\nO:PT END STAGE HEART FAILURE, ICD BATTERY REPLACEMENT ON HOLD. PT W/ SEVERE DYSPNEA ON EXERTION. SATS REMAIN >95%. LUNGS W/ BIB CRACKLES. EXTREMITIES COLD AND MOTTLED, NOW COOL AND W/SLT COLOR IMPROVEMENT.\\nPT W/ A GREY HUE TO GENERAL COLORING. NAUSEA ON AND OFF THROUGH THE NOC. TOL LIQ AND MEDS. VOIDING ON BED PAN. PT RECEIVED ATIVAN FOR ANXIETY W/ GOOD EFFECT. AMBIEN FOR SLEEP W/ SOME EFFECT.\\nA/P:PT PRESENTLY FULL CODE, DISCUSS FINAL CODE STATUS IF PT WILL NOTE BE GOING TO EP LAB. SEE FLOW SHEET FOR ADDITIONAL INFORMATION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569288,\n \"text\": \"CCU NSG NOTE: ALT IN CV:CARDIOMYOPATHY/SP VF ARREST\\nS: \\\"I'd rather go tomorrow. I'm now hungry for the first time\\\"\\nTHis 59y old woman with hx of cardiomyopathy with EF ~15% with -V pacer and AICD was transfered from OSH .She went after fall at home with dig toxicity and increasing creatinine. She received 4 vials of digibind after VF arrest and slow response from AICD. ONce arriving here AICD reprogramed to shock at lower rate. ACE and lasix stopped.\\nO: For complete VS see CCU flow sheet.\\nID: Pt remains afebrile. UA neg for infection.\\nCV: No episodes of chest discomfort today. She remains AV paced at a rate of 60s. No ectopy seen. EP should increase her hr, but have not yet done it. It was decided to change her generator tomorrow. Dig, lasix and ace continue to be held. Hydralizine was increased to 20mg . AM Ptt was subtheraputic and she was bolused with 1000u and drip increased to 900u/hr. Repeat PTT theraputic at 67.9. Heparin should be stopped at 4am in preparation for pacer generator change tomorrow. Trial was lying flat on usual analgesic-nothing aditional was successful. She had no sob lying flat.\\nRESP: Pt has BBR. She had no C/O of dyspnea. She is sating 98-100% on 3.5 L NP.\\nGI: THough c/o of baseline mild nausea she ate well at lunch and dinner. No BM.\\nRENAL: Creatinine continues to decrease to 1.2 today. Urine output is poor and urine appears very consentrated. She is considered to be uvolemic at this point. She is ~700cc pos for the day. and 1900cc pos LOS.\\nSKIN: She has multiple eccomotic areas on her arms and legs. She has two small stage one skin tears to left and right of coccyx. Thin duoderm applied.\\nCOMFORT: Pt conts on standing MS SR 15mg and 1000mg tylenol Q 8 and occasional percocette which is giving fair relief. She appears comfortable if not being moved. She has been able to sleep.\\nA: Stable/awaiting replacement of pacer generated.\\nP: Shut off heparin at 4am . Continue with standing back pain regimine. Monitor for heart failure. Keep careful I & O.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569284,\n \"text\": \"Nursing Progress Note 7am-7pm\\nS: The pain in my back radiates down my legs and they feel numb.\\n\\nO: Please see carevue for complete objective data.\\n\\nCV-HR=80 AV paced, no ectopy. BP-100-110/69-73. Started Hydralazine, tolerating well. PTT-113.9, reduced heparin to 900 units/hour. EP requesting a goal PTT of 60-80 on heparin. PTT redrawn at 1630, results pending. Scheduled for ICD battery change on \\n\\nRESP- RR=14-22, varies on pain level and activity. Lungs clear with bilateral base crackles. O2 stopped after rounds and sats remained 92 and above. After CT scan sats dropped to high 80's. Gave O2 2L via nc and sats increased to high 90's. Pt remains on 1L nc.\\n\\nGI/GU- No BM, BS present x 4, abd soft. Voiding dark yellow urine via bedpan. Foley cath is not appropriate d/t pending procedure on Mon. Voided only 95cc for this shift. + 1.1L DC'd 1500cc restrictive diet. Gave 250 NS bolus for potential of being dry. Need UA on next void.\\n\\nSkin- PIV 22G in left hand, WNL. Impaired skin on coccyx area. Cov'd with duoderm, CD&I. Stitches on scalp due to fall, clean and intact.\\n\\nNeuro- hx of depression, taking zoloft and ativan. No s/s of confusion. A&O x3. Radiating pain from back down the legs. Legs are tingling and numb and has difficulty moving legs. Had pain consult and new meds prescribed. Heating pad applied to back, and pt expressed relief. CT scan done to locate pain source.\\n\\nSocial- very pleasant and cooperative. 2 nieces came to visitand made phone calls.\\n\\nA/P: 59 yo female with end satge cardiomyopathy, EF 15-20%, s/p CABG and MI with LAD dissection. Admitted for GI distress, N/V, dig tox, and episodes of VF/VT relieved by ICD. ICD reprogrammed and set for generator replacement on mon .\\n\\nMonitor VS and lab values to adjust heparin according to goal PTT 60-80. Attempt to wean off O2, keeping sats above 93%. Assess and manage pain with appropriate therapies.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1569285,\n \"text\": \"ccu npn 7p-7a\\nS:\\\"I'm tired tonight.\\\"\\nO: Please see carevue for VS and objective data\\nCVS: Hemodynamically stable with HR 80 AVpaced, rare PVC noted. BP ranges 100-117/50-70, tolerating po Hydralazine. IV Heparin at 800u/hour with repeat PTT 81.7, decreased to 700u/hour at 0000, to have PTT/PT, INR with am labs.\\nResp; Sats 95-99% on 2l n/c. Lungs clear, diminished right base, left with fine rales.\\nGI:GU: Taking po's, no N/V. Abdomen soft with active bowel sounds, no stool this shift. Voiding qs clear, yellow urine via bedpan. Urine lytes sent as ordered, pnd. Total I/O remains positive.\\nID: afebrile\\nNeuro: Pt. A/A/0x3, pleasant and cooperative, appreciative of care. Conts with back and leg pain, slightly improved with heating pad prn, Morphine sulfate SR 15mg q12hours and tylenol 1000mg po q 8hours. Given backrub and frequent repositioned. Slept well at intervals.\\nA: Hemodynamically stable, no sign. vea noted, awaiting battery change by EP.\\nP: Cont to monitor hemodynamics, rhythm, maintain IV Heparin with goal PTT 60-80, follow up with am labs. Plan for battery change with EP. Cont to assess Pt's response to pain management. Comfort and emotional support to Pt. and family.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283830,\n \"text\": \"A-V paced rhythm. Since the previous tracing of no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283831,\n \"text\": \"A-V paced rhythm\\nPacemaker rhythm - no further analysis\\nSince previous tracing, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283832,\n \"text\": \"A-V sequential paced rhythm\\nNo change from previous\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283833,\n \"text\": \"A-V paced rhythm. Since the previous tracing of no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283834,\n \"text\": \"A-V sequential paced rhythm\\nCompared to previous tracing, no change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283835,\n \"text\": \"A-V sequential paced rhythm\\nSince previous tracing, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 283836,\n \"text\": \"A-V sequentially paced rhythm, new compared to the previous tracing of .\\nOtherwise, no diagnostic interim change.\\n\\n\"\n }\n]"}}},{"rowIdx":781,"cells":{"subject_id":{"kind":"number","value":17644,"string":"17,644"},"hadm_id":{"kind":"number","value":108088,"string":"108,088"},"target_text":{"kind":"string","value":"The patient was admitted for further surgical therapy of his recurrent rectal cancer. In the operating room, the decision was made to proceed with abdominoperineal resection. The patient seemed to tolerate the procedure well without complication. Postoperatively, the patient was recovering nicely on bedrest until the morning of , postoperative day number two. The patient on postoperative day number two had some mental status changes and was initially somewhat lethargic and became agitated and intermittently violent. The patient became disoriented although he was alert. Initial workup including cardiac and metabolic workups proved to be negative. The patient did have some crackles on physical examination throughout his lung fields. After speaking with the family, the patient had a history of some altered mental status changes preceding a previous episode of pneumonia that he had had. Working diagnosis at that time was pneumonia versus hospital psychosis. The patient's mental status did not improve over the course of the following two days with some intermittent agitation. The patient was medicated with Haldol and Ativan. This had some success. On the evening of postoperative day number four, the patient had an acute episode of respiratory distress and required intubation on the floor. Subsequent to this, the patient was transferred to the Intensive Care Unit for closer monitoring and ventilatory management. In the Intensive Care Unit, the patient did well and was extubated postoperative day number six. The patient was empirically covered for a probable aspiration pneumonia with Levaquin, a seven day course. The patient was transferred back to the floor on postoperative day number six. His mental status was normal at that time. Throughout the rest of his hospital course, the patient did quite well. His diet was advanced as tolerated. The patient was discharged on postoperative day number ten tolerating a regular diet and having regular ostomy output, good pain control on p.o. pain medications."},"extractive_notes_summ":{"kind":"string","value":"There is probable COPD and a persistent small right pleural effusion with associated atelecatasis in the right lower zone, unchanged since the prior film of the same date if allowances are made for technical differences. Right CV line is in distal SVC. Since the previous tracing of ventricular premature beats are seen.TRACING #1 There is haziness of the pulmonary vasculature centrally. Tip of right subclavian cv line is in distal SVC. The cardiomediastinal silhouette is within normal limits. Slight left heart failure is again noted. TECHNIQUE: Noncontrast head CT. Small bilateral pleural effusions and atelectasis right lung base. 3) Mild mucosal thickening of the right ethmoid air cells. There is continued, residual, right mid lung and right lower lobe interstitial pattern. This is most likely due to an intrathoracic goiter. IMPRESSION: 1) Cardiomegaly with CHF. Interval improvement in appearance of right lung, but with residual interstitial patern in right mid lung and right lower lung. Persistent opacity consistent with atelectasis and possible small pleural effusion is present at the right lung base and there is a probable tiny left pleural effusion. Resp. Indeterminate frontal QRS axis. Indeterminate frontal QRS axis. Probable COPD. Sinus rhythm. Sinus rhythm. Sinus rhythm. Minimal blunting of the left costophrenic angle is present. Since the previous tracing of probably nosignificant change.TRACING #3 Lungs clear and decreased at bases. 11:53 AM CHEST (PA & LAT) Clip # Reason: ? Comparison is made to a spot film from chest fluoroscopy dated . PORTABLE AP CHEST: A single AP semiupright view. Extubated after ABG 7.40/52/80. Baseline artifact. Baseline artifact. Currently, low O2 sats. doing well post-ext. The central venous line is again seen with its tip in the right atrium and is in unchanged position. Right bundle-branch block. Right bundle-branch block. Right bundle-branch block. Some ill defined infiltrate is noted in the right lower lobe. The right hemidiaphragm is not well identified and a small right pleural effusion might be present. There is a minimal amount of mucosal thickening within the right ethmoid air cells. Currently hypoxic. 2) Mild brain atrophy and chronic small vessel ischemic changes. There is a low attenuation in the periventricular white matter consistent with chronic small vessel ischemic changes. Rightbundle-branch block. Right subclavian portacath is in upper right atrium. ot HR is 110-140.Resp: pt was tranfered on 2 liters, pt sao2 decreased to 88 and ABG drawn 7.42/53/59/36. 10:53 AM CT HEAD W/O CONTRAST Clip # Reason: PT FOUND UNRESPONSIVE, CHANGE IN MENTAL STATUS, R/O BLEED FINAL REPORT INDICATION: Mental status changes. There has been interval improvement in the appearance of the right lung. There is slight cardiomegaly with pulmonary vascular engorgement and small bilateral pleural effusions consistent with CHF, likely superimposed on background of COPD. Cont. Heart size is borderline for supine technique. Sinus tachycardia. Pt. Pt. Pt. Pt. Sincethe previous tracing of ventricular premature beats are not seen.TRACING #2 The endotracheal tube, the left and right subclavian lines remain in satisfactory and unchanged positions. Overall appearances are essentially unchanged, when compared with prior study of . offered small amount of cl with no signs of aspiration noted.P: Encourage activity, couging/deep breathing, increase activity as tolerated. The ventricles are mildly prominent as well as mild prominence of the sulci consistent with mild brain atrophy. There is cardiomegaly but no definite chf. pt is able to answer questions appropriatly and able to aid in own care.CV: Pt Bp is stable @ 140-130/70-80. effusion ? effusion ? There is narrowing of the trachea in the mid portion. pt PERLA. Since the previous film of the same date, a left subclavian CV line has been introduced with tip overlying proximal SVC. Background emphysema is appreciated. There is cardiomegaly. There is cardiomegaly. review of systems:Neuro: pt is A & O x3, pt is appropriate and MAE x4. A right subclavian central venous line is seen with tip in the right atrium. Cardiomegaly, but no definite pulmonary edema. expectorating moderate amount clear-white sputum. The heart again shows slight left ventricular enlargement and there is some unfolding of the aorta. ?ASPIR.PNA FINAL REPORT CHEST, SINGLE AP FILM. ETT is cm above carina. These findings are consistent with slight left heart failure, unchanged since the prior study. IMPRESSION: There has been slight clearing of the ill defined infiltrate at both lung bases since the prior study. Low QRS voltages in the limb leads.Since the previous tracing of probably no significant change.TRACING #4 Pt denies pain or other distress. 2) Narrowing of the trachea in its mid portion. Pt assisted oob to chair with transfer accomplished with one assist. IMPRESSION: Right subclavian catheter with tip in the right atrium. Respitory hygiene encouraged with pt. The pulmonary vessels show upper zone redistribution and there is some blurring of vascular detail at the bases suggesting slight left heart failure. No congestive heart failure. ET tube is 2 cm above carina."},"n_notes":{"kind":"number","value":14,"string":"14"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2197-11-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":774674,"text":" 11:53 AM\n CHEST (PA & LAT) Clip # \n Reason: ? effusion ? infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p for rectal CA. Currently, low O2 sats.\n REASON FOR THIS EXAMINATION:\n ? effusion ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63 year old man status post for rectal cancer. Currently\n hypoxic.\n\n CHEST X-RAY, PA AND LATERAL: Comparison is made to films of . A right\n subclavian central venous line is seen with tip in the right atrium. There\n has been interval improvement in the appearance of the right lung. There is\n continued, residual, right mid lung and right lower lobe interstitial pattern.\n The cardiomediastinal silhouette is within normal limits. Background\n emphysema is appreciated.\n\n IMPRESSION: Right subclavian catheter with tip in the right atrium. No\n pneumothorax. Interval improvement in appearance of right lung, but with\n residual interstitial patern in right mid lung and right lower lung.\n Recommend further followup to confirm clearing. No congestive heart failure.\n\n"},{"category":"Radiology","chartdate":"2197-11-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":774123,"text":" 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute process, ?pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p for rectal CA, with mental status changes.\n REASON FOR THIS EXAMINATION:\n ?acute process, ?pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63 year old man status post for rectal carcinoma with mental\n status change, evaluate for pneumonia.\n\n CHEST PORTABLE: No prior studies are available for comparison. There is\n cardiomegaly. Comparison is made to a spot film from chest fluoroscopy dated\n . There is cardiomegaly. There is narrowing of the trachea in the mid\n portion. There is upper zone vascular redistribution. There is haziness of\n the pulmonary vasculature centrally. The right hemidiaphragm is not well\n identified and a small right pleural effusion might be present. The central\n venous line is again seen with its tip in the right atrium and is in unchanged\n position.\n\n IMPRESSION:\n\n 1) Cardiomegaly with CHF.\n\n 2) Narrowing of the trachea in its mid portion. This is most likely due to an\n intrathoracic goiter. Comparison with prior outside studies is recommended, if\n available. Otherwise a CT examination of the chest could be performed to\n exclude other etiologies of a mediastinal mass.\n\n"},{"category":"Radiology","chartdate":"2197-11-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1260452,"text":" 8:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP FILM:\n\n HISTORY: Respiratory distress with intubation and line placements.\n\n Since the previous film of the same date, a left subclavian CV line has been\n introduced with tip overlying proximal SVC. Right CV line is in distal SVC.\n ETT is ____ cm above carina. No pneumothorax. There is slight cardiomegaly\n with pulmonary vascular engorgement and small bilateral pleural effusions\n consistent with CHF, likely superimposed on background of COPD.\n\n"},{"category":"Radiology","chartdate":"2197-11-18 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1260416,"text":" 10:53 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: PT FOUND UNRESPONSIVE, CHANGE IN MENTAL STATUS, R/O BLEED\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status changes.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intra axial or extra axial hemorrhage. There is no\n shift of normally midline structures or mass effect. The ventricles are mildly\n prominent as well as mild prominence of the sulci consistent with mild brain\n atrophy. There is a low attenuation in the periventricular white matter\n consistent with chronic small vessel ischemic changes.\n\n On bone windows there are no skull fractures. There is a minimal amount of\n mucosal thickening within the right ethmoid air cells. The orbits are\n unremarkable.\n\n IMPRESSION:\n\n 1) No evidence of intracranial hemorrhage.\n 2) Mild brain atrophy and chronic small vessel ischemic changes.\n 3) Mild mucosal thickening of the right ethmoid air cells.\n\n"},{"category":"Radiology","chartdate":"2197-11-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1260270,"text":" 12:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: Intubation and line placement in patient with recent surgery for\n rectal and colonic cancer and persistent respiratory distress.\n\n ET tube is 2 cm above carina. Tip of right subclavian cv line is in distal\n SVC. No pneumothorax. Heart size is borderline for supine technique. There\n is probable COPD and a persistent small right pleural effusion with\n associated atelecatasis in the right lower zone, unchanged since the prior\n film of the same date if allowances are made for technical differences. No\n pneumothorax.\n\n\n\n"},{"category":"ECG","chartdate":"2197-11-19 00:00:00.000","description":"Report","row_id":176041,"text":"Sinus rhythm. Right bundle-branch block. Low QRS voltages in the limb leads.\nSince the previous tracing of probably no significant change.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2197-11-17 00:00:00.000","description":"Report","row_id":176042,"text":"Baseline artifact. Sinus tachycardia. Indeterminate frontal QRS axis. Right\nbundle-branch block. Since the previous tracing of probably no\nsignificant change.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2197-11-16 00:00:00.000","description":"Report","row_id":176043,"text":"Sinus rhythm. Indeterminate frontal QRS axis. Right bundle-branch block. Since\nthe previous tracing of ventricular premature beats are not seen.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2197-11-15 00:00:00.000","description":"Report","row_id":176044,"text":"Baseline artifact. Sinus rhythm. Frequent multiform ventricular premature\nbeats. Right bundle-branch block. Since the previous tracing of \nventricular premature beats are seen.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2197-11-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1260461,"text":" 7:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Cough and fever. Check for pneumonia.\n\n PORTABLE AP CHEST: A single AP semiupright view. Comparison is made to\n previous films from . The heart again shows slight left ventricular\n enlargement and there is some unfolding of the aorta. The pulmonary vessels\n show upper zone redistribution and there is some blurring of vascular detail\n at the bases suggesting slight left heart failure. Some ill defined\n infiltrate is noted in the right lower lobe. Minimal blunting of the left\n costophrenic angle is present. These findings are consistent with slight left\n heart failure, unchanged since the prior study. The endotracheal tube, the\n left and right subclavian lines remain in satisfactory and unchanged\n positions.\n\n IMPRESSION: There has been slight clearing of the ill defined infiltrate at\n both lung bases since the prior study. The appearances are otherwise\n unchanged. Slight left heart failure is again noted.\n\n"},{"category":"Radiology","chartdate":"2197-11-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1260269,"text":" 12:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB.?ASPIR.PNA\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: Rectal/colon cancer resection with chemo/radiation therapy and line\n placement with persistent respiratory distress.\n\n Right subclavian portacath is in upper right atrium. No pneumothorax. There\n is cardiomegaly but no definite chf. Persistent opacity consistent with\n atelectasis and possible small pleural effusion is present at the right lung\n base and there is a probable tiny left pleural effusion. Overall appearances\n are essentially unchanged, when compared with prior study of .\n\n IMPRESSION: No significant change since prior studies. Cardiomegaly, but no\n definite pulmonary edema. Small bilateral pleural effusions and atelectasis\n right lung base. Probable COPD.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-11-21 00:00:00.000","description":"Report","row_id":1493972,"text":"review of systems:\n\nNeuro: pt is A & O x3, pt is appropriate and MAE x4. pt PERLA. pt is able to answer questions appropriatly and able to aid in own care.\n\nCV: Pt Bp is stable @ 140-130/70-80. pt is in Atrial fib and on a amio gtt @ .5 mg/min and is being transitioned to PO amio. ot HR is 110-140.\n\nResp: pt was tranfered on 2 liters, pt sao2 decreased to 88 and ABG drawn 7.42/53/59/36. pt o2 was increased to 6 liters. pt sao2 increased to 97%, ABG pending. pt is able to give himeslf nebs PRN\n\nGI/GU: pt has good UO per foly cath, pt urine is yellow with seds. pt has had no BM since transfer, and is reciving tube feeds @ 50 cc/hr\n"},{"category":"Nursing/other","chartdate":"2197-11-21 00:00:00.000","description":"Report","row_id":1493973,"text":"D: Please see , MD progress notes/orders for assessment and all pertinent data. Pt. a&o this a.m., team member in on rounds and dc/d NGT. A-line and foley catheter, IVF and amiodorone gtt also discontinued. Pt assisted oob to chair with transfer accomplished with one assist. Pt denies pain or other distress. Pt. converted to SR with occ PAC's from Afib early this morning. 02 decr to 4L nc from 6L with sats ranging 91-94%. Lungs clear and decreased at bases. Respitory hygiene encouraged with pt. expectorating moderate amount clear-white sputum. Pt. with soft abd, +bs and colostomy draining brown liquid stool to gravity in moderate amounts. Stoma is pink. Pt. offered small amount of cl with no signs of aspiration noted.\n\nP: Encourage activity, couging/deep breathing, increase activity as tolerated. Cont. to assess comfort level, vs and 02 sats, notify team of any change. Continue on CL diet and monitor for any signs of aspiration.\n\nR: as above, pt up in chair for most of day with vs/02 sats stable. No signs of aspiration noted, no pain voiced. Pt for transfer to telemetry when bed available.\n"},{"category":"Nursing/other","chartdate":"2197-11-20 00:00:00.000","description":"Report","row_id":1493971,"text":"Resp. Care Note\nPt received intubated and vented on PSV 10 peep 5 35%. Pt weaned to CPAP5 and 35%. Extubated after ABG 7.40/52/80. doing well post-ext. currently on 2L NP with sats 91%. Using MDI's with spacer, excellent technique.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-11-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 774674,\n \"text\": \" 11:53 AM\\n CHEST (PA & LAT) Clip # \\n Reason: ? effusion ? infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man s/p for rectal CA. Currently, low O2 sats.\\n REASON FOR THIS EXAMINATION:\\n ? effusion ? infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 63 year old man status post for rectal cancer. Currently\\n hypoxic.\\n\\n CHEST X-RAY, PA AND LATERAL: Comparison is made to films of . A right\\n subclavian central venous line is seen with tip in the right atrium. There\\n has been interval improvement in the appearance of the right lung. There is\\n continued, residual, right mid lung and right lower lobe interstitial pattern.\\n The cardiomediastinal silhouette is within normal limits. Background\\n emphysema is appreciated.\\n\\n IMPRESSION: Right subclavian catheter with tip in the right atrium. No\\n pneumothorax. Interval improvement in appearance of right lung, but with\\n residual interstitial patern in right mid lung and right lower lung.\\n Recommend further followup to confirm clearing. No congestive heart failure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-11-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 774123,\n \"text\": \" 9:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?acute process, ?pneumonia\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man s/p for rectal CA, with mental status changes.\\n REASON FOR THIS EXAMINATION:\\n ?acute process, ?pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 63 year old man status post for rectal carcinoma with mental\\n status change, evaluate for pneumonia.\\n\\n CHEST PORTABLE: No prior studies are available for comparison. There is\\n cardiomegaly. Comparison is made to a spot film from chest fluoroscopy dated\\n . There is cardiomegaly. There is narrowing of the trachea in the mid\\n portion. There is upper zone vascular redistribution. There is haziness of\\n the pulmonary vasculature centrally. The right hemidiaphragm is not well\\n identified and a small right pleural effusion might be present. The central\\n venous line is again seen with its tip in the right atrium and is in unchanged\\n position.\\n\\n IMPRESSION:\\n\\n 1) Cardiomegaly with CHF.\\n\\n 2) Narrowing of the trachea in its mid portion. This is most likely due to an\\n intrathoracic goiter. Comparison with prior outside studies is recommended, if\\n available. Otherwise a CT examination of the chest could be performed to\\n exclude other etiologies of a mediastinal mass.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-11-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1260452,\n \"text\": \" 8:03 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: SOB\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP FILM:\\n\\n HISTORY: Respiratory distress with intubation and line placements.\\n\\n Since the previous film of the same date, a left subclavian CV line has been\\n introduced with tip overlying proximal SVC. Right CV line is in distal SVC.\\n ETT is ____ cm above carina. No pneumothorax. There is slight cardiomegaly\\n with pulmonary vascular engorgement and small bilateral pleural effusions\\n consistent with CHF, likely superimposed on background of COPD.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-11-18 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1260416,\n \"text\": \" 10:53 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: PT FOUND UNRESPONSIVE, CHANGE IN MENTAL STATUS, R/O BLEED\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Mental status changes.\\n\\n TECHNIQUE: Noncontrast head CT.\\n\\n FINDINGS: There is no intra axial or extra axial hemorrhage. There is no\\n shift of normally midline structures or mass effect. The ventricles are mildly\\n prominent as well as mild prominence of the sulci consistent with mild brain\\n atrophy. There is a low attenuation in the periventricular white matter\\n consistent with chronic small vessel ischemic changes.\\n\\n On bone windows there are no skull fractures. There is a minimal amount of\\n mucosal thickening within the right ethmoid air cells. The orbits are\\n unremarkable.\\n\\n IMPRESSION:\\n\\n 1) No evidence of intracranial hemorrhage.\\n 2) Mild brain atrophy and chronic small vessel ischemic changes.\\n 3) Mild mucosal thickening of the right ethmoid air cells.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-11-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1260270,\n \"text\": \" 12:20 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ETT PLACEMENT\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n CHEST, SINGLE AP FILM.\\n\\n HISTORY: Intubation and line placement in patient with recent surgery for\\n rectal and colonic cancer and persistent respiratory distress.\\n\\n ET tube is 2 cm above carina. Tip of right subclavian cv line is in distal\\n SVC. No pneumothorax. Heart size is borderline for supine technique. There\\n is probable COPD and a persistent small right pleural effusion with\\n associated atelecatasis in the right lower zone, unchanged since the prior\\n film of the same date if allowances are made for technical differences. No\\n pneumothorax.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2197-11-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176041,\n \"text\": \"Sinus rhythm. Right bundle-branch block. Low QRS voltages in the limb leads.\\nSince the previous tracing of probably no significant change.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2197-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176042,\n \"text\": \"Baseline artifact. Sinus tachycardia. Indeterminate frontal QRS axis. Right\\nbundle-branch block. Since the previous tracing of probably no\\nsignificant change.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2197-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176043,\n \"text\": \"Sinus rhythm. Indeterminate frontal QRS axis. Right bundle-branch block. Since\\nthe previous tracing of ventricular premature beats are not seen.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2197-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 176044,\n \"text\": \"Baseline artifact. Sinus rhythm. Frequent multiform ventricular premature\\nbeats. Right bundle-branch block. Since the previous tracing of \\nventricular premature beats are seen.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-11-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1260461,\n \"text\": \" 7:41 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Cough and fever. Check for pneumonia.\\n\\n PORTABLE AP CHEST: A single AP semiupright view. Comparison is made to\\n previous films from . The heart again shows slight left ventricular\\n enlargement and there is some unfolding of the aorta. The pulmonary vessels\\n show upper zone redistribution and there is some blurring of vascular detail\\n at the bases suggesting slight left heart failure. Some ill defined\\n infiltrate is noted in the right lower lobe. Minimal blunting of the left\\n costophrenic angle is present. These findings are consistent with slight left\\n heart failure, unchanged since the prior study. The endotracheal tube, the\\n left and right subclavian lines remain in satisfactory and unchanged\\n positions.\\n\\n IMPRESSION: There has been slight clearing of the ill defined infiltrate at\\n both lung bases since the prior study. The appearances are otherwise\\n unchanged. Slight left heart failure is again noted.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-11-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1260269,\n \"text\": \" 12:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: SOB.?ASPIR.PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n CHEST, SINGLE AP FILM.\\n\\n HISTORY: Rectal/colon cancer resection with chemo/radiation therapy and line\\n placement with persistent respiratory distress.\\n\\n Right subclavian portacath is in upper right atrium. No pneumothorax. There\\n is cardiomegaly but no definite chf. Persistent opacity consistent with\\n atelectasis and possible small pleural effusion is present at the right lung\\n base and there is a probable tiny left pleural effusion. Overall appearances\\n are essentially unchanged, when compared with prior study of .\\n\\n IMPRESSION: No significant change since prior studies. Cardiomegaly, but no\\n definite pulmonary edema. Small bilateral pleural effusions and atelectasis\\n right lung base. Probable COPD.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1493972,\n \"text\": \"review of systems:\\n\\nNeuro: pt is A & O x3, pt is appropriate and MAE x4. pt PERLA. pt is able to answer questions appropriatly and able to aid in own care.\\n\\nCV: Pt Bp is stable @ 140-130/70-80. pt is in Atrial fib and on a amio gtt @ .5 mg/min and is being transitioned to PO amio. ot HR is 110-140.\\n\\nResp: pt was tranfered on 2 liters, pt sao2 decreased to 88 and ABG drawn 7.42/53/59/36. pt o2 was increased to 6 liters. pt sao2 increased to 97%, ABG pending. pt is able to give himeslf nebs PRN\\n\\nGI/GU: pt has good UO per foly cath, pt urine is yellow with seds. pt has had no BM since transfer, and is reciving tube feeds @ 50 cc/hr\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1493973,\n \"text\": \"D: Please see , MD progress notes/orders for assessment and all pertinent data. Pt. a&o this a.m., team member in on rounds and dc/d NGT. A-line and foley catheter, IVF and amiodorone gtt also discontinued. Pt assisted oob to chair with transfer accomplished with one assist. Pt denies pain or other distress. Pt. converted to SR with occ PAC's from Afib early this morning. 02 decr to 4L nc from 6L with sats ranging 91-94%. Lungs clear and decreased at bases. Respitory hygiene encouraged with pt. expectorating moderate amount clear-white sputum. Pt. with soft abd, +bs and colostomy draining brown liquid stool to gravity in moderate amounts. Stoma is pink. Pt. offered small amount of cl with no signs of aspiration noted.\\n\\nP: Encourage activity, couging/deep breathing, increase activity as tolerated. Cont. to assess comfort level, vs and 02 sats, notify team of any change. Continue on CL diet and monitor for any signs of aspiration.\\n\\nR: as above, pt up in chair for most of day with vs/02 sats stable. No signs of aspiration noted, no pain voiced. Pt for transfer to telemetry when bed available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-11-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1493971,\n \"text\": \"Resp. Care Note\\nPt received intubated and vented on PSV 10 peep 5 35%. Pt weaned to CPAP5 and 35%. Extubated after ABG 7.40/52/80. doing well post-ext. currently on 2L NP with sats 91%. Using MDI's with spacer, excellent technique.\\n\"\n }\n]"}}},{"rowIdx":782,"cells":{"subject_id":{"kind":"number","value":31986,"string":"31,986"},"hadm_id":{"kind":"number","value":178804,"string":"178,804"},"target_text":{"kind":"string","value":"81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB, wheezing and hypoxia w/ possible LLL opacity on OSH film. ICU course by problem: . #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status thought PNA (either NH/CAP vs. aspiration). Her PNA was supported by possible infiltrate but also by heavy secretions. Secretions improved within 2 days. We suspect PNA may have triggered COPD flare. Minimal evidence of CHF exacerbation on imaging, exam and labs, but does have CHF history. We treated her as follows: - PNA: treated with vanco, ceftaz, flagyl for nosocomial coverage with plans for an 8 day course. She will need 4 more days of this regimen. Note that her vanco trough on am of was 35 so we recommend rechecking vanco trough on and dose 1gm q24 for trough<20. We also treated with azithromycin to cover atypicals. She will need two more doses of this. - COPD: We treated with prednisone 40mg daily and tapered down. Recommend 20mg daily x3d, 10mg daily x3d then stop. We also treated with q1-2h albuterol nebs and q6h ipratropium nebs. This was spaced out to q4h with breakthrough prn nebs. - UCx negative but BCx still pending - low suspicion for MI. CE as above - she was on 4L NC prior to discharge from the hospital. . #. COPD: -- management as above . #. chronic systolic CHF: no evidence of volume overload on exam; BNP 38 (negative) at OSH. Echo here was of poor quality but did not reveal obvious wall motion abnl. We gently diuresed with lasix 10mg IV to keep her even to slightly negative. She tolerated this well. . #. HTN: Initially held her metoprolol but this was restarted. . #. Hypothyroidism -- continue levothyroxine 88 mcg QD . #. Dementia: not currently on medications . #. Depression: was on venlafaxine in past; held on last admission for c/f NMS. Nothing on med list currently. . #. Osteoporosis: currently on calcium supplements -- cont calcium; -- fall precautions . #. FEN: on admission, takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc free water flushes Qshift. we used Replete w/fiber Full strength during her ICU stay. Nutrition recs included in d/c paperwork. . #. PPX: no indication for PPI currently; SHQ (wears boots at rehab); bowel regimen . #. Code: DNR/DNI, confirmed with family by ED staff. . #. Contacts: Spoke with daughter (HCP) for ICU consent and confirm code status. . #. Dispo: to Rehab from the ICU. . #. Access: PICC placed on . It was confirmed on CXR. Please d/c PICC when done with IV abx."},"extractive_notes_summ":{"kind":"string","value":"81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. Resting tachycardia (HR>100bpm). Right ventricular function.Height: (in) 63Weight (lb): 150BSA (m2): 1.71 m2BP (mm Hg): 115/70HR (bpm): 103Status: InpatientDate/Time: at 11:29Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.LEFT VENTRICLE: LV not well seen. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status likely PNA (either NH/CAP vs. aspiration). FINDINGS: The hand of the patient obscures most of the right hemithorax. Depression: was on venlafaxine in past; held on last admission for c/f NMS. The rhythmappears to be atrial fibrillation.Conclusions:The left atrium is dilated. Pt asymptomatic other than more lethargic: responding only to sternal rub when crackles developed. Chest pt given with turns. IMPRESSION: Limited exam. Hypothyroidism -- continue levothyroxine 88 mcg QD . Nebs and Chest PT to help Pt. Osteoporosis: currently on calcium supplements -- cont calcium; t/c starting Vit D -- fall precautions . LS rhonkie with occ wheez. FINDINGS: In comparison with the earlier study of this date, there has been placement of a left subclavian PICC line that extends to the mid portion of the SVC. Left PICC remains in place, there is mild increase in right lower lobe atelectasis. I/O at this time +112cc. Response: Remains afebrile. Baseline artifact makes interpretation difficultSinus tachycardiaSince previous tracing of the same date, baseline artifact present Baseline artifactSinus tachycardiaPoor R wave progressionNonspecific T wave flatteningSince previous tracing of , no significant change Pneumonia, other Assessment: Scattered rhonchi t/o lungs at beginning of shit with sats in mid 90s on 70% cool neb. Leftventricular function is probably normal, a focal wall motion abnormalitycannot be fully excluded. on 70% cool neb mask. Overall normal LVEF (>55%).No resting LVOT gradient.RIGHT VENTRICLE: RV not well seen.AORTIC VALVE: Aortic valve not well seen.MITRAL VALVE: Mitral valve leaflets not well seen.TRICUSPID VALVE: Tricuspid valve not well visualized.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Today was hypoxemic and transferred to - Afeb, 99.8 HR 106, 122.68, RR 22, 92% on 2L NC, WBC 28 with 19% bands, troponin <0.04. # Hypothyroidism - cont. # Hypothyroidism - cont. #PPx: PPI, SQH, bowel regimen . #PPx: PPI, SQH, bowel regimen . #.HTN: -cont. #.HTN: -cont. Cont require ICU care for tenuous resp status with desats and requiring suctioning q1-2hrs. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status likely PNA (either NH/CAP vs. aspiration). Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status likely PNA (either NH/CAP vs. aspiration). Chief Complaint: hypoxia/dyspnea 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. #COPD -cont. #COPD -cont. albuterol nebs q2h -atrovent nebs q6h . albuterol nebs q2h -atrovent nebs q6h . Pt turned freq. #F/E/N -TF via g-tube -goal: -even to negative . TFs through G-tube. Assessment and Plan ASSESSMENT/PLAN: 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB, wheezing and hypoxia w/ possible LLL opacity on OSH film. levothyroxine . levothyroxine . Hypothyroidism -- continue levothyroxine 88 mcg QD . Hypothyroidism -- continue levothyroxine 88 mcg QD . #F/E/N -TF via g-tube -may consider S&S eval, G-tube study to eval. # PNA Unimproved clinically with persistent leukocytosis (perhaps an element of reactive WBC from steroids) and copious purulent secretions -cont. # PNA Unimproved clinically with persistent leukocytosis (perhaps an element of reactive WBC from steroids) and copious purulent secretions -cont. 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. # Hypothyroidism - cont. # Hypothyroidism - cont. # Hypothyroidism - cont. #.HTN: -cont. #.HTN: -cont. #.HTN: -cont. #PPx: PPI, SQH, bowel regimen #. -albuterol nebs at q2h -atrovent nebs q6h #.CHF - CXR reflects mild degree of volume overload. albuterol nebs q2h -atrovent nebs q6h #.CHF - CXR reflects mild degree of volume overload. #COPD -cont. #COPD -cont. #COPD -cont. #PPx: PPI, SQH, bowel regimen . #F/E/N -TF via g-tube -goal: -even to negative . #F/E/N -TF via g-tube -goal: -even to negative . albuterol nebs q2h -atrovent nebs q6h . Rhochi diffusely CV: RRR, s1 & s2 nl, no m/r/g ABD: + BS, nt, nd, soft, G-tube in place with dressing C-D-I. Chief Complaint: hypoxia/dyspnea 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. levothyroxine . levothyroxine . Vancomycin d/c Response: Pt presently tolerating 2l/m nasal cannula with adequate o2 sats. Chief Complaint: hypoxia & dyspnea 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. Chief Complaint: hypoxia & dyspnea 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. Hypothyroidism -- continue levothyroxine 88 mcg QD . Hypothyroidism -- continue levothyroxine 88 mcg QD . Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status likely PNA (either NH/CAP vs. aspiration)."},"n_notes":{"kind":"number","value":41,"string":"41"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2152-06-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1022648,"text":" 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, PNA\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: COPD, pneumonia.\n\n Comparison is made with prior study .\n\n There are low lung volumes. Atelectasis in the left base has improved. Left\n PICC remains in place, there is mild increase in right lower lobe atelectasis.\n There is mild fluid overload.\n\n DR. \n"},{"category":"Radiology","chartdate":"2152-06-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1022477,"text":" 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 81 year old woman with ? LLL pneumonia in ICU; please evalua\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with ? LLL pneumonia in ICU; please evaluate for interval\n change in infiltrates and effusions.\n REASON FOR THIS EXAMINATION:\n 81 year old woman with ? LLL pneumonia in ICU; please evaluate for interval\n change in infiltrates and effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible left lower lobe pneumonia.\n\n FINDINGS: In comparison with the study of , there are lower lung volumes.\n Some increased opacification at the left base with silhouetting in the\n hemidiaphragm is most consistent with pleural fluid and atelectatic change,\n though the possibility of supervening pneumonia cannot be definitely excluded.\n Similar changes are seen at the right base medially, though some of this may\n merely be crowding of vessels.\n\n Indistinct prominence of pulmonary vessels suggests some elevated pulmonary\n venous pressure.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1022210,"text":" 8:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate, pulm edema\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, PNA a/w congestion, hypoxia\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 81-year-old woman with COPD and hypoxia.\n\n FINDINGS: Comparison is made to previous study from .\n\n The cardiac silhouette is upper limits of normal but unchanged. There is\n again seen some subsegmental atelectasis at the left base. The rest of the\n lung fields are clear. There are no signs for overt pulmonary edema.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1022314,"text":" 5:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD a/w PNA\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD with possible pneumonia.\n\n FINDINGS: The hand of the patient obscures most of the right hemithorax.\n Otherwise, there is little change in the appearance of the heart and lungs\n from the study of . A repeat examination would be helpful.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1022156,"text":" 8:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with cough and hypoxia\n REASON FOR THIS EXAMINATION:\n assess pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female with cough and hypoxia. Please assess for\n pneumonia.\n\n FINDINGS: AP upright chest radiograph is reviewed and compared to .\n Evaluation is limited by rotation, despite technologist's attempts to properly\n position the patient. Evaluation is also limited by low lung volumes. There\n is no large consolidation, though retrocardiac area cannot be reliably\n assessed. There is no definite pleural effusion or pneumothorax.\n\n IMPRESSION: Limited exam. No focal consolidation.\n\n"},{"category":"Echo","chartdate":"2152-06-05 00:00:00.000","description":"Report","row_id":82576,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 63\nWeight (lb): 150\nBSA (m2): 1.71 m2\nBP (mm Hg): 115/70\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 11:29\nTest: Portable TTE (Complete)\nDoppler: Full 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.\n\nLEFT VENTRICLE: LV not well seen. Suboptimal technical quality, a focal LV\nwall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%).\nNo resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - bandages, defibrillator pads or electrodes. Suboptimal image\nquality as the patient was difficult to position. Suboptimal image quality -\npatient unable to cooperate. Resting tachycardia (HR>100bpm). The rhythm\nappears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is dilated. The left ventricle is not well seen. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is normal (LVEF>55%). The\naortic valve is not well seen. The mitral valve leaflets are not well seen.\n\nIMPRESSION: poor technical quality due to patient's body habitus. Left\nventricular function is probably normal, a focal wall motion abnormality\ncannot be fully excluded. The right ventricle is not well seen. Valvular\nfunction could not be evaluated.\n\n\n"},{"category":"Radiology","chartdate":"2152-06-06 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1022579,"text":" 2:48 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: l dl picc 43cm\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with\n REASON FOR THIS EXAMINATION:\n l dl picc 43cm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left subclavian PICC line that extends to the mid portion of\n the SVC. Little change in the appearance of the heart and lungs.\n\n\n"},{"category":"ECG","chartdate":"2152-06-03 00:00:00.000","description":"Report","row_id":199242,"text":"Baseline artifact makes interpretation difficult\nSinus tachycardia\nSince previous tracing of the same date, baseline artifact present\n\n"},{"category":"ECG","chartdate":"2152-06-03 00:00:00.000","description":"Report","row_id":199243,"text":"Baseline artifact\nSinus tachycardia\nPoor R wave progression\nNonspecific T wave flattening\nSince previous tracing of , no significant change\n\n"},{"category":"Nursing","chartdate":"2152-06-05 00:00:00.000","description":"Nursing Progress Note","row_id":330481,"text":"81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\n presented to Hospital from with dyspnea.\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\n 1700 via foley. Pt is DNR/DNI, admitted to for further\n management of pneumonia.\n Pneumonia, other\n Assessment:\n Pt continues on 40% cool neb, CXR~ LLL infiltrate. Pt suctioned q 2\n -3 hours for thick yellow secretions, afebrile, WBC 20.8 pt remains\n on Vanco, Ceftazidime, and Flagyl. On prednisone 40 mg per G-tube qd.\n Prednisone 40 mg qd, cpt done\n Action:\n Suctioned q 2 hrs, nebs q 6 hrs, aggressive pulmonary toilet\n Response:\n Sx helps clear airway\n Plan:\n Continue current therapies, monitor for worsening resp status\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt with Alzheimers dementia, parkinsonian gehavior, repetitive\n speech, expressive aphasia\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2152-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":330464,"text":"Alteration in Nutrition\n Assessment:\n Family states noted poor po intake over last few weeks, possibly due to\n compromised resp status\n Action:\n TF held for now poor resp status frequent NT suctioning w/ copious\n amts of secretions, coughing\n Response:\n Pt w/o s/s nutritional compromise, dehydration\n Plan:\n Re assess nutrition needs may start TF in 24 hr when pt settles\n Pneumonia, other\n Assessment:\n Pt w/ pneu w/ worsening cxr, copious amt thick yellow secretions, , low\n grade temp\n Action:\n Suctioned q1 hr , nebs q2-4 hrs prn , aggressive pulm toileting, ab tx\n Response:\n Cont to have need for freq suctioning, pulm toileting transient relief\n noted\n Plan:\n Cont current therapies, monitor for worsening resp status pt is\n DNR/DNI\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/ alzheimers dementia, parkinsonian behavior, repetitive speech,\n expressive aphasia\n Action:\n Allowed pt to answer question at own , occ be lucid\n Response:\n Able to communicate at times, able to answer appropriately when asked\n oif she was soilded or in pain\n Plan:\n Cont focused patient interaction with pt\n"},{"category":"Nursing","chartdate":"2152-06-05 00:00:00.000","description":"Nursing Progress Note","row_id":330547,"text":"81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\n presented to Hospital from with dyspnea.\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\n 1700 via foley. Pt is DNR/DNI, admitted to for further\n management of pneumonia.\n Pneumonia, other\n Assessment:\n Pt. on 70% cool neb mask. Pulling mask off face frequently and desating\n to 85%. LS rhonkie with occ wheez.\n Action:\n Lasix 10 mg IV for I/O goal -500cc. Nebs and Chest PT to help Pt.\n mobilize secretions. NT suctioned few time this shift for thick yellow\n sectretions. IV abx as ordered.\n Response:\n Remains afebrile. I/O at this time +112cc.\n Plan:\n Cont. current care. Will give additional Lasix to meet I/O goal.\n"},{"category":"Nursing","chartdate":"2152-06-07 00:00:00.000","description":"Nursing Progress Note","row_id":330638,"text":"81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation. Pt with s/p L cva summer of with\n residual aphasia and dementia including Alzheimers, multi-infarct.\n Pneumonia, other\n Assessment:\n Scattered rhonchi t/o lungs at beginning of shit with sats in mid 90s\n on 70% cool neb.\n Action:\n Pt nt suctioned for moderate amts clear white/clear secretions. Chest\n pt given with turns.\n Response:\n 02 sats remaining stable on 70% cool neb. Pt developed crackles around\n 9:30pm and noted to have a drop in urine to 17cc/hr. pt was given 10mg\n iv lasix with good response. At this time, pt has also been having\n short runs v tach up to 10 beat runs. Pt asymptomatic other than more\n lethargic: responding only to sternal rub when crackles developed.\n Still lethargic but more easily arousable.\n Plan:\n Continue nt suction prn, chest pt with turns, monitor fluid status, f/u\n with am labs and replete lytes prn.\n Alteration in Nutrition\n Assessment:\n Nutren pulmonary increased to goal of 65cc/hr . 100cc free water\n boluses given q6hrs. large loose ob + brown stool.\n Action:\n Tolerating tube feedings well with no residuals.\n Response:\n Continues to tolerate tube feedings.\n Plan:\n Continue tube feedings with free water boluses. Hold colace as pt\n having loose stool.\n"},{"category":"Physician ","chartdate":"2152-06-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":330454,"text":"Chief Complaint: SOB\n 24 Hour Events:\n SPUTUM CULTURE - At 05:11 AM\n --\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 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 07:35 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: 93 (78 - 104) bpm\n BP: 112/44(62) {89/27(42) - 117/56(70)} mmHg\n RR: 24 (16 - 24) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 57 Inch\n Total In:\n 4,835 mL\n PO:\n TF:\n IVF:\n 135 mL\n Blood products:\n Total out:\n 0 mL\n 2,650 mL\n Urine:\n 2,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,185 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG:\n Physical Examination\n Gen:\n Lungs:\n CV:\n ABD:\n EXT\n Labs / Radiology\n [image002.jpg]\n PROBLEM LIST:\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT AND PLAN:\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- will place on vanco/zosyn for NH/HAP broad coverage esp since she\n failed the levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- will order sputum cultures\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- monitor for signs of volume overload; gentle IVF overnight if needed\n .\n #. HTN:\n -- will hold home metoprolol overnight to ensure that BP remains stable\n in light of possible infection.\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: no indication for PPI currently; SHQ (wears boots at rehab);\n bowel regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"General","chartdate":"2152-06-04 00:00:00.000","description":"Generic Note","row_id":330457,"text":"TITLE:\n Broadened abx regimen overnight to Vanc/Zosyn. This morning\n desaturation requiring inc. FiO2. and suctioning. Requiring frequent\n suctioning yielding tenacious white material. Outside film with\n bibasilar infiltrates. Repeat film at less impressive though\n rotated. Cont require ICU care for tenuous resp status with desats\n and requiring suctioning q1-2hrs.\n Pt is critically ill. 35min spent on care.\n"},{"category":"Physician ","chartdate":"2152-06-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":330459,"text":"Chief Complaint: SOB\n 24 Hour Events:\n Overnight patient was placed on vanco/zosyn for broad coverage in a\n pt. She was placed on O2.\n SPUTUM CULTURE - At 05:11 AM\n Episode of SOB this AM, Desat to 88% on 4L NC. Patient was\n suctioned. Started on FM with 100% FiO2 briefly and then quickly down\n to 40%. Afebrile at the time. She was given a neb treatment without\n much effect. A repeat CXR was obtained. Per nursing patient has\n copious resp secretions that are white.\n Subjective: patient is aphasic and incoherent.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 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 07:35 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: 93 (78 - 104) bpm\n BP: 112/44(62) {89/27(42) - 117/56(70)} mmHg\n RR: 24 (16 - 24) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 57 Inch\n Total In:\n 4,835 mL\n PO:\n TF:\n IVF:\n 135 mL\n Blood products:\n Total out:\n 0 mL\n 2,650 mL\n Urine:\n 2,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,185 mL\n Respiratory support\n O2 Delivery Device: FM 40% FiO2\n SpO2: 96%\n ABG:\n Physical Examination\n Gen: aphasic, with residual right sided hemiparesis, repeating sounds\n incoherently.\n Lungs: diffuse rhonchi\n CV: rapid rate, regular rhythm, s1 & s2 nl, no m/r/g\n ABD: + bs, nt, nd, soft\n EXT: some LE edema bilat\n Labs / Radiology\n [image002.jpg]\n Labs pending this morning due to difficult draw.\n PROBLEM LIST:\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT AND PLAN:\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history. Patient has copious\n respiratory secretions.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\n levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- follow up re: sputum cx\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n --suctioning Q1 hr., Chest PT.\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- d/c maintenance fluids\n -- obtain ECHO\n .\n #. HTN:\n -- restart home dose of metoprolol\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- holding TF pending improved respiratory status. Concern re:\n aspiration if patient requires BPAP.\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\n regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2152-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":330440,"text":"81 y.o.female with h/o CVA, dementia, COPD presented to \n Hospital from with dyspnea. Tranferred to \n EW, diagnosed with pneumonia, sat 88% on 4 liters n/c, temp 102.4 HR\n 136, lactate 3.1 WBC 22..4 received Vanco, Cefepime,\n Azithromycin. Pt received 3-4 liters NS, urine output 1700 via\n foley. Pt is DNR/DNI, admitted to for further management of\n pneumonia.\n Pneumonia, other\n Assessment:\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. Os sat\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\n cough, pt sleeping on/off. Nonverbal (mumbles words)\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Left hip\n stage 1 skin broken, area cleansed with foam cleanser,\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2152-06-04 00:00:00.000","description":"Physician Attending Admission Note","row_id":330441,"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 81 yo women resident of Rehab p/w hypoxemia (sat of 90s on 2L\n NC). Has had\n two weeks of worsening SOB, cough with sputum, and 3 days of fever to\n 101. Was started on Levoquin. Today was hypoxemic and transferred to\n - Afeb, 99.8 HR 106, 122.68, RR 22, 92% on 2L NC, WBC 28 with\n 19% bands, troponin <0.04. BNP 38. ABG 7.46/32/91. Got Medrol, Nebs,\n Tylenol, CTX and Flagyl. CXR with ? LLL infiltrate and Right\n infiltrate. Transferred to where she got 3L of saline, and\n Vanco,Cefepine,Azithro.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD\n aspiration PNA\n Dementia\n CVA with expressive aphasia\n G-tube\n legally blind\n pulmonary HTN\n CHF\n Meds at home:\n Synthroid\n Albuterol/atroven\n Prednisone 5mg qd\n lopressor 25 \n unremarkable\n Occupation: Rehab\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: Daughter is \n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough\n Gastrointestinal: No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Anemia\n Neurologic: No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Flowsheet Data as of 03:04 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: 95 (95 - 104) bpm\n BP: 89/27(42) {89/27(42) - 117/42(56)} mmHg\n RR: 18 (18 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 4,700 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 2,050 mL\n Urine:\n 2,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,650 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases, Rhonchorous: )\n Abdominal: Soft, Non-tender, G-tube\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 338\n 39.3\n 187\n 0.7\n 15\n 20\n 102\n 4.3\n 138\n 22.4\n [image002.jpg]\n Other labs: Lactic Acid:3.1\n Fluid analysis / Other labs: U/A: 0-2 WBC\n Assessment and Plan\n Aspiration PNA: High WBC, ? of multilobar infilatrates on CXR. Vanco\n and Zosyn for HAP as she is from institution and failed levoflox\n therapy. Check sputum cultures.\n COPD: Continue nebs, lower dose to prednisone 40mg.\n Dementia: Poor MS not far from her baseline, no need to image head\n HTN: Hold antihypertensives as BP is low.\n HOTN: Likely due to sepsis from aspiration PNA.\n TFs through G-tube.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 20 Gauge - 01:08 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2152-06-04 00:00:00.000","description":"Physician Resident Admission Note","row_id":330444,"text":"Chief Complaint: SOB, decreasing O2 sats\n HPI:\n Ms. is an 81 yo F with h/o aspiration PNA, COPD and\n CVA/aphasia, who presented to the ED from Rehab with SOB,\n wheezing and low O2 sats (92% on 2LNC). Her daughter states that she\n became progressively more SOB with cough and inc sputum and decreasing\n PO intake for the past 2 weeks. 2 days ago she ran a temp to 100.1 F\n and she was given two doses of levaquin at the rehab yesterday (unclear\n if had gotten more) for increased secretions. She was also given lasix\n 40 mg PO x1. She initially presented to the ED this afternoon\n but was transferred to the per the request of her family.\n At , VS were 99.8, 106, 22, 142/68, and 92% 2LNC. WBC was 28.1\n w/ 19% bands, trop < 0.04, BNP 38, bicarb 26; ABG was 7.46/32/91 on ?\n O2. She was given solumedrol, duonebs, Tylenol, ceftriaxone x 1, and\n flagyl x 1. She had one set of cardiac enzymes that were nagtive and\n CXR reportedly had a LLL PNA. VS on arrival to were 99.5, HR\n 134, BP 100/78, RR 22, 92% on 4L NC. She was given 3 L NS as well as\n vancomycin 1 g IV, azithromycin 500 mg IV and cefepime 2 g IV.\n Per daughter: She was placed in long-term care facility ~3.5 yrs ago\n for alzheimer's dementia. About 1-2 years ago she fell out of bed at\n NH and fx'ed her hip. She has not ambulated since then. She had 2\n strokes in summer of that left her with an expressive aphasia. She\n can speak in simple sentences/phrases when well. She will often string\n together non-coherent words and believe she is communicating\n coherently. Daughter states the current babbling of word fragments is\n worse than her baseline.\n Unable to obtain ROS due to MS, aphasia.\n Patient admitted from: Transfer from other hospital, via ED;\n transferred per family's wishes\n History obtained from Family / Medical records\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS (per d/c summary and ED notes):\n Synthroid 88 mcg QD\n Albuterol nebs Q4 hours PRN\n Ipratropium neb Q6 hours PRN\n levaquin 250 mg PO qday (day )\n Prednisone 5 mg QD\n Senna, colace, MOM\n \n Metoprolol Tartrate 25 mg \n Calcium carbonate\n hyocysamine 0.25 mg Q4 hours PRN\n MVI, Vit C\n Tylenol 325-650mg PO PRN\n Past medical history:\n Family history:\n Social History:\n COPD\n Dementia\n HTN\n Hypothyroidism\n CVA-- aphasic, right sided weakness; has G tube\n Legally blind (macular degeneration)\n Pulmonary hypertension\n CHF\n Depression\n Left hallux ulceration\n s/p R humerous and pelvic fx\n s/p CCY\n s/p TAH for adenocarcinoma\n Osteoporosis\n Non-contributory\n Occupation: NC\n Drugs: denied\n Tobacco: denied\n Alcohol: denied\n Other: lives at Rehab\n Review of systems: could not obtain aphasia, mental status\n Flowsheet Data as of 03:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 95 (95 - 104) bpm\n BP: 89/27(42) {89/27(42) - 117/42(56)} mmHg\n RR: 18 (18 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 4,700 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 2,050 mL\n Urine:\n 2,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,650 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, No(t)\n Diaphoretic\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases b/l, Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , Obese, G tube\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: No(t) Follows simple commands, Responds to: Tactile\n stimuli, No(t) Oriented (to): cannot communicate, Movement: Not\n assessed, Tone: Not assessed, rt arm contracture; rt foot fixed\n extension;RU/LE weakness/paralysis; CN II - XII symmetric; aphasic\n Labs / Radiology\n 338\n 187\n 0.7\n 15\n 20\n 102\n 4.3\n 138\n 39.3\n 22.4\n [image002.jpg]\n 95% PMN\ns, 0% bands\n Lactate 3.1\n Trop 0.04, CK 134, MB 5\n UA negative\n Imaging: ADMISSION CXR:\n AP upright chest radiograph is reviewed and compared to .\n Evaluation is limited by rotation, despite technologist's attempts to\n properly position the patient. Evaluation is also limited by low lung\n volumes. There is no large consolidation, though retrocardiac area\n cannot be reliably assessed. There is no definite pleural effusion or\n pneumothorax.\n IMPRESSION: Limited exam. No focal consolidation.\n Microbiology: UCx, BCx pending\n ECG: AMDISSION EKG: noisy background, sinus tach at 130; poor R wave\n progression; no ST seg changes or TWI; LAD.\n Assessment and Plan\n ASSESSMENT/PLAN:\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n .\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- will place on vanco/zosyn for NH/HAP broad coverage esp since she\n failed the levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- will order sputum cultures\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n .\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- monitor for signs of volume overload; gentle IVF overnight if needed\n .\n #. HTN:\n -- will hold home metoprolol overnight to ensure that BP remains stable\n in light of possible infection.\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: no indication for PPI currently; SHQ (wears boots at rehab);\n bowel regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Comments: NPO for now; will clarify tube feed vs. PO feed regimen in am\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT: SQ UF Heparin(bowel regimen)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments: Spoke with daughter on admission\n Code status: DNR / DNI\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2152-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":330438,"text":"81 y.o. with h/o CVA, dementia, COPD presented to Hospital\n from with dyspnea. CXR~ pneumonia. Pt received 3\n liters of IVF, Tylenol x 1, Vanco, Cefepime, Azithromycin\n"},{"category":"Nursing","chartdate":"2152-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":330439,"text":"81 y.o.female with h/o CVA, dementia, COPD presented to \n Hospital from with dyspnea. Tranferred to \n EW, diagnosed with pneumonia, sat 88% on 4 liters n/c, temp 102.4 HR\n 136, lactate 3.1 WBC 22..4 received Vanco, Cefepime,\n Azithromycin. Pt received 3-4 liters NS, urine output 1700 via\n foley. Pt is DNR/DNI, admitted to for further management of\n pneumonia.\n Pneumonia, other\n Assessment:\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. Os sat\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\n cough, pt sleeping on/off. Nonverbal (mumbles words)\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2152-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":330446,"text":"81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\n presented to Hospital from with dyspnea.\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\n 1700 via foley. Pt is DNR/DNI, admitted to for further\n management of pneumonia.\n Pneumonia, other\n Assessment:\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. O2 sat\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\n cough, pt sleeping on/off. Nonverbal (mumbles words) pt on Vanco and\n Zosyn, prednisone po, Albuterol/Atovent inhalers q 6 hrs\n Action:\n Pt with coarse breath sounds, nasally suctioned for thick yellow\n secretions\n sent for gram stain, and culture.\n Response:\n Pt sounds better\n Plan:\n Continue with pulmonary toilet. Check sputum cx, continue antibx for\n ?LLL infiltrate from OSH film. Continue steroids, nebs.\n Impaired Skin Integrity\n Assessment:\n Left hip\n stage 1 skin broken, area cleansed with foam cleanser,\n aloe vesta cream applied. Pt turned freq.\n Action:\n Kept off back\n Response:\n Plan:\n Consult skin care for left hip. Keep off back. Follow closely.\n NEURO: Per daughter: She was placed in long-term care facility ~3.5\n yrs ago for alzheimer's dementia. About 1-2 years ago she fell out of\n bed at NH and fx'ed her hip. She has not ambulated since then. She\n had 2 strokes in summer of that left her with an expressive\n aphasia. She can speak in simple sentences/phrases when well. She\n will often string together non-coherent words and believe she is\n communicating coherently. Daughter states the current babbling of word\n fragments is worse than her baseline.\n per resident\ns note. Pt\n currently babbling, r arm contracted, can move though, moves left\n arm. Unable to draw pt\ns blood\n intern will need to perform groin\n stick. Pt is legally blind.\n GI: pt with a G-tube. Was on Probalance 65 cc/hr on at 9 pm, off\n at 6 am.\n GU: great urine output. >2 liters.\n"},{"category":"Physician ","chartdate":"2152-06-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":330532,"text":"Chief Complaint: Pneumonia\n 24 Hour Events: per ID, zosyn changed to ceftaz/flagyl\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 PM\n Metronidazole - 12:00 AM\n Ceftazidime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 12:34 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: pt non-communicative\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: 35.9\nC (96.6\n HR: 84 (57 - 132) bpm\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\n RR: 28 (16 - 37) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 5,549 mL\n 386 mL\n PO:\n TF:\n 33 mL\n IVF:\n 849 mL\n 353 mL\n Blood products:\n Total out:\n 3,950 mL\n 330 mL\n Urine:\n 3,950 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 92%\n Physical Examination\n Gen: aphasic, with residual right sided hemiparesis, perseverative,\n incoherent\n CV: reg tachy, nl S1S2 no m/r/g\n PULM: diffuse rhonchi and wheezing bilat\n ABD: soft NTND + BS G-tube site c/d/i\n EXT: warm, dry 1+LE edema bilat\n Labs / Radiology\n 321 K/uL\n 11.3 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 143 mEq/L\n 34.0 %\n 20.8 K/uL\n [image002.jpg]\n 06:15 PM\n WBC\n 20.8\n Hct\n 34.0\n Plt\n 321\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 130\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n .\n # PNA\n Unimproved clinically with persistent leukocytosis (perhaps an\n element of reactive WBC from steroids) and copious purulent secretions\n -cont. vanco/ceftaz/flagyl (day 2), and start azithro (day 1) for\n atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n -consider bronch if suspect severe plugging or not improved\n .\n #COPD\n -cont. prednisone 40 mg, may taper if improves clinically\n -incr. freq. albuterol nebs q2h\n -atrovent nebs q6h\n .\n #.CHF - CXR reflects mild degree of volume overload\n -gentle diuresis, 10 mg lasix IV now, goal: -500 cc/day\n -TTE today, f/u final read\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n .\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -may consider S&S eval, G-tube study to eval. aspiration risk prior to\n giving anything PO\n -goal: -500 cc/day\n -- has G tube; will obtain c/s for tube feeds in am\n .\n #PPx: PPI, SQH, bowel regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"},{"category":"Nutrition","chartdate":"2152-06-05 00:00:00.000","description":"Clinical Nutrition Note","row_id":330520,"text":"Subjective\n Patient with poor PO intake PTA. Noted per chart, on TFs of Probalance\n at 65ml/hr x 9 hours (provides 702kcal and 46g protein)\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 160 cm\n 75 kg\n 29.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 52.2 kg\n 144%\n 66\n Diagnosis: Pneumonia\n PMH : CVA, dementia, aspiration pneumonia, COPD\n Food allergies and intolerances: none noted\n Pertinent medications: prednisone, 20meqKCl\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 07:27 AM\n BUN\n 16 mg/dL\n 07:27 AM\n Creatinine\n 0.5 mg/dL\n 07:27 AM\n Sodium\n 143 mEq/L\n 07:27 AM\n Potassium\n 3.7 mEq/L\n 07:27 AM\n Chloride\n 111 mEq/L\n 07:27 AM\n TCO2\n 23 mEq/L\n 07:27 AM\n Calcium non-ionized\n 8.8 mg/dL\n 07:27 AM\n Phosphorus\n 2.5 mg/dL\n 07:27 AM\n Magnesium\n 2.2 mg/dL\n 07:27 AM\n Current diet order / nutrition support: Nutren Pulmonary at 40ml/hr x\n 24 hours (currently at 20ml/hr) to provide 1440kcal and 65g protein\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Low po intake\n Estimated Nutritional Needs\n Calories: 1650- (BEE x or / 25-30 cal/kg)\n Protein: 80-100 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n 81 year old female with history of CVA, dementia, aphasia presenting\n with SOB to OSH now transferred to with pneumonia. Noted patient\n with stage I ulcer on hip. Patient was on night tube feedings at NH.\n Consult received for tube feedings. For now would recommend doing feeds\n to meet 100% of needs. Suggest goal of Replete with Fiber at 65ml/hr x\n 24 hours to provide 1560kcal and 97g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Change tube feeding to Replete with Fiber at 65ml/hr x 24\n hours\n 2. Monitor residuals q4H and hold if >150ml\n 10:03\n"},{"category":"Physician ","chartdate":"2152-06-05 00:00:00.000","description":"Physician Attending Progress Note","row_id":330521,"text":"Chief Complaint: Pneuomonia\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 admit with aspiration PNA and COPD exacerbation\n 24 Hour Events:\n Persistent close treatment with some improvement in level of\n respiratory distress.\n She has remaining significant pulmonary secretions requiring frequent\n suctioning and also has continued wheezing throughout her exam.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 PM\n Metronidazole - 08:04 AM\n Ceftazidime - 09:07 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:04 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 Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\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: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.9\n HR: 92 (57 - 114) bpm\n BP: 135/52(74) {83/34(36) - 159/111(110)} mmHg\n RR: 28 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 5,549 mL\n 919 mL\n PO:\n TF:\n 80 mL\n IVF:\n 849 mL\n 699 mL\n Blood products:\n Total out:\n 3,950 mL\n 390 mL\n Urine:\n 3,950 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 529 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\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: Bronchial: , Wheezes : ) She does have significant\n increase in expiratory time and evidence of persistent airflow\n obstruction.\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.4 g/dL\n 330 K/uL\n 91 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 111 mEq/L\n 143 mEq/L\n 34.6 %\n 20.6 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n WBC\n 20.8\n 20.6\n Hct\n 34.0\n 34.6\n Plt\n 321\n 330\n Cr\n 0.5\n 0.5\n TropT\n 0.02\n Glucose\n 130\n 91\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/11/0.02, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n CXR\nShe has right mid-lung zone opacity which is her right arm\n overlying. She persists in left lower lobe ill defined opacity.\n Assessment and Plan\n 81 yo female\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION-\n -continue prednisone and will move to taper as possible.\n -Will have to follow exam to determine taper\n -Will continue with current prednisone dosing as she is requiring nebs\n PRN (atrovent) and will need to get a better and more durable response\n to bronchodilators.\n -This may require intermittent IPPV to aid with lung recruitment.\n PNEUMONIA, OTHER-\n -Will move to vanco/CTZ/Flagyl/Azithro for ongoing Rx of Pneumonia\n -She raises clear concern for persistent aspiration events leading to\n inability to clear her pulmonary secretions and pneumonia.\n -Add urine legnionella to testing.\n -Will need Chest PT and continued support\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:44 AM 20 mL/hour\n Glycemic Control:\n Lines: NO CVL\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n"},{"category":"Nursing","chartdate":"2152-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":330624,"text":"Pneumonia, other\n Assessment:\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\n suctioning\n Action:\n Aggressive pulm toileting , suctioning q 2hr\n Response:\n Pt maint sats 96-99%\n Plan:\n Cont ab tx, cont aggressive pulm toileting\n Alteration in Nutrition\n Assessment:\n Pt was taking po\ns in rehab along w/ nighttime supplement TF ,\n unable to take pos at this time\n Action:\n Pt tolerating cont TF at goal\n Response:\n No s/s malnutrition or weight loss\n Plan:\n Cont TF as ordered ,resume PO intake when indicated\n K of 3.5 repleted w/ 40 K via peg, as well as phos. Pt currently being\n evaluated for PICC for antibiotic course as well as blood draws\n ------ Protected Section ------\n At 1600 pt medicated with 10 mg ivp lasix and will follow fluid balance\n closely.\n ------ Protected Section Addendum Entered By: , RN\n on: 17:07 ------\n"},{"category":"Physician ","chartdate":"2152-06-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":330623,"text":"Chief Complaint: hypoxia/dyspnea\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:33 AM\n following cardiac enzymes\n CK 134 ->-264 -->224\n Trop .04 -->.02 -->.03\n diuresis overnight with lasix 10 x 3.\n Patient lost last PIV this morning. Difficulty to obtain blood for\n labs.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 AM\n Metronidazole - 04:00 PM\n Ceftazidime - 04:56 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 06:10 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 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 104 (76 - 109) bpm\n BP: 108/64(74) {89/32(47) - 158/99(102)} mmHg\n RR: 23 (10 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 2,076 mL\n 355 mL\n PO:\n TF:\n 476 mL\n 286 mL\n IVF:\n 1,240 mL\n 69 mL\n Blood products:\n Total out:\n 2,317 mL\n 785 mL\n Urine:\n 2,317 mL\n 785 mL\n NG:\n Stool:\n Drains:\n Balance:\n -241 mL\n -430 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Gen: Less agitated and interactive this morning. Breathing\n comfortably, in NAd\n Lungs: breathing symmetrically, diffuse rhonchi and moderate secretions\n CV: rapid rate, regular rhythm s1 & s2 nl, no m/r/g\n Abd: +bs, non-tender, nd, soft\n Ext: warm dry trace edema\n Labs / Radiology\n 330 K/uL\n 11.4 g/dL\n 91 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 111 mEq/L\n 143 mEq/L\n 34.6 %\n 20.6 K/uL\n : [image002.jpg]\n :\n 142\n [image004.gif]\n 108\n [image004.gif]\n 16\n [image006.gif]\n 103\n AGap=15\n [image007.gif]\n 3.5\n [image004.gif]\n 23\n [image004.gif]\n 0.6\n [image009.gif]\n Comments:\n K: Hemolysis Falsely Elevates K\n Ca: 8.3 Mg: 2.0 P: 1.8\n Comments:\n Mg: Hemolysis Falsely Elevates Mg\n 86\n 17.4\n [image009.gif]\n 11.5\n [image006.gif]\n 371\n [image010.gif]\n [image006.gif]\n 35.0\n [image009.gif]\n 06:15 PM\n 07:27 AM\n WBC\n 20.8\n 20.6\n Hct\n 34.0\n 34.6\n Plt\n 321\n 330\n Cr\n 0.5\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n Other labs: PT / PTT / INR:12.9/26.0/1.0,\n CK / CKMB / Troponin-T:224/10/0.03,\n ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR \n hazy LL infiltrate bilaterally. Right side\n appears improved from previous.\n ECHO \n CONCLUSION:\n The left atrium is dilated. The left ventricle is not well seen. Due to\n suboptimal technical quality, a focal wall motion abnormality cannot be\n fully excluded. Overall left ventricular systolic function is normal\n (LVEF>55%). The aortic valve is not well seen. The mitral valve\n leaflets are not well seen.\n IMPRESSION: poor technical quality due to patient's body habitus. Left\n ventricular function is probably normal, a focal wall motion\n abnormality cannot be fully excluded. The right ventricle is not well\n seen. Valvular function could not be evaluated.\n Microbiology: urine cx neg\n urine leg neg\n blood cx neg\n sputum cx - contaminated\n Assessment and \n PROBLEM LIST:\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT & PLAN:\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n # PNA\n Unimproved clinically with persistent leukocytosis (perhaps an\n element of reactive WBC from steroids) and copious purulent secretions\n -cont. vanco/ceftaz/flagyl (day 3), and start azithro (day ) for\n atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n -consider bronch if suspect severe plugging or not improved\n .\n #COPD\n -cont. prednisone 40 mg, wrote to decrease to 30mg PO tomorrow AM.\n -incr. freq. albuterol nebs q2h\n -atrovent nebs q6h\n .\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\n study but showed good overall LV fn so less likely to be playing a role\n in pt\ns dyspnea.\n -gentle diuresis, 10 mg lasix IV now, goal: even to negative\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n .\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -goal: -even to negative\n .\n #PPx: PPI, SQH, bowel regimen\n .\n #Access: lost PIV this am, hard to get venous access. Place PICC today\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 06:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2152-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":330615,"text":"Pneumonia, other\n Assessment:\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\n suctioning\n Action:\n Aggressive pulm toileting , suctioning q 2hr\n Response:\n Pt maint sats 96-99%\n Plan:\n Cont ab tx, cont aggressive pulm toileting\n Alteration in Nutrition\n Assessment:\n Pt was taking po\ns in rehab along w/ nighttime supplement TF ,\n unable to take pos at this time\n Action:\n Pt tolerating cont TF at goal\n Response:\n No s/s malnutrition or weight loss\n Plan:\n Cont TF as ordered ,resume PO intake when indicated\n K of 3.5 repleted w/ 40 K via peg, as well as phos. Pt currently being\n evaluated for PICC for antibiotic course as well as blood draws\n"},{"category":"Physician ","chartdate":"2152-06-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":330506,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 PM\n Metronidazole - 12:00 AM\n Ceftazidime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 12:34 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 07:00 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: 35.9\nC (96.6\n HR: 84 (57 - 132) bpm\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\n RR: 28 (16 - 37) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 5,549 mL\n 386 mL\n PO:\n TF:\n 33 mL\n IVF:\n 849 mL\n 353 mL\n Blood products:\n Total out:\n 3,950 mL\n 330 mL\n Urine:\n 3,950 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 92%\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 321 K/uL\n 11.3 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 143 mEq/L\n 34.0 %\n 20.8 K/uL\n [image002.jpg]\n 06:15 PM\n WBC\n 20.8\n Hct\n 34.0\n Plt\n 321\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 130\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history. Patient has copious\n respiratory secretions.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\n levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- follow up re: sputum cx\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n --suctioning Q1 hr., Chest PT.\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- d/c maintenance fluids\n -- obtain ECHO\n .\n #. HTN:\n -- restart home dose of metoprolol\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- holding TF pending improved respiratory status. Concern re:\n aspiration if patient requires BPAP.\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\n regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2152-06-05 00:00:00.000","description":"Physician Resident Progress Note","row_id":330507,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 PM\n Metronidazole - 12:00 AM\n Ceftazidime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 12:34 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 07:00 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: 35.9\nC (96.6\n HR: 84 (57 - 132) bpm\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\n RR: 28 (16 - 37) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 5,549 mL\n 386 mL\n PO:\n TF:\n 33 mL\n IVF:\n 849 mL\n 353 mL\n Blood products:\n Total out:\n 3,950 mL\n 330 mL\n Urine:\n 3,950 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 92%\n ABG: ///22/\n Physical Examination\n Gen: aphasic, with residual right sided hemiparesis, repeating sounds\n incoherently.\n Lungs: diffuse rhonchi\n CV: rapid rate, regular rhythm, s1 & s2 nl, no m/r/g\n ABD: + bs, nt, nd, soft\n EXT: some LE edema bilat\n Labs / Radiology\n 321 K/uL\n 11.3 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 143 mEq/L\n 34.0 %\n 20.8 K/uL\n [image002.jpg]\n 06:15 PM\n WBC\n 20.8\n Hct\n 34.0\n Plt\n 321\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 130\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history. Patient has copious\n respiratory secretions.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\n levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- follow up re: sputum cx\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n --suctioning Q1 hr., Chest PT.\n .\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- d/c maintenance fluids\n -- obtain ECHO\n .\n #. HTN:\n -- restart home dose of metoprolol\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- holding TF pending improved respiratory status. Concern re:\n aspiration if patient requires BPAP.\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\n regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2152-06-06 00:00:00.000","description":"Physician Attending Progress Note","row_id":330603,"text":"Chief Complaint: Respiratory Failure/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 TRANSTHORACIC ECHO - At 11:33 AM\n Lasix given with diuresis effected overnight\n History obtained from Medical records\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Ceftazidime - 04:56 PM\n Metronidazole - 08:11 AM\n Vancomycin - 09:15 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 PM\n Heparin Sodium (Prophylaxis) - 08:11 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) Fever\n Cardiovascular: Tachycardia\n Psychiatric / Sleep: Delirious, MIld\n Flowsheet Data as of 12:06 PM\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: 36.1\nC (97\n HR: 98 (76 - 110) bpm\n BP: 116/53(69) {86/32(45) - 158/99(102)} mmHg\n RR: 26 (4 - 26) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 2,076 mL\n 980 mL\n PO:\n TF:\n 476 mL\n 560 mL\n IVF:\n 1,240 mL\n 420 mL\n Blood products:\n Total out:\n 2,317 mL\n 985 mL\n Urine:\n 2,317 mL\n 985 mL\n NG:\n Stool:\n Drains:\n Balance:\n -241 mL\n -5 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed, More withdrawn\n Labs / Radiology\n 11.5 g/dL\n 371 K/uL\n 103 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 16 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.0 %\n 17.4 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n 08:00 AM\n WBC\n 20.8\n 20.6\n 17.4\n Hct\n 34.0\n 34.6\n 35.0\n Plt\n \n Cr\n 0.5\n 0.5\n 0.6\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n 103\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 81 yo female with history of COPD now admit with acute exacerbation and\n has complicating issues of volume overload and signficiant aspiraiton\n risk contributing to clinical worsening\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n -Pred 40mg/d\ntaper to 30mg today\n -Continue with nebs\n PNEUMONIA, OTHER\n Vanco/Ceftaz/Flagyl/Azithro\n be aspiration triggering clinical worsening\nwill need 7 day Rx.\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:28 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT: Boots\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":"Nursing","chartdate":"2152-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":330614,"text":"Pneumonia, other\n Assessment:\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\n suctioning\n Action:\n Aggressive pulm toileting , suctioning q 2hr\n Response:\n Pt maint sats 96-99%\n Plan:\n Cont ab tx, cont aggressive pulm toileting\n Alteration in Nutrition\n Assessment:\n Pt was taking po\ns in rehab along w/ nighttime supplement TF ,\n unable to take pos at this time\n Action:\n Pt tolerating cont TF at goal\n Response:\n No s/s malnutrition or weight loss\n Plan:\n Cont TF as ordered ,resume PO intake when indicated\n"},{"category":"Nursing","chartdate":"2152-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":330576,"text":"81 y/o female with h/o CVA,Dementia,Aspiration PNA,COPD presented to\n hospital from rehab centre with dyspnea.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n On face mask with 70% Fio2,desats to 85% when mask is off ,LS coarse\n t/o,normal breathing efforts RR 20-26 sats 90-95%\n Action:\n Suctioned nasally 2-3 hrs for thick yellow secretions,pt has very\n weak cough,chest PT prior to suction and nebs as ordered.Gentlre\n diuresis with bolus dose,did receive Lasix 10mg at midnight with\n moderate effect.\n Response\n Pt was more comfortable after suction.Stas were maintained.\n Plan:\n DNR/DNI,monitor resp staus,ICU care at this time Pulmonary hygene,\n wean Fio2 as tolerated.\n Redness and bruises on lt hand MD was notified,Couldn\nt collect AM\n , try later.\n"},{"category":"Physician ","chartdate":"2152-06-07 00:00:00.000","description":"Physician Attending Progress Note","row_id":330669,"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 PICC LINE - START 04:16 PM\n Ventricular Tachycardia noted overnight--non sustained and\n approximately 9 events\n Diuresis effected with Lasix IV yesterday--but net fluid balance\n minimally negative for 24 hours\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:45 PM\n Ceftazidime - 08:00 AM\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:45 PM\n Heparin Sodium (Prophylaxis) - 07:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Flowsheet Data as of 10:07 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: 72 (64 - 111) bpm\n BP: 124/67(78) {98/42(60) - 144/105(110)} mmHg\n RR: 21 (13 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,607 mL\n 1,313 mL\n PO:\n TF:\n 1,267 mL\n 652 mL\n IVF:\n 1,140 mL\n 300 mL\n Blood products:\n Total out:\n 2,472 mL\n 761 mL\n Urine:\n 2,472 mL\n 761 mL\n NG:\n Stool:\n Drains:\n Balance:\n 135 mL\n 552 mL\n Respiratory support\n O2 Delivery Device: None, Aerosol-cool\n SpO2: 98%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No(t) Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : , Rhonchorous: Centrally)\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.3 g/dL\n 346 K/uL\n 108 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 18 mg/dL\n 105 mEq/L\n 142 mEq/L\n 34.8 %\n 16.0 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n 08:00 AM\n 04:32 PM\n 06:00 PM\n 03:50 AM\n WBC\n 20.8\n 20.6\n 17.4\n 16.0\n Hct\n 34.0\n 34.6\n 35.0\n 34.8\n Plt\n 46\n Cr\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n 103\n 200\n 190\n 108\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR----no significant change--some suggestion of mild\n clearing in left lung\n Assessment and Plan\n 81 yo female admit with respiratory failure in the setting of Chronic\n Obstructive Pulmonary Disease\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Atrovent/Albuterol nebs given\n Prednisone at 30mg and will continue to taper tomorrow\n Will likely need prolonged rehab to return to independent status\n PNEUMONIA, OTHER--she has had some significant improvement in terms\n of secretion volume but still with significant limitation in capacity\n to mobilize secreations\n vanco/CTX/Flagyl\n Ventricular Tachycardia\nnon sustained, mono-morphic, not triggered\n -Follow Lytes\n -Maintain telemetry\n -Check ECG\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:16 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":"2152-06-06 00:00:00.000","description":"Physician Resident Progress Note","row_id":330583,"text":"Chief Complaint: hypoxia/dyspnea\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:33 AM\n following cardiac enzymes\n CK 134 ->-264 -->224\n Trop .04 -->.02 -->.03\n diuresis overnight with lasix 10 x 3.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 AM\n Metronidazole - 04:00 PM\n Ceftazidime - 04:56 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 06:10 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 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 104 (76 - 109) bpm\n BP: 108/64(74) {89/32(47) - 158/99(102)} mmHg\n RR: 23 (10 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 2,076 mL\n 355 mL\n PO:\n TF:\n 476 mL\n 286 mL\n IVF:\n 1,240 mL\n 69 mL\n Blood products:\n Total out:\n 2,317 mL\n 785 mL\n Urine:\n 2,317 mL\n 785 mL\n NG:\n Stool:\n Drains:\n Balance:\n -241 mL\n -430 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\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 330 K/uL\n 11.4 g/dL\n 91 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 111 mEq/L\n 143 mEq/L\n 34.6 %\n 20.6 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n WBC\n 20.8\n 20.6\n Hct\n 34.0\n 34.6\n Plt\n 321\n 330\n Cr\n 0.5\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n Other labs: PT / PTT / INR:12.9/26.0/1.0,\n CK / CKMB / Troponin-T:224/10/0.03,\n ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR \n ECHO \n The left atrium is dilated. The left ventricle is not well seen. Due to\n suboptimal technical quality, a focal wall motion abnormality cannot be\n fully excluded. Overall left ventricular systolic function is normal\n (LVEF>55%). The aortic valve is not well seen. The mitral valve\n leaflets are not well seen.\n IMPRESSION: poor technical quality due to patient's body habitus. Left\n ventricular function is probably normal, a focal wall motion\n abnormality cannot be fully excluded. The right ventricle is not well\n seen. Valvular function could not be evaluated.\n Microbiology: urine cx neg\n urine leg neg\n blood cx neg\n sputum cx - contaminated\n Assessment and \n PROBLEM LIST:\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n summer ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT & PLAN:\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n # PNA\n Unimproved clinically with persistent leukocytosis (perhaps an\n element of reactive WBC from steroids) and copious purulent secretions\n -cont. vanco/ceftaz/flagyl (day 2), and start azithro (day 1) for\n atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n -consider bronch if suspect severe plugging or not improved\n .\n #COPD\n -cont. prednisone 40 mg, may taper if improves clinically\n -incr. freq. albuterol nebs q2h\n -atrovent nebs q6h\n .\n #.CHF - CXR reflects mild degree of volume overload\n -gentle diuresis, 10 mg lasix IV now, goal: -500 cc/day\n -TTE today, f/u final read\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n .\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -may consider S&S eval, G-tube study to eval. aspiration risk prior to\n giving anything PO\n -goal: -500 cc/day\n -- has G tube; will obtain c/s for tube feeds in am\n .\n #PPx: PPI, SQH, bowel regimen\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 06:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2152-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":330672,"text":"Chief Complaint: hypoxia & dyspnea\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n 24 Hour Events:\n PICC LINE - START 04:16 PM\n lasix 10 mg 1V x2 yesterday. decreased UOP to 20-27 cc/hr x hrs this\n morning. no increase in BUN or Cr.\n Patient had multiple separate episodes of non-sustained VTACH \n beats of monomorphic VTACH each time. Occurred on approx 7 times\n overnight. Patients electrolytes were WNL at the time of these\n episodes. No intervention was taken.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:45 PM\n Ceftazidime - 11:37 PM\n Metronidazole - 11:58 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:11 AM\n Furosemide (Lasix) - 10:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.5\n HR: 94 (64 - 111) bpm\n BP: 129/74(88) {86/32(45) - 144/105(110)} mmHg\n RR: 22 (4 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,607 mL\n 763 mL\n PO:\n TF:\n 1,267 mL\n 453 mL\n IVF:\n 1,140 mL\n 70 mL\n Blood products:\n Total out:\n 2,472 mL\n 734 mL\n Urine:\n 2,472 mL\n 734 mL\n NG:\n Stool:\n Drains:\n Balance:\n 135 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool 40% FM\n SpO2: 98%\n Physical Examination\n GEN: patient is more alert this morning; she is making eye contact and\n following commands. Patient is aphasic.\n LUNGS: wheezing diffusely. Rhochi diffusely\n CV: RRR, s1 & s2 nl, no m/r/g\n ABD: + BS, nt, nd, soft, G-tube in place with dressing C-D-I.\n EXT: warm dry. No cyanosis, clubbing or edema.\n Labs / Radiology\n 346 K/uL\n 11.3 g/dL\n 108 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 18 mg/dL\n 105 mEq/L\n 142 mEq/L\n 34.8 %\n 16.0 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n 08:00 AM\n 04:32 PM\n 06:00 PM\n 03:50 AM\n WBC\n 20.8\n 20.6\n 17.4\n 16.0\n Hct\n 34.0\n 34.6\n 35.0\n 34.8\n Plt\n 46\n Cr\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n 103\n 200\n 190\n 108\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR: no significant interval change.\n Microbiology: blood cx neg x1\n urine legionella neg x2\n urine cx neg x1\n sputum contaminated.\n Problem :\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT & PLAN:\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n # PNA\n some clinical improvement with decreased secretions.\n leukocytosis trending down.\n -cont. vanco/ceftaz/flagyl (day 4)\n possible 10 day course, and start\n azithro (day ) for atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n .\n #COPD\n -cont. 30mg PO today\n possible taper regimen. continue for 2 days and\n then decrease to 20mg PO daily for 2days.\n -albuterol nebs at q2h\n -atrovent nebs q6h\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\n study but showed good overall LV fn so less likely to be playing a role\n in pt\ns dyspnea.\n -gentle diuresis, 10 mg lasix IV PRN with goal: even to negative\n # VTACH\n nonsustained and monomorphic with no precipitating cause. No\n intervention warranted.\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -goal: -even to negative\n .\n #PPx: PPI, SQH, bowel regimen, add ISS while patient is on steroids.\n .\n #Access: lost PIV this am, hard to get venous access. Place PICC today\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n #. Dispo: consider dispo to rehab facility.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2152-06-07 00:00:00.000","description":"Nursing Progress Note","row_id":330680,"text":"Pneumonia, other\n Assessment:\n Received pt on 70% cool neb mask. Rr in the 20-s t low 30\ns depending\n on her level of agitation. O2 sats> 93% rhoncherous bs bil on\n auscultation with crackles at tha bases.Congested but nonproductive\n cough.\n Action:\n O2 weaned as pt tolerates to keep o2 sats> 92%. Nasotracheally\n suctioned for sm to mod amts of thick yellow sputum.resp status\n monitored closely. When resp status drops to < 90% it indicates that pt\n needs to be suctioned . antibiotics administered as ordered.\n Vancomycin d/c\n Response:\n Pt presently tolerating 2l/m nasal cannula with adequate o2 sats. Pt\n tolerating chest pt and resp toileting. O2 sats improve with\n nasotracheal suctioning.\n Plan:\n Pt being transferred this afternoon to rehab facility to acute\n floor for aggressive resp toileting. manager notified pt\n daughter about pt\ns transfer to rehab.\n"},{"category":"Nursing","chartdate":"2152-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":330574,"text":"Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n On face mask with 70% Fio2,desats to 85% when mask is off ,LS coarse\n t/o,normal breathing efforts RR 20-26 sats 90-95%\n Action:\n Suctioned nasally 2-3 hrs for thick yellow secretions,pt has very\n weak cough,chest PT prior to suction and nebs as ordered.\n Response\n Pt was more comfortable after suction.Stas were maintained.\n Plan:\n DNR/DNI,monitor resp staus,ICU care at this time Pulmonary hygene,\n wean Fio2 as tolerated.\n"},{"category":"Nursing","chartdate":"2152-06-07 00:00:00.000","description":"Nursing Progress Note","row_id":330655,"text":"81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation. Pt with s/p L cva summer of with\n residual aphasia and dementia including Alzheimers, multi-infarct.\n Pneumonia, other\n Assessment:\n Scattered rhonchi t/o lungs at beginning of shit with sats in mid 90s\n on 70% cool neb.\n Action:\n Pt nt suctioned for moderate amts clear white/clear secretions. Chest\n pt given with turns.\n Response:\n 02 sats remaining stable on 70% cool neb. Pt developed crackles around\n 9:30pm and noted to have a drop in urine to 17cc/hr. pt was given 10mg\n iv lasix with good response. At this time, pt has also been having\n short runs v tach up to 10 beat runs. Pt asymptomatic other than more\n lethargic: responding only to sternal rub when crackles developed.\n Still lethargic but more easily arousable. Runs of v tach subsided\n after diuresed. Urine output slowed down again the last few hours of\n the shift. Repeat cxr improved from yesterday per team and pt with sats\n in upper 90s with no increased 02 need. Appears comfortable but still\n with crackles at bases, rhonchi in upper airways. K and phosphate\n repleted.\n Plan:\n Continue nt suction prn, chest pt with turns, monitor fluid status,\n replete lytes prn.\n Alteration in Nutrition\n Assessment:\n Nutren pulmonary increased to goal of 65cc/hr . 100cc free water\n boluses given q6hrs. large loose ob + brown stool.\n Action:\n Tolerating tube feedings well with no residuals.\n Response:\n Continues to tolerate tube feedings.\n Plan:\n Continue tube feedings with free water boluses. Hold colace as pt\n having loose stool.\n"},{"category":"Physician ","chartdate":"2152-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":330660,"text":"Chief Complaint: hypoxia & dyspnea\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n 24 Hour Events:\n PICC LINE - START 04:16 PM\n --> lasix 10 mg 1V x2 yesterday. decreased UOP to 20-27 cc/hr x hrs\n this morning. no increase in BUN or Cr.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:45 PM\n Ceftazidime - 11:37 PM\n Metronidazole - 11:58 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:11 AM\n Furosemide (Lasix) - 10:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.5\n HR: 94 (64 - 111) bpm\n BP: 129/74(88) {86/32(45) - 144/105(110)} mmHg\n RR: 22 (4 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,607 mL\n 763 mL\n PO:\n TF:\n 1,267 mL\n 453 mL\n IVF:\n 1,140 mL\n 70 mL\n Blood products:\n Total out:\n 2,472 mL\n 734 mL\n Urine:\n 2,472 mL\n 734 mL\n NG:\n Stool:\n Drains:\n Balance:\n 135 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///30/\n Physical Examination\n GEN:\n HEENT:\n LUNGS\n CV:\n ABD\n EXT:\n Labs / Radiology\n 346 K/uL\n 11.3 g/dL\n 108 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 18 mg/dL\n 105 mEq/L\n 142 mEq/L\n 34.8 %\n 16.0 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n 08:00 AM\n 04:32 PM\n 06:00 PM\n 03:50 AM\n WBC\n 20.8\n 20.6\n 17.4\n 16.0\n Hct\n 34.0\n 34.6\n 35.0\n 34.8\n Plt\n 46\n Cr\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n 103\n 200\n 190\n 108\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR: improved from previous. lung fields clearer bilat.\n hemidiaphragm seen more easily especially on left.\n Microbiology: blood cx neg x1\n urine legionella neg x2\n urine cx neg x1\n sputum contaminated.\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT & PLAN:\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n # PNA\n Unimproved clinically with persistent leukocytosis (perhaps an\n element of reactive WBC from steroids) and copious purulent secretions\n -cont. vanco/ceftaz/flagyl (day 3), and start azithro (day ) for\n atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n -consider bronch if suspect severe plugging or not improved\n .\n #COPD\n -cont. prednisone 40 mg, wrote to decrease to 30mg PO tomorrow AM.\n -incr. freq. albuterol nebs q2h\n -atrovent nebs q6h\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\n study but showed good overall LV fn so less likely to be playing a role\n in pt\ns dyspnea.\n -gentle diuresis, 10 mg lasix IV now, goal: even to negative\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n .\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -goal: -even to negative\n .\n #PPx: PPI, SQH, bowel regimen\n .\n #Access: lost PIV this am, hard to get venous access. Place PICC today\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Nursing","chartdate":"2152-06-05 00:00:00.000","description":"Nursing Progress Note","row_id":330482,"text":"81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\n presented to Hospital from with dyspnea.\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\n 1700 via foley. Pt is DNR/DNI, admitted to for further\n management of pneumonia.\n Pneumonia, other\n Assessment:\n Pt continues on 40% cool neb, CXR~ LLL infiltrate. Pt suctioned q 2\n -3 hours for thick yellow secretions, afebrile, WBC 20.8 pt remains\n on Vanco, Ceftazidime, and Flagyl. On prednisone 40 mg per G-tube qd.\n cpt done bp stable 109/50 HR 80\ns SR occ pvc, (4 beat run\n V-tach)\n Action:\n Suctioned q 2 hrs, nebs q 6 hrs, aggressive pulmonary toilet\n Response:\n Sx helps clear airway\n Plan:\n Continue current therapies, monitor for worsening resp status\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt with Alzheimers dementia, parkinsonian behavior, repetitive\n speech, expressive aphasia\n Action:\n Support pt, occ pt will be lucid\n Response:\n Pt able to communicate at times, able to answer appropriately when\n asked if she needs to be changed\n Plan:\n Continue focused pt interaction with pt\n Alteration in Nutrition\n Assessment:\n Tube feeds started FS Nutren pulmonary at 10 cc/hr via G-tube at 12\n midnight according to team good urine output.\n Action:\n Tube feeds started at a low rate\n Response:\n No issues\n Plan:\n Increase as tolerated to 40 cc/hr flush with 100 cc water q 6 hrs.\n Impaired Skin Integrity\n Assessment:\n Pt turned frequently, left hip looks better\n stage 1\n Action:\n Pt turned freq, skin care\n Response:\n Plan:\n Continue to turn freq, good skin care.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1022648,\n \"text\": \" 4:33 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for interval change\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with COPD, PNA\\n REASON FOR THIS EXAMINATION:\\n Eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: COPD, pneumonia.\\n\\n Comparison is made with prior study .\\n\\n There are low lung volumes. Atelectasis in the left base has improved. Left\\n PICC remains in place, there is mild increase in right lower lobe atelectasis.\\n There is mild fluid overload.\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1022477,\n \"text\": \" 5:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 81 year old woman with ? LLL pneumonia in ICU; please evalua\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with ? LLL pneumonia in ICU; please evaluate for interval\\n change in infiltrates and effusions.\\n REASON FOR THIS EXAMINATION:\\n 81 year old woman with ? LLL pneumonia in ICU; please evaluate for interval\\n change in infiltrates and effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Possible left lower lobe pneumonia.\\n\\n FINDINGS: In comparison with the study of , there are lower lung volumes.\\n Some increased opacification at the left base with silhouetting in the\\n hemidiaphragm is most consistent with pleural fluid and atelectatic change,\\n though the possibility of supervening pneumonia cannot be definitely excluded.\\n Similar changes are seen at the right base medially, though some of this may\\n merely be crowding of vessels.\\n\\n Indistinct prominence of pulmonary vessels suggests some elevated pulmonary\\n venous pressure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1022210,\n \"text\": \" 8:39 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for infiltrate, pulm edema\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with COPD, PNA a/w congestion, hypoxia\\n REASON FOR THIS EXAMINATION:\\n Eval for infiltrate, pulm edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: AP chest .\\n\\n HISTORY: 81-year-old woman with COPD and hypoxia.\\n\\n FINDINGS: Comparison is made to previous study from .\\n\\n The cardiac silhouette is upper limits of normal but unchanged. There is\\n again seen some subsegmental atelectasis at the left base. The rest of the\\n lung fields are clear. There are no signs for overt pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1022314,\n \"text\": \" 5:55 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for interval change\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with COPD a/w PNA\\n REASON FOR THIS EXAMINATION:\\n Eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: COPD with possible pneumonia.\\n\\n FINDINGS: The hand of the patient obscures most of the right hemithorax.\\n Otherwise, there is little change in the appearance of the heart and lungs\\n from the study of . A repeat examination would be helpful.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1022156,\n \"text\": \" 8:12 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with cough and hypoxia\\n REASON FOR THIS EXAMINATION:\\n assess pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 81-year-old female with cough and hypoxia. Please assess for\\n pneumonia.\\n\\n FINDINGS: AP upright chest radiograph is reviewed and compared to .\\n Evaluation is limited by rotation, despite technologist's attempts to properly\\n position the patient. Evaluation is also limited by low lung volumes. There\\n is no large consolidation, though retrocardiac area cannot be reliably\\n assessed. There is no definite pleural effusion or pneumothorax.\\n\\n IMPRESSION: Limited exam. No focal consolidation.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 82576,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Right ventricular function.\\nHeight: (in) 63\\nWeight (lb): 150\\nBSA (m2): 1.71 m2\\nBP (mm Hg): 115/70\\nHR (bpm): 103\\nStatus: Inpatient\\nDate/Time: at 11:29\\nTest: Portable TTE (Complete)\\nDoppler: Full 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.\\n\\nLEFT VENTRICLE: LV not well seen. Suboptimal technical quality, a focal LV\\nwall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%).\\nNo resting LVOT gradient.\\n\\nRIGHT VENTRICLE: RV not well seen.\\n\\nAORTIC VALVE: Aortic valve not well seen.\\n\\nMITRAL VALVE: Mitral valve leaflets not well seen.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\\nimage quality - bandages, defibrillator pads or electrodes. Suboptimal image\\nquality as the patient was difficult to position. Suboptimal image quality -\\npatient unable to cooperate. Resting tachycardia (HR>100bpm). The rhythm\\nappears to be atrial fibrillation.\\n\\nConclusions:\\nThe left atrium is dilated. The left ventricle is not well seen. Due to\\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\\nexcluded. Overall left ventricular systolic function is normal (LVEF>55%). The\\naortic valve is not well seen. The mitral valve leaflets are not well seen.\\n\\nIMPRESSION: poor technical quality due to patient's body habitus. Left\\nventricular function is probably normal, a focal wall motion abnormality\\ncannot be fully excluded. The right ventricle is not well seen. Valvular\\nfunction could not be evaluated.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1022579,\n \"text\": \" 2:48 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: l dl picc 43cm\\n Admitting Diagnosis: PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with\\n REASON FOR THIS EXAMINATION:\\n l dl picc 43cm\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: PICC line placement.\\n\\n FINDINGS: In comparison with the earlier study of this date, there has been\\n placement of a left subclavian PICC line that extends to the mid portion of\\n the SVC. Little change in the appearance of the heart and lungs.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-06-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 199242,\n \"text\": \"Baseline artifact makes interpretation difficult\\nSinus tachycardia\\nSince previous tracing of the same date, baseline artifact present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-06-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 199243,\n \"text\": \"Baseline artifact\\nSinus tachycardia\\nPoor R wave progression\\nNonspecific T wave flattening\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330481,\n \"text\": \"81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\\n presented to Hospital from with dyspnea.\\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\\n 1700 via foley. Pt is DNR/DNI, admitted to for further\\n management of pneumonia.\\n Pneumonia, other\\n Assessment:\\n Pt continues on 40% cool neb, CXR~ LLL infiltrate. Pt suctioned q 2\\n -3 hours for thick yellow secretions, afebrile, WBC 20.8 pt remains\\n on Vanco, Ceftazidime, and Flagyl. On prednisone 40 mg per G-tube qd.\\n Prednisone 40 mg qd, cpt done\\n Action:\\n Suctioned q 2 hrs, nebs q 6 hrs, aggressive pulmonary toilet\\n Response:\\n Sx helps clear airway\\n Plan:\\n Continue current therapies, monitor for worsening resp status\\n Dementia (including Alzheimer's, Multi Infarct)\\n Assessment:\\n Pt with Alzheimers dementia, parkinsonian gehavior, repetitive\\n speech, expressive aphasia\\n Action:\\n Response:\\n Plan:\\n Alteration in Nutrition\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330464,\n \"text\": \"Alteration in Nutrition\\n Assessment:\\n Family states noted poor po intake over last few weeks, possibly due to\\n compromised resp status\\n Action:\\n TF held for now poor resp status frequent NT suctioning w/ copious\\n amts of secretions, coughing\\n Response:\\n Pt w/o s/s nutritional compromise, dehydration\\n Plan:\\n Re assess nutrition needs may start TF in 24 hr when pt settles\\n Pneumonia, other\\n Assessment:\\n Pt w/ pneu w/ worsening cxr, copious amt thick yellow secretions, , low\\n grade temp\\n Action:\\n Suctioned q1 hr , nebs q2-4 hrs prn , aggressive pulm toileting, ab tx\\n Response:\\n Cont to have need for freq suctioning, pulm toileting transient relief\\n noted\\n Plan:\\n Cont current therapies, monitor for worsening resp status pt is\\n DNR/DNI\\n Dementia (including Alzheimer's, Multi Infarct)\\n Assessment:\\n Pt w/ alzheimers dementia, parkinsonian behavior, repetitive speech,\\n expressive aphasia\\n Action:\\n Allowed pt to answer question at own , occ be lucid\\n Response:\\n Able to communicate at times, able to answer appropriately when asked\\n oif she was soilded or in pain\\n Plan:\\n Cont focused patient interaction with pt\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330547,\n \"text\": \"81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\\n presented to Hospital from with dyspnea.\\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\\n 1700 via foley. Pt is DNR/DNI, admitted to for further\\n management of pneumonia.\\n Pneumonia, other\\n Assessment:\\n Pt. on 70% cool neb mask. Pulling mask off face frequently and desating\\n to 85%. LS rhonkie with occ wheez.\\n Action:\\n Lasix 10 mg IV for I/O goal -500cc. Nebs and Chest PT to help Pt.\\n mobilize secretions. NT suctioned few time this shift for thick yellow\\n sectretions. IV abx as ordered.\\n Response:\\n Remains afebrile. I/O at this time +112cc.\\n Plan:\\n Cont. current care. Will give additional Lasix to meet I/O goal.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330638,\n \"text\": \"81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation. Pt with s/p L cva summer of with\\n residual aphasia and dementia including Alzheimers, multi-infarct.\\n Pneumonia, other\\n Assessment:\\n Scattered rhonchi t/o lungs at beginning of shit with sats in mid 90s\\n on 70% cool neb.\\n Action:\\n Pt nt suctioned for moderate amts clear white/clear secretions. Chest\\n pt given with turns.\\n Response:\\n 02 sats remaining stable on 70% cool neb. Pt developed crackles around\\n 9:30pm and noted to have a drop in urine to 17cc/hr. pt was given 10mg\\n iv lasix with good response. At this time, pt has also been having\\n short runs v tach up to 10 beat runs. Pt asymptomatic other than more\\n lethargic: responding only to sternal rub when crackles developed.\\n Still lethargic but more easily arousable.\\n Plan:\\n Continue nt suction prn, chest pt with turns, monitor fluid status, f/u\\n with am labs and replete lytes prn.\\n Alteration in Nutrition\\n Assessment:\\n Nutren pulmonary increased to goal of 65cc/hr . 100cc free water\\n boluses given q6hrs. large loose ob + brown stool.\\n Action:\\n Tolerating tube feedings well with no residuals.\\n Response:\\n Continues to tolerate tube feedings.\\n Plan:\\n Continue tube feedings with free water boluses. Hold colace as pt\\n having loose stool.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330454,\n \"text\": \"Chief Complaint: SOB\\n 24 Hour Events:\\n SPUTUM CULTURE - At 05:11 AM\\n --\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 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 07:35 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: 93 (78 - 104) bpm\\n BP: 112/44(62) {89/27(42) - 117/56(70)} mmHg\\n RR: 24 (16 - 24) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 57 Inch\\n Total In:\\n 4,835 mL\\n PO:\\n TF:\\n IVF:\\n 135 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,650 mL\\n Urine:\\n 2,650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,185 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 90%\\n ABG:\\n Physical Examination\\n Gen:\\n Lungs:\\n CV:\\n ABD:\\n EXT\\n Labs / Radiology\\n [image002.jpg]\\n PROBLEM LIST:\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION\\n PNEUMONIA, OTHER\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ASSESSMENT AND PLAN:\\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \\n have triggered COPD flare. Minimal evidence of CHF exacerbation on\\n imaging, exam and labs, but does have CHF history.\\n -- continue steroids; will start prednisone 40 mg QD in am\\n -- standing albuterol and ipratropium nebs overnight; will consider\\n changing to PRN in the am pending improvement\\n -- will place on vanco/zosyn for NH/HAP broad coverage esp since she\\n failed the levaquin tx\\n -- deferring further w/u for PE given PNA likely cause\\n -- UCx, BCx pending from ED\\n -- will order sputum cultures\\n -- low suspicion for MI, but will continue cycling enzymes with second\\n set with am labs (first set negative)\\n #. COPD:\\n -- management as above\\n .\\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\\n OSH. No echo in file at the .\\n -- monitor for signs of volume overload; gentle IVF overnight if needed\\n .\\n #. HTN:\\n -- will hold home metoprolol overnight to ensure that BP remains stable\\n in light of possible infection.\\n .\\n #. Hypothyroidism\\n -- continue levothyroxine 88 mcg QD\\n .\\n #. Dementia: not currently on medications\\n .\\n #. Depression: was on venlafaxine in past; held on last admission for\\n c/f NMS. Nothing on med list currently.\\n .\\n #. Osteoporosis: currently on calcium supplements\\n -- cont calcium; t/c starting Vit D\\n -- fall precautions\\n .\\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\\n free water flushes Qshift; unclear what she takes in PO if anything\\n (confusion records vs. reports frm daughter)\\n -- has G tube; will obtain c/s for tube feeds in am\\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\\n IVF overnight\\n .\\n #. PPX: no indication for PPI currently; SHQ (wears boots at rehab);\\n bowel regimen\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n .\\n #. Dispo: to remain in ICU overnight for tx and observation\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 330457,\n \"text\": \"TITLE:\\n Broadened abx regimen overnight to Vanc/Zosyn. This morning\\n desaturation requiring inc. FiO2. and suctioning. Requiring frequent\\n suctioning yielding tenacious white material. Outside film with\\n bibasilar infiltrates. Repeat film at less impressive though\\n rotated. Cont require ICU care for tenuous resp status with desats\\n and requiring suctioning q1-2hrs.\\n Pt is critically ill. 35min spent on care.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330459,\n \"text\": \"Chief Complaint: SOB\\n 24 Hour Events:\\n Overnight patient was placed on vanco/zosyn for broad coverage in a\\n pt. She was placed on O2.\\n SPUTUM CULTURE - At 05:11 AM\\n Episode of SOB this AM, Desat to 88% on 4L NC. Patient was\\n suctioned. Started on FM with 100% FiO2 briefly and then quickly down\\n to 40%. Afebrile at the time. She was given a neb treatment without\\n much effect. A repeat CXR was obtained. Per nursing patient has\\n copious resp secretions that are white.\\n Subjective: patient is aphasic and incoherent.\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 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 07:35 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: 93 (78 - 104) bpm\\n BP: 112/44(62) {89/27(42) - 117/56(70)} mmHg\\n RR: 24 (16 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 57 Inch\\n Total In:\\n 4,835 mL\\n PO:\\n TF:\\n IVF:\\n 135 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,650 mL\\n Urine:\\n 2,650 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,185 mL\\n Respiratory support\\n O2 Delivery Device: FM 40% FiO2\\n SpO2: 96%\\n ABG:\\n Physical Examination\\n Gen: aphasic, with residual right sided hemiparesis, repeating sounds\\n incoherently.\\n Lungs: diffuse rhonchi\\n CV: rapid rate, regular rhythm, s1 & s2 nl, no m/r/g\\n ABD: + bs, nt, nd, soft\\n EXT: some LE edema bilat\\n Labs / Radiology\\n [image002.jpg]\\n Labs pending this morning due to difficult draw.\\n PROBLEM LIST:\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION\\n PNEUMONIA, OTHER\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ASSESSMENT AND PLAN:\\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \\n have triggered COPD flare. Minimal evidence of CHF exacerbation on\\n imaging, exam and labs, but does have CHF history. Patient has copious\\n respiratory secretions.\\n -- continue steroids; will start prednisone 40 mg QD in am\\n -- standing albuterol and ipratropium nebs overnight; will consider\\n changing to PRN in the am pending improvement\\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\\n levaquin tx\\n -- deferring further w/u for PE given PNA likely cause\\n -- UCx, BCx pending from ED\\n -- follow up re: sputum cx\\n -- low suspicion for MI, but will continue cycling enzymes with second\\n set with am labs (first set negative)\\n --suctioning Q1 hr., Chest PT.\\n #. COPD:\\n -- management as above\\n .\\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\\n OSH. No echo in file at the .\\n -- d/c maintenance fluids\\n -- obtain ECHO\\n .\\n #. HTN:\\n -- restart home dose of metoprolol\\n .\\n #. Hypothyroidism\\n -- continue levothyroxine 88 mcg QD\\n .\\n #. Dementia: not currently on medications\\n .\\n #. Depression: was on venlafaxine in past; held on last admission for\\n c/f NMS. Nothing on med list currently.\\n .\\n #. Osteoporosis: currently on calcium supplements\\n -- cont calcium; t/c starting Vit D\\n -- fall precautions\\n .\\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\\n free water flushes Qshift; unclear what she takes in PO if anything\\n (confusion records vs. reports frm daughter)\\n -- holding TF pending improved respiratory status. Concern re:\\n aspiration if patient requires BPAP.\\n -- has G tube; will obtain c/s for tube feeds in am\\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\\n IVF overnight\\n .\\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\\n regimen\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n .\\n #. Dispo: to remain in ICU overnight for tx and observation\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330440,\n \"text\": \"81 y.o.female with h/o CVA, dementia, COPD presented to \\n Hospital from with dyspnea. Tranferred to \\n EW, diagnosed with pneumonia, sat 88% on 4 liters n/c, temp 102.4 HR\\n 136, lactate 3.1 WBC 22..4 received Vanco, Cefepime,\\n Azithromycin. Pt received 3-4 liters NS, urine output 1700 via\\n foley. Pt is DNR/DNI, admitted to for further management of\\n pneumonia.\\n Pneumonia, other\\n Assessment:\\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. Os sat\\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\\n cough, pt sleeping on/off. Nonverbal (mumbles words)\\n Action:\\n Response:\\n Plan:\\n Impaired Skin Integrity\\n Assessment:\\n Left hip\\n stage 1 skin broken, area cleansed with foam cleanser,\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note\",\n \"row_id\": 330441,\n \"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 81 yo women resident of Rehab p/w hypoxemia (sat of 90s on 2L\\n NC). Has had\\n two weeks of worsening SOB, cough with sputum, and 3 days of fever to\\n 101. Was started on Levoquin. Today was hypoxemic and transferred to\\n - Afeb, 99.8 HR 106, 122.68, RR 22, 92% on 2L NC, WBC 28 with\\n 19% bands, troponin <0.04. BNP 38. ABG 7.46/32/91. Got Medrol, Nebs,\\n Tylenol, CTX and Flagyl. CXR with ? LLL infiltrate and Right\\n infiltrate. Transferred to where she got 3L of saline, and\\n Vanco,Cefepine,Azithro.\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n aspiration PNA\\n Dementia\\n CVA with expressive aphasia\\n G-tube\\n legally blind\\n pulmonary HTN\\n CHF\\n Meds at home:\\n Synthroid\\n Albuterol/atroven\\n Prednisone 5mg qd\\n lopressor 25 \\n unremarkable\\n Occupation: Rehab\\n Drugs: none\\n Tobacco: none\\n Alcohol: none\\n Other: Daughter is \\n Review of systems:\\n Constitutional: Fever\\n Cardiovascular: No(t) Chest pain\\n Respiratory: Cough\\n Gastrointestinal: No(t) Diarrhea\\n Genitourinary: No(t) Dysuria\\n Integumentary (skin): No(t) Rash\\n Endocrine: No(t) Hyperglycemia\\n Heme / Lymph: No(t) Anemia\\n Neurologic: No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated\\n Signs or concerns for abuse : No\\n Flowsheet Data as of 03:04 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: 95 (95 - 104) bpm\\n BP: 89/27(42) {89/27(42) - 117/42(56)} mmHg\\n RR: 18 (18 - 19) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 57 Inch\\n Total In:\\n 4,700 mL\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 2,050 mL\\n Urine:\\n 2,050 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,650 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n ABG: ////\\n Physical Examination\\n General Appearance: Thin\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Crackles : bases, Rhonchorous: )\\n Abdominal: Soft, Non-tender, G-tube\\n Extremities: Right: Absent, Left: Absent\\n Skin: Warm, No(t) Rash:\\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\\n to: Tactile stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 338\\n 39.3\\n 187\\n 0.7\\n 15\\n 20\\n 102\\n 4.3\\n 138\\n 22.4\\n [image002.jpg]\\n Other labs: Lactic Acid:3.1\\n Fluid analysis / Other labs: U/A: 0-2 WBC\\n Assessment and Plan\\n Aspiration PNA: High WBC, ? of multilobar infilatrates on CXR. Vanco\\n and Zosyn for HAP as she is from institution and failed levoflox\\n therapy. Check sputum cultures.\\n COPD: Continue nebs, lower dose to prednisone 40mg.\\n Dementia: Poor MS not far from her baseline, no need to image head\\n HTN: Hold antihypertensives as BP is low.\\n HOTN: Likely due to sepsis from aspiration PNA.\\n TFs through G-tube.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Blood sugar well controlled\\n Lines / Intubation:\\n 20 Gauge - 01:08 AM\\n Comments:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition: ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 330444,\n \"text\": \"Chief Complaint: SOB, decreasing O2 sats\\n HPI:\\n Ms. is an 81 yo F with h/o aspiration PNA, COPD and\\n CVA/aphasia, who presented to the ED from Rehab with SOB,\\n wheezing and low O2 sats (92% on 2LNC). Her daughter states that she\\n became progressively more SOB with cough and inc sputum and decreasing\\n PO intake for the past 2 weeks. 2 days ago she ran a temp to 100.1 F\\n and she was given two doses of levaquin at the rehab yesterday (unclear\\n if had gotten more) for increased secretions. She was also given lasix\\n 40 mg PO x1. She initially presented to the ED this afternoon\\n but was transferred to the per the request of her family.\\n At , VS were 99.8, 106, 22, 142/68, and 92% 2LNC. WBC was 28.1\\n w/ 19% bands, trop < 0.04, BNP 38, bicarb 26; ABG was 7.46/32/91 on ?\\n O2. She was given solumedrol, duonebs, Tylenol, ceftriaxone x 1, and\\n flagyl x 1. She had one set of cardiac enzymes that were nagtive and\\n CXR reportedly had a LLL PNA. VS on arrival to were 99.5, HR\\n 134, BP 100/78, RR 22, 92% on 4L NC. She was given 3 L NS as well as\\n vancomycin 1 g IV, azithromycin 500 mg IV and cefepime 2 g IV.\\n Per daughter: She was placed in long-term care facility ~3.5 yrs ago\\n for alzheimer's dementia. About 1-2 years ago she fell out of bed at\\n NH and fx'ed her hip. She has not ambulated since then. She had 2\\n strokes in summer of that left her with an expressive aphasia. She\\n can speak in simple sentences/phrases when well. She will often string\\n together non-coherent words and believe she is communicating\\n coherently. Daughter states the current babbling of word fragments is\\n worse than her baseline.\\n Unable to obtain ROS due to MS, aphasia.\\n Patient admitted from: Transfer from other hospital, via ED;\\n transferred per family's wishes\\n History obtained from Family / Medical records\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n HOME MEDICATIONS (per d/c summary and ED notes):\\n Synthroid 88 mcg QD\\n Albuterol nebs Q4 hours PRN\\n Ipratropium neb Q6 hours PRN\\n levaquin 250 mg PO qday (day )\\n Prednisone 5 mg QD\\n Senna, colace, MOM\\n \\n Metoprolol Tartrate 25 mg \\n Calcium carbonate\\n hyocysamine 0.25 mg Q4 hours PRN\\n MVI, Vit C\\n Tylenol 325-650mg PO PRN\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n Dementia\\n HTN\\n Hypothyroidism\\n CVA-- aphasic, right sided weakness; has G tube\\n Legally blind (macular degeneration)\\n Pulmonary hypertension\\n CHF\\n Depression\\n Left hallux ulceration\\n s/p R humerous and pelvic fx\\n s/p CCY\\n s/p TAH for adenocarcinoma\\n Osteoporosis\\n Non-contributory\\n Occupation: NC\\n Drugs: denied\\n Tobacco: denied\\n Alcohol: denied\\n Other: lives at Rehab\\n Review of systems: could not obtain aphasia, mental status\\n Flowsheet Data as of 03:41 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.8\\nC (96.4\\n Tcurrent: 35.8\\nC (96.4\\n HR: 95 (95 - 104) bpm\\n BP: 89/27(42) {89/27(42) - 117/42(56)} mmHg\\n RR: 18 (18 - 19) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 57 Inch\\n Total In:\\n 4,700 mL\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 2,050 mL\\n Urine:\\n 2,050 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 2,650 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 99%\\n Physical Examination\\n General Appearance: Well nourished, Overweight / Obese, No(t)\\n Diaphoretic\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\\n at bases b/l, Wheezes : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\\n Tender: , Obese, G tube\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Skin: Not assessed\\n Neurologic: No(t) Follows simple commands, Responds to: Tactile\\n stimuli, No(t) Oriented (to): cannot communicate, Movement: Not\\n assessed, Tone: Not assessed, rt arm contracture; rt foot fixed\\n extension;RU/LE weakness/paralysis; CN II - XII symmetric; aphasic\\n Labs / Radiology\\n 338\\n 187\\n 0.7\\n 15\\n 20\\n 102\\n 4.3\\n 138\\n 39.3\\n 22.4\\n [image002.jpg]\\n 95% PMN\\ns, 0% bands\\n Lactate 3.1\\n Trop 0.04, CK 134, MB 5\\n UA negative\\n Imaging: ADMISSION CXR:\\n AP upright chest radiograph is reviewed and compared to .\\n Evaluation is limited by rotation, despite technologist's attempts to\\n properly position the patient. Evaluation is also limited by low lung\\n volumes. There is no large consolidation, though retrocardiac area\\n cannot be reliably assessed. There is no definite pleural effusion or\\n pneumothorax.\\n IMPRESSION: Limited exam. No focal consolidation.\\n Microbiology: UCx, BCx pending\\n ECG: AMDISSION EKG: noisy background, sinus tach at 130; poor R wave\\n progression; no ST seg changes or TWI; LAD.\\n Assessment and Plan\\n ASSESSMENT/PLAN:\\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\\n .\\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \\n have triggered COPD flare. Minimal evidence of CHF exacerbation on\\n imaging, exam and labs, but does have CHF history.\\n -- continue steroids; will start prednisone 40 mg QD in am\\n -- standing albuterol and ipratropium nebs overnight; will consider\\n changing to PRN in the am pending improvement\\n -- will place on vanco/zosyn for NH/HAP broad coverage esp since she\\n failed the levaquin tx\\n -- deferring further w/u for PE given PNA likely cause\\n -- UCx, BCx pending from ED\\n -- will order sputum cultures\\n -- low suspicion for MI, but will continue cycling enzymes with second\\n set with am labs (first set negative)\\n .\\n #. COPD:\\n -- management as above\\n .\\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\\n OSH. No echo in file at the .\\n -- monitor for signs of volume overload; gentle IVF overnight if needed\\n .\\n #. HTN:\\n -- will hold home metoprolol overnight to ensure that BP remains stable\\n in light of possible infection.\\n .\\n #. Hypothyroidism\\n -- continue levothyroxine 88 mcg QD\\n .\\n #. Dementia: not currently on medications\\n .\\n #. Depression: was on venlafaxine in past; held on last admission for\\n c/f NMS. Nothing on med list currently.\\n .\\n #. Osteoporosis: currently on calcium supplements\\n -- cont calcium; t/c starting Vit D\\n -- fall precautions\\n .\\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\\n free water flushes Qshift; unclear what she takes in PO if anything\\n (confusion records vs. reports frm daughter)\\n -- has G tube; will obtain c/s for tube feeds in am\\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\\n IVF overnight\\n .\\n #. PPX: no indication for PPI currently; SHQ (wears boots at rehab);\\n bowel regimen\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n .\\n #. Dispo: to remain in ICU overnight for tx and observation\\n ICU Care\\n Nutrition:\\n Comments: NPO for now; will clarify tube feed vs. PO feed regimen in am\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin(bowel regimen)\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: Comments: Spoke with daughter on admission\\n Code status: DNR / DNI\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330438,\n \"text\": \"81 y.o. with h/o CVA, dementia, COPD presented to Hospital\\n from with dyspnea. CXR~ pneumonia. Pt received 3\\n liters of IVF, Tylenol x 1, Vanco, Cefepime, Azithromycin\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330439,\n \"text\": \"81 y.o.female with h/o CVA, dementia, COPD presented to \\n Hospital from with dyspnea. Tranferred to \\n EW, diagnosed with pneumonia, sat 88% on 4 liters n/c, temp 102.4 HR\\n 136, lactate 3.1 WBC 22..4 received Vanco, Cefepime,\\n Azithromycin. Pt received 3-4 liters NS, urine output 1700 via\\n foley. Pt is DNR/DNI, admitted to for further management of\\n pneumonia.\\n Pneumonia, other\\n Assessment:\\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. Os sat\\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\\n cough, pt sleeping on/off. Nonverbal (mumbles words)\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330446,\n \"text\": \"81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\\n presented to Hospital from with dyspnea.\\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\\n 1700 via foley. Pt is DNR/DNI, admitted to for further\\n management of pneumonia.\\n Pneumonia, other\\n Assessment:\\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. O2 sat\\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\\n cough, pt sleeping on/off. Nonverbal (mumbles words) pt on Vanco and\\n Zosyn, prednisone po, Albuterol/Atovent inhalers q 6 hrs\\n Action:\\n Pt with coarse breath sounds, nasally suctioned for thick yellow\\n secretions\\n sent for gram stain, and culture.\\n Response:\\n Pt sounds better\\n Plan:\\n Continue with pulmonary toilet. Check sputum cx, continue antibx for\\n ?LLL infiltrate from OSH film. Continue steroids, nebs.\\n Impaired Skin Integrity\\n Assessment:\\n Left hip\\n stage 1 skin broken, area cleansed with foam cleanser,\\n aloe vesta cream applied. Pt turned freq.\\n Action:\\n Kept off back\\n Response:\\n Plan:\\n Consult skin care for left hip. Keep off back. Follow closely.\\n NEURO: Per daughter: She was placed in long-term care facility ~3.5\\n yrs ago for alzheimer's dementia. About 1-2 years ago she fell out of\\n bed at NH and fx'ed her hip. She has not ambulated since then. She\\n had 2 strokes in summer of that left her with an expressive\\n aphasia. She can speak in simple sentences/phrases when well. She\\n will often string together non-coherent words and believe she is\\n communicating coherently. Daughter states the current babbling of word\\n fragments is worse than her baseline.\\n per resident\\ns note. Pt\\n currently babbling, r arm contracted, can move though, moves left\\n arm. Unable to draw pt\\ns blood\\n intern will need to perform groin\\n stick. Pt is legally blind.\\n GI: pt with a G-tube. Was on Probalance 65 cc/hr on at 9 pm, off\\n at 6 am.\\n GU: great urine output. >2 liters.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330532,\n \"text\": \"Chief Complaint: Pneumonia\\n 24 Hour Events: per ID, zosyn changed to ceftaz/flagyl\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\\n Vancomycin - 10:00 PM\\n Metronidazole - 12:00 AM\\n Ceftazidime - 12:19 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 10:17 AM\\n Heparin Sodium (Prophylaxis) - 12:34 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: pt non-communicative\\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: 35.9\\nC (96.6\\n HR: 84 (57 - 132) bpm\\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\\n RR: 28 (16 - 37) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 57 Inch\\n Total In:\\n 5,549 mL\\n 386 mL\\n PO:\\n TF:\\n 33 mL\\n IVF:\\n 849 mL\\n 353 mL\\n Blood products:\\n Total out:\\n 3,950 mL\\n 330 mL\\n Urine:\\n 3,950 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,599 mL\\n 56 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 92%\\n Physical Examination\\n Gen: aphasic, with residual right sided hemiparesis, perseverative,\\n incoherent\\n CV: reg tachy, nl S1S2 no m/r/g\\n PULM: diffuse rhonchi and wheezing bilat\\n ABD: soft NTND + BS G-tube site c/d/i\\n EXT: warm, dry 1+LE edema bilat\\n Labs / Radiology\\n 321 K/uL\\n 11.3 g/dL\\n 130 mg/dL\\n 0.5 mg/dL\\n 22 mEq/L\\n 3.8 mEq/L\\n 15 mg/dL\\n 112 mEq/L\\n 143 mEq/L\\n 34.0 %\\n 20.8 K/uL\\n [image002.jpg]\\n 06:15 PM\\n WBC\\n 20.8\\n Hct\\n 34.0\\n Plt\\n 321\\n Cr\\n 0.5\\n TropT\\n 0.02\\n Glucose\\n 130\\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n .\\n # PNA\\n Unimproved clinically with persistent leukocytosis (perhaps an\\n element of reactive WBC from steroids) and copious purulent secretions\\n -cont. vanco/ceftaz/flagyl (day 2), and start azithro (day 1) for\\n atypicals\\n -freq. suctioning, chest PT\\n -repeat sputum cx, urinary legionella AG\\n -blood cx NGTD\\n -consider bronch if suspect severe plugging or not improved\\n .\\n #COPD\\n -cont. prednisone 40 mg, may taper if improves clinically\\n -incr. freq. albuterol nebs q2h\\n -atrovent nebs q6h\\n .\\n #.CHF - CXR reflects mild degree of volume overload\\n -gentle diuresis, 10 mg lasix IV now, goal: -500 cc/day\\n -TTE today, f/u final read\\n .\\n #.HTN:\\n -cont. lopressor\\n .\\n # Hypothyroidism\\n - cont. levothyroxine\\n .\\n #.Osteoporosis: currently on calcium supplements\\n - cont calcium; t/c starting Vit D\\n - fall precautions\\n .\\n #F/E/N\\n -TF via g-tube\\n -may consider S&S eval, G-tube study to eval. aspiration risk prior to\\n giving anything PO\\n -goal: -500 cc/day\\n -- has G tube; will obtain c/s for tube feeds in am\\n .\\n #PPx: PPI, SQH, bowel regimen\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n .\\n #. Dispo: ICU\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT: SQH\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 330520,\n \"text\": \"Subjective\\n Patient with poor PO intake PTA. Noted per chart, on TFs of Probalance\\n at 65ml/hr x 9 hours (provides 702kcal and 46g protein)\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 160 cm\\n 75 kg\\n 29.1\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 52.2 kg\\n 144%\\n 66\\n Diagnosis: Pneumonia\\n PMH : CVA, dementia, aspiration pneumonia, COPD\\n Food allergies and intolerances: none noted\\n Pertinent medications: prednisone, 20meqKCl\\n Labs:\\n Value\\n Date\\n Glucose\\n 91 mg/dL\\n 07:27 AM\\n BUN\\n 16 mg/dL\\n 07:27 AM\\n Creatinine\\n 0.5 mg/dL\\n 07:27 AM\\n Sodium\\n 143 mEq/L\\n 07:27 AM\\n Potassium\\n 3.7 mEq/L\\n 07:27 AM\\n Chloride\\n 111 mEq/L\\n 07:27 AM\\n TCO2\\n 23 mEq/L\\n 07:27 AM\\n Calcium non-ionized\\n 8.8 mg/dL\\n 07:27 AM\\n Phosphorus\\n 2.5 mg/dL\\n 07:27 AM\\n Magnesium\\n 2.2 mg/dL\\n 07:27 AM\\n Current diet order / nutrition support: Nutren Pulmonary at 40ml/hr x\\n 24 hours (currently at 20ml/hr) to provide 1440kcal and 65g protein\\n GI: Abdomen soft with positive bowel sounds\\n Assessment of Nutritional Status\\n At risk for malnutrition\\n Pt at risk due to: Low po intake\\n Estimated Nutritional Needs\\n Calories: 1650- (BEE x or / 25-30 cal/kg)\\n Protein: 80-100 (1.2-1.5 g/kg)\\n Fluid: per team\\n Specifics:\\n 81 year old female with history of CVA, dementia, aphasia presenting\\n with SOB to OSH now transferred to with pneumonia. Noted patient\\n with stage I ulcer on hip. Patient was on night tube feedings at NH.\\n Consult received for tube feedings. For now would recommend doing feeds\\n to meet 100% of needs. Suggest goal of Replete with Fiber at 65ml/hr x\\n 24 hours to provide 1560kcal and 97g protein.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1. Change tube feeding to Replete with Fiber at 65ml/hr x 24\\n hours\\n 2. Monitor residuals q4H and hold if >150ml\\n 10:03\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 330521,\n \"text\": \"Chief Complaint: Pneuomonia\\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 admit with aspiration PNA and COPD exacerbation\\n 24 Hour Events:\\n Persistent close treatment with some improvement in level of\\n respiratory distress.\\n She has remaining significant pulmonary secretions requiring frequent\\n suctioning and also has continued wheezing throughout her exam.\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\\n Vancomycin - 10:00 PM\\n Metronidazole - 08:04 AM\\n Ceftazidime - 09:07 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 10:17 AM\\n Heparin Sodium (Prophylaxis) - 08:04 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 Genitourinary: Foley\\n Heme / Lymph: Anemia\\n Pain: No pain / appears comfortable\\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: 36.9\\nC (98.4\\n Tcurrent: 36.6\\nC (97.9\\n HR: 92 (57 - 114) bpm\\n BP: 135/52(74) {83/34(36) - 159/111(110)} mmHg\\n RR: 28 (16 - 31) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 5,549 mL\\n 919 mL\\n PO:\\n TF:\\n 80 mL\\n IVF:\\n 849 mL\\n 699 mL\\n Blood products:\\n Total out:\\n 3,950 mL\\n 390 mL\\n Urine:\\n 3,950 mL\\n 390 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,599 mL\\n 529 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 98%\\n ABG: ///23/\\n Physical Examination\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL\\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: Bronchial: , Wheezes : ) She does have significant\\n increase in expiratory time and evidence of persistent airflow\\n obstruction.\\n Abdominal: Soft\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 11.4 g/dL\\n 330 K/uL\\n 91 mg/dL\\n 0.5 mg/dL\\n 23 mEq/L\\n 3.7 mEq/L\\n 16 mg/dL\\n 111 mEq/L\\n 143 mEq/L\\n 34.6 %\\n 20.6 K/uL\\n [image002.jpg]\\n 06:15 PM\\n 07:27 AM\\n WBC\\n 20.8\\n 20.6\\n Hct\\n 34.0\\n 34.6\\n Plt\\n 321\\n 330\\n Cr\\n 0.5\\n 0.5\\n TropT\\n 0.02\\n Glucose\\n 130\\n 91\\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\\n Troponin-T:224/11/0.02, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\\n CXR\\nShe has right mid-lung zone opacity which is her right arm\\n overlying. She persists in left lower lobe ill defined opacity.\\n Assessment and Plan\\n 81 yo female\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION-\\n -continue prednisone and will move to taper as possible.\\n -Will have to follow exam to determine taper\\n -Will continue with current prednisone dosing as she is requiring nebs\\n PRN (atrovent) and will need to get a better and more durable response\\n to bronchodilators.\\n -This may require intermittent IPPV to aid with lung recruitment.\\n PNEUMONIA, OTHER-\\n -Will move to vanco/CTZ/Flagyl/Azithro for ongoing Rx of Pneumonia\\n -She raises clear concern for persistent aspiration events leading to\\n inability to clear her pulmonary secretions and pneumonia.\\n -Add urine legnionella to testing.\\n -Will need Chest PT and continued support\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 03:44 AM 20 mL/hour\\n Glycemic Control:\\n Lines: NO CVL\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition :ICU\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330624,\n \"text\": \"Pneumonia, other\\n Assessment:\\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\\n suctioning\\n Action:\\n Aggressive pulm toileting , suctioning q 2hr\\n Response:\\n Pt maint sats 96-99%\\n Plan:\\n Cont ab tx, cont aggressive pulm toileting\\n Alteration in Nutrition\\n Assessment:\\n Pt was taking po\\ns in rehab along w/ nighttime supplement TF ,\\n unable to take pos at this time\\n Action:\\n Pt tolerating cont TF at goal\\n Response:\\n No s/s malnutrition or weight loss\\n Plan:\\n Cont TF as ordered ,resume PO intake when indicated\\n K of 3.5 repleted w/ 40 K via peg, as well as phos. Pt currently being\\n evaluated for PICC for antibiotic course as well as blood draws\\n ------ Protected Section ------\\n At 1600 pt medicated with 10 mg ivp lasix and will follow fluid balance\\n closely.\\n ------ Protected Section Addendum Entered By: , RN\\n on: 17:07 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330623,\n \"text\": \"Chief Complaint: hypoxia/dyspnea\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 11:33 AM\\n following cardiac enzymes\\n CK 134 ->-264 -->224\\n Trop .04 -->.02 -->.03\\n diuresis overnight with lasix 10 x 3.\\n Patient lost last PIV this morning. Difficulty to obtain blood for\\n labs.\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\\n Vancomycin - 10:00 AM\\n Metronidazole - 04:00 PM\\n Ceftazidime - 04:56 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 04:00 PM\\n Furosemide (Lasix) - 06:10 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 06:58 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 104 (76 - 109) bpm\\n BP: 108/64(74) {89/32(47) - 158/99(102)} mmHg\\n RR: 23 (10 - 32) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 2,076 mL\\n 355 mL\\n PO:\\n TF:\\n 476 mL\\n 286 mL\\n IVF:\\n 1,240 mL\\n 69 mL\\n Blood products:\\n Total out:\\n 2,317 mL\\n 785 mL\\n Urine:\\n 2,317 mL\\n 785 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -241 mL\\n -430 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n Gen: Less agitated and interactive this morning. Breathing\\n comfortably, in NAd\\n Lungs: breathing symmetrically, diffuse rhonchi and moderate secretions\\n CV: rapid rate, regular rhythm s1 & s2 nl, no m/r/g\\n Abd: +bs, non-tender, nd, soft\\n Ext: warm dry trace edema\\n Labs / Radiology\\n 330 K/uL\\n 11.4 g/dL\\n 91 mg/dL\\n 0.5 mg/dL\\n 23 mEq/L\\n 3.7 mEq/L\\n 16 mg/dL\\n 111 mEq/L\\n 143 mEq/L\\n 34.6 %\\n 20.6 K/uL\\n : [image002.jpg]\\n :\\n 142\\n [image004.gif]\\n 108\\n [image004.gif]\\n 16\\n [image006.gif]\\n 103\\n AGap=15\\n [image007.gif]\\n 3.5\\n [image004.gif]\\n 23\\n [image004.gif]\\n 0.6\\n [image009.gif]\\n Comments:\\n K: Hemolysis Falsely Elevates K\\n Ca: 8.3 Mg: 2.0 P: 1.8\\n Comments:\\n Mg: Hemolysis Falsely Elevates Mg\\n 86\\n 17.4\\n [image009.gif]\\n 11.5\\n [image006.gif]\\n 371\\n [image010.gif]\\n [image006.gif]\\n 35.0\\n [image009.gif]\\n 06:15 PM\\n 07:27 AM\\n WBC\\n 20.8\\n 20.6\\n Hct\\n 34.0\\n 34.6\\n Plt\\n 321\\n 330\\n Cr\\n 0.5\\n 0.5\\n TropT\\n 0.02\\n 0.03\\n Glucose\\n 130\\n 91\\n Other labs: PT / PTT / INR:12.9/26.0/1.0,\\n CK / CKMB / Troponin-T:224/10/0.03,\\n ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\\n Imaging: CXR \\n hazy LL infiltrate bilaterally. Right side\\n appears improved from previous.\\n ECHO \\n CONCLUSION:\\n The left atrium is dilated. The left ventricle is not well seen. Due to\\n suboptimal technical quality, a focal wall motion abnormality cannot be\\n fully excluded. Overall left ventricular systolic function is normal\\n (LVEF>55%). The aortic valve is not well seen. The mitral valve\\n leaflets are not well seen.\\n IMPRESSION: poor technical quality due to patient's body habitus. Left\\n ventricular function is probably normal, a focal wall motion\\n abnormality cannot be fully excluded. The right ventricle is not well\\n seen. Valvular function could not be evaluated.\\n Microbiology: urine cx neg\\n urine leg neg\\n blood cx neg\\n sputum cx - contaminated\\n Assessment and \\n PROBLEM LIST:\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION\\n PNEUMONIA, OTHER\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ASSESSMENT & PLAN:\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n # PNA\\n Unimproved clinically with persistent leukocytosis (perhaps an\\n element of reactive WBC from steroids) and copious purulent secretions\\n -cont. vanco/ceftaz/flagyl (day 3), and start azithro (day ) for\\n atypicals\\n -freq. suctioning, chest PT\\n -repeat sputum cx, urinary legionella AG\\n -blood cx NGTD\\n -consider bronch if suspect severe plugging or not improved\\n .\\n #COPD\\n -cont. prednisone 40 mg, wrote to decrease to 30mg PO tomorrow AM.\\n -incr. freq. albuterol nebs q2h\\n -atrovent nebs q6h\\n .\\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\\n study but showed good overall LV fn so less likely to be playing a role\\n in pt\\ns dyspnea.\\n -gentle diuresis, 10 mg lasix IV now, goal: even to negative\\n .\\n #.HTN:\\n -cont. lopressor\\n .\\n # Hypothyroidism\\n - cont. levothyroxine\\n .\\n #.Osteoporosis: currently on calcium supplements\\n - cont calcium; t/c starting Vit D\\n - fall precautions\\n .\\n #F/E/N\\n -TF via g-tube\\n -goal: -even to negative\\n .\\n #PPx: PPI, SQH, bowel regimen\\n .\\n #Access: lost PIV this am, hard to get venous access. Place PICC today\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n .\\n #. Dispo: ICU\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 06:00 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330615,\n \"text\": \"Pneumonia, other\\n Assessment:\\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\\n suctioning\\n Action:\\n Aggressive pulm toileting , suctioning q 2hr\\n Response:\\n Pt maint sats 96-99%\\n Plan:\\n Cont ab tx, cont aggressive pulm toileting\\n Alteration in Nutrition\\n Assessment:\\n Pt was taking po\\ns in rehab along w/ nighttime supplement TF ,\\n unable to take pos at this time\\n Action:\\n Pt tolerating cont TF at goal\\n Response:\\n No s/s malnutrition or weight loss\\n Plan:\\n Cont TF as ordered ,resume PO intake when indicated\\n K of 3.5 repleted w/ 40 K via peg, as well as phos. Pt currently being\\n evaluated for PICC for antibiotic course as well as blood draws\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330506,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\\n Vancomycin - 10:00 PM\\n Metronidazole - 12:00 AM\\n Ceftazidime - 12:19 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 10:17 AM\\n Heparin Sodium (Prophylaxis) - 12:34 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 07:00 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: 35.9\\nC (96.6\\n HR: 84 (57 - 132) bpm\\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\\n RR: 28 (16 - 37) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 57 Inch\\n Total In:\\n 5,549 mL\\n 386 mL\\n PO:\\n TF:\\n 33 mL\\n IVF:\\n 849 mL\\n 353 mL\\n Blood products:\\n Total out:\\n 3,950 mL\\n 330 mL\\n Urine:\\n 3,950 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,599 mL\\n 56 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 92%\\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 321 K/uL\\n 11.3 g/dL\\n 130 mg/dL\\n 0.5 mg/dL\\n 22 mEq/L\\n 3.8 mEq/L\\n 15 mg/dL\\n 112 mEq/L\\n 143 mEq/L\\n 34.0 %\\n 20.8 K/uL\\n [image002.jpg]\\n 06:15 PM\\n WBC\\n 20.8\\n Hct\\n 34.0\\n Plt\\n 321\\n Cr\\n 0.5\\n TropT\\n 0.02\\n Glucose\\n 130\\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \\n have triggered COPD flare. Minimal evidence of CHF exacerbation on\\n imaging, exam and labs, but does have CHF history. Patient has copious\\n respiratory secretions.\\n -- continue steroids; will start prednisone 40 mg QD in am\\n -- standing albuterol and ipratropium nebs overnight; will consider\\n changing to PRN in the am pending improvement\\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\\n levaquin tx\\n -- deferring further w/u for PE given PNA likely cause\\n -- UCx, BCx pending from ED\\n -- follow up re: sputum cx\\n -- low suspicion for MI, but will continue cycling enzymes with second\\n set with am labs (first set negative)\\n --suctioning Q1 hr., Chest PT.\\n #. COPD:\\n -- management as above\\n .\\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\\n OSH. No echo in file at the .\\n -- d/c maintenance fluids\\n -- obtain ECHO\\n .\\n #. HTN:\\n -- restart home dose of metoprolol\\n .\\n #. Hypothyroidism\\n -- continue levothyroxine 88 mcg QD\\n .\\n #. Dementia: not currently on medications\\n .\\n #. Depression: was on venlafaxine in past; held on last admission for\\n c/f NMS. Nothing on med list currently.\\n .\\n #. Osteoporosis: currently on calcium supplements\\n -- cont calcium; t/c starting Vit D\\n -- fall precautions\\n .\\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\\n free water flushes Qshift; unclear what she takes in PO if anything\\n (confusion records vs. reports frm daughter)\\n -- holding TF pending improved respiratory status. Concern re:\\n aspiration if patient requires BPAP.\\n -- has G tube; will obtain c/s for tube feeds in am\\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\\n IVF overnight\\n .\\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\\n regimen\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n .\\n #. Dispo: to remain in ICU overnight for tx and observation\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330507,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\\n Vancomycin - 10:00 PM\\n Metronidazole - 12:00 AM\\n Ceftazidime - 12:19 AM\\n Infusions:\\n Other ICU medications:\\n Lansoprazole (Prevacid) - 10:17 AM\\n Heparin Sodium (Prophylaxis) - 12:34 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 07:00 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: 35.9\\nC (96.6\\n HR: 84 (57 - 132) bpm\\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\\n RR: 28 (16 - 37) insp/min\\n SpO2: 92%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 57 Inch\\n Total In:\\n 5,549 mL\\n 386 mL\\n PO:\\n TF:\\n 33 mL\\n IVF:\\n 849 mL\\n 353 mL\\n Blood products:\\n Total out:\\n 3,950 mL\\n 330 mL\\n Urine:\\n 3,950 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,599 mL\\n 56 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 92%\\n ABG: ///22/\\n Physical Examination\\n Gen: aphasic, with residual right sided hemiparesis, repeating sounds\\n incoherently.\\n Lungs: diffuse rhonchi\\n CV: rapid rate, regular rhythm, s1 & s2 nl, no m/r/g\\n ABD: + bs, nt, nd, soft\\n EXT: some LE edema bilat\\n Labs / Radiology\\n 321 K/uL\\n 11.3 g/dL\\n 130 mg/dL\\n 0.5 mg/dL\\n 22 mEq/L\\n 3.8 mEq/L\\n 15 mg/dL\\n 112 mEq/L\\n 143 mEq/L\\n 34.0 %\\n 20.8 K/uL\\n [image002.jpg]\\n 06:15 PM\\n WBC\\n 20.8\\n Hct\\n 34.0\\n Plt\\n 321\\n Cr\\n 0.5\\n TropT\\n 0.02\\n Glucose\\n 130\\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\\n Assessment and Plan\\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \\n have triggered COPD flare. Minimal evidence of CHF exacerbation on\\n imaging, exam and labs, but does have CHF history. Patient has copious\\n respiratory secretions.\\n -- continue steroids; will start prednisone 40 mg QD in am\\n -- standing albuterol and ipratropium nebs overnight; will consider\\n changing to PRN in the am pending improvement\\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\\n levaquin tx\\n -- deferring further w/u for PE given PNA likely cause\\n -- UCx, BCx pending from ED\\n -- follow up re: sputum cx\\n -- low suspicion for MI, but will continue cycling enzymes with second\\n set with am labs (first set negative)\\n --suctioning Q1 hr., Chest PT.\\n .\\n #. COPD:\\n -- management as above\\n .\\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\\n OSH. No echo in file at the .\\n -- d/c maintenance fluids\\n -- obtain ECHO\\n .\\n #. HTN:\\n -- restart home dose of metoprolol\\n .\\n #. Hypothyroidism\\n -- continue levothyroxine 88 mcg QD\\n .\\n #. Dementia: not currently on medications\\n .\\n #. Depression: was on venlafaxine in past; held on last admission for\\n c/f NMS. Nothing on med list currently.\\n .\\n #. Osteoporosis: currently on calcium supplements\\n -- cont calcium; t/c starting Vit D\\n -- fall precautions\\n .\\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\\n free water flushes Qshift; unclear what she takes in PO if anything\\n (confusion records vs. reports frm daughter)\\n -- holding TF pending improved respiratory status. Concern re:\\n aspiration if patient requires BPAP.\\n -- has G tube; will obtain c/s for tube feeds in am\\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\\n IVF overnight\\n .\\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\\n regimen\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n .\\n #. Dispo: to remain in ICU overnight for tx and observation\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 330603,\n \"text\": \"Chief Complaint: Respiratory Failure/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 TRANSTHORACIC ECHO - At 11:33 AM\\n Lasix given with diuresis effected overnight\\n History obtained from Medical records\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\\n Ceftazidime - 04:56 PM\\n Metronidazole - 08:11 AM\\n Vancomycin - 09:15 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 06:10 PM\\n Heparin Sodium (Prophylaxis) - 08:11 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) Fever\\n Cardiovascular: Tachycardia\\n Psychiatric / Sleep: Delirious, MIld\\n Flowsheet Data as of 12:06 PM\\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: 36.1\\nC (97\\n HR: 98 (76 - 110) bpm\\n BP: 116/53(69) {86/32(45) - 158/99(102)} mmHg\\n RR: 26 (4 - 26) insp/min\\n SpO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 2,076 mL\\n 980 mL\\n PO:\\n TF:\\n 476 mL\\n 560 mL\\n IVF:\\n 1,240 mL\\n 420 mL\\n Blood products:\\n Total out:\\n 2,317 mL\\n 985 mL\\n Urine:\\n 2,317 mL\\n 985 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -241 mL\\n -5 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 96%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: No acute distress\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\\n (Breath Sounds: Diminished: )\\n Extremities: Right: 1+, Left: 1+\\n Skin: Not assessed\\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\\n Movement: Not assessed, Tone: Not assessed, More withdrawn\\n Labs / Radiology\\n 11.5 g/dL\\n 371 K/uL\\n 103 mg/dL\\n 0.6 mg/dL\\n 23 mEq/L\\n 3.5 mEq/L\\n 16 mg/dL\\n 108 mEq/L\\n 142 mEq/L\\n 35.0 %\\n 17.4 K/uL\\n [image002.jpg]\\n 06:15 PM\\n 07:27 AM\\n 08:00 AM\\n WBC\\n 20.8\\n 20.6\\n 17.4\\n Hct\\n 34.0\\n 34.6\\n 35.0\\n Plt\\n \\n Cr\\n 0.5\\n 0.5\\n 0.6\\n TropT\\n 0.02\\n 0.03\\n Glucose\\n 130\\n 91\\n 103\\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\\n Assessment and Plan\\n 81 yo female with history of COPD now admit with acute exacerbation and\\n has complicating issues of volume overload and signficiant aspiraiton\\n risk contributing to clinical worsening\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION\\n -Pred 40mg/d\\ntaper to 30mg today\\n -Continue with nebs\\n PNEUMONIA, OTHER\\n Vanco/Ceftaz/Flagyl/Azithro\\n be aspiration triggering clinical worsening\\nwill need 7 day Rx.\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 10:28 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT: Boots\\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\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330614,\n \"text\": \"Pneumonia, other\\n Assessment:\\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\\n suctioning\\n Action:\\n Aggressive pulm toileting , suctioning q 2hr\\n Response:\\n Pt maint sats 96-99%\\n Plan:\\n Cont ab tx, cont aggressive pulm toileting\\n Alteration in Nutrition\\n Assessment:\\n Pt was taking po\\ns in rehab along w/ nighttime supplement TF ,\\n unable to take pos at this time\\n Action:\\n Pt tolerating cont TF at goal\\n Response:\\n No s/s malnutrition or weight loss\\n Plan:\\n Cont TF as ordered ,resume PO intake when indicated\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330576,\n \"text\": \"81 y/o female with h/o CVA,Dementia,Aspiration PNA,COPD presented to\\n hospital from rehab centre with dyspnea.\\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\\n with Acute Exacerbation\\n Assessment:\\n On face mask with 70% Fio2,desats to 85% when mask is off ,LS coarse\\n t/o,normal breathing efforts RR 20-26 sats 90-95%\\n Action:\\n Suctioned nasally 2-3 hrs for thick yellow secretions,pt has very\\n weak cough,chest PT prior to suction and nebs as ordered.Gentlre\\n diuresis with bolus dose,did receive Lasix 10mg at midnight with\\n moderate effect.\\n Response\\n Pt was more comfortable after suction.Stas were maintained.\\n Plan:\\n DNR/DNI,monitor resp staus,ICU care at this time Pulmonary hygene,\\n wean Fio2 as tolerated.\\n Redness and bruises on lt hand MD was notified,Couldn\\nt collect AM\\n , try later.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-07 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 330669,\n \"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 PICC LINE - START 04:16 PM\\n Ventricular Tachycardia noted overnight--non sustained and\\n approximately 9 events\\n Diuresis effected with Lasix IV yesterday--but net fluid balance\\n minimally negative for 24 hours\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 09:45 PM\\n Ceftazidime - 08:00 AM\\n Metronidazole - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 10:45 PM\\n Heparin Sodium (Prophylaxis) - 07:45 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Tachycardia\\n Flowsheet Data as of 10:07 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: 72 (64 - 111) bpm\\n BP: 124/67(78) {98/42(60) - 144/105(110)} mmHg\\n RR: 21 (13 - 29) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 2,607 mL\\n 1,313 mL\\n PO:\\n TF:\\n 1,267 mL\\n 652 mL\\n IVF:\\n 1,140 mL\\n 300 mL\\n Blood products:\\n Total out:\\n 2,472 mL\\n 761 mL\\n Urine:\\n 2,472 mL\\n 761 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 135 mL\\n 552 mL\\n Respiratory support\\n O2 Delivery Device: None, Aerosol-cool\\n SpO2: 98%\\n ABG: ///30/\\n Physical Examination\\n General Appearance: Well nourished, No(t) Thin\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Distant)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Wheezes : , Rhonchorous: Centrally)\\n Extremities: Right: Trace, Left: Trace\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 11.3 g/dL\\n 346 K/uL\\n 108 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 18 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 34.8 %\\n 16.0 K/uL\\n [image002.jpg]\\n 06:15 PM\\n 07:27 AM\\n 08:00 AM\\n 04:32 PM\\n 06:00 PM\\n 03:50 AM\\n WBC\\n 20.8\\n 20.6\\n 17.4\\n 16.0\\n Hct\\n 34.0\\n 34.6\\n 35.0\\n 34.8\\n Plt\\n 46\\n Cr\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n TropT\\n 0.02\\n 0.03\\n Glucose\\n 130\\n 91\\n 103\\n 200\\n 190\\n 108\\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\\n Imaging: CXR----no significant change--some suggestion of mild\\n clearing in left lung\\n Assessment and Plan\\n 81 yo female admit with respiratory failure in the setting of Chronic\\n Obstructive Pulmonary Disease\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION\\n Atrovent/Albuterol nebs given\\n Prednisone at 30mg and will continue to taper tomorrow\\n Will likely need prolonged rehab to return to independent status\\n PNEUMONIA, OTHER--she has had some significant improvement in terms\\n of secretion volume but still with significant limitation in capacity\\n to mobilize secreations\\n vanco/CTX/Flagyl\\n Ventricular Tachycardia\\nnon sustained, mono-morphic, not triggered\\n -Follow Lytes\\n -Maintain telemetry\\n -Check ECG\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 04:16 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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330583,\n \"text\": \"Chief Complaint: hypoxia/dyspnea\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n 24 Hour Events:\\n TRANSTHORACIC ECHO - At 11:33 AM\\n following cardiac enzymes\\n CK 134 ->-264 -->224\\n Trop .04 -->.02 -->.03\\n diuresis overnight with lasix 10 x 3.\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\\n Vancomycin - 10:00 AM\\n Metronidazole - 04:00 PM\\n Ceftazidime - 04:56 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 04:00 PM\\n Furosemide (Lasix) - 06:10 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 06:58 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.1\\nC (98.8\\n Tcurrent: 37.1\\nC (98.8\\n HR: 104 (76 - 109) bpm\\n BP: 108/64(74) {89/32(47) - 158/99(102)} mmHg\\n RR: 23 (10 - 32) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 63 Inch\\n Total In:\\n 2,076 mL\\n 355 mL\\n PO:\\n TF:\\n 476 mL\\n 286 mL\\n IVF:\\n 1,240 mL\\n 69 mL\\n Blood products:\\n Total out:\\n 2,317 mL\\n 785 mL\\n Urine:\\n 2,317 mL\\n 785 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -241 mL\\n -430 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 99%\\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 330 K/uL\\n 11.4 g/dL\\n 91 mg/dL\\n 0.5 mg/dL\\n 23 mEq/L\\n 3.7 mEq/L\\n 16 mg/dL\\n 111 mEq/L\\n 143 mEq/L\\n 34.6 %\\n 20.6 K/uL\\n [image002.jpg]\\n 06:15 PM\\n 07:27 AM\\n WBC\\n 20.8\\n 20.6\\n Hct\\n 34.0\\n 34.6\\n Plt\\n 321\\n 330\\n Cr\\n 0.5\\n 0.5\\n TropT\\n 0.02\\n 0.03\\n Glucose\\n 130\\n 91\\n Other labs: PT / PTT / INR:12.9/26.0/1.0,\\n CK / CKMB / Troponin-T:224/10/0.03,\\n ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\\n Imaging: CXR \\n ECHO \\n The left atrium is dilated. The left ventricle is not well seen. Due to\\n suboptimal technical quality, a focal wall motion abnormality cannot be\\n fully excluded. Overall left ventricular systolic function is normal\\n (LVEF>55%). The aortic valve is not well seen. The mitral valve\\n leaflets are not well seen.\\n IMPRESSION: poor technical quality due to patient's body habitus. Left\\n ventricular function is probably normal, a focal wall motion\\n abnormality cannot be fully excluded. The right ventricle is not well\\n seen. Valvular function could not be evaluated.\\n Microbiology: urine cx neg\\n urine leg neg\\n blood cx neg\\n sputum cx - contaminated\\n Assessment and \\n PROBLEM LIST:\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION\\n PNEUMONIA, OTHER\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n summer ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ASSESSMENT & PLAN:\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n # PNA\\n Unimproved clinically with persistent leukocytosis (perhaps an\\n element of reactive WBC from steroids) and copious purulent secretions\\n -cont. vanco/ceftaz/flagyl (day 2), and start azithro (day 1) for\\n atypicals\\n -freq. suctioning, chest PT\\n -repeat sputum cx, urinary legionella AG\\n -blood cx NGTD\\n -consider bronch if suspect severe plugging or not improved\\n .\\n #COPD\\n -cont. prednisone 40 mg, may taper if improves clinically\\n -incr. freq. albuterol nebs q2h\\n -atrovent nebs q6h\\n .\\n #.CHF - CXR reflects mild degree of volume overload\\n -gentle diuresis, 10 mg lasix IV now, goal: -500 cc/day\\n -TTE today, f/u final read\\n .\\n #.HTN:\\n -cont. lopressor\\n .\\n # Hypothyroidism\\n - cont. levothyroxine\\n .\\n #.Osteoporosis: currently on calcium supplements\\n - cont calcium; t/c starting Vit D\\n - fall precautions\\n .\\n #F/E/N\\n -TF via g-tube\\n -may consider S&S eval, G-tube study to eval. aspiration risk prior to\\n giving anything PO\\n -goal: -500 cc/day\\n -- has G tube; will obtain c/s for tube feeds in am\\n .\\n #PPx: PPI, SQH, bowel regimen\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n .\\n #. Dispo: ICU\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 06:00 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 01:08 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330672,\n \"text\": \"Chief Complaint: hypoxia & dyspnea\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n 24 Hour Events:\\n PICC LINE - START 04:16 PM\\n lasix 10 mg 1V x2 yesterday. decreased UOP to 20-27 cc/hr x hrs this\\n morning. no increase in BUN or Cr.\\n Patient had multiple separate episodes of non-sustained VTACH \\n beats of monomorphic VTACH each time. Occurred on approx 7 times\\n overnight. Patients electrolytes were WNL at the time of these\\n episodes. No intervention was taken.\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 09:45 PM\\n Ceftazidime - 11:37 PM\\n Metronidazole - 11:58 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:11 AM\\n Furosemide (Lasix) - 10:45 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.4\\nC (97.5\\n HR: 94 (64 - 111) bpm\\n BP: 129/74(88) {86/32(45) - 144/105(110)} mmHg\\n RR: 22 (4 - 29) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 2,607 mL\\n 763 mL\\n PO:\\n TF:\\n 1,267 mL\\n 453 mL\\n IVF:\\n 1,140 mL\\n 70 mL\\n Blood products:\\n Total out:\\n 2,472 mL\\n 734 mL\\n Urine:\\n 2,472 mL\\n 734 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 135 mL\\n 29 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool 40% FM\\n SpO2: 98%\\n Physical Examination\\n GEN: patient is more alert this morning; she is making eye contact and\\n following commands. Patient is aphasic.\\n LUNGS: wheezing diffusely. Rhochi diffusely\\n CV: RRR, s1 & s2 nl, no m/r/g\\n ABD: + BS, nt, nd, soft, G-tube in place with dressing C-D-I.\\n EXT: warm dry. No cyanosis, clubbing or edema.\\n Labs / Radiology\\n 346 K/uL\\n 11.3 g/dL\\n 108 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 18 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 34.8 %\\n 16.0 K/uL\\n [image002.jpg]\\n 06:15 PM\\n 07:27 AM\\n 08:00 AM\\n 04:32 PM\\n 06:00 PM\\n 03:50 AM\\n WBC\\n 20.8\\n 20.6\\n 17.4\\n 16.0\\n Hct\\n 34.0\\n 34.6\\n 35.0\\n 34.8\\n Plt\\n 46\\n Cr\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n TropT\\n 0.02\\n 0.03\\n Glucose\\n 130\\n 91\\n 103\\n 200\\n 190\\n 108\\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\\n Imaging: CXR: no significant interval change.\\n Microbiology: blood cx neg x1\\n urine legionella neg x2\\n urine cx neg x1\\n sputum contaminated.\\n Problem :\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION\\n PNEUMONIA, OTHER\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ASSESSMENT & PLAN:\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n # PNA\\n some clinical improvement with decreased secretions.\\n leukocytosis trending down.\\n -cont. vanco/ceftaz/flagyl (day 4)\\n possible 10 day course, and start\\n azithro (day ) for atypicals\\n -freq. suctioning, chest PT\\n -repeat sputum cx, urinary legionella AG\\n -blood cx NGTD\\n .\\n #COPD\\n -cont. 30mg PO today\\n possible taper regimen. continue for 2 days and\\n then decrease to 20mg PO daily for 2days.\\n -albuterol nebs at q2h\\n -atrovent nebs q6h\\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\\n study but showed good overall LV fn so less likely to be playing a role\\n in pt\\ns dyspnea.\\n -gentle diuresis, 10 mg lasix IV PRN with goal: even to negative\\n # VTACH\\n nonsustained and monomorphic with no precipitating cause. No\\n intervention warranted.\\n .\\n #.HTN:\\n -cont. lopressor\\n .\\n # Hypothyroidism\\n - cont. levothyroxine\\n #.Osteoporosis: currently on calcium supplements\\n - cont calcium; t/c starting Vit D\\n - fall precautions\\n .\\n #F/E/N\\n -TF via g-tube\\n -goal: -even to negative\\n .\\n #PPx: PPI, SQH, bowel regimen, add ISS while patient is on steroids.\\n .\\n #Access: lost PIV this am, hard to get venous access. Place PICC today\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n #. Dispo: consider dispo to rehab facility.\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 04:16 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330680,\n \"text\": \"Pneumonia, other\\n Assessment:\\n Received pt on 70% cool neb mask. Rr in the 20-s t low 30\\ns depending\\n on her level of agitation. O2 sats> 93% rhoncherous bs bil on\\n auscultation with crackles at tha bases.Congested but nonproductive\\n cough.\\n Action:\\n O2 weaned as pt tolerates to keep o2 sats> 92%. Nasotracheally\\n suctioned for sm to mod amts of thick yellow sputum.resp status\\n monitored closely. When resp status drops to < 90% it indicates that pt\\n needs to be suctioned . antibiotics administered as ordered.\\n Vancomycin d/c\\n Response:\\n Pt presently tolerating 2l/m nasal cannula with adequate o2 sats. Pt\\n tolerating chest pt and resp toileting. O2 sats improve with\\n nasotracheal suctioning.\\n Plan:\\n Pt being transferred this afternoon to rehab facility to acute\\n floor for aggressive resp toileting. manager notified pt\\n daughter about pt\\ns transfer to rehab.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330574,\n \"text\": \"Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\\n with Acute Exacerbation\\n Assessment:\\n On face mask with 70% Fio2,desats to 85% when mask is off ,LS coarse\\n t/o,normal breathing efforts RR 20-26 sats 90-95%\\n Action:\\n Suctioned nasally 2-3 hrs for thick yellow secretions,pt has very\\n weak cough,chest PT prior to suction and nebs as ordered.\\n Response\\n Pt was more comfortable after suction.Stas were maintained.\\n Plan:\\n DNR/DNI,monitor resp staus,ICU care at this time Pulmonary hygene,\\n wean Fio2 as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330655,\n \"text\": \"81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation. Pt with s/p L cva summer of with\\n residual aphasia and dementia including Alzheimers, multi-infarct.\\n Pneumonia, other\\n Assessment:\\n Scattered rhonchi t/o lungs at beginning of shit with sats in mid 90s\\n on 70% cool neb.\\n Action:\\n Pt nt suctioned for moderate amts clear white/clear secretions. Chest\\n pt given with turns.\\n Response:\\n 02 sats remaining stable on 70% cool neb. Pt developed crackles around\\n 9:30pm and noted to have a drop in urine to 17cc/hr. pt was given 10mg\\n iv lasix with good response. At this time, pt has also been having\\n short runs v tach up to 10 beat runs. Pt asymptomatic other than more\\n lethargic: responding only to sternal rub when crackles developed.\\n Still lethargic but more easily arousable. Runs of v tach subsided\\n after diuresed. Urine output slowed down again the last few hours of\\n the shift. Repeat cxr improved from yesterday per team and pt with sats\\n in upper 90s with no increased 02 need. Appears comfortable but still\\n with crackles at bases, rhonchi in upper airways. K and phosphate\\n repleted.\\n Plan:\\n Continue nt suction prn, chest pt with turns, monitor fluid status,\\n replete lytes prn.\\n Alteration in Nutrition\\n Assessment:\\n Nutren pulmonary increased to goal of 65cc/hr . 100cc free water\\n boluses given q6hrs. large loose ob + brown stool.\\n Action:\\n Tolerating tube feedings well with no residuals.\\n Response:\\n Continues to tolerate tube feedings.\\n Plan:\\n Continue tube feedings with free water boluses. Hold colace as pt\\n having loose stool.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2152-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 330660,\n \"text\": \"Chief Complaint: hypoxia & dyspnea\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n 24 Hour Events:\\n PICC LINE - START 04:16 PM\\n --> lasix 10 mg 1V x2 yesterday. decreased UOP to 20-27 cc/hr x hrs\\n this morning. no increase in BUN or Cr.\\n Allergies:\\n Ciprofloxacin\\n Unknown;\\n Last dose of Antibiotics:\\n Vancomycin - 09:45 PM\\n Ceftazidime - 11:37 PM\\n Metronidazole - 11:58 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:11 AM\\n Furosemide (Lasix) - 10:45 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.7\\nC (98.1\\n Tcurrent: 36.4\\nC (97.5\\n HR: 94 (64 - 111) bpm\\n BP: 129/74(88) {86/32(45) - 144/105(110)} mmHg\\n RR: 22 (4 - 29) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 63 Inch\\n Total In:\\n 2,607 mL\\n 763 mL\\n PO:\\n TF:\\n 1,267 mL\\n 453 mL\\n IVF:\\n 1,140 mL\\n 70 mL\\n Blood products:\\n Total out:\\n 2,472 mL\\n 734 mL\\n Urine:\\n 2,472 mL\\n 734 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 135 mL\\n 29 mL\\n Respiratory support\\n O2 Delivery Device: Aerosol-cool\\n SpO2: 98%\\n ABG: ///30/\\n Physical Examination\\n GEN:\\n HEENT:\\n LUNGS\\n CV:\\n ABD\\n EXT:\\n Labs / Radiology\\n 346 K/uL\\n 11.3 g/dL\\n 108 mg/dL\\n 0.5 mg/dL\\n 30 mEq/L\\n 3.4 mEq/L\\n 18 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 34.8 %\\n 16.0 K/uL\\n [image002.jpg]\\n 06:15 PM\\n 07:27 AM\\n 08:00 AM\\n 04:32 PM\\n 06:00 PM\\n 03:50 AM\\n WBC\\n 20.8\\n 20.6\\n 17.4\\n 16.0\\n Hct\\n 34.0\\n 34.6\\n 35.0\\n 34.8\\n Plt\\n 46\\n Cr\\n 0.5\\n 0.5\\n 0.6\\n 0.6\\n 0.5\\n TropT\\n 0.02\\n 0.03\\n Glucose\\n 130\\n 91\\n 103\\n 200\\n 190\\n 108\\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\\n Imaging: CXR: improved from previous. lung fields clearer bilat.\\n hemidiaphragm seen more easily especially on left.\\n Microbiology: blood cx neg x1\\n urine legionella neg x2\\n urine cx neg x1\\n sputum contaminated.\\n Assessment and Plan\\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\\n WITH ACUTE EXACERBATION\\n PNEUMONIA, OTHER\\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\\n ; residual aphasia\\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\\n NH resident\\n ASSESSMENT & PLAN:\\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\\n PNA and COPD exacerbation.\\n # PNA\\n Unimproved clinically with persistent leukocytosis (perhaps an\\n element of reactive WBC from steroids) and copious purulent secretions\\n -cont. vanco/ceftaz/flagyl (day 3), and start azithro (day ) for\\n atypicals\\n -freq. suctioning, chest PT\\n -repeat sputum cx, urinary legionella AG\\n -blood cx NGTD\\n -consider bronch if suspect severe plugging or not improved\\n .\\n #COPD\\n -cont. prednisone 40 mg, wrote to decrease to 30mg PO tomorrow AM.\\n -incr. freq. albuterol nebs q2h\\n -atrovent nebs q6h\\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\\n study but showed good overall LV fn so less likely to be playing a role\\n in pt\\ns dyspnea.\\n -gentle diuresis, 10 mg lasix IV now, goal: even to negative\\n .\\n #.HTN:\\n -cont. lopressor\\n .\\n # Hypothyroidism\\n - cont. levothyroxine\\n .\\n #.Osteoporosis: currently on calcium supplements\\n - cont calcium; t/c starting Vit D\\n - fall precautions\\n .\\n #F/E/N\\n -TF via g-tube\\n -goal: -even to negative\\n .\\n #PPx: PPI, SQH, bowel regimen\\n .\\n #Access: lost PIV this am, hard to get venous access. Place PICC today\\n .\\n #. Code: DNR/DNI, confirmed with family by ED staff.\\n .\\n #. Contacts: Spoke with daughter (HCP) \\n for ICU consent and confirm code status.\\n #. Dispo: ICU\\n ICU Care\\n Nutrition:\\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 04:16 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2152-06-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 330482,\n \"text\": \"81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\\n presented to Hospital from with dyspnea.\\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\\n 1700 via foley. Pt is DNR/DNI, admitted to for further\\n management of pneumonia.\\n Pneumonia, other\\n Assessment:\\n Pt continues on 40% cool neb, CXR~ LLL infiltrate. Pt suctioned q 2\\n -3 hours for thick yellow secretions, afebrile, WBC 20.8 pt remains\\n on Vanco, Ceftazidime, and Flagyl. On prednisone 40 mg per G-tube qd.\\n cpt done bp stable 109/50 HR 80\\ns SR occ pvc, (4 beat run\\n V-tach)\\n Action:\\n Suctioned q 2 hrs, nebs q 6 hrs, aggressive pulmonary toilet\\n Response:\\n Sx helps clear airway\\n Plan:\\n Continue current therapies, monitor for worsening resp status\\n Dementia (including Alzheimer's, Multi Infarct)\\n Assessment:\\n Pt with Alzheimers dementia, parkinsonian behavior, repetitive\\n speech, expressive aphasia\\n Action:\\n Support pt, occ pt will be lucid\\n Response:\\n Pt able to communicate at times, able to answer appropriately when\\n asked if she needs to be changed\\n Plan:\\n Continue focused pt interaction with pt\\n Alteration in Nutrition\\n Assessment:\\n Tube feeds started FS Nutren pulmonary at 10 cc/hr via G-tube at 12\\n midnight according to team good urine output.\\n Action:\\n Tube feeds started at a low rate\\n Response:\\n No issues\\n Plan:\\n Increase as tolerated to 40 cc/hr flush with 100 cc water q 6 hrs.\\n Impaired Skin Integrity\\n Assessment:\\n Pt turned frequently, left hip looks better\\n stage 1\\n Action:\\n Pt turned freq, skin care\\n Response:\\n Plan:\\n Continue to turn freq, good skin care.\\n\"\n }\n]"}}},{"rowIdx":783,"cells":{"subject_id":{"kind":"number","value":65956,"string":"65,956"},"hadm_id":{"kind":"number","value":104972,"string":"104,972"},"target_text":{"kind":"string","value":"BRIEF HOSPITAL COURSE: 49yo male w/ EtOH cirrhosis with h/o multiple prior upper GI bleeds from esophageal varices and gastric ulcers transferred from with hematemesis. His Hct was stable and here he did not require further intervention. His course was complicated by grand mal seizure (toxic/metabolic vs EtOH w/d). He was discharged home with Hepatology and PCP ."},"extractive_notes_summ":{"kind":"string","value":"Minor ST segment abnormality. Chr atrophy. Chr atrophy. Cerebellum is also mildly atrophic. Sinus rhythm. Sinus rhythm. Periventricular and subcortical white matter hypodensities reflect small vessel ischemic disease. Chronic atrophy and microvascular disease. Q-T interval prolongation. Noprevious tracing available for comparison.TRACING #1 Baseline artifact. IMPRESSION: No acute intracranial process. Since the previous tracing there is nosignificant change in previously noted findings.TRACING #2 The paranasal sinuses are well aerated. If clin indicated, MR would be more sensitive for subtle lesions. There are dense calcifications in the bilateral cavernous carotid arteries. The ventricles and sulci are prominent, consistent with age-related involutional changes and alcoholism. Midline structures are intact. Mastoid air cells and middle ear cavities are clear. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or vascular territorial infarct. No prior examinations for comparison. TECHNIQUE: Contiguous non-contrast axial images were obtained through the brain, and reconstructed at 5-mm intervals. WET READ VERSION #1 6:35 PM No ICH, mass effect, edema, or infarct. FINAL REPORT INDICATION: 49-year-old male with alcoholic cirrhosis, first episode of seizure."},"n_notes":{"kind":"number","value":3,"string":"3"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2158-12-28 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1220962,"text":" 6:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for focal abnormality\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with alcoholic cirrhosis with first episode seizure\n REASON FOR THIS EXAMINATION:\n eval for focal abnormality\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:40 PM\n No ICH, mass effect, edema, or infarct. Chr atrophy.\n If clin indicated, MR would be more sensitive for subtle lesions.\n WET READ VERSION #1 6:35 PM\n No ICH, mass effect, edema, or infarct. Chr atrophy.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old male with alcoholic cirrhosis, first episode of\n seizure.\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.\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 and alcoholism. Cerebellum\n is also mildly atrophic. Periventricular and subcortical white matter\n hypodensities reflect small vessel ischemic disease. There are dense\n calcifications in the bilateral cavernous carotid arteries. Midline\n structures are intact.\n\n The paranasal sinuses are well aerated. Mastoid air cells and middle ear\n cavities are clear.\n\n IMPRESSION: No acute intracranial process. Chronic atrophy and microvascular\n disease.\n\n"},{"category":"ECG","chartdate":"2158-12-27 00:00:00.000","description":"Report","row_id":248202,"text":"Baseline artifact. Sinus rhythm. Since the previous tracing there is no\nsignificant change in previously noted findings.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2158-12-26 00:00:00.000","description":"Report","row_id":248203,"text":"Sinus rhythm. Q-T interval prolongation. Minor ST segment abnormality. No\nprevious tracing available for comparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2158-12-28 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1220962,\n \"text\": \" 6:00 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for focal abnormality\\n Admitting Diagnosis: GASTROINTESTINAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old man with alcoholic cirrhosis with first episode seizure\\n REASON FOR THIS EXAMINATION:\\n eval for focal abnormality\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 6:40 PM\\n No ICH, mass effect, edema, or infarct. Chr atrophy.\\n If clin indicated, MR would be more sensitive for subtle lesions.\\n WET READ VERSION #1 6:35 PM\\n No ICH, mass effect, edema, or infarct. Chr atrophy.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 49-year-old male with alcoholic cirrhosis, first episode of\\n seizure.\\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.\\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 and alcoholism. Cerebellum\\n is also mildly atrophic. Periventricular and subcortical white matter\\n hypodensities reflect small vessel ischemic disease. There are dense\\n calcifications in the bilateral cavernous carotid arteries. Midline\\n structures are intact.\\n\\n The paranasal sinuses are well aerated. Mastoid air cells and middle ear\\n cavities are clear.\\n\\n IMPRESSION: No acute intracranial process. Chronic atrophy and microvascular\\n disease.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2158-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 248202,\n \"text\": \"Baseline artifact. Sinus rhythm. Since the previous tracing there is no\\nsignificant change in previously noted findings.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2158-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 248203,\n \"text\": \"Sinus rhythm. Q-T interval prolongation. Minor ST segment abnormality. No\\nprevious tracing available for comparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":784,"cells":{"subject_id":{"kind":"number","value":26112,"string":"26,112"},"hadm_id":{"kind":"number","value":130893,"string":"130,893"},"target_text":{"kind":"string","value":"This is a F c multiple comorbities with profound sepsis of unclear etiology (?PNA, cultures pending), who after lengthy discussion with the team and the family, was made comfort measures only. She was on morphine for pain control and respiration ease. She passed peacefully on ."},"extractive_notes_summ":{"kind":"string","value":"start morphin gtt 1mg/hr.resp: non-rebris mask, given nebs, LC coarse bilat. Thoracic aorta is mildly unfolded. COMPARISON: Chest radiograph dated . pt unable to cough.cv: HR 90-100's, SR/NSR, with rare PVC's. SBP 90-105. temp 99.8, last lactate 3.3.gi/gu: foley in place. FINDINGS: The cardiac and mediastinal contours are unchanged compared to the prior study, including tortuous aorta. Tortuous aorta. There is some retrocardiac opacity identified. Right IJ line is terminating at the junction of SVC and right atrium. Sinus tachycardia with frequent atrial ectopy. LLL opacity and effusion. BAD distending, BS hypoactive. A PA and lateral chest radiograph is recommended for further evaluation. Opacity in left lower lobe with effusion. in ED temp 103.8, WBC 35K, lactate 4.6, put on MUST protokol, given Lasix, 3L fluid and levo/vanco/flagyl for sepsis/pna. The right costophrenic angle is excluded from the film. Pulmonary vasculature appears within normal limits. IMPRESSION: Right IJ line terminating at the junction of SVC and right atrium. Metallic opacity overlying the neck, probably outside of the patient, however, please correlate clinically. Note is made of opacity in left lower lobe, with small effusion. 7:40 PM CHEST (PORTABLE AP) Clip # Reason: SOB FINAL REPORT INDICATION: Shortness of breath. ?c/o to the floor. pt has stool x2. TECHNIQUE: Portable chest radiograph. IMPRESSION: Left lower lobe opacity may represent atelectasis or early pneumonia. There isotherwise, no diagnostic change. Check line placement. There is metallic opacity overlying the neck, probably outside of the body, however, clinical correlation is recommended. in ED family confirmed pt DNR/DNI, after discussion with family about poor prognosis of recovery from rofound sepsis, family decided to make pt comfort measures.in the unit stopped Must protokol.neuro: pt arousable to voice/stimul, does not follows commands, opens eyes spont/voice, pt does not c/o of pain. There continues to show non-specificST-T wave abnormalities which may be due in part, to the rapid rate. pt NPO.skin: abrasion on coccyx, open to air, skin cream protector applied.access: RIJ, 1piv.social: DNI/DNR, family make pt comfort to measuers. 9:29 PM CHEST PORT. Surrounding osseous and soft tissue structures demonstrate surgical material in the right upper quadrant of the abdomen. The wet read was faxed to the ED dashboard. please call son with changes phone number on the board.plan: cont morphine gtt for comfort. u/o 25-40cc/hr. Metalic opacity overlying the neck, probably outside, however please check. SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The heart is not enlarged. sat 97%. Since the previous tracingof the rate is more rapid and atrial ectopy is a new finding. No pneumothorax. COMPARISON: None. FINAL REPORT INDICATION: -year-old woman with fever and shortness of breath. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: line placement MEDICAL CONDITION: year old woman with fever, sob REASON FOR THIS EXAMINATION: line placement WET READ: MNIa FRI 10:08 PM Rt IJ line terminating at junction of SVC and rt atrium. Lungs are otherwise clear. No pneumothoraces are identified."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2174-05-21 00:00:00.000","description":"Report","row_id":1602339,"text":" y.o female with h/o COPD, nursing home resident, who has decling mental status for 5 years and worsing past 6 month admitted ED d/t fever, cough, dyspnea,hypotension, pt fell in NH. in ED temp 103.8, WBC 35K, lactate 4.6, put on MUST protokol, given Lasix, 3L fluid and levo/vanco/flagyl for sepsis/pna. in ED family confirmed pt DNR/DNI, after discussion with family about poor prognosis of recovery from rofound sepsis, family decided to make pt comfort measures.\nin the unit stopped Must protokol.\nneuro: pt arousable to voice/stimul, does not follows commands, opens eyes spont/voice, pt does not c/o of pain. start morphin gtt 1mg/hr.\n\nresp: non-rebris mask, given nebs, LC coarse bilat. sat 97%. pt unable to cough.\n\ncv: HR 90-100's, SR/NSR, with rare PVC's. SBP 90-105. temp 99.8, last lactate 3.3.\n\ngi/gu: foley in place. u/o 25-40cc/hr. BAD distending, BS hypoactive. pt has stool x2. pt NPO.\n\nskin: abrasion on coccyx, open to air, skin cream protector applied.\n\naccess: RIJ, 1piv.\n\nsocial: DNI/DNR, family make pt comfort to measuers. please call son with changes phone number on the board.\n\nplan: cont morphine gtt for comfort.\n ?c/o to the floor.\n"},{"category":"ECG","chartdate":"2174-05-20 00:00:00.000","description":"Report","row_id":164497,"text":"Sinus tachycardia with frequent atrial ectopy. Since the previous tracing\nof the rate is more rapid and atrial ectopy is a new finding. There is\notherwise, no diagnostic change. There continues to show non-specific\nST-T wave abnormalities which may be due in part, to the rapid rate.\n\n"},{"category":"Radiology","chartdate":"2174-05-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":914477,"text":" 7:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: None.\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The heart is not enlarged.\n Thoracic aorta is mildly unfolded. There is some retrocardiac opacity\n identified. Lungs are otherwise clear. Pulmonary vasculature appears within\n normal limits. The right costophrenic angle is excluded from the film. No\n pneumothoraces are identified. Surrounding osseous and soft tissue structures\n demonstrate surgical material in the right upper quadrant of the abdomen.\n\n IMPRESSION: Left lower lobe opacity may represent atelectasis or early\n pneumonia. A PA and lateral chest radiograph is recommended for further\n evaluation.\n\n"},{"category":"Radiology","chartdate":"2174-05-20 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":914481,"text":" 9:29 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fever, sob\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: MNIa FRI 10:08 PM\n Rt IJ line terminating at junction of SVC and rt atrium. LLL opacity and\n effusion. Metalic opacity overlying the neck, probably outside, however please\n check.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with fever and shortness of breath.\n\n Check line placement.\n\n TECHNIQUE: Portable chest radiograph.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: The cardiac and mediastinal contours are unchanged compared to the\n prior study, including tortuous aorta. Right IJ line is terminating at the\n junction of SVC and right atrium. No pneumothorax. Note is made of opacity\n in left lower lobe, with small effusion. There is metallic opacity overlying\n the neck, probably outside of the body, however, clinical correlation is\n recommended.\n\n IMPRESSION: Right IJ line terminating at the junction of SVC and right\n atrium. Tortuous aorta. Opacity in left lower lobe with effusion. Metallic\n opacity overlying the neck, probably outside of the patient, however, please\n correlate clinically.\n\n The wet read was faxed to the ED dashboard.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2174-05-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1602339,\n \"text\": \" y.o female with h/o COPD, nursing home resident, who has decling mental status for 5 years and worsing past 6 month admitted ED d/t fever, cough, dyspnea,hypotension, pt fell in NH. in ED temp 103.8, WBC 35K, lactate 4.6, put on MUST protokol, given Lasix, 3L fluid and levo/vanco/flagyl for sepsis/pna. in ED family confirmed pt DNR/DNI, after discussion with family about poor prognosis of recovery from rofound sepsis, family decided to make pt comfort measures.\\nin the unit stopped Must protokol.\\nneuro: pt arousable to voice/stimul, does not follows commands, opens eyes spont/voice, pt does not c/o of pain. start morphin gtt 1mg/hr.\\n\\nresp: non-rebris mask, given nebs, LC coarse bilat. sat 97%. pt unable to cough.\\n\\ncv: HR 90-100's, SR/NSR, with rare PVC's. SBP 90-105. temp 99.8, last lactate 3.3.\\n\\ngi/gu: foley in place. u/o 25-40cc/hr. BAD distending, BS hypoactive. pt has stool x2. pt NPO.\\n\\nskin: abrasion on coccyx, open to air, skin cream protector applied.\\n\\naccess: RIJ, 1piv.\\n\\nsocial: DNI/DNR, family make pt comfort to measuers. please call son with changes phone number on the board.\\n\\nplan: cont morphine gtt for comfort.\\n ?c/o to the floor.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2174-05-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 164497,\n \"text\": \"Sinus tachycardia with frequent atrial ectopy. Since the previous tracing\\nof the rate is more rapid and atrial ectopy is a new finding. There is\\notherwise, no diagnostic change. There continues to show non-specific\\nST-T wave abnormalities which may be due in part, to the rapid rate.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-05-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 914477,\n \"text\": \" 7:40 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: SOB\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Shortness of breath.\\n\\n COMPARISON: None.\\n\\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The heart is not enlarged.\\n Thoracic aorta is mildly unfolded. There is some retrocardiac opacity\\n identified. Lungs are otherwise clear. Pulmonary vasculature appears within\\n normal limits. The right costophrenic angle is excluded from the film. No\\n pneumothoraces are identified. Surrounding osseous and soft tissue structures\\n demonstrate surgical material in the right upper quadrant of the abdomen.\\n\\n IMPRESSION: Left lower lobe opacity may represent atelectasis or early\\n pneumonia. A PA and lateral chest radiograph is recommended for further\\n evaluation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2174-05-20 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 914481,\n \"text\": \" 9:29 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: line placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old woman with fever, sob\\n REASON FOR THIS EXAMINATION:\\n line placement\\n ______________________________________________________________________________\\n WET READ: MNIa FRI 10:08 PM\\n Rt IJ line terminating at junction of SVC and rt atrium. LLL opacity and\\n effusion. Metalic opacity overlying the neck, probably outside, however please\\n check.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: -year-old woman with fever and shortness of breath.\\n\\n Check line placement.\\n\\n TECHNIQUE: Portable chest radiograph.\\n\\n COMPARISON: Chest radiograph dated .\\n\\n FINDINGS: The cardiac and mediastinal contours are unchanged compared to the\\n prior study, including tortuous aorta. Right IJ line is terminating at the\\n junction of SVC and right atrium. No pneumothorax. Note is made of opacity\\n in left lower lobe, with small effusion. There is metallic opacity overlying\\n the neck, probably outside of the body, however, clinical correlation is\\n recommended.\\n\\n IMPRESSION: Right IJ line terminating at the junction of SVC and right\\n atrium. Tortuous aorta. Opacity in left lower lobe with effusion. Metallic\\n opacity overlying the neck, probably outside of the patient, however, please\\n correlate clinically.\\n\\n The wet read was faxed to the ED dashboard.\\n\\n\"\n }\n]"}}},{"rowIdx":785,"cells":{"subject_id":{"kind":"number","value":22657,"string":"22,657"},"hadm_id":{"kind":"number","value":135103,"string":"135,103"},"target_text":{"kind":"string","value":"The patient had a complicated hospital course due to the multiple sources of infection. In addition to the sources noted in the history of present illness the patient also was found to have multiple dental abscesses, the decubitus ulcers noted and pneumonia and a Methacillin sensitive staph aureus high grade bacteremia. He was treated initially with broad spectrum antibiotics and the coverage was later narrowed according to the sensitivities of the organisms, which grew out in the culture. The patient failed to progress on the floor and ultimately was transferred to the Intensive Care Unit on for respiratory failure and was intubated and supported with mechanical ventilation. The patient was found at that point to have large pleural effusions bilaterally and thoracentesis, however, revealed no active infection in the fluid. The patient was also found on CT to have a new fracture on the right iliac crest. The Orthopedic Service was consulted and felt that no surgical treatment was warranted given the patient's grave medical condition. The CT also revealed fluid collection in the right gluteal area, which was drained under CT guidance, however, this also did not reveal a source for the patient's high grade bacteremia. Ultimately the patient was extubated, however, his condition deteriorated and on the morning of the patient became acutely hypotensive and his respirations became labored and the patient's daughter was consulted who chose to make the patient comfort measures only. He expired on of respiratory failure secondary to sepsis and hypotension."},"extractive_notes_summ":{"kind":"string","value":"RECIEVED COZAAR THIS AM. R TLC P/I. HO in to asess, EKG done confirming Afib, ? Resp Care Note:Pt required NT suct for mod th brn sput. Lung sound prior to suct rhonchi improving w/ sx. RECTAL BAG REPLACED TODAY. Pt currently in NARD on cool mist aerosol @ .4FIO2. HCT STABLE AT 31.5 . ABG WNL.CV: SR ON MONITOR, VSS PER L RADIAL ALINE. ANASARCA NOTED UPPER AND LOWER EXT'S. NURSING PROGRESS NOTE:PT CONT TO DO WELL EXTUBATED. Diltiazem 5mg IVP by HO with rate down to 90's and SBP 120-130. NPN 7a-7p: RESP: Pt requiring NT x 3 this shift... copious to moderate amts thick tan/yellow secretions. LS very course, bronchial at bases... team aware that pt is also + 1L fb... to discuss dose lasix. found fit for extubation. POST ABG WNL. LUNGS COARSE THROUGHOUT, RECIEIVNG LASIX IV FOR DUIRESIS. Resp CarePressure support increased to during noc to rest pt. PT IS A DNR BUT WOULD BE REINTUBATED. wbc 9.0... as noted aline dc'd, and resited... cont on unasyn and oxacillin. K+ and Ca++ replaced this am.RESP: Remians orally intubated. PLAN IS TO EXTUBATE TODAY.GI: ABD SOFT WITH UMBILICAL HERNIA. Cards feels this is d/t abx therapy. Access: remains with TLC to R SC... to have PICC placed tomorrow by iv team.. please save L antecube.a/P: pt with tenuous resp status... large amts secretions.. desats easily, but perking up... to cont abx, follow abg's, cont skin care, pulmonary toilet.. PICC line tomorrow. Resp Care,Pt. RESP CARE,PT. F/E: lytes wnl. ?HYPOALBUMINEMIA. DNRSKIN CARE AS ORDEREDATTEMPT TO EXTUBATE POSS. BP 90s/30-40sPt is febrile with temp of 99.9 rectally.GI: Abdomen distended, soft. Prolonged QTC noted. GU: pt cont with clots via foley today. team to place new aline, as pt's resp status tenuous. ABG THIS AM 67/36/7.32/19. ON OXACILLIN AND AUGMENTIN. DSD WITH WOUND JELLY APPLIED.ID: OXACILLIN D18 OF 42. TOMMORROWCONT ANTIBX AS ORDEREDSUPPORT FAMILY PT MED WITH ATIVAN 1MG IVP WITH GOOD EFFECT.PT CONT ON GOAL RATE TUBE FEEDS WITH ACCEPTABLE RESIDUALS. P-MICU RNNOTECV: STABLE WITH DILTIAZEM.RESP: ENT CONSULTED FOR HOARSENESS. TF REMAIN ON HOLD...HIGH RESIDUALS (GASTRIC HEME +...PH 2). Lung sounds bilat rhonchi clearing significantly after suct. CVP 9-10.RESP: PT REMAINS ON AC/450/14/40%/PEEP DOWN TO 7.5. ABG DONE AND WNL. R RADIAL ALINE PLACED AND ABG AT THE TIME=7.15/96/81/35/1. LUNGS CLEAR WITH SCT RHONCHI THROUGHOUT BASES AND DECREASED BASES. Resp Care Note:Pt cont on mech vent aas per vent flowsheet. need to further wean ativan as pt essentually unresponsive.GI:Abdomen soft. Cont in sinus brady hr in 50's.Neuro: remains sedated on 1mg ativan. TEAM AWARE, BOLUS WITH MORE FLUID.INTEG: R IJ TLC P/I. Drs' and pronounced. WILL CONT TO CHECK RESIDUALS AND ATTEMPT TO RESTART TF.INTEG: R IJ TLC P/I...CVP OFF DISTAL PORT. PEJ DRSG FOR AMT OS SEROUS DRAINAGE. R RADIAL ALINE P/I. S1S2 ON AUSCULTATION.RESP: PT TO AC/40/450/10/14...BREATHING WITH VENT. RESP RATE REGULAR. O2 SAT'S IN HIGH 90'S.PT'S VITAL SIGNS STABLE, AFEBRILE. UO ADEQAUTE VIAFOLEY CATH . Received CPT q4h with NT suctioning. ALTERED REPS STATUSD: PT A&O AND FOLLWS SIMPLE COMMANDS. TF's held ~1hr with CPT and sxning. S2S1 murmur noted. Last ABG WNL.GI: NGT intact with + placement. Lung sounds rhonchi impr after suct mod th tan sput. S1S2 with murmur noted. Labs WNL.RESP: Remains vented. Troponin of yest negative. P-MICU NPN 7p-7aSystems Review:Resp: LS coarse bilat throughout. Hypoactive bowel sounds noted. Continue with abx regimine. Ca++ repleted.Resp: Vent settings unchanged. Resp Care Note:Pt cont on vent as per Carevue. F/E: pt with marginal UO this shift.. ? +bs, tolerating TF's with minimal residuals. Lytes wnl. EKG due this am. R hip wound debrided by plastics today. PT/RSD Re-evaluationS: IntubatedO: Please refer to initial evaluation for further information regarding PMH and HPILabs: 13.6>32.1<313Vent: PS 5/PEEP 5, Tv 450, 40%FiO2Pulmonary: Breath sounds coarse throughoutMobility: Pt sedated, no active movement at this timeROM: PROM all joints WFL although stiffness noted throughoutVital Signs: Pre-rx: 148/60 77 28 99% During/post-rx: 140/60 78-84 28 98-100%Rx: Gentle passive ROM bilateral upper and lower extremities.Percussion to right lung field in left sidelying followed by in line suctioning for minimal yellow secretions. There are simpleatheroma in the ascending aorta. Trace aortic regurgitation is seen. These changes are consistent with anterolateral myocardial infarctionof indeterminate age. Small bilateral pleural effusions with bibasilar atelectasis. Thereare simple atheroma in the aortic arch. There are simple atheroma inthe aortic arch. 2) Bibasilar atelectasis and pleural effusions. Pulmonary vascularity is indistinct, consistent with CHF. Prior anteroseptalmyocardial infarction. There is nosignificant aortic valve stenosis. Compared to the previous tracingof sinus rhythm has replaced rapid atrial fibrillation, low voltageis now present in the precordial leads and voltage appears decreased in thelimb leads. Prior anteroseptal myocardial infarction.Compared to the previous tracing of there is variation in precordiallead placement. There are simple atheroma in the aortic root.There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracicaorta.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Prioranteroseptal myocardial infarction. The appearance is consistent with a multiseptated collection/abscess. Left anterior fascicular block. Left atrial abnormality. Left atrial abnormality. PORTABLE UPRIGHT CHEST @ 10:08: Again seen are small bilateral pleural effusions, right greater than left. IMPRESSION: There is prominence of the interstitium, probably related to chronic process with a superimposed interstitial edema. A limited ultrasound of the right hemithorax revealed a pleural effusion. SINGLE AP PORTABLE VIEW OF THE CHEST: There is marked patient rotation, which alters cardiomediastinal borders. IMPRESSION: Persistent, mild interstitial edema with bilateral pleural effusions. There is prominence of the interstitium which probably relates to a chronic process, although superimposed interstitial edema will have a similar appearance. A CAPD catheter is incidentally noted. The catheter was removed and the MIC G-J tube was advanced over the wire and positioned with tip in proximal jejunum. CV line is in mid to distal SVC, probably obscured by spinal rod. There is bibasilar passive atelectasis associated with the effusions. There is persistent right basilar pleural thickening which may be chronic, or a loculated pleural effusion. Contrast was administered which documented intragastric location of the needle. There has been interval insertion of an orogastric feeding tube which projects below the level of the diaphragm."},"n_notes":{"kind":"number","value":119,"string":"119"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2131-09-16 00:00:00.000","description":"Report","row_id":1558190,"text":"MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT VERY LETHARGIC EARLY THIS AM AND WAS NOT RESPONDING TO VERBAL STIMULI. BY 1400, PT FOLLOWING COMMANDS AND MORE AWAKE. EXTUBATED AND DOING WELL. CONT TO FOLLOW COMMANDS, MOVING AROUND MORE AND INTERACTING WITH FAMILY. PT ABLE TO VERBALIZE ONE WORD ON OCCASSION. APPEARS TO BE ORIENTED TO FAMILY. AFEBRILE.\n\nCV: SR ON MONITOR, NO ECTOPY NOTED. VSS...BP HIGH ON OCCASSION PER ALINE, (170-190/60-70'S). RECIEVED COZAAR THIS AM. S1S2M ON AUSCULTATION. R TLC P/I. OVERALL ANASARCA NOTED, POOR PALPABLE PULSES ALL AROUND.\n\nRESP: PT EXTUBATED THIS AFTERNOON, ON 50%FM AND TOLERATING WELL. POST ABG WNL. RR 20-26. LUNGS REMAIN COARSE ANTERIORLY AND UPPER POST LOBES...CLEAR,DECREASED B/L BASES. ORALLY SUCTIONING SMALL AMT'S THICK YELLOW. NTSUCTIONED X1. O2SATS 99-100%.\n\nGI/GU: FOLEY CHANGED TODAY...LEAKING AROUND INSERTION SITE. #16 FR FOLEY PLACED AND DRAINING BLD TINGED URINE. LASIX GIVEN WITH GOOD RESULTS. IMMODIUM GAVE THIS AM X1..NO BM NOTED TODAY. ABD SLIGHTLY DISTENDED WITH POSITIVE BS..WHEN TF INFUSING, NO RESIDUALS WERE NOTED.\n\nCURRENTLY: D5NS @75CC/HR INFUSING VIA TLC. FAMILY AT BEDSIDE AND PT DOING WELL. TLC AND ALINE FROM ...TEAM AWARE AND WILL PT FOR PICC LINE.\n"},{"category":"Nursing/other","chartdate":"2131-09-17 00:00:00.000","description":"Report","row_id":1558191,"text":"NURSING PROGRESS NOTES:\nPT REMAINS EXTUBATED WITH 50%FACE MASK. O2 SAT'S MAINTAINED HIGH 90'S . LUNG SOUNDS COARSE AND IS ABLE TO COUGH UP SOME SECRETIONS WITH MUCH ENCOURAGEMENT. ABLE TO SUCTION THEM FROM BACK OF THE THROAT.\nPT VERY LETHARGIC AT START OF THE SHIFT BUT BECAME INCREASINGLY MORE ALERT AND OPENING EYES AND ATTEMPTING TO SPEAK. WILL COUGH A WEAK COUGH WHEN TOLD TO.\nVITAL SIGNS STABLE. LOW GRADE TEMP.\nFOLEY CATH DRAINING GOOD AMT'S OF PINK TINGED URINE AND OOZING CLOTS AROUND CATH FROM PENIS. CATH IRRIGATED TO CLEAR CLOTS. OCC WILL DRAIN LRG AMT'S OF URINE AROUND CATH IF CLOTS HAVE OBSTRUCTED CATH.\nHIP DSG CHG, WOUND LOOKS SLIGHTLY IMPROVED.\nFAMIL WENT HOME EARLY AND CHECKED IN DURING THE NIGHT.\nPT STARTED ON IV UNASYN SINCE UNABLE TO TAKE PO MEDS.\n"},{"category":"Nursing/other","chartdate":"2131-09-17 00:00:00.000","description":"Report","row_id":1558192,"text":"REHAB SERVICES/PT\nS: MOANING\nO: PT SEEN FOR PROBS/GOALS PER R/E \nMS: ALERT, ORIENTED TO NAME AND HOSPITAL, MIN VERBALIZATION T/O RX\nVS'S: 96 97%(50%FM) 20\nBS'S: DECREASED BILAT WITH CRACKLES LL'S\nCOUGH: WEAK, CONGESTED, INEFFECTIVE\nBR PATTERN: NON-LABORED\nRX: PROM X4 EXTREMITIES, POSITIONED S-S WITH HOB LEVEL FOR PERC/SHAKING TO BILAT LUNG FIELDS, PRE-OXYGENATED WITH 100% FIO2 AND NTS FOR MOD TO LARGE AMOUNTS THICK YELLOW SECRETIONS.\nCOMMUNICATION WITH RN AND MD RE: PTS STATUS\nA: PT DOING FAIRLY WELL S/P EXTUBATION BUT DOES HAVE A LOT OF SECRETIONS, UNABLE TO CLEAR ON OWN AND NEEDS FREQUENT NTS. PTS EXTREMITIES VERY STIFF WITH KNEE FLEXION CONTRACTURES PRESENT.\nP: CONTINUE TO FOLLOW FOR BPH, ROM AND MOBILITY AS ABLE\nPG \n"},{"category":"Nursing/other","chartdate":"2131-09-21 00:00:00.000","description":"Report","row_id":1558204,"text":"Resp Care Note:\n\nPt requires frequent NT suct for mod to large amt th beige sput. Lung sound prior to suct rhonchi improving w/ sx. Pt currently in NARD on cool mist aerosol @ .4FIO2. Cont to encourage deep breathing and coughing.\n"},{"category":"Nursing/other","chartdate":"2131-09-21 00:00:00.000","description":"Report","row_id":1558205,"text":"NURSING PROGRESS NOTE:\nPT CONT TO DO WELL EXTUBATED. NASAL TRACHEAL SX X 1 FOR LRG AMT OF THICK TAN SECRETIONS. O2SAT'S IN HIGH 90'S. LUNG SOUNDS VERY COARSE THROUGHOUT.\nTUBE FEEDS TOL WELL VIA NGT. SM RESIDUALS. ABD DISTENDED BUT SOFT, BOWEL SOUNDS PRESENT. NO STOOL TONIGHT.\nHEPARIN INJ GIVEN AND PT OOZING FROM SITE MOST OF NIGHT.\nU/O ADEQUATE.\nFAMILY UPDATED.\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1558200,"text":"Rehabilitation Services/physical therapy\n\n8:30 - 9:15\n\nS: Speaking appropriately, tho difficult to understand secondary to upper airway sounds\n\nO: Seen to address problems and goals of \nVital signs: 81, 150/54, 98% on 40% face tent, 21\n with Sx: 98, 162/68, 85% with poor tracing on 100%\n p Rx: 82, 147//53, 98% on 40%\nBreath sounds: upper airway sounds throughout\n p Rx: mid to end expiratory wheezes, improved air movement\nRx: NTS for small amounts of bright red blood, difficult to enter airway. Used an oral airway for suctioning for large amounts of thick yellow secretions.\nPositioning: Patient's position changed to opposite sidelying p suctioning.\n\nA: Patient with increased secretions, cleared well with oral airway and deep suctioning. Unable to perform percussion and shaking second to right rib fractures. Nursing to discuss weight bearing status with team on rounds.\n\nP: Plan to be developed with input from team re: weight bearing status.\n"},{"category":"Nursing/other","chartdate":"2131-09-21 00:00:00.000","description":"Report","row_id":1558206,"text":"ALTERED RESP STATUS\nD: PT ALERT AND ORIENTED. FOLLOWS SIMPLE COMMANDS. ON INITIAL ASSESSMENT O2 AT=89%. ON 40% FACE TENT. SUCTIONE NASLLY VIA L NARE FOR MODERATE AMT OF THICK CREAMY YELLOW SPUTUM AND O2 SATS NOW 96-98%. COARSE BS BIL. CONTINUES ON PROMODE TUBE FDGS VIA NGT WITH MINIMAL RESIDUALS SO RATE NOW INCREASED TO GOAL RATE OF 60CC'S/HR WITH NO SIGNS OF ASPIRATION. INCONITNNENT OF MOD AMT OF LOOSE BROWN STOOL. AWAITING FAMILY'S CONSENT TO PLACE PEG AND ALSO AWAITING PALCEMENT AT OR . VSS. UO ADEQUATE. WILL CONTINUE WITH PRESENT MEDICAL TX. WILL CONTINUE TO UPDATE FAMILY AS NEEDED AND OFFER EMOTIONAL SUPPORT. PT IS A DNR BUT WOULD BE REINTUBATED IF RESP STATUS WERE TO WORSEN.\n"},{"category":"Nursing/other","chartdate":"2131-09-21 00:00:00.000","description":"Report","row_id":1558207,"text":"MICU NPN 11AM-7PM:\nNeuro: Awake and alert most of the day. Asked to get up OOB and stayed up for 2hrs or so and was most comfortable in the chair. Otherwise he has been restless, calling for me to reposition him frequently. I explained to him that it is not possible to repeostion him as frequently as he is asking and that every two hours would be the most frequent turn that is reasonable. His speech is very diffucult to understand since his voice is weak and he is congested in the upper airway.\n\nResp: Still requires close monitoring of his resp status for need to suction him. He is on 40% TM and his sats were best while in the chair. He was suctioned twice today for thick blood tinged yellow sputum. Lungs are coarse. RR in the 20's. O2 sat 96% most of the day but were 100% while in the chair.\n\nCardiac: Remains hypertensive in the 150's to 190's. Up with activity. Cozaar was increased to 50mg QD and extra 25mg was given as requested by the physician. 70-80's.\n\nGI: Two small stool today. Tolerates goal rate tube feeds.\n\nGU: Adequate UO via the foley.\n\nSocial: I spoke to pt's son via the phone today. Also MD updated pt's daughter and spoke to the ppt and to her about the need for PEG next week.\n"},{"category":"Nursing/other","chartdate":"2131-09-22 00:00:00.000","description":"Report","row_id":1558208,"text":"Resp Care Note:\n\nPt required NT suct for mod th brn sput. Pt placed on FIO2 .4 via cool mist aerosol via face tent with stable O2 sats. Cont aggressive pulmonary toilet.\n"},{"category":"Nursing/other","chartdate":"2131-09-15 00:00:00.000","description":"Report","row_id":1558185,"text":"MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT SLEEPING MOST OF DAY, OPENS EYES AND SQUEEZES HANDS ON COMMAND...OTHERWISE NOT MOVING AROUND OR AWAKE. NOT ANSWERING ANY QUESTIONS. TMAX 99.8 AX. TEAM AWARE. ATIVAN DC'D AND PRN FOR HALDOL IF NEEDED.\n\nCV: SR ON MONITOR, NO ECTOPY NOTED. BP SLIGHTLY HIGH AT TIMES, 140-160/50'S PER ALINE. ANASARCA NOTED UPPER AND LOWER EXT'S. S1S2M ON AUSCULTATION.\n\nRESP: VENT TO CPAP 40%/...ABG WNL. PLAN TO HOLD ON EXTUBATING SECONDARY TO LG AMT ORAL SECRETIONS. SUCTIONED SMALL AMT VIA ETT, THICK TAN, BLD TINGED. LUNGS CLEAR TO COARSE THROUGHOUT. VT 400-500, RR 20-30'S. FAMILY MADE AWARE OF DECISION TO WAIT ON EXTUBATION.\n\nGI/GU: CONT TO BE OF LOOSE STOOL, 3RD CDIFF CULTURE SENT. RECTAL BAG REPLACED TODAY. PLAN TO START IMMODIUM IF LAST CULTURE IS NEGATIVE. FOLEY NOT DRAINING THIS AM, CHANGED TO #14G AND DRAINING CLEAR BLD TINGED CLEAR YELLLW URINE. MIVF STARTED TO D5NS @75CC/HR. TF INFUSING WITHOUT DIFF. WILL FOLLOW.\n"},{"category":"Nursing/other","chartdate":"2131-09-15 00:00:00.000","description":"Report","row_id":1558186,"text":"resp. care note: pt received intubated with a 7.5 ett, secured at the 23cm mark. pt also mech. ventilated, current settings: cpap 5 psv 5 and 40%. pt received general ventilator management as well as suctioning when needed. pt is to remain intubated overnight secondary to excess oral secretions. possible plan to extubate tomorrow. rrt\n"},{"category":"Nursing/other","chartdate":"2131-09-16 00:00:00.000","description":"Report","row_id":1558187,"text":"Resp Care\nPressure support increased to during noc to rest pt. Settings will be returned to in morning, plan is to extubate on days. Sxn'd thick yellow moderate amts x2 during shift. No abgs drawn, will follow.\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1558201,"text":"MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT APPEARS A@OX3...APPROPRIATE WITH FAMILY, FOLLOWING COMMANDS. AFEBRILE.\n\nRESP: REMAINS ON FACE TENT 40% WITH O2SATS 96%. LUNGS COARSE THROUGHOUT, RECIEIVNG LASIX IV FOR DUIRESIS. ABG WNL.\n\nCV: SR ON MONITOR, VSS PER L RADIAL ALINE. NO AFIB NOTED. S1S2 ON AUSCULTATION. ANASARCA NOTED ALL AROUND.\n\nGI/GU: FOLEY OUTPUT DROPPED OFF, FOLEY IRRIGATED WITHOUT DIFF. WILL MONITOR OUTPUT. ABD S,NT,D...TOLERATING TF'S, RATE INCREASED TO 30CC/HR...NO RESIDUALS. WILL FOLLOW.\n\nTODAY; HCT DOWN TO 25...RECIEIVING ONE UNIT PRBC'S. L PICC PLACED, PLACEMENT OKAY PER XRAY; WILL PULL TLC AFTER BLOOD INFUSED.\n\n"},{"category":"Nursing/other","chartdate":"2131-09-20 00:00:00.000","description":"Report","row_id":1558202,"text":"Nursing Progress Note\nNeuro: Awake, calling out at times, remains difficult to understand with weak voice, upper airway congestion\nResp: Sats 92-96% on 40% cool neb face tent, BS coarse throughout, required N-P suctioning x4 overnight for thick tan sputum, has weak cough, at times can cough up to back of throat, can use Yankauer suctioning\nCV: Stable, remains in NSR, no ectopy noted, continues on Diltiazem 30mg via NGT q6hrs\nGI: Tol TF's at now 40ml/hr with minimal residuals. Blue dye in feeds, no evidence of aspiration overnight. scant amt soft brown stool\nGU: I/O neg ~700ml/24hrs after lasix dose given on day shift, continues with u/o >60ml/hr\nSkin: No change in hip wound, Duoderm intact on back area\nSocial: Telephone update to pt's daughter, overnight\n"},{"category":"Nursing/other","chartdate":"2131-09-20 00:00:00.000","description":"Report","row_id":1558203,"text":"ALTERED RESP STATUS\nD:PT AWAKE AND ALERT AND FOLLOWS SIMPLE COMMANDS APPROPRIATELY. CONVERSING WITH FAMILY IN FEW WORD SENTENCES. REMAINS ON 40% FACE TENT WITH ABG=7.35/49/87/28/0. SUCTIONED WITH DIFFICULTY VIA R NARE FOR COPIOUS AMTS OF THICK TAN SPUTUM AND THEN THICK YELLOW SPUTUM. THIS AFTERNOON PT ABLE TO COUGH AND RAISE TO BACK OF HIS THROAT THICK TAN SPUTUM. COARSE BS BIL ON AUSCULTATON. MAX TEMP=96.9 AXILLARY. SBP 160-179. AND RR 18-26. TUBE FDGS OF PROMODE INCREASED TO 50CC'S/HR WITH MINIMAL RESIDUALS. GOAL RATE FOR TUBE FDGS IS 60CC'S. PT STILL WITHOUT GAG AND THIS WAS VERIFIED BY SPEECH SWALLOW THERAPIST WHO RECOMMENDS THAT PT WILL NEED PEG. HCT STABLE AT 31.5 . K+ 3.6 AND REPLACED WITH 20 MEQ KCL VIA NGT. PT IS A DNR BUT WOULD BE REINTUBATED. PT EVALUATED AND SCREENED BY AND . PT BE TRANSFERED WHEN BED AVAILABLE TO REHAB AS EARLY AS MON.\n"},{"category":"Nursing/other","chartdate":"2131-09-16 00:00:00.000","description":"Report","row_id":1558188,"text":"NURSING PROGRESS NOTES:\nPT CONT TO BE INTUBATED AND VENTED. REMAINS ON PRESSURE SUPPORT AND PEEP, SEE FLOWSHEET FOR SETTINGS. SX OCC FOR MOD AMT'S OF THICK YELLOW SPUTUM. LUNG SOUNDS COARSE THROUGHOUT. O2 SAT'S IN THE HIGH 90'S.\nPT CONT TO BE QUITE SEDATED BARELY RESPONDING TO STIMULI.\nBP OCC GOING UP TO 180 RANGE WHEN STIMULATED WITH TURNING OR SUCTIONING.\nFOLEY CATH DRAINING ADEQUATE AMT'S OF YELLOW URINE. RECTAL BAG CHG'D, NOT DRAINING MUCH STOOL, IMODIUM HELD.\nTUBE FEEDS CONT AT 40/HR WITH SM RESIDUALS. BOWEL SOUNDS PRESENT AND ABD SOFT/DISTENDE.\nFAMILY VISITING TILL MIDNIGHT AND UPDATED.\n"},{"category":"Nursing/other","chartdate":"2131-09-16 00:00:00.000","description":"Report","row_id":1558189,"text":"resp. care note: pt assessed for extubation by rrt, rn, and md. pt. found fit for extubation. pt extubated, and placed on a cool aerosol mask at 50%, which will be titrated to keep spo2 > than92%. following extubation there were no increases in resp. rate, heartrate, or decrease in spo2. all is well at this time. rrt\n"},{"category":"Nursing/other","chartdate":"2131-09-18 00:00:00.000","description":"Report","row_id":1558196,"text":"NPN 7a-7p:\n RESP: Pt requiring NT x 3 this shift... copious to moderate amts thick tan/yellow secretions. LS very course, bronchial at bases... team aware that pt is also + 1L fb... to discuss dose lasix. Cont on 50% csm with sats 99-100%... abg wnl.. po2 66-90's... po2 lower with pt on R side. RR 20's.\n ID: afebrile. abx changed... unasyn dc'd and po augmentin started.. cont on ox.\n F/E: fb + as noted.. repleted with Kcl, MG per med sheets. TF's reinstituted... now at 10cc/hr ... goal is 40cc/hr.. Discussion r/e peg for long term feeding.. Pt to have swallow study tomorrow... pending results of this, pt to decide r/e PEg.\n Access: IV team in to for PICC... state that arm is too edematous at this time.. if unable to place will need hickman.\n CV: no active issues.\n social: pt's daughter in to visit.. discussion held with team/pt/... pt statign would want to be reintubated... no cpr.\n A/P: pt with adequate abg'd, but cont with secretions although less.. cont to follow o/n.. line tomorrow for long term abx.. may diurese tonight.\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1558197,"text":"Nursing Progress Note\nPt noted to convert to Afib rate up as high as 130's with compromised BP to as low as the 80's. HO in to asess, EKG done confirming Afib, ? new ischemic changes, cycling CK's. Given fluid bolus NS 250ml. Diltiazem 5mg IVP by HO with rate down to 90's and SBP 120-130. Orders received for Diltiazem via NGT q6hrs, initial dose given at 2400. Monitor showing Afib rate 90's-110's with SBP 120's at this time. HO called pt's daughter at pt's request, updated re: events. Pt's code status remains no CPR.\n"},{"category":"Nursing/other","chartdate":"2131-09-15 00:00:00.000","description":"Report","row_id":1558183,"text":"resp. care note:\n Pressure support increased to 10cmh2o. Pt's resp rate 30s-40s, decreased sats and increased BP. Pt suctioned for a moderate amount of thick tan secretions. Plan is to try to wean pressure support back to 5; then extubate. For further information please refer to carevue charting.\n"},{"category":"Nursing/other","chartdate":"2131-09-15 00:00:00.000","description":"Report","row_id":1558184,"text":"P-MICU NSG PROGRESS NOTE 7P-7A\nNEURO: PATIENT AWAKE AT TIMES WOULD OPEN EYES SPONTANEOUSLY AND TO VOICE. FOLLOW COMMANDS BY SQUEEZING HANDS. MOVING HEAD AND FEET AND OCCASIONALLY ARMS. GIVEN 0.5MG ATIVAN IV THIS AM AS PATIENT BP ^200 AND NOT COMING DOWN AS IT WAS DOING PREVIOUSLY IN THE SHIFT. THIS HAD GOOD EFFECT AS BP DECREASED AND PATIENT STILL RESPONDING.\n\nCARDIAC: HR 80'S IN SR WITH NO NOTED ECTOPY. BP 140-206/ 50-77. WHEN PEACEFUL AND SLEEPING SBP 140'S-150'S. PATIENT WITH SEVERAL EPISODES DURING THE SHIFT WHEN HE WOULD BE FULLY AWAKE WITH EYES OPEN AND BP WOULD INCREASED TO 190-200. THIS WOULD LAST FOR ~5MIN AND THEN RETURN TO BASELINE. THIS MORNING BP WOULD NOT DECREASE, COZAAR WAS STARTED AND THEN PATIENT GIVEN THE ATIVAN. HCT 29 THIS AM. PATIENT WITH PERIPHERAL EDEMA.\n\nRESP: STARTED SHIFT ON PS 5/5 AT 40%. BREATHING 30'S WAS CHANGED TO PS 10 WITH RR IN THE 20'S. SATS 89-96% RR20-40. TV'S 400'S. LS CLEAR TO COARSE. SXT FOR SMALL AMOUNTS ON TAN YELLOW TO BLOODTINGED THICK SPUTUM. ABG THIS AM 67/36/7.32/19. PLAN IS TO EXTUBATE TODAY.\n\nGI: ABD SOFT WITH UMBILICAL HERNIA. BS+ WITH BROWN LIQUID STOOL IN FIC BAG. OGT IN PLACE WITH PROMOTE W/FIBER AT 40CC/HR. NO RESUDUALS.\n\nGU: U/O TAPERING TO 0. 250CC FLB BOLUS X2 WITH NO EFFECT. FOLEY FLUSHED EASILY. URINE WAS YELLOW AND CLEAR.\n\nSKIN: RIGHT UPPER HIP 4X2.5X1CM WOUND. YELLOW SLOUGH AND PINK WOUND BASE. WOUND GEL AND W/D DSG APPLIED. ALSO DUODERM TO UPPER BACK.\n\nID: WBC 17.6. ON OXACILLIN AND AUGMENTIN. CULTURES PENDING. TMAX 99.3.\n\nACCESS: RIJ CL, LEFT ART LINE.\n\nSOCIAL: DAUGHTERS HAVE BEEN HERE ALL SHIFT. UNDERSTAND PLAN TO EXTUBATE TODAY AND WISH PATIENT TO BE REINTUBATED IF NECESSARY. PATIENT IS A DNR.\n\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1558198,"text":"Nursing Progress Note\n1:15 - 1:30\n\nPatient transferred out of bed to chair with supine slide transfer. Patient unable to assist with transfers. On rounds, MD confirm that patient is to maintain non-weightbearing status due to pelvic fractures\n\nA/P: As patient is unable to receive percussion and shaking due to rib fractures and unable to be weightbearing to progress activity, will d/c from service as this time. If patient is able to participate in activity progression in the future, please reconsult our service.\n"},{"category":"Nursing/other","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":1558199,"text":"Nursing Progress Note\nNeuro: Awake, alert, difficult to understand what pt is saying most of the time d/t weak voice, secretions\nResp: BS coarse bilat, sats 95% on 40% cool neb mask. NP suctioned x3 for mod amt thick tan-yellow sputum\nCV: Converted to NSR 80's at 0530, receiving Diltiazem 30mg via NG tube BP back to baseline 130's-150's\nGI: Tube feedings at 10ml/hr with min residuals, +bowel sounds, no stool overnight\nGU: Adequate urine output, although still + ~1L/24hrs\nSkin: Hip packing changed, site without change from previous documentation\nSocial: No further contact with family overnight.\nPlan: Needs to be evaluated for PICC line insertion, venous access team aware.\n"},{"category":"Nursing/other","chartdate":"2131-09-14 00:00:00.000","description":"Report","row_id":1558178,"text":"NURSING PROGRESS NOTES:\nPT STILL AND VENTED ON SAME SETTINGS. SEE FLOWSHEET. PT SX FOR LRG AMT'S OF YELLOW BLD TINGED SECRETIONS. O2SAT'S MAINTAINING HIGH 90'S WITH NO DROPS. LUNG SOUNDS COARSE THROUGHOUT.\nPT CONT TO BE VERY SEDATED BUT HAS PERIODS WHEN SBP GOES UP TO THE 170'S AND IS ATTEMPTING TO OPEN EYES BUT UNABLE. PT MED WITH ATIVAN 1MG IVP WITH GOOD EFFECT.\nPT CONT ON GOAL RATE TUBE FEEDS WITH ACCEPTABLE RESIDUALS. RECTAL BAG DRAINING SM AMT'S OF LIQ BROWN STOOL.\nRIGHT HIP DSG CHG WITH SM AMT OF YELLOW DRAINAGE. WOUND CLEANSED/WOUND GEL APPLIED AND PACKED WITH WET TO DRY DSG.\nDUODERM ON SPINE INTACT.\nFAMILY CHECKED IN BY PHONE AND WERE UPDATED.\nPT CONT ON ANTIBIOTICS AND IV FLUID DISCONTINUED.\nPT HAS SEVERE GENERALIZED PITTING EDEMA. FOLEY CATH DRAINING MOD AMT'S OF YELLOW URINE.\nPT HAS LOW GRADE TEMP AND VITAL SIGNS ARE STABLE.\n"},{"category":"Nursing/other","chartdate":"2131-09-14 00:00:00.000","description":"Report","row_id":1558179,"text":"Resp Care,\nPt. remains intubated on CPAP IPS 10/.4/5peep. VT 500, RR 20. Suctioned for yellow sputum. Cont. to wean as tol.\n"},{"category":"Nursing/other","chartdate":"2131-09-14 00:00:00.000","description":"Report","row_id":1558180,"text":"PT/RSD\nS: Intubated, opened eyes during chest physical therapy\nO: Pt seen to address goals set at re-evaluation on \nLabs: 15.6>29.1<353, Tm 99.8\nVent: 40%FiO2/PS 10/PEEP 5/TV 500\nVital Signs: Pre-rx: 128/41, 77, 95%, 23\n During rx: 170/60, 83, 98% 23\nBreath Sounds: Coarse anterior, diminished bilateral lower lobes\nRx: Chest PT, percussion and vibration, to bilateral anterior lung fields in supine, bilateral lower lobes in sidelying. Followed by in-line suction for minimal amount of yellow secretions. Mouth yank. suctioned for moderate amount yellow sputum.\nA: Pt continues to benefit from chest PT and mobility in the bed to assist with secretion clearance. Pt continues to have less secretions and require less frequent suctioning.\nP: F/U \nPager #\nTime Frame: 3:15-4:00pm\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-14 00:00:00.000","description":"Report","row_id":1558181,"text":"Respiratory Care Note\n\nPt weaned to CPAP with PSV 5 and PEEP 50. 40%. Pt tol wean well Vt 460 and RR 20-26. pt x2 for small/mod amount of white sputum. Bs with scattered rhonchi. Pt much more awake today...following some commands. Plan to ? extubate in next couple of days.\n"},{"category":"Nursing/other","chartdate":"2131-09-14 00:00:00.000","description":"Report","row_id":1558182,"text":"s. ett\nO. NEURO PEARLA RESPONSE TO PAINFUL STIMULI AT 1800 PT MY HAND WITH HIS RT HAND WEAK OPENS EYES TO PAINFUL STIMULI\nCARDIAC HR 80'S NSR WITHOUT ECTOPY BP 130/-180/ EKG QT INTERVAL WNL AFTER D/C OF FLAGYL.\nRESP CPAP 40% PS 5 PEEP 5 ABG 75/42/7.36 LUNGS RHONCI TO CLEAR SX FOR SCANT AMT OF WHITE SPUTUM\nGI TF 40CC GOAL RESIDUALS MIN. BS+ STOOL DARK LIQ BROWN OB NEG ABD SNT UMBILICAL HERNIA UNCHANGED\nGU FOLEY U/O>40CC QHR CLEAR YELLOW\nSKIN RT HIP ANT 4X3CM .5-1CM DEEP POST SIZE DIME 1-2MM DEEP YELLOW DRAINAGE SCANT LUMBAR DECUB DUODERM INTACT PITTING EDEMA UE\nID AFEB ON OXACILLIN Q 4 IV\nCODE STATUS FAMILY HAS MADE PT DNR ATTENDING TO COSIGN ORDER\nA. ALT NEURO STATUS UNCLEAR IF RELATED TO ATIVAN STOPPED \nALT IN RESP VENT DEPENDENT\nS/P THORACENTESIS\nP. DNR\nSKIN CARE AS ORDERED\nATTEMPT TO EXTUBATE POSS. TOMMORROW\nCONT ANTIBX AS ORDERED\nSUPPORT FAMILY\n"},{"category":"Nursing/other","chartdate":"2131-09-17 00:00:00.000","description":"Report","row_id":1558193,"text":"NPN 7a-7p:\n Review of Systems:\n Resp: pt sx for copious amts yellow/tan secretions this shift... q 2hrs.. CPT done x 1 by PT as well. Cont on 50% CSM, with sats 99%, although abg 68/44/.7.37/26. desats to 85% quickly with mask off. RR 16-28. Aline dc'd as was red and small amt puss at site... tip sent for cx. team to place new aline, as pt's resp status tenuous.\n CV: pt in NSR 80's-90's. BP 130's-150's. NGT placed to give meds.. ASA and Cozaar.\n GU: pt cont with clots via foley today. irrigated x 1 d/t pt reporting unable to \"Pee\".. large clot removed... 3 way foley placed and await GU irrigant to run o/n. uo 40-60cc/hr.\n F/E: lytes wnl. cont on maintanence ivf. Cont edematous.\n ID: afebrile. wbc 9.0... as noted aline dc'd, and resited... cont on unasyn and oxacillin.\n Integument: Skincare CNS in to evaluate R hip wound today... Per CNS report.. wound with slightly more yellow, \"dead\" tissue... sharp debrided by CNS, cleansed with wound cleanser, and filled with wound gel and moist 2x2's, dsd ... taped to duoderm border... also, small blister on upper back cleansed and duoderm replaced.\n Social: pt's daughter and son in all day.. met with team to discuss plan of care.. pt to remain DNR, but would be reintubated. family very attentive.\n NEuro: pt A+ O x ... more awake this afternoon, voice much more clear. asking to watch tv.\n Access: remains with TLC to R SC... to have PICC placed tomorrow by iv team.. please save L antecube.\na/P: pt with tenuous resp status... large amts secretions.. desats easily, but perking up... to cont abx, follow abg's, cont skin care, pulmonary toilet.. PICC line tomorrow. cont emotional support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2131-09-18 00:00:00.000","description":"Report","row_id":1558194,"text":"NPN\n\nCV: SBP into the 180s, he was given his cozaar which decreased it to the 160s at times.\n\nPulm: Wet cough, not always able to get very much back from NT suctioning. Cool neb conts at 40% with SATs in the high 90s-100%, desats to the low 90s with his mask off .\n\nGI: TF on hold, to discuss with the team today.\n\nGU: He no longer has any blood in his foley, continuous flush has been stopped.\n\nNeuro: Weak, calling out when he wants assistance.\n"},{"category":"Nursing/other","chartdate":"2131-09-18 00:00:00.000","description":"Report","row_id":1558195,"text":"Rehabilitation Services/physical Therapy\n10:15 - 10:45\n1:00 - 1:15\n\nS:\n\nO: Seen to address problems and goals of .\nVital signs: 84, 186/60, 99%, 24, Temp 97.1\nLabs: 90/48/7.34/27, WBC 7.9, Hct 25.4, CXR with Right rib fractures\nBreath sounds: rhonchi throughout, crackles at left base\nRx: NTS for large amounts of yellow/tan secretions. Perc and shaking not done secondary to rib fractures.\nMobility: Due to pelvic fractures, non weightbearing transfers out of bed to chair this am. Returned to bed this PM. Patient with stable vital signs throughout.\n\nA: Patient with rib fractures and airway secretions. NTS used to remove secretions with good results. Out of bed to chair.\n\nP: COntinue to follow for pulmonary care out of bed to chair\n"},{"category":"Nursing/other","chartdate":"2131-09-12 00:00:00.000","description":"Report","row_id":1558172,"text":"Resp. Care Note\nPt remains intubatd and vented on current settings CPAP 5 PSV 5 and 40%. Pt changed to these settings today from A/C and has done well with stable ABG's and RR 24 TV 450-500. RSBI today 66. Sxn for pale yellow secretions, decreased amount today. Pt with cough response and slight gag but still uresponsive to commands. Cont present settings, assess for ext. when Pt more alert.\n"},{"category":"Nursing/other","chartdate":"2131-09-13 00:00:00.000","description":"Report","row_id":1558173,"text":"RESP CARE,\nPT. REMAINS ON CPAP IPS5/.4/5PEEP. VT 400, RR HIGH 20'S. RESTED COMFORTABLY, NO VENT CHANGES.\n"},{"category":"Nursing/other","chartdate":"2131-09-13 00:00:00.000","description":"Report","row_id":1558174,"text":"NURSING PROGRESS NOTES:\nPT REMAINED ON CPAP THROUGHOUT THE NIGHT. SX FOR MOD AMT'S OF THICK YELLOW SECRETIONS. LUNG SOUNDS VERY COARSE THROUGHOUT. MAINTAINING O2SAT'S IN THE HIGH 90'S.\nPT CONT TO BE VERY LETHARGIC AND BARELY RESPONSIVE WITH STIMULI.\nVITAL SIGNS STABLE. TEMP 99.8 PO.\nFOLEY CATH DRAINING ADEQ AMT'S OF CLOUDY URINE.\nDSG CHG TO R HIP. NO CHG' IN APPEARANCE.\nNO STOOL AND RECTAL APPLIANCE INTACT.\nFAMILY CALLED DURING THE NIGHT AND UPDATED.\n"},{"category":"Nursing/other","chartdate":"2131-09-13 00:00:00.000","description":"Report","row_id":1558175,"text":"Rehabilitation services/physical therapy\n\nPatient traveling to CT for needle aspiration and having echo presently. Unable to see for pulmonary care, tho nursing has been able to position and suction patient throughout day.\n\nWill follow \n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-13 00:00:00.000","description":"Report","row_id":1558176,"text":"NPN\nNEURO: Tmax 99.4. Remains lethargic. PERRLA. Has not recieved Ativan since 6am on .\n\nCV: Monitor shows SR without ectopy. Prolonged QTC noted. Cards feels this is d/t abx therapy. PPx4. S1S2. VSS. K+ and Ca++ replaced this am.\n\nRESP: Remians orally intubated. Vent settings per flow. ABG pending. US guided tap done today. 750cc Fluid removed. Lungs remain coarse. Suctioning for large amounts of thick yellow secretions.\n\nGI: Tolerating TF well. Rectal bag remains intact. No stools.\n\nGU: Foley draining clear amber urine in adequate amounts.\n\nINTEG: Stoma RN following for R hip wound. CT of area done today, abcess not drained d/t risk of infection and location of abcess.\n\nSOCIAL: Family spoke with team today. updated on POC. Questions answered.\n\nPLAN: Wean from vent as tolerated. Pulmonary toilet.\n"},{"category":"Nursing/other","chartdate":"2131-09-13 00:00:00.000","description":"Report","row_id":1558177,"text":"Respiratory Care Note\n\nPt remains on CPAP PSV 10 PEEP 5 40%. Vt 450-500 RR 24-28. Last ABG was 7.42/32/82. Pt seems comfortable on these settings. Pt transported to CT scan today for pelvic scan. Pt also had R sided pleural effusion tapped for 750cc. Pt sxnd for mod amount of thick tan secretions. BS much improved this evening. Will maintain current settings and wean when patient is more alert.\n"},{"category":"Nursing/other","chartdate":"2131-09-06 00:00:00.000","description":"Report","row_id":1558147,"text":"MICU Admit note\n Pt admitted to MICU from 3 for increasing SOB. Mr. was admitted to for increasing confusion, weakness, and SOB on . This was increasing for several days, he was also having loose stools and decreased mobility. He was recently dc'd from TCU with prolonged stay of 99 days. He was home for one month. He lives at with 24 hour health aide.\nPMHX:\nRLL pneumonia with Staph bacteremia, HTN, Osteoprosis, prostate CA', GERD, s/p pelvic fx4/01, right arm fx , left hip decub ulcer, s/p back surgery '.\nDaughter is health care proxy. is very involved in care.\n Pt was admitted at 1300. Upon admission Mr. was on 100%NRB with NC at 6ltr. Pt's breathing was labored at 24-32 BPM. Pt was alert, nods yes and no to quesions appropriately, follows commands.\nFamily accompianied Mr. to unit. Pt's daughter spoke to ICU team. ICU team spoke with patient and family regarding intubation. Pt wishes to be intubated if necessary.\n TLC and Artline were placed at 1730 per ICU team. Consents obtained from patient and family.\nReview of systems:\nNeuro: Pt is awake, alert. Follows simple commands. Answers questions appropriately.\nResp: Lungs sounds coarse. Pt 2 94-97% on 100%NRB and 6ltr NC. Respirations labored, tachypneaic. ABG per lab flow sheet.\nCV: Heart rate SR with occcaisional PVC's/PAC's. BP 90s/30-40s\nPt is febrile with temp of 99.9 rectally.\nGI: Abdomen distended, soft. Positive bowel sounds. Pt is having frequent loose stools.\nGU: Foley catheter draining clear/yellow urine. Pt recieved a 120 lasix on floor this am and put out approx a liter of urine since then.\nPlan: Continue to monitor respiratory status.\n"},{"category":"Nursing/other","chartdate":"2131-09-23 00:00:00.000","description":"Report","row_id":1558214,"text":" RN NOTE\nMR HAD AN IMPROVED DAY TODAY. INITIALLY Q2 HOUR NT SUCTIONIGN. BUT HE WENT FROM 12NOON TO 1700 WITH SATS >95%. REMAINS ON 40% FT. NO IMPROVEMENT IN VOICE YET (ENT CONSULT FOR VOICE ON HOLD). THE CT REVEALE D INCREASING IN SIZE D/T ??HYPOALBUMINEMIA. POSSIBLE PLAN INCLUDES CT GUIDED TAP...MARK BROWNING (RESIDENT) WORKING ON THIS.\n\nHE HAS BEEN TIRED TODAY, SLEEPIING INTERMITTANLY AND AWAKENING APPROPRIATELY WHEN I GO IN ROOM OR CALL HIS NAME.\n\nGI/GU: STOOLS X3 TODAY. TOL GOAL PROMOTE WITH FIBER.\n\nSKINL RT HIP WOUND WITH TAN BASE. DSD WITH WOUND JELLY APPLIED.\n\nID: OXACILLIN D18 OF 42. AND AUGUMANTIN DAY8 OF 14. AWAITING SPUTUM AND URINE SENT YESTERDAY. PICC SINCE \n\nSOCIAL: I HAD AN EXTENSIVE DISCUSSION WITH DTR AND HER HUSBAND RE: , TRACH, HIS HOSPITAL STAY, A REHAB STAY, MANY QUESTIONS WERE ASKED AND ANSWERED FROM BOTH SHE AND I... THIS INFO COMMUNICATED IN DETAIL TO DR .\n\n\nPLAN: FAMILY MEETING TOMORROW AFTERNOON , PENDING A TIME FROM RESUMING ATTENDING DR . ----THIS TIME MUST BE DECIDED UPON DURING ROUNDS RN AND FAMILY CAN BE AVAILABLE. FAMILY IS COMING IN THE EARLY AFTERNOON ADN ARE AWARE THEY HAVE TO WAIT.\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-24 00:00:00.000","description":"Report","row_id":1558215,"text":"P-MICU NPN 7p-7a\nSystems Review:\n\nCV: Has been hemodynamically stable. BP 90's-120's, HR 70's SR, no ectopy. Received 20meq KCl last eve. AM labs drawn, awaiting results.\n\nResp: Aggressive pulmonary toilet cont's. Secretions thick and tan. Attempting to suction less this shift due to trauma and discomfort. LS coarse throughout.\n\nID: IV oxacillin, per ID, to con't until to complete 8wk coarse. Aumentin for oral infx. Will need oral surgery consult..\n\nF/E: Just about even at present.\n\nHeme: Hct up this am to 34.2 after receiving 2nd unit PRBC's.\n\nSocial: Son from called last eve. Wanted to know what meds pt was on and if steroids or inhalers/nebulizers would help.. He had spoken to a friend who suggested this. I told him that the MD's were aware of the meds. He said he has a good relationship with his sister, who has been updating him frequently. He is in agreement with her decisions and wants what is best for the pt. Also he was unclear whether or not pt would benefit from a trach. I asked him if his father would want this aggressive tx and he stated that if it gave him some quality of life, he believes he would. He is aware of the family meeting scheduled for today, and expects to be updated by sister.\n\n"},{"category":"Nursing/other","chartdate":"2131-09-10 00:00:00.000","description":"Report","row_id":1558159,"text":"Resp Care Note:\n\nPt cont on mech vent aas per vent flowsheet. Lung sounds ess clear. No changes made this shift. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2131-09-10 00:00:00.000","description":"Report","row_id":1558160,"text":"NPN\n\nCV: conts on neo, his dose has needed to be increased through the night to maintain a SBP in the 100s. His HR has been in the 50s SB.\n\nPulm: Conts on the respirator no changes were made. LS cleared after suctioning, bronchial on the R. He has had a lg amount of tan, thick putum from the ETT and from the back of his throat.\n\nGI: Conts to have loose, golden stool. He had a 270cc residual from his NGT, they were OB pos, TFs were shut off.\n\nGU: U/O has increased from yesterday.\n\nNeuro: Well sedated on the propofol, appears comfortable.\n\nSkin: Dressing on his R hip changed no change in the wound during the last 2 days.\n"},{"category":"Nursing/other","chartdate":"2131-09-10 00:00:00.000","description":"Report","row_id":1558161,"text":"RESP NOTE:PT REMAINS SEDATED AND VENTED WITH NO REMARKABLE CHANGES IN RESP STATUS.PRESENT VENT SETTINGS AC/450/14/40% WITH PEEP LOWERED TO 10 AND TOLERATING WELL.SECRETIONS MINIMAL AND PALE/YELLOW,B/S DIMINISHED BILAT,ABG\"S AVAILABLE IN CAREVUE.SATS BEING MAINTAINED AT 99/100% ON CURRENT SETTINGS,WILL CONTINUE TO MONITOR AND WEAN AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2131-09-10 00:00:00.000","description":"Report","row_id":1558163,"text":"NURSING PROGRESS NOTE:\nPT REMAINS /VENTED, NO FURTHER CHG'S MADE. FOLLOWING O2SAT'S, MAINTAINING SAT'S 95-97%. LUNG SOUNDS CONT TO BE VERY COARSE. SX FOR MOD AMT'S OF THICK YELLOW SECRETIONS.\nWEANING OFF PROPOFOL AND CONT ON ATIVAN WITH ADEQUATE LEVEL OF SEDATION.\nNEO REMAINS OFF, RECEIVED 500CC NS BOLUS TO KEEP SBP ELEV AND INC U/O.\nCONT ON ANTIBIOTICS.\nTUBE FEEDS REMAIN ON HOLD. PT INC SM AMT'S OF LIQ BROWN STOOL.\nHIP DSG CHG'D NO CHG IN APPEARANCE. WET TO DRY DSG APPLIED AFTER BEING CLEANED AND GEL APPLIED.\nFOLEY CATH DRAINING ADEQ AMT'S OF CLEAR DK YELLOW URINE.\nFAMILY SPOKE WITH HO ABOUT BRINGING IN A CONSULT FROM THE . HO SPOKE WITH DR. ABOUT THIS.\n\n"},{"category":"Nursing/other","chartdate":"2131-09-11 00:00:00.000","description":"Report","row_id":1558164,"text":"Resp Care Note:\n\nPt cont on mech vent as per Carevue. Lung sounds ess cl. No changes made this shift. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2131-09-11 00:00:00.000","description":"Report","row_id":1558165,"text":"Pmicu nsg progress note\nResp: remains /vented on ac 450x14 40% 10 peep with sats high 90's abg 79/37/7.36. suctioned for mimimal secretions. Remains afebrile.\nCardiac: bp stable 100-110/40-50 without further fluid boluses. Remains off neo. Cont in sinus brady hr in 50's.\nNeuro: remains sedated on 1mg ativan. Pt off propofol. ? need to further wean ativan as pt essentually unresponsive.\nGI:Abdomen soft. passing loose brown stool. Tube feeds remain on hold. ?restart today.\n\n"},{"category":"Nursing/other","chartdate":"2131-09-11 00:00:00.000","description":"Report","row_id":1558166,"text":"Resp. Care Note\nPt remains intubated with 7.5ETT secured at 23c lip. Current settings A/C 450x 14x 40% peep 7.5 with ABG 70/37/7.36/22/-3. Peep decreased today from 10-7.5 with adequate oxygenation. Pt occas assisting above vent, could probably be changed to PSV. Sxn for mod. amount of thick tannish secretions. Cont support.\n"},{"category":"Nursing/other","chartdate":"2131-09-10 00:00:00.000","description":"Report","row_id":1558162,"text":"MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT REMAINS SEDATED ON PROPOPHOL...ATIVAN JUST STARTED THIS EVENING. GOAL IS TO WHEEN PROPOPHOL OFF AND CONT WITH JUST ATIVAN. PT UNRESPONSIVE TO STIMULI...FACIAL GRIMACING WITH TACTILE STIMULI. AFEBRILE.\n\nCV: NEO TO OFF THIS AFTERNOON. BP RANGING FROM 90-110/40-50'S VIA R RADIAL ALINE. SB WITH NO ECTOPY NOTED. POOR PALPABLE PULSES ALL AROUND. S1S2 ON AUSCULTATION.\n\nRESP: PT TO AC/40/450/10/14...BREATHING WITH VENT. SUCTIONED FOR LG AMTS THICK YELLOW SECRETIONS ORALLY AND VIA ETT. PT HERE THIS EVENING AND WORKING WITH PT. LUNGS CLEAR WITH SCT RHONCHI THROUGHOUT BASES AND DECREASED BASES. WILL SEND ABG 30 MINS AFTER PT DONE SUCTIONING AND DOING CPT. ETT 23CM AT LIPLINE.\n\nGI/GU: FOLEY DRAINING CLOUDY YELLOW URINE. UO RANGES FROM 0-100CC/HR. NSS BOLUSES GIVEN THROUGHOUT DAY TO IMPROVE UO AND BP. TOLERATED WELL. TF REMAIN ON HOLD...HIGH RESIDUALS (GASTRIC HEME +...PH 2). TEAM AWARE. WILL START ON REGLAN. PT SEVERAL TIMES OF LIQUID BM...DULCOLAX GIVEN YEST D/T PT BARIUM IN CT SCAN. ABD S,D,NT...ACTIVE BSX4. WILL CONT TO CHECK RESIDUALS AND ATTEMPT TO RESTART TF.\n\nINTEG: R IJ TLC P/I...CVP OFF DISTAL PORT. R RADIAL ALINE P/I. R HIP WOUND REPACKED AND CLEANSED THIS AFTERNOON. TUNNELLING AREA YELLOW WITH PINK TISSUE SURROUNDING EDGES. ESCHAR NOTED IN CENTER APPROX 1MMX1MM. CONT TURNING PT Q2H. PT WITH NEW R HIP FRACTURE...ORTHO BY TO SEE PT.\n\nSOCIAL: SPOKE WITH DAUGHTER ON PHONE SEVERAL TIMES TODAY. SHE WAS UPDATED ON PT STATUS AND WILL BE STOPPING BY LATER TODAY.\n"},{"category":"Nursing/other","chartdate":"2131-09-27 00:00:00.000","description":"Report","row_id":1558224,"text":"NURSING PROGRESS NOTE:\nPT ALERT AND ORIENTED. WEARING FACE MASK AND O2SAT'S IN THE HIGH 90'S. ABD DSG FOR PEJ TUBE DRY AND INTACT. GASTRIC PORT DRAINED 175CC BILE.\nTUBE FEEDS INF AT 30/HR WITH LOW RESIDUALS.\nPT CONT TO BE OF SM AMT'S OF LIQ GREEN STOOL.\nPERIANL AREA CONT TO BE VERY REDENED AND EXCORIATED. DESITIN OINT APPLIED AND SEEMS TO BE HELPING.\nPT RECEIVED LASIX ON EVENING SHIFT AND PT CONT TO DIURESE LRG AMT OF DILUTE URINE.\nPT CONT TO HAVE MUCH DIFF COUGHING AND RAISING SECRETIONS.\nHIP DSG CHG AS ORDERED NO CHG IN APPEARANCE OF WOUND.\nDAUGHTER CALLED AND WAS UPDATED.\n"},{"category":"Nursing/other","chartdate":"2131-09-27 00:00:00.000","description":"Report","row_id":1558225,"text":"altered resp status\nD: ALERT WHEN AWAKE BUT VERY LETHARGIC TODAY AND SLEEPING IN LONG NAPS. COARSE BS . SUCTIONED X 2 FOR THICK TAN SPTUM AND O2 SATS93-98%. REMAINS ON 50% OPEN FACE TENT BECAUSE PT RECEIVING MORE MOISTURE WITH THIS MODE. PT'S DAUGHTER AND SON AT THE BEDSIDE. RECIVING PROMODE WITH FIBER AT GOAL RATE NOW OF 60CC'S/HR VIA NEW PEJ. PEJ DRSG FOR AMT OS SEROUS DRAINAGE. POS BOWEL SOUNDS AND PT HAS HAD 2 EPISODES OF SM AMTS BLUE STOOL. UO ADEQAUTE VIAFOLEY CATH . R HIP DRSG AS ORDERED AND NO CHANGE IN APPEARANCE. PT HAS REQUIRED LESS SUCTIONING TODAY AND DOES NOT NEED NURSING CARE THOUGH HIS RESP STATUS WILL NEED TO BE MONITORED CAREFULLY.. CONITNUE TO OFFER EMOTIONAL SUPPORT TO FAMILY\n"},{"category":"Nursing/other","chartdate":"2131-09-11 00:00:00.000","description":"Report","row_id":1558167,"text":"MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT REMAINS EXTREMELY SEDATED ON ATIVAN GTT...GTT DOWN TO 0.5MG/HR. CONVERT TO PRN ATIVAN IV...PLAN TO ASSESS PT AND SEDATION REQUIREMENTS. AFEBRILE.\n\nCV: PT REMAINS OFF NEO. ABP 110-120/40-50'S. L ALINE CORRELATING WELL. SB WITH 1ST AV AND BBB ON MONITOR. EKG THIS SHOWED NEW T WAVE ABNORMALITIES AND POSSIBLE NEW ISCHEMIA. TEE DONE...NEGATIVE FOR VEGETATION. CARDIAC ENZYMES SENT X2. RESULTS PENDING. S1S2M ON AUSCULTATION. POOR PALPABLE PULSES ALL AROUND. CVP 9-10.\n\nRESP: PT REMAINS ON AC/450/14/40%/PEEP DOWN TO 7.5. ABG DONE AND WNL. SUCTIONING OUT THICK TAN SECRETIONS ORALLY AND VIA ETT. LUNG SOUNDS COARSE, DECREASED LOWER LOBES. O2SATS 96% WHEN TRACKING.\n\nGI/GU: OGT PULLED FOR TEE. REPLACED AND XRAY DONE..WAITING TO HEAR IF PLACEMENT IS GOOD. ABLE TO START TF THIS AM AT 0900...RESIDUALS OF 10CC. TF ON HOLD SINCE NOON FOR TEE. ABD S,D, ACTIVE BSX4. CONT WITH FREQ LIQUID STOOLS. SENT FOR CDIFF. FOLEY DRAINING SMALL AMTS YELLOW URINE. TEAM AWARE, BOLUS WITH MORE FLUID.\n\nINTEG: R IJ TLC P/I. SKIN NURSE BY TO R HIP WOUND. TUNNELING WITH YELLOW AND ESCHAR TISSUE IN CENTER, PINK TISSUE SURROUNDING EDGES. ORTHO BY TO PT...SUSPECT HIP WOUND IS ACTUALLY A TUMOR VS ABSCESS. FAMILY NOT AWARE YET. CAST REMOVED FROM R HAND...SPLINT ON.\nCONT ON FIRST STEP MATTRESS.\n"},{"category":"Nursing/other","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":1558229,"text":"ALTERED HEMODYNAMICS\nD: PT THIS AM TALKING AND RECOGNIZED HIS CAREGIVER, . O2 SAT=93& SO PT SUCTIONED FOR LG AMT OF THICK YELLOW TO TAN SPUTUM. COARSE BS . O2 SATS AFTER SX'ING WERE 96%. TURNED PT AT 0930 FOR BACK CARE AND TO CHANGE R HIP DRSG. ALARM SOUNDED AND SBP DOWN TO 84 WITH HR 50 AND O2 SAT=93%. MD'S CALLED TO BEDSIDE. PT NOT RESPONDING. NS BOLUS OF 500CC'S GIVEN. O2 REMAINED AT 100% FACE TENT WITH 6L/M NC. HR THEN DROPPED TO 41 AND SBP DROPPED TO 74. R RADIAL ALINE PLACED AND ABG AT THE TIME=7.15/96/81/35/1. PT'S DAUGHTER CALLED AND AFTER DISCUSSION WITH DR. ,DAUGHTER AND MYSELF AS WELL AS PHONE CONVERSATION WITH PT'S SON IN THE DECISION WAS MADE TO KEEP PT COMFORTABLE. O2 SATS DROPPED TO A LOW OF 62% AND SBP 70'S. THIS AFTERNOON WITHOUT PT'S HR HAS RETURNED TO THE 50'S AND SBP 90'S. O2 SATS HAVE REAMINED 90-94%. PT HAS MINIMAL CORNEAL REFLEX AND DR. HAS SPOKEN TO PT'S FAMILY AND THEY UNDERSTAND HIS GRIM PROGNOSIS. PT HAS RECEIVED 2 MG IVP MSO4 X3 AND WILL START MSO4 GTT IF MSO4 NEED INCREASES. UO HAS ALSO DROPPED TO MINIMAL AMTS SINCE HYPOTENSION. FAMILY HAS REMAINED AT THE BEDSIDE. PT AND AWAITING THE ARRIVAL OF HIS SON.\n"},{"category":"Nursing/other","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":1558230,"text":"addendum to above note: pt's son arrived and dr. met with famil. minimal corneal reflex to r and absent to l. unresponsive. family witnessed md's exam and aware of his status. o2 nc removed but continues with open tent mask. shortly after son arrived hr down to 43 and sbp 70's o2 sats dropped to 79-81%. mso gtt initated at 2 mg /hr and will continue to titrate as needed to keep pt comfortable.\n"},{"category":"Nursing/other","chartdate":"2131-09-29 00:00:00.000","description":"Report","row_id":1558231,"text":"Pmicu Nursing Note:\n\nPt expired on at 1:17am. Family in attendance. Drs' and pronounced.\n"},{"category":"Nursing/other","chartdate":"2131-09-22 00:00:00.000","description":"Report","row_id":1558209,"text":"NURSING PROGRESS NOTE:\nPT CONT TO STAY EXTUBATED ON FACE MASK. LUNG SOUNDS VERY COARSE THROUGHOUT, COUGHING AND ABLE TO RAISE SECRETIONS TO BACK OF THROAT AT TIMES. NASOTRACH SX Q4/HR FOR THICK TAN SECRETIONS. O2 SAT'S IN HIGH 90'S.\nPT'S VITAL SIGNS STABLE, AFEBRILE. RESP RATE REGULAR. NO SOB.\nTUBE FEEDS CONT AT 60/HR MINIMAL RESIDUAL. BOWEL SOUNDS PRESENT AND PASSING SM AMT'S OF SOFT GREEN STOOL.\nPT HAS BEEN VERY ALERT AND TALKING. SLEPT VERY LITTLE DURING THE NIGHT.\nNO CHG IN R HIP DECUBITUS. DSG CHG' NO SIG SIGNS OF IMPROVEMENT.\nFAMILY CHECKED IN AND UPDATED.\n"},{"category":"Nursing/other","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":1558226,"text":"PMICU Nursing Progress Note:\n\nResp/CV: Desat to 85% on 100% shovel mask. NT sx for min thick tan secretons. 5L NC added w/ O2 sats remain > 94%. Dropped sats again later in evening--required NT sx x 3 times for large amt of thick tan secretions with sats eventually >94%. Hemodynamically stable.\n\nGI/GU: 200cc output from gastric drainage. Cont on tf's at goal. Stool x 6 sm amts blue/grn. Buttocks excoriated, cream applied. U/O poor.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":1558227,"text":"Chart re-reviewed this afternoon. Events noted. No further PT needs at this time, will defer further treatment.\nTime: 6:00pm\nPager: #\n"},{"category":"Nursing/other","chartdate":"2131-09-28 00:00:00.000","description":"Report","row_id":1558228,"text":"PT/RSD\nRe-consult received, pt known to physical therapy department. At this time we are unable to progress pt's mobility as he is NWB secondary to bilateral pelvic fractures. Will re-evaluate status on , deferred rx today as pt unstable this am.\nPager: #\nTime: 10:00am\n"},{"category":"Nursing/other","chartdate":"2131-09-22 00:00:00.000","description":"Report","row_id":1558210,"text":"P-MICU RNNOTE\nCV: STABLE WITH DILTIAZEM.\n\nRESP: ENT CONSULTED FOR HOARSENESS. FAILED SWALLOW STUDY YESTERDAY SECONDARY TO INABILITY TO BALL FOOD TO BACK OF MOUTH. AT 1800 ABG= 58/42/7.45...CHANGED TO NRB, NT SUCTIONED, SAMPLE SENT.\n\nPLAN: WILL REDO ABG\n CONT CPT Q4 HOURS.\n CONT NT SUCTIONING PRN\n\nGI/GU: FOLEY BAG CHANGED AND CULTURE SENT AS URINE DARKENED LATE TODAY. TOL GOAL RATE PROMOD WITH FIBER AT 60CC/HOUR. FREE WATER BOLUSES D/C' N ATTEMPT TO MAKE HIM ABOUT 500CC (-).\n\nID: AFEBRILE. OXACILLIN (D#17 OF 6WEEKS) AND AUGUMENTIN (D#7 OF 14). HE HAS MULTIPLE DENTAL ABCESSES THAT DENTAL HAS ASSESSED AND DOES NOT FEEL WILL SEED... OMF (ORAL MAXILOFACIAL SURGERY) DOES NOT HAVE O.R. PRIVELAGES, THUS HE WOULD NEED TO LEAVE , HAVE SURGERY AND RETURN.\nDSD TO RT HIP DECUBITUS.\n"},{"category":"Nursing/other","chartdate":"2131-09-23 00:00:00.000","description":"Report","row_id":1558211,"text":"Resp Care Note:\n\nPt requires aggressive pulmonary toilet. Pt suct for copious th beige sput. Lung sounds bilat rhonchi clearing significantly after suct. Pt currently w/ O2 Sat ~ 95% breathing comfortably in NARD. Cont aggressive pulmonary toilet.\n"},{"category":"Nursing/other","chartdate":"2131-09-23 00:00:00.000","description":"Report","row_id":1558212,"text":"P-MICU NPN 7p-7a\nSystems Review:\n\nResp: LS coarse bilat throughout. Aggressive CPT maintained throughout shift. Received CPT q4h with NT suctioning. Pt with large amts of tan thick secretions. O2 sats have been 94-97%, with rr in the 20's. ABG 63/47/7.39/30/2 on 40%CN. No further ABG's obtained, due to A-Line falling out with turning.\n\nCV: VS have remained stable.\n\nNeuro: extremely difficult to understand due to pt being very weak, he has not been able to expectorate any secretions.\n\nID: Afebrile, on IVABX. Sputum cx sent.\n\nGU; +fluid status by 12am, 330cc's + by 6am.\n\nSkin: Right hip decub drsg protocol.\n\nGI: Small amts green stool. +bs, tolerating TF's with minimal residuals. TF's held ~1hr with CPT and sxning.\n"},{"category":"Nursing/other","chartdate":"2131-09-23 00:00:00.000","description":"Report","row_id":1558213,"text":"P-MICU NPN 7p-7a\nPt's urine output has steadily been declining. 15-20cc's/hr House officer notified. Will con't to assess.\n"},{"category":"Nursing/other","chartdate":"2131-09-12 00:00:00.000","description":"Report","row_id":1558168,"text":"PMICU NURSING PROGRESS NOTE:\n\nNeuro: all sedation off. unresponsive to stimuli.\n\nCV: stable, SBP 110-130. HR 60's BBB. Troponin of yest negative. TEE negative. EKG due this am. Ca++ repleted.\n\nResp: Vent settings unchanged. Sx x 3 for thick yellow mod amt. ^^oral secretions. LS crackle, coarse.\n\nID: afebrile. cont on Oxacillin, clinda for + bld cx\n\nSkin: buttocks excoriated from constant mucoid green stool. Rectal bag applied. R hip dsg x 2. Need to contact skin care RN for more appropriate chemical debriding gel (collagenase?), wound sloughing-tunneling.\n\nGI/GU: TF's restarted, now 35cc. U/O sporatic but averaging ~30cc/h.\n\nSocial: no calls from family. Remains full code.\n"},{"category":"Nursing/other","chartdate":"2131-09-12 00:00:00.000","description":"Report","row_id":1558169,"text":"Resp Care Note:\n\nPt cont on vent as per Carevue. Lung sounds rhonchi impr after suct mod th tan sput. No changes made this shift. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2131-09-08 00:00:00.000","description":"Report","row_id":1558152,"text":"NPN\nNEURO: Remains sedated on Propofol gtt currently at 40 mcg/kg/min. Withdraws to painful stimuli. PERRLA. Afeb.\n\nCV: Monitor shows SR without ectopy. VSS. MAP>60. PPx4. S2S1 murmur noted. Lytes this am WNL.\n\nRESP: Orally intubated with 7.5 ETT 23 at the lip. AC / 450x10/ 50%/ 15peep. PAP 35-39. O2 sats 98-100%. Lungs very coarse. Suctioning for large amounts of thick yellow pasty secretions. Last ABG WNL.\n\nGI: NGT intact with + placement. Readicat given for CT of Abd scheduled for 5pm. Hypoactive bowel sounds noted. No stool today.\n\nGU: Borderline uop today. Foley flushed x1 with very slight increase in uop. UOP remains > 30cc/hr.\n\nSKIN: No edema noted. R hip wound debrided by plastics today. Recommend tid dressing changes. Duoderm to coccyx intact.\n\nSOCIAL: Daughter very involved in pt care. Very inquisitive. Questions answered.\n\nID: BC + staph aureus 4/4 bottles. Sensitive to Oxacillin and Clindamycin. Covered with both. No fevers. WBC count is down to 16.9. Plastics does not feel R hip is source of infestion.\n\nPLAN: Continue vent support. Abd CT this pm. Continue with abx regimine. Pulmonary toilet.\n"},{"category":"Nursing/other","chartdate":"2131-09-08 00:00:00.000","description":"Report","row_id":1558153,"text":"NPN\nPt dropped SBP to 60's. Fluid bolus 500cc given and Neosynephrine started. BP now in the low 100's. CT on hold for now, will retry later.\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-08 00:00:00.000","description":"Report","row_id":1558154,"text":"RESP NOTE:PT REMAINS INTUBATED AND VENTILATED AT THIS TIME WITH NO RESP DISTRESS NOTED.B/S DIMINISHED BILAT WITH SX FOR SMALL/LARGE AMOUNTS OF THICK TAN/YELLOW SECRETIONS DURING SHIFT.PRESENT VENT SETTINGS AC/450/10/50% PEEP15 AND TOLERATING WELL. ABG\"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH PRESENT COARSE AND WEAN AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2131-09-09 00:00:00.000","description":"Report","row_id":1558155,"text":"NPN\n\nCV: Pt still requiring neo, gtt increased a little due to low BP. he remains in a SR, HR 60-70s.\n\nPulm: LS bronchial on the R, clear on the L, very little sputum from his ETT. No changes were made in his vent.\n\nGI: Stooled x2, gelatonous, brown, OB neg. TF started Replete with fiber at 10cc/hr\n\nGU: decreased u/o\n\nNeuro: Remains on Propofol, he has been well sedated\n\nSkin: Decube on his R hip, dressing done, white base, very little drainage\n\n"},{"category":"Nursing/other","chartdate":"2131-09-09 00:00:00.000","description":"Report","row_id":1558156,"text":"Resp Care Note:\n\nPt cont on mech vent as per vent flowsheet. Lung sounds coarse. Sx mod th pale yellow. No changes made this shift. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2131-09-09 00:00:00.000","description":"Report","row_id":1558157,"text":"NPN\nNEURO: Remains sedated on Propofol gtt. PERRLA. Responds to painful stimuli.\n\nCV: Monitor shows SR without ectopy. VSS. Remains on Neo at 32mcg/min. S1S2. PPx4. Labs WNL.\n\nRESP: Remains vented. AC 450x10 40% 15peep. Lungs coarse. Suctioning for thick yellow sputum. Sats 100%.\n\nGI: CT done today. Results pending. Tol po well. Replete with fiber at 20cc/hr. Stooling today.\n\nGU: UOP decreased. Fluid bolus given with slight increase in uop. Continue to monitor closely.\n\nSKIN: R hip wound culture sent. Dressing change tid. Duoderm to coccyx intact.\n\nSOCIAL: Daughters into see pt. Spoke with team.\n\nPLAN: Wean vent as tolerated. Support BP.\n"},{"category":"Nursing/other","chartdate":"2131-09-09 00:00:00.000","description":"Report","row_id":1558158,"text":"RESP NOTE:PT REMAINS INTUBATED AND VENTILATED THOUGH SOME IMPROVEMENT IN RESP STATUS TODAY.FIO2 LOWERED TO 40% WITH PT MAINTAINING SATS 98-100% AND NO RESP DISTRESS EVIDENT.SECRETIONS MINIMAL AND PALE/YELLOW,B/S GEN CLEAR AND DECREASED R>L.ABG\"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH VENTILATORY SUPPORT AND WEAN AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2131-09-12 00:00:00.000","description":"Report","row_id":1558170,"text":"NPN\nNEURO: Afeb. Has received no sedation since 6 am. Will open eyes slightly verbal command. Not following any commands. BC x1 sent today. per orders.\n\nCV: Remains in SR without ectopy. VSS. Continue with d5.45NS at 75cc/hr. PPx4. S1S2 murmur. No edema noted. EKG unchanged from yesterday.\n\nRESP: Vent changed to CPAP 5/5 this am. Tolerating well. ABG WNL on this setting. Lungs coarse. Suctioning for thick yellow sputum.\n\nGI: Tolerating TF well. Replete with fiber at 40cc/hr. Stooling, rectal bag intact. ABS. ABD S/ND/NT.\n\nGU: Foley draining clear amber urine in adequate amounts. Remains + for this hospitalization.\n\nID: Remians on Oxacillin and Clindamycin. WBC this am was32.1. Remains Afeb.\n\nINTEG: R hip ulceration with yellow tissue. Continue with dressing changes TID. Coccyx with duoderm.\n\nSOCIAL: Family into visit today. Spoke with myself and Dr. . Questions answered. Asked to speak with social worker. Meeting arranged for tommorow afternoon.\n\nPLAN: Allow to wake up from sedation. Wean vent as tolerated. ? Tap pleural effusion today. Consent signed and on chart.\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-12 00:00:00.000","description":"Report","row_id":1558171,"text":"PT/RSD Re-evaluation\nS: Intubated\nO: Please refer to initial evaluation for further information regarding PMH and HPI\nLabs: 13.6>32.1<313\nVent: PS 5/PEEP 5, Tv 450, 40%FiO2\nPulmonary: Breath sounds coarse throughout\nMobility: Pt sedated, no active movement at this time\nROM: PROM all joints WFL although stiffness noted throughout\nVital Signs: Pre-rx: 148/60 77 28 99%\n During/post-rx: 140/60 78-84 28 98-100%\nRx: Gentle passive ROM bilateral upper and lower extremities.\nPercussion to right lung field in left sidelying followed by in line suctioning for minimal yellow secretions. Pt positioned back in supine post rx.\nA: 85y.o male with staph aureus bacteremia and hypoxic respiratory failure. Pt presents with impaired respiration, ventilation and secretion clearance associated with respiratory failure. Pt tolerated chest PT well today and will benefit from continued pulmonary toileting. Should begin mobility when pt able to participate. Pt will require rehab placement once medically stable with guarded potential given prolonged hospitalization/bed rest.\nGoals(5-7 days):\n1.Pt will maintain O2 saturation >95% without mechanical ventilation\n2.Pt will be independent in secretion clearance\n2.Pt will transfer bed to chair with moderate assist of 2\nP: F/U \nPager #\nTime Frame:4:30-5:30pm\n"},{"category":"Nursing/other","chartdate":"2131-09-26 00:00:00.000","description":"Report","row_id":1558222,"text":"ALTERED REPS STATUS\nD: PT A&O AND FOLLWS SIMPLE COMMANDS. O2 AT 6L/M NC WITH O2 SATS>90%. COARSE BS AND PT SUCTIONED X1 FOR THICK TAN SPUTUM. COARSE BS . PT REMAINS NPO FOR PEJ PLACEMENT TO BE DONE TODAY. RECEIVING D 5 1/2 NS AT 60CC'S HR AND HOURLY URINE IS MARGINAL. PASSED MEDIUM SIZED GREENISH BLUE SOFT STOOL AND DESITIN OINTMENT APPLIED TO EXCORIATED BUTOCKS. R HIP DRSG AND OF THE WOUND IS UNCHANGED. PT'S DAUGHTER AT BEDSIDE AND UPDATED. CASE MANAGEMENT CALLED TO BEDSIDE PER DAUGHTER'S REQUEST.\n"},{"category":"Nursing/other","chartdate":"2131-09-26 00:00:00.000","description":"Report","row_id":1558223,"text":"MICU NPN 11AM-11PM:\nNeuro: Pt awake and alert. Sometimes speech is difficult to understand. Today was talking about making a phone call but it was difficult due to his poor speech. Pt wanted to get up OOB but did not due to the placement procedure. He is very stiff, requires full lift and assist with all ADL's.\n\nCardiac: One dose of diltiazem held today due to HR in the 50's. BP stable 120-140. Pt was given a dose of 20mg IV lasix today. Has had good effect.\n\n\n\n\nResp: Had to go back to the 50% face tent due to pt desating and not coming up after suctioning. I suctioned him twice. Large amt secretions initially but small amt in the evening. Lungs are decreased and coarse. RR in the 20's. Current sat 95%.\n\nGI: Had a J-tube inserted in radiology today and tolerated this well. We can use it for meds and give him his tube feeds at half the normal goal rate until tomorrow afternoon when we can increase it back to the goal rate. Currently on promote w/fiber at 30cc/hr. The site is draining moderate to lrge amts serous drainage and the dressing was changed by myself twice. I caled the radiologist who inserted the tube and she feels as long as the bleeding is not grossly bloody and just clear to serous that it is probably due to his generalized body edema and may drain for a while. I have the Gastric port hooked up to gravity drainage and the j-port has the tube feeds. Gastric drainage is golden/yellow clear bile. Pt stooled three times today, green loose.\n\nGU: Foley draining drk urine at first but now clear yellow since he got the lasix. I did run the irrigant for a while but have it off now trying to get an accurate I+O.\n\nSkin: Unchanged. Buttocks are red and excoriated and I have been using triple cream ordered by team.\n\nSocial: Pt's daughter was in most of the day. Pleased at pt's progress today and will call later tonight.\n"},{"category":"Nursing/other","chartdate":"2131-09-07 00:00:00.000","description":"Report","row_id":1558148,"text":"NPN\n\nCV: BP stabalized, now in SN in the 70-80s, able to wean him off of the neo during the night.\n\nPulm: Resp status is still tenuous, he remains on 100% and 6 L NC, his SATs are in the upper 90s but when his mask comes off he quickly desats to the 70s-80s though this does return to the 90s as fast as he desaturated. He has a wet cough when he is encouraged to cough but no production. His ABG has slowly improved now with a Pa02 of 82. Oxacillian conts.\n\nGI: Drinking liquids, rather thirsty, sm amount of stool\n\nGU: fair u/o\n\nNeuro: A&Ox3, good memory, asking approapriate questions\n"},{"category":"Nursing/other","chartdate":"2131-09-07 00:00:00.000","description":"Report","row_id":1558149,"text":"NPN\nNEURO: A+Ox3. Afeb. Follows all commands. Asks appropriate questions.\n\nCV: Monitor shows SR without ectopy. VSS. PPx4. No edema noted. S1S2 with murmur noted. K+ this am was 2.9, replaced with 60meq IV. recheck was 4.1.\n\nRESP: Remains on 100% and 6LNC. Lungs very coarse. Has wet cough, but unable to produce any sputum. Sats are 98-100% while pt at rest, drops to 70-80's if mask removed. Also drops with anxiety. Sputum culture ordered but not sent d/t lack of specimen.\n\nGI: Taking po's well, although restricting to po fluids d/t possibility of intubation. ABSx4. Stoolsx2 today. OB-. Abd S/ND/NT.\n\nGU: Foley draining clear yellow urine in adequate amounts.\n\nSOCIAL: Family at bedside. Very inquisitive. Questions answered. Pt has home health aide at bedside ATC.\n\nPLAN: Monitor resp status. pulmonary toilet. Encouarge family to allow pt to rest. pt that he is not alone.\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-08 00:00:00.000","description":"Report","row_id":1558150,"text":"NURSING PROGRESS NOTE:\nPT ON 100%NRBM AND 6LNC. PT HAVING MUCH DIFF BREATHING USING ALL ACCESSORY MUSCLES. HAVING MUCH DIFF RAISING SPUTUM. LUNG SOUNDS VERY COARSE. DOPPED 02 SAT'S OFF AND ON DURING THE NIGHT.\nPT SX FOR LRG AMT OF PASTEY YELLOW/TAN SECRETIONS WHICH DROPPED HIS O2 SAT'S TO THE LOW 80'S AND PT WAS UNABLE TO RECOVER FROM THIS AND WAS DECIDED AT THIS TIME TO INTUBATE PT AND PT AGREED.\nANESTHESIA CALLED, PT MED WITH ETOMADATE AND SUCCX IV. PT INTUBATED EASILY WITH #7.5 ETT AT 23CM AT THE LIP. TUBE PLACEMENT CHECKED BY XRAY. PLACEMENT GOOD. PT STARTED ON PROPOFOL DRIP TO MAINTAIN SEDATION AND COMFORT.\nFOLEY CATH DRAINING ADEQUATE AMT'S OF YELLOW URINE. INCON SM AMT'S OF SOFT STOOL DURING THE NIGHT.\nK 3.4 RECEIVED 60MEQ KCL.\nPT HAS REMAINED IN SR ALL SHIFT, BP STABLE BUT DROPPED SLIGHTLY WHEN STARTED ON PROPOFOL. RATE AND BP BACK UP TO ACCEPTABLE RANGE.\nFAMILY MADE AWARE OF INTUBATION.\n"},{"category":"Nursing/other","chartdate":"2131-09-08 00:00:00.000","description":"Report","row_id":1558151,"text":"Resp Care Note:\n\nPt on NRB mask + 6L NC required NT sx due inability to clear secretions. Sx copious th yellow sput. Pt sats didn't recover after sx + A&A Tx. Pt intubated and placed on vent setting as per vent flowsheet. CXR confirmed ETT placement and ABG's stable. Pt sx after intub for mod th yellow. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2131-09-24 00:00:00.000","description":"Report","row_id":1558216,"text":"NPN 7a-7p:\n Review of Systems:\n RESP: Cont on 50% CSM, with weak, nonproductive, thickly congested cough. NT sx q 3-4 hrs for thick tan secretions. LS with exp wheezes, bronchial at bases... L thoracentesis done via bedside US for 900cc pleural fluid. RR 16-24. Sputum spec growing out yeast. Remains npo. Seen by Speech and swallow therapist who is to return to discess speach excercises with pt to strengthen voice... to be seen by eNT to evaluate vocal chords.\n ID: pt hyothermic this shift.. now on bearhugger with slow improvement. team aware.. in light of hypothermia, pt fully cx'd... sutum, blood with fungal isolator (peripheral), urine. cont on IV OX... po augmentin dc'd.\n F/E: pt with marginal UO this shift.. ? d/t No input, as TF's off for thoracentesis.. 250cc NS fluid bolus up over one hr... await effect. Lytes wnl. fluid bolus neg 600 today, + 2L yesterday... pt with peripheral edema throughout, + scrotal edema.\n GU: pt with yeast growing in urine... foley changed o/n... pt with intermittent BRB via foley.. irrigated with NS to clear.\n GI: pt with blue/green stool d/t dye in TF's... Butt bag placed as buttocks excoriated d/t frequent stooling. ab softly distended, BS + with + umbilical hernia.\n Integument: Skin care CNS to be paged tomorrow am to observe wound to R hip during dressing change... cont lined with yellow dead tissue.. dressing process unchanged. duoderm intact to upper back. wax placed to metal rod in tooth, R upper gumline.\n Social: family meeting held, attended by pt's daughter, son in law, Dr. , Dr. , and this RN.. Dr. explained to family that if pt wants to cont. aggressive treatment, then a trach and are recommended at this point... pt lethargic this afternoon, but when arouses, family to return to be present for discussion intern to have with pt... Pt prefers daughter to be present when he makes decisions about his care... also, pt would be reintubated at this point, but otherwise DNR.\nA/P: follow cx.. will follow MS/hypothermia carefully.. no further abx changes at this time. page skin care cns in am, and call family when pt more alert, in order to have discussion.\n"},{"category":"Nursing/other","chartdate":"2131-09-24 00:00:00.000","description":"Report","row_id":1558217,"text":"Brief NPN 7PM-11PM:\nPt awake, looking a little uncomfortable at 8PM. Unable to guess what the problem was so I turned him to the right at 9PM and he has looked more comfortable since then. RR 16-20. On 40% mask his sats have been 98%-100% most of the evening. UO was 20cc/hr early in the shift. Urine is grossly bloody, no clots noted. Last UO at 10PM was up to 50cc/hr. An order was written for 250cc NS bolus if UO drops below 30cc/hr for two consecutive hours tonight. Pt is on the tube feeds at goal rate. Vital signs are stable. Family was not present this evening.\n"},{"category":"Nursing/other","chartdate":"2131-09-25 00:00:00.000","description":"Report","row_id":1558218,"text":"NURSING PROGRESS NOTE:\nPT SLEPT OFF AND ON DURING THE NIGHT MAINTAINING GOOD O2 SAT'S AND GOOD VITAL SIGNS. PT AFEBRILE.\nU/O LOW FOR 2/HRS 250CC NS BOLUS X 1. U/O PICKED UP SLIGHTLY.\nTUBE FEEDS TURNED OFF AFTER MIDNIGHT, SX BLUE TUBE FEED OUT OF TRACHEA WHEN NASOTRACH SX.\nPT'S LUNG SOUNDS COARSE THROUGHOUT.\nFOLEY CATH DRAINING BROWN URINE WITH OCC CLOTS.\nHIP DSG CHG'D NO CHG IN APPEARANCE.\nPT' HAS GENERALIZED THIRD SPACING, WITH SCROTAL EDEMA.\nFIB REMOVED DUE TO LEAKAGE. PERIANAL AND PERINEAL AREA VERY REDENED.\nMICONAZOL POWDER AND SKIN CREAM APPLIED.\nPT SEEMS ORIENTED BUT CONT TO SCREAM OUT AT TIMES.\n"},{"category":"Nursing/other","chartdate":"2131-09-25 00:00:00.000","description":"Report","row_id":1558219,"text":"NPN 7a-7p:\n S/O: Cont with copious secretions via nts, blue tinged still. changed to 6L o2nc with sats 98%, rr 20.kept npo/npgt... Most likely to have interventional radiology to place a post pyloric tube for feeding. NO trach per pt/family at this point. Currently with ns with 60meq kcl up over 10 hrs via midline... UO very poor all am.. team aware and 250cc ns fluid bolus given. Urine also very bloody... 3way foley placed and irrigated for 1200cc.. now urine clear and yellow... has order for maintenance ivf once K repletion compelte.. cont with frequent loose stools. C-diff sent x 2.. after 3rd cdiff, can give lomotil. Skin on bottom very broken and excoriated... barrier cream applied. Daughter spoke at length with rn and md's.. many ?'s answered.\na/P: await feeding tube placement.. cont skin care, follow uO. needs one more c-diff and sputum spec with next sx. cont support to pt/family.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2131-09-26 00:00:00.000","description":"Report","row_id":1558220,"text":"Resp Care Note:\n\nPt required NT suct for large amt th white. Lung sounds rhonchi w/ significant improvement after suct. Cont with aggressive pulmonary toilet.\n"},{"category":"Nursing/other","chartdate":"2131-09-26 00:00:00.000","description":"Report","row_id":1558221,"text":"NURSING PROGRESS NOTE\"\nPT ALERT AND ORIENTED CONT TO MAINTAIN GOOD 02SAT'S AND GOOD VITAL SIGNS. LUNG SOUNDS CONT TO BE COARSE AND WHEEZY AT TIMES. NASOTRACH SX X 2 DURING THE NIGHT FOR THICK THICK TAN/YELLOW SECRETIONS.\nPT RUNNING VERY LOW TEMPS. PT CONT TO HAVE WORSENING THIRD SPACING GENERALIZED ESP IN SCROTUM. SCROTUM SUPPORTED WITH TOWEL.\nPT IV FLUID CONT AT 60/HR BUT U/O RUNNING ABOUT 20-25/HR.\nCONT OOZING SM AMT'S OF BLUE/GREEN STOOL. PERIANAL AREA VERY REDENED AND EXCORIATED, IMPROVING WITH DESITIN OINT.\nPT SCHEDULED FOR PLACEMENT, PT HAS BEEN NPO, NGT PLACED TO SX DRAINING SM AMT'S OF BILIOUS/ TINGED MATERIAL.\nDAUGHTER CALLED DURING NIGHT AND UPDATED. PT CONT TO BE DNR BUT WILL BE REINTUBATED IF NECESSARY.\n"},{"category":"Echo","chartdate":"2131-09-11 00:00:00.000","description":"Report","row_id":69100,"text":"PATIENT/TEST INFORMATION:\nIndication: ?endocarditis\nHeight: (in) 66\nWeight (lb): 104\nBSA (m2): 1.52 m2\nBP (mm Hg): 111/43\nStatus: Inpatient\nDate/Time: at 13:57\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. There are simple atheroma in the\naortic root. The ascending aorta is normal in diameter. There are simple\natheroma in the ascending aorta. The aortic arch is normal in diameter. There\nare simple atheroma in the aortic arch. The descending thoracic aorta is\nnormal in diameter. There are simple atheroma in the descending thoracic\naorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. There is no\nsignificant aortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. There is mild thickening of the mitral valve\nchordae. The tips of the papillary muscles are calcified. Physiologic mitral\nregurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. There were no TEE related complications. The patient appears to be\nin sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal. Right ventricular chamber size and\nfree wall motion are normal. There are simple atheroma in the aortic root.\nThere are simple atheroma in the ascending aorta. There are simple atheroma in\nthe aortic arch. There are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened. There is no significant\naortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no pericardial effusion.\n\nNo masses, vegetations or thrombus seen.\n\n\n"},{"category":"ECG","chartdate":"2131-09-04 00:00:00.000","description":"Report","row_id":158134,"text":"Sinus rhythm. Wandering baseline makes adequate ST segment changes difficult to\ninterpret. There is no apparent diagnostic interim change as compared to the\nprevious tracing of . However, repeat tracing is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2131-09-03 00:00:00.000","description":"Report","row_id":158135,"text":"Sinus rhythm. Left ventricular hypertrophy. Left axis deviation. Prior\nanteroseptal myocardial infarction. Compared to the previous tracing\nof , no change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2131-09-11 00:00:00.000","description":"Report","row_id":157891,"text":"Sinus rhythm. P-R interval is 0.20. Left atrial abnormality. Left axis\ndeviation. Incomplete right bundle-branch block pattern with Q waves in\nleads V2-V3 and slow R wave progression in leads V4-V5 consistent with an\nanterior myocardial infarction of indeterminate age, with persistent ST segment\ncoving and inverted T waves in the precordium. Low voltage in the precordial\nleads. The Q-T interval is prolonged. Compared to the previous tracing\nof sinus rhythm has replaced rapid atrial fibrillation, low voltage\nis now present in the precordial leads and voltage appears decreased in the\nlimb leads. The T waves are now inverted in the precordium and Q-T interval is\nmore prolonged. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2131-09-20 00:00:00.000","description":"Report","row_id":157885,"text":"Sinus rhythm. Axis to the left. Compared to the previous tracing of \nthere is clear evidence of anterior myocardial infarction of undetermined age,\nbecause of ST segment elevations in lead V3.\n\n"},{"category":"ECG","chartdate":"2131-09-19 00:00:00.000","description":"Report","row_id":157886,"text":"Sinus rhythm. Left atrial abnormality. Left axis deviation. Compared to the\nprevious tracing of there is more prominent ST-T wave flattening in\nleads I, aVL and V5-V6. No diagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2131-09-16 00:00:00.000","description":"Report","row_id":157887,"text":"Sinus rhythm. Left axis deviation. Compared to the previous tracing\nof there is variation in the precordial lead placement and there are\nlow amplitude T waves. Otherwise, no change.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2131-09-15 00:00:00.000","description":"Report","row_id":157888,"text":"Sinus rhythm. Left axis deviation. Prior anteroseptal myocardial infarction.\nCompared to the previous tracing of there is variation in precordial\nlead placement. Otherwise, no change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2131-09-14 00:00:00.000","description":"Report","row_id":157889,"text":"Sinus rhythm. The P-R interval is 0.19. Left axis deviation. Prior anteroseptal\nmyocardial infarction. Compared to the previous tracing of the\nQ-T interval has normalized and there is improvement in the T wave\nabnormalities, previously recorded in the anterolateral leads, consistent with\nan active ischemic process. Followup and clinical correlation are suggested.\nThe rate is increased.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2131-09-12 00:00:00.000","description":"Report","row_id":157890,"text":"Sinus rhythm. Left anterior fascicular block. Q waves in leads V2-V3 with\ndelayed R wave progression in the remaining precordial leads and Q waves in\nlead aVL. These changes are consistent with anterolateral myocardial infarction\nof indeterminate age. Residual minimal ST segment elevations in leads V2-V3.\nT wave inversions in the anterolateral leads. The Q-T interval is 0.64 and the\nQ-Tc interval is 0.68 which is markedly prolonged. Low voltage persists in the\nprecordial leads. Compared to the previous tracing of the Q-T interval\nis more prolonged. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2131-09-06 00:00:00.000","description":"Report","row_id":157892,"text":"Atrial fibrillation with a rapid ventricular response, average rate 128.\nCompared to the previous tracing of atrial fibrillation with a rapid\nventricular response is new. There is new T wave inversion in leads I and aVL,\nmost likely related to the rapid rate, but lateral ischemia cannot be ruled\nout. Clinical correlation is suggested.\n\n"},{"category":"Radiology","chartdate":"2131-09-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740468,"text":" 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation.\n\n FINDINGS: Comparison was made with the previous examination of .\n\n There has been interval placement of an ET tube, the distal end of which is\n approximately 2 cm above the carina. Allowing for marked patient rotation,\n the appearances in the chest are unchanged since with extensive\n bilateral interstitial infiltrates and a loculated right pleural effusion.\n The interstitial changes were not present on and most likely\n represent either acute fluid overload or pulmonary edema. Does this patient\n have clinical evidence of cardiac failure?\n\n IMPRESSION: Satisfactory position of ET tube. Pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2131-09-09 00:00:00.000","description":"CT ABD W&W/O C","row_id":740508,"text":" 8:36 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abcess\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n r/o abcess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of multiple pelvic fractures, decubitus ulcer,\n bacteremia, septic.\n\n CT OF THE ABDOMEN AND PELVIS WITH CONTRAST.\n\n COMPARISON: Comparison is made to prior study performed .\n\n TECHNIQUE: Contiguous serial axial images were obtained from the lung bases\n to the pubic symphysis after the administration of 150 cc of nonionic Optiray\n contrast.\n\n CT OF THE ABDOMEN WITH CONTRAST: The visualized lung bases demonstrate\n bilateral pleural effusions with associated left lower lobe\n collapse/consolidation. The liver, pancreas and spleen are unremarkable.\n There are small stones within the gallbladder, but no gallbladder wall\n thickening or pericholecystic fluid collections. Evaluation of the abdomen is\n somewhat limited by streak artifact from rods. There are bilateral\n renal cysts. There is a large abdominal hernia and loops of bowel are seen\n extending cephalad anterior to the ribs bilaterally. There is no focal bowel\n dilatation to suggest obstruction. There are dense vascular calcifications.\n\n CT OF THE PELVIS WITH CONTRAST: Air and a Foley catheter are seen within a\n mildly distended bladder. The rectum and intrapelvic loops of bowel are\n unremarkable. No intrapelvic fluid collections or abscesses are present.\n There are numerous small inguinal lymph nodes not significantly changed from\n prior study. A small amount of fluid is seen in the region of the right\n proximal femur as well as stranding of the right gluteal subcutaneous fat. A\n focal area of heterogeneous enhancement is seen within the right gluteus\n muscle measuring approximately 3 x 4.7 cm. The appearance is consistent with\n a multiseptated collection/abscess. This exists in close proximity to a right\n gluteal decubitus ulcer, although they appear separated by an intact fat\n plane. There is an adjacent right iliac fracture, not present on the prior\n study.\n\n Osseous structures are diffusely demineralized. Multiple pelvic fractures are\n noted as on the prior study. A new comminuted and impacted right iliac\n fracture is present. Sclerosis of the SI joints is again seen. \n rods have been placed since the prior exam. Marked degenerative changes are\n again noted in the lumbar spine.\n\n IMPRESSION:\n 1. Bilateral pleural effusions with left lower lobe collapse/consolidation.\n 2. Ventral hernia.\n 3. Dense vascular calcifications.\n (Over)\n\n 8:36 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abcess\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Multiple pelvic fractures. New right iliac fracture with associated right\n gluteal collection and edema within the right gluteal subcutaneous fat. The\n collection is multiloculated and demonstrates peripheral enhancement\n consistent with a small infected collection. Myositis osifficans less likely,\n but can not be excluded in the absence of non contrast evaluation.\n 5. Right decubitus gluteal ulcer.\n\n\n"},{"category":"Radiology","chartdate":"2131-09-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740277,"text":" 5:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f failure, cardiomegaly\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\n REASON FOR THIS EXAMINATION:\n e/f failure, cardiomegaly\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dyspnea.\n\n PORTABLE CHEST: Comparison is made to . Paraspinal rods are noted\n in the lower thoracic and upper lumbar spine. The cardiac silhouette is\n largely obscured, limiting evaluation of heart size. There is upper zone\n redistribution of the pulmonary vasculature, but no pulmonary edema. There\n are small pleural effusions bilaterally, coinciding with chronic pleural\n changes, predominantly on the right. There is atelectasis at the lung bases;\n pneumonia cannot be excluded.\n\n IMPRESSION:\n 1) Pulmonary vascular redistribution without overt edema.\n 2) Bibasilar atelectasis and pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2131-09-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740372,"text":" 9:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: shortness of breath\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\n REASON FOR THIS EXAMINATION:\n shortness of breath\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: SOB. Crackles. Hypoxia.\n\n COMPARISON: @ 16:55.\n\n PORTABLE UPRIGHT CHEST @ 10:08: Again seen are small bilateral pleural\n effusions, right greater than left. There is associated bibasilar atelectasis\n present. There is a more focal area of confluent opacity in the right mid lung\n zone which could represent an area of pneumonia vs. atelectasis. Pulmonary\n vascularity is indistinct, consistent with CHF. This is worsened since the\n previous examination. Spinal fusion rods are noted.\n\n IMPRESSION: Worsening CHF. Small bilateral pleural effusions with bibasilar\n atelectasis. Developing confluent opacity in the right mid lung zone which may\n represent atelectasis vs. pneumonia.\n\n"},{"category":"Radiology","chartdate":"2131-09-05 00:00:00.000","description":"CHEST (PA & LAT)","row_id":740327,"text":" 10:14 AM\n CHEST (PA & LAT) Clip # \n Reason: H/O GRAM POS. COCCI BACTERIUM W/ HX OF BL PL EFFUSION W/ INC O2 REQ. SOB, SOB, R/O INFILTRATE, SOB, NO EWNW S.S.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with gram positive cocci bacteremia\n REASON FOR THIS EXAMINATION:\n 85 y/o male with gram positive cocci bacteremia with hx of BLL pleural\n effusions and increasing O2 requirement and SOB.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISONS: Prior study from .\n\n HISTORY: Increasing oxygen requirement. Rule out dissection.\n\n FINDINGS: There is increased density at the right base suggesting the\n accumulation of a right pleural effusion. There is a small left pleural\n effusion. There is increased vascular congestion bilateral suggesting\n increased pulmonary edema compared to the prior study.\n\n IMPRESSION: Cardiac failure compared to the prior study.\n\n"},{"category":"Radiology","chartdate":"2131-09-13 00:00:00.000","description":"RP PLEURAL ASP BY RADIOLOGIST RIGHT PORT","row_id":740741,"text":" 3:45 PM\n PLEURAL ASP BY RADIOLOGIST RIGHT PORT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n CHEST U.S.\n Reason: localize effusion for thoracentesis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with MSSA pneumonia, likely loculated\n REASON FOR THIS EXAMINATION:\n localize effusion for thoracentesis\n ______________________________________________________________________________\n FINAL REPORT\n REASON: Loculated MSRA pneumonia on intubated patient. Diagnostic and\n therapeutic tap requested.\n\n A limited ultrasound of the right hemithorax revealed a pleural effusion.\n Risks and benefits of the procedure were discussed with the patient's\n designated Power of Attorney, informed consent was obtained, and placed on\n the patient's chart. The patient was draped in a sterile fashion. An 18\n gauge catheter was placed in the right-sided pleural effusion under\n direct ultrasound guidance. 750 cc of clear, yellowish fluid was aspirated.\n Samples were provided to the house staff to send for laboratory analysis. The\n patient tolerated the procedure well. Dr. was present for and performed\n the procedure.\n\n\n\n"},{"category":"Radiology","chartdate":"2131-09-24 00:00:00.000","description":"L PLEURAL ASP BY RADIOLOGIST LEFT","row_id":741305,"text":" 1:06 PM\n PLEURAL ASP BY RADIOLOGIST LEFT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n CHEST U.S. PORT\n Reason: pt w/ large pleural effusions, needs therapeutic drainage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with MSSA pneumonia, likely loculated; large pleural effusions,\n requires dainage.\n REASON FOR THIS EXAMINATION:\n pt w/ large pleural effusions, needs therapeutic drainage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia. Large pleural effusion. Needs therapeutic drainage.\n\n PROCEDURE: After informed consent was obtained, the left back was prepped and\n draped in the usual sterile fashion. 1% Lidocaine was administered as a local\n anesthetic. Under ultrasound guidance, a large left pleural effusion was\n localized and accessed using a 19 gauge needle. Approximately 900 cc of clear\n fluid was aspirated. No immediate complications occurred.\n\n Dr. was in attendance during the procedure.\n\n IMPRESSION: Successful ultrasound-guided left thoracentesis.\n\n"},{"category":"Radiology","chartdate":"2131-09-13 00:00:00.000","description":"CT LOC DRAINAGE","row_id":740736,"text":" 1:53 PM\n CT LOC DRAINAGE; CT FINE NEEDLE ASP Clip # \n CT RETROPERITONEAL DRAINAGE\n Reason: ABCESS DRAINAGE\n ______________________________________________________________________________\n FINAL REPORT\n CT LOCALIZATION AND ASPIRATION OF FLUID COLLECTION:\n\n INDICATION: History of pelvic fracture with focal fluid collection. Evaluate\n for drainage.\n\n COMPARISONS: CT of the abdomen and pelvis dated .\n\n CT LOCALIZATION: Axial helical images were obtained through the region of\n interest to the patient in the lateral/semisupine position.\n\n CT GUIDANCE: Using CT guidance and CT fluoroscopy, an 18 gauge spinal needle\n was advanced into the fluid collection in the region of the right buttock.\n Approximately 3 cc of serosanguinous fluid was aspirated and sent for\n cultures. The patient tolerated the procedure well without immediate\n complications.\n\n CT OF THE PELVIS: Again seen are multiple pelvic fractures. Pagetoid changes\n are seen in the bilateral ischium and sacrum. Calcifications are seen in the\n right buttock muscle. There has been interval reduction in size of the soft\n tissue mass in the right iliac fossa. The fluid collections in the right\n buttock region have also decreased. Again seen is the large decubitus ulcer\n in the right buttock region. This ulcer overlies the fracture and soft tissue\n change. A CAPD catheter is incidentally noted.\n\n IMPRESSION: Interval reduction in size of the soft tissue mass in the right\n iliac and fluid collections in the right buttock area. These changes are\n consistent with a resolving hemoatoma vs improving myositis. Given the\n proximity of the decubitus ulcer to the soft tissue changes, no bone biopsy\n was attempted (risk of introducing infection to this region). Serosanguinous\n fluid was aspirated from the buttock collection and sent for cultures.\n\n\n"},{"category":"Radiology","chartdate":"2131-09-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740401,"text":" 4:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CENTRAL LINE PLACEMENT, POST FILM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam,\n hypoxia.\n REASON FOR THIS EXAMINATION:\n CENTRAL LINE PLACEMENT, POST FILM\n ______________________________________________________________________________\n FINAL REPORT\n Single view of the chest is compared to a prior study performed earlier today.\n\n HISTORY: Acute shortness of breath.\n\n There is a new right IJ line in the appropriate position. The\n cardiomediastinal contours are stable. There is persistent right basilar\n pleural thickening which may be chronic, or a loculated pleural effusion.\n There is prominence of the interstitium which probably relates to a chronic\n process, although superimposed interstitial edema will have a similar\n appearance. There is no pneumothorax. Bilateral posterior rods\n are visualized. The bones are demineralized.\n\n IMPRESSION: There is prominence of the interstitium, probably related to\n chronic process with a superimposed interstitial edema.\n\n Right basilar pleural thickening vs. loculated pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2131-09-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740349,"text":" 4:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB, increasing respiratory effort and hypoxemia on ABG, SOB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with gram positive cocci bacteremia, bilat pulmonary edema\n REASON FOR THIS EXAMINATION:\n SOB, increasing respiratory effort and hypoxemia on ABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bacteremia, pulmonary edema, SOB and increased respiratory\n effort.\n\n COMPARISON: at 10:21.\n\n PORTABLE UPRIGHT CHEST AT 16:55: The pulmonary vascularity is\n increased consistent with interstitial edema. There are bilateral pleural\n effusions, right greater than left. There is evidence of bibasilar\n atelectasis. The possibility of consolidation at the lung bases cannot be\n excluded.\n\n IMPRESSION: Persistent, mild interstitial edema with bilateral pleural\n effusions. Cannot exclude infectious process at the bases.\n\n\n"},{"category":"Radiology","chartdate":"2131-09-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740626,"text":" 3:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post placement of OG tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p intubation\n REASON FOR THIS EXAMINATION:\n post placement of OG tube\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Orogastric tube placement.\n\n Single frontal supine radiograph of the chest dated is compared\n to a prior study dated . There has been interval insertion of an\n orogastric feeding tube which projects below the level of the diaphragm. The\n film is very rotated, limiting evaluation of the lung parenchyma. Again noted\n is a loculated pleural effusion on the right. There is also a moderate-sized\n pleural effusion on the left. rods are noted overlying the spine.\n\n IMPRESSION:\n\n 1) Satisfactory placement of orogastric tube.\n\n 2) Continued bilateral pleural effusions with loculation on the right.\n\n 3) Repeat non-rotated film would be better suited for evaluation of the\n pulmonary parenchyma.\n\n"},{"category":"Radiology","chartdate":"2131-09-11 00:00:00.000","description":"BP PELVIS WITH JUDET VIEWS BILAT PORT","row_id":740616,"text":" 1:28 PM\n PELVIS WITH JUDET VIEWS BILAT PORT Clip # \n Reason: new pelvic fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with pelvic fx\n REASON FOR THIS EXAMINATION:\n new pelvic fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New pelvic fracture.\n\n COMPARISON: CT of .\n\n PELVIS WITH 2 OBLIQUE VIEWS: The distal end of spinal rods are\n seen. The images are markedly suboptimal in evaluation of the pelvis. The\n patient has Foley catheter. Multiple fractures seen on the prior CT of \n are not adequately assessed on these films.\n\n"},{"category":"Radiology","chartdate":"2131-09-03 00:00:00.000","description":"PELVIS (AP ONLY)","row_id":740278,"text":" 5:42 PM\n PELVIS (AP ONLY) Clip # \n Reason: e/f fracture, dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\n also with new right hip pain, pain on lateral extention of right leg\n REASON FOR THIS EXAMINATION:\n e/f fracture, dislocation\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS AP .\n\n INDICATION: Hip pain.\n\n FINDINGS:\n\n Evaluation of the pelvis is limited nonstandard patient\n posiitoning. There is a history of old bilateral inferior pubic ramus\n fractures, and SI joints fusion. There is lower lumbar spinal fusion with\n rods posteriorly. No acute fracture is appreciated.\n\n IMPRESSION:\n 1. Limited study.\n 2. No evidence of hip fracture.\n\n\n"},{"category":"Radiology","chartdate":"2131-09-03 00:00:00.000","description":"CHEST CTA WITH CONTRAST","row_id":740280,"text":" 7:10 PM\n CHEST CTA WITH CONTRAST Clip # \n Reason: e/f PE, also evaluate old pneumonia in RLL scar vx persiste\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\n also with new right hip pain, pain on lateral extention of right leg\n REASON FOR THIS EXAMINATION:\n e/f PE, also evaluate old pneumonia in RLL scar vx persistent pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST.\n\n INDICATION: 85 year old man with shortness of breath.\n\n TECHNIQUE: Contiguous helical imaging was obtained from the lung bases to the\n lung apices utilizing the CTA protocol for pulmonary embolus.\n\n CONTRAST: 150 cc of Optiray contrast used secondary to history of rapid rate\n of injection.\n\n CT SCAN OF THE CHEST WITH CONTRAST: There is no significant axillary,\n mediastinal or hilar lymphadenopathy. The contrast bolus was optimally timed\n for evaluation of the pulmonary arteries. No intraluminal filling defect is\n seen to suggest pulmonary embolus.\n\n The lung windows demonstrate bilateral large layering pleural effusions. There\n is also associated collapse/consolidation of the right lower lobe, as well as\n some partial collapse of the left lower lobe. Also noted is diffuse moderate\n centrilobular emphysema.\n\n BONE ELEMENTS: Multiple right-sided rib fractures are seen. rods\n are seen within the posterior elements. The patient is severely kyphotic.\n\n IMPRESSION:\n\n 1) No pulmonary embolus.\n\n 2) Bilateral large pleural effusions with consolidation/collapse of the right\n lower lobe and partial collapse/consolidation of the left lower lobe.\n\n 3) Moderate diffuse centrilobular emphysema.\n\n 4) Multiple old healed right-sided rib fractures. Severe kyphosis with\n rods seen in the posterior elements.\n\n"},{"category":"Radiology","chartdate":"2131-09-22 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":741235,"text":" 3:48 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: COPIOUS SECRETIONS, S/P PPNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with COPD, s/p pneumonia, still with thick copious secretions.\n REASON FOR THIS EXAMINATION:\n Please evaluate pleural effusions, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, copious secretions.\n\n TECHNIQUE: Helically-acquired axial images were obtained from the thoracic\n inlet through the lung bases without the administration of IV contrast.\n Contrast was not given due to inability to obtain IV access.\n\n CHEST CT WITHOUT CONTRAST: No significantly enlarged lymph nodes are seen\n within the mediastinum or axilla. It is difficult to assess for hilar\n adenopathy due to large bilateral pleural effusions and adjacent atelectasis.\n The size of the pleural effusions has increased since the previous exam of\n . There does appear to be a small loculated component on the right\n superolaterally.\n\n There is bibasilar passive atelectasis associated with the effusions. The\n aerated portions of the lungs are clear. Although the right main stem\n bronchus and bronchus to the right upper and middle lobes are narrowed, they\n are patent. It is difficult to assess the bronchi going to the lower lobes\n bilaterally due to the large pleural effusions and atelectasis.\n\n There is a PICC present in the distal SVC. There is an NG tube within the\n stomach. Limited images of the upper abdomen reveal a possible small low-\n attenuation lesion in the dome of the liver which cannot be characterized\n further. It is unchanged. The upper poles of the kidneys, imaged portions of\n the pancreatic tail and spleen are unremarkable.\n\n Several right-sided healed rib fractures are again noted. Fusion rods are\n seen along the posterior aspect of the thoracic spine.\n\n IMPRESSION:\n\n 1) Large bilateral pleural effusions with associated passive atelectasis.\n There is a loculated component on the right superolaterally. It is difficult\n to know if the pleural fluid is potentially infected without IV contrast. The\n effusions have increased since the previous exam from .\n\n 2) The aerated portions of the upper lobes appear clear.\n\n 3) Healed right-sided rib fractures are again noted.\n\n (Over)\n\n 3:48 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: COPIOUS SECRETIONS, S/P PPNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2131-09-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740967,"text":" 4:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT placement; also eval for pna.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, s/p thoracentesis, newly dc'd from vent, with new NGT\n placement; please comment on change in pna, as well as NGT placement.\n REASON FOR THIS EXAMINATION:\n s/p NGT placement; also eval for pna.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: MSSA bacteremia, check NG tube placement and follow up\n pneumonia.\n\n Single AP supine chest radiograph dated is compared with prior chest\n radiograph dated .\n\n There is interval removal of the ET tube. The NG tube terminates in the\n stomach. Again a mild left convex scoliosis is demonstrated with \n rod in place.\n\n Extensive air space opacities are present bilaterally, of no significant\n interval change since the prior study. There is also no significant interval\n change of the previousl reported bilateral pleural effusions.\n\n IMPRESSION: NG tube terminates in the stomach. No significant interval\n change of the parenchymal opacities and pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2131-09-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740826,"text":" 8:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, s/p thoracentesis, weaning from vent\n REASON FOR THIS EXAMINATION:\n assess infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess infiltrates. MRSA bactermia, status post thoracentesis,\n weaning from ventilator.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST: There is marked patient rotation, which\n alters cardiomediastinal borders. Allowing for this, the ET tube is present,\n tip 4.8 cm above the carina. AN NG tube is present, coiled in the stomach,\n with tip overlying the fundus. A right IJ central line is present, tip over\n proximal/mid SVC. There appear to be right sided rib fractures. There are\n layering left greater than right effusions with underlying collapse and/or\n consolidation. We cannot exclude underlying CHF. The patient's spinal rods\n are noted. Marked narrowing of the right shoulder acromiohumeral distance is\n compatible with a chronic rotator cuff tear.\n\n IMPRESSION: Bilateral layering left greater than right effusions with\n underlying collapse and/or consolidation overlying appearances, allowing for\n marked differences in position, are similar to those of one day earlier. There\n may have been some interval improvement in the left upper zone. Right sided\n rib fractures and associated pleural thickening/hematoma noted.\n\n\n"},{"category":"Radiology","chartdate":"2131-09-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":741046,"text":" 7:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess interval change in b/l airspace dz and pleural effusi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, s/p thoracentesis, please\n comment on change in pna, pleural effusions.\n REASON FOR THIS EXAMINATION:\n Assess interval change in b/l airspace dz and pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracentesis.\n\n CHEST, SINGLE VIEW\n\n There are spinal rods seen to project over the lower thoracic upper lumbar\n region. There is a central venous catheter which enters from right IJ\n approach but tip is not visualized past the SVC/RA junction. There is a right\n IJ line also in place with tip not seen below the middle SVC. There are\n persistent bilateral effusions but have decreased in size since the prior\n study. The right effusion is much larger than the left.\n\n IMPRESSION:\n 1. PICC line in probable SVC/RA junction. Right IJ line with tip not clearly\n demonstrated due to overlying rods but seen as far as the middle SVC. No\n pneumothorax is seen. Findings communicated to IV team.\n\n"},{"category":"Radiology","chartdate":"2131-09-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":741217,"text":" 6:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for effusions and/or infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, still with copious secretions and oxygen requirements.\n REASON FOR THIS EXAMINATION:\n please evaluate for effusions and/or infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New fever and shortness of breath.\n\n FINDINGS: A single AP view of the chest compared to prior exams dated \n and demonstrates an interval increase in the size of the left pleural\n effusion since the exam. The size of the effusion appears comparable\n to the examination. In addition, abnormal ill-defined opacity in the\n right upper lobe appears increased since the exam. The left lung\n remains unchanged.\n\n IMPRESSION:\n\n 1. Interval increase in left pleural effusion since .\n\n 2. Bibasilar atelectasis/consolidation persists.\n\n 3. Right upper lobe opacity increased since the and suggests evolved\n right upper lobe pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2131-09-13 00:00:00.000","description":"CT PELVIS ORTHO W/O C","row_id":740730,"text":" 12:57 PM\n CT PELVIS ORTHO W/O C; CT,CORONAL,SAGITAL,OBL RECONSTRUCTION Clip # \n Reason: better characterize pelvis in patient with multiple pelvic f\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with MSSA bacteremia, respiratory failure, multiple pelvic\n fractures. On vent.\n REASON FOR THIS EXAMINATION:\n better characterize pelvis in patient with multiple pelvic fractures\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: fractures. For further evaluation.\n\n FINDINGS: Comparison CT scan and CT abdomen .\n\n In addition to the previously described pubic ramus and left sacral fractures\n seen on as reported on the abdominal CT there is a comminuted fracture\n of the right iliac involving the anterior portions of the ilium as well\n as the broad posterior and lateral portions of the iliac . In addition to\n the iliac fracture these thin cuts demonstrate an essentially undisplaced\n fracture through the anterior lip of the sacrum on the right.\n\n The iliac fracture while comminuted is not significantly displaced with only a\n few mm displacement of small fracture fragments from the main ilium.\n\n Note made that the enhancing collection seen on CT has been drained.\n Minimal linear hyperdensity in the soft tissues of the right gluteal region\n could represent residual contrast or possibly some soft tissue calcifications.\n\n IMPRESSION:\n 1. comminuted fracture right ilium and undisplaced fracture anterior lip of\n right sacrum in addition to previously described fractures.\n\n"},{"category":"Radiology","chartdate":"2131-09-26 00:00:00.000","description":"PERC PLCMT GASTROMY TUBE","row_id":741429,"text":" 12:25 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: FEEDING TUBE\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PLCT GJ TUBE *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT ENTROCLYSIS TUBE *\n * PERC PLCMT GASTROSOTMY TUBE NON-IONIC 50 CC *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post respiratory compromise requiring intubation from\n sepsis and pneumonia. Patient is an aspiration risk and failed swallowing\n study.\n\n RADIOLOGISTS: Dr. , supervising staff radiologist Dr. .\n\n TECHNIQUE: Patient was explained risks and benefits of procedure. Informed\n consent was obtained. An NG tube had been placed on low intermittent suction\n on night prior to the study. 1% Lidocaine was administered locally after air\n was insufflated into the stomach and appropriate location for puncture\n determined utilizing fluoroscopy. A T fastener needle system was introduced\n into the lumen in the body of the stomach under fluoroscopic guidance. The two\n T fasteners were deployed and the anterior wall of the stomach was tacked to\n the anterior abdominal wall. Subsequently a small incision was made into the\n skin between T fasteners securing anchors and the T fastener single wall\n needle was advanced into the lumen in the direction of the pylorus. Contrast\n was administered which documented intragastric location of the needle.\n Subsequently a .035 wire was introduced into the lumen of the stomach\n and was coiled. The single wall needle was removed and replaced with a 7 FR\n bright tipped long sheath which was positioned just proximal to the pylorus. A\n .035 glide wire was advanced in through the sheath. An attempt was made to\n cannulate the pylorus which was unsuccessful. Subsequently a 4 FR hockey stick\n catheter was advanced over the wire and utilizing the catheter and glide wire\n the catheter and glide wire were able to be positioned in a post pyloric\n location. The glide wire was exchanged for a .035 amplatz wire which was able\n to positioned past the ligament of Treitz into the proximal jejunum. The\n catheter was removed. Multiple dilatation were performed utilizing a 10 FR and\n 12 FR dilator, followed by placement of an 18 FR peal-away sheath. The MIC G-\n J tube was lubricated and an attempt was made to pass the tube over the\n amplatz wire. This was difficult secondary to dryness of the wire.\n Consequently the hockey stick catheter was readvanced over the amplatz wire\n and the amplatz wire was exchanged for a .035 stiff glide wire and was\n positioned within the proximal jejunum. The catheter was removed and the MIC\n G-J tube was advanced over the wire and positioned with tip in proximal\n jejunum. Initially 7 cc contrast was administered into the balloon which was\n documented on fluoroscopy to be present within the stomach. The contrast\n solution was replaced with saline. Contrast was administered through the\n gastric and jejunal ports and a post procedure radiograph was performed.\n\n FINDINGS: The G-J tip is located in proximal jejunum. The balloon is located\n within the stomach. Contrast is seen in the stomach as well as jejunum after\n administration.\n (Over)\n\n 12:25 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: FEEDING TUBE\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MEDICATIONS/CONTRAST: 1% Lidocaine was administered locally. 50 cc optiray\n administered. Optiray was selected secondary to patient's debilitated state.\n\n COMPLICATIONS: No immediate complications.\n\n IMPRESSION: Status post placement of MIC G-J tube. It should be noted the\n outer disc is at marker #4. This was dressed and a flexitract system was\n applied to the external tube.\n\n\n"},{"category":"Radiology","chartdate":"2131-09-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":741327,"text":" 5:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt is now s/p therapeutic thoracentesis - please check for p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, still with copious secretions and oxygen requirements - now\n s/p thoracentesis with removal of approx 900cc pleural fluid.\n REASON FOR THIS EXAMINATION:\n Pt is now s/p therapeutic thoracentesis - please check for pneumothorax s/p\n procedure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Thoracentesis.\n\n TECHNIQUE: Single view chest.\n\n Comparison is made with . There is limitation of evaluation of the\n examination due to overlying structures and low lung volumes. There is\n persistent bilateral pleural effusions. No pneumothorax is identified in\n either hemithorax.\n\n The NG tube is seen to course into the stomach but the tip is not included in\n the radiograph. There are bilateral patchy consolidations which are difficult\n to evaluate and compared from the prior study.\n\n IMPRESSION: Bilateral pleural effusions. No pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2131-09-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":740768,"text":" 8:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for line position, pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n eval for line position, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thoracentesis and line placement.\n\n CV line is in mid to distal SVC, probably obscured by spinal rod.\n Endotracheal tube is 3 cm above carina. NG tube extends below diaphragm. No\n pneumothorax. There are bilateral pleural effusions with possible loculation\n on the right.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558190,\n \"text\": \"MICU NURSING PROGRESS NOTE 7A-7P\\nNEURO: PT VERY LETHARGIC EARLY THIS AM AND WAS NOT RESPONDING TO VERBAL STIMULI. BY 1400, PT FOLLOWING COMMANDS AND MORE AWAKE. EXTUBATED AND DOING WELL. CONT TO FOLLOW COMMANDS, MOVING AROUND MORE AND INTERACTING WITH FAMILY. PT ABLE TO VERBALIZE ONE WORD ON OCCASSION. APPEARS TO BE ORIENTED TO FAMILY. AFEBRILE.\\n\\nCV: SR ON MONITOR, NO ECTOPY NOTED. VSS...BP HIGH ON OCCASSION PER ALINE, (170-190/60-70'S). RECIEVED COZAAR THIS AM. S1S2M ON AUSCULTATION. R TLC P/I. OVERALL ANASARCA NOTED, POOR PALPABLE PULSES ALL AROUND.\\n\\nRESP: PT EXTUBATED THIS AFTERNOON, ON 50%FM AND TOLERATING WELL. POST ABG WNL. RR 20-26. LUNGS REMAIN COARSE ANTERIORLY AND UPPER POST LOBES...CLEAR,DECREASED B/L BASES. ORALLY SUCTIONING SMALL AMT'S THICK YELLOW. NTSUCTIONED X1. O2SATS 99-100%.\\n\\nGI/GU: FOLEY CHANGED TODAY...LEAKING AROUND INSERTION SITE. #16 FR FOLEY PLACED AND DRAINING BLD TINGED URINE. LASIX GIVEN WITH GOOD RESULTS. IMMODIUM GAVE THIS AM X1..NO BM NOTED TODAY. ABD SLIGHTLY DISTENDED WITH POSITIVE BS..WHEN TF INFUSING, NO RESIDUALS WERE NOTED.\\n\\nCURRENTLY: D5NS @75CC/HR INFUSING VIA TLC. FAMILY AT BEDSIDE AND PT DOING WELL. TLC AND ALINE FROM ...TEAM AWARE AND WILL PT FOR PICC LINE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558191,\n \"text\": \"NURSING PROGRESS NOTES:\\nPT REMAINS EXTUBATED WITH 50%FACE MASK. O2 SAT'S MAINTAINED HIGH 90'S . LUNG SOUNDS COARSE AND IS ABLE TO COUGH UP SOME SECRETIONS WITH MUCH ENCOURAGEMENT. ABLE TO SUCTION THEM FROM BACK OF THE THROAT.\\nPT VERY LETHARGIC AT START OF THE SHIFT BUT BECAME INCREASINGLY MORE ALERT AND OPENING EYES AND ATTEMPTING TO SPEAK. WILL COUGH A WEAK COUGH WHEN TOLD TO.\\nVITAL SIGNS STABLE. LOW GRADE TEMP.\\nFOLEY CATH DRAINING GOOD AMT'S OF PINK TINGED URINE AND OOZING CLOTS AROUND CATH FROM PENIS. CATH IRRIGATED TO CLEAR CLOTS. OCC WILL DRAIN LRG AMT'S OF URINE AROUND CATH IF CLOTS HAVE OBSTRUCTED CATH.\\nHIP DSG CHG, WOUND LOOKS SLIGHTLY IMPROVED.\\nFAMIL WENT HOME EARLY AND CHECKED IN DURING THE NIGHT.\\nPT STARTED ON IV UNASYN SINCE UNABLE TO TAKE PO MEDS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558192,\n \"text\": \"REHAB SERVICES/PT\\nS: MOANING\\nO: PT SEEN FOR PROBS/GOALS PER R/E \\nMS: ALERT, ORIENTED TO NAME AND HOSPITAL, MIN VERBALIZATION T/O RX\\nVS'S: 96 97%(50%FM) 20\\nBS'S: DECREASED BILAT WITH CRACKLES LL'S\\nCOUGH: WEAK, CONGESTED, INEFFECTIVE\\nBR PATTERN: NON-LABORED\\nRX: PROM X4 EXTREMITIES, POSITIONED S-S WITH HOB LEVEL FOR PERC/SHAKING TO BILAT LUNG FIELDS, PRE-OXYGENATED WITH 100% FIO2 AND NTS FOR MOD TO LARGE AMOUNTS THICK YELLOW SECRETIONS.\\nCOMMUNICATION WITH RN AND MD RE: PTS STATUS\\nA: PT DOING FAIRLY WELL S/P EXTUBATION BUT DOES HAVE A LOT OF SECRETIONS, UNABLE TO CLEAR ON OWN AND NEEDS FREQUENT NTS. PTS EXTREMITIES VERY STIFF WITH KNEE FLEXION CONTRACTURES PRESENT.\\nP: CONTINUE TO FOLLOW FOR BPH, ROM AND MOBILITY AS ABLE\\nPG \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558204,\n \"text\": \"Resp Care Note:\\n\\nPt requires frequent NT suct for mod to large amt th beige sput. Lung sound prior to suct rhonchi improving w/ sx. Pt currently in NARD on cool mist aerosol @ .4FIO2. Cont to encourage deep breathing and coughing.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558205,\n \"text\": \"NURSING PROGRESS NOTE:\\nPT CONT TO DO WELL EXTUBATED. NASAL TRACHEAL SX X 1 FOR LRG AMT OF THICK TAN SECRETIONS. O2SAT'S IN HIGH 90'S. LUNG SOUNDS VERY COARSE THROUGHOUT.\\nTUBE FEEDS TOL WELL VIA NGT. SM RESIDUALS. ABD DISTENDED BUT SOFT, BOWEL SOUNDS PRESENT. NO STOOL TONIGHT.\\nHEPARIN INJ GIVEN AND PT OOZING FROM SITE MOST OF NIGHT.\\nU/O ADEQUATE.\\nFAMILY UPDATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558200,\n \"text\": \"Rehabilitation Services/physical therapy\\n\\n8:30 - 9:15\\n\\nS: Speaking appropriately, tho difficult to understand secondary to upper airway sounds\\n\\nO: Seen to address problems and goals of \\nVital signs: 81, 150/54, 98% on 40% face tent, 21\\n with Sx: 98, 162/68, 85% with poor tracing on 100%\\n p Rx: 82, 147//53, 98% on 40%\\nBreath sounds: upper airway sounds throughout\\n p Rx: mid to end expiratory wheezes, improved air movement\\nRx: NTS for small amounts of bright red blood, difficult to enter airway. Used an oral airway for suctioning for large amounts of thick yellow secretions.\\nPositioning: Patient's position changed to opposite sidelying p suctioning.\\n\\nA: Patient with increased secretions, cleared well with oral airway and deep suctioning. Unable to perform percussion and shaking second to right rib fractures. Nursing to discuss weight bearing status with team on rounds.\\n\\nP: Plan to be developed with input from team re: weight bearing status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558206,\n \"text\": \"ALTERED RESP STATUS\\nD: PT ALERT AND ORIENTED. FOLLOWS SIMPLE COMMANDS. ON INITIAL ASSESSMENT O2 AT=89%. ON 40% FACE TENT. SUCTIONE NASLLY VIA L NARE FOR MODERATE AMT OF THICK CREAMY YELLOW SPUTUM AND O2 SATS NOW 96-98%. COARSE BS BIL. CONTINUES ON PROMODE TUBE FDGS VIA NGT WITH MINIMAL RESIDUALS SO RATE NOW INCREASED TO GOAL RATE OF 60CC'S/HR WITH NO SIGNS OF ASPIRATION. INCONITNNENT OF MOD AMT OF LOOSE BROWN STOOL. AWAITING FAMILY'S CONSENT TO PLACE PEG AND ALSO AWAITING PALCEMENT AT OR . VSS. UO ADEQUATE. WILL CONTINUE WITH PRESENT MEDICAL TX. WILL CONTINUE TO UPDATE FAMILY AS NEEDED AND OFFER EMOTIONAL SUPPORT. PT IS A DNR BUT WOULD BE REINTUBATED IF RESP STATUS WERE TO WORSEN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558207,\n \"text\": \"MICU NPN 11AM-7PM:\\nNeuro: Awake and alert most of the day. Asked to get up OOB and stayed up for 2hrs or so and was most comfortable in the chair. Otherwise he has been restless, calling for me to reposition him frequently. I explained to him that it is not possible to repeostion him as frequently as he is asking and that every two hours would be the most frequent turn that is reasonable. His speech is very diffucult to understand since his voice is weak and he is congested in the upper airway.\\n\\nResp: Still requires close monitoring of his resp status for need to suction him. He is on 40% TM and his sats were best while in the chair. He was suctioned twice today for thick blood tinged yellow sputum. Lungs are coarse. RR in the 20's. O2 sat 96% most of the day but were 100% while in the chair.\\n\\nCardiac: Remains hypertensive in the 150's to 190's. Up with activity. Cozaar was increased to 50mg QD and extra 25mg was given as requested by the physician. 70-80's.\\n\\nGI: Two small stool today. Tolerates goal rate tube feeds.\\n\\nGU: Adequate UO via the foley.\\n\\nSocial: I spoke to pt's son via the phone today. Also MD updated pt's daughter and spoke to the ppt and to her about the need for PEG next week.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558208,\n \"text\": \"Resp Care Note:\\n\\nPt required NT suct for mod th brn sput. Pt placed on FIO2 .4 via cool mist aerosol via face tent with stable O2 sats. Cont aggressive pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558185,\n \"text\": \"MICU NURSING PROGRESS NOTE 7A-7P\\nNEURO: PT SLEEPING MOST OF DAY, OPENS EYES AND SQUEEZES HANDS ON COMMAND...OTHERWISE NOT MOVING AROUND OR AWAKE. NOT ANSWERING ANY QUESTIONS. TMAX 99.8 AX. TEAM AWARE. ATIVAN DC'D AND PRN FOR HALDOL IF NEEDED.\\n\\nCV: SR ON MONITOR, NO ECTOPY NOTED. BP SLIGHTLY HIGH AT TIMES, 140-160/50'S PER ALINE. ANASARCA NOTED UPPER AND LOWER EXT'S. S1S2M ON AUSCULTATION.\\n\\nRESP: VENT TO CPAP 40%/...ABG WNL. PLAN TO HOLD ON EXTUBATING SECONDARY TO LG AMT ORAL SECRETIONS. SUCTIONED SMALL AMT VIA ETT, THICK TAN, BLD TINGED. LUNGS CLEAR TO COARSE THROUGHOUT. VT 400-500, RR 20-30'S. FAMILY MADE AWARE OF DECISION TO WAIT ON EXTUBATION.\\n\\nGI/GU: CONT TO BE OF LOOSE STOOL, 3RD CDIFF CULTURE SENT. RECTAL BAG REPLACED TODAY. PLAN TO START IMMODIUM IF LAST CULTURE IS NEGATIVE. FOLEY NOT DRAINING THIS AM, CHANGED TO #14G AND DRAINING CLEAR BLD TINGED CLEAR YELLLW URINE. MIVF STARTED TO D5NS @75CC/HR. TF INFUSING WITHOUT DIFF. WILL FOLLOW.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558186,\n \"text\": \"resp. care note: pt received intubated with a 7.5 ett, secured at the 23cm mark. pt also mech. ventilated, current settings: cpap 5 psv 5 and 40%. pt received general ventilator management as well as suctioning when needed. pt is to remain intubated overnight secondary to excess oral secretions. possible plan to extubate tomorrow. rrt\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558187,\n \"text\": \"Resp Care\\nPressure support increased to during noc to rest pt. Settings will be returned to in morning, plan is to extubate on days. Sxn'd thick yellow moderate amts x2 during shift. No abgs drawn, will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558201,\n \"text\": \"MICU NURSING PROGRESS NOTE 7A-7P\\nNEURO: PT APPEARS A@OX3...APPROPRIATE WITH FAMILY, FOLLOWING COMMANDS. AFEBRILE.\\n\\nRESP: REMAINS ON FACE TENT 40% WITH O2SATS 96%. LUNGS COARSE THROUGHOUT, RECIEIVNG LASIX IV FOR DUIRESIS. ABG WNL.\\n\\nCV: SR ON MONITOR, VSS PER L RADIAL ALINE. NO AFIB NOTED. S1S2 ON AUSCULTATION. ANASARCA NOTED ALL AROUND.\\n\\nGI/GU: FOLEY OUTPUT DROPPED OFF, FOLEY IRRIGATED WITHOUT DIFF. WILL MONITOR OUTPUT. ABD S,NT,D...TOLERATING TF'S, RATE INCREASED TO 30CC/HR...NO RESIDUALS. WILL FOLLOW.\\n\\nTODAY; HCT DOWN TO 25...RECIEIVING ONE UNIT PRBC'S. L PICC PLACED, PLACEMENT OKAY PER XRAY; WILL PULL TLC AFTER BLOOD INFUSED.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558202,\n \"text\": \"Nursing Progress Note\\nNeuro: Awake, calling out at times, remains difficult to understand with weak voice, upper airway congestion\\nResp: Sats 92-96% on 40% cool neb face tent, BS coarse throughout, required N-P suctioning x4 overnight for thick tan sputum, has weak cough, at times can cough up to back of throat, can use Yankauer suctioning\\nCV: Stable, remains in NSR, no ectopy noted, continues on Diltiazem 30mg via NGT q6hrs\\nGI: Tol TF's at now 40ml/hr with minimal residuals. Blue dye in feeds, no evidence of aspiration overnight. scant amt soft brown stool\\nGU: I/O neg ~700ml/24hrs after lasix dose given on day shift, continues with u/o >60ml/hr\\nSkin: No change in hip wound, Duoderm intact on back area\\nSocial: Telephone update to pt's daughter, overnight\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558203,\n \"text\": \"ALTERED RESP STATUS\\nD:PT AWAKE AND ALERT AND FOLLOWS SIMPLE COMMANDS APPROPRIATELY. CONVERSING WITH FAMILY IN FEW WORD SENTENCES. REMAINS ON 40% FACE TENT WITH ABG=7.35/49/87/28/0. SUCTIONED WITH DIFFICULTY VIA R NARE FOR COPIOUS AMTS OF THICK TAN SPUTUM AND THEN THICK YELLOW SPUTUM. THIS AFTERNOON PT ABLE TO COUGH AND RAISE TO BACK OF HIS THROAT THICK TAN SPUTUM. COARSE BS BIL ON AUSCULTATON. MAX TEMP=96.9 AXILLARY. SBP 160-179. AND RR 18-26. TUBE FDGS OF PROMODE INCREASED TO 50CC'S/HR WITH MINIMAL RESIDUALS. GOAL RATE FOR TUBE FDGS IS 60CC'S. PT STILL WITHOUT GAG AND THIS WAS VERIFIED BY SPEECH SWALLOW THERAPIST WHO RECOMMENDS THAT PT WILL NEED PEG. HCT STABLE AT 31.5 . K+ 3.6 AND REPLACED WITH 20 MEQ KCL VIA NGT. PT IS A DNR BUT WOULD BE REINTUBATED. PT EVALUATED AND SCREENED BY AND . PT BE TRANSFERED WHEN BED AVAILABLE TO REHAB AS EARLY AS MON.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558188,\n \"text\": \"NURSING PROGRESS NOTES:\\nPT CONT TO BE INTUBATED AND VENTED. REMAINS ON PRESSURE SUPPORT AND PEEP, SEE FLOWSHEET FOR SETTINGS. SX OCC FOR MOD AMT'S OF THICK YELLOW SPUTUM. LUNG SOUNDS COARSE THROUGHOUT. O2 SAT'S IN THE HIGH 90'S.\\nPT CONT TO BE QUITE SEDATED BARELY RESPONDING TO STIMULI.\\nBP OCC GOING UP TO 180 RANGE WHEN STIMULATED WITH TURNING OR SUCTIONING.\\nFOLEY CATH DRAINING ADEQUATE AMT'S OF YELLOW URINE. RECTAL BAG CHG'D, NOT DRAINING MUCH STOOL, IMODIUM HELD.\\nTUBE FEEDS CONT AT 40/HR WITH SM RESIDUALS. BOWEL SOUNDS PRESENT AND ABD SOFT/DISTENDE.\\nFAMILY VISITING TILL MIDNIGHT AND UPDATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558189,\n \"text\": \"resp. care note: pt assessed for extubation by rrt, rn, and md. pt. found fit for extubation. pt extubated, and placed on a cool aerosol mask at 50%, which will be titrated to keep spo2 > than92%. following extubation there were no increases in resp. rate, heartrate, or decrease in spo2. all is well at this time. rrt\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558196,\n \"text\": \"NPN 7a-7p:\\n RESP: Pt requiring NT x 3 this shift... copious to moderate amts thick tan/yellow secretions. LS very course, bronchial at bases... team aware that pt is also + 1L fb... to discuss dose lasix. Cont on 50% csm with sats 99-100%... abg wnl.. po2 66-90's... po2 lower with pt on R side. RR 20's.\\n ID: afebrile. abx changed... unasyn dc'd and po augmentin started.. cont on ox.\\n F/E: fb + as noted.. repleted with Kcl, MG per med sheets. TF's reinstituted... now at 10cc/hr ... goal is 40cc/hr.. Discussion r/e peg for long term feeding.. Pt to have swallow study tomorrow... pending results of this, pt to decide r/e PEg.\\n Access: IV team in to for PICC... state that arm is too edematous at this time.. if unable to place will need hickman.\\n CV: no active issues.\\n social: pt's daughter in to visit.. discussion held with team/pt/... pt statign would want to be reintubated... no cpr.\\n A/P: pt with adequate abg'd, but cont with secretions although less.. cont to follow o/n.. line tomorrow for long term abx.. may diurese tonight.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558197,\n \"text\": \"Nursing Progress Note\\nPt noted to convert to Afib rate up as high as 130's with compromised BP to as low as the 80's. HO in to asess, EKG done confirming Afib, ? new ischemic changes, cycling CK's. Given fluid bolus NS 250ml. Diltiazem 5mg IVP by HO with rate down to 90's and SBP 120-130. Orders received for Diltiazem via NGT q6hrs, initial dose given at 2400. Monitor showing Afib rate 90's-110's with SBP 120's at this time. HO called pt's daughter at pt's request, updated re: events. Pt's code status remains no CPR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558183,\n \"text\": \"resp. care note:\\n Pressure support increased to 10cmh2o. Pt's resp rate 30s-40s, decreased sats and increased BP. Pt suctioned for a moderate amount of thick tan secretions. Plan is to try to wean pressure support back to 5; then extubate. For further information please refer to carevue charting.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558184,\n \"text\": \"P-MICU NSG PROGRESS NOTE 7P-7A\\nNEURO: PATIENT AWAKE AT TIMES WOULD OPEN EYES SPONTANEOUSLY AND TO VOICE. FOLLOW COMMANDS BY SQUEEZING HANDS. MOVING HEAD AND FEET AND OCCASIONALLY ARMS. GIVEN 0.5MG ATIVAN IV THIS AM AS PATIENT BP ^200 AND NOT COMING DOWN AS IT WAS DOING PREVIOUSLY IN THE SHIFT. THIS HAD GOOD EFFECT AS BP DECREASED AND PATIENT STILL RESPONDING.\\n\\nCARDIAC: HR 80'S IN SR WITH NO NOTED ECTOPY. BP 140-206/ 50-77. WHEN PEACEFUL AND SLEEPING SBP 140'S-150'S. PATIENT WITH SEVERAL EPISODES DURING THE SHIFT WHEN HE WOULD BE FULLY AWAKE WITH EYES OPEN AND BP WOULD INCREASED TO 190-200. THIS WOULD LAST FOR ~5MIN AND THEN RETURN TO BASELINE. THIS MORNING BP WOULD NOT DECREASE, COZAAR WAS STARTED AND THEN PATIENT GIVEN THE ATIVAN. HCT 29 THIS AM. PATIENT WITH PERIPHERAL EDEMA.\\n\\nRESP: STARTED SHIFT ON PS 5/5 AT 40%. BREATHING 30'S WAS CHANGED TO PS 10 WITH RR IN THE 20'S. SATS 89-96% RR20-40. TV'S 400'S. LS CLEAR TO COARSE. SXT FOR SMALL AMOUNTS ON TAN YELLOW TO BLOODTINGED THICK SPUTUM. ABG THIS AM 67/36/7.32/19. PLAN IS TO EXTUBATE TODAY.\\n\\nGI: ABD SOFT WITH UMBILICAL HERNIA. BS+ WITH BROWN LIQUID STOOL IN FIC BAG. OGT IN PLACE WITH PROMOTE W/FIBER AT 40CC/HR. NO RESUDUALS.\\n\\nGU: U/O TAPERING TO 0. 250CC FLB BOLUS X2 WITH NO EFFECT. FOLEY FLUSHED EASILY. URINE WAS YELLOW AND CLEAR.\\n\\nSKIN: RIGHT UPPER HIP 4X2.5X1CM WOUND. YELLOW SLOUGH AND PINK WOUND BASE. WOUND GEL AND W/D DSG APPLIED. ALSO DUODERM TO UPPER BACK.\\n\\nID: WBC 17.6. ON OXACILLIN AND AUGMENTIN. CULTURES PENDING. TMAX 99.3.\\n\\nACCESS: RIJ CL, LEFT ART LINE.\\n\\nSOCIAL: DAUGHTERS HAVE BEEN HERE ALL SHIFT. UNDERSTAND PLAN TO EXTUBATE TODAY AND WISH PATIENT TO BE REINTUBATED IF NECESSARY. PATIENT IS A DNR.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558198,\n \"text\": \"Nursing Progress Note\\n1:15 - 1:30\\n\\nPatient transferred out of bed to chair with supine slide transfer. Patient unable to assist with transfers. On rounds, MD confirm that patient is to maintain non-weightbearing status due to pelvic fractures\\n\\nA/P: As patient is unable to receive percussion and shaking due to rib fractures and unable to be weightbearing to progress activity, will d/c from service as this time. If patient is able to participate in activity progression in the future, please reconsult our service.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558199,\n \"text\": \"Nursing Progress Note\\nNeuro: Awake, alert, difficult to understand what pt is saying most of the time d/t weak voice, secretions\\nResp: BS coarse bilat, sats 95% on 40% cool neb mask. NP suctioned x3 for mod amt thick tan-yellow sputum\\nCV: Converted to NSR 80's at 0530, receiving Diltiazem 30mg via NG tube BP back to baseline 130's-150's\\nGI: Tube feedings at 10ml/hr with min residuals, +bowel sounds, no stool overnight\\nGU: Adequate urine output, although still + ~1L/24hrs\\nSkin: Hip packing changed, site without change from previous documentation\\nSocial: No further contact with family overnight.\\nPlan: Needs to be evaluated for PICC line insertion, venous access team aware.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558178,\n \"text\": \"NURSING PROGRESS NOTES:\\nPT STILL AND VENTED ON SAME SETTINGS. SEE FLOWSHEET. PT SX FOR LRG AMT'S OF YELLOW BLD TINGED SECRETIONS. O2SAT'S MAINTAINING HIGH 90'S WITH NO DROPS. LUNG SOUNDS COARSE THROUGHOUT.\\nPT CONT TO BE VERY SEDATED BUT HAS PERIODS WHEN SBP GOES UP TO THE 170'S AND IS ATTEMPTING TO OPEN EYES BUT UNABLE. PT MED WITH ATIVAN 1MG IVP WITH GOOD EFFECT.\\nPT CONT ON GOAL RATE TUBE FEEDS WITH ACCEPTABLE RESIDUALS. RECTAL BAG DRAINING SM AMT'S OF LIQ BROWN STOOL.\\nRIGHT HIP DSG CHG WITH SM AMT OF YELLOW DRAINAGE. WOUND CLEANSED/WOUND GEL APPLIED AND PACKED WITH WET TO DRY DSG.\\nDUODERM ON SPINE INTACT.\\nFAMILY CHECKED IN BY PHONE AND WERE UPDATED.\\nPT CONT ON ANTIBIOTICS AND IV FLUID DISCONTINUED.\\nPT HAS SEVERE GENERALIZED PITTING EDEMA. FOLEY CATH DRAINING MOD AMT'S OF YELLOW URINE.\\nPT HAS LOW GRADE TEMP AND VITAL SIGNS ARE STABLE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558179,\n \"text\": \"Resp Care,\\nPt. remains intubated on CPAP IPS 10/.4/5peep. VT 500, RR 20. Suctioned for yellow sputum. Cont. to wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558180,\n \"text\": \"PT/RSD\\nS: Intubated, opened eyes during chest physical therapy\\nO: Pt seen to address goals set at re-evaluation on \\nLabs: 15.6>29.1<353, Tm 99.8\\nVent: 40%FiO2/PS 10/PEEP 5/TV 500\\nVital Signs: Pre-rx: 128/41, 77, 95%, 23\\n During rx: 170/60, 83, 98% 23\\nBreath Sounds: Coarse anterior, diminished bilateral lower lobes\\nRx: Chest PT, percussion and vibration, to bilateral anterior lung fields in supine, bilateral lower lobes in sidelying. Followed by in-line suction for minimal amount of yellow secretions. Mouth yank. suctioned for moderate amount yellow sputum.\\nA: Pt continues to benefit from chest PT and mobility in the bed to assist with secretion clearance. Pt continues to have less secretions and require less frequent suctioning.\\nP: F/U \\nPager #\\nTime Frame: 3:15-4:00pm\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558181,\n \"text\": \"Respiratory Care Note\\n\\nPt weaned to CPAP with PSV 5 and PEEP 50. 40%. Pt tol wean well Vt 460 and RR 20-26. pt x2 for small/mod amount of white sputum. Bs with scattered rhonchi. Pt much more awake today...following some commands. Plan to ? extubate in next couple of days.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558182,\n \"text\": \"s. ett\\nO. NEURO PEARLA RESPONSE TO PAINFUL STIMULI AT 1800 PT MY HAND WITH HIS RT HAND WEAK OPENS EYES TO PAINFUL STIMULI\\nCARDIAC HR 80'S NSR WITHOUT ECTOPY BP 130/-180/ EKG QT INTERVAL WNL AFTER D/C OF FLAGYL.\\nRESP CPAP 40% PS 5 PEEP 5 ABG 75/42/7.36 LUNGS RHONCI TO CLEAR SX FOR SCANT AMT OF WHITE SPUTUM\\nGI TF 40CC GOAL RESIDUALS MIN. BS+ STOOL DARK LIQ BROWN OB NEG ABD SNT UMBILICAL HERNIA UNCHANGED\\nGU FOLEY U/O>40CC QHR CLEAR YELLOW\\nSKIN RT HIP ANT 4X3CM .5-1CM DEEP POST SIZE DIME 1-2MM DEEP YELLOW DRAINAGE SCANT LUMBAR DECUB DUODERM INTACT PITTING EDEMA UE\\nID AFEB ON OXACILLIN Q 4 IV\\nCODE STATUS FAMILY HAS MADE PT DNR ATTENDING TO COSIGN ORDER\\nA. ALT NEURO STATUS UNCLEAR IF RELATED TO ATIVAN STOPPED \\nALT IN RESP VENT DEPENDENT\\nS/P THORACENTESIS\\nP. DNR\\nSKIN CARE AS ORDERED\\nATTEMPT TO EXTUBATE POSS. TOMMORROW\\nCONT ANTIBX AS ORDERED\\nSUPPORT FAMILY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558193,\n \"text\": \"NPN 7a-7p:\\n Review of Systems:\\n Resp: pt sx for copious amts yellow/tan secretions this shift... q 2hrs.. CPT done x 1 by PT as well. Cont on 50% CSM, with sats 99%, although abg 68/44/.7.37/26. desats to 85% quickly with mask off. RR 16-28. Aline dc'd as was red and small amt puss at site... tip sent for cx. team to place new aline, as pt's resp status tenuous.\\n CV: pt in NSR 80's-90's. BP 130's-150's. NGT placed to give meds.. ASA and Cozaar.\\n GU: pt cont with clots via foley today. irrigated x 1 d/t pt reporting unable to \\\"Pee\\\".. large clot removed... 3 way foley placed and await GU irrigant to run o/n. uo 40-60cc/hr.\\n F/E: lytes wnl. cont on maintanence ivf. Cont edematous.\\n ID: afebrile. wbc 9.0... as noted aline dc'd, and resited... cont on unasyn and oxacillin.\\n Integument: Skincare CNS in to evaluate R hip wound today... Per CNS report.. wound with slightly more yellow, \\\"dead\\\" tissue... sharp debrided by CNS, cleansed with wound cleanser, and filled with wound gel and moist 2x2's, dsd ... taped to duoderm border... also, small blister on upper back cleansed and duoderm replaced.\\n Social: pt's daughter and son in all day.. met with team to discuss plan of care.. pt to remain DNR, but would be reintubated. family very attentive.\\n NEuro: pt A+ O x ... more awake this afternoon, voice much more clear. asking to watch tv.\\n Access: remains with TLC to R SC... to have PICC placed tomorrow by iv team.. please save L antecube.\\na/P: pt with tenuous resp status... large amts secretions.. desats easily, but perking up... to cont abx, follow abg's, cont skin care, pulmonary toilet.. PICC line tomorrow. cont emotional support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558194,\n \"text\": \"NPN\\n\\nCV: SBP into the 180s, he was given his cozaar which decreased it to the 160s at times.\\n\\nPulm: Wet cough, not always able to get very much back from NT suctioning. Cool neb conts at 40% with SATs in the high 90s-100%, desats to the low 90s with his mask off .\\n\\nGI: TF on hold, to discuss with the team today.\\n\\nGU: He no longer has any blood in his foley, continuous flush has been stopped.\\n\\nNeuro: Weak, calling out when he wants assistance.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558195,\n \"text\": \"Rehabilitation Services/physical Therapy\\n10:15 - 10:45\\n1:00 - 1:15\\n\\nS:\\n\\nO: Seen to address problems and goals of .\\nVital signs: 84, 186/60, 99%, 24, Temp 97.1\\nLabs: 90/48/7.34/27, WBC 7.9, Hct 25.4, CXR with Right rib fractures\\nBreath sounds: rhonchi throughout, crackles at left base\\nRx: NTS for large amounts of yellow/tan secretions. Perc and shaking not done secondary to rib fractures.\\nMobility: Due to pelvic fractures, non weightbearing transfers out of bed to chair this am. Returned to bed this PM. Patient with stable vital signs throughout.\\n\\nA: Patient with rib fractures and airway secretions. NTS used to remove secretions with good results. Out of bed to chair.\\n\\nP: COntinue to follow for pulmonary care out of bed to chair\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558172,\n \"text\": \"Resp. Care Note\\nPt remains intubatd and vented on current settings CPAP 5 PSV 5 and 40%. Pt changed to these settings today from A/C and has done well with stable ABG's and RR 24 TV 450-500. RSBI today 66. Sxn for pale yellow secretions, decreased amount today. Pt with cough response and slight gag but still uresponsive to commands. Cont present settings, assess for ext. when Pt more alert.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558173,\n \"text\": \"RESP CARE,\\nPT. REMAINS ON CPAP IPS5/.4/5PEEP. VT 400, RR HIGH 20'S. RESTED COMFORTABLY, NO VENT CHANGES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558174,\n \"text\": \"NURSING PROGRESS NOTES:\\nPT REMAINED ON CPAP THROUGHOUT THE NIGHT. SX FOR MOD AMT'S OF THICK YELLOW SECRETIONS. LUNG SOUNDS VERY COARSE THROUGHOUT. MAINTAINING O2SAT'S IN THE HIGH 90'S.\\nPT CONT TO BE VERY LETHARGIC AND BARELY RESPONSIVE WITH STIMULI.\\nVITAL SIGNS STABLE. TEMP 99.8 PO.\\nFOLEY CATH DRAINING ADEQ AMT'S OF CLOUDY URINE.\\nDSG CHG TO R HIP. NO CHG' IN APPEARANCE.\\nNO STOOL AND RECTAL APPLIANCE INTACT.\\nFAMILY CALLED DURING THE NIGHT AND UPDATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558175,\n \"text\": \"Rehabilitation services/physical therapy\\n\\nPatient traveling to CT for needle aspiration and having echo presently. Unable to see for pulmonary care, tho nursing has been able to position and suction patient throughout day.\\n\\nWill follow \\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558176,\n \"text\": \"NPN\\nNEURO: Tmax 99.4. Remains lethargic. PERRLA. Has not recieved Ativan since 6am on .\\n\\nCV: Monitor shows SR without ectopy. Prolonged QTC noted. Cards feels this is d/t abx therapy. PPx4. S1S2. VSS. K+ and Ca++ replaced this am.\\n\\nRESP: Remians orally intubated. Vent settings per flow. ABG pending. US guided tap done today. 750cc Fluid removed. Lungs remain coarse. Suctioning for large amounts of thick yellow secretions.\\n\\nGI: Tolerating TF well. Rectal bag remains intact. No stools.\\n\\nGU: Foley draining clear amber urine in adequate amounts.\\n\\nINTEG: Stoma RN following for R hip wound. CT of area done today, abcess not drained d/t risk of infection and location of abcess.\\n\\nSOCIAL: Family spoke with team today. updated on POC. Questions answered.\\n\\nPLAN: Wean from vent as tolerated. Pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558177,\n \"text\": \"Respiratory Care Note\\n\\nPt remains on CPAP PSV 10 PEEP 5 40%. Vt 450-500 RR 24-28. Last ABG was 7.42/32/82. Pt seems comfortable on these settings. Pt transported to CT scan today for pelvic scan. Pt also had R sided pleural effusion tapped for 750cc. Pt sxnd for mod amount of thick tan secretions. BS much improved this evening. Will maintain current settings and wean when patient is more alert.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558147,\n \"text\": \"MICU Admit note\\n Pt admitted to MICU from 3 for increasing SOB. Mr. was admitted to for increasing confusion, weakness, and SOB on . This was increasing for several days, he was also having loose stools and decreased mobility. He was recently dc'd from TCU with prolonged stay of 99 days. He was home for one month. He lives at with 24 hour health aide.\\nPMHX:\\nRLL pneumonia with Staph bacteremia, HTN, Osteoprosis, prostate CA', GERD, s/p pelvic fx4/01, right arm fx , left hip decub ulcer, s/p back surgery '.\\nDaughter is health care proxy. is very involved in care.\\n Pt was admitted at 1300. Upon admission Mr. was on 100%NRB with NC at 6ltr. Pt's breathing was labored at 24-32 BPM. Pt was alert, nods yes and no to quesions appropriately, follows commands.\\nFamily accompianied Mr. to unit. Pt's daughter spoke to ICU team. ICU team spoke with patient and family regarding intubation. Pt wishes to be intubated if necessary.\\n TLC and Artline were placed at 1730 per ICU team. Consents obtained from patient and family.\\nReview of systems:\\nNeuro: Pt is awake, alert. Follows simple commands. Answers questions appropriately.\\nResp: Lungs sounds coarse. Pt 2 94-97% on 100%NRB and 6ltr NC. Respirations labored, tachypneaic. ABG per lab flow sheet.\\nCV: Heart rate SR with occcaisional PVC's/PAC's. BP 90s/30-40s\\nPt is febrile with temp of 99.9 rectally.\\nGI: Abdomen distended, soft. Positive bowel sounds. Pt is having frequent loose stools.\\nGU: Foley catheter draining clear/yellow urine. Pt recieved a 120 lasix on floor this am and put out approx a liter of urine since then.\\nPlan: Continue to monitor respiratory status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558214,\n \"text\": \" RN NOTE\\nMR HAD AN IMPROVED DAY TODAY. INITIALLY Q2 HOUR NT SUCTIONIGN. BUT HE WENT FROM 12NOON TO 1700 WITH SATS >95%. REMAINS ON 40% FT. NO IMPROVEMENT IN VOICE YET (ENT CONSULT FOR VOICE ON HOLD). THE CT REVEALE D INCREASING IN SIZE D/T ??HYPOALBUMINEMIA. POSSIBLE PLAN INCLUDES CT GUIDED TAP...MARK BROWNING (RESIDENT) WORKING ON THIS.\\n\\nHE HAS BEEN TIRED TODAY, SLEEPIING INTERMITTANLY AND AWAKENING APPROPRIATELY WHEN I GO IN ROOM OR CALL HIS NAME.\\n\\nGI/GU: STOOLS X3 TODAY. TOL GOAL PROMOTE WITH FIBER.\\n\\nSKINL RT HIP WOUND WITH TAN BASE. DSD WITH WOUND JELLY APPLIED.\\n\\nID: OXACILLIN D18 OF 42. AND AUGUMANTIN DAY8 OF 14. AWAITING SPUTUM AND URINE SENT YESTERDAY. PICC SINCE \\n\\nSOCIAL: I HAD AN EXTENSIVE DISCUSSION WITH DTR AND HER HUSBAND RE: , TRACH, HIS HOSPITAL STAY, A REHAB STAY, MANY QUESTIONS WERE ASKED AND ANSWERED FROM BOTH SHE AND I... THIS INFO COMMUNICATED IN DETAIL TO DR .\\n\\n\\nPLAN: FAMILY MEETING TOMORROW AFTERNOON , PENDING A TIME FROM RESUMING ATTENDING DR . ----THIS TIME MUST BE DECIDED UPON DURING ROUNDS RN AND FAMILY CAN BE AVAILABLE. FAMILY IS COMING IN THE EARLY AFTERNOON ADN ARE AWARE THEY HAVE TO WAIT.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558215,\n \"text\": \"P-MICU NPN 7p-7a\\nSystems Review:\\n\\nCV: Has been hemodynamically stable. BP 90's-120's, HR 70's SR, no ectopy. Received 20meq KCl last eve. AM labs drawn, awaiting results.\\n\\nResp: Aggressive pulmonary toilet cont's. Secretions thick and tan. Attempting to suction less this shift due to trauma and discomfort. LS coarse throughout.\\n\\nID: IV oxacillin, per ID, to con't until to complete 8wk coarse. Aumentin for oral infx. Will need oral surgery consult..\\n\\nF/E: Just about even at present.\\n\\nHeme: Hct up this am to 34.2 after receiving 2nd unit PRBC's.\\n\\nSocial: Son from called last eve. Wanted to know what meds pt was on and if steroids or inhalers/nebulizers would help.. He had spoken to a friend who suggested this. I told him that the MD's were aware of the meds. He said he has a good relationship with his sister, who has been updating him frequently. He is in agreement with her decisions and wants what is best for the pt. Also he was unclear whether or not pt would benefit from a trach. I asked him if his father would want this aggressive tx and he stated that if it gave him some quality of life, he believes he would. He is aware of the family meeting scheduled for today, and expects to be updated by sister.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558159,\n \"text\": \"Resp Care Note:\\n\\nPt cont on mech vent aas per vent flowsheet. Lung sounds ess clear. No changes made this shift. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558160,\n \"text\": \"NPN\\n\\nCV: conts on neo, his dose has needed to be increased through the night to maintain a SBP in the 100s. His HR has been in the 50s SB.\\n\\nPulm: Conts on the respirator no changes were made. LS cleared after suctioning, bronchial on the R. He has had a lg amount of tan, thick putum from the ETT and from the back of his throat.\\n\\nGI: Conts to have loose, golden stool. He had a 270cc residual from his NGT, they were OB pos, TFs were shut off.\\n\\nGU: U/O has increased from yesterday.\\n\\nNeuro: Well sedated on the propofol, appears comfortable.\\n\\nSkin: Dressing on his R hip changed no change in the wound during the last 2 days.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558161,\n \"text\": \"RESP NOTE:PT REMAINS SEDATED AND VENTED WITH NO REMARKABLE CHANGES IN RESP STATUS.PRESENT VENT SETTINGS AC/450/14/40% WITH PEEP LOWERED TO 10 AND TOLERATING WELL.SECRETIONS MINIMAL AND PALE/YELLOW,B/S DIMINISHED BILAT,ABG\\\"S AVAILABLE IN CAREVUE.SATS BEING MAINTAINED AT 99/100% ON CURRENT SETTINGS,WILL CONTINUE TO MONITOR AND WEAN AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558163,\n \"text\": \"NURSING PROGRESS NOTE:\\nPT REMAINS /VENTED, NO FURTHER CHG'S MADE. FOLLOWING O2SAT'S, MAINTAINING SAT'S 95-97%. LUNG SOUNDS CONT TO BE VERY COARSE. SX FOR MOD AMT'S OF THICK YELLOW SECRETIONS.\\nWEANING OFF PROPOFOL AND CONT ON ATIVAN WITH ADEQUATE LEVEL OF SEDATION.\\nNEO REMAINS OFF, RECEIVED 500CC NS BOLUS TO KEEP SBP ELEV AND INC U/O.\\nCONT ON ANTIBIOTICS.\\nTUBE FEEDS REMAIN ON HOLD. PT INC SM AMT'S OF LIQ BROWN STOOL.\\nHIP DSG CHG'D NO CHG IN APPEARANCE. WET TO DRY DSG APPLIED AFTER BEING CLEANED AND GEL APPLIED.\\nFOLEY CATH DRAINING ADEQ AMT'S OF CLEAR DK YELLOW URINE.\\nFAMILY SPOKE WITH HO ABOUT BRINGING IN A CONSULT FROM THE . HO SPOKE WITH DR. ABOUT THIS.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558164,\n \"text\": \"Resp Care Note:\\n\\nPt cont on mech vent as per Carevue. Lung sounds ess cl. No changes made this shift. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558165,\n \"text\": \"Pmicu nsg progress note\\nResp: remains /vented on ac 450x14 40% 10 peep with sats high 90's abg 79/37/7.36. suctioned for mimimal secretions. Remains afebrile.\\nCardiac: bp stable 100-110/40-50 without further fluid boluses. Remains off neo. Cont in sinus brady hr in 50's.\\nNeuro: remains sedated on 1mg ativan. Pt off propofol. ? need to further wean ativan as pt essentually unresponsive.\\nGI:Abdomen soft. passing loose brown stool. Tube feeds remain on hold. ?restart today.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558166,\n \"text\": \"Resp. Care Note\\nPt remains intubated with 7.5ETT secured at 23c lip. Current settings A/C 450x 14x 40% peep 7.5 with ABG 70/37/7.36/22/-3. Peep decreased today from 10-7.5 with adequate oxygenation. Pt occas assisting above vent, could probably be changed to PSV. Sxn for mod. amount of thick tannish secretions. Cont support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558162,\n \"text\": \"MICU NURSING PROGRESS NOTE 7A-7P\\nNEURO: PT REMAINS SEDATED ON PROPOPHOL...ATIVAN JUST STARTED THIS EVENING. GOAL IS TO WHEEN PROPOPHOL OFF AND CONT WITH JUST ATIVAN. PT UNRESPONSIVE TO STIMULI...FACIAL GRIMACING WITH TACTILE STIMULI. AFEBRILE.\\n\\nCV: NEO TO OFF THIS AFTERNOON. BP RANGING FROM 90-110/40-50'S VIA R RADIAL ALINE. SB WITH NO ECTOPY NOTED. POOR PALPABLE PULSES ALL AROUND. S1S2 ON AUSCULTATION.\\n\\nRESP: PT TO AC/40/450/10/14...BREATHING WITH VENT. SUCTIONED FOR LG AMTS THICK YELLOW SECRETIONS ORALLY AND VIA ETT. PT HERE THIS EVENING AND WORKING WITH PT. LUNGS CLEAR WITH SCT RHONCHI THROUGHOUT BASES AND DECREASED BASES. WILL SEND ABG 30 MINS AFTER PT DONE SUCTIONING AND DOING CPT. ETT 23CM AT LIPLINE.\\n\\nGI/GU: FOLEY DRAINING CLOUDY YELLOW URINE. UO RANGES FROM 0-100CC/HR. NSS BOLUSES GIVEN THROUGHOUT DAY TO IMPROVE UO AND BP. TOLERATED WELL. TF REMAIN ON HOLD...HIGH RESIDUALS (GASTRIC HEME +...PH 2). TEAM AWARE. WILL START ON REGLAN. PT SEVERAL TIMES OF LIQUID BM...DULCOLAX GIVEN YEST D/T PT BARIUM IN CT SCAN. ABD S,D,NT...ACTIVE BSX4. WILL CONT TO CHECK RESIDUALS AND ATTEMPT TO RESTART TF.\\n\\nINTEG: R IJ TLC P/I...CVP OFF DISTAL PORT. R RADIAL ALINE P/I. R HIP WOUND REPACKED AND CLEANSED THIS AFTERNOON. TUNNELLING AREA YELLOW WITH PINK TISSUE SURROUNDING EDGES. ESCHAR NOTED IN CENTER APPROX 1MMX1MM. CONT TURNING PT Q2H. PT WITH NEW R HIP FRACTURE...ORTHO BY TO SEE PT.\\n\\nSOCIAL: SPOKE WITH DAUGHTER ON PHONE SEVERAL TIMES TODAY. SHE WAS UPDATED ON PT STATUS AND WILL BE STOPPING BY LATER TODAY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558224,\n \"text\": \"NURSING PROGRESS NOTE:\\nPT ALERT AND ORIENTED. WEARING FACE MASK AND O2SAT'S IN THE HIGH 90'S. ABD DSG FOR PEJ TUBE DRY AND INTACT. GASTRIC PORT DRAINED 175CC BILE.\\nTUBE FEEDS INF AT 30/HR WITH LOW RESIDUALS.\\nPT CONT TO BE OF SM AMT'S OF LIQ GREEN STOOL.\\nPERIANL AREA CONT TO BE VERY REDENED AND EXCORIATED. DESITIN OINT APPLIED AND SEEMS TO BE HELPING.\\nPT RECEIVED LASIX ON EVENING SHIFT AND PT CONT TO DIURESE LRG AMT OF DILUTE URINE.\\nPT CONT TO HAVE MUCH DIFF COUGHING AND RAISING SECRETIONS.\\nHIP DSG CHG AS ORDERED NO CHG IN APPEARANCE OF WOUND.\\nDAUGHTER CALLED AND WAS UPDATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558225,\n \"text\": \"altered resp status\\nD: ALERT WHEN AWAKE BUT VERY LETHARGIC TODAY AND SLEEPING IN LONG NAPS. COARSE BS . SUCTIONED X 2 FOR THICK TAN SPTUM AND O2 SATS93-98%. REMAINS ON 50% OPEN FACE TENT BECAUSE PT RECEIVING MORE MOISTURE WITH THIS MODE. PT'S DAUGHTER AND SON AT THE BEDSIDE. RECIVING PROMODE WITH FIBER AT GOAL RATE NOW OF 60CC'S/HR VIA NEW PEJ. PEJ DRSG FOR AMT OS SEROUS DRAINAGE. POS BOWEL SOUNDS AND PT HAS HAD 2 EPISODES OF SM AMTS BLUE STOOL. UO ADEQAUTE VIAFOLEY CATH . R HIP DRSG AS ORDERED AND NO CHANGE IN APPEARANCE. PT HAS REQUIRED LESS SUCTIONING TODAY AND DOES NOT NEED NURSING CARE THOUGH HIS RESP STATUS WILL NEED TO BE MONITORED CAREFULLY.. CONITNUE TO OFFER EMOTIONAL SUPPORT TO FAMILY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558167,\n \"text\": \"MICU NURSING PROGRESS NOTE 7A-7P\\nNEURO: PT REMAINS EXTREMELY SEDATED ON ATIVAN GTT...GTT DOWN TO 0.5MG/HR. CONVERT TO PRN ATIVAN IV...PLAN TO ASSESS PT AND SEDATION REQUIREMENTS. AFEBRILE.\\n\\nCV: PT REMAINS OFF NEO. ABP 110-120/40-50'S. L ALINE CORRELATING WELL. SB WITH 1ST AV AND BBB ON MONITOR. EKG THIS SHOWED NEW T WAVE ABNORMALITIES AND POSSIBLE NEW ISCHEMIA. TEE DONE...NEGATIVE FOR VEGETATION. CARDIAC ENZYMES SENT X2. RESULTS PENDING. S1S2M ON AUSCULTATION. POOR PALPABLE PULSES ALL AROUND. CVP 9-10.\\n\\nRESP: PT REMAINS ON AC/450/14/40%/PEEP DOWN TO 7.5. ABG DONE AND WNL. SUCTIONING OUT THICK TAN SECRETIONS ORALLY AND VIA ETT. LUNG SOUNDS COARSE, DECREASED LOWER LOBES. O2SATS 96% WHEN TRACKING.\\n\\nGI/GU: OGT PULLED FOR TEE. REPLACED AND XRAY DONE..WAITING TO HEAR IF PLACEMENT IS GOOD. ABLE TO START TF THIS AM AT 0900...RESIDUALS OF 10CC. TF ON HOLD SINCE NOON FOR TEE. ABD S,D, ACTIVE BSX4. CONT WITH FREQ LIQUID STOOLS. SENT FOR CDIFF. FOLEY DRAINING SMALL AMTS YELLOW URINE. TEAM AWARE, BOLUS WITH MORE FLUID.\\n\\nINTEG: R IJ TLC P/I. SKIN NURSE BY TO R HIP WOUND. TUNNELING WITH YELLOW AND ESCHAR TISSUE IN CENTER, PINK TISSUE SURROUNDING EDGES. ORTHO BY TO PT...SUSPECT HIP WOUND IS ACTUALLY A TUMOR VS ABSCESS. FAMILY NOT AWARE YET. CAST REMOVED FROM R HAND...SPLINT ON.\\nCONT ON FIRST STEP MATTRESS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558229,\n \"text\": \"ALTERED HEMODYNAMICS\\nD: PT THIS AM TALKING AND RECOGNIZED HIS CAREGIVER, . O2 SAT=93& SO PT SUCTIONED FOR LG AMT OF THICK YELLOW TO TAN SPUTUM. COARSE BS . O2 SATS AFTER SX'ING WERE 96%. TURNED PT AT 0930 FOR BACK CARE AND TO CHANGE R HIP DRSG. ALARM SOUNDED AND SBP DOWN TO 84 WITH HR 50 AND O2 SAT=93%. MD'S CALLED TO BEDSIDE. PT NOT RESPONDING. NS BOLUS OF 500CC'S GIVEN. O2 REMAINED AT 100% FACE TENT WITH 6L/M NC. HR THEN DROPPED TO 41 AND SBP DROPPED TO 74. R RADIAL ALINE PLACED AND ABG AT THE TIME=7.15/96/81/35/1. PT'S DAUGHTER CALLED AND AFTER DISCUSSION WITH DR. ,DAUGHTER AND MYSELF AS WELL AS PHONE CONVERSATION WITH PT'S SON IN THE DECISION WAS MADE TO KEEP PT COMFORTABLE. O2 SATS DROPPED TO A LOW OF 62% AND SBP 70'S. THIS AFTERNOON WITHOUT PT'S HR HAS RETURNED TO THE 50'S AND SBP 90'S. O2 SATS HAVE REAMINED 90-94%. PT HAS MINIMAL CORNEAL REFLEX AND DR. HAS SPOKEN TO PT'S FAMILY AND THEY UNDERSTAND HIS GRIM PROGNOSIS. PT HAS RECEIVED 2 MG IVP MSO4 X3 AND WILL START MSO4 GTT IF MSO4 NEED INCREASES. UO HAS ALSO DROPPED TO MINIMAL AMTS SINCE HYPOTENSION. FAMILY HAS REMAINED AT THE BEDSIDE. PT AND AWAITING THE ARRIVAL OF HIS SON.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558230,\n \"text\": \"addendum to above note: pt's son arrived and dr. met with famil. minimal corneal reflex to r and absent to l. unresponsive. family witnessed md's exam and aware of his status. o2 nc removed but continues with open tent mask. shortly after son arrived hr down to 43 and sbp 70's o2 sats dropped to 79-81%. mso gtt initated at 2 mg /hr and will continue to titrate as needed to keep pt comfortable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558231,\n \"text\": \"Pmicu Nursing Note:\\n\\nPt expired on at 1:17am. Family in attendance. Drs' and pronounced.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558209,\n \"text\": \"NURSING PROGRESS NOTE:\\nPT CONT TO STAY EXTUBATED ON FACE MASK. LUNG SOUNDS VERY COARSE THROUGHOUT, COUGHING AND ABLE TO RAISE SECRETIONS TO BACK OF THROAT AT TIMES. NASOTRACH SX Q4/HR FOR THICK TAN SECRETIONS. O2 SAT'S IN HIGH 90'S.\\nPT'S VITAL SIGNS STABLE, AFEBRILE. RESP RATE REGULAR. NO SOB.\\nTUBE FEEDS CONT AT 60/HR MINIMAL RESIDUAL. BOWEL SOUNDS PRESENT AND PASSING SM AMT'S OF SOFT GREEN STOOL.\\nPT HAS BEEN VERY ALERT AND TALKING. SLEPT VERY LITTLE DURING THE NIGHT.\\nNO CHG IN R HIP DECUBITUS. DSG CHG' NO SIG SIGNS OF IMPROVEMENT.\\nFAMILY CHECKED IN AND UPDATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558226,\n \"text\": \"PMICU Nursing Progress Note:\\n\\nResp/CV: Desat to 85% on 100% shovel mask. NT sx for min thick tan secretons. 5L NC added w/ O2 sats remain > 94%. Dropped sats again later in evening--required NT sx x 3 times for large amt of thick tan secretions with sats eventually >94%. Hemodynamically stable.\\n\\nGI/GU: 200cc output from gastric drainage. Cont on tf's at goal. Stool x 6 sm amts blue/grn. Buttocks excoriated, cream applied. U/O poor.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558227,\n \"text\": \"Chart re-reviewed this afternoon. Events noted. No further PT needs at this time, will defer further treatment.\\nTime: 6:00pm\\nPager: #\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558228,\n \"text\": \"PT/RSD\\nRe-consult received, pt known to physical therapy department. At this time we are unable to progress pt's mobility as he is NWB secondary to bilateral pelvic fractures. Will re-evaluate status on , deferred rx today as pt unstable this am.\\nPager: #\\nTime: 10:00am\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558210,\n \"text\": \"P-MICU RNNOTE\\nCV: STABLE WITH DILTIAZEM.\\n\\nRESP: ENT CONSULTED FOR HOARSENESS. FAILED SWALLOW STUDY YESTERDAY SECONDARY TO INABILITY TO BALL FOOD TO BACK OF MOUTH. AT 1800 ABG= 58/42/7.45...CHANGED TO NRB, NT SUCTIONED, SAMPLE SENT.\\n\\nPLAN: WILL REDO ABG\\n CONT CPT Q4 HOURS.\\n CONT NT SUCTIONING PRN\\n\\nGI/GU: FOLEY BAG CHANGED AND CULTURE SENT AS URINE DARKENED LATE TODAY. TOL GOAL RATE PROMOD WITH FIBER AT 60CC/HOUR. FREE WATER BOLUSES D/C' N ATTEMPT TO MAKE HIM ABOUT 500CC (-).\\n\\nID: AFEBRILE. OXACILLIN (D#17 OF 6WEEKS) AND AUGUMENTIN (D#7 OF 14). HE HAS MULTIPLE DENTAL ABCESSES THAT DENTAL HAS ASSESSED AND DOES NOT FEEL WILL SEED... OMF (ORAL MAXILOFACIAL SURGERY) DOES NOT HAVE O.R. PRIVELAGES, THUS HE WOULD NEED TO LEAVE , HAVE SURGERY AND RETURN.\\nDSD TO RT HIP DECUBITUS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558211,\n \"text\": \"Resp Care Note:\\n\\nPt requires aggressive pulmonary toilet. Pt suct for copious th beige sput. Lung sounds bilat rhonchi clearing significantly after suct. Pt currently w/ O2 Sat ~ 95% breathing comfortably in NARD. Cont aggressive pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558212,\n \"text\": \"P-MICU NPN 7p-7a\\nSystems Review:\\n\\nResp: LS coarse bilat throughout. Aggressive CPT maintained throughout shift. Received CPT q4h with NT suctioning. Pt with large amts of tan thick secretions. O2 sats have been 94-97%, with rr in the 20's. ABG 63/47/7.39/30/2 on 40%CN. No further ABG's obtained, due to A-Line falling out with turning.\\n\\nCV: VS have remained stable.\\n\\nNeuro: extremely difficult to understand due to pt being very weak, he has not been able to expectorate any secretions.\\n\\nID: Afebrile, on IVABX. Sputum cx sent.\\n\\nGU; +fluid status by 12am, 330cc's + by 6am.\\n\\nSkin: Right hip decub drsg protocol.\\n\\nGI: Small amts green stool. +bs, tolerating TF's with minimal residuals. TF's held ~1hr with CPT and sxning.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558213,\n \"text\": \"P-MICU NPN 7p-7a\\nPt's urine output has steadily been declining. 15-20cc's/hr House officer notified. Will con't to assess.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558168,\n \"text\": \"PMICU NURSING PROGRESS NOTE:\\n\\nNeuro: all sedation off. unresponsive to stimuli.\\n\\nCV: stable, SBP 110-130. HR 60's BBB. Troponin of yest negative. TEE negative. EKG due this am. Ca++ repleted.\\n\\nResp: Vent settings unchanged. Sx x 3 for thick yellow mod amt. ^^oral secretions. LS crackle, coarse.\\n\\nID: afebrile. cont on Oxacillin, clinda for + bld cx\\n\\nSkin: buttocks excoriated from constant mucoid green stool. Rectal bag applied. R hip dsg x 2. Need to contact skin care RN for more appropriate chemical debriding gel (collagenase?), wound sloughing-tunneling.\\n\\nGI/GU: TF's restarted, now 35cc. U/O sporatic but averaging ~30cc/h.\\n\\nSocial: no calls from family. Remains full code.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558169,\n \"text\": \"Resp Care Note:\\n\\nPt cont on vent as per Carevue. Lung sounds rhonchi impr after suct mod th tan sput. No changes made this shift. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558152,\n \"text\": \"NPN\\nNEURO: Remains sedated on Propofol gtt currently at 40 mcg/kg/min. Withdraws to painful stimuli. PERRLA. Afeb.\\n\\nCV: Monitor shows SR without ectopy. VSS. MAP>60. PPx4. S2S1 murmur noted. Lytes this am WNL.\\n\\nRESP: Orally intubated with 7.5 ETT 23 at the lip. AC / 450x10/ 50%/ 15peep. PAP 35-39. O2 sats 98-100%. Lungs very coarse. Suctioning for large amounts of thick yellow pasty secretions. Last ABG WNL.\\n\\nGI: NGT intact with + placement. Readicat given for CT of Abd scheduled for 5pm. Hypoactive bowel sounds noted. No stool today.\\n\\nGU: Borderline uop today. Foley flushed x1 with very slight increase in uop. UOP remains > 30cc/hr.\\n\\nSKIN: No edema noted. R hip wound debrided by plastics today. Recommend tid dressing changes. Duoderm to coccyx intact.\\n\\nSOCIAL: Daughter very involved in pt care. Very inquisitive. Questions answered.\\n\\nID: BC + staph aureus 4/4 bottles. Sensitive to Oxacillin and Clindamycin. Covered with both. No fevers. WBC count is down to 16.9. Plastics does not feel R hip is source of infestion.\\n\\nPLAN: Continue vent support. Abd CT this pm. Continue with abx regimine. Pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558153,\n \"text\": \"NPN\\nPt dropped SBP to 60's. Fluid bolus 500cc given and Neosynephrine started. BP now in the low 100's. CT on hold for now, will retry later.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558154,\n \"text\": \"RESP NOTE:PT REMAINS INTUBATED AND VENTILATED AT THIS TIME WITH NO RESP DISTRESS NOTED.B/S DIMINISHED BILAT WITH SX FOR SMALL/LARGE AMOUNTS OF THICK TAN/YELLOW SECRETIONS DURING SHIFT.PRESENT VENT SETTINGS AC/450/10/50% PEEP15 AND TOLERATING WELL. ABG\\\"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH PRESENT COARSE AND WEAN AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558155,\n \"text\": \"NPN\\n\\nCV: Pt still requiring neo, gtt increased a little due to low BP. he remains in a SR, HR 60-70s.\\n\\nPulm: LS bronchial on the R, clear on the L, very little sputum from his ETT. No changes were made in his vent.\\n\\nGI: Stooled x2, gelatonous, brown, OB neg. TF started Replete with fiber at 10cc/hr\\n\\nGU: decreased u/o\\n\\nNeuro: Remains on Propofol, he has been well sedated\\n\\nSkin: Decube on his R hip, dressing done, white base, very little drainage\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558156,\n \"text\": \"Resp Care Note:\\n\\nPt cont on mech vent as per vent flowsheet. Lung sounds coarse. Sx mod th pale yellow. No changes made this shift. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558157,\n \"text\": \"NPN\\nNEURO: Remains sedated on Propofol gtt. PERRLA. Responds to painful stimuli.\\n\\nCV: Monitor shows SR without ectopy. VSS. Remains on Neo at 32mcg/min. S1S2. PPx4. Labs WNL.\\n\\nRESP: Remains vented. AC 450x10 40% 15peep. Lungs coarse. Suctioning for thick yellow sputum. Sats 100%.\\n\\nGI: CT done today. Results pending. Tol po well. Replete with fiber at 20cc/hr. Stooling today.\\n\\nGU: UOP decreased. Fluid bolus given with slight increase in uop. Continue to monitor closely.\\n\\nSKIN: R hip wound culture sent. Dressing change tid. Duoderm to coccyx intact.\\n\\nSOCIAL: Daughters into see pt. Spoke with team.\\n\\nPLAN: Wean vent as tolerated. Support BP.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558158,\n \"text\": \"RESP NOTE:PT REMAINS INTUBATED AND VENTILATED THOUGH SOME IMPROVEMENT IN RESP STATUS TODAY.FIO2 LOWERED TO 40% WITH PT MAINTAINING SATS 98-100% AND NO RESP DISTRESS EVIDENT.SECRETIONS MINIMAL AND PALE/YELLOW,B/S GEN CLEAR AND DECREASED R>L.ABG\\\"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH VENTILATORY SUPPORT AND WEAN AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558170,\n \"text\": \"NPN\\nNEURO: Afeb. Has received no sedation since 6 am. Will open eyes slightly verbal command. Not following any commands. BC x1 sent today. per orders.\\n\\nCV: Remains in SR without ectopy. VSS. Continue with d5.45NS at 75cc/hr. PPx4. S1S2 murmur. No edema noted. EKG unchanged from yesterday.\\n\\nRESP: Vent changed to CPAP 5/5 this am. Tolerating well. ABG WNL on this setting. Lungs coarse. Suctioning for thick yellow sputum.\\n\\nGI: Tolerating TF well. Replete with fiber at 40cc/hr. Stooling, rectal bag intact. ABS. ABD S/ND/NT.\\n\\nGU: Foley draining clear amber urine in adequate amounts. Remains + for this hospitalization.\\n\\nID: Remians on Oxacillin and Clindamycin. WBC this am was32.1. Remains Afeb.\\n\\nINTEG: R hip ulceration with yellow tissue. Continue with dressing changes TID. Coccyx with duoderm.\\n\\nSOCIAL: Family into visit today. Spoke with myself and Dr. . Questions answered. Asked to speak with social worker. Meeting arranged for tommorow afternoon.\\n\\nPLAN: Allow to wake up from sedation. Wean vent as tolerated. ? Tap pleural effusion today. Consent signed and on chart.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558171,\n \"text\": \"PT/RSD Re-evaluation\\nS: Intubated\\nO: Please refer to initial evaluation for further information regarding PMH and HPI\\nLabs: 13.6>32.1<313\\nVent: PS 5/PEEP 5, Tv 450, 40%FiO2\\nPulmonary: Breath sounds coarse throughout\\nMobility: Pt sedated, no active movement at this time\\nROM: PROM all joints WFL although stiffness noted throughout\\nVital Signs: Pre-rx: 148/60 77 28 99%\\n During/post-rx: 140/60 78-84 28 98-100%\\nRx: Gentle passive ROM bilateral upper and lower extremities.\\nPercussion to right lung field in left sidelying followed by in line suctioning for minimal yellow secretions. Pt positioned back in supine post rx.\\nA: 85y.o male with staph aureus bacteremia and hypoxic respiratory failure. Pt presents with impaired respiration, ventilation and secretion clearance associated with respiratory failure. Pt tolerated chest PT well today and will benefit from continued pulmonary toileting. Should begin mobility when pt able to participate. Pt will require rehab placement once medically stable with guarded potential given prolonged hospitalization/bed rest.\\nGoals(5-7 days):\\n1.Pt will maintain O2 saturation >95% without mechanical ventilation\\n2.Pt will be independent in secretion clearance\\n2.Pt will transfer bed to chair with moderate assist of 2\\nP: F/U \\nPager #\\nTime Frame:4:30-5:30pm\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558222,\n \"text\": \"ALTERED REPS STATUS\\nD: PT A&O AND FOLLWS SIMPLE COMMANDS. O2 AT 6L/M NC WITH O2 SATS>90%. COARSE BS AND PT SUCTIONED X1 FOR THICK TAN SPUTUM. COARSE BS . PT REMAINS NPO FOR PEJ PLACEMENT TO BE DONE TODAY. RECEIVING D 5 1/2 NS AT 60CC'S HR AND HOURLY URINE IS MARGINAL. PASSED MEDIUM SIZED GREENISH BLUE SOFT STOOL AND DESITIN OINTMENT APPLIED TO EXCORIATED BUTOCKS. R HIP DRSG AND OF THE WOUND IS UNCHANGED. PT'S DAUGHTER AT BEDSIDE AND UPDATED. CASE MANAGEMENT CALLED TO BEDSIDE PER DAUGHTER'S REQUEST.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558223,\n \"text\": \"MICU NPN 11AM-11PM:\\nNeuro: Pt awake and alert. Sometimes speech is difficult to understand. Today was talking about making a phone call but it was difficult due to his poor speech. Pt wanted to get up OOB but did not due to the placement procedure. He is very stiff, requires full lift and assist with all ADL's.\\n\\nCardiac: One dose of diltiazem held today due to HR in the 50's. BP stable 120-140. Pt was given a dose of 20mg IV lasix today. Has had good effect.\\n\\n\\n\\n\\nResp: Had to go back to the 50% face tent due to pt desating and not coming up after suctioning. I suctioned him twice. Large amt secretions initially but small amt in the evening. Lungs are decreased and coarse. RR in the 20's. Current sat 95%.\\n\\nGI: Had a J-tube inserted in radiology today and tolerated this well. We can use it for meds and give him his tube feeds at half the normal goal rate until tomorrow afternoon when we can increase it back to the goal rate. Currently on promote w/fiber at 30cc/hr. The site is draining moderate to lrge amts serous drainage and the dressing was changed by myself twice. I caled the radiologist who inserted the tube and she feels as long as the bleeding is not grossly bloody and just clear to serous that it is probably due to his generalized body edema and may drain for a while. I have the Gastric port hooked up to gravity drainage and the j-port has the tube feeds. Gastric drainage is golden/yellow clear bile. Pt stooled three times today, green loose.\\n\\nGU: Foley draining drk urine at first but now clear yellow since he got the lasix. I did run the irrigant for a while but have it off now trying to get an accurate I+O.\\n\\nSkin: Unchanged. Buttocks are red and excoriated and I have been using triple cream ordered by team.\\n\\nSocial: Pt's daughter was in most of the day. Pleased at pt's progress today and will call later tonight.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558148,\n \"text\": \"NPN\\n\\nCV: BP stabalized, now in SN in the 70-80s, able to wean him off of the neo during the night.\\n\\nPulm: Resp status is still tenuous, he remains on 100% and 6 L NC, his SATs are in the upper 90s but when his mask comes off he quickly desats to the 70s-80s though this does return to the 90s as fast as he desaturated. He has a wet cough when he is encouraged to cough but no production. His ABG has slowly improved now with a Pa02 of 82. Oxacillian conts.\\n\\nGI: Drinking liquids, rather thirsty, sm amount of stool\\n\\nGU: fair u/o\\n\\nNeuro: A&Ox3, good memory, asking approapriate questions\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558149,\n \"text\": \"NPN\\nNEURO: A+Ox3. Afeb. Follows all commands. Asks appropriate questions.\\n\\nCV: Monitor shows SR without ectopy. VSS. PPx4. No edema noted. S1S2 with murmur noted. K+ this am was 2.9, replaced with 60meq IV. recheck was 4.1.\\n\\nRESP: Remains on 100% and 6LNC. Lungs very coarse. Has wet cough, but unable to produce any sputum. Sats are 98-100% while pt at rest, drops to 70-80's if mask removed. Also drops with anxiety. Sputum culture ordered but not sent d/t lack of specimen.\\n\\nGI: Taking po's well, although restricting to po fluids d/t possibility of intubation. ABSx4. Stoolsx2 today. OB-. Abd S/ND/NT.\\n\\nGU: Foley draining clear yellow urine in adequate amounts.\\n\\nSOCIAL: Family at bedside. Very inquisitive. Questions answered. Pt has home health aide at bedside ATC.\\n\\nPLAN: Monitor resp status. pulmonary toilet. Encouarge family to allow pt to rest. pt that he is not alone.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558150,\n \"text\": \"NURSING PROGRESS NOTE:\\nPT ON 100%NRBM AND 6LNC. PT HAVING MUCH DIFF BREATHING USING ALL ACCESSORY MUSCLES. HAVING MUCH DIFF RAISING SPUTUM. LUNG SOUNDS VERY COARSE. DOPPED 02 SAT'S OFF AND ON DURING THE NIGHT.\\nPT SX FOR LRG AMT OF PASTEY YELLOW/TAN SECRETIONS WHICH DROPPED HIS O2 SAT'S TO THE LOW 80'S AND PT WAS UNABLE TO RECOVER FROM THIS AND WAS DECIDED AT THIS TIME TO INTUBATE PT AND PT AGREED.\\nANESTHESIA CALLED, PT MED WITH ETOMADATE AND SUCCX IV. PT INTUBATED EASILY WITH #7.5 ETT AT 23CM AT THE LIP. TUBE PLACEMENT CHECKED BY XRAY. PLACEMENT GOOD. PT STARTED ON PROPOFOL DRIP TO MAINTAIN SEDATION AND COMFORT.\\nFOLEY CATH DRAINING ADEQUATE AMT'S OF YELLOW URINE. INCON SM AMT'S OF SOFT STOOL DURING THE NIGHT.\\nK 3.4 RECEIVED 60MEQ KCL.\\nPT HAS REMAINED IN SR ALL SHIFT, BP STABLE BUT DROPPED SLIGHTLY WHEN STARTED ON PROPOFOL. RATE AND BP BACK UP TO ACCEPTABLE RANGE.\\nFAMILY MADE AWARE OF INTUBATION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558151,\n \"text\": \"Resp Care Note:\\n\\nPt on NRB mask + 6L NC required NT sx due inability to clear secretions. Sx copious th yellow sput. Pt sats didn't recover after sx + A&A Tx. Pt intubated and placed on vent setting as per vent flowsheet. CXR confirmed ETT placement and ABG's stable. Pt sx after intub for mod th yellow. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558216,\n \"text\": \"NPN 7a-7p:\\n Review of Systems:\\n RESP: Cont on 50% CSM, with weak, nonproductive, thickly congested cough. NT sx q 3-4 hrs for thick tan secretions. LS with exp wheezes, bronchial at bases... L thoracentesis done via bedside US for 900cc pleural fluid. RR 16-24. Sputum spec growing out yeast. Remains npo. Seen by Speech and swallow therapist who is to return to discess speach excercises with pt to strengthen voice... to be seen by eNT to evaluate vocal chords.\\n ID: pt hyothermic this shift.. now on bearhugger with slow improvement. team aware.. in light of hypothermia, pt fully cx'd... sutum, blood with fungal isolator (peripheral), urine. cont on IV OX... po augmentin dc'd.\\n F/E: pt with marginal UO this shift.. ? d/t No input, as TF's off for thoracentesis.. 250cc NS fluid bolus up over one hr... await effect. Lytes wnl. fluid bolus neg 600 today, + 2L yesterday... pt with peripheral edema throughout, + scrotal edema.\\n GU: pt with yeast growing in urine... foley changed o/n... pt with intermittent BRB via foley.. irrigated with NS to clear.\\n GI: pt with blue/green stool d/t dye in TF's... Butt bag placed as buttocks excoriated d/t frequent stooling. ab softly distended, BS + with + umbilical hernia.\\n Integument: Skin care CNS to be paged tomorrow am to observe wound to R hip during dressing change... cont lined with yellow dead tissue.. dressing process unchanged. duoderm intact to upper back. wax placed to metal rod in tooth, R upper gumline.\\n Social: family meeting held, attended by pt's daughter, son in law, Dr. , Dr. , and this RN.. Dr. explained to family that if pt wants to cont. aggressive treatment, then a trach and are recommended at this point... pt lethargic this afternoon, but when arouses, family to return to be present for discussion intern to have with pt... Pt prefers daughter to be present when he makes decisions about his care... also, pt would be reintubated at this point, but otherwise DNR.\\nA/P: follow cx.. will follow MS/hypothermia carefully.. no further abx changes at this time. page skin care cns in am, and call family when pt more alert, in order to have discussion.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558217,\n \"text\": \"Brief NPN 7PM-11PM:\\nPt awake, looking a little uncomfortable at 8PM. Unable to guess what the problem was so I turned him to the right at 9PM and he has looked more comfortable since then. RR 16-20. On 40% mask his sats have been 98%-100% most of the evening. UO was 20cc/hr early in the shift. Urine is grossly bloody, no clots noted. Last UO at 10PM was up to 50cc/hr. An order was written for 250cc NS bolus if UO drops below 30cc/hr for two consecutive hours tonight. Pt is on the tube feeds at goal rate. Vital signs are stable. Family was not present this evening.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558218,\n \"text\": \"NURSING PROGRESS NOTE:\\nPT SLEPT OFF AND ON DURING THE NIGHT MAINTAINING GOOD O2 SAT'S AND GOOD VITAL SIGNS. PT AFEBRILE.\\nU/O LOW FOR 2/HRS 250CC NS BOLUS X 1. U/O PICKED UP SLIGHTLY.\\nTUBE FEEDS TURNED OFF AFTER MIDNIGHT, SX BLUE TUBE FEED OUT OF TRACHEA WHEN NASOTRACH SX.\\nPT'S LUNG SOUNDS COARSE THROUGHOUT.\\nFOLEY CATH DRAINING BROWN URINE WITH OCC CLOTS.\\nHIP DSG CHG'D NO CHG IN APPEARANCE.\\nPT' HAS GENERALIZED THIRD SPACING, WITH SCROTAL EDEMA.\\nFIB REMOVED DUE TO LEAKAGE. PERIANAL AND PERINEAL AREA VERY REDENED.\\nMICONAZOL POWDER AND SKIN CREAM APPLIED.\\nPT SEEMS ORIENTED BUT CONT TO SCREAM OUT AT TIMES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558219,\n \"text\": \"NPN 7a-7p:\\n S/O: Cont with copious secretions via nts, blue tinged still. changed to 6L o2nc with sats 98%, rr 20.kept npo/npgt... Most likely to have interventional radiology to place a post pyloric tube for feeding. NO trach per pt/family at this point. Currently with ns with 60meq kcl up over 10 hrs via midline... UO very poor all am.. team aware and 250cc ns fluid bolus given. Urine also very bloody... 3way foley placed and irrigated for 1200cc.. now urine clear and yellow... has order for maintenance ivf once K repletion compelte.. cont with frequent loose stools. C-diff sent x 2.. after 3rd cdiff, can give lomotil. Skin on bottom very broken and excoriated... barrier cream applied. Daughter spoke at length with rn and md's.. many ?'s answered.\\na/P: await feeding tube placement.. cont skin care, follow uO. needs one more c-diff and sputum spec with next sx. cont support to pt/family.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558220,\n \"text\": \"Resp Care Note:\\n\\nPt required NT suct for large amt th white. Lung sounds rhonchi w/ significant improvement after suct. Cont with aggressive pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1558221,\n \"text\": \"NURSING PROGRESS NOTE\\\"\\nPT ALERT AND ORIENTED CONT TO MAINTAIN GOOD 02SAT'S AND GOOD VITAL SIGNS. LUNG SOUNDS CONT TO BE COARSE AND WHEEZY AT TIMES. NASOTRACH SX X 2 DURING THE NIGHT FOR THICK THICK TAN/YELLOW SECRETIONS.\\nPT RUNNING VERY LOW TEMPS. PT CONT TO HAVE WORSENING THIRD SPACING GENERALIZED ESP IN SCROTUM. SCROTUM SUPPORTED WITH TOWEL.\\nPT IV FLUID CONT AT 60/HR BUT U/O RUNNING ABOUT 20-25/HR.\\nCONT OOZING SM AMT'S OF BLUE/GREEN STOOL. PERIANAL AREA VERY REDENED AND EXCORIATED, IMPROVING WITH DESITIN OINT.\\nPT SCHEDULED FOR PLACEMENT, PT HAS BEEN NPO, NGT PLACED TO SX DRAINING SM AMT'S OF BILIOUS/ TINGED MATERIAL.\\nDAUGHTER CALLED DURING NIGHT AND UPDATED. PT CONT TO BE DNR BUT WILL BE REINTUBATED IF NECESSARY.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2131-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 69100,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: ?endocarditis\\nHeight: (in) 66\\nWeight (lb): 104\\nBSA (m2): 1.52 m2\\nBP (mm Hg): 111/43\\nStatus: Inpatient\\nDate/Time: at 13:57\\nTest: Portable TEE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\\n\\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\\nfunction are normal.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is normal in diameter. There are simple atheroma in the\\naortic root. The ascending aorta is normal in diameter. There are simple\\natheroma in the ascending aorta. The aortic arch is normal in diameter. There\\nare simple atheroma in the aortic arch. The descending thoracic aorta is\\nnormal in diameter. There are simple atheroma in the descending thoracic\\naorta.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. There is no\\nsignificant aortic valve stenosis. Trace aortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\\nmitral annular calcification. There is mild thickening of the mitral valve\\nchordae. The tips of the papillary muscles are calcified. Physiologic mitral\\nregurgitation is seen (within normal limits).\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\\nregurgitation is seen.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\\nstructurally normal with physiologic pulmonic regurgitation.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\\nlocation listed above. I certify I was present in compliance with HCFA\\nregulations. The patient was monitored by a nurse throughout the\\nprocedure. There were no TEE related complications. The patient appears to be\\nin sinus rhythm.\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\\nsize, and systolic function are normal. Right ventricular chamber size and\\nfree wall motion are normal. There are simple atheroma in the aortic root.\\nThere are simple atheroma in the ascending aorta. There are simple atheroma in\\nthe aortic arch. There are simple atheroma in the descending thoracic aorta.\\nThe aortic valve leaflets (3) are mildly thickened. There is no significant\\naortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve\\nleaflets are mildly thickened. There is no pericardial effusion.\\n\\nNo masses, vegetations or thrombus seen.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 158134,\n \"text\": \"Sinus rhythm. Wandering baseline makes adequate ST segment changes difficult to\\ninterpret. There is no apparent diagnostic interim change as compared to the\\nprevious tracing of . However, repeat tracing is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 158135,\n \"text\": \"Sinus rhythm. Left ventricular hypertrophy. Left axis deviation. Prior\\nanteroseptal myocardial infarction. Compared to the previous tracing\\nof , no change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 157891,\n \"text\": \"Sinus rhythm. P-R interval is 0.20. Left atrial abnormality. Left axis\\ndeviation. Incomplete right bundle-branch block pattern with Q waves in\\nleads V2-V3 and slow R wave progression in leads V4-V5 consistent with an\\nanterior myocardial infarction of indeterminate age, with persistent ST segment\\ncoving and inverted T waves in the precordium. Low voltage in the precordial\\nleads. The Q-T interval is prolonged. Compared to the previous tracing\\nof sinus rhythm has replaced rapid atrial fibrillation, low voltage\\nis now present in the precordial leads and voltage appears decreased in the\\nlimb leads. The T waves are now inverted in the precordium and Q-T interval is\\nmore prolonged. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 157885,\n \"text\": \"Sinus rhythm. Axis to the left. Compared to the previous tracing of \\nthere is clear evidence of anterior myocardial infarction of undetermined age,\\nbecause of ST segment elevations in lead V3.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 157886,\n \"text\": \"Sinus rhythm. Left atrial abnormality. Left axis deviation. Compared to the\\nprevious tracing of there is more prominent ST-T wave flattening in\\nleads I, aVL and V5-V6. No diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 157887,\n \"text\": \"Sinus rhythm. Left axis deviation. Compared to the previous tracing\\nof there is variation in the precordial lead placement and there are\\nlow amplitude T waves. Otherwise, no change.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 157888,\n \"text\": \"Sinus rhythm. Left axis deviation. Prior anteroseptal myocardial infarction.\\nCompared to the previous tracing of there is variation in precordial\\nlead placement. Otherwise, no change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 157889,\n \"text\": \"Sinus rhythm. The P-R interval is 0.19. Left axis deviation. Prior anteroseptal\\nmyocardial infarction. Compared to the previous tracing of the\\nQ-T interval has normalized and there is improvement in the T wave\\nabnormalities, previously recorded in the anterolateral leads, consistent with\\nan active ischemic process. Followup and clinical correlation are suggested.\\nThe rate is increased.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 157890,\n \"text\": \"Sinus rhythm. Left anterior fascicular block. Q waves in leads V2-V3 with\\ndelayed R wave progression in the remaining precordial leads and Q waves in\\nlead aVL. These changes are consistent with anterolateral myocardial infarction\\nof indeterminate age. Residual minimal ST segment elevations in leads V2-V3.\\nT wave inversions in the anterolateral leads. The Q-T interval is 0.64 and the\\nQ-Tc interval is 0.68 which is markedly prolonged. Low voltage persists in the\\nprecordial leads. Compared to the previous tracing of the Q-T interval\\nis more prolonged. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 157892,\n \"text\": \"Atrial fibrillation with a rapid ventricular response, average rate 128.\\nCompared to the previous tracing of atrial fibrillation with a rapid\\nventricular response is new. There is new T wave inversion in leads I and aVL,\\nmost likely related to the rapid rate, but lateral ischemia cannot be ruled\\nout. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740468,\n \"text\": \" 4:36 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p intubation\\n ______________________________________________________________________________\\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\\n s/p intubation\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post intubation.\\n\\n FINDINGS: Comparison was made with the previous examination of .\\n\\n There has been interval placement of an ET tube, the distal end of which is\\n approximately 2 cm above the carina. Allowing for marked patient rotation,\\n the appearances in the chest are unchanged since with extensive\\n bilateral interstitial infiltrates and a loculated right pleural effusion.\\n The interstitial changes were not present on and most likely\\n represent either acute fluid overload or pulmonary edema. Does this patient\\n have clinical evidence of cardiac failure?\\n\\n IMPRESSION: Satisfactory position of ET tube. Pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-09 00:00:00.000\",\n \"description\": \"CT ABD W&W/O C\",\n \"row_id\": 740508,\n \"text\": \" 8:36 AM\\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \\n Reason: r/o abcess\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\\n r/o abcess\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of multiple pelvic fractures, decubitus ulcer,\\n bacteremia, septic.\\n\\n CT OF THE ABDOMEN AND PELVIS WITH CONTRAST.\\n\\n COMPARISON: Comparison is made to prior study performed .\\n\\n TECHNIQUE: Contiguous serial axial images were obtained from the lung bases\\n to the pubic symphysis after the administration of 150 cc of nonionic Optiray\\n contrast.\\n\\n CT OF THE ABDOMEN WITH CONTRAST: The visualized lung bases demonstrate\\n bilateral pleural effusions with associated left lower lobe\\n collapse/consolidation. The liver, pancreas and spleen are unremarkable.\\n There are small stones within the gallbladder, but no gallbladder wall\\n thickening or pericholecystic fluid collections. Evaluation of the abdomen is\\n somewhat limited by streak artifact from rods. There are bilateral\\n renal cysts. There is a large abdominal hernia and loops of bowel are seen\\n extending cephalad anterior to the ribs bilaterally. There is no focal bowel\\n dilatation to suggest obstruction. There are dense vascular calcifications.\\n\\n CT OF THE PELVIS WITH CONTRAST: Air and a Foley catheter are seen within a\\n mildly distended bladder. The rectum and intrapelvic loops of bowel are\\n unremarkable. No intrapelvic fluid collections or abscesses are present.\\n There are numerous small inguinal lymph nodes not significantly changed from\\n prior study. A small amount of fluid is seen in the region of the right\\n proximal femur as well as stranding of the right gluteal subcutaneous fat. A\\n focal area of heterogeneous enhancement is seen within the right gluteus\\n muscle measuring approximately 3 x 4.7 cm. The appearance is consistent with\\n a multiseptated collection/abscess. This exists in close proximity to a right\\n gluteal decubitus ulcer, although they appear separated by an intact fat\\n plane. There is an adjacent right iliac fracture, not present on the prior\\n study.\\n\\n Osseous structures are diffusely demineralized. Multiple pelvic fractures are\\n noted as on the prior study. A new comminuted and impacted right iliac\\n fracture is present. Sclerosis of the SI joints is again seen. \\n rods have been placed since the prior exam. Marked degenerative changes are\\n again noted in the lumbar spine.\\n\\n IMPRESSION:\\n 1. Bilateral pleural effusions with left lower lobe collapse/consolidation.\\n 2. Ventral hernia.\\n 3. Dense vascular calcifications.\\n (Over)\\n\\n 8:36 AM\\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \\n Reason: r/o abcess\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 4. Multiple pelvic fractures. New right iliac fracture with associated right\\n gluteal collection and edema within the right gluteal subcutaneous fat. The\\n collection is multiloculated and demonstrates peripheral enhancement\\n consistent with a small infected collection. Myositis osifficans less likely,\\n but can not be excluded in the absence of non contrast evaluation.\\n 5. Right decubitus gluteal ulcer.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740277,\n \"text\": \" 5:40 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: e/f failure, cardiomegaly\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\\n REASON FOR THIS EXAMINATION:\\n e/f failure, cardiomegaly\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Dyspnea.\\n\\n PORTABLE CHEST: Comparison is made to . Paraspinal rods are noted\\n in the lower thoracic and upper lumbar spine. The cardiac silhouette is\\n largely obscured, limiting evaluation of heart size. There is upper zone\\n redistribution of the pulmonary vasculature, but no pulmonary edema. There\\n are small pleural effusions bilaterally, coinciding with chronic pleural\\n changes, predominantly on the right. There is atelectasis at the lung bases;\\n pneumonia cannot be excluded.\\n\\n IMPRESSION:\\n 1) Pulmonary vascular redistribution without overt edema.\\n 2) Bibasilar atelectasis and pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740372,\n \"text\": \" 9:55 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: shortness of breath\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\\n REASON FOR THIS EXAMINATION:\\n shortness of breath\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: SOB. Crackles. Hypoxia.\\n\\n COMPARISON: @ 16:55.\\n\\n PORTABLE UPRIGHT CHEST @ 10:08: Again seen are small bilateral pleural\\n effusions, right greater than left. There is associated bibasilar atelectasis\\n present. There is a more focal area of confluent opacity in the right mid lung\\n zone which could represent an area of pneumonia vs. atelectasis. Pulmonary\\n vascularity is indistinct, consistent with CHF. This is worsened since the\\n previous examination. Spinal fusion rods are noted.\\n\\n IMPRESSION: Worsening CHF. Small bilateral pleural effusions with bibasilar\\n atelectasis. Developing confluent opacity in the right mid lung zone which may\\n represent atelectasis vs. pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-05 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 740327,\n \"text\": \" 10:14 AM\\n CHEST (PA & LAT) Clip # \\n Reason: H/O GRAM POS. COCCI BACTERIUM W/ HX OF BL PL EFFUSION W/ INC O2 REQ. SOB, SOB, R/O INFILTRATE, SOB, NO EWNW S.S.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with gram positive cocci bacteremia\\n REASON FOR THIS EXAMINATION:\\n 85 y/o male with gram positive cocci bacteremia with hx of BLL pleural\\n effusions and increasing O2 requirement and SOB.\\n ______________________________________________________________________________\\n FINAL REPORT\\n COMPARISONS: Prior study from .\\n\\n HISTORY: Increasing oxygen requirement. Rule out dissection.\\n\\n FINDINGS: There is increased density at the right base suggesting the\\n accumulation of a right pleural effusion. There is a small left pleural\\n effusion. There is increased vascular congestion bilateral suggesting\\n increased pulmonary edema compared to the prior study.\\n\\n IMPRESSION: Cardiac failure compared to the prior study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-13 00:00:00.000\",\n \"description\": \"RP PLEURAL ASP BY RADIOLOGIST RIGHT PORT\",\n \"row_id\": 740741,\n \"text\": \" 3:45 PM\\n PLEURAL ASP BY RADIOLOGIST RIGHT PORT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \\n CHEST U.S.\\n Reason: localize effusion for thoracentesis\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with MSSA pneumonia, likely loculated\\n REASON FOR THIS EXAMINATION:\\n localize effusion for thoracentesis\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON: Loculated MSRA pneumonia on intubated patient. Diagnostic and\\n therapeutic tap requested.\\n\\n A limited ultrasound of the right hemithorax revealed a pleural effusion.\\n Risks and benefits of the procedure were discussed with the patient's\\n designated Power of Attorney, informed consent was obtained, and placed on\\n the patient's chart. The patient was draped in a sterile fashion. An 18\\n gauge catheter was placed in the right-sided pleural effusion under\\n direct ultrasound guidance. 750 cc of clear, yellowish fluid was aspirated.\\n Samples were provided to the house staff to send for laboratory analysis. The\\n patient tolerated the procedure well. Dr. was present for and performed\\n the procedure.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"L PLEURAL ASP BY RADIOLOGIST LEFT\",\n \"row_id\": 741305,\n \"text\": \" 1:06 PM\\n PLEURAL ASP BY RADIOLOGIST LEFT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \\n CHEST U.S. PORT\\n Reason: pt w/ large pleural effusions, needs therapeutic drainage\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with MSSA pneumonia, likely loculated; large pleural effusions,\\n requires dainage.\\n REASON FOR THIS EXAMINATION:\\n pt w/ large pleural effusions, needs therapeutic drainage\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Pneumonia. Large pleural effusion. Needs therapeutic drainage.\\n\\n PROCEDURE: After informed consent was obtained, the left back was prepped and\\n draped in the usual sterile fashion. 1% Lidocaine was administered as a local\\n anesthetic. Under ultrasound guidance, a large left pleural effusion was\\n localized and accessed using a 19 gauge needle. Approximately 900 cc of clear\\n fluid was aspirated. No immediate complications occurred.\\n\\n Dr. was in attendance during the procedure.\\n\\n IMPRESSION: Successful ultrasound-guided left thoracentesis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-13 00:00:00.000\",\n \"description\": \"CT LOC DRAINAGE\",\n \"row_id\": 740736,\n \"text\": \" 1:53 PM\\n CT LOC DRAINAGE; CT FINE NEEDLE ASP Clip # \\n CT RETROPERITONEAL DRAINAGE\\n Reason: ABCESS DRAINAGE\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT LOCALIZATION AND ASPIRATION OF FLUID COLLECTION:\\n\\n INDICATION: History of pelvic fracture with focal fluid collection. Evaluate\\n for drainage.\\n\\n COMPARISONS: CT of the abdomen and pelvis dated .\\n\\n CT LOCALIZATION: Axial helical images were obtained through the region of\\n interest to the patient in the lateral/semisupine position.\\n\\n CT GUIDANCE: Using CT guidance and CT fluoroscopy, an 18 gauge spinal needle\\n was advanced into the fluid collection in the region of the right buttock.\\n Approximately 3 cc of serosanguinous fluid was aspirated and sent for\\n cultures. The patient tolerated the procedure well without immediate\\n complications.\\n\\n CT OF THE PELVIS: Again seen are multiple pelvic fractures. Pagetoid changes\\n are seen in the bilateral ischium and sacrum. Calcifications are seen in the\\n right buttock muscle. There has been interval reduction in size of the soft\\n tissue mass in the right iliac fossa. The fluid collections in the right\\n buttock region have also decreased. Again seen is the large decubitus ulcer\\n in the right buttock region. This ulcer overlies the fracture and soft tissue\\n change. A CAPD catheter is incidentally noted.\\n\\n IMPRESSION: Interval reduction in size of the soft tissue mass in the right\\n iliac and fluid collections in the right buttock area. These changes are\\n consistent with a resolving hemoatoma vs improving myositis. Given the\\n proximity of the decubitus ulcer to the soft tissue changes, no bone biopsy\\n was attempted (risk of introducing infection to this region). Serosanguinous\\n fluid was aspirated from the buttock collection and sent for cultures.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740401,\n \"text\": \" 4:44 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: CENTRAL LINE PLACEMENT, POST FILM\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam,\\n hypoxia.\\n REASON FOR THIS EXAMINATION:\\n CENTRAL LINE PLACEMENT, POST FILM\\n ______________________________________________________________________________\\n FINAL REPORT\\n Single view of the chest is compared to a prior study performed earlier today.\\n\\n HISTORY: Acute shortness of breath.\\n\\n There is a new right IJ line in the appropriate position. The\\n cardiomediastinal contours are stable. There is persistent right basilar\\n pleural thickening which may be chronic, or a loculated pleural effusion.\\n There is prominence of the interstitium which probably relates to a chronic\\n process, although superimposed interstitial edema will have a similar\\n appearance. There is no pneumothorax. Bilateral posterior rods\\n are visualized. The bones are demineralized.\\n\\n IMPRESSION: There is prominence of the interstitium, probably related to\\n chronic process with a superimposed interstitial edema.\\n\\n Right basilar pleural thickening vs. loculated pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740349,\n \"text\": \" 4:24 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: SOB, increasing respiratory effort and hypoxemia on ABG, SOB\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with gram positive cocci bacteremia, bilat pulmonary edema\\n REASON FOR THIS EXAMINATION:\\n SOB, increasing respiratory effort and hypoxemia on ABG\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Bacteremia, pulmonary edema, SOB and increased respiratory\\n effort.\\n\\n COMPARISON: at 10:21.\\n\\n PORTABLE UPRIGHT CHEST AT 16:55: The pulmonary vascularity is\\n increased consistent with interstitial edema. There are bilateral pleural\\n effusions, right greater than left. There is evidence of bibasilar\\n atelectasis. The possibility of consolidation at the lung bases cannot be\\n excluded.\\n\\n IMPRESSION: Persistent, mild interstitial edema with bilateral pleural\\n effusions. Cannot exclude infectious process at the bases.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740626,\n \"text\": \" 3:06 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: post placement of OG tube\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n s/p intubation\\n REASON FOR THIS EXAMINATION:\\n post placement of OG tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: Orogastric tube placement.\\n\\n Single frontal supine radiograph of the chest dated is compared\\n to a prior study dated . There has been interval insertion of an\\n orogastric feeding tube which projects below the level of the diaphragm. The\\n film is very rotated, limiting evaluation of the lung parenchyma. Again noted\\n is a loculated pleural effusion on the right. There is also a moderate-sized\\n pleural effusion on the left. rods are noted overlying the spine.\\n\\n IMPRESSION:\\n\\n 1) Satisfactory placement of orogastric tube.\\n\\n 2) Continued bilateral pleural effusions with loculation on the right.\\n\\n 3) Repeat non-rotated film would be better suited for evaluation of the\\n pulmonary parenchyma.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-11 00:00:00.000\",\n \"description\": \"BP PELVIS WITH JUDET VIEWS BILAT PORT\",\n \"row_id\": 740616,\n \"text\": \" 1:28 PM\\n PELVIS WITH JUDET VIEWS BILAT PORT Clip # \\n Reason: new pelvic fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with pelvic fx\\n REASON FOR THIS EXAMINATION:\\n new pelvic fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: New pelvic fracture.\\n\\n COMPARISON: CT of .\\n\\n PELVIS WITH 2 OBLIQUE VIEWS: The distal end of spinal rods are\\n seen. The images are markedly suboptimal in evaluation of the pelvis. The\\n patient has Foley catheter. Multiple fractures seen on the prior CT of \\n are not adequately assessed on these films.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-03 00:00:00.000\",\n \"description\": \"PELVIS (AP ONLY)\",\n \"row_id\": 740278,\n \"text\": \" 5:42 PM\\n PELVIS (AP ONLY) Clip # \\n Reason: e/f fracture, dislocation\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\\n also with new right hip pain, pain on lateral extention of right leg\\n REASON FOR THIS EXAMINATION:\\n e/f fracture, dislocation\\n ______________________________________________________________________________\\n FINAL REPORT\\n PELVIS AP .\\n\\n INDICATION: Hip pain.\\n\\n FINDINGS:\\n\\n Evaluation of the pelvis is limited nonstandard patient\\n posiitoning. There is a history of old bilateral inferior pubic ramus\\n fractures, and SI joints fusion. There is lower lumbar spinal fusion with\\n rods posteriorly. No acute fracture is appreciated.\\n\\n IMPRESSION:\\n 1. Limited study.\\n 2. No evidence of hip fracture.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-03 00:00:00.000\",\n \"description\": \"CHEST CTA WITH CONTRAST\",\n \"row_id\": 740280,\n \"text\": \" 7:10 PM\\n CHEST CTA WITH CONTRAST Clip # \\n Reason: e/f PE, also evaluate old pneumonia in RLL scar vx persiste\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\\n also with new right hip pain, pain on lateral extention of right leg\\n REASON FOR THIS EXAMINATION:\\n e/f PE, also evaluate old pneumonia in RLL scar vx persistent pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST.\\n\\n INDICATION: 85 year old man with shortness of breath.\\n\\n TECHNIQUE: Contiguous helical imaging was obtained from the lung bases to the\\n lung apices utilizing the CTA protocol for pulmonary embolus.\\n\\n CONTRAST: 150 cc of Optiray contrast used secondary to history of rapid rate\\n of injection.\\n\\n CT SCAN OF THE CHEST WITH CONTRAST: There is no significant axillary,\\n mediastinal or hilar lymphadenopathy. The contrast bolus was optimally timed\\n for evaluation of the pulmonary arteries. No intraluminal filling defect is\\n seen to suggest pulmonary embolus.\\n\\n The lung windows demonstrate bilateral large layering pleural effusions. There\\n is also associated collapse/consolidation of the right lower lobe, as well as\\n some partial collapse of the left lower lobe. Also noted is diffuse moderate\\n centrilobular emphysema.\\n\\n BONE ELEMENTS: Multiple right-sided rib fractures are seen. rods\\n are seen within the posterior elements. The patient is severely kyphotic.\\n\\n IMPRESSION:\\n\\n 1) No pulmonary embolus.\\n\\n 2) Bilateral large pleural effusions with consolidation/collapse of the right\\n lower lobe and partial collapse/consolidation of the left lower lobe.\\n\\n 3) Moderate diffuse centrilobular emphysema.\\n\\n 4) Multiple old healed right-sided rib fractures. Severe kyphosis with\\n rods seen in the posterior elements.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-22 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 741235,\n \"text\": \" 3:48 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: COPIOUS SECRETIONS, S/P PPNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with COPD, s/p pneumonia, still with thick copious secretions.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate pleural effusions, infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: COPD, copious secretions.\\n\\n TECHNIQUE: Helically-acquired axial images were obtained from the thoracic\\n inlet through the lung bases without the administration of IV contrast.\\n Contrast was not given due to inability to obtain IV access.\\n\\n CHEST CT WITHOUT CONTRAST: No significantly enlarged lymph nodes are seen\\n within the mediastinum or axilla. It is difficult to assess for hilar\\n adenopathy due to large bilateral pleural effusions and adjacent atelectasis.\\n The size of the pleural effusions has increased since the previous exam of\\n . There does appear to be a small loculated component on the right\\n superolaterally.\\n\\n There is bibasilar passive atelectasis associated with the effusions. The\\n aerated portions of the lungs are clear. Although the right main stem\\n bronchus and bronchus to the right upper and middle lobes are narrowed, they\\n are patent. It is difficult to assess the bronchi going to the lower lobes\\n bilaterally due to the large pleural effusions and atelectasis.\\n\\n There is a PICC present in the distal SVC. There is an NG tube within the\\n stomach. Limited images of the upper abdomen reveal a possible small low-\\n attenuation lesion in the dome of the liver which cannot be characterized\\n further. It is unchanged. The upper poles of the kidneys, imaged portions of\\n the pancreatic tail and spleen are unremarkable.\\n\\n Several right-sided healed rib fractures are again noted. Fusion rods are\\n seen along the posterior aspect of the thoracic spine.\\n\\n IMPRESSION:\\n\\n 1) Large bilateral pleural effusions with associated passive atelectasis.\\n There is a loculated component on the right superolaterally. It is difficult\\n to know if the pleural fluid is potentially infected without IV contrast. The\\n effusions have increased since the previous exam from .\\n\\n 2) The aerated portions of the upper lobes appear clear.\\n\\n 3) Healed right-sided rib fractures are again noted.\\n\\n (Over)\\n\\n 3:48 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: COPIOUS SECRETIONS, S/P PPNEUMONIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740967,\n \"text\": \" 4:11 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p NGT placement; also eval for pna.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n MSSA bacteremia, s/p thoracentesis, newly dc'd from vent, with new NGT\\n placement; please comment on change in pna, as well as NGT placement.\\n REASON FOR THIS EXAMINATION:\\n s/p NGT placement; also eval for pna.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INDICATION: MSSA bacteremia, check NG tube placement and follow up\\n pneumonia.\\n\\n Single AP supine chest radiograph dated is compared with prior chest\\n radiograph dated .\\n\\n There is interval removal of the ET tube. The NG tube terminates in the\\n stomach. Again a mild left convex scoliosis is demonstrated with \\n rod in place.\\n\\n Extensive air space opacities are present bilaterally, of no significant\\n interval change since the prior study. There is also no significant interval\\n change of the previousl reported bilateral pleural effusions.\\n\\n IMPRESSION: NG tube terminates in the stomach. No significant interval\\n change of the parenchymal opacities and pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740826,\n \"text\": \" 8:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess infiltrates\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n MSSA bacteremia, s/p thoracentesis, weaning from vent\\n REASON FOR THIS EXAMINATION:\\n assess infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Assess infiltrates. MRSA bactermia, status post thoracentesis,\\n weaning from ventilator.\\n\\n SINGLE AP PORTABLE VIEW OF THE CHEST: There is marked patient rotation, which\\n alters cardiomediastinal borders. Allowing for this, the ET tube is present,\\n tip 4.8 cm above the carina. AN NG tube is present, coiled in the stomach,\\n with tip overlying the fundus. A right IJ central line is present, tip over\\n proximal/mid SVC. There appear to be right sided rib fractures. There are\\n layering left greater than right effusions with underlying collapse and/or\\n consolidation. We cannot exclude underlying CHF. The patient's spinal rods\\n are noted. Marked narrowing of the right shoulder acromiohumeral distance is\\n compatible with a chronic rotator cuff tear.\\n\\n IMPRESSION: Bilateral layering left greater than right effusions with\\n underlying collapse and/or consolidation overlying appearances, allowing for\\n marked differences in position, are similar to those of one day earlier. There\\n may have been some interval improvement in the left upper zone. Right sided\\n rib fractures and associated pleural thickening/hematoma noted.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 741046,\n \"text\": \" 7:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess interval change in b/l airspace dz and pleural effusi\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n MSSA bacteremia, s/p thoracentesis, please\\n comment on change in pna, pleural effusions.\\n REASON FOR THIS EXAMINATION:\\n Assess interval change in b/l airspace dz and pleural effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post thoracentesis.\\n\\n CHEST, SINGLE VIEW\\n\\n There are spinal rods seen to project over the lower thoracic upper lumbar\\n region. There is a central venous catheter which enters from right IJ\\n approach but tip is not visualized past the SVC/RA junction. There is a right\\n IJ line also in place with tip not seen below the middle SVC. There are\\n persistent bilateral effusions but have decreased in size since the prior\\n study. The right effusion is much larger than the left.\\n\\n IMPRESSION:\\n 1. PICC line in probable SVC/RA junction. Right IJ line with tip not clearly\\n demonstrated due to overlying rods but seen as far as the middle SVC. No\\n pneumothorax is seen. Findings communicated to IV team.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 741217,\n \"text\": \" 6:26 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for effusions and/or infiltrates\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n MSSA bacteremia, still with copious secretions and oxygen requirements.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for effusions and/or infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: New fever and shortness of breath.\\n\\n FINDINGS: A single AP view of the chest compared to prior exams dated \\n and demonstrates an interval increase in the size of the left pleural\\n effusion since the exam. The size of the effusion appears comparable\\n to the examination. In addition, abnormal ill-defined opacity in the\\n right upper lobe appears increased since the exam. The left lung\\n remains unchanged.\\n\\n IMPRESSION:\\n\\n 1. Interval increase in left pleural effusion since .\\n\\n 2. Bibasilar atelectasis/consolidation persists.\\n\\n 3. Right upper lobe opacity increased since the and suggests evolved\\n right upper lobe pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-13 00:00:00.000\",\n \"description\": \"CT PELVIS ORTHO W/O C\",\n \"row_id\": 740730,\n \"text\": \" 12:57 PM\\n CT PELVIS ORTHO W/O C; CT,CORONAL,SAGITAL,OBL RECONSTRUCTION Clip # \\n Reason: better characterize pelvis in patient with multiple pelvic f\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with MSSA bacteremia, respiratory failure, multiple pelvic\\n fractures. On vent.\\n REASON FOR THIS EXAMINATION:\\n better characterize pelvis in patient with multiple pelvic fractures\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: fractures. For further evaluation.\\n\\n FINDINGS: Comparison CT scan and CT abdomen .\\n\\n In addition to the previously described pubic ramus and left sacral fractures\\n seen on as reported on the abdominal CT there is a comminuted fracture\\n of the right iliac involving the anterior portions of the ilium as well\\n as the broad posterior and lateral portions of the iliac . In addition to\\n the iliac fracture these thin cuts demonstrate an essentially undisplaced\\n fracture through the anterior lip of the sacrum on the right.\\n\\n The iliac fracture while comminuted is not significantly displaced with only a\\n few mm displacement of small fracture fragments from the main ilium.\\n\\n Note made that the enhancing collection seen on CT has been drained.\\n Minimal linear hyperdensity in the soft tissues of the right gluteal region\\n could represent residual contrast or possibly some soft tissue calcifications.\\n\\n IMPRESSION:\\n 1. comminuted fracture right ilium and undisplaced fracture anterior lip of\\n right sacrum in addition to previously described fractures.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-26 00:00:00.000\",\n \"description\": \"PERC PLCMT GASTROMY TUBE\",\n \"row_id\": 741429,\n \"text\": \" 12:25 PM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: FEEDING TUBE\\n Contrast: OPTIRAY Amt: 60\\n ********************************* CPT Codes ********************************\\n * PERC PLCMT GASTROMY TUBE PLCT GJ TUBE *\\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT ENTROCLYSIS TUBE *\\n * PERC PLCMT GASTROSOTMY TUBE NON-IONIC 50 CC *\\n ****************************************************************************\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post respiratory compromise requiring intubation from\\n sepsis and pneumonia. Patient is an aspiration risk and failed swallowing\\n study.\\n\\n RADIOLOGISTS: Dr. , supervising staff radiologist Dr. .\\n\\n TECHNIQUE: Patient was explained risks and benefits of procedure. Informed\\n consent was obtained. An NG tube had been placed on low intermittent suction\\n on night prior to the study. 1% Lidocaine was administered locally after air\\n was insufflated into the stomach and appropriate location for puncture\\n determined utilizing fluoroscopy. A T fastener needle system was introduced\\n into the lumen in the body of the stomach under fluoroscopic guidance. The two\\n T fasteners were deployed and the anterior wall of the stomach was tacked to\\n the anterior abdominal wall. Subsequently a small incision was made into the\\n skin between T fasteners securing anchors and the T fastener single wall\\n needle was advanced into the lumen in the direction of the pylorus. Contrast\\n was administered which documented intragastric location of the needle.\\n Subsequently a .035 wire was introduced into the lumen of the stomach\\n and was coiled. The single wall needle was removed and replaced with a 7 FR\\n bright tipped long sheath which was positioned just proximal to the pylorus. A\\n .035 glide wire was advanced in through the sheath. An attempt was made to\\n cannulate the pylorus which was unsuccessful. Subsequently a 4 FR hockey stick\\n catheter was advanced over the wire and utilizing the catheter and glide wire\\n the catheter and glide wire were able to be positioned in a post pyloric\\n location. The glide wire was exchanged for a .035 amplatz wire which was able\\n to positioned past the ligament of Treitz into the proximal jejunum. The\\n catheter was removed. Multiple dilatation were performed utilizing a 10 FR and\\n 12 FR dilator, followed by placement of an 18 FR peal-away sheath. The MIC G-\\n J tube was lubricated and an attempt was made to pass the tube over the\\n amplatz wire. This was difficult secondary to dryness of the wire.\\n Consequently the hockey stick catheter was readvanced over the amplatz wire\\n and the amplatz wire was exchanged for a .035 stiff glide wire and was\\n positioned within the proximal jejunum. The catheter was removed and the MIC\\n G-J tube was advanced over the wire and positioned with tip in proximal\\n jejunum. Initially 7 cc contrast was administered into the balloon which was\\n documented on fluoroscopy to be present within the stomach. The contrast\\n solution was replaced with saline. Contrast was administered through the\\n gastric and jejunal ports and a post procedure radiograph was performed.\\n\\n FINDINGS: The G-J tip is located in proximal jejunum. The balloon is located\\n within the stomach. Contrast is seen in the stomach as well as jejunum after\\n administration.\\n (Over)\\n\\n 12:25 PM\\n PERC G/G-J TUBE PLMT Clip # \\n Reason: FEEDING TUBE\\n Contrast: OPTIRAY Amt: 60\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n MEDICATIONS/CONTRAST: 1% Lidocaine was administered locally. 50 cc optiray\\n administered. Optiray was selected secondary to patient's debilitated state.\\n\\n COMPLICATIONS: No immediate complications.\\n\\n IMPRESSION: Status post placement of MIC G-J tube. It should be noted the\\n outer disc is at marker #4. This was dressed and a flexitract system was\\n applied to the external tube.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 741327,\n \"text\": \" 5:43 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Pt is now s/p therapeutic thoracentesis - please check for p\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n MSSA bacteremia, still with copious secretions and oxygen requirements - now\\n s/p thoracentesis with removal of approx 900cc pleural fluid.\\n REASON FOR THIS EXAMINATION:\\n Pt is now s/p therapeutic thoracentesis - please check for pneumothorax s/p\\n procedure.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Thoracentesis.\\n\\n TECHNIQUE: Single view chest.\\n\\n Comparison is made with . There is limitation of evaluation of the\\n examination due to overlying structures and low lung volumes. There is\\n persistent bilateral pleural effusions. No pneumothorax is identified in\\n either hemithorax.\\n\\n The NG tube is seen to course into the stomach but the tip is not included in\\n the radiograph. There are bilateral patchy consolidations which are difficult\\n to evaluate and compared from the prior study.\\n\\n IMPRESSION: Bilateral pleural effusions. No pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-09-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 740768,\n \"text\": \" 8:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for line position, pneumothorax\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n s/p thoracentesis\\n REASON FOR THIS EXAMINATION:\\n eval for line position, pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Thoracentesis and line placement.\\n\\n CV line is in mid to distal SVC, probably obscured by spinal rod.\\n Endotracheal tube is 3 cm above carina. NG tube extends below diaphragm. No\\n pneumothorax. There are bilateral pleural effusions with possible loculation\\n on the right.\\n\\n\"\n }\n]"}}},{"rowIdx":786,"cells":{"subject_id":{"kind":"number","value":18054,"string":"18,054"},"hadm_id":{"kind":"number","value":138511,"string":"138,511"},"target_text":{"kind":"string","value":"Due to the clinical findings the patient was admitted to the hospital and shortly after admission the patient had tongs applied with weights for extension of the neck and the patient tolerated the procedure and placement of the Well tongs quite well and he was seen in consultation by the Medicine Service and was admitted to the Neurosurgical Intensive Care Unit for stabilization and monitoring. He was subsequently taken to the Operating Room on the morning of the where under general endotracheal anesthetic the patient underwent a C7-T1 posterior wiring of the spinous process with good results and good positioning of the C7-T1 subluxation. The patient tolerated the procedure well. He returned to the Neurosurgical Intensive Care Unit for recovery in stable condition. However, the patient failed to awaken from anesthesia and was found to have no evidence of eye opening to noxious stimuli. The pupils were 6 mm and unreactive bilaterally. There was trace corneals bilaterally, but no movement of the arms or legs. The blood pressure was 200/70 and the patient emergently was taken for a CT scan to rule out intracranial hemorrhage or massive cerebrovascular accident or a pontine angle hemorrhage. The cranial CT demonstrated some blood in the bilateral occipital horns and a small amount of convexity traumatic subarachnoid hemorrhage. There was only mild ventriculomegaly and there was no mass effect or shift. However, due to the findings the patient was returned to the Neurosurgical Intensive Care Unit and after attempts to reach the patient's family were unsuccessful, the patient had a ventriculostomy drain placed and he tolerated this procedure well. His ventricular drain and intracerebral pressures remained in normal physiologic ranges and on the morning following surgery the patient began to awaken, he was easily arousable and began to show evidence of moving all extremities spontaneously. He was mouthing words over his endotracheal tube and following simple commands. Due to the improvement in his clinical condition, the ventricular drain was removed and the patient spent the next several days in the Neurosurgical Intensive Care Unit with stabilization of his mental status and he remained hemodynamically stable. The patient was subsequently transferred to the hospital floor where he began a rigorous course of physiotherapy and occupational therapy. He was seen in consultation by the Medicine and Hematology/Oncology Service for a persistent elevated white blood cell count and shortly prior to discharge the patient had a febrile episode and was found on cultures to have a positive sputum culture and was placed on Vancomycin and Levaquin. The patient was subsequently discharged to a rehab center with a PICC line in place for continuation of the Vancomycin antibiotic treatment for his positive culture and he was discharged to rehab on the with follow up to see Dr. in the clinic in approximately two weeks time."},"extractive_notes_summ":{"kind":"string","value":"NIPRIDE GTT D/C'D. Nipride gtt titrated to effect. BOLT D/C'D & EXTUBATED . SEROSANGUINOUS DRAINAGE. There is interval appearance of a small pleural effusion and a new retrocardiac density which may represent atelectasis although consolidation in this region cannot be excluded. ; C-SPINE (PORTABLE) IN O.R. The tract of the previous intraventricular drain is identified. CT of head done this AM. Compared to the previoustracing of sinus bradycardia has replaced atrial fibrillation andrepolarization abnormalities are now present. IMPRESSION: 1) Persistent bilateral pleural effusions. AMIODARONE FOR HX OF AFIB. Left bundle-branch block typeintraventricular conduction delay. LS clear with some upper airway congestion. FINDINGS: Duplex evaluation was performed of the right upper extremity venous system. Hypertensive when stimulated. SINUS BRADY BASELINE. Degenerative changes are seen in the spine and postoperative changes are noted in the cervicothoracic region. Stable intraventricular hemorrhage. clondine patch started. Intracranial and intraventricular gas, possibly related to recent intervention. There remains small bilateral pleural effusions. There is a superoanterior fragment from the T1 vertebral body which maintains anterior alignment with the anterior spinal margin, while the large posterior component of the body is retropulsed. Sinus bradycardia. poor appitite/tol clears. There is a nondisplaced fracture through the right posterolateral aspect of the C7 vertebral body. Stable pneumoencephaly. AFEBRILE. HEMOVAC DRAIN IN POSTERIOR NECK. FINAL REPORT CT C SPINE WITH RECONSTRUCTIONS . ABX PROX FOR DRAINS. DRAING PATENT AND DRAINING. IMPRESSION: Small bilateral pleural effusions and possible faint right lower lobe infiltrates. Subarachnoid hemorrhage. Small bilateral subdural hematomas. FINAL REPORT PA & LATERAL CHEST: HISTORY: Pleural effusions, follow up abnormal chest. Coronal and sagittal reformations were created. VITAL SIGNS PER FLOW SHEET. Visualized paranasal sinuses demonstrate mucosal thickening in bilateral maxillary sinuses and a retention cyst of right maxillary sinus. left hip drsg - hemovac dc from hip. There are bilateral pleural effusions and there is an infiltrate in the right lower lobe posteriorly. Please evaluate for hydrocephalus. CHEST, SINGLE VIEW: Comparison study dated . TECHNIQUE: Axial C spine CT was performed. TX WITH DROPERIDOL. BP STILL LABILE AND NIPRIDE BEING TITRATED. The width of the spinal canal is preserved by the retropulsion of the posterior elements of C7. 3 LPM NC. TECHNIQUE: Standard multiplanar T1 and T2 weighted imaging sequences were performed. Aline mildly positional. UO=QS. Status post cervical fusion. Nursing noteAlert/oriented x3. FX SPINE. drain out this AM. 11:19 AM CHEST (PA & LAT) Clip # Reason: Follow-up bilateral opacities. Left subclavian vein line with tip in mid SVC. Had c-spine fi FINAL REPORT (Cont) canal is wide. pt weaned to cpap+ps secondary to dyssynchrony w/vent. CT recommended. Again seen is an area of opacification in the right retrocardiac region. IMPRESSION: 1) Limited examination excluding the extreme right costophrenic angle. There remains bilateral small pleural effusions. There is interval clearing of the left retrocardiac region. of retrocardiac opacity. DRG. There is still gross anterolisthesis of C7 on T1. There is still gross anterolisthesis of C7 on T1. Bridging anterior osteophytes are again seen, unchanged. IMPRESSION: C7-T1 subluxation/fracture. COMINO BOLT PLACED PR MD. IMPRESSION: Stable appearance of C7-T1 spinal fusion and grade III anterolisthesis of C7 on T1. NPO x meds with sip. 2) Bilateral small pleural effusions. The spinous process of C7 appears posteriorly positioned. Paresthesias in hand. sxn tk tan. Abd soft with + BS. PORTABLE AP CHEST is compared with CXR of . lytes repleted prn. bolt in place/intact, ICP 5-11. The ET tube has been removed. 3) Widening of the left sternoclavicular joint of uncertain chronicity. FINDINGS: A preprocedural left upper extremity ultrasound shows a widely patent and compressible left basilic vein. The left subclavian central venous catheter has been removed. NSG PROGRESS NOTERETURNED FROM OR INTUBATED AND NONRESPONSIVE. Nursing notePt alert/oriented x3. AP AND TWO LATERAL VIEWS OF THE CERVICAL SPINE AND LATERAL THORACIC SPINE: There are bridging anterior osteophytes suggesting early DISH. Monitor traction, VS, neuro status. There is angulation of the spinal canal secondary to the displacement of C7 over T1. IMPRESSION: Interval spinal fusion C7-T1 area which is not adequately assessed in this series of radiographs. Pt states slight numbness/tingling of bil forearms conts. Subsequent CT scan was obtained. plan: cont w/mech support. IMPRESSION: 1) Persistent right retrocardiac density with interval improvement of the left retrocardiac density. IMPRESSION: Bilateral lower lobe collapse/consolidation. The left sternoclavicular joint is widened, of uncertain chronicity. There are bilateral basilar opacities, consistent with consolidation/collapse. There is calcification of the anterior longitudinal ligament. Neuro signs WNL. BUN/CR=45/1.9. At the C4-5 level there is mild canal and neural foraminal narrowing secondary to degenerative change. HCT 29. STARTED VENODYNES. FINDINGS: Two views of the chest worsen to . UO=QS. IMPRESSION: Probable fracture/dislocation at poorly assessed C7/T1 level. Gradient echo axial images were obtained from the C3 through the T1 levels. Afebrile. AFEBRILE. The mediastinal and hilar contours are normal. 8:32 AM PICC LINE PLACMENT SCH Clip # Reason: S/P cervical instrumentation.Needs vancomycin. There is osteopenia throughout the thoracic spine. Outside cervical spine radiographs inadequately assess C7-T1. A post procedural radiograph shows the tip of the PICC within the lower SVC. The tip is in the lower SVC. LATERAL XRAY. resp carept remains intubated and mech ventilated. The seven cervical vertebral bodies are normally aligned but there is a poorly visualized apparent fracture of T1 with grade spondylolisthesis of C7 body anteriorly on T1 body."},"n_notes":{"kind":"number","value":33,"string":"33"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2147-11-27 00:00:00.000","description":"Report","row_id":1499671,"text":"NURSING TRANSFER NOTE\nupdate transfer note - cont requiring nipride for bp control overnight. Increase pressure related to pain. mso4 pca started - pca currently at basal rate 0.5/hr and demand dose 1 mg q6min with 10mg/1 hr lockout. increase anxiety with activity. with anxiety rr inc to 30's w/o desaturation. sbp up to 190's. clondine patch started. somi on. hemovac x1 from neck incision. left hip drsg - hemovac dc from hip. poor appitite/tol clears. hydalazine po increase to 50 mg q6.\n"},{"category":"Nursing/other","chartdate":"2147-11-25 00:00:00.000","description":"Report","row_id":1499666,"text":"Nursing note\nAlert/oriented x3. Anxious at times. drain out this AM. Sutures intact to scalp. No drainage. CT of head done this AM. Aspen collar on and tol well. MAE freely. move/position for comfort. Denies headache. LS clear with some upper airway congestion. Extubated without incident. Sats 96-98 with humidified O2 by mask. Cough/gag intact. Abd soft, nontender. No bowel sounds heard yet. Sips of clear liqs tol in PM. Able to swallow PO meds. Hypertensive when stimulated. Nipride gtt titrated to effect. Hydralazine started. Foley patent, draining QS yellow urine with sediment. Dsgs to c spine and L iliac crest intact with sm amt s/s drainage noted. Aline mildly positional. B/P correlated with cuff. Left TLC patent. Site benign. Family anxious. Cont to monitor B/P and titrate Nipride gtt to maintain B/P below 150. Monitor and treat pain.\n"},{"category":"Nursing/other","chartdate":"2147-11-26 00:00:00.000","description":"Report","row_id":1499667,"text":"pain\nD: PT C/O OF PAIN IN SHOULDERS AND ACROSS BACK. PT ABLE TO MOVE ALL EXTREMITIES AND FOLLOW COMMANDS. HE IS HAVING OCCASIONAL EPISODES OF CONFUSION, WANTING TO MOVE HIS CAR WHICH IS PARKED IN THE STREET AND FIX THE TILE ON THE CEILING. HE IS EASILY REORIENTED AND REALIZES HE IS CONFUSED. NIPRIDE TITRATED FOR BP CONTROL.\nA: MORPHINE FOR PAIN WITH GOOD RELIEF. HYDRALIZINE INCREASED TO 30MG Q6. NIPRIDE TITRATED FOR BP\nR: DOING WELL POST FUSION. MORPHINE EFFECTIVE IN CONTROLLING PAIN.\n"},{"category":"Nursing/other","chartdate":"2147-11-26 00:00:00.000","description":"Report","row_id":1499668,"text":"FOCUS: CONDITION UPDATE\nD: PATIENT'S CONDITION CONTINUES TO IMPROVE. ALERT AND ORIENTED, GOOD STREGNTH IN ALL EXTREMITIES. ASPEN COLLAR REMAINS ON. COMPLAINING OF SHOULDER PAIN, MEDICATED TWICE WITH GOOD RELIEF. BEGINNING TO ADVANCE DIET--TOLERATING WELL. UNABLE TO WEAN SNP--BLOOD PRESSURE RISES WITH ANY INTERRUPTION IN NIRPIDE INFUSION. FAMILY IN/OUT MOST OF THE DAY. VITAL SIGNS PER FLOW SHEET. DRAING PATENT AND DRAINING. AWAITING PT CONSULT AND PLACEMENT OF SOMI BRACE TOMORROW.\n"},{"category":"Nursing/other","chartdate":"2147-11-27 00:00:00.000","description":"Report","row_id":1499669,"text":"PAIN\nD: PT IS ALERT AND ORIENTED. NORMAL STRENGTH IN ALL EXTREMITIES. PT COMPLAINING OF PAIN BETWEEN SHOULDER BLADES. SBP STILL LABILE AND NIPRIDE TITRATED FOR BP. COUGHING AND RAISING THICK YELLOW SPUTUM.\nA: CONTINUE TO MEDICATE WITH MORPHINE FOR PAIN. CONTINUE TO ENCOURAGE AGGRESSIVE PULMONARY TOLIET. HYDRALAZINE INCREASED TO 40 MG\nR: MORPHINE EFFECTIVE IN CONTROLLING PAIN. PT APPEARS COMFORTABLE ON 4L NC. BP STILL LABILE AND NIPRIDE BEING TITRATED. PT WITH GOOD RESPONSE TO HYDRALAZINE BUT SHORT LIVED.\n"},{"category":"Nursing/other","chartdate":"2147-11-27 00:00:00.000","description":"Report","row_id":1499670,"text":"NURSING TRANSFER NOTE\nADMITTED S/P FALL FROM LADDER. FX SPINE. C7 TO T1 FUSION LAMINECTOMY. UNRESPONSIVE ON RETURN FROM OR. BOLT IN TO MEASURE ICP. BOLT D/C'D & EXTUBATED . NOW A&O. MOVES ALL EXTREMITIES. ASPEN COLLAR. SCHEDULED FOR TODAY. SINUS BRADY BASELINE. NIPRIDE GTT D/C'D. CONTROLLING SBP < 150 WITH HYDRALAZINE, LOPRESSOR, NITROPASTE. AFEBRILE. 3 LPM NC. UPPERAIRWAY CONGESTION. WEAK COUGH. INCENTIVE SPIROMETER. MRI OF HEAD DONE TODAY. TRIED PERCOCET FOR PAIN. NAUSEA. TX WITH DROPERIDOL. PRN ORDER CHANGED TO #3. NOT TRIED YET. ALSO MORPHINE IVP GIVEN FOR PAIN POST MRI. REGULAR DIET. EATING SMALL AMOUNTS. HEMOVAC DRAIN IN POSTERIOR NECK. SEROSANGUINOUS DRAINAGE. FOLEY. UO=QS. NO BM. ABX PROX FOR DRAINS. AMIODARONE FOR HX OF AFIB.\n"},{"category":"ECG","chartdate":"2147-11-23 00:00:00.000","description":"Report","row_id":119510,"text":"Sinus bradycardia. Left axis deviation. Left bundle-branch block type\nintraventricular conduction delay. Prominent U waves. Compared to the previous\ntracing of sinus bradycardia has replaced atrial fibrillation and\nrepolarization abnormalities are now present. These may be due to electrolyte\nabnormalities or medication effect.\n\n"},{"category":"Radiology","chartdate":"2147-11-30 00:00:00.000","description":"VENOUS DUP EXT UNI (MAP/DVT)","row_id":748384,"text":" 2:57 PM\n VENOUS DUP EXT UNI (MAP/DVT) Clip # \n Reason: 75 year old male with erythema and tenderness to the right u\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n 75 year old male with erythema and tenderness to the right upper extremity with\n also a high wbc count of 18 please assess for upper extremity DVT\n ______________________________________________________________________________\n FINAL REPORT\n REASON:\n Patient with pain and swelling right upper extremity.\n\n FINDINGS:\n Duplex evaluation was performed of the right upper extremity venous system.\n Due to the brace on her neck and shoulders her jugular vein cannot be scanned.\n\n The right subclavian, axillary, brachial, basilic, radial and ulnar veins are\n all patent without evidence of thrombus or obstruction. There is normal\n compression at those levels. Cephalic vein was not visualized.\n\n IMPRESSION:\n No evidence of right upper extremity DVT. As noted study was somewhat\n difficult due to the brace on the neck and shoulders.\n\n"},{"category":"Radiology","chartdate":"2147-11-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":747974,"text":" 2:55 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: NOT WAKING AFTER SURGERY S/P CERVICAL FUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n s/p cervical fusion\n ______________________________________________________________________________\n FINAL REPORT\n TECHNIQUE: Contiguous axial images were obtained from the foramen Magnum to\n the cranial vertex.\n\n HISTORY: Post op. Status post cervical fusion. Unable to walk.\n\n CT HEAD W/O CONTRAST: There is a large amount of intraventricular hemorrhage\n seen layering within the atria of the lateral ventricles. Additionally there\n is diffuse subarachnoid hemorrhage most prominent over the left parietal\n convexity. There are no definite attenuation abnormalities of the parenchyma.\n\n There is no fracture. Visualized paranasal sinuses demonstrate mucosal\n thickening in bilateral maxillary sinuses and a retention cyst of right\n maxillary sinus.\n\n IMPRESSION: Intraventricular and subarachnoid hemorrhage without\n hydrocephalus. No major vascular territorial infarction is noted. Follow up is\n recommended.\n\n"},{"category":"Radiology","chartdate":"2147-11-25 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":748016,"text":" 8:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with see above\n REASON FOR THIS EXAMINATION:\n please perform a head CT s/p cervical fracture stabilization surgery w/ neuro\n changes and depressed mental status postop. Please evaluate for hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75 year old male with mental status changes, intracranial hemorrhage\n for follow up.\n\n Comparison to prior study from .\n\n TECHNIQUE: Axial noncontrast imaging was performed from the skull base to\n vertex.\n\n FINDINGS: Again seen is high density material layering posteriorly within both\n lateral ventricles consistent with hemorrhage and not significantly changed\n from prior study. Diffuse subarachnoid blood is also identified most prominent\n over the convexities. There is no mass effect. Gas is identified anterior to\n the right frontal lobe and anteriorly within the left lateral ventricle.\n Craniotomy defect is noted in the right frontal bone there is no\n hydrocephalus. Again noted is opacification of multiple ethmoid air cells and\n fluid within the maxillary sinuses.\n\n IMPRESSION:\n\n 1. Intraventricular and subarachnoid hemorrhage, not significantly changed\n from the prior study.\n\n 2. Intracranial and intraventricular gas, possibly related to recent\n intervention. Suggest clinical correlation.\n\n 3. No hydrocephalus.\n\n"},{"category":"Radiology","chartdate":"2147-12-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":748550,"text":" 11:19 AM\n CHEST (PA & LAT) Clip # \n Reason: Follow-up bilateral opacities.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\n REASON FOR THIS EXAMINATION:\n Follow-up bilateral opacities.\n ______________________________________________________________________________\n FINAL REPORT\n PA & LATERAL CHEST:\n\n HISTORY: Pleural effusions, follow up abnormal chest.\n\n The inferolateral aspect of the right lung is not included on the examination.\n The heart is normal in size. There are bilateral pleural effusions and there\n is an infiltrate in the right lower lobe posteriorly. There are no other\n significant findings.\n\n IMPRESSION: Small bilateral pleural effusions and possible faint right lower\n lobe infiltrates.\n\n"},{"category":"Radiology","chartdate":"2147-11-22 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":747812,"text":" 6:34 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: 75 y/o male s/p fall from tree earlier today. Had c-spine fi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with as abive\n REASON FOR THIS EXAMINATION:\n 75 y/o male s/p fall from tree earlier today. Had c-spine films with\n ?involvement of T1. several X rays taken but without definitive results. Please\n evaluate.\n ______________________________________________________________________________\n FINAL REPORT\n CT C SPINE WITH RECONSTRUCTIONS .\n\n INDICATION: Trauma, neck pain and paresthesias.\n\n TECHNIQUE: Axial C spine CT was performed. Coronal and sagittal reformations\n were created.\n\n CT C SPINE: At the C7 level, there is a complete transverse fracture through\n the laminae bilaterally, with approximately 1.6 cm posterior displacement of\n the posterior elements. There is a nondisplaced fracture through the right\n posterolateral aspect of the C7 vertebral body. A small chip fracture is\n retropulsed approximately 4 mm into the central canal.\n\n There is a grade 3 anterolisthesis of C7 on T1. There are bilateral C7 pars\n interarticularis fractures, with diasthesis of the C7-T1 facet articulations.\n The width of the spinal canal is preserved by the retropulsion of the\n posterior elements of C7.\n\n At T1, there is a severe anterior wedge compression fracture. There is a\n superoanterior fragment from the T1 vertebral body which maintains anterior\n alignment with the anterior spinal margin, while the large posterior component\n of the body is retropulsed.\n\n There is also a superoanterior endplate fracture of T2. The remainder of this\n vertebra is not completely imaged.\n\n There is degenerative change at multiple levels. Specifically, there is\n anterior osteophyte formation at C2-3 and to a lesser extent C3-4, C4-5 and\n C5-6. There is narrowing of the intervertebral disc spaces at all levels,\n degenerative in appearance.\n\n There is also a small fracture of the posterior limb of the right foramen\n transversarium at C5.\n\n There is degenerative narrowing of the right C5-6 neural foramen secondary to\n uncovertebral degeneration.\n\n\n IMPRESSION: Fracture dislocation of the C7-T1 interspace with T1 anterior\n wedge compression fracture and posterior elements fracture at C7. There is\n likely to be cord injury, secondary to the dislocation, though the spinal\n (Over)\n\n 6:34 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: 75 y/o male s/p fall from tree earlier today. Had c-spine fi\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n canal is wide. These findings were communicated emergently to Dr. \n , at the time of the exam.\n\n\n"},{"category":"Radiology","chartdate":"2147-11-23 00:00:00.000","description":"C-SPINE (PORTABLE)","row_id":747858,"text":" 10:02 AM\n C-SPINE (PORTABLE) Clip # \n Reason: C7-T1 spinal fracture with sublux, now in traction, please e\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with as above\n REASON FOR THIS EXAMINATION:\n C7-T1 spinal fracture with sublux, now in traction, please eval for\n alignment/reduction of subluxation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fracture of C7 and T1 with anterolisthesis of C7 on the cervical\n spine CT of .\n\n CERVICAL SPINE 2 VIEWS: 2 lateral views of the cervical spine are provided. C7\n and T1 are not well visualized due to overlapping osseous structures. The\n degree of anterolisthesis of C7 on T1 is probably unchanged from the cervical\n spine CT of .\n\n"},{"category":"Radiology","chartdate":"2147-11-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747993,"text":" 5:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CVL L SCLV\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cervical fracture\n REASON FOR THIS EXAMINATION:\n s/p CVL L SCLV\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post central line placement.\n\n CHEST, SINGLE VIEW: Comparison study dated . There is now an ET tube\n whose tip is approximately 8.2 cm above the carina. There is a new left\n subclavian vein line with its tip in the mid SVC, no pneumothorax is\n detected. There is interval appearance of a small pleural effusion and a new\n retrocardiac density which may represent atelectasis although consolidation in\n this region cannot be excluded. There are marked degenerative changes\n identified in the thoracic spine and metallic staples are seen projecting over\n the lower cervical spine and thoracic inlet.\n\n IMPRESSION: 1. Left subclavian vein line with tip in mid SVC. No\n pneumothorax. 2. New small left effusion and retrocardiac density likely\n representing left lobe atelectasis but consolidation cannot be excluded.\n\n"},{"category":"Radiology","chartdate":"2147-11-27 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":748131,"text":" 1:30 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: 2:15P\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p cervical fracture stabilization surgery\n REASON FOR THIS EXAMINATION:\n please eval with diffusion weighted images for infarction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cervical fracture stabilization and mental status\n change.\n\n TECHNIQUE: Standard multiplanar T1 and T2 weighted imaging sequences were\n performed. Additional diffusion weighted imaging sequences were also\n performed.\n\n MRI OF THE HEAD WITHOUT CONTRAST: Bilateral subdural hematomas are identified.\n There is a small amount of pneumoencephaly seen just anterior to the right\n frontal lobe. Additional intraventricular hemorrhage is seen layering and the\n atria bilateral lateral ventricles. There is also susceptibility-induced\n artifact or signal loss within the septum related to prior drain placement.\n Additionally, susceptibility-induced signal loss is seen within the left\n temporal related to gas in this location. The tract of the previous\n intraventricular drain is identified. A craniotomy defect is seen in the\n right frontal lobe. Also again seen is subarachnoid hemorrhage, not changed\n from prior CT. No measured vascular territorial infarction is seen and no\n acute ischemic event is identified on diffusion-weighted imaging sequences.\n There is some minimal mucosal thickening in bilateral maxillary sinuses. There\n is air-fluid level seen in bilateral mastoid air cells. Soft tissue\n structures are unremarkable.\n\n IMPRESSION:\n 1. Small bilateral subdural hematomas. Stable intraventricular hemorrhage.\n Septal hemorrhage related to drain placement. Subarachnoid hemorrhage.\n\n 2. Stable pneumoencephaly.\n\n 3. No ventriculomegaly.\n\n 4. Minimal mucosal thickening in the maxillary sinuses and fluid seen within\n the mastoid air cells.\n\n 5. No acute infarction.\n\n\n\n"},{"category":"Radiology","chartdate":"2147-11-30 00:00:00.000","description":"CHEST (PA & LAT)","row_id":748390,"text":" 3:26 PM\n CHEST (PA & LAT) Clip # \n Reason: 75 yr old male s/p C7 and T1 fusion please assess chest for\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n 75 yr old male s/p C7 and T1 fusion please assess chest for infiltrate with\n patient with high wbc count\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: S/P cervical spine surgery. Assess for infiltrate. High white\n blood cell count.\n\n Comparison is made to recent postoperative study of 2 days earlier.\n\n Cardiac and mediastinal contours are stable. There remains small bilateral\n pleural effusions. There is some improving increased opacity in the\n retrocardiac region bilaterally. Degenerative changes are seen in the spine\n and postoperative changes are noted in the cervicothoracic region.\n\n IMPRESSION: 1) Persistent bilateral pleural effusions. 2) Improving bibasilar\n opacities, likely due to atelectasis, but infection is not excluded.\n\n"},{"category":"Radiology","chartdate":"2147-11-24 00:00:00.000","description":"O C-SPINE (PORTABLE) IN O.R.","row_id":747939,"text":" 9:11 AM\n C-SPINE (PORTABLE) IN O.R.; C-SPINE (PORTABLE) IN O.R. Clip # \n Reason: POST.CERV.FUSION\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE 2 LATERAL FILMS IN OR:\n\n For localization prior to cervical fusion.\n\n 2 posterior marker clamps are present. The superior of these overlies the\n spinous process of CV4 and the more inferior overlies the interspinous space\n of C5 and 6 directed towards the C5/6 disc.\n\n"},{"category":"Radiology","chartdate":"2147-11-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":748195,"text":" 9:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p spine surgery w/ productive cough and increased WBC coun\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cervical fracture\n REASON FOR THIS EXAMINATION:\n s/p spine surgery w/ productive cough and increased WBC count\n please eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: S/P Spinal surgery with productive cough and elevated wbc.\n\n PORTABLE AP CHEST is compared with CXR of .\n\n The ET tube has been removed. The left subclavian central venous catheter has\n been removed. There are bilateral basilar opacities, consistent with\n consolidation/collapse. Pleural effusions cannot be excluded. Surgical\n staples and surgical wires are noted overlying the upper cervical spine.\n\n IMPRESSION: Bilateral lower lobe collapse/consolidation.\n\n\n"},{"category":"Radiology","chartdate":"2147-11-29 00:00:00.000","description":"C-SPINE, NON-TRAUMA","row_id":748278,"text":" 10:20 AM\n C-SPINE, NON-TRAUMA; T-SPINE Clip # \n Reason: s/p cervical fracture and fusion\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P cervical fracture and fusion.\n\n AP AND TWO LATERAL VIEWS OF THE CERVICAL SPINE AND LATERAL THORACIC SPINE:\n There are bridging anterior osteophytes suggesting early DISH. The lower\n cervical spine and upper thoracic spine are not visualized. There are\n posterior skin staples and wires overlying the posterior cervical spine. The\n patient is wearing an external fixation device.\n\n IMPRESSION: Interval spinal fusion C7-T1 area which is not adequately\n assessed in this series of radiographs.\n\n"},{"category":"Radiology","chartdate":"2147-11-23 00:00:00.000","description":"C-SPINE (PORTABLE)","row_id":747911,"text":" 7:05 PM\n C-SPINE (PORTABLE) Clip # \n Reason: S/P traction,reduction of subluxed Ti\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with as above\n REASON FOR THIS EXAMINATION:\n S/P traction,reduction of subluxed Ti\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is in traction for C7 and T1 fractures. Evaluate\n alignment of the lower cervical spine.\n\n CERVICAL SPINE, 2 VIEWS: Two swimmer's views were provided. Evaluation of\n C7-T1 is difficult due to overlapping osseous structures. There is still\n gross anterolisthesis of C7 on T1.\n\n IMPRESSION: The C7-T1 relationship is difficult to evaluate due to\n overlapping osseous structures. There is still gross anterolisthesis of C7 on\n T1. If clinically indicated, the C7-T1 relationship could be better evaluated\n on CT.\n\n"},{"category":"Radiology","chartdate":"2147-11-22 00:00:00.000","description":"C-SPINE, TRAUMA","row_id":747806,"text":" 5:21 PM\n C-SPINE, TRAUMA Clip # \n Reason: 75 y/o male s/p fall from tree, had x rays at outside hospit\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with as above\n REASON FOR THIS EXAMINATION:\n 75 y/o male s/p fall from tree, had x rays at outside hospital with ?T1\n involvement. please do b/l oblique neck films for a better look at C7-T1.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall. Outside cervical spine radiographs inadequately assess C7-T1.\n\n Exam consists of swimmers view of the lower cervical spine and bilateral\n oblique views. The oblique views include only the mid portion of the spine\n and are inadequate for assessment. The seven cervical vertebral bodies are\n normally aligned but there is a poorly visualized apparent fracture of T1 with\n grade spondylolisthesis of C7 body anteriorly on T1 body. The posterior\n elements cannot be assessed with presumed C7 spondylolysis. This exam was\n interpreted at the time of the study but is available for official one\n week later. Subsequent CT scan was obtained.\n\n IMPRESSION: C7-T1 subluxation/fracture.\n\n\n"},{"category":"Radiology","chartdate":"2147-11-22 00:00:00.000","description":"C-SPINE, TRAUMA (WITH OBLS)","row_id":747794,"text":" 2:04 PM\n C-SPINE, TRAUMA (WITH OBLS); T-SPINE Clip # \n Reason: NECK & MID-BACK PAIN W/ BILATERAL RADICULOPATHY & PARESTHESIAS HANDS S/P FELL 6 FT WHILE TRIMMING A TREE TODAY R/O FX,DISLOCATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n do not remove collar, fell 6 feet, has paresthesias in hand, pain over T1, C8\n processes, no flexion or extension of neck until ap and lateral cleared\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Six-foot fall. Paresthesias in hand.\n\n These radiographs were preliminarily interpretated at time they were obtained\n but are not available for official interpretation until several weeks later\n (interval patient hospital admission). The thoracic spine exam was ordered &\n apparently obtained but these radiographs not available for itnerpretation.\n There are eight radiographs of the C-spine including obliques and attempted\n spot radiographs of the cervical-thoracic junction. There is a poorly\n visualized apparent grade 2 anterolisthesis of C7 on T1, and the T1 body is\n poorly visualized with possible fracture. There is a large bridging\n osteophyte anteriorly at the C2/3 level, suggesting ossifying diaphysis and\n possible DISH elswhere in the spine. No fractures or dislocations seen C1\n through C6, although even these vertebral bodies are poorly assessed. The\n spinous process of C7 appears posteriorly positioned.\n\n IMPRESSION: Probable fracture/dislocation at poorly assessed C7/T1 level. CT\n recommended. Thoracic spine radiographs not available for interpretation.\n\n"},{"category":"Radiology","chartdate":"2147-11-22 00:00:00.000","description":"MR CERVICAL SPINE","row_id":747827,"text":" 10:51 PM\n MR CERVICAL SPINE Clip # \n Reason: 75 yo fell out of tree onto outstretched arms, sustained\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with fractured neck with C7-T1 subluxation\n REASON FOR THIS EXAMINATION:\n 75 yo fell out of tree onto outstretched arms, sustained C7-T1 grade 3\n subluxation and fractures of bilateral pedicles, please evaluate spinal cord as\n well as ligaments, etc.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess spinal cord and ligaments in patient with known cervical\n fractures after fall from tree.\n\n No prior MR studies are available for comparison.\n\n TECHNIQUE: T1 and T2 weighted images were obtained through the cervical\n spine. Gradient echo axial images were obtained from the C3 through the T1\n levels.\n\n FINDINGS: The fracture of the T7 and T1 vertebrae are seen with\n anterolisthesis of the C7 over the T1 vertebral body. For detailed\n description of these fractures, please see the report on the cervical spine CT\n scan obtained on (clip #).\n\n Sagittal images reveal rupture of the anterior spinal ligament at the C7-T1\n level. Additionally there is likely rupture of the posterior longitudinal\n ligament, however this is not well visualized. There is angulation of the\n spinal canal secondary to the displacement of C7 over T1. The cord\n transverses this dislocation with a bend but there are no signal abnormalities\n of the cord at this level. Additionally the cord is normal in its caliber.\n\n On the axial images, there is disruption of the soft tissues immediately\n posterior to the cord at the C7-T1 level however it is difficult to evaluate\n the thecal sac at this level due to image blurring. There are degenerative\n changes in the cervical spine superior to the known fractures. At the C4-5\n level there is mild canal and neural foraminal narrowing secondary to\n degenerative change. At C5-6, again there is mild canal narrowing at this\n level; however there is severe narrowing of the left neural foramina at this\n level.\n\n High signal on T2 weighted images show swelling of the soft tissues posterior\n to the spinous processes of the cervical spine, associated with the known\n injuries.\n\n IMPRESSION: Despite fracture and angulation of the spinal canal, the spinal\n cord is normal in signal intensity and caliber suggesting that there is\n minimal if any cord injury.\n\n\n\n (Over)\n\n 10:51 PM\n MR CERVICAL SPINE Clip # \n Reason: 75 yo fell out of tree onto outstretched arms, sustained\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2147-11-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":747867,"text":" 11:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pre-op CXR for OR on \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cervical fracture\n REASON FOR THIS EXAMINATION:\n Pre-op CXR for OR on \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-op for cervical spine fracture.\n\n No prior studies are available for comparison.\n\n PORTABLE AP CHEST: Please note that the extreme right costophrenic angle is\n not included in this film. The cardiomediastinal silhouette is normal. The\n pulmonary vasculature is normal. There is no consolidation or effusion on the\n left. The left sternoclavicular joint is widened, of uncertain chronicity.\n\n IMPRESSION: 1) Limited examination excluding the extreme right costophrenic\n angle. This examination will be repeated at no additional charge.\n\n 2) No acute cardiopulmonary abnormality apparent.\n\n 3) Widening of the left sternoclavicular joint of uncertain chronicity.\n\n"},{"category":"Radiology","chartdate":"2147-12-05 00:00:00.000","description":"C-SPINE, NON-TRAUMA","row_id":748716,"text":" 3:38 PM\n C-SPINE, NON-TRAUMA Clip # \n Reason: 75 yr old male s/p C7-T1 decopression please do ap and lat f\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n 75 yr old male s/p C7-T1 decopression please do ap and lat films standing in\n brace with swimmers view if necessary must view top of T1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post C7-T1 decompression, follow-up study.\n\n Comparison is made to the prior study of .\n\n Three views of the cervical spine demonstrate fixation wires overlying the\n posterior cervical spine at the C5 through T1 levels and skin staples. Grade\n III anterolisthesis is demonstrated on the swimmer's view and is unchanged\n compared to prior studies. Bridging anterior osteophytes are again seen,\n unchanged.\n\n IMPRESSION: Stable appearance of C7-T1 spinal fusion and grade III\n anterolisthesis of C7 on T1.\n\n"},{"category":"Radiology","chartdate":"2147-12-05 00:00:00.000","description":"CHEST (PA & LAT)","row_id":748715,"text":" 3:38 PM\n CHEST (PA & LAT) Clip # \n Reason: Elevated white cell couynt and low spo2.Evaluate for progre\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\n REASON FOR THIS EXAMINATION:\n Elevated white cell couynt and low spo2.Evaluate for progression of\n effusion/infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Rising white count with question of retrocardiac density.\n\n FINDINGS:\n Two views of the chest worsen to . Again seen is an area of\n opacification in the right retrocardiac region. There is interval clearing of\n the left retrocardiac region. There remains bilateral small pleural effusions.\n There is no congestive heart failure. There is artifact from overlying\n metallic device. No pneumothorax is seen.\n\n IMPRESSION:\n 1) Persistent right retrocardiac density with interval improvement of the left\n retrocardiac density.\n 2) Bilateral small pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2147-12-08 00:00:00.000","description":"CVL/PICC","row_id":748910,"text":" 8:32 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: S/P cervical instrumentation.Needs vancomycin.\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * CHEST AP ONLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n S/P cervical instrumentation.Needs vancomycin.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 y/o man with recent cervical spine trauma and instrumentation.\n He is now infected and requires IV access for longterm antibiotics.\n\n RADIOLOGISTS: Dr. and Dr. , staff Radiologist, was present for\n the entire procedure.\n\n CONTRAST/MEDICATIONS: 1% Lidocaine for local anesthesia.\n\n PROCEDURE/TECHNIQUE: Informed and signed consent was obtained from the\n patient. The patient was placed in a supine position on the angiographic table\n and the left upper extremity was prepped and draped in the usual sterile\n fashion. A left upper extremity ultrasound was performed as no superficial\n palpable veins could be found. After administration of local anesthesia, the\n left basilic vein was accessed with a 21 gauge needle under son\n guidance. A .018 wire was then advanced through the needle to the level of the\n lower SVC under continuous fluoroscopy. The needle was then exchanged for a 4\n FR dilator and peelaway sheath. The dilator was removed and a 4 FR single\n lumen PICC, trimmed to 47 cm, was advanced to the lower SVC under continuous\n fluoroscopy. The peelaway sheath was simultaneously removed. The guide wire\n was then removed and a radiograph obtained to confirm PICC position. The skin\n was cleaned and the PICC secured to the skin using a stat lock and overlying\n dressing. The patient tolerated the procedure well.\n\n COMPLICATIONS: None.\n\n FINDINGS: A preprocedural left upper extremity ultrasound shows a widely\n patent and compressible left basilic vein. A post procedural radiograph shows\n the tip of the PICC within the lower SVC. There is no pneumothorax.\n\n IMPRESSION: Technically successful placement of a 47 cm long, 4 FR single\n lumen PICC via the left basilic vein. The tip is in the lower SVC. The line\n is ready for immediate use.\n\n\n"},{"category":"Radiology","chartdate":"2147-12-07 00:00:00.000","description":"CHEST (PA & LAT)","row_id":748869,"text":" 3:29 PM\n CHEST (PA & LAT) Clip # \n Reason: 75 yr old male with question of retrocardiac opacity on cxr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\n REASON FOR THIS EXAMINATION:\n 75 yr old male with question of retrocardiac opacity on cxr from please\n assess for progress or improvemtn of this ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with rising WBC, ? of retrocardiac opacity.\n\n FINDINGS: PA and lateral radiographs are compared with the PA and lateral\n study dated . The heart size is normal. No retrocardiac opacities\n are appreciated on the current study. The mediastinal and hilar contours are\n normal. The pulmonary vascularity appears normal. The lungs appear clear.\n There are no pleural effusions.\n\n There is osteopenia throughout the thoracic spine. There is calcification of\n the anterior longitudinal ligament.\n\n IMPRESSION: 1) No evidence for retrocardiac opacities or pleural effusions.\n No evidence for pneumonia.\n\n"},{"category":"Nursing/other","chartdate":"2147-11-23 00:00:00.000","description":"Report","row_id":1499661,"text":"Nursing note\nPt alert/oriented x3. VSS. Afebrile. Aspen cervical collar in place. Tongs to scalp in place with 27 lbs traction. Pt verbalizes understanding of traction and need for immobility. Neuro signs WNL. MAE. Pt states slight numbness/tingling of bil forearms conts. LS clear. Sats 96-97 on room air. Abd soft with + BS. Foley patent, draining QS clear yellow urine.\n#20 IV intact in right forearm, infusing LR at 100cc/h. #18 IV intact in left AC infusing Solumedrol at 22cc/h. Sites benign. Denies pain. NPO x meds with sip. Monitor traction, VS, neuro status. Maintain traction. Maintain position with no movement/logrolling. For OR in AM. Family in to visit.\n"},{"category":"Nursing/other","chartdate":"2147-11-24 00:00:00.000","description":"Report","row_id":1499662,"text":"NURSING PROGRESS NOTE\n12/6-7 B-SHIFT. A&O. MAE. CONSISTENT STRENGTH IN EXTREMS THROUGHOUT THE NITE. ASPEN COLLAR. HEAD/BACK IN TRACTION. VSS. BRADYCARDIA. AFEBRILE. RA. CLEAR LUNGS. NPO EXCEPT SIPS FOR MEDS. FOLEY. UO=QS. LR @ 100/HR. LATERAL XRAY. STARTED VENODYNES. BUN/CR=45/1.9. WBC=22.\n"},{"category":"Nursing/other","chartdate":"2147-11-24 00:00:00.000","description":"Report","row_id":1499663,"text":"NSG PROGRESS NOTE\nRETURNED FROM OR INTUBATED AND NONRESPONSIVE. SOLUMEDROL GTT ON PR ANESTHESIA AT 5.4MG/KG/HR. TO RUN CONT GTT X23 HRS. NIPRIDE GTT STARTED FOR SBP 180-200. GOAL SBP < 150. NOT MOVING EXT OR FOLLOWING COMMAND INITIALLY ON ARRIVAL BEGINNING TO MOVE LOWER EXT, SQEEZE HANDS ON COMMAND AND ATTEMPT TO OPEN EYES AFTER 2-3 HRS IN SICU. HCT 29. RECEIVED 1 UNIT PRBC IN SICU. HAD RECEIVED 3 UNITS IN OR AS WELL AS 4 FFP. ASPEN COLLAR ON. HEMOVAC X2 WITH SANG. DRG. COMINO BOLT PLACED PR MD. UNABLE TO PLACE VENT DRAIN. ICP 4-10. HAD HEAD CT POST OP - POS INTRAVENT BLEED PR MD, BUT \"2ND TO BLEED FROM INITIAL FALL). FAMILY AT BEDSIDE.\n"},{"category":"Nursing/other","chartdate":"2147-11-25 00:00:00.000","description":"Report","row_id":1499664,"text":"Nursing note:\nNEURO: Opening eyes spont, MAE, following commands inconsistently, PERRLA. bolt in place/intact, ICP 5-11. Hemovac drains x 2 draining bloody drainage. Remains on 23hour Solumedrol gtt.\nRESP: No vent changes overnight, remains on SIMV/PS 5, 35%, RR 12-16 w/spont. TVs of 500. Lung sounds coarse, sxn'd via ETT for thick tan secretions. Biting on tube.\nCV: NSR 60-75, no ectopy. lytes repleted prn. Nipride gtt titrated to keep SBP <150, BP labile. Becomes hypertensive w/agitation.\nGI: abdomen softly distended, -bs.\nGU: foley patent adequate amounts yellow urine w/sediment.\nACT: no turning/repositioning overnight per HO. Neurosurg to reevaluate in am. Aspen collar on, collar care done. no areas of breakdown noted. neck not to be flexed.\nSOCIAL: supportive family at bedside much of evening.\n\n"},{"category":"Nursing/other","chartdate":"2147-11-25 00:00:00.000","description":"Report","row_id":1499665,"text":"resp care\n\npt remains intubated and mech ventilated. pt weaned to cpap+ps secondary to dyssynchrony w/vent. ps 8 peep 5 fio2 35%. vt 500-600's rr teens to low 20's. b/s coarse. sxn tk tan. plan: cont w/mech support. wean as tolerated. pt to be tx to ct scan today.\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499671,\n \"text\": \"NURSING TRANSFER NOTE\\nupdate transfer note - cont requiring nipride for bp control overnight. Increase pressure related to pain. mso4 pca started - pca currently at basal rate 0.5/hr and demand dose 1 mg q6min with 10mg/1 hr lockout. increase anxiety with activity. with anxiety rr inc to 30's w/o desaturation. sbp up to 190's. clondine patch started. somi on. hemovac x1 from neck incision. left hip drsg - hemovac dc from hip. poor appitite/tol clears. hydalazine po increase to 50 mg q6.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499666,\n \"text\": \"Nursing note\\nAlert/oriented x3. Anxious at times. drain out this AM. Sutures intact to scalp. No drainage. CT of head done this AM. Aspen collar on and tol well. MAE freely. move/position for comfort. Denies headache. LS clear with some upper airway congestion. Extubated without incident. Sats 96-98 with humidified O2 by mask. Cough/gag intact. Abd soft, nontender. No bowel sounds heard yet. Sips of clear liqs tol in PM. Able to swallow PO meds. Hypertensive when stimulated. Nipride gtt titrated to effect. Hydralazine started. Foley patent, draining QS yellow urine with sediment. Dsgs to c spine and L iliac crest intact with sm amt s/s drainage noted. Aline mildly positional. B/P correlated with cuff. Left TLC patent. Site benign. Family anxious. Cont to monitor B/P and titrate Nipride gtt to maintain B/P below 150. Monitor and treat pain.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499667,\n \"text\": \"pain\\nD: PT C/O OF PAIN IN SHOULDERS AND ACROSS BACK. PT ABLE TO MOVE ALL EXTREMITIES AND FOLLOW COMMANDS. HE IS HAVING OCCASIONAL EPISODES OF CONFUSION, WANTING TO MOVE HIS CAR WHICH IS PARKED IN THE STREET AND FIX THE TILE ON THE CEILING. HE IS EASILY REORIENTED AND REALIZES HE IS CONFUSED. NIPRIDE TITRATED FOR BP CONTROL.\\nA: MORPHINE FOR PAIN WITH GOOD RELIEF. HYDRALIZINE INCREASED TO 30MG Q6. NIPRIDE TITRATED FOR BP\\nR: DOING WELL POST FUSION. MORPHINE EFFECTIVE IN CONTROLLING PAIN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499668,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: PATIENT'S CONDITION CONTINUES TO IMPROVE. ALERT AND ORIENTED, GOOD STREGNTH IN ALL EXTREMITIES. ASPEN COLLAR REMAINS ON. COMPLAINING OF SHOULDER PAIN, MEDICATED TWICE WITH GOOD RELIEF. BEGINNING TO ADVANCE DIET--TOLERATING WELL. UNABLE TO WEAN SNP--BLOOD PRESSURE RISES WITH ANY INTERRUPTION IN NIRPIDE INFUSION. FAMILY IN/OUT MOST OF THE DAY. VITAL SIGNS PER FLOW SHEET. DRAING PATENT AND DRAINING. AWAITING PT CONSULT AND PLACEMENT OF SOMI BRACE TOMORROW.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499669,\n \"text\": \"PAIN\\nD: PT IS ALERT AND ORIENTED. NORMAL STRENGTH IN ALL EXTREMITIES. PT COMPLAINING OF PAIN BETWEEN SHOULDER BLADES. SBP STILL LABILE AND NIPRIDE TITRATED FOR BP. COUGHING AND RAISING THICK YELLOW SPUTUM.\\nA: CONTINUE TO MEDICATE WITH MORPHINE FOR PAIN. CONTINUE TO ENCOURAGE AGGRESSIVE PULMONARY TOLIET. HYDRALAZINE INCREASED TO 40 MG\\nR: MORPHINE EFFECTIVE IN CONTROLLING PAIN. PT APPEARS COMFORTABLE ON 4L NC. BP STILL LABILE AND NIPRIDE BEING TITRATED. PT WITH GOOD RESPONSE TO HYDRALAZINE BUT SHORT LIVED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499670,\n \"text\": \"NURSING TRANSFER NOTE\\nADMITTED S/P FALL FROM LADDER. FX SPINE. C7 TO T1 FUSION LAMINECTOMY. UNRESPONSIVE ON RETURN FROM OR. BOLT IN TO MEASURE ICP. BOLT D/C'D & EXTUBATED . NOW A&O. MOVES ALL EXTREMITIES. ASPEN COLLAR. SCHEDULED FOR TODAY. SINUS BRADY BASELINE. NIPRIDE GTT D/C'D. CONTROLLING SBP < 150 WITH HYDRALAZINE, LOPRESSOR, NITROPASTE. AFEBRILE. 3 LPM NC. UPPERAIRWAY CONGESTION. WEAK COUGH. INCENTIVE SPIROMETER. MRI OF HEAD DONE TODAY. TRIED PERCOCET FOR PAIN. NAUSEA. TX WITH DROPERIDOL. PRN ORDER CHANGED TO #3. NOT TRIED YET. ALSO MORPHINE IVP GIVEN FOR PAIN POST MRI. REGULAR DIET. EATING SMALL AMOUNTS. HEMOVAC DRAIN IN POSTERIOR NECK. SEROSANGUINOUS DRAINAGE. FOLEY. UO=QS. NO BM. ABX PROX FOR DRAINS. AMIODARONE FOR HX OF AFIB.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2147-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 119510,\n \"text\": \"Sinus bradycardia. Left axis deviation. Left bundle-branch block type\\nintraventricular conduction delay. Prominent U waves. Compared to the previous\\ntracing of sinus bradycardia has replaced atrial fibrillation and\\nrepolarization abnormalities are now present. These may be due to electrolyte\\nabnormalities or medication effect.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-30 00:00:00.000\",\n \"description\": \"VENOUS DUP EXT UNI (MAP/DVT)\",\n \"row_id\": 748384,\n \"text\": \" 2:57 PM\\n VENOUS DUP EXT UNI (MAP/DVT) Clip # \\n Reason: 75 year old male with erythema and tenderness to the right u\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with\\n REASON FOR THIS EXAMINATION:\\n 75 year old male with erythema and tenderness to the right upper extremity with\\n also a high wbc count of 18 please assess for upper extremity DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON:\\n Patient with pain and swelling right upper extremity.\\n\\n FINDINGS:\\n Duplex evaluation was performed of the right upper extremity venous system.\\n Due to the brace on her neck and shoulders her jugular vein cannot be scanned.\\n\\n The right subclavian, axillary, brachial, basilic, radial and ulnar veins are\\n all patent without evidence of thrombus or obstruction. There is normal\\n compression at those levels. Cephalic vein was not visualized.\\n\\n IMPRESSION:\\n No evidence of right upper extremity DVT. As noted study was somewhat\\n difficult due to the brace on the neck and shoulders.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 747974,\n \"text\": \" 2:55 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: NOT WAKING AFTER SURGERY S/P CERVICAL FUSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p cervical fusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n TECHNIQUE: Contiguous axial images were obtained from the foramen Magnum to\\n the cranial vertex.\\n\\n HISTORY: Post op. Status post cervical fusion. Unable to walk.\\n\\n CT HEAD W/O CONTRAST: There is a large amount of intraventricular hemorrhage\\n seen layering within the atria of the lateral ventricles. Additionally there\\n is diffuse subarachnoid hemorrhage most prominent over the left parietal\\n convexity. There are no definite attenuation abnormalities of the parenchyma.\\n\\n There is no fracture. Visualized paranasal sinuses demonstrate mucosal\\n thickening in bilateral maxillary sinuses and a retention cyst of right\\n maxillary sinus.\\n\\n IMPRESSION: Intraventricular and subarachnoid hemorrhage without\\n hydrocephalus. No major vascular territorial infarction is noted. Follow up is\\n recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-25 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 748016,\n \"text\": \" 8:38 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? HYDROCEPHALUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with see above\\n REASON FOR THIS EXAMINATION:\\n please perform a head CT s/p cervical fracture stabilization surgery w/ neuro\\n changes and depressed mental status postop. Please evaluate for hydrocephalus.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 75 year old male with mental status changes, intracranial hemorrhage\\n for follow up.\\n\\n Comparison to prior study from .\\n\\n TECHNIQUE: Axial noncontrast imaging was performed from the skull base to\\n vertex.\\n\\n FINDINGS: Again seen is high density material layering posteriorly within both\\n lateral ventricles consistent with hemorrhage and not significantly changed\\n from prior study. Diffuse subarachnoid blood is also identified most prominent\\n over the convexities. There is no mass effect. Gas is identified anterior to\\n the right frontal lobe and anteriorly within the left lateral ventricle.\\n Craniotomy defect is noted in the right frontal bone there is no\\n hydrocephalus. Again noted is opacification of multiple ethmoid air cells and\\n fluid within the maxillary sinuses.\\n\\n IMPRESSION:\\n\\n 1. Intraventricular and subarachnoid hemorrhage, not significantly changed\\n from the prior study.\\n\\n 2. Intracranial and intraventricular gas, possibly related to recent\\n intervention. Suggest clinical correlation.\\n\\n 3. No hydrocephalus.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 748550,\n \"text\": \" 11:19 AM\\n CHEST (PA & LAT) Clip # \\n Reason: Follow-up bilateral opacities.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\\n REASON FOR THIS EXAMINATION:\\n Follow-up bilateral opacities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA & LATERAL CHEST:\\n\\n HISTORY: Pleural effusions, follow up abnormal chest.\\n\\n The inferolateral aspect of the right lung is not included on the examination.\\n The heart is normal in size. There are bilateral pleural effusions and there\\n is an infiltrate in the right lower lobe posteriorly. There are no other\\n significant findings.\\n\\n IMPRESSION: Small bilateral pleural effusions and possible faint right lower\\n lobe infiltrates.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-22 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 747812,\n \"text\": \" 6:34 PM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: 75 y/o male s/p fall from tree earlier today. Had c-spine fi\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with as abive\\n REASON FOR THIS EXAMINATION:\\n 75 y/o male s/p fall from tree earlier today. Had c-spine films with\\n ?involvement of T1. several X rays taken but without definitive results. Please\\n evaluate.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT C SPINE WITH RECONSTRUCTIONS .\\n\\n INDICATION: Trauma, neck pain and paresthesias.\\n\\n TECHNIQUE: Axial C spine CT was performed. Coronal and sagittal reformations\\n were created.\\n\\n CT C SPINE: At the C7 level, there is a complete transverse fracture through\\n the laminae bilaterally, with approximately 1.6 cm posterior displacement of\\n the posterior elements. There is a nondisplaced fracture through the right\\n posterolateral aspect of the C7 vertebral body. A small chip fracture is\\n retropulsed approximately 4 mm into the central canal.\\n\\n There is a grade 3 anterolisthesis of C7 on T1. There are bilateral C7 pars\\n interarticularis fractures, with diasthesis of the C7-T1 facet articulations.\\n The width of the spinal canal is preserved by the retropulsion of the\\n posterior elements of C7.\\n\\n At T1, there is a severe anterior wedge compression fracture. There is a\\n superoanterior fragment from the T1 vertebral body which maintains anterior\\n alignment with the anterior spinal margin, while the large posterior component\\n of the body is retropulsed.\\n\\n There is also a superoanterior endplate fracture of T2. The remainder of this\\n vertebra is not completely imaged.\\n\\n There is degenerative change at multiple levels. Specifically, there is\\n anterior osteophyte formation at C2-3 and to a lesser extent C3-4, C4-5 and\\n C5-6. There is narrowing of the intervertebral disc spaces at all levels,\\n degenerative in appearance.\\n\\n There is also a small fracture of the posterior limb of the right foramen\\n transversarium at C5.\\n\\n There is degenerative narrowing of the right C5-6 neural foramen secondary to\\n uncovertebral degeneration.\\n\\n\\n IMPRESSION: Fracture dislocation of the C7-T1 interspace with T1 anterior\\n wedge compression fracture and posterior elements fracture at C7. There is\\n likely to be cord injury, secondary to the dislocation, though the spinal\\n (Over)\\n\\n 6:34 PM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: 75 y/o male s/p fall from tree earlier today. Had c-spine fi\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n canal is wide. These findings were communicated emergently to Dr. \\n , at the time of the exam.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-23 00:00:00.000\",\n \"description\": \"C-SPINE (PORTABLE)\",\n \"row_id\": 747858,\n \"text\": \" 10:02 AM\\n C-SPINE (PORTABLE) Clip # \\n Reason: C7-T1 spinal fracture with sublux, now in traction, please e\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with as above\\n REASON FOR THIS EXAMINATION:\\n C7-T1 spinal fracture with sublux, now in traction, please eval for\\n alignment/reduction of subluxation.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fracture of C7 and T1 with anterolisthesis of C7 on the cervical\\n spine CT of .\\n\\n CERVICAL SPINE 2 VIEWS: 2 lateral views of the cervical spine are provided. C7\\n and T1 are not well visualized due to overlapping osseous structures. The\\n degree of anterolisthesis of C7 on T1 is probably unchanged from the cervical\\n spine CT of .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747993,\n \"text\": \" 5:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p CVL L SCLV\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with cervical fracture\\n REASON FOR THIS EXAMINATION:\\n s/p CVL L SCLV\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post central line placement.\\n\\n CHEST, SINGLE VIEW: Comparison study dated . There is now an ET tube\\n whose tip is approximately 8.2 cm above the carina. There is a new left\\n subclavian vein line with its tip in the mid SVC, no pneumothorax is\\n detected. There is interval appearance of a small pleural effusion and a new\\n retrocardiac density which may represent atelectasis although consolidation in\\n this region cannot be excluded. There are marked degenerative changes\\n identified in the thoracic spine and metallic staples are seen projecting over\\n the lower cervical spine and thoracic inlet.\\n\\n IMPRESSION: 1. Left subclavian vein line with tip in mid SVC. No\\n pneumothorax. 2. New small left effusion and retrocardiac density likely\\n representing left lobe atelectasis but consolidation cannot be excluded.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-27 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 748131,\n \"text\": \" 1:30 PM\\n MR HEAD W/O CONTRAST Clip # \\n Reason: 2:15P\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with s/p cervical fracture stabilization surgery\\n REASON FOR THIS EXAMINATION:\\n please eval with diffusion weighted images for infarction\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post cervical fracture stabilization and mental status\\n change.\\n\\n TECHNIQUE: Standard multiplanar T1 and T2 weighted imaging sequences were\\n performed. Additional diffusion weighted imaging sequences were also\\n performed.\\n\\n MRI OF THE HEAD WITHOUT CONTRAST: Bilateral subdural hematomas are identified.\\n There is a small amount of pneumoencephaly seen just anterior to the right\\n frontal lobe. Additional intraventricular hemorrhage is seen layering and the\\n atria bilateral lateral ventricles. There is also susceptibility-induced\\n artifact or signal loss within the septum related to prior drain placement.\\n Additionally, susceptibility-induced signal loss is seen within the left\\n temporal related to gas in this location. The tract of the previous\\n intraventricular drain is identified. A craniotomy defect is seen in the\\n right frontal lobe. Also again seen is subarachnoid hemorrhage, not changed\\n from prior CT. No measured vascular territorial infarction is seen and no\\n acute ischemic event is identified on diffusion-weighted imaging sequences.\\n There is some minimal mucosal thickening in bilateral maxillary sinuses. There\\n is air-fluid level seen in bilateral mastoid air cells. Soft tissue\\n structures are unremarkable.\\n\\n IMPRESSION:\\n 1. Small bilateral subdural hematomas. Stable intraventricular hemorrhage.\\n Septal hemorrhage related to drain placement. Subarachnoid hemorrhage.\\n\\n 2. Stable pneumoencephaly.\\n\\n 3. No ventriculomegaly.\\n\\n 4. Minimal mucosal thickening in the maxillary sinuses and fluid seen within\\n the mastoid air cells.\\n\\n 5. No acute infarction.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-30 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 748390,\n \"text\": \" 3:26 PM\\n CHEST (PA & LAT) Clip # \\n Reason: 75 yr old male s/p C7 and T1 fusion please assess chest for\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with\\n REASON FOR THIS EXAMINATION:\\n 75 yr old male s/p C7 and T1 fusion please assess chest for infiltrate with\\n patient with high wbc count\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST:\\n\\n INDICATION: S/P cervical spine surgery. Assess for infiltrate. High white\\n blood cell count.\\n\\n Comparison is made to recent postoperative study of 2 days earlier.\\n\\n Cardiac and mediastinal contours are stable. There remains small bilateral\\n pleural effusions. There is some improving increased opacity in the\\n retrocardiac region bilaterally. Degenerative changes are seen in the spine\\n and postoperative changes are noted in the cervicothoracic region.\\n\\n IMPRESSION: 1) Persistent bilateral pleural effusions. 2) Improving bibasilar\\n opacities, likely due to atelectasis, but infection is not excluded.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-24 00:00:00.000\",\n \"description\": \"O C-SPINE (PORTABLE) IN O.R.\",\n \"row_id\": 747939,\n \"text\": \" 9:11 AM\\n C-SPINE (PORTABLE) IN O.R.; C-SPINE (PORTABLE) IN O.R. Clip # \\n Reason: POST.CERV.FUSION\\n ______________________________________________________________________________\\n FINAL REPORT\\n CERVICAL SPINE 2 LATERAL FILMS IN OR:\\n\\n For localization prior to cervical fusion.\\n\\n 2 posterior marker clamps are present. The superior of these overlies the\\n spinous process of CV4 and the more inferior overlies the interspinous space\\n of C5 and 6 directed towards the C5/6 disc.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 748195,\n \"text\": \" 9:27 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p spine surgery w/ productive cough and increased WBC coun\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with cervical fracture\\n REASON FOR THIS EXAMINATION:\\n s/p spine surgery w/ productive cough and increased WBC count\\n please eval for pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: S/P Spinal surgery with productive cough and elevated wbc.\\n\\n PORTABLE AP CHEST is compared with CXR of .\\n\\n The ET tube has been removed. The left subclavian central venous catheter has\\n been removed. There are bilateral basilar opacities, consistent with\\n consolidation/collapse. Pleural effusions cannot be excluded. Surgical\\n staples and surgical wires are noted overlying the upper cervical spine.\\n\\n IMPRESSION: Bilateral lower lobe collapse/consolidation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-29 00:00:00.000\",\n \"description\": \"C-SPINE, NON-TRAUMA\",\n \"row_id\": 748278,\n \"text\": \" 10:20 AM\\n C-SPINE, NON-TRAUMA; T-SPINE Clip # \\n Reason: s/p cervical fracture and fusion\\n ______________________________________________________________________________\\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: S/P cervical fracture and fusion.\\n\\n AP AND TWO LATERAL VIEWS OF THE CERVICAL SPINE AND LATERAL THORACIC SPINE:\\n There are bridging anterior osteophytes suggesting early DISH. The lower\\n cervical spine and upper thoracic spine are not visualized. There are\\n posterior skin staples and wires overlying the posterior cervical spine. The\\n patient is wearing an external fixation device.\\n\\n IMPRESSION: Interval spinal fusion C7-T1 area which is not adequately\\n assessed in this series of radiographs.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-23 00:00:00.000\",\n \"description\": \"C-SPINE (PORTABLE)\",\n \"row_id\": 747911,\n \"text\": \" 7:05 PM\\n C-SPINE (PORTABLE) Clip # \\n Reason: S/P traction,reduction of subluxed Ti\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with as above\\n REASON FOR THIS EXAMINATION:\\n S/P traction,reduction of subluxed Ti\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is in traction for C7 and T1 fractures. Evaluate\\n alignment of the lower cervical spine.\\n\\n CERVICAL SPINE, 2 VIEWS: Two swimmer's views were provided. Evaluation of\\n C7-T1 is difficult due to overlapping osseous structures. There is still\\n gross anterolisthesis of C7 on T1.\\n\\n IMPRESSION: The C7-T1 relationship is difficult to evaluate due to\\n overlapping osseous structures. There is still gross anterolisthesis of C7 on\\n T1. If clinically indicated, the C7-T1 relationship could be better evaluated\\n on CT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-22 00:00:00.000\",\n \"description\": \"C-SPINE, TRAUMA\",\n \"row_id\": 747806,\n \"text\": \" 5:21 PM\\n C-SPINE, TRAUMA Clip # \\n Reason: 75 y/o male s/p fall from tree, had x rays at outside hospit\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with as above\\n REASON FOR THIS EXAMINATION:\\n 75 y/o male s/p fall from tree, had x rays at outside hospital with ?T1\\n involvement. please do b/l oblique neck films for a better look at C7-T1.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Fall. Outside cervical spine radiographs inadequately assess C7-T1.\\n\\n Exam consists of swimmers view of the lower cervical spine and bilateral\\n oblique views. The oblique views include only the mid portion of the spine\\n and are inadequate for assessment. The seven cervical vertebral bodies are\\n normally aligned but there is a poorly visualized apparent fracture of T1 with\\n grade spondylolisthesis of C7 body anteriorly on T1 body. The posterior\\n elements cannot be assessed with presumed C7 spondylolysis. This exam was\\n interpreted at the time of the study but is available for official one\\n week later. Subsequent CT scan was obtained.\\n\\n IMPRESSION: C7-T1 subluxation/fracture.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-22 00:00:00.000\",\n \"description\": \"C-SPINE, TRAUMA (WITH OBLS)\",\n \"row_id\": 747794,\n \"text\": \" 2:04 PM\\n C-SPINE, TRAUMA (WITH OBLS); T-SPINE Clip # \\n Reason: NECK & MID-BACK PAIN W/ BILATERAL RADICULOPATHY & PARESTHESIAS HANDS S/P FELL 6 FT WHILE TRIMMING A TREE TODAY R/O FX,DISLOCATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with\\n REASON FOR THIS EXAMINATION:\\n do not remove collar, fell 6 feet, has paresthesias in hand, pain over T1, C8\\n processes, no flexion or extension of neck until ap and lateral cleared\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Six-foot fall. Paresthesias in hand.\\n\\n These radiographs were preliminarily interpretated at time they were obtained\\n but are not available for official interpretation until several weeks later\\n (interval patient hospital admission). The thoracic spine exam was ordered &\\n apparently obtained but these radiographs not available for itnerpretation.\\n There are eight radiographs of the C-spine including obliques and attempted\\n spot radiographs of the cervical-thoracic junction. There is a poorly\\n visualized apparent grade 2 anterolisthesis of C7 on T1, and the T1 body is\\n poorly visualized with possible fracture. There is a large bridging\\n osteophyte anteriorly at the C2/3 level, suggesting ossifying diaphysis and\\n possible DISH elswhere in the spine. No fractures or dislocations seen C1\\n through C6, although even these vertebral bodies are poorly assessed. The\\n spinous process of C7 appears posteriorly positioned.\\n\\n IMPRESSION: Probable fracture/dislocation at poorly assessed C7/T1 level. CT\\n recommended. Thoracic spine radiographs not available for interpretation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-22 00:00:00.000\",\n \"description\": \"MR CERVICAL SPINE\",\n \"row_id\": 747827,\n \"text\": \" 10:51 PM\\n MR CERVICAL SPINE Clip # \\n Reason: 75 yo fell out of tree onto outstretched arms, sustained\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with fractured neck with C7-T1 subluxation\\n REASON FOR THIS EXAMINATION:\\n 75 yo fell out of tree onto outstretched arms, sustained C7-T1 grade 3\\n subluxation and fractures of bilateral pedicles, please evaluate spinal cord as\\n well as ligaments, etc.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Assess spinal cord and ligaments in patient with known cervical\\n fractures after fall from tree.\\n\\n No prior MR studies are available for comparison.\\n\\n TECHNIQUE: T1 and T2 weighted images were obtained through the cervical\\n spine. Gradient echo axial images were obtained from the C3 through the T1\\n levels.\\n\\n FINDINGS: The fracture of the T7 and T1 vertebrae are seen with\\n anterolisthesis of the C7 over the T1 vertebral body. For detailed\\n description of these fractures, please see the report on the cervical spine CT\\n scan obtained on (clip #).\\n\\n Sagittal images reveal rupture of the anterior spinal ligament at the C7-T1\\n level. Additionally there is likely rupture of the posterior longitudinal\\n ligament, however this is not well visualized. There is angulation of the\\n spinal canal secondary to the displacement of C7 over T1. The cord\\n transverses this dislocation with a bend but there are no signal abnormalities\\n of the cord at this level. Additionally the cord is normal in its caliber.\\n\\n On the axial images, there is disruption of the soft tissues immediately\\n posterior to the cord at the C7-T1 level however it is difficult to evaluate\\n the thecal sac at this level due to image blurring. There are degenerative\\n changes in the cervical spine superior to the known fractures. At the C4-5\\n level there is mild canal and neural foraminal narrowing secondary to\\n degenerative change. At C5-6, again there is mild canal narrowing at this\\n level; however there is severe narrowing of the left neural foramina at this\\n level.\\n\\n High signal on T2 weighted images show swelling of the soft tissues posterior\\n to the spinous processes of the cervical spine, associated with the known\\n injuries.\\n\\n IMPRESSION: Despite fracture and angulation of the spinal canal, the spinal\\n cord is normal in signal intensity and caliber suggesting that there is\\n minimal if any cord injury.\\n\\n\\n\\n (Over)\\n\\n 10:51 PM\\n MR CERVICAL SPINE Clip # \\n Reason: 75 yo fell out of tree onto outstretched arms, sustained\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-11-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 747867,\n \"text\": \" 11:24 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Pre-op CXR for OR on \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with cervical fracture\\n REASON FOR THIS EXAMINATION:\\n Pre-op CXR for OR on \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Pre-op for cervical spine fracture.\\n\\n No prior studies are available for comparison.\\n\\n PORTABLE AP CHEST: Please note that the extreme right costophrenic angle is\\n not included in this film. The cardiomediastinal silhouette is normal. The\\n pulmonary vasculature is normal. There is no consolidation or effusion on the\\n left. The left sternoclavicular joint is widened, of uncertain chronicity.\\n\\n IMPRESSION: 1) Limited examination excluding the extreme right costophrenic\\n angle. This examination will be repeated at no additional charge.\\n\\n 2) No acute cardiopulmonary abnormality apparent.\\n\\n 3) Widening of the left sternoclavicular joint of uncertain chronicity.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"C-SPINE, NON-TRAUMA\",\n \"row_id\": 748716,\n \"text\": \" 3:38 PM\\n C-SPINE, NON-TRAUMA Clip # \\n Reason: 75 yr old male s/p C7-T1 decopression please do ap and lat f\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with\\n REASON FOR THIS EXAMINATION:\\n 75 yr old male s/p C7-T1 decopression please do ap and lat films standing in\\n brace with swimmers view if necessary must view top of T1\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post C7-T1 decompression, follow-up study.\\n\\n Comparison is made to the prior study of .\\n\\n Three views of the cervical spine demonstrate fixation wires overlying the\\n posterior cervical spine at the C5 through T1 levels and skin staples. Grade\\n III anterolisthesis is demonstrated on the swimmer's view and is unchanged\\n compared to prior studies. Bridging anterior osteophytes are again seen,\\n unchanged.\\n\\n IMPRESSION: Stable appearance of C7-T1 spinal fusion and grade III\\n anterolisthesis of C7 on T1.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-05 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 748715,\n \"text\": \" 3:38 PM\\n CHEST (PA & LAT) Clip # \\n Reason: Elevated white cell couynt and low spo2.Evaluate for progre\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\\n REASON FOR THIS EXAMINATION:\\n Elevated white cell couynt and low spo2.Evaluate for progression of\\n effusion/infiltrates.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION:\\n Rising white count with question of retrocardiac density.\\n\\n FINDINGS:\\n Two views of the chest worsen to . Again seen is an area of\\n opacification in the right retrocardiac region. There is interval clearing of\\n the left retrocardiac region. There remains bilateral small pleural effusions.\\n There is no congestive heart failure. There is artifact from overlying\\n metallic device. No pneumothorax is seen.\\n\\n IMPRESSION:\\n 1) Persistent right retrocardiac density with interval improvement of the left\\n retrocardiac density.\\n 2) Bilateral small pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-08 00:00:00.000\",\n \"description\": \"CVL/PICC\",\n \"row_id\": 748910,\n \"text\": \" 8:32 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: S/P cervical instrumentation.Needs vancomycin.\\n ********************************* CPT Codes ********************************\\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\\n * CHEST AP ONLY *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with\\n REASON FOR THIS EXAMINATION:\\n S/P cervical instrumentation.Needs vancomycin.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 75 y/o man with recent cervical spine trauma and instrumentation.\\n He is now infected and requires IV access for longterm antibiotics.\\n\\n RADIOLOGISTS: Dr. and Dr. , staff Radiologist, was present for\\n the entire procedure.\\n\\n CONTRAST/MEDICATIONS: 1% Lidocaine for local anesthesia.\\n\\n PROCEDURE/TECHNIQUE: Informed and signed consent was obtained from the\\n patient. The patient was placed in a supine position on the angiographic table\\n and the left upper extremity was prepped and draped in the usual sterile\\n fashion. A left upper extremity ultrasound was performed as no superficial\\n palpable veins could be found. After administration of local anesthesia, the\\n left basilic vein was accessed with a 21 gauge needle under son\\n guidance. A .018 wire was then advanced through the needle to the level of the\\n lower SVC under continuous fluoroscopy. The needle was then exchanged for a 4\\n FR dilator and peelaway sheath. The dilator was removed and a 4 FR single\\n lumen PICC, trimmed to 47 cm, was advanced to the lower SVC under continuous\\n fluoroscopy. The peelaway sheath was simultaneously removed. The guide wire\\n was then removed and a radiograph obtained to confirm PICC position. The skin\\n was cleaned and the PICC secured to the skin using a stat lock and overlying\\n dressing. The patient tolerated the procedure well.\\n\\n COMPLICATIONS: None.\\n\\n FINDINGS: A preprocedural left upper extremity ultrasound shows a widely\\n patent and compressible left basilic vein. A post procedural radiograph shows\\n the tip of the PICC within the lower SVC. There is no pneumothorax.\\n\\n IMPRESSION: Technically successful placement of a 47 cm long, 4 FR single\\n lumen PICC via the left basilic vein. The tip is in the lower SVC. The line\\n is ready for immediate use.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2147-12-07 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 748869,\n \"text\": \" 3:29 PM\\n CHEST (PA & LAT) Clip # \\n Reason: 75 yr old male with question of retrocardiac opacity on cxr\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\\n REASON FOR THIS EXAMINATION:\\n 75 yr old male with question of retrocardiac opacity on cxr from please\\n assess for progress or improvemtn of this ? infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 75-year-old male with rising WBC, ? of retrocardiac opacity.\\n\\n FINDINGS: PA and lateral radiographs are compared with the PA and lateral\\n study dated . The heart size is normal. No retrocardiac opacities\\n are appreciated on the current study. The mediastinal and hilar contours are\\n normal. The pulmonary vascularity appears normal. The lungs appear clear.\\n There are no pleural effusions.\\n\\n There is osteopenia throughout the thoracic spine. There is calcification of\\n the anterior longitudinal ligament.\\n\\n IMPRESSION: 1) No evidence for retrocardiac opacities or pleural effusions.\\n No evidence for pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499661,\n \"text\": \"Nursing note\\nPt alert/oriented x3. VSS. Afebrile. Aspen cervical collar in place. Tongs to scalp in place with 27 lbs traction. Pt verbalizes understanding of traction and need for immobility. Neuro signs WNL. MAE. Pt states slight numbness/tingling of bil forearms conts. LS clear. Sats 96-97 on room air. Abd soft with + BS. Foley patent, draining QS clear yellow urine.\\n#20 IV intact in right forearm, infusing LR at 100cc/h. #18 IV intact in left AC infusing Solumedrol at 22cc/h. Sites benign. Denies pain. NPO x meds with sip. Monitor traction, VS, neuro status. Maintain traction. Maintain position with no movement/logrolling. For OR in AM. Family in to visit.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499662,\n \"text\": \"NURSING PROGRESS NOTE\\n12/6-7 B-SHIFT. A&O. MAE. CONSISTENT STRENGTH IN EXTREMS THROUGHOUT THE NITE. ASPEN COLLAR. HEAD/BACK IN TRACTION. VSS. BRADYCARDIA. AFEBRILE. RA. CLEAR LUNGS. NPO EXCEPT SIPS FOR MEDS. FOLEY. UO=QS. LR @ 100/HR. LATERAL XRAY. STARTED VENODYNES. BUN/CR=45/1.9. WBC=22.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499663,\n \"text\": \"NSG PROGRESS NOTE\\nRETURNED FROM OR INTUBATED AND NONRESPONSIVE. SOLUMEDROL GTT ON PR ANESTHESIA AT 5.4MG/KG/HR. TO RUN CONT GTT X23 HRS. NIPRIDE GTT STARTED FOR SBP 180-200. GOAL SBP < 150. NOT MOVING EXT OR FOLLOWING COMMAND INITIALLY ON ARRIVAL BEGINNING TO MOVE LOWER EXT, SQEEZE HANDS ON COMMAND AND ATTEMPT TO OPEN EYES AFTER 2-3 HRS IN SICU. HCT 29. RECEIVED 1 UNIT PRBC IN SICU. HAD RECEIVED 3 UNITS IN OR AS WELL AS 4 FFP. ASPEN COLLAR ON. HEMOVAC X2 WITH SANG. DRG. COMINO BOLT PLACED PR MD. UNABLE TO PLACE VENT DRAIN. ICP 4-10. HAD HEAD CT POST OP - POS INTRAVENT BLEED PR MD, BUT \\\"2ND TO BLEED FROM INITIAL FALL). FAMILY AT BEDSIDE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499664,\n \"text\": \"Nursing note:\\nNEURO: Opening eyes spont, MAE, following commands inconsistently, PERRLA. bolt in place/intact, ICP 5-11. Hemovac drains x 2 draining bloody drainage. Remains on 23hour Solumedrol gtt.\\nRESP: No vent changes overnight, remains on SIMV/PS 5, 35%, RR 12-16 w/spont. TVs of 500. Lung sounds coarse, sxn'd via ETT for thick tan secretions. Biting on tube.\\nCV: NSR 60-75, no ectopy. lytes repleted prn. Nipride gtt titrated to keep SBP <150, BP labile. Becomes hypertensive w/agitation.\\nGI: abdomen softly distended, -bs.\\nGU: foley patent adequate amounts yellow urine w/sediment.\\nACT: no turning/repositioning overnight per HO. Neurosurg to reevaluate in am. Aspen collar on, collar care done. no areas of breakdown noted. neck not to be flexed.\\nSOCIAL: supportive family at bedside much of evening.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2147-11-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1499665,\n \"text\": \"resp care\\n\\npt remains intubated and mech ventilated. pt weaned to cpap+ps secondary to dyssynchrony w/vent. ps 8 peep 5 fio2 35%. vt 500-600's rr teens to low 20's. b/s coarse. sxn tk tan. plan: cont w/mech support. wean as tolerated. pt to be tx to ct scan today.\\n\"\n }\n]"}}},{"rowIdx":787,"cells":{"subject_id":{"kind":"number","value":28671,"string":"28,671"},"hadm_id":{"kind":"number","value":125868,"string":"125,868"},"target_text":{"kind":"string","value":"Pt was admitted and taken to the OR for left pneumonectomy for lung cancer. An epidural was placed for pain control w/ good effect. Pt was transferred to the ICU for post op management including brief IV vasopressor support. drain was placed in the left chest at the time of the operation and was d/c'd on POD#1. POD#1 an NGT was placed for decompression of a large gastric bubble and was removed w/in 24 hrs. Pt was started on sips and diet was progressed and well. POD#3 epidural was d/c'd and pt was transferred out of the ICU. He progressed well and steadily w/his post op recovery. On POD#4 pt had brief non-sustained episodes of Afib. Cardiology was consulted and pt was treated w/ lopressor and amiodarone w/ good response and conversion to NSR. Anticoag w/ IV heparin was initiated for known PE. Pt had been on lovenox prior to surgery. At the time of discharge pt was on coumadin w/ lovenox bridge. He was ambulatory w/ sats 97% on room air."},"extractive_notes_summ":{"kind":"string","value":"son in this aft, updates provided.a/p: remains hypotensive d/t epidural infusion, orthostatic with any movement. NC 02 REMAINS BUT CAN BE WEANED OFF PER THORACICS. hypotensive w/ infusion, neo dose maintaining goal sbp as per thoracics. COMMENCED ON CLEAR LIQUIDS PER THORACICS THIS PM.GU: U/O ADEQUATE. (-) fluid balance for day, given fluid bolus x1 this am w/ little effect and albumin bolus this pm x1. L chest tube clamped this am by thoracics, plan to d/c this pm.cv: as above, remains hypotensive w/ epidural infusion. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Since the previous tracing of atrial fibrillation is absent, T wave changes are seen and the QTc intervalappears longer.TRACING #1 Pt remains on sm amt of neo despite attempts to wean off.Pt SV on 2L NC, sats 97-100%, LS clear to coarse in upper R lobe and RLL diminished. 0700-1900SEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.EVENTS: EPIDURAL REMOVED. Transmitral Doppler E>A and TDI E/e' <8 suggestingnormal diastolic function, and normal LV filling pressure (PCWP<12mmHg).LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). FINDINGS: On this upright study, there is a long air-fluid level slightly above the mid portion of the left hemithorax, consistent with the previous pneumonectomy. Pt requiring neo d/t epidural (as described by RN/team giving report to this RN).CV: NSR, HR 90-110, no ectopy, ABP goal >90's, maintained by neo-currently .6mg/kg/min. Dsg d & i, drainage to CT is serosanguinous. pt receiving last dose of Kefzol this AM, T max 99.8 PO.Endo- blood sugar wnl's, no sliding scale.Skin- left incision intact w/ durabond, superior midsternal incision intact w/ durabond as well.A/ pt w/ post-op arrythmias , BP further compromised by Afib, rate responding to dilt yet thoracic team requests switch to amiodarone this AM. FINDINGS: Status post left-sided pneumonectomy. Epidural at level T7/8 w/ dilaudid & bupivicane infusing at 3cc/hr, pt c/o minimal discomfort. HOLS AM HEPARIN PER APS FOR EPIDURAL REMOVAL IN AM. 0700-1900SEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.EVENTS: AMIODARONE DRIP COMMENCED. following trend w/ correlating nibp.gi: ngt placed for post op gastric distention on cxr, sm amts bilious output draining. Now on Dilt gtt as well.Current ROS pt alert and oriented even w/ low BP w/ afib. with moderate globalfree wall hypokinesis. Pneumonectomy space remains partially filled with fluid with similar level of air-fluid level to recent examination at the level of the interspace between the left sixth and seventh posterior ribs. CT to H2O seal, +fluctuation/+leak/+crepitous. FOLEY REMOVED @ 1600HRS AND PT HAS VOIDED SINCE REMOVAL.SKIN: THORACOTOMY INCISION CLEAN AND DRY. denies sob/distress.cv: as above, hypotensive w/ epidural infusion, per thoracics, to continue for pain control, using phenylephrine drip to maintain sbp>90. Easily palpable pedal pulses, heparin sc, Pboots on.Resp: Right lung sounds clear throughout, no adventitious sounds. LS CLEAR/COARSE ON R. ABSENT ON L. RR WNL.GI: NGT REMOVED THIS AM. true dermatome level around T7.resp: weaned to 4L nc o2, ls clear to R, dimin to L. L chest tube to h2o seal w/ bloody drainage for shift. HR 70-80, SBP 77-110, neo infusing at 0.4mcg/kg/min- attempted to wean off mult times, however pts BP cont to be labile. The MPIstayed 0.9 to 1.0 after pnemonectomy.LV function normal with cardiac output of 4.5-5l/min.LEFT ATRIUM: Mild LA enlargement. Con't on epidural of bupivicaine and dilaudid, rate decreased to 3cc's hr w/ hypotension and rhythm issues. INDICATION: Status post left pneumonectomy. The mitral valve appears structurally normal withtrivial mitral regurgitation. NEO WEANED FROM 1.0MCG/KG/MIN TO OFF. Left ventricularhypertrophy. Pt denies nausea. Mild RV free wallhypokinesia with trace TR. hypotension w/ drip, changed to 0.05% bupivicaine w/ same effect to bp only not quite as much so. FINAL REPORT INDICATION: Status post pneumonectomy. Since the previous tracingearlier the same date atrial flutter is present.TRACING #2 FINDINGS: As compared to the previous examination, the nasogastric tube has been removed. Compared to the previous tracing rapid atrial fibrillation isnew.TRACING #1 LYTES REPLETED.NEURO: A&O X3. true dermatome level approx T6-T9 level. The small amount of left supraclavicular subcutaneous emphysema is slowly resorbing. Family updated as to pts POC and status.POC: Wean supplemental O2, encourage CDB & use of IS, hemodynamics, titrate neo to maintain MAP >60, cont to manage Afib/Aflutter with amio gtt at 1mg/min x6 hrs, followed by 0.5mg/min x18 hrs. pt denies nausea, bs present x4 quads. D/c epidural today, ? DRIP STILL ATTACHED IF NEEDED.RESP: 02 SATS >99% ON 2L NC. epidural in place for pain control w/ 0.5% bupiv&dilaudid effective. NOW ON AMIOFARONE REGIMEN. One fluid bolus of 250cc's NS given as well for hypotension. There is a continued slow reabsorption of the left supraclavicular subcutaneous emphysema. CHEST DRAIN DRESSING LEFT INTACT. Foley patent, draining adequate amts of c/y/u- uop 30-50cc/hr. APS TO REMOVE EPIDURAL IN AM. Wean off neo as tolerated. The ascending, transverse and descending thoracic aortaare normal in diameter and free of atherosclerotic plaque . pain improved at rate 12cc/h 0.1% bupiv&dilaudid. wbc stable this am.skin: thoracotomy approach incision c/d/i, dermabond glue remains intact, area OTA. NGT REMOVED.NEURO: A&O X3. ALL APPROPRIATE AND RESPECTFUL OF PT NEEDING REST.PLAN: WEAN 02 TO OFF. TDI of tricuspid annulus MPI 1.4 on three readings.MPI stayed 1.2 after two lung ventilation on left lateral position. ++ FLATUS PASSED. BOWELS MOVED X 1 SMALL CONSTIPATED."},"n_notes":{"kind":"number","value":20,"string":"20"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2151-03-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1005590,"text":" 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval fluid collection in L hemithorax\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p L pneumonectomy\n REASON FOR THIS EXAMINATION:\n please eval fluid collection in L hemithorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left pneumonectomy to evaluate for fluid collection.\n\n FINDINGS: In comparison with the study of , there is little change in the\n left hemithorax. There is elevation of the hemidiaphragm with some shift of\n the mediastinal contents to this side. The residual spaces are filled with\n gas.\n\n Gas is seen subcutaneously adjacent to the lower left neck and upper thorax.\n The thick band of atelectasis on the right seen previously is not appreciated\n at this time. The prominence of interstitial markings most likely represents\n the fact that all pulmonary blood flow is now on the right.\n\n\n"},{"category":"Radiology","chartdate":"2151-03-10 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1006319,"text":" 9:31 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate left thorax fluid level\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p left pneumonectomy\n REASON FOR THIS EXAMINATION:\n evaluate left thorax fluid level\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST X-RAY DATED \n\n COMPARISON: .\n\n INDICATION: Status post left pneumonectomy.\n\n There is persistent expected shift of the mediastinum towards the left\n following left pneumonectomy. Pneumonectomy space remains partially filled\n with fluid with similar level of air-fluid level to recent examination at the\n level of the interspace between the left sixth and seventh posterior ribs.\n However, the amount of fluid has gradually increased over time compared to\n earlier postoperative radiographs. Within the right lung, there is mild\n vascular engorgement and a subtle interstitial pattern attributed to\n interstitial edema. No right pleural effusion is identified. Subcutaneous\n emphysema is again demonstrated in the left chest wall.\n\n IMPRESSION:\n 1. Similar appearance of left pneumonectomy space compared to recent\n postoperative radiograph but gradual increase in fluid since earlier\n radiographs.\n\n 2. Mild interstitial edema within the right lung.\n\n\n"},{"category":"Radiology","chartdate":"2151-03-09 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1006130,"text":" 6:11 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion/atelectasisobtain at 6AM\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with left pneumonectomy\n REASON FOR THIS EXAMINATION:\n evaluate for effusion/atelectasisobtain at 6AM\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left pneumonectomy, to compare with previous studies.\n\n FINDINGS: On this upright study, there is a long air-fluid level slightly\n above the mid portion of the left hemithorax, consistent with the previous\n pneumonectomy. The right lung remains clear. There is a continued slow\n reabsorption of the left supraclavicular subcutaneous emphysema.\n\n\n"},{"category":"Radiology","chartdate":"2151-03-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1005983,"text":" 6:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for fluid level\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p pneumonectomy\n REASON FOR THIS EXAMINATION:\n please eval for fluid level\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man status post pneumonectomy.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The patient is status post pneumonectomy and the\n amount of fluid within the left hemithorax is unchanged. The small amount of\n left supraclavicular subcutaneous emphysema is slowly resorbing. The right\n lung is unremarkable.\n\n\n\n"},{"category":"Radiology","chartdate":"2151-03-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1005493,"text":" 12:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for fluid level and PTX\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p L pneumonectomy\n REASON FOR THIS EXAMINATION:\n Please eval for fluid level and PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left pneumonectomy to evaluate for fluid level and pneumothorax.\n\n FINDINGS: In comparison with study of , there has been resection of the\n left lung. Loss of volume in the left hemithorax is seen with primarily gas\n filling the cavity. Small amount of fluid is seen at the base. Subcutaneous\n gas is seen along the left lateral chest wall.\n\n Dense streak of atelectasis is seen in the right lower lung zone.\n\n\n"},{"category":"Radiology","chartdate":"2151-03-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1005878,"text":" 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p pneumonectomy \n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: , 5:29 a.m.\n\n FINDINGS: As compared to the previous examination, the nasogastric tube has\n been removed. The left-sided hemithorax is slowly filling with fluid (status\n post left-sided pneumectomy). The small air collection in the suprascapular\n region, left is unchanged in extent. The right lung is unremarkable, no\n evidence of pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2151-03-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1005746,"text":" 4:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p pneumoectomy\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: Status post left-sided pneumonectomy. Subtle air collection in the\n left-sided soft tissues. Moderate pleural effusion. Empty pneumectomy space.\n The right lung shows subtle suprabasal atelectasis, but no evidence of opacity\n or effusion. No nasogastric tube in place.\n\n\n"},{"category":"Radiology","chartdate":"2151-03-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1005697,"text":" 5:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ct removal - ngt placement\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p pneumoectomy\n REASON FOR THIS EXAMINATION:\n ct removal - ngt placement\n ______________________________________________________________________________\n WET READ: BTCa FRI 9:31 PM\n Very limited study due to overpenetration. NGT appears to terminate just\n below the GE junction and should be advanced. Lung fields cannot be assessed\n and repeat radiographs are recommended. Findings discussed with Dr. \n at 9 pm on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pneumonectomy. Check NG tube placement.\n\n COMPARISON: at 6 a.m.\n\n FINDINGS: Cardiac silhouette is unchanged. The NG tube tip is at the GE\n junction and the patient may benefit from advancement. Findings were\n communicated to Dr. _____ at 9 p.m. on by Dr. .\n Limited assessment for the lungs due to hyperinflation.\n\n\n"},{"category":"Echo","chartdate":"2151-03-04 00:00:00.000","description":"Report","row_id":86056,"text":"PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Left ventricular function. Right ventricular function.\nStatus: Inpatient\nDate/Time: at 15:11\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n57 years old man for L thoracotomy and pneumonectomy. Mild RV free wall\nhypokinesia with trace TR. TDI of tricuspid annulus MPI 1.4 on three readings.\nMPI stayed 1.2 after two lung ventilation on left lateral position. MPI\ndropped to 1.1 on one lung ventilation after 5 minutes, 10 minutes. The MPI\nstayed 0.9 to 1.0 after pnemonectomy.\nLV function normal with cardiac output of 4.5-5l/min.\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the\nLAA. All four pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Low normal LVEF. Transmitral Doppler E>A and TDI E/e' <8 suggesting\nnormal diastolic function, and normal LV filling pressure (PCWP<12mmHg).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope.\n\nConclusions:\nThe left atrium is mildly dilated. No spontaneous echo contrast is seen in the\nleft atrial appendage. No atrial septal defect is seen by 2D or color Doppler.\nOverall left ventricular systolic function is low normal (LVEF 50-55%).\nTransmitral and tissue Doppler imaging suggests normal diastolic function, and\na normal left ventricular filling pressure (PCWP<12mmHg). with moderate global\nfree wall hypokinesis. The ascending, transverse and descending thoracic aorta\nare normal in diameter and free of atherosclerotic plaque . The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation.\n\n\n"},{"category":"Nursing/other","chartdate":"2151-03-04 00:00:00.000","description":"Report","row_id":1635634,"text":"nursing admit/progress note\n\npt is a 57 yo male w/ recent diagnosis of squamous cell CA of L lung, found in . pt is s/p chemotx treatment, admitted today to TSICU after L thoracotomy, pneumonectomy. intraop course uneventful, minimal blood loss noted. pt to ICU for observation extubated, on supplemental o2 w/ epidural catheter in place at T7-8.\n\nsee h+p for full medical hx and meds.\n\nneuro: initially sleepy post op, clearing over afternoon, pain initially not well controlled, epidural infusion increased slowly after bolus dosing as per APS. pain improved at rate 12cc/h 0.1% bupiv&dilaudid. due to signif. hypotension w/ drip, changed to 0.05% bupivicaine w/ same effect to bp only not quite as much so. pt currently comfortable w/ rate 6cc/h. true dermatome level around T7.\n\nresp: weaned to 4L nc o2, ls clear to R, dimin to L. L chest tube to h2o seal w/ bloody drainage for shift. no crepitus, no air leak. denies sob/distress.\n\ncv: as above, hypotensive w/ epidural infusion, per thoracics, to continue for pain control, using phenylephrine drip to maintain sbp>90. extrem warm, pulses intact. sinus brady to nsr, no ectope noted. lytes, hct stable post op.\n\ngi: npo, taking ice chips. belly soft/nt/nd. bs present. denies nausea.\n\ngu: foley patent clear yellow urine, qs.\n\nendo: glucose levels stable.\n\nid: afebrile, wbc 9.9 post op. ancef dosing x3 days post op.\n\nskin: L thoracotomy incision c/d/approximated, dermabond glue to entire line, OTA.\n\nsocial: pt's son and daughter in to visit, very supportive. son is HCP.\n\na/p: 57 yo male s/p L thoracotomy, pneumonectomy. doing well, pain well controlled w/ epidural. hypotensive w/ infusion, neo dose maintaining goal sbp as per thoracics. breathing unlabored, cough and deep breathing improving. plan for epidural overnight, wean neo as tol. follow chest tube output, hemodynamics.\n"},{"category":"Nursing/other","chartdate":"2151-03-05 00:00:00.000","description":"Report","row_id":1635636,"text":"nursing progress note\n\nneuro: a+ox3, mae. epidural in place for pain control w/ 0.5% bupiv&dilaudid effective. pt rates pain for shift when moving, zero when at rest. true dermatome level approx T6-T9 level. attempted to sit on edge of bed today w/ pt becoming very dizzy/lightheaded and hypotensive. unable to stand to get into chair.\n\nresp: ls mildly coarse to upper fields this morning, clearing well this pm w/ i/s usage and pulm exercise. weaned fio2 to 2l nc w/out incident. L chest tube clamped this am by thoracics, plan to d/c this pm.\n\ncv: as above, remains hypotensive w/ epidural infusion. thoracics and ICU teams aware. cont to require neo drip to maintain goal sbp >90. titrated to effect as ordered, rotating peripheral infusion sites per protocol. extrem warm, pulses intact, no edema. (-) fluid balance for day, given fluid bolus x1 this am w/ little effect and albumin bolus this pm x1. will monitor and titrate neo as able. lytes repleted this am, wnl this pm. a line positional, waveform at times dampened. following trend w/ correlating nibp.\n\ngi: ngt placed for post op gastric distention on cxr, sm amts bilious output draining. pt denies nausea, bs present x4 quads. belly soft/nt/nd. remains strictly npo.\n\ngu: autodiuresis slowing throughout morning, hourly output 30-80cc this pm. foley patent for clear yellow, qs.\n\nendo: glucose levels stable.\n\nid: tmax 99.4, ancef dosing x2 more doses per orders. wbc stable this am.\n\nskin: thoracotomy approach incision c/d/i, dermabond glue remains intact, area OTA. small anterior neck incision from pre op bx healing well, dermabond glue intact to area as well.\n\nsocial: many family in for visits today, very supportive. son in this aft, updates provided.\n\na/p: remains hypotensive d/t epidural infusion, orthostatic with any movement. pain very well controlled. doing well w/ pulm toileting, using i/s well. albumin dosing for this afternoon, will follow bp.\n"},{"category":"Nursing/other","chartdate":"2151-03-06 00:00:00.000","description":"Report","row_id":1635637,"text":"TSICU NPN 7p-7a\nEvents of the shift: Pt con't neo dependent attempts to wean unsucessful, Pt went into rapid afib w/ rate 150's at 3am, had received lopressor 5mg w/ no effect, followed by esmolol bolus by Dr. and ultimately Diltiazam bolus w/ decreased HR into the 80's, still afib initially then converted to SR yet still with frequent APC's, neo requirement increased back up during this time, one fluid bolus of 250cc's as well. Now on Dilt gtt as well.\n\nCurrent ROS\n\n pt alert and oriented even w/ low BP w/ afib. Con't on epidural of bupivicaine and dilaudid, rate decreased to 3cc's hr w/ hypotension and rhythm issues. Pt still rates pain at 2-3 on scale of with activity yet no pain at rest. Pt still c/o dizziness at times so unable to mobilize from bed, epidural level to mid sternum.\n\nCV- rapid afib as above w/ rates up to 150's, BP as low as 68/45, neo titrated up as high as 1.5mcg/kg/min and dilt gtt started after bolus as above, please see flow sheet for exact pressures. One fluid bolus of 250cc's NS given as well for hypotension. Lytes wnl's, hct stable, pt 1200cc's negative for the day yesterday, weight 68.8kg.\n\n pt on 2 l NP w/ RR 14-20 non labored, sats 95-98%, pt cough more congested this AM, CHXray pnd. Con't to do IS up to 750cc's, denies any SOB. Breath sounds absent on left and clear on right with slight crackles at right base towards the AM.\n\nGI- NGT advanced by HO, abd soft non distended, NGT draining small amts green bilious output. Pt denies nausea.\n\n pt con't w/ brisk u/o .\n\n pt receiving last dose of Kefzol this AM, T max 99.8 PO.\n\nEndo- blood sugar wnl's, no sliding scale.\n\nSkin- left incision intact w/ durabond, superior midsternal incision intact w/ durabond as well.\n\nA/ pt w/ post-op arrythmias , BP further compromised by Afib, rate responding to dilt yet thoracic team requests switch to amiodarone this AM. Lung sounds slightly more congested this AM, still doing IS well, good pain control even with decreased epidural rate. Con't to wean neo as tolerated.\n"},{"category":"Nursing/other","chartdate":"2151-03-06 00:00:00.000","description":"Report","row_id":1635638,"text":"0700-1900\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nEVENTS: AMIODARONE DRIP COMMENCED.\n NEO WEANED TO OFF.\n OOB TO CHAIR X2.\n NGT REMOVED.\n\nNEURO: A&O X3. MAE WELL.\n\nCV: AMIODARONE LOADING DOSE 150MG IV GIVEN. NOW ON AMIOFARONE REGIMEN. CURRENTLY @ 0.5MG/HR FOR 18HRS COMMENCED @ 1415HRS. MAINLY IN SR 70-80'S WITH PAC'S OCCASIONAL RATE CONTROLLED AFIB. NEO WEANED FROM 1.0MCG/KG/MIN TO OFF. GOAL SBP >90. CURRENTLY BORDERLINE SBP 86-92. WAS ON 0.4MCGS PRIOR TO SWITCHING OFF. DRIP STILL ATTACHED IF NEEDED.\n\nRESP: 02 SATS >99% ON 2L NC. COUGHING UP CLEAR/WHITE WITH OCCASIONAL BLOOD TINGED SPUTUM. LS CLEAR/COARSE ON R. ABSENT ON L. RR WNL.\n\nGI: NGT REMOVED THIS AM. ICE CHIPS AND PO MEDS TOLERATED WELL. COMMENCED ON BOWEL REGIMEN. HYPOACTIVE BOWEL SOUNDS. NO GAS PER PT REPORT. ABDOMEN SOFT NON TENDER.\n\nGU: FOLEY DRAINING CLEAR AMBER URINE 30-50ML/HR. CURRENTLY EVEN BALANCE.\n\nSKIN: THORACOTOMY INCISION CLEAN, DRY AND INTACT. OPEN TO AIR. EPIDURAL SITE REDRESSED AT THE EDGES AS DRESSING ROLLING UP. APS TO REMOVE EPIDURAL IN AM. PLEASE HOLD AM HEPARIN PER APS TEAM. REMIANING SKIN INTACT.\n\nSOCIAL: DAUGHTER TELEPHONED AND VISITED AND UPDATED ON PT CONDITION AND CURRENT PLANNED CARE.\n\nPLAN: WEAN NEO TO OFF WHILST MAINTAININS SBP >90.\n CONTINUE AMIODARONE DRIP FOR DURATION.\n ENSURE PT COMFORT AND SAFETY.\n HOLS AM HEPARIN PER APS FOR EPIDURAL REMOVAL IN AM.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2151-03-05 00:00:00.000","description":"Report","row_id":1635635,"text":"Nursing Progress Note\nSee Carevue for Specific Data.\n\nSignificant Events: Epidural increased to 9cc/hr d/t increased pain at incision site. BP dropped to 80's systolic 1-2 times during early evening, neo was down to .2mcg/kg/min, had to be increased to .6mcg/kg/min to maintain adequate BP.\n\nNeuro: Pt alert and oriented x3, follows commands, communicates effectively.\n\nPain: Pt has epidural, WNL, level checked with ice at T6 (xyphoid to hips). Pt still c/o pain overnight, rate increased to 9cc/hr. Pt requiring neo d/t epidural (as described by RN/team giving report to this RN).\n\nCV: NSR, HR 90-110, no ectopy, ABP goal >90's, maintained by neo-currently .6mg/kg/min. Easily palpable pedal pulses, heparin sc, Pboots on.\n\nResp: Right lung sounds clear throughout, no adventitious sounds. 4L nc, maintaining sats >96%. weak nonproductive cough. CT to H2O seal, +fluctuation/+leak/+crepitous. Dsg d & i, drainage to CT is serosanguinous. Incision d & i, no drainage, approximated with dermabond.\n\nGI: Abdomen soft, not distended, +BS, -BM since Tuesday according to pt. NPO, goal to keep pt dry. Maintenance fluid: LR 10cc/hr.\n\nGU: Pt autodiuresing->100cc/hr clear, light yellow urine through foley.\n\nEndo: No insulin administered, checking BS qid.\n\nID: Tmax 100.4, continues on cefazolin.\n\nSkin: Incision intact, approximated with dermabond, no drainage. back intact. Pt turning onto right side only.\n\nSocial: Son, daughter-in-law, and brother in to visit in evening, very supportive, joking with pt, appropriate. No calls overnight.\n\nPlan: ?Change epidural to PCA so pt can regulate pain management more effectively? Wean off neo as tolerated. Encourage IS/coughing/deep breathing. Transfer to floor when off neo.\n"},{"category":"Nursing/other","chartdate":"2151-03-07 00:00:00.000","description":"Report","row_id":1635639,"text":"Nursing Progress Note, 1900-0730\nPlease refer careview for specifics.\n\nSHIFT EVENTS: Pt went into rapid Afib with HR in the 160s with significant decrease in BP- 70/30s. Pt given 150mg bolus of amio with no effect in rate control, followed by 10mg diltiazem ivp. Pt given second 150mg amio bolus 3 hours later with return to SR. Amio gtt continues at 1mg/min. Pt remains on sm amt of neo despite attempts to wean off.\n\nPt SV on 2L NC, sats 97-100%, LS clear to coarse in upper R lobe and RLL diminished. Productive cough noted, able to expectorate secretions. Denies SOB. Pt in SR at beginning of shift and converted into rapid Afib w/ HR 130-160s at 1045, pt bolused with 150mg amio twice and given 10mg diltiazem ivp whereupon pt converted back into SR. Pt conts on amio gtt at 1mg/min x6 hrs. HR 70-80, SBP 77-110, neo infusing at 0.4mcg/kg/min- attempted to wean off mult times, however pts BP cont to be labile. Afebrile, no anbx coverage at this time. PIV x2 for access. L radial aline dampened, positional, & difficult to draw blood off of. 4 AM SC heparin held for removal of epidural, heparin to be changed to lovenox later today. Pt alert and oriented x3, no neuro deficits noted, OOB to chair with one assist, gait steady. Epidural at level T7/8 w/ dilaudid & bupivicane infusing at 3cc/hr, pt c/o minimal discomfort. Plan to d/c epidural today and start dilaudid PCA for pain control. Abd soft, + BS, no BM, on bowel regimen, NPO- tol ice chips/PO meds well. Foley patent, draining adequate amts of c/y/u- uop 30-50cc/hr. Lytes pnding.\n\nSOCIAL: Son and daughter into visit pt last night, will be in later today. Family updated as to pts POC and status.\n\nPOC: Wean supplemental O2, encourage CDB & use of IS, hemodynamics, titrate neo to maintain MAP >60, cont to manage Afib/Aflutter with amio gtt at 1mg/min x6 hrs, followed by 0.5mg/min x18 hrs. D/c epidural today, ? start po diet today if ok by thoracics, cont to provide pt and family with emotional support.\n"},{"category":"Nursing/other","chartdate":"2151-03-07 00:00:00.000","description":"Report","row_id":1635640,"text":"0700-1900\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nEVENTS: EPIDURAL REMOVED.\n NEO WEANED OFF BY 11AM.\n CLEAR LIQUID DIET COMMENCED.\n BOWELS MOVED.\n FOLEY REMOVED.\n REMAINED IN SR ALL SHIFT.\n LYTES REPLETED.\n\nNEURO: A&O X3. NO NEUROLOGICAL DEFICITS.\n\nRESP: COUGHING ALL DAY WITH SOME SPUTUM PRODUCTION. NC 02 REMAINS BUT CAN BE WEANED OFF PER THORACICS. CXR DONE THIS AM. REMAINING R LUNG CLEAR. NO C/O PAIN SINCE EPIDURAL REMOVAL.\n\nCV: REMAINED IN SR 80'S ALL SHIFT. AMIODARONE DRIP DUE FOR COMPLETION @ 2300HRS. SBP MAINTAINED >90 AND MEAN >60 OFF NEO SINCE 1100HRS.\n\nGI: + BOWEL SOUNDS. BOWELS MOVED X 1 SMALL CONSTIPATED. ++ FLATUS PASSED. COMMENCED ON CLEAR LIQUIDS PER THORACICS THIS PM.\n\nGU: U/O ADEQUATE. FOLEY REMOVED @ 1600HRS AND PT HAS VOIDED SINCE REMOVAL.\n\nSKIN: THORACOTOMY INCISION CLEAN AND DRY. CHEST DRAIN DRESSING LEFT INTACT. NO SEEPAGE. REMAINING SKIN INTACT. NO C/O OF PAIN.\n\nSOCIAL: ++ FAMILY AND FRIENDS INTO VISIT PT. ALL APPROPRIATE AND RESPECTFUL OF PT NEEDING REST.\n\nPLAN: WEAN 02 TO OFF.\n COMPLETE AMIODARONE DRIP REGIMEN AND CONVERT TO PO DOSE.\n TX TO FLOOR WITH TELEMETRY ON COMPLETION OF AMIODARONE DRIP.\n ENSURE PT COMFORT AND SAFETY.\n\n\n\n"},{"category":"ECG","chartdate":"2151-03-08 00:00:00.000","description":"Report","row_id":217882,"text":"Atrial flutter with rapid ventricular response. Left ventricular hypertrophy\nby voltage. Non-specific ST-T wave changes. Since the previous tracing\nearlier the same date atrial flutter is present.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2151-03-08 00:00:00.000","description":"Report","row_id":217883,"text":"Rhythm may be initially atrial flutter followed by sinus rhythm. Consider\nleft ventricular hypertrophy by voltage. The QTc interval appears prolonged\nbut it is difficult to measure. ST-T wave changes. Findings are non-specific.\nClinical correlation is suggested. Since the previous tracing of \natrial fibrillation is absent, T wave changes are seen and the QTc interval\nappears longer.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2151-03-06 00:00:00.000","description":"Report","row_id":217884,"text":"Atrial fibrillation versus atrial flutter with a variable block. Left\nventricular hypertrophy. Compared to the previous tracing the rate is slower.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2151-03-06 00:00:00.000","description":"Report","row_id":217885,"text":"Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy. Compared to the previous tracing rapid atrial fibrillation is\nnew.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2151-03-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1005590,\n \"text\": \" 5:27 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval fluid collection in L hemithorax\\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p L pneumonectomy\\n REASON FOR THIS EXAMINATION:\\n please eval fluid collection in L hemithorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Left pneumonectomy to evaluate for fluid collection.\\n\\n FINDINGS: In comparison with the study of , there is little change in the\\n left hemithorax. There is elevation of the hemidiaphragm with some shift of\\n the mediastinal contents to this side. The residual spaces are filled with\\n gas.\\n\\n Gas is seen subcutaneously adjacent to the lower left neck and upper thorax.\\n The thick band of atelectasis on the right seen previously is not appreciated\\n at this time. The prominence of interstitial markings most likely represents\\n the fact that all pulmonary blood flow is now on the right.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2151-03-10 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1006319,\n \"text\": \" 9:31 AM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate left thorax fluid level\\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p left pneumonectomy\\n REASON FOR THIS EXAMINATION:\\n evaluate left thorax fluid level\\n ______________________________________________________________________________\\n FINAL REPORT\\n TWO-VIEW CHEST X-RAY DATED \\n\\n COMPARISON: .\\n\\n INDICATION: Status post left pneumonectomy.\\n\\n There is persistent expected shift of the mediastinum towards the left\\n following left pneumonectomy. Pneumonectomy space remains partially filled\\n with fluid with similar level of air-fluid level to recent examination at the\\n level of the interspace between the left sixth and seventh posterior ribs.\\n However, the amount of fluid has gradually increased over time compared to\\n earlier postoperative radiographs. Within the right lung, there is mild\\n vascular engorgement and a subtle interstitial pattern attributed to\\n interstitial edema. No right pleural effusion is identified. Subcutaneous\\n emphysema is again demonstrated in the left chest wall.\\n\\n IMPRESSION:\\n 1. Similar appearance of left pneumonectomy space compared to recent\\n postoperative radiograph but gradual increase in fluid since earlier\\n radiographs.\\n\\n 2. Mild interstitial edema within the right lung.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2151-03-09 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1006130,\n \"text\": \" 6:11 AM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for effusion/atelectasisobtain at 6AM\\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with left pneumonectomy\\n REASON FOR THIS EXAMINATION:\\n evaluate for effusion/atelectasisobtain at 6AM\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Left pneumonectomy, to compare with previous studies.\\n\\n FINDINGS: On this upright study, there is a long air-fluid level slightly\\n above the mid portion of the left hemithorax, consistent with the previous\\n pneumonectomy. The right lung remains clear. There is a continued slow\\n reabsorption of the left supraclavicular subcutaneous emphysema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2151-03-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1005983,\n \"text\": \" 6:17 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for fluid level\\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p pneumonectomy\\n REASON FOR THIS EXAMINATION:\\n please eval for fluid level\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 57-year-old man status post pneumonectomy.\\n\\n COMPARISON: .\\n\\n FRONTAL CHEST RADIOGRAPH: The patient is status post pneumonectomy and the\\n amount of fluid within the left hemithorax is unchanged. The small amount of\\n left supraclavicular subcutaneous emphysema is slowly resorbing. The right\\n lung is unremarkable.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2151-03-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1005493,\n \"text\": \" 12:02 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for fluid level and PTX\\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p L pneumonectomy\\n REASON FOR THIS EXAMINATION:\\n Please eval for fluid level and PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Left pneumonectomy to evaluate for fluid level and pneumothorax.\\n\\n FINDINGS: In comparison with study of , there has been resection of the\\n left lung. Loss of volume in the left hemithorax is seen with primarily gas\\n filling the cavity. Small amount of fluid is seen at the base. Subcutaneous\\n gas is seen along the left lateral chest wall.\\n\\n Dense streak of atelectasis is seen in the right lower lung zone.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2151-03-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1005878,\n \"text\": \" 7:30 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate\\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p pneumonectomy \\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Followup.\\n\\n COMPARISON: , 5:29 a.m.\\n\\n FINDINGS: As compared to the previous examination, the nasogastric tube has\\n been removed. The left-sided hemithorax is slowly filling with fluid (status\\n post left-sided pneumectomy). The small air collection in the suprascapular\\n region, left is unchanged in extent. The right lung is unremarkable, no\\n evidence of pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2151-03-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1005746,\n \"text\": \" 4:52 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: f/u\\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with s/p pneumoectomy\\n REASON FOR THIS EXAMINATION:\\n f/u\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Followup.\\n\\n COMPARISON: .\\n\\n FINDINGS: Status post left-sided pneumonectomy. Subtle air collection in the\\n left-sided soft tissues. Moderate pleural effusion. Empty pneumectomy space.\\n The right lung shows subtle suprabasal atelectasis, but no evidence of opacity\\n or effusion. No nasogastric tube in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2151-03-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1005697,\n \"text\": \" 5:36 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: ct removal - ngt placement\\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with s/p pneumoectomy\\n REASON FOR THIS EXAMINATION:\\n ct removal - ngt placement\\n ______________________________________________________________________________\\n WET READ: BTCa FRI 9:31 PM\\n Very limited study due to overpenetration. NGT appears to terminate just\\n below the GE junction and should be advanced. Lung fields cannot be assessed\\n and repeat radiographs are recommended. Findings discussed with Dr. \\n at 9 pm on .\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post pneumonectomy. Check NG tube placement.\\n\\n COMPARISON: at 6 a.m.\\n\\n FINDINGS: Cardiac silhouette is unchanged. The NG tube tip is at the GE\\n junction and the patient may benefit from advancement. Findings were\\n communicated to Dr. _____ at 9 p.m. on by Dr. .\\n Limited assessment for the lungs due to hyperinflation.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2151-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 86056,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Chronic lung disease. Left ventricular function. Right ventricular function.\\nStatus: Inpatient\\nDate/Time: at 15:11\\nTest: Portable TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\n57 years old man for L thoracotomy and pneumonectomy. Mild RV free wall\\nhypokinesia with trace TR. TDI of tricuspid annulus MPI 1.4 on three readings.\\nMPI stayed 1.2 after two lung ventilation on left lateral position. MPI\\ndropped to 1.1 on one lung ventilation after 5 minutes, 10 minutes. The MPI\\nstayed 0.9 to 1.0 after pnemonectomy.\\nLV function normal with cardiac output of 4.5-5l/min.\\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the\\nLAA. All four pulmonary veins identified and enter the left atrium.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\\nimages. Low normal LVEF. Transmitral Doppler E>A and TDI E/e' <8 suggesting\\nnormal diastolic function, and normal LV filling pressure (PCWP<12mmHg).\\n\\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\\n\\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis.\\n\\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\\natherosclerotic plaque.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The TEE probe was passed\\nwith assistance from the anesthesioology staff using a laryngoscope.\\n\\nConclusions:\\nThe left atrium is mildly dilated. No spontaneous echo contrast is seen in the\\nleft atrial appendage. No atrial septal defect is seen by 2D or color Doppler.\\nOverall left ventricular systolic function is low normal (LVEF 50-55%).\\nTransmitral and tissue Doppler imaging suggests normal diastolic function, and\\na normal left ventricular filling pressure (PCWP<12mmHg). with moderate global\\nfree wall hypokinesis. The ascending, transverse and descending thoracic aorta\\nare normal in diameter and free of atherosclerotic plaque . The aortic valve\\nleaflets (3) appear structurally normal with good leaflet excursion and no\\naortic regurgitation. The mitral valve appears structurally normal with\\ntrivial mitral regurgitation.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2151-03-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1635634,\n \"text\": \"nursing admit/progress note\\n\\npt is a 57 yo male w/ recent diagnosis of squamous cell CA of L lung, found in . pt is s/p chemotx treatment, admitted today to TSICU after L thoracotomy, pneumonectomy. intraop course uneventful, minimal blood loss noted. pt to ICU for observation extubated, on supplemental o2 w/ epidural catheter in place at T7-8.\\n\\nsee h+p for full medical hx and meds.\\n\\nneuro: initially sleepy post op, clearing over afternoon, pain initially not well controlled, epidural infusion increased slowly after bolus dosing as per APS. pain improved at rate 12cc/h 0.1% bupiv&dilaudid. due to signif. hypotension w/ drip, changed to 0.05% bupivicaine w/ same effect to bp only not quite as much so. pt currently comfortable w/ rate 6cc/h. true dermatome level around T7.\\n\\nresp: weaned to 4L nc o2, ls clear to R, dimin to L. L chest tube to h2o seal w/ bloody drainage for shift. no crepitus, no air leak. denies sob/distress.\\n\\ncv: as above, hypotensive w/ epidural infusion, per thoracics, to continue for pain control, using phenylephrine drip to maintain sbp>90. extrem warm, pulses intact. sinus brady to nsr, no ectope noted. lytes, hct stable post op.\\n\\ngi: npo, taking ice chips. belly soft/nt/nd. bs present. denies nausea.\\n\\ngu: foley patent clear yellow urine, qs.\\n\\nendo: glucose levels stable.\\n\\nid: afebrile, wbc 9.9 post op. ancef dosing x3 days post op.\\n\\nskin: L thoracotomy incision c/d/approximated, dermabond glue to entire line, OTA.\\n\\nsocial: pt's son and daughter in to visit, very supportive. son is HCP.\\n\\na/p: 57 yo male s/p L thoracotomy, pneumonectomy. doing well, pain well controlled w/ epidural. hypotensive w/ infusion, neo dose maintaining goal sbp as per thoracics. breathing unlabored, cough and deep breathing improving. plan for epidural overnight, wean neo as tol. follow chest tube output, hemodynamics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2151-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1635636,\n \"text\": \"nursing progress note\\n\\nneuro: a+ox3, mae. epidural in place for pain control w/ 0.5% bupiv&dilaudid effective. pt rates pain for shift when moving, zero when at rest. true dermatome level approx T6-T9 level. attempted to sit on edge of bed today w/ pt becoming very dizzy/lightheaded and hypotensive. unable to stand to get into chair.\\n\\nresp: ls mildly coarse to upper fields this morning, clearing well this pm w/ i/s usage and pulm exercise. weaned fio2 to 2l nc w/out incident. L chest tube clamped this am by thoracics, plan to d/c this pm.\\n\\ncv: as above, remains hypotensive w/ epidural infusion. thoracics and ICU teams aware. cont to require neo drip to maintain goal sbp >90. titrated to effect as ordered, rotating peripheral infusion sites per protocol. extrem warm, pulses intact, no edema. (-) fluid balance for day, given fluid bolus x1 this am w/ little effect and albumin bolus this pm x1. will monitor and titrate neo as able. lytes repleted this am, wnl this pm. a line positional, waveform at times dampened. following trend w/ correlating nibp.\\n\\ngi: ngt placed for post op gastric distention on cxr, sm amts bilious output draining. pt denies nausea, bs present x4 quads. belly soft/nt/nd. remains strictly npo.\\n\\ngu: autodiuresis slowing throughout morning, hourly output 30-80cc this pm. foley patent for clear yellow, qs.\\n\\nendo: glucose levels stable.\\n\\nid: tmax 99.4, ancef dosing x2 more doses per orders. wbc stable this am.\\n\\nskin: thoracotomy approach incision c/d/i, dermabond glue remains intact, area OTA. small anterior neck incision from pre op bx healing well, dermabond glue intact to area as well.\\n\\nsocial: many family in for visits today, very supportive. son in this aft, updates provided.\\n\\na/p: remains hypotensive d/t epidural infusion, orthostatic with any movement. pain very well controlled. doing well w/ pulm toileting, using i/s well. albumin dosing for this afternoon, will follow bp.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2151-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1635637,\n \"text\": \"TSICU NPN 7p-7a\\nEvents of the shift: Pt con't neo dependent attempts to wean unsucessful, Pt went into rapid afib w/ rate 150's at 3am, had received lopressor 5mg w/ no effect, followed by esmolol bolus by Dr. and ultimately Diltiazam bolus w/ decreased HR into the 80's, still afib initially then converted to SR yet still with frequent APC's, neo requirement increased back up during this time, one fluid bolus of 250cc's as well. Now on Dilt gtt as well.\\n\\nCurrent ROS\\n\\n pt alert and oriented even w/ low BP w/ afib. Con't on epidural of bupivicaine and dilaudid, rate decreased to 3cc's hr w/ hypotension and rhythm issues. Pt still rates pain at 2-3 on scale of with activity yet no pain at rest. Pt still c/o dizziness at times so unable to mobilize from bed, epidural level to mid sternum.\\n\\nCV- rapid afib as above w/ rates up to 150's, BP as low as 68/45, neo titrated up as high as 1.5mcg/kg/min and dilt gtt started after bolus as above, please see flow sheet for exact pressures. One fluid bolus of 250cc's NS given as well for hypotension. Lytes wnl's, hct stable, pt 1200cc's negative for the day yesterday, weight 68.8kg.\\n\\n pt on 2 l NP w/ RR 14-20 non labored, sats 95-98%, pt cough more congested this AM, CHXray pnd. Con't to do IS up to 750cc's, denies any SOB. Breath sounds absent on left and clear on right with slight crackles at right base towards the AM.\\n\\nGI- NGT advanced by HO, abd soft non distended, NGT draining small amts green bilious output. Pt denies nausea.\\n\\n pt con't w/ brisk u/o .\\n\\n pt receiving last dose of Kefzol this AM, T max 99.8 PO.\\n\\nEndo- blood sugar wnl's, no sliding scale.\\n\\nSkin- left incision intact w/ durabond, superior midsternal incision intact w/ durabond as well.\\n\\nA/ pt w/ post-op arrythmias , BP further compromised by Afib, rate responding to dilt yet thoracic team requests switch to amiodarone this AM. Lung sounds slightly more congested this AM, still doing IS well, good pain control even with decreased epidural rate. Con't to wean neo as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2151-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1635638,\n \"text\": \"0700-1900\\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\\n\\nEVENTS: AMIODARONE DRIP COMMENCED.\\n NEO WEANED TO OFF.\\n OOB TO CHAIR X2.\\n NGT REMOVED.\\n\\nNEURO: A&O X3. MAE WELL.\\n\\nCV: AMIODARONE LOADING DOSE 150MG IV GIVEN. NOW ON AMIOFARONE REGIMEN. CURRENTLY @ 0.5MG/HR FOR 18HRS COMMENCED @ 1415HRS. MAINLY IN SR 70-80'S WITH PAC'S OCCASIONAL RATE CONTROLLED AFIB. NEO WEANED FROM 1.0MCG/KG/MIN TO OFF. GOAL SBP >90. CURRENTLY BORDERLINE SBP 86-92. WAS ON 0.4MCGS PRIOR TO SWITCHING OFF. DRIP STILL ATTACHED IF NEEDED.\\n\\nRESP: 02 SATS >99% ON 2L NC. COUGHING UP CLEAR/WHITE WITH OCCASIONAL BLOOD TINGED SPUTUM. LS CLEAR/COARSE ON R. ABSENT ON L. RR WNL.\\n\\nGI: NGT REMOVED THIS AM. ICE CHIPS AND PO MEDS TOLERATED WELL. COMMENCED ON BOWEL REGIMEN. HYPOACTIVE BOWEL SOUNDS. NO GAS PER PT REPORT. ABDOMEN SOFT NON TENDER.\\n\\nGU: FOLEY DRAINING CLEAR AMBER URINE 30-50ML/HR. CURRENTLY EVEN BALANCE.\\n\\nSKIN: THORACOTOMY INCISION CLEAN, DRY AND INTACT. OPEN TO AIR. EPIDURAL SITE REDRESSED AT THE EDGES AS DRESSING ROLLING UP. APS TO REMOVE EPIDURAL IN AM. PLEASE HOLD AM HEPARIN PER APS TEAM. REMIANING SKIN INTACT.\\n\\nSOCIAL: DAUGHTER TELEPHONED AND VISITED AND UPDATED ON PT CONDITION AND CURRENT PLANNED CARE.\\n\\nPLAN: WEAN NEO TO OFF WHILST MAINTAININS SBP >90.\\n CONTINUE AMIODARONE DRIP FOR DURATION.\\n ENSURE PT COMFORT AND SAFETY.\\n HOLS AM HEPARIN PER APS FOR EPIDURAL REMOVAL IN AM.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2151-03-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1635635,\n \"text\": \"Nursing Progress Note\\nSee Carevue for Specific Data.\\n\\nSignificant Events: Epidural increased to 9cc/hr d/t increased pain at incision site. BP dropped to 80's systolic 1-2 times during early evening, neo was down to .2mcg/kg/min, had to be increased to .6mcg/kg/min to maintain adequate BP.\\n\\nNeuro: Pt alert and oriented x3, follows commands, communicates effectively.\\n\\nPain: Pt has epidural, WNL, level checked with ice at T6 (xyphoid to hips). Pt still c/o pain overnight, rate increased to 9cc/hr. Pt requiring neo d/t epidural (as described by RN/team giving report to this RN).\\n\\nCV: NSR, HR 90-110, no ectopy, ABP goal >90's, maintained by neo-currently .6mg/kg/min. Easily palpable pedal pulses, heparin sc, Pboots on.\\n\\nResp: Right lung sounds clear throughout, no adventitious sounds. 4L nc, maintaining sats >96%. weak nonproductive cough. CT to H2O seal, +fluctuation/+leak/+crepitous. Dsg d & i, drainage to CT is serosanguinous. Incision d & i, no drainage, approximated with dermabond.\\n\\nGI: Abdomen soft, not distended, +BS, -BM since Tuesday according to pt. NPO, goal to keep pt dry. Maintenance fluid: LR 10cc/hr.\\n\\nGU: Pt autodiuresing->100cc/hr clear, light yellow urine through foley.\\n\\nEndo: No insulin administered, checking BS qid.\\n\\nID: Tmax 100.4, continues on cefazolin.\\n\\nSkin: Incision intact, approximated with dermabond, no drainage. back intact. Pt turning onto right side only.\\n\\nSocial: Son, daughter-in-law, and brother in to visit in evening, very supportive, joking with pt, appropriate. No calls overnight.\\n\\nPlan: ?Change epidural to PCA so pt can regulate pain management more effectively? Wean off neo as tolerated. Encourage IS/coughing/deep breathing. Transfer to floor when off neo.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2151-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1635639,\n \"text\": \"Nursing Progress Note, 1900-0730\\nPlease refer careview for specifics.\\n\\nSHIFT EVENTS: Pt went into rapid Afib with HR in the 160s with significant decrease in BP- 70/30s. Pt given 150mg bolus of amio with no effect in rate control, followed by 10mg diltiazem ivp. Pt given second 150mg amio bolus 3 hours later with return to SR. Amio gtt continues at 1mg/min. Pt remains on sm amt of neo despite attempts to wean off.\\n\\nPt SV on 2L NC, sats 97-100%, LS clear to coarse in upper R lobe and RLL diminished. Productive cough noted, able to expectorate secretions. Denies SOB. Pt in SR at beginning of shift and converted into rapid Afib w/ HR 130-160s at 1045, pt bolused with 150mg amio twice and given 10mg diltiazem ivp whereupon pt converted back into SR. Pt conts on amio gtt at 1mg/min x6 hrs. HR 70-80, SBP 77-110, neo infusing at 0.4mcg/kg/min- attempted to wean off mult times, however pts BP cont to be labile. Afebrile, no anbx coverage at this time. PIV x2 for access. L radial aline dampened, positional, & difficult to draw blood off of. 4 AM SC heparin held for removal of epidural, heparin to be changed to lovenox later today. Pt alert and oriented x3, no neuro deficits noted, OOB to chair with one assist, gait steady. Epidural at level T7/8 w/ dilaudid & bupivicane infusing at 3cc/hr, pt c/o minimal discomfort. Plan to d/c epidural today and start dilaudid PCA for pain control. Abd soft, + BS, no BM, on bowel regimen, NPO- tol ice chips/PO meds well. Foley patent, draining adequate amts of c/y/u- uop 30-50cc/hr. Lytes pnding.\\n\\nSOCIAL: Son and daughter into visit pt last night, will be in later today. Family updated as to pts POC and status.\\n\\nPOC: Wean supplemental O2, encourage CDB & use of IS, hemodynamics, titrate neo to maintain MAP >60, cont to manage Afib/Aflutter with amio gtt at 1mg/min x6 hrs, followed by 0.5mg/min x18 hrs. D/c epidural today, ? start po diet today if ok by thoracics, cont to provide pt and family with emotional support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2151-03-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1635640,\n \"text\": \"0700-1900\\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\\n\\nEVENTS: EPIDURAL REMOVED.\\n NEO WEANED OFF BY 11AM.\\n CLEAR LIQUID DIET COMMENCED.\\n BOWELS MOVED.\\n FOLEY REMOVED.\\n REMAINED IN SR ALL SHIFT.\\n LYTES REPLETED.\\n\\nNEURO: A&O X3. NO NEUROLOGICAL DEFICITS.\\n\\nRESP: COUGHING ALL DAY WITH SOME SPUTUM PRODUCTION. NC 02 REMAINS BUT CAN BE WEANED OFF PER THORACICS. CXR DONE THIS AM. REMAINING R LUNG CLEAR. NO C/O PAIN SINCE EPIDURAL REMOVAL.\\n\\nCV: REMAINED IN SR 80'S ALL SHIFT. AMIODARONE DRIP DUE FOR COMPLETION @ 2300HRS. SBP MAINTAINED >90 AND MEAN >60 OFF NEO SINCE 1100HRS.\\n\\nGI: + BOWEL SOUNDS. BOWELS MOVED X 1 SMALL CONSTIPATED. ++ FLATUS PASSED. COMMENCED ON CLEAR LIQUIDS PER THORACICS THIS PM.\\n\\nGU: U/O ADEQUATE. FOLEY REMOVED @ 1600HRS AND PT HAS VOIDED SINCE REMOVAL.\\n\\nSKIN: THORACOTOMY INCISION CLEAN AND DRY. CHEST DRAIN DRESSING LEFT INTACT. NO SEEPAGE. REMAINING SKIN INTACT. NO C/O OF PAIN.\\n\\nSOCIAL: ++ FAMILY AND FRIENDS INTO VISIT PT. ALL APPROPRIATE AND RESPECTFUL OF PT NEEDING REST.\\n\\nPLAN: WEAN 02 TO OFF.\\n COMPLETE AMIODARONE DRIP REGIMEN AND CONVERT TO PO DOSE.\\n TX TO FLOOR WITH TELEMETRY ON COMPLETION OF AMIODARONE DRIP.\\n ENSURE PT COMFORT AND SAFETY.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2151-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 217882,\n \"text\": \"Atrial flutter with rapid ventricular response. Left ventricular hypertrophy\\nby voltage. Non-specific ST-T wave changes. Since the previous tracing\\nearlier the same date atrial flutter is present.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2151-03-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 217883,\n \"text\": \"Rhythm may be initially atrial flutter followed by sinus rhythm. Consider\\nleft ventricular hypertrophy by voltage. The QTc interval appears prolonged\\nbut it is difficult to measure. ST-T wave changes. Findings are non-specific.\\nClinical correlation is suggested. Since the previous tracing of \\natrial fibrillation is absent, T wave changes are seen and the QTc interval\\nappears longer.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2151-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 217884,\n \"text\": \"Atrial fibrillation versus atrial flutter with a variable block. Left\\nventricular hypertrophy. Compared to the previous tracing the rate is slower.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2151-03-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 217885,\n \"text\": \"Atrial fibrillation with a rapid ventricular response. Left ventricular\\nhypertrophy. Compared to the previous tracing rapid atrial fibrillation is\\nnew.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":788,"cells":{"subject_id":{"kind":"number","value":98089,"string":"98,089"},"hadm_id":{"kind":"number","value":179750,"string":"179,750"},"target_text":{"kind":"string","value":"75 year old man with colon cancer s/p hemicolectomy and s/p bilateral ureteral stent placement initially admitted to the for UGIB in setting of constipation and hematuria. Was transferred to the floor once hemodynamically stable. UGIB resolved, but constipation persisted. After an extensive workup, was found to have a partial LBO likely secondary to malignancy. . #1. Partial LBO: The patient reported chronic constipation (BM q 7 days) worsening over the prior 3 weeks. Had + flatus, but passing only very small stools. KUB was suggestive of obstruction. Flex sig and colonoscopy were initially attempted but failed to pass beyond 20 cm with poor visualization due to stool. The patient did not tolerate NGT decompression. A PET/CT showed dilated loops of small and large bowel with no VDG avid foci. A second attempt at colonoscopy showed an obstruction at approximately 30 cm beyond which the scope could not pass. Gastrografin enemas were refused by the patient. MR d marked small and large bowel dilation with a transition point at the colosigmoid junction. This is likely due to external compression from metastatic disease. Clinically, the patient's abdomen remains distended and tympanic, but soft and nontender. He continues to have flatus and very small, liquid stools. There is no abdominal pain and no nausea/vomiting. He was placed on TPN for persistent poor PO intake. He was taken to the OR on for palliative ileostomy. . #2. UGIB: The patient initially presented with coffee grounds emesis in setting of constipation. Etiology of UGIB thought to be likely tear from repeated emesis. NG tube was placed to suction with Gastroccult positive. Stable hemodynamically during stay. The patient has not had a dramatic drop in Hct. Remained HD stable during stay without current evidence of active bleed. GI consulted performed EGD showing food in the esophagus without evidence of active bleed. Hct was trended upwards and the patient was maintained on PPIs. . #3. UTI/Hematuria: Likely related to Foley and recent stent placement. Was treated as complicated UTI for 7 days with Ciprofloxacin per Urology. Course has been completed. Blood and urine cultures were negative. Foley has since been D/Ced and there is no evidence of UTI. The patient is urinary incontinent. . #4. Ureteral obstruction/s/p stent placement: The patient's creatinine has improved, max 2.5, down to 1.2 currently, since placement of bilateral stents and passing adequate UOP. Post void residuals have been <200. Per Urology recs, if >200, should give prophylactic antibiotics. . #5. s/p CVA: The patient was kept on Aggrenox. It was held on in anticipation of surgical intervention. . #6. HTN: Lisinopril was held in the setting of normal BPs. . #7. Hyperlipidemia: Statin was discontinued on in the setting of LBO. . #8.8 Diabetes: Diet controlled at home. Had FS QID and Insulin Sliding Scale. . #9. h/o prostate cancer: The patient was continued on his home dose of Flomax. He has been urinary incontinent. . #10. Depression: the patient was continued on his home does of SSRIs. . PPx: Pneumoboots, Heparin SC CODE: DNR/DNI EMERGENCY CONTACT: Wife Surgery: Patient continue to have symptoms of partial small bowel obstruction, poor food tolerance, abdominal distension and pain. He had A MRI that showed extensive dilated loops of small bowel and colon with apparent transition deep in the pelvis at distal colon. The decision was made to take him to the operating room. On for exploratory laparotomy, we founded a copious amount of clear ascitic fluid in the abdominal cavity. Palpation of the abdomen revealed carcinomatosis studding the mesentery, the small bowel, the residual large bowel and the liver. There was a loop of small bowel in the right lower quadrant that was solidly adherent to the retroperitoneum. He had a loop ileostomy in order to try to decrease acute symptoms of bowel obstruction. The patient was admitted to the General Surgical Service for evaluation and treatment. After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids and antibiotics, with a Foley catheter. The patient was hemodynamically stable. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropiate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Palliative care was consulted, they had an extensive meeting with patient and family. They both understand the goals of care are palliative and comfort oriented, patient and family decided they would like to have hospice involvement. Ostomy nurse service was consulted, they worked extensively on Ostomy care teaching and management. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. Patient was discharge to hospice for pain management and comfort. Medications on Admission: lipitor 10mg PO daily Flomax 0.4mg PO daily Keflex 500mg PO TID since Tylenol #3 prn Lisinopril 10mg PO daily Effexor XR 37.5mg PO daily Cipro 250mg PO daily? wife denies 100mg PO TID Mag citrate OFF AGGRENOX x 1 week . Medications on Transfer: Bisacodyl PR Pantoprazole 40mg IV Q12H Cephalexin 500mg Q8H (day 6) Zofran PRN Insulin SS Ciprofloxacin 400mg IV Q12H (day 2) 100mg Venlafaxine 37.5mg QD Tylenol PRN Atorvastatin 10mg QD Discharge Medications: 1. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*85 Tablet(s)* Refills:*0* 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 2 weeks. 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 8. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 10. Insulin Sliding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 1 Units 1 Units 1 Units 1 Units 201-250 mg/dL 2 Units 2 Units 2 Units 2 Units 251-300 mg/dL 3 Units 3 Units 3 Units 3 Units 301-350 mg/dL 4 Units 4 Units 4 Units 4 Units 351-400 mg/dL 5 Units 5 Units 5 Units 5 Units 11. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* 12. Morphine 20 mg/5 mL Solution Sig: 5mg PO every four (4) hours as needed for Severe pain or breathlessness: Comfort care. Disp:*30 ml* Refills:*0* 13. Lorazepam 2 mg/mL Concentrate Sig: One (1) PO every six (6) hours as needed for anxiety or agitation: Comfort care. Disp:*30 ml* Refills:*0* 14. Atropine 1 % Drops Sig: Two (2) drops Ophthalmic every four (4) hours as needed for secretions: S/L Comfort Care. Disp:*5 ml* Refills:*0* Discharge Disposition: Extended Care Facility: Hospice at Discharge Diagnosis: Partial Large Bowel Obstruction Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Lethargic but arousable Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Monitoring Ostomy output/Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Appointment #1 MD: Dr. Specialty: Surgery Please schedule an appointment in 2 week. ( Appointment #2 MD: Dr Specialty: Urology Date/ Time: at 3:45pm Location: , bldg, Phone number: Appointment #3 MD: Dr Specialty: Primary Care Date/ Time: at 10am Location: , Phone number: MD, Completed by:[**2201-2-25**"},"extractive_notes_summ":{"kind":"string","value":"HTN: Hold antihypertensives in setting of GIB #. HTN: Hold antihypertensives in setting of GIB #. HTN: Hold antihypertensives in setting of GIB #. HTN: Hold antihypertensives in setting of GIB #. - continue PPI drip for now, change to dosing in am - maintain PIVs x 2 - monitor HCT q8, next HCT likely to be lower since has received IVF but transfuse for HCT <27 or active bleed - maintain NPO with IVF - appreciate GI recommendations, possible EGD in am - guaiac all stool - continue NGT to wall suction - NS bolus x 1 L now #. - continue PPI drip for now, change to dosing in am - maintain PIVs x 2 - monitor HCT q8, next HCT likely to be lower since has received IVF but transfuse for HCT <27 or active bleed - maintain NPO with IVF - appreciate GI recommendations, possible EGD in am - guaiac all stool - continue NGT to wall suction - NS bolus x 1 L now #. - continue PPI drip for now, change to dosing in am - maintain PIVs x 2 - monitor HCT q8, next HCT likely to be lower since has received IVF but transfuse for HCT <27 or active bleed - maintain NPO with IVF - appreciate GI recommendations, possible EGD in am - guaiac all stool - continue NGT to wall suction - NS bolus x 1 L now #. WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? Hematuria: Likely related to foley and recent stent placement - appreciate urology recommendations who will see in am # ?UTI: Patient has foley catheter in place and positive UA although is asymptomatic other than urinary urgency related to foley catheter. Hematuria: Likely related to foley and recent stent placement - appreciate urology recommendations who will see in am # ?UTI: Patient has foley catheter in place and positive UA although is asymptomatic other than urinary urgency related to foley catheter. HTN: Hold antihypertensives in setting of GIB #. Action: Pt medicated again with dulcolax suppose. Action: Pt medicated again with dulcolax suppose. Right hemicolectomy changes. FINDINGS: Right hemicolectomy changes are noted. Hematemesis (upper GI bleed, UGIB) Assessment: Action: Response: Plan: Constipation (Obstipation, FOS) Assessment: Action: Response: Plan: There is no (Over) 2:08 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval for obstruction FINAL REPORT (Cont) point of transition seen. WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? Bilateral ureteral obstruction s/p b/l stent placement ; unclear etiology of obstruction per review of notes 3. Interval placement of bilateral ureteral stents with resolution of previously noted hydronephrosis. UTI hematuria, possibly related to recent stent placement. He received 1LNS, pantoprazole, levofloxacin, flagyl and Zofran. - continue PPI drip for now, change to dosing in am - maintain PIVs x 2 - monitor HCT q8, next HCT likely to be lower since has received IVF but transfuse for HCT <27 or active bleed - maintain NPO with IVF - appreciate GI recommendations, possible EGD in am - guaiac all stool - continue NGT to wall suction - NS bolus x 1 L now #. FINDINGS: The left-sided PICC line has been removed in the interim. Received protonix iv,flagyl and started with protonix drip and transffered to for further management. Received protonix iv,flagyl and started with protonix drip and transffered to for further management. Received protonix iv,flagyl and started with protonix drip and transffered to for further management. Received protonix iv,flagyl and started with protonix drip and transffered to for further management. for stent placement, will d/w urology #. Hematuria: Likely related to foley and recent stent placement - appreciate urology recommendations who will see in am # ?UTI: Patient has foley catheter in place and positive UA although is asymptomatic other than urinary urgency related to foley catheter."},"n_notes":{"kind":"number","value":22,"string":"22"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2201-02-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":514705,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Tap Water enema that he did not retain\n - Bisacodyl suppository without effect\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:11 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.1\n HR: 79 (68 - 86) bpm\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 95%\n Total In:\n 1,702 mL\n 613 mL\n PO:\n TF:\n IVF:\n 1,702 mL\n 613 mL\n Blood products:\n Total out:\n 250 mL\n 670 mL\n Urine:\n 250 mL\n 520 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.4 g/dL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n CONSTIPATION (OBSTIPATION, FOS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2201-02-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":514707,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Tap Water enema that he did not retain\n - Bisacodyl suppository without effect\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:11 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.1\n HR: 79 (68 - 86) bpm\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 95%\n Total In:\n 1,702 mL\n 613 mL\n PO:\n TF:\n IVF:\n 1,702 mL\n 613 mL\n Blood products:\n Total out:\n 250 mL\n 670 mL\n Urine:\n 250 mL\n 520 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.4 g/dL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 75 year old man with colon cancer s/p hemicolectomy and s/p\n bilateral ureteral stent placement now admitted to with UGIB in\n setting of constipation and hematuria\n #. UGIB: Patient presented with coffee grounds emesis in setting of\n constipation. Differential diagnosis includes gastritis, \n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\n prior history of varices or liver disease. He is guaiac negative from\n below and has been constipated which would be atypical for brisk GIB\n especially given still passing flatus and no clear obstruction on CT\n scan. Most likely scenario would be constipation leading to nausea and\n vomiting and possible tear related to emesis. Remains HD\n stable without current evidence of active bleed and HCT as well as BUN\n are currently improved from baseline. He denies recent NSAID or steroid\n use that would increase risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, possible EGD in am\n - guaiac all stool\n - continue NGT to wall suction\n - NS bolus x 1 L now\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n PPX:\n -DVT ppx with pneumoboots in setting of GIB\n -Bowel regimen with enemas, home regimen\n -Pain management with tylenol\n ACCESS: PIV's\n .\n CODE STATUS: DNR/DNI\n .\n EMERGENCY CONTACT: Wife \n .\n DISPOSITION: ICU for now, likely call out if stable in am\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2201-02-04 00:00:00.000","description":"Physician Attending Progress Note","row_id":514811,"text":"Chief Complaint: 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 24 Hour Events:\n Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. This BM was hard\n but brown and not black or tarry. Has continued to pass flatus. Denies\n abdominal pain, melena, hematochezia, chest pain, SOB, fever, chills,\n lightheadedness, decreased PO intake, NSAID or steroid use. His wife\n called ambulance to take him to ED for weakness and consripation and he\n had coffee grounds emesis x 2 in ambulance and subsequently in ED. He\n also reprots hematuria since stents and foley placed 4 days prior.\n Denies any prior h/o GIB or similar symptoms.\n .\n In the emergency department, initial vitals were: 97.8 91 142/79 16\n 98%RA. NG lavage was positive for hemoccult positive coffee grounds\n which did not clear after 1L. He was guaiac negative but was noted to\n have abdominal tenderness so CT abdomen/pelvis was obtained and\n revealed distended small and large bowel with air fluid levels\n suggestive of gastroenteritis. GI and Surgery evaluated patient and\n recommended decompressing from above with NGT and enemas from below but\n no urgent indication for scope since HD stable. UA was positive and\n blood cx x 2 were drawn. He received 1LNS, pantoprazole, levofloxacin,\n flagyl and Zofran. Labs significant for HCT 34 from baseline 32 and Cr\n 1.7 from baseline 2.0.\n .\n Vitals prior to transfer were: 77 131/78 16 95%RA\n Passed brown stool overnight.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 07:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\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: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 84 (68 - 95) bpm\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\n RR: 19 (12 - 24) insp/min\n SpO2: 98%\n Total In:\n 1,702 mL\n 1,003 mL\n PO:\n 180 mL\n TF:\n IVF:\n 1,702 mL\n 823 mL\n Blood products:\n Total out:\n 250 mL\n 870 mL\n Urine:\n 250 mL\n 720 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.4 g/dL\n 226 K/uL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\n stent placement, now admitted to with UGIB.\n GI BLEED -- with coffee grounds emesis concern for .\n in setting of constipation. Differential diagnosis includes gastritis,\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have\n varices given no prior history of varices or liver disease. He is\n guaiac negative from below and has been constipated which would be\n atypical for brisk GIB especially given still passing flatus and no\n clear obstruction on CT scan. Most likely scenario would be\n constipation leading to nausea and vomiting and possible \n tear related to emesis. Remains HD stable without current evidence of\n active bleed and HCT as well as BUN are currently improved from\n baseline. He denies recent NSAID or steroid use that would increase\n risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, possible EGD in am\n - guaiac all stool\n - continue NGT to wall suction\n - NS bolus x 1 L now\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"General","chartdate":"2201-02-03 00:00:00.000","description":"Generic Note","row_id":514600,"text":"MICU ATTENDING ADM ISSION 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 Dr\n \ns note above, including the assessment and plan. I would\n emphasize and add the following points:\n Mr was recently admitted to the for evaluation of bilateral\n hydro-uretero-nephrosis of unclear etiology. He had placement of\n bilateral stents and was discharged home with an indwelling foley and\n PO antibiotics. He now presents with weakness, coffee ground emesis and\n hematuria. He denies abdominal pain but does admit to significant\n thirst. He has not had a syncopal event or fevers.\n His PMH is notable for a right hemicoleectomy with R/A by Dr in\n for Stage 3B colon Cancer. He had a pelvic nodule excised at the\n time of laparotomy which revealed fat necrosis. He has also had a prior\n CVA and CRI ( with creatinine close to 2.0) in the past. His recent Hct\n on D/C was 28. His CEA has been rising.\n Exam notable for Tm of 98, BP of 142/80 HR of 90 RR of 16 with sats of\n 98% on RA . He has significantly diminished skin turgor and coffee\n grounds on NG lavage. He has clear lung fields and a soft belly. His\n foley catheter is draining dark urine.\n Labs notable for WBC 11.8K, HCT of 24 ( 28) , K+ of 4.7, Cr of 1.7 (\n 2.0) , lactate of 1.4. CXR with elevated left hemidiaphragm and\n distended loops of bowel without free air. His Abd CT shows air fluid\n levels in colon and extensive fecal material in colon. There does not\n appear to be migration of stents either.\n He is severely volume deplete and made worse with his h/o chronic\n constipation. He has likely had an UGI bleed ( gastritis vs esophagitis\n vs M-W tear) but is hemodynamically stable with no concerns regarding\n ongoing active bleeding. He does not appear septic either but we will\n need to monitor closely for this. He has received 1 L NS thus far in\n addition to IV PPI and antibiotics. He will need continued fluid\n rescucitation and decompression of colon with enemas to allow for\n improvement of colonic/ small bowel distension/ emesis. GI staff to see\n in am regarding need for EGD. Appreciate surgical and urology input. If\n there are no hemodynamic issues overnight, he will leave the ICU in am\n . Oncology staff to provide further advise regarding concerns\n for rising CEA and possibly recurrent/ metastatic colon Ca once acute\n issues have resolved.\n Remainder of plan as outlined above.\n Patient is chronically ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n"},{"category":"Physician ","chartdate":"2201-02-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":514756,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Tap Water enema that he did not retain\n - Bisacodyl suppository without effect\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:11 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.1\n HR: 79 (68 - 86) bpm\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 95%\n Total In:\n 1,702 mL\n 613 mL\n PO:\n TF:\n IVF:\n 1,702 mL\n 613 mL\n Blood products:\n Total out:\n 250 mL\n 670 mL\n Urine:\n 250 mL\n 520 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n GENERAL: Pleasant, well appearing elderly gentleman in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. Dry MM. OP clear with dried blood in posterior\n OP. NGT in place with gastroccult positive coffee grounds material in\n canister.\n Neck: Supple, No LAD, No thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur heard best RUSB. No rubs or . JVP=7-8cm\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Distended abdomen. Well healed midline scar. Hyperactive BS.\n Palpable peristalsis. TTP with involuntary guarding LLQ. No rebound or\n HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses. Scar R knee\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Speech slow and deliberate. Initially reported was in\n but later reoriented to in , MA. Oriented\n to self and wife and able to relate her phone number. Oriented to month\n and year but not date. Appropriate. CN 2-12 intact. 5/5 strength\n throughout. + reflexes, equal BL. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 226 K/uL\n 10.4 g/dL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 75 year old man with colon cancer s/p hemicolectomy and s/p\n bilateral ureteral stent placement now admitted to with UGIB in\n setting of constipation and hematuria\n #. UGIB: Patient presented with coffee grounds emesis in setting of\n constipation. Differential diagnosis includes gastritis, \n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\n prior history of varices or liver disease. He is guaiac negative from\n below and has been constipated which would be atypical for brisk GIB\n especially given still passing flatus and no clear obstruction on CT\n scan. Most likely scenario would be constipation leading to nausea and\n vomiting and possible tear related to emesis. Remains HD\n stable without current evidence of active bleed and HCT as well as BUN\n are currently improved from baseline. He denies recent NSAID or steroid\n use that would increase risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, EGD in several days\n - guaiac all stool\n - continue NGT to wall suction\n .\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n PPX:\n -DVT ppx with pneumoboots in setting of GIB\n -Bowel regimen with enemas, home regimen\n -Pain management with tylenol\n ACCESS: PIV's\n .\n CODE STATUS: DNR/DNI\n .\n EMERGENCY CONTACT: Wife \n .\n DISPOSITION: ICU for now, likely call out if stable HCT at Noon\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"},{"category":"Physician ","chartdate":"2201-02-04 00:00:00.000","description":"Physician Attending Progress Note","row_id":514743,"text":"Chief Complaint: 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 24 Hour Events:\n Passed brown stool overnight.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 07:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\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: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 84 (68 - 95) bpm\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\n RR: 19 (12 - 24) insp/min\n SpO2: 98%\n Total In:\n 1,702 mL\n 1,003 mL\n PO:\n 180 mL\n TF:\n IVF:\n 1,702 mL\n 823 mL\n Blood products:\n Total out:\n 250 mL\n 870 mL\n Urine:\n 250 mL\n 720 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.4 g/dL\n 226 K/uL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\n stent placement, now admitted to with UGIB.\n GI BLEED -- with coffee grounds emesis concern for .\n in setting of constipation. Differential diagnosis includes gastritis,\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have\n varices given no prior history of varices or liver disease. He is\n guaiac negative from below and has been constipated which would be\n atypical for brisk GIB especially given still passing flatus and no\n clear obstruction on CT scan. Most likely scenario would be\n constipation leading to nausea and vomiting and possible \n tear related to emesis. Remains HD stable without current evidence of\n active bleed and HCT as well as BUN are currently improved from\n baseline. He denies recent NSAID or steroid use that would increase\n risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, possible EGD in am\n - guaiac all stool\n - continue NGT to wall suction\n - NS bolus x 1 L now\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":514627,"text":"Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":514667,"text":"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt c/o nausea and vomitted once watery mixed with coffee ground\n particles early am. denies any pain,abd firm,BS hypoactive.\n Action:\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":514671,"text":"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt c/o nausea and vomitted once watery mixed with coffee ground\n particles early am. denies any pain,abd firm,BS hypoactive. Foley to\n gravity, bloody urine initially,but more clear later on.\n Action:\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\n Response:\n Crit drop from 41 to 29 with am labs. VSS. No further vomiting or\n .\n Plan:\n f/u with am labs and monitor further .\n Constipation (Obstipation, FOS)\n Assessment:\n Pt without BM for last ~ 10 days. Abd firm,BS hypo, NGT tube in place,\n connected to LWIS .\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":514673,"text":"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt c/o nausea and vomitted once watery mixed with coffee ground\n particles early am. denies any pain,abd firm,BS hypoactive. Foley to\n gravity, bloody urine initially,but more clear later on.\n Action:\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\n Response:\n Crit drop from 41 to 29 with am labs. VSS. No further vomiting or\n .\n Plan:\n f/u with am labs and monitor further .\n Constipation (Obstipation, FOS)\n Assessment:\n Pt without BM for last ~ 10 days. Abd firm,BS hypo, NGT tube in place,\n connected to LWIS .\n Action:\n Tried for tap water enema ,but not retained. Bisacodyl PR given . NPO\n except meds and ice chips. On docusate .\n Response:\n Pt stayed on bedpan for long time, but No BM yet.\n Plan:\n need another dose of PR medication or any strong bowel regimen\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":514664,"text":"Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2201-02-04 00:00:00.000","description":"Physician Attending Progress Note","row_id":514874,"text":"Chief Complaint: 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 24 Hour Events:\n Passed brown stool overnight.\n No new complaints this AM.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 07:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\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: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 84 (68 - 95) bpm\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\n RR: 19 (12 - 24) insp/min\n SpO2: 98%\n Total In:\n 1,702 mL\n 1,003 mL\n PO:\n 180 mL\n TF:\n IVF:\n 1,702 mL\n 823 mL\n Blood products:\n Total out:\n 250 mL\n 870 mL\n Urine:\n 250 mL\n 720 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.4 g/dL\n 226 K/uL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\n stent placement, now admitted to with GI bleed.\n GI BLEED -- with coffee grounds emesis concern for upper source.\n Concerns include gastritis, PUD, - tear, Dieulafoys ulcer,\n AVM. No clnical concern for varices. Plan maintain iv access, monitor\n serial Hct, PPI infusion, GI consultation to assess for EGD.\n FLUIDS\n hypovolemia; plan to net replete.\n CONSTIPATION\n chronic. Signs of mild ileus. Monitor abd exam.\n General surgery to follow.\n UTI\n hematuria, possibly related to recent stent placement. Possible\n UTI. Ciprofloxicin. Urology to follow up.\n s/p CVA -- Hold aggrenox in setting of GIB\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":514780,"text":"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":514782,"text":"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt presented to ed with coffee grounds in the setting of\n constipation( no stool x 10 days). Differential dx included gastritis,\n tear. No clear obstruction on ct scan. Most likely\n scenarion would be constipation leading to nausea and vomiting and\n possible tear related to emesis. Pt hemodynamically\n stable since admit with hr 80-90\ns and sbp 121-149. ngt to low\n continuous sx has drained about 500cc\n colored drainage with\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\n presently off.\n Action:\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\n maintained. Ngt continued to low wall suction.\n Response:\n Stable hct and hemodynamics.\n Plan:\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\n hemodynamics. Maintain 2 piv\ns and keep pt npo except for meds. Gi\n consult team following pt and will most likely pt will have endoscopy\n in days.ppi changed to pantoprazole iv .\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Progress Note","row_id":514784,"text":"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt presented to ed with coffee grounds in the setting of\n constipation( no stool x 10 days). Differential dx included gastritis,\n tear. No clear obstruction on ct scan. Most likely\n scenarion would be constipation leading to nausea and vomiting and\n possible tear related to emesis. Pt hemodynamically\n stable since admit with hr 80-90\ns and sbp 121-149. ngt to low\n continuous sx has drained about 500cc\n colored drainage with\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\n presently off.\n Action:\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\n maintained. Ngt continued to low wall suction.\n Response:\n Stable hct and hemodynamics.\n Plan:\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\n hemodynamics. Maintain 2 piv\ns and keep pt npo except for meds. Gi\n consult team following pt and will most likely pt will have endoscopy\n in days.ppi changed to pantoprazole iv .\n Constipation (Obstipation, FOS)\n Assessment:\n Constipation likely related to chronic constipation as pt reports that\n he typically has bm q 7 days. This constipation may be worsened by\n recent surgery and Tylenol with codeine use as well as dehydratons\n given his dry appearance on exam. Abd firm and distended with few bowel\n sounds on auscultation. Ct neg for obstruction. Pt given sse on noc\n shift which he was unable to retain and dulocolax supp . pt has passed\n sm soft brown stool.\n Action:\n Pt medicated again with dulcolax suppose. Ngt to wall suction to\n decompress from above.\n Response:\n Still with little stool output.\n Plan:\n Continue to follow stool output and guiac all stools. Continue with\n aggressive bowel regimen and administer colace as ordered. Maintain ngt\n to low wall suction in order to decompress from above. Avoid narcotics.\n"},{"category":"Nursing","chartdate":"2201-02-04 00:00:00.000","description":"Nursing Transfer Note","row_id":514785,"text":"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt presented to ed with coffee grounds in the setting of\n constipation( no stool x 10 days). Differential dx included gastritis,\n tear. No clear obstruction on ct scan. Most likely\n scenarion would be constipation leading to nausea and vomiting and\n possible tear related to emesis. Pt hemodynamically\n stable since admit with hr 80-90\ns and sbp 121-149. ngt to low\n continuous sx has drained about 500cc\n colored drainage with\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\n presently off.\n Action:\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\n maintained. Ngt continued to low wall suction.\n Response:\n Stable hct and hemodynamics.\n Plan:\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\n hemodynamics. Maintain 2 piv\ns and keep pt npo except for meds. Gi\n consult team following pt and will most likely pt will have endoscopy\n in days.ppi changed to pantoprazole iv .\n Constipation (Obstipation, FOS)\n Assessment:\n Constipation likely related to chronic constipation as pt reports that\n he typically has bm q 7 days. This constipation may be worsened by\n recent surgery and Tylenol with codeine use as well as dehydratons\n given his dry appearance on exam. Abd firm and distended with few bowel\n sounds on auscultation. Ct neg for obstruction. Pt given sse on noc\n shift which he was unable to retain and dulocolax supp . pt has passed\n sm soft brown stool.\n Action:\n Pt medicated again with dulcolax suppose. Ngt to wall suction to\n decompress from above.\n Response:\n Still with little stool output.\n Plan:\n Continue to follow stool output and guiac all stools. Continue with\n aggressive bowel regimen and administer colace as ordered. Maintain ngt\n to low wall suction in order to decompress from above. Avoid narcotics.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n UPPER GASTROINTESTINAL BLEED\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Colon cancer, stage IIIB, status post hemicolectomy\n on in the setting of bowel obstruction, received 7 cycles of\n Xeloda, stopped concern for progression of disease ,\n Bilateral ureteral obstruction s/p b/l stent placement ; unclear\n etiology of obstruction per review of notes , CVA with residual R\n sided weakness and R facial droop , Hypertension , Diabetes (diet\n controlled) , Hyperlipidemia , Prostate cancer s/p treatment with\n external beam radiation \"many years ago\" -,\n Surgery / Procedure and date: hemicolectomy \n bilateral uretral stent placement \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:78\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 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 FiO2 set:\n 24h total in:\n 1,003 mL\n 24h total out:\n 1,030 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:13 AM\n Potassium:\n 3.5 mEq/L\n 04:13 AM\n Chloride:\n 103 mEq/L\n 04:13 AM\n CO2:\n 25 mEq/L\n 04:13 AM\n BUN:\n 25 mg/dL\n 04:13 AM\n Creatinine:\n 1.6 mg/dL\n 04:13 AM\n Glucose:\n 166\n 06:00 AM\n Hematocrit:\n 30.0 %\n 11:36 AM\n Finger Stick Glucose:\n 209\n 12:00 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 409\n Transferred to: 1184\n Date & time of Transfer: 1430\n"},{"category":"Physician ","chartdate":"2201-02-03 00:00:00.000","description":"Physician Resident Admission Note","row_id":514604,"text":"Chief Complaint: Hematemesis\n HPI:\n Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. This BM was hard\n but brown and not black or tarry. Has continued to pass flatus. Denies\n abdominal pain, melena, hematochezia, chest pain, SOB, fever, chills,\n lightheadedness, decreased PO intake, NSAID or steroid use. His wife\n called ambulance to take him to ED for weakness and consripation and he\n had coffee grounds emesis x 2 in ambulance and subsequently in ED. He\n also reprots hematuria since stents and foley placed 4 days prior.\n Denies any prior h/o GIB or similar symptoms.\n .\n In the emergency department, initial vitals were: 97.8 91 142/79 16\n 98%RA. NG lavage was positive for hemoccult positive coffee grounds\n which did not clear after 1L. He was guaiac negative but was noted to\n have abdominal tenderness so CT abdomen/pelvis was obtained and\n revealed distended small and large bowel with air fluid levels\n suggestive of gastroenteritis. GI and Surgery evaluated patient and\n recommended decompressing from above with NGT and enemas from below but\n no urgent indication for scope since HD stable. UA was positive and\n blood cx x 2 were drawn. He received 1LNS, pantoprazole, levofloxacin,\n flagyl and Zofran. Labs significant for HCT 34 from baseline 32 and Cr\n 1.7 from baseline 2.0.\n .\n Vitals prior to transfer were: 77 131/78 16 95%RA\n .\n REVIEW OF SYSTEMS:\n (+)ve: Urinary urgency since foley catheter placed.\n (-)ve: As above. Denies fever, chills, night sweats, loss of appetite,\n weight loss, palpitations, nasal congestion, cough, sputum production,\n hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, focal\n numbness, focal weakness, myalgias, arthralgias\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:11 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Home Meds:\n Lipitor 10mg PO daily\n Flomax 0.4mg PO daily\n Keflex 500mg PO TID since \n Tylenol #3 prn\n Lisinopril 10mg PO daily\n Effexor XR 37.5mg PO daily\n Colace 100mg PO TID\n Mag citrate prn\n OFF AGGRENOX x 1 week\n Past medical history:\n Family history:\n Social History:\n 1. Colon cancer, stage IIIB, status post hemicolectomy on in\n the setting of bowel obstruction, received 7 cycles of Xeloda, stopped\n concern for progression of disease\n 2. Bilateral ureteral obstruction s/p b/l stent placement ;\n unclear etiology of obstruction per review of notes\n 3. CVA with residual R sided weakness and R facial droop\n 4. Hypertension\n 5. Diabetes (diet controlled)\n 6. Hyperlipidemia\n 7. Prostate cancer s/p treatment with external beam radiation \"many\n years ago\" -\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is married with two children. He is a retired\n electrician from in and currently lives in ,\n MA with wife. denies tobacco, alcohol or drug abuse.\n Review of systems:\n Flowsheet Data as of 11:32 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (98.9\n HR: 84 (77 - 86) bpm\n BP: 134/70(85) {132/70(85) - 157/91(103)} mmHg\n RR: 14 (12 - 24) insp/min\n SpO2: 97%\n Total In:\n 601 mL\n PO:\n TF:\n IVF:\n 601 mL\n Blood products:\n Total out:\n 0 mL\n 250 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 351 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: Pleasant, well appearing elderly gentleman in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. Dry MM. OP clear with dried blood in posterior\n OP. NGT in place with gastroccult positive coffee grounds material in\n canister.\n Neck: Supple, No LAD, No thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur heard best RUSB. No rubs or . JVP=7-8cm\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Distended abdomen. Well healed midline scar. Hyperactive BS.\n Palpable peristalsis. TTP with involuntary guarding LLQ. No rebound or\n HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses. Scar R knee\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Speech slow and deliberate. Initially reported was in\n but later reoriented to in , MA. Oriented\n to self and wife and able to relate her phone number. Oriented to month\n and year but not date. Appropriate. CN 2-12 intact. 5/5 strength\n throughout. + reflexes, equal BL. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n Imaging: CT A/P:Distended large and small bowel suggestive of\n gastroenteritis\n CXR: (my read): NGT in stomach. No infiltrate or effusion. Normal\n cardiac silhouette. Large stomach gas bubble and dilated loops of bowel\n with elevated left hemidiaphragm. Blunted rigth costophrenic angle\n Microbiology: Urine cx: Pending\n Blood cx x 2 pending\n ECG: ECG:NSR HR 75. Normal axis and intervals with slight IVCD QRS\n 90msec. Q waves in V5-V6. No acute ST or T wave changes. ? U waves\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 75 year old man with colon cancer s/p hemicolectomy and s/p\n bilateral ureteral stent placement now admitted to with UGIB in\n setting of constipation and hematuria\n #. UGIB: Patient presented with coffee grounds emesis in setting of\n constipation. Differential diagnosis includes gastritis, \n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\n prior history of varices or liver disease. He is guaiac negative from\n below and has been constipated which would be atypical for brisk GIB\n especially given still passing flatus and no clear obstruction on CT\n scan. Most likely scenario would be constipation leading to nausea and\n vomiting and possible tear related to emesis. Remains HD\n stable without current evidence of active bleed and HCT as well as BUN\n are currently improved from baseline. He denies recent NSAID or steroid\n use that would increase risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, possible EGD in am\n - guaiac all stool\n - continue NGT to wall suction\n - NS bolus x 1 L now\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n PPX:\n -DVT ppx with pneumoboots in setting of GIB\n -Bowel regimen with enemas, home regimen\n -Pain management with tylenol\n ACCESS: PIV's\n .\n CODE STATUS: DNR/DNI\n .\n EMERGENCY CONTACT: Wife \n .\n DISPOSITION: ICU for now, likely call out if stable in am\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"},{"category":"ECG","chartdate":"2201-02-03 00:00:00.000","description":"Report","row_id":252773,"text":"Sinus rhythm. Tracing may be within normal limits but unstable baseline makes\nassessment difficult. Since the previous tracing of there may be no\nsignificant change but unstable baseline makes comparison difficult.\n\n"},{"category":"Radiology","chartdate":"2201-02-03 00:00:00.000","description":"CT PELVIS W/O CONTRAST","row_id":1118239,"text":" 2:08 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with left sided abdominal pain\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine;\n ______________________________________________________________________________\n WET READ: ASpf 4:36 PM\n Distended small and large bowel with air fluid levels suggestive of\n gastroenteritis.\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE ABDOMEN AND PELVIS PERFORMED ON .\n\n CLINICAL HISTORY: 75-year-old male with left-sided abdominal pain, question\n obstruction.\n\n Comparison is made with a prior CT abdomen and pelvis dated .\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images through the\n abdomen and pelvis without oral or IV contrast material. IV contrast was\n withheld due to patient's elevated creatinine. Coronal and sagittal\n reformations were provided.\n\n FINDINGS:\n\n LUNG BASES: There is slight interval increase in the layering\n simple-appearing right-sided pleural effusion. Mild compressive atelectasis\n is also noted at the right lung base. There is a 3-mm focus of nodularity\n along the major fissure on series 2, image 10. Additional tiny vague areas of\n nodularity in the right middle lobe are seen on series 2, image 12, likely as\n well as image 14, which may be inflammatory. An NG tube courses into the\n upper abdomen with the distal side-port at the level of the GE junction. A\n small hiatal hernia is noted. Coronary artery calcifications are noted.\n\n ABDOMEN: Non-contrast appearance of the liver is unremarkable. There is a\n small amount of perihepatic free fluid. Gallbladder is collapsed. The spleen\n is unremarkable. Adrenal glands appear normal bilaterally. The pancreas is\n grossly normal. Kidneys have been internally decompressed with bilateral\n ureteral stents in place with proximal coils well positioned in the bilateral\n renal pelves and distal coils in the urinary bladder. Nonspecific perinephric\n stranding is stable. The abdominal aorta contains atherosclerotic\n calcifications notably at the origin of the major branch vessel. There is no\n aneurysm seen. Retroperitoneal lymph nodes do not appear enlarged.\n\n The stomach is decompressed. The duodenum appears grossly unremarkable.\n\n PELVIS: There is diffuse fluid distention of small bowel with numerous\n air-fluid levels and bowel measuring up to 3.4 cm in diameter. There is no\n (Over)\n\n 2:08 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n point of transition seen. An anastomosis in the right mid abdomen is noted in\n this patient with prior right colonic resection. Distal to the anastomosis\n there is gaseous distention and mild dilation of the large bowel without\n discrete point of obstruction though note is made of the significant fecal\n loading of the sigmoid colon. There is no gross bowel wall thickening seen.\n The urinary bladder is decompressed with a Foley catheter in place. Small\n amount of free fluid extends into the pelvis.\n\n BONES: Degenerative changes are noted in the lower lumbar spine. Significant\n facet arthropathy is also noted at the lumbosacral junction.\n\n IMPRESSION:\n 1. Diffuse distention and mild dilation of small and large bowel without\n transition and with numerous air-fluid levels seen. Overall, the\n configuration suggests a diagnosis of gastroenteritis, though clinical\n correlation is strongly advised.\n 2. Slight interval increase in right-sided simple-appearing pleural effusion.\n 3. Stable volume of small abdominal ascites.\n 4. Interval placement of bilateral ureteral stents with resolution of\n previously noted hydronephrosis.\n\n"},{"category":"Radiology","chartdate":"2201-02-16 00:00:00.000","description":"BY SAME PHYSICIAN","row_id":1120454,"text":" 3:23 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: r picc 50cm\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n G I bleed\n REASON FOR THIS EXAMINATION:\n r picc 50cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with right-sided PICC placement, evaluate for\n PICC placement.\n\n COMPARISON: Portable chest radiograph, at 12:53 p.m.\n\n TECHNIQUE: Portable chest radiograph, at 15:33 p.m.\n\n FINDINGS: The left-sided PICC line has been removed in the interim. A new\n right-sided PICC line tip terminates within the mid SVC. Opacification within\n the right lower lobe is most likely due to layering right-sided pleural\n effusion. The cardiac, mediastinal, and hilar contours appear unchanged from\n most recent prior and are normal.\n\n IMPRESSION: Right-sided PICC tip projects over the mid SVC. IV nurse, \n , was notified of the results on . Dr. was\n also notified of the results at 17:11 on .\n\n"},{"category":"Radiology","chartdate":"2201-02-16 00:00:00.000","description":"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS","row_id":1120422,"text":" 12:29 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: MR enterography - ? mass, stricture\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with h/o colon cancer, now with obstruction seen on\n colonoscopy. Please perform MR enterography\n REASON FOR THIS EXAMINATION:\n MR enterography - ? mass, stricture\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MON 9:58 PM\n 1. Markedly dilated small bowel and large bowel loops compatible with\n obstruction. Apparent transition point at colosigmoid junction. Distal\n collapse of bowel demonstrates markedly thickened wall - however, difficult to\n delineate for underlying discrete mass or stricture. ? adhesions.\n 2. Right hemicolectomy changes area of anastomosis in right mid abdomen\n appears okay.\n 3. Moderate ascites. Further evaluation for bowel perforation would be\n better assessed on upright x-ray or CT.\n ______________________________________________________________________________\n FINAL REPORT\n MR ABDOMEN WITHOUT AND WITH CONTRAST\n\n INDICATION: 75-year-old male with history of colon cancer with right\n hemicolectomy in and remote history of prostate cancer with external beam\n radiation treatment presents with obstruction seen on colonoscopy. Evaluate\n for underlying mass or stricture.\n\n COMPARISON: CT abdomen and pelvis exam date .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained on a 1.5\n Tesla magnet including dynamic 3D imaging obtained prior to, during, and after\n the uneventful IV administration of 0.1 mmol/kg of gadolinium-DTPA (17 cc\n Magnevist). A total of 1800 ml VoLumen was orally administered. No\n intramuscular glucagon was given. Multiplanar 2D and 3D reformations and\n subtraction images were generated on an independent workstation.\n\n FINDINGS: Right hemicolectomy changes are noted. Extensive and diffuse\n dilated small bowel and colon is identified with apparent transition point at\n the colosigmoid junction deep within the pelvis. In the pelvis, multiple\n collapsed and clustered bowel loops are noted with extensive wall thickening\n and vague enhancement. Regional inflammatory changes and enhancement are seen\n in the pelvis with some areas of nodular enhancement in the adjacent\n peritoneum. Note is made on dynamic SSFSE images of diffusely sluggish bowel\n motility, but with virtually none in these abnormal-appearing pelvic loops.\n These findings are suggestive of an obstruction of unclear etiology. Given\n the peritoneal enhancement and lack of FDG avidity in this region upon\n correlation with recent PET exam findings suggest a fibrotic process, possibly\n from prior radiation treatment with, or without changes due to prior ischemic\n episodes.\n (Over)\n\n 12:29 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: MR enterography - ? mass, stricture\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n A few prominent pelvic lymph nodes are noted, the largest seen anteromedial to\n the left psoas, measuring 12 mm. None of these are accessible for biopsy due\n to location, with surrounding dilated bowel loops as well as osseous\n structures.\n\n A moderate amount of ascites is present. Bilateral renal cysts are noted.\n The bladder wall is diffusely thickened measuring 4 mm. Ureteral stents are\n not clearly visualized, but is as expected for MRI.\n\n 2D reformations and 3D volume rendered images were reviewed at interpretation,\n supporting these findings.\n\n IMPRESSION:\n\n 1. Extensive dilated loops of small bowel and colon with apparent transition\n deep in the pelvis at distal colon. Diffuse surrounding enhancement and\n suggestion of wall thickening of the colon is of unclear etiology, but given\n the lack of preferential FDG uptake on PET findings, this more likely is\n attributed to a fibrotic process from prior radiation treatment and/or\n stricturing from superimposed ischemic episodes than a high grade tumor.\n However, given the presumed recent onset of these findings, with the\n remoteness of regional radiation treatment, neoplasm as a cause of this\n stricture cannot be excluded based on imaging.\n\n A dedicated MRI pelvis with rectal contrast and glucagon to reduce bowel\n motion artifacts may be considered in attempts obtain higher resolution\n imaging of the abnormal pelvic loops.\n\n 2. Prominent pelvic lymph nodes, inaccessible for biopsy.\n\n 3. Bilateral renal cysts.\n\n 4. Right hemicolectomy changes.\n\n Findings discussed with Dr. at 1115hrs via telephone\n report by Dr. .\n\n"},{"category":"Radiology","chartdate":"2201-02-16 00:00:00.000","description":"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS","row_id":1120423,"text":", N. MED 11R 12:29 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: MR enterography - ? mass, stricture\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with h/o colon cancer, now with obstruction seen on\n colonoscopy. Please perform MR enterography\n REASON FOR THIS EXAMINATION:\n MR enterography - ? mass, stricture\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Markedly dilated small bowel and large bowel loops compatible with\n obstruction. Apparent transition point at colosigmoid junction. Distal\n collapse of bowel demonstrates markedly thickened wall - however, difficult to\n delineate for underlying discrete mass or stricture. ? adhesions.\n 2. Right hemicolectomy changes area of anastomosis in right mid abdomen\n appears okay.\n 3. Moderate ascites. Further evaluation for bowel perforation would be\n better assessed on upright x-ray or CT.\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 514705,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - Tap Water enema that he did not retain\\n - Bisacodyl suppository without effect\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:11 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.3\\nC (99.1\\n HR: 79 (68 - 86) bpm\\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 95%\\n Total In:\\n 1,702 mL\\n 613 mL\\n PO:\\n TF:\\n IVF:\\n 1,702 mL\\n 613 mL\\n Blood products:\\n Total out:\\n 250 mL\\n 670 mL\\n Urine:\\n 250 mL\\n 520 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,452 mL\\n -58 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 95%\\n ABG: ///25/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 226 K/uL\\n 10.4 g/dL\\n 166\\n 1.6 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 25 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 29.9 %\\n 11.7 K/uL\\n [image002.jpg]\\n 11:08 PM\\n 04:13 AM\\n 06:00 AM\\n WBC\\n 11.7\\n Hct\\n 41.8\\n 29.9\\n Plt\\n 226\\n Cr\\n 1.5\\n 1.6\\n Glucose\\n 165\\n 125\\n 166\\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n HEMATEMESIS (UPPER GI BLEED, UGIB)\\n CONSTIPATION (OBSTIPATION, FOS)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 514707,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - Tap Water enema that he did not retain\\n - Bisacodyl suppository without effect\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:11 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.3\\nC (99.1\\n HR: 79 (68 - 86) bpm\\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 95%\\n Total In:\\n 1,702 mL\\n 613 mL\\n PO:\\n TF:\\n IVF:\\n 1,702 mL\\n 613 mL\\n Blood products:\\n Total out:\\n 250 mL\\n 670 mL\\n Urine:\\n 250 mL\\n 520 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,452 mL\\n -58 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 95%\\n ABG: ///25/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 226 K/uL\\n 10.4 g/dL\\n 166\\n 1.6 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 25 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 29.9 %\\n 11.7 K/uL\\n [image002.jpg]\\n 11:08 PM\\n 04:13 AM\\n 06:00 AM\\n WBC\\n 11.7\\n Hct\\n 41.8\\n 29.9\\n Plt\\n 226\\n Cr\\n 1.5\\n 1.6\\n Glucose\\n 165\\n 125\\n 166\\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n ASSESSMENT AND PLAN:\\n 75 year old man with colon cancer s/p hemicolectomy and s/p\\n bilateral ureteral stent placement now admitted to with UGIB in\\n setting of constipation and hematuria\\n #. UGIB: Patient presented with coffee grounds emesis in setting of\\n constipation. Differential diagnosis includes gastritis, \\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\\n prior history of varices or liver disease. He is guaiac negative from\\n below and has been constipated which would be atypical for brisk GIB\\n especially given still passing flatus and no clear obstruction on CT\\n scan. Most likely scenario would be constipation leading to nausea and\\n vomiting and possible tear related to emesis. Remains HD\\n stable without current evidence of active bleed and HCT as well as BUN\\n are currently improved from baseline. He denies recent NSAID or steroid\\n use that would increase risk of bleeding.\\n - continue PPI drip for now, change to dosing in am\\n - maintain PIVs x 2\\n - monitor HCT q8, next HCT likely to be lower since has received IVF\\n but transfuse for HCT <27 or active bleed\\n - maintain NPO with IVF\\n - appreciate GI recommendations, possible EGD in am\\n - guaiac all stool\\n - continue NGT to wall suction\\n - NS bolus x 1 L now\\n #. Constipation: Likely related to chronic constipation (reports\\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\\n codeine use as well as dehydration given dry appearance on exam. Per\\n surgery, no signs of obstruction on CT related to -enteric\\n anastamoses and has fluid passing through. He continues to pass flatus\\n so not fully obstructed and is relatively asymptomatic.\\n - NGT to wall suction to decompress from above\\n - tap water enema and bisacodyl suppository, continue colace\\n - appreciate surgery recs\\n - serial abdominal exams\\n - avoid narcotics\\n #. Hematuria: Likely related to foley and recent stent placement\\n - appreciate urology recommendations who will see in am\\n # ?UTI: Patient has foley catheter in place and positive UA although is\\n asymptomatic other than urinary urgency related to foley catheter. WBC\\n mildly elevated which may be related to UTI\\n - cipro for now as below\\n - follow up urine cx\\n - continue keflex, ? for stent placement, will d/w urology\\n #. Ureteral obstruction: Cr improved since placement of bilateral\\n stents and passing adequate UOP\\n - continue to monitor\\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\\n diarrhea or fever or chills. Appearance may just be secondary to\\n inflammation from obstruction and/or ileus.\\n - continue cipro/flagyl for now, likely d/c if no further evidence of\\n infection\\n # s/p CVA: Continue to hold aggrenox in setting of GIB\\n #. HTN: Hold antihypertensives in setting of GIB\\n #. Hyperlipidemia: Continue statin\\n # Diabetes: Diet controlled.\\n - FS QID and HISS\\n #. h/o prostate cancer\\n - hold flomax given GIB, consider restart in am if HD stable\\n FEN: NPO with IVF\\n PPX:\\n -DVT ppx with pneumoboots in setting of GIB\\n -Bowel regimen with enemas, home regimen\\n -Pain management with tylenol\\n ACCESS: PIV's\\n .\\n CODE STATUS: DNR/DNI\\n .\\n EMERGENCY CONTACT: Wife \\n .\\n DISPOSITION: ICU for now, likely call out if stable in am\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 514811,\n \"text\": \"Chief Complaint: 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 24 Hour Events:\\n Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. This BM was hard\\n but brown and not black or tarry. Has continued to pass flatus. Denies\\n abdominal pain, melena, hematochezia, chest pain, SOB, fever, chills,\\n lightheadedness, decreased PO intake, NSAID or steroid use. His wife\\n called ambulance to take him to ED for weakness and consripation and he\\n had coffee grounds emesis x 2 in ambulance and subsequently in ED. He\\n also reprots hematuria since stents and foley placed 4 days prior.\\n Denies any prior h/o GIB or similar symptoms.\\n .\\n In the emergency department, initial vitals were: 97.8 91 142/79 16\\n 98%RA. NG lavage was positive for hemoccult positive coffee grounds\\n which did not clear after 1L. He was guaiac negative but was noted to\\n have abdominal tenderness so CT abdomen/pelvis was obtained and\\n revealed distended small and large bowel with air fluid levels\\n suggestive of gastroenteritis. GI and Surgery evaluated patient and\\n recommended decompressing from above with NGT and enemas from below but\\n no urgent indication for scope since HD stable. UA was positive and\\n blood cx x 2 were drawn. He received 1LNS, pantoprazole, levofloxacin,\\n flagyl and Zofran. Labs significant for HCT 34 from baseline 32 and Cr\\n 1.7 from baseline 2.0.\\n .\\n Vitals prior to transfer were: 77 131/78 16 95%RA\\n Passed brown stool overnight.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 07:40 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\\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: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.1\\nC (98.8\\n HR: 84 (68 - 95) bpm\\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\\n RR: 19 (12 - 24) insp/min\\n SpO2: 98%\\n Total In:\\n 1,702 mL\\n 1,003 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 1,702 mL\\n 823 mL\\n Blood products:\\n Total out:\\n 250 mL\\n 870 mL\\n Urine:\\n 250 mL\\n 720 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,452 mL\\n 133 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 98%\\n ABG: ///25/\\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 10.4 g/dL\\n 226 K/uL\\n 166\\n 1.6 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 25 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 29.9 %\\n 11.7 K/uL\\n [image002.jpg]\\n 11:08 PM\\n 04:13 AM\\n 06:00 AM\\n WBC\\n 11.7\\n Hct\\n 41.8\\n 29.9\\n Plt\\n 226\\n Cr\\n 1.5\\n 1.6\\n Glucose\\n 165\\n 125\\n 166\\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\\n stent placement, now admitted to with UGIB.\\n GI BLEED -- with coffee grounds emesis concern for .\\n in setting of constipation. Differential diagnosis includes gastritis,\\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have\\n varices given no prior history of varices or liver disease. He is\\n guaiac negative from below and has been constipated which would be\\n atypical for brisk GIB especially given still passing flatus and no\\n clear obstruction on CT scan. Most likely scenario would be\\n constipation leading to nausea and vomiting and possible \\n tear related to emesis. Remains HD stable without current evidence of\\n active bleed and HCT as well as BUN are currently improved from\\n baseline. He denies recent NSAID or steroid use that would increase\\n risk of bleeding.\\n - continue PPI drip for now, change to dosing in am\\n - maintain PIVs x 2\\n - monitor HCT q8, next HCT likely to be lower since has received IVF\\n but transfuse for HCT <27 or active bleed\\n - maintain NPO with IVF\\n - appreciate GI recommendations, possible EGD in am\\n - guaiac all stool\\n - continue NGT to wall suction\\n - NS bolus x 1 L now\\n #. Constipation: Likely related to chronic constipation (reports\\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\\n codeine use as well as dehydration given dry appearance on exam. Per\\n surgery, no signs of obstruction on CT related to -enteric\\n anastamoses and has fluid passing through. He continues to pass flatus\\n so not fully obstructed and is relatively asymptomatic.\\n - NGT to wall suction to decompress from above\\n - tap water enema and bisacodyl suppository, continue colace\\n - appreciate surgery recs\\n - serial abdominal exams\\n - avoid narcotics\\n #. Hematuria: Likely related to foley and recent stent placement\\n - appreciate urology recommendations who will see in am\\n # ?UTI: Patient has foley catheter in place and positive UA although is\\n asymptomatic other than urinary urgency related to foley catheter. WBC\\n mildly elevated which may be related to UTI\\n - cipro for now as below\\n - follow up urine cx\\n - continue keflex, ? for stent placement, will d/w urology\\n #. Ureteral obstruction: Cr improved since placement of bilateral\\n stents and passing adequate UOP\\n - continue to monitor\\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\\n diarrhea or fever or chills. Appearance may just be secondary to\\n inflammation from obstruction and/or ileus.\\n - continue cipro/flagyl for now, likely d/c if no further evidence of\\n infection\\n # s/p CVA: Continue to hold aggrenox in setting of GIB\\n #. HTN: Hold antihypertensives in setting of GIB\\n #. Hyperlipidemia: Continue statin\\n # Diabetes: Diet controlled.\\n - FS QID and HISS\\n #. h/o prostate cancer\\n - hold flomax given GIB, consider restart in am if HD stable\\n FEN: NPO with IVF\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition :ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2201-02-03 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 514600,\n \"text\": \"MICU ATTENDING ADM ISSION 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 Dr\\n \\ns note above, including the assessment and plan. I would\\n emphasize and add the following points:\\n Mr was recently admitted to the for evaluation of bilateral\\n hydro-uretero-nephrosis of unclear etiology. He had placement of\\n bilateral stents and was discharged home with an indwelling foley and\\n PO antibiotics. He now presents with weakness, coffee ground emesis and\\n hematuria. He denies abdominal pain but does admit to significant\\n thirst. He has not had a syncopal event or fevers.\\n His PMH is notable for a right hemicoleectomy with R/A by Dr in\\n for Stage 3B colon Cancer. He had a pelvic nodule excised at the\\n time of laparotomy which revealed fat necrosis. He has also had a prior\\n CVA and CRI ( with creatinine close to 2.0) in the past. His recent Hct\\n on D/C was 28. His CEA has been rising.\\n Exam notable for Tm of 98, BP of 142/80 HR of 90 RR of 16 with sats of\\n 98% on RA . He has significantly diminished skin turgor and coffee\\n grounds on NG lavage. He has clear lung fields and a soft belly. His\\n foley catheter is draining dark urine.\\n Labs notable for WBC 11.8K, HCT of 24 ( 28) , K+ of 4.7, Cr of 1.7 (\\n 2.0) , lactate of 1.4. CXR with elevated left hemidiaphragm and\\n distended loops of bowel without free air. His Abd CT shows air fluid\\n levels in colon and extensive fecal material in colon. There does not\\n appear to be migration of stents either.\\n He is severely volume deplete and made worse with his h/o chronic\\n constipation. He has likely had an UGI bleed ( gastritis vs esophagitis\\n vs M-W tear) but is hemodynamically stable with no concerns regarding\\n ongoing active bleeding. He does not appear septic either but we will\\n need to monitor closely for this. He has received 1 L NS thus far in\\n addition to IV PPI and antibiotics. He will need continued fluid\\n rescucitation and decompression of colon with enemas to allow for\\n improvement of colonic/ small bowel distension/ emesis. GI staff to see\\n in am regarding need for EGD. Appreciate surgical and urology input. If\\n there are no hemodynamic issues overnight, he will leave the ICU in am\\n . Oncology staff to provide further advise regarding concerns\\n for rising CEA and possibly recurrent/ metastatic colon Ca once acute\\n issues have resolved.\\n Remainder of plan as outlined above.\\n Patient is chronically ill\\n Total time: 50 min\\n _________\\n , MD\\n Division of Pulmonary, Critical Care and Sleep Medicine\\n \\n , KS-B23\\n , \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 514756,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - Tap Water enema that he did not retain\\n - Bisacodyl suppository without effect\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:11 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.3\\nC (99.1\\n HR: 79 (68 - 86) bpm\\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\\n RR: 18 (12 - 24) insp/min\\n SpO2: 95%\\n Total In:\\n 1,702 mL\\n 613 mL\\n PO:\\n TF:\\n IVF:\\n 1,702 mL\\n 613 mL\\n Blood products:\\n Total out:\\n 250 mL\\n 670 mL\\n Urine:\\n 250 mL\\n 520 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,452 mL\\n -58 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 95%\\n ABG: ///25/\\n Physical Examination\\n GENERAL: Pleasant, well appearing elderly gentleman in NAD\\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\\n icterus. PERRLA/EOMI. Dry MM. OP clear with dried blood in posterior\\n OP. NGT in place with gastroccult positive coffee grounds material in\\n canister.\\n Neck: Supple, No LAD, No thyromegaly.\\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\\n murmur heard best RUSB. No rubs or . JVP=7-8cm\\n LUNGS: CTAB, good air movement biaterally.\\n ABDOMEN: Distended abdomen. Well healed midline scar. Hyperactive BS.\\n Palpable peristalsis. TTP with involuntary guarding LLQ. No rebound or\\n HSM\\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\\n pulses. Scar R knee\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: A&Ox3. Speech slow and deliberate. Initially reported was in\\n but later reoriented to in , MA. Oriented\\n to self and wife and able to relate her phone number. Oriented to month\\n and year but not date. Appropriate. CN 2-12 intact. 5/5 strength\\n throughout. + reflexes, equal BL. Gait assessment deferred\\n PSYCH: Listens and responds to questions appropriately, pleasant\\n Labs / Radiology\\n 226 K/uL\\n 10.4 g/dL\\n 166\\n 1.6 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 25 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 29.9 %\\n 11.7 K/uL\\n [image002.jpg]\\n 11:08 PM\\n 04:13 AM\\n 06:00 AM\\n WBC\\n 11.7\\n Hct\\n 41.8\\n 29.9\\n Plt\\n 226\\n Cr\\n 1.5\\n 1.6\\n Glucose\\n 165\\n 125\\n 166\\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n ASSESSMENT AND PLAN:\\n 75 year old man with colon cancer s/p hemicolectomy and s/p\\n bilateral ureteral stent placement now admitted to with UGIB in\\n setting of constipation and hematuria\\n #. UGIB: Patient presented with coffee grounds emesis in setting of\\n constipation. Differential diagnosis includes gastritis, \\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\\n prior history of varices or liver disease. He is guaiac negative from\\n below and has been constipated which would be atypical for brisk GIB\\n especially given still passing flatus and no clear obstruction on CT\\n scan. Most likely scenario would be constipation leading to nausea and\\n vomiting and possible tear related to emesis. Remains HD\\n stable without current evidence of active bleed and HCT as well as BUN\\n are currently improved from baseline. He denies recent NSAID or steroid\\n use that would increase risk of bleeding.\\n - continue PPI drip for now, change to dosing in am\\n - maintain PIVs x 2\\n - monitor HCT q8, next HCT likely to be lower since has received IVF\\n but transfuse for HCT <27 or active bleed\\n - maintain NPO with IVF\\n - appreciate GI recommendations, EGD in several days\\n - guaiac all stool\\n - continue NGT to wall suction\\n .\\n #. Constipation: Likely related to chronic constipation (reports\\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\\n codeine use as well as dehydration given dry appearance on exam. Per\\n surgery, no signs of obstruction on CT related to -enteric\\n anastamoses and has fluid passing through. He continues to pass flatus\\n so not fully obstructed and is relatively asymptomatic.\\n - NGT to wall suction to decompress from above\\n - tap water enema and bisacodyl suppository, continue colace\\n - appreciate surgery recs\\n - serial abdominal exams\\n - avoid narcotics\\n #. Hematuria: Likely related to foley and recent stent placement\\n - appreciate urology recommendations who will see in am\\n # ?UTI: Patient has foley catheter in place and positive UA although is\\n asymptomatic other than urinary urgency related to foley catheter. WBC\\n mildly elevated which may be related to UTI\\n - cipro for now as below\\n - follow up urine cx\\n - continue keflex, ? for stent placement, will d/w urology\\n #. Ureteral obstruction: Cr improved since placement of bilateral\\n stents and passing adequate UOP\\n - continue to monitor\\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\\n diarrhea or fever or chills. Appearance may just be secondary to\\n inflammation from obstruction and/or ileus.\\n - continue cipro/flagyl for now, likely d/c if no further evidence of\\n infection\\n # s/p CVA: Continue to hold aggrenox in setting of GIB\\n #. HTN: Hold antihypertensives in setting of GIB\\n #. Hyperlipidemia: Continue statin\\n # Diabetes: Diet controlled.\\n - FS QID and HISS\\n #. h/o prostate cancer\\n - hold flomax given GIB, consider restart in am if HD stable\\n FEN: NPO with IVF\\n PPX:\\n -DVT ppx with pneumoboots in setting of GIB\\n -Bowel regimen with enemas, home regimen\\n -Pain management with tylenol\\n ACCESS: PIV's\\n .\\n CODE STATUS: DNR/DNI\\n .\\n EMERGENCY CONTACT: Wife \\n .\\n DISPOSITION: ICU for now, likely call out if stable HCT at Noon\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 514743,\n \"text\": \"Chief Complaint: 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 24 Hour Events:\\n Passed brown stool overnight.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 07:40 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\\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: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.1\\nC (98.8\\n HR: 84 (68 - 95) bpm\\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\\n RR: 19 (12 - 24) insp/min\\n SpO2: 98%\\n Total In:\\n 1,702 mL\\n 1,003 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 1,702 mL\\n 823 mL\\n Blood products:\\n Total out:\\n 250 mL\\n 870 mL\\n Urine:\\n 250 mL\\n 720 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,452 mL\\n 133 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 98%\\n ABG: ///25/\\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 10.4 g/dL\\n 226 K/uL\\n 166\\n 1.6 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 25 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 29.9 %\\n 11.7 K/uL\\n [image002.jpg]\\n 11:08 PM\\n 04:13 AM\\n 06:00 AM\\n WBC\\n 11.7\\n Hct\\n 41.8\\n 29.9\\n Plt\\n 226\\n Cr\\n 1.5\\n 1.6\\n Glucose\\n 165\\n 125\\n 166\\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\\n stent placement, now admitted to with UGIB.\\n GI BLEED -- with coffee grounds emesis concern for .\\n in setting of constipation. Differential diagnosis includes gastritis,\\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have\\n varices given no prior history of varices or liver disease. He is\\n guaiac negative from below and has been constipated which would be\\n atypical for brisk GIB especially given still passing flatus and no\\n clear obstruction on CT scan. Most likely scenario would be\\n constipation leading to nausea and vomiting and possible \\n tear related to emesis. Remains HD stable without current evidence of\\n active bleed and HCT as well as BUN are currently improved from\\n baseline. He denies recent NSAID or steroid use that would increase\\n risk of bleeding.\\n - continue PPI drip for now, change to dosing in am\\n - maintain PIVs x 2\\n - monitor HCT q8, next HCT likely to be lower since has received IVF\\n but transfuse for HCT <27 or active bleed\\n - maintain NPO with IVF\\n - appreciate GI recommendations, possible EGD in am\\n - guaiac all stool\\n - continue NGT to wall suction\\n - NS bolus x 1 L now\\n #. Constipation: Likely related to chronic constipation (reports\\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\\n codeine use as well as dehydration given dry appearance on exam. Per\\n surgery, no signs of obstruction on CT related to -enteric\\n anastamoses and has fluid passing through. He continues to pass flatus\\n so not fully obstructed and is relatively asymptomatic.\\n - NGT to wall suction to decompress from above\\n - tap water enema and bisacodyl suppository, continue colace\\n - appreciate surgery recs\\n - serial abdominal exams\\n - avoid narcotics\\n #. Hematuria: Likely related to foley and recent stent placement\\n - appreciate urology recommendations who will see in am\\n # ?UTI: Patient has foley catheter in place and positive UA although is\\n asymptomatic other than urinary urgency related to foley catheter. WBC\\n mildly elevated which may be related to UTI\\n - cipro for now as below\\n - follow up urine cx\\n - continue keflex, ? for stent placement, will d/w urology\\n #. Ureteral obstruction: Cr improved since placement of bilateral\\n stents and passing adequate UOP\\n - continue to monitor\\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\\n diarrhea or fever or chills. Appearance may just be secondary to\\n inflammation from obstruction and/or ileus.\\n - continue cipro/flagyl for now, likely d/c if no further evidence of\\n infection\\n # s/p CVA: Continue to hold aggrenox in setting of GIB\\n #. HTN: Hold antihypertensives in setting of GIB\\n #. Hyperlipidemia: Continue statin\\n # Diabetes: Diet controlled.\\n - FS QID and HISS\\n #. h/o prostate cancer\\n - hold flomax given GIB, consider restart in am if HD stable\\n FEN: NPO with IVF\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition :ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 514627,\n \"text\": \"Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 514667,\n \"text\": \"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. His wife called\\n ambulance to take him to ED for weakness and consripation and he had\\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\\n reprots hematuria since stents and foley placed 4 days prior. Denies\\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\\n and started with protonix drip and transffered to for further\\n management.\\n Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Pt c/o nausea and vomitted once watery mixed with coffee ground\\n particles early am. denies any pain,abd firm,BS hypoactive.\\n Action:\\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\\n Response:\\n Plan:\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 514671,\n \"text\": \"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. His wife called\\n ambulance to take him to ED for weakness and consripation and he had\\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\\n reprots hematuria since stents and foley placed 4 days prior. Denies\\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\\n and started with protonix drip and transffered to for further\\n management.\\n Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Pt c/o nausea and vomitted once watery mixed with coffee ground\\n particles early am. denies any pain,abd firm,BS hypoactive. Foley to\\n gravity, bloody urine initially,but more clear later on.\\n Action:\\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\\n Response:\\n Crit drop from 41 to 29 with am labs. VSS. No further vomiting or\\n .\\n Plan:\\n f/u with am labs and monitor further .\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Pt without BM for last ~ 10 days. Abd firm,BS hypo, NGT tube in place,\\n connected to LWIS .\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 514673,\n \"text\": \"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. His wife called\\n ambulance to take him to ED for weakness and consripation and he had\\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\\n reprots hematuria since stents and foley placed 4 days prior. Denies\\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\\n and started with protonix drip and transffered to for further\\n management.\\n Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Pt c/o nausea and vomitted once watery mixed with coffee ground\\n particles early am. denies any pain,abd firm,BS hypoactive. Foley to\\n gravity, bloody urine initially,but more clear later on.\\n Action:\\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\\n Response:\\n Crit drop from 41 to 29 with am labs. VSS. No further vomiting or\\n .\\n Plan:\\n f/u with am labs and monitor further .\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Pt without BM for last ~ 10 days. Abd firm,BS hypo, NGT tube in place,\\n connected to LWIS .\\n Action:\\n Tried for tap water enema ,but not retained. Bisacodyl PR given . NPO\\n except meds and ice chips. On docusate .\\n Response:\\n Pt stayed on bedpan for long time, but No BM yet.\\n Plan:\\n need another dose of PR medication or any strong bowel regimen\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 514664,\n \"text\": \"Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 514874,\n \"text\": \"Chief Complaint: 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 24 Hour Events:\\n Passed brown stool overnight.\\n No new complaints this AM.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 07:40 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\\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: No(t) Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:36 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.1\\nC (98.8\\n HR: 84 (68 - 95) bpm\\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\\n RR: 19 (12 - 24) insp/min\\n SpO2: 98%\\n Total In:\\n 1,702 mL\\n 1,003 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 1,702 mL\\n 823 mL\\n Blood products:\\n Total out:\\n 250 mL\\n 870 mL\\n Urine:\\n 250 mL\\n 720 mL\\n NG:\\n 150 mL\\n Stool:\\n Drains:\\n Balance:\\n 1,452 mL\\n 133 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 98%\\n ABG: ///25/\\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 10.4 g/dL\\n 226 K/uL\\n 166\\n 1.6 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 25 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 29.9 %\\n 11.7 K/uL\\n [image002.jpg]\\n 11:08 PM\\n 04:13 AM\\n 06:00 AM\\n WBC\\n 11.7\\n Hct\\n 41.8\\n 29.9\\n Plt\\n 226\\n Cr\\n 1.5\\n 1.6\\n Glucose\\n 165\\n 125\\n 166\\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\\n mg/dL, PO4:2.5 mg/dL\\n Assessment and Plan\\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\\n stent placement, now admitted to with GI bleed.\\n GI BLEED -- with coffee grounds emesis concern for upper source.\\n Concerns include gastritis, PUD, - tear, Dieulafoys ulcer,\\n AVM. No clnical concern for varices. Plan maintain iv access, monitor\\n serial Hct, PPI infusion, GI consultation to assess for EGD.\\n FLUIDS\\n hypovolemia; plan to net replete.\\n CONSTIPATION\\n chronic. Signs of mild ileus. Monitor abd exam.\\n General surgery to follow.\\n UTI\\n hematuria, possibly related to recent stent placement. Possible\\n UTI. Ciprofloxicin. Urology to follow up.\\n s/p CVA -- Hold aggrenox in setting of GIB\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: H2 blocker\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition :ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 514780,\n \"text\": \"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. His wife called\\n ambulance to take him to ED for weakness and consripation and he had\\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\\n reprots hematuria since stents and foley placed 4 days prior. Denies\\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\\n and started with protonix drip and transffered to for further\\n management.\\n Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 514782,\n \"text\": \"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. His wife called\\n ambulance to take him to ED for weakness and consripation and he had\\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\\n reprots hematuria since stents and foley placed 4 days prior. Denies\\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\\n and started with protonix drip and transffered to for further\\n management.\\n Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Pt presented to ed with coffee grounds in the setting of\\n constipation( no stool x 10 days). Differential dx included gastritis,\\n tear. No clear obstruction on ct scan. Most likely\\n scenarion would be constipation leading to nausea and vomiting and\\n possible tear related to emesis. Pt hemodynamically\\n stable since admit with hr 80-90\\ns and sbp 121-149. ngt to low\\n continuous sx has drained about 500cc\\n colored drainage with\\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\\n presently off.\\n Action:\\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\\n maintained. Ngt continued to low wall suction.\\n Response:\\n Stable hct and hemodynamics.\\n Plan:\\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\\n hemodynamics. Maintain 2 piv\\ns and keep pt npo except for meds. Gi\\n consult team following pt and will most likely pt will have endoscopy\\n in days.ppi changed to pantoprazole iv .\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 514784,\n \"text\": \"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. His wife called\\n ambulance to take him to ED for weakness and consripation and he had\\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\\n reprots hematuria since stents and foley placed 4 days prior. Denies\\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\\n and started with protonix drip and transffered to for further\\n management.\\n Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Pt presented to ed with coffee grounds in the setting of\\n constipation( no stool x 10 days). Differential dx included gastritis,\\n tear. No clear obstruction on ct scan. Most likely\\n scenarion would be constipation leading to nausea and vomiting and\\n possible tear related to emesis. Pt hemodynamically\\n stable since admit with hr 80-90\\ns and sbp 121-149. ngt to low\\n continuous sx has drained about 500cc\\n colored drainage with\\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\\n presently off.\\n Action:\\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\\n maintained. Ngt continued to low wall suction.\\n Response:\\n Stable hct and hemodynamics.\\n Plan:\\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\\n hemodynamics. Maintain 2 piv\\ns and keep pt npo except for meds. Gi\\n consult team following pt and will most likely pt will have endoscopy\\n in days.ppi changed to pantoprazole iv .\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Constipation likely related to chronic constipation as pt reports that\\n he typically has bm q 7 days. This constipation may be worsened by\\n recent surgery and Tylenol with codeine use as well as dehydratons\\n given his dry appearance on exam. Abd firm and distended with few bowel\\n sounds on auscultation. Ct neg for obstruction. Pt given sse on noc\\n shift which he was unable to retain and dulocolax supp . pt has passed\\n sm soft brown stool.\\n Action:\\n Pt medicated again with dulcolax suppose. Ngt to wall suction to\\n decompress from above.\\n Response:\\n Still with little stool output.\\n Plan:\\n Continue to follow stool output and guiac all stools. Continue with\\n aggressive bowel regimen and administer colace as ordered. Maintain ngt\\n to low wall suction in order to decompress from above. Avoid narcotics.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2201-02-04 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 514785,\n \"text\": \"Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. His wife called\\n ambulance to take him to ED for weakness and consripation and he had\\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\\n reprots hematuria since stents and foley placed 4 days prior. Denies\\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\\n and started with protonix drip and transffered to for further\\n management.\\n Hematemesis (upper GI bleed, UGIB)\\n Assessment:\\n Pt presented to ed with coffee grounds in the setting of\\n constipation( no stool x 10 days). Differential dx included gastritis,\\n tear. No clear obstruction on ct scan. Most likely\\n scenarion would be constipation leading to nausea and vomiting and\\n possible tear related to emesis. Pt hemodynamically\\n stable since admit with hr 80-90\\ns and sbp 121-149. ngt to low\\n continuous sx has drained about 500cc\\n colored drainage with\\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\\n presently off.\\n Action:\\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\\n maintained. Ngt continued to low wall suction.\\n Response:\\n Stable hct and hemodynamics.\\n Plan:\\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\\n hemodynamics. Maintain 2 piv\\ns and keep pt npo except for meds. Gi\\n consult team following pt and will most likely pt will have endoscopy\\n in days.ppi changed to pantoprazole iv .\\n Constipation (Obstipation, FOS)\\n Assessment:\\n Constipation likely related to chronic constipation as pt reports that\\n he typically has bm q 7 days. This constipation may be worsened by\\n recent surgery and Tylenol with codeine use as well as dehydratons\\n given his dry appearance on exam. Abd firm and distended with few bowel\\n sounds on auscultation. Ct neg for obstruction. Pt given sse on noc\\n shift which he was unable to retain and dulocolax supp . pt has passed\\n sm soft brown stool.\\n Action:\\n Pt medicated again with dulcolax suppose. Ngt to wall suction to\\n decompress from above.\\n Response:\\n Still with little stool output.\\n Plan:\\n Continue to follow stool output and guiac all stools. Continue with\\n aggressive bowel regimen and administer colace as ordered. Maintain ngt\\n to low wall suction in order to decompress from above. Avoid narcotics.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n UPPER GASTROINTESTINAL BLEED\\n Code status:\\n DNR / DNI\\n Height:\\n Admission weight:\\n 71.2 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history: Colon cancer, stage IIIB, status post hemicolectomy\\n on in the setting of bowel obstruction, received 7 cycles of\\n Xeloda, stopped concern for progression of disease ,\\n Bilateral ureteral obstruction s/p b/l stent placement ; unclear\\n etiology of obstruction per review of notes , CVA with residual R\\n sided weakness and R facial droop , Hypertension , Diabetes (diet\\n controlled) , Hyperlipidemia , Prostate cancer s/p treatment with\\n external beam radiation \\\"many years ago\\\" -,\\n Surgery / Procedure and date: hemicolectomy \\n bilateral uretral stent placement \\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:144\\n D:78\\n Temperature:\\n 98.6\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 16 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 FiO2 set:\\n 24h total in:\\n 1,003 mL\\n 24h total out:\\n 1,030 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 04:13 AM\\n Potassium:\\n 3.5 mEq/L\\n 04:13 AM\\n Chloride:\\n 103 mEq/L\\n 04:13 AM\\n CO2:\\n 25 mEq/L\\n 04:13 AM\\n BUN:\\n 25 mg/dL\\n 04:13 AM\\n Creatinine:\\n 1.6 mg/dL\\n 04:13 AM\\n Glucose:\\n 166\\n 06:00 AM\\n Hematocrit:\\n 30.0 %\\n 11:36 AM\\n Finger Stick Glucose:\\n 209\\n 12:00 AM\\n Valuables / Signature\\n Patient valuables: none\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: 409\\n Transferred to: 1184\\n Date & time of Transfer: 1430\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2201-02-03 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 514604,\n \"text\": \"Chief Complaint: Hematemesis\\n HPI:\\n Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\\n s/p bilateral ureteral stent placement now presenting with\\n constipation, coffee grounds emesis and hematuria. He had been in USOH\\n until today when he noted \\\"weakness\\\" and dizziness with standing. He\\n also has been constipated with last BM 10 days prior. This BM was hard\\n but brown and not black or tarry. Has continued to pass flatus. Denies\\n abdominal pain, melena, hematochezia, chest pain, SOB, fever, chills,\\n lightheadedness, decreased PO intake, NSAID or steroid use. His wife\\n called ambulance to take him to ED for weakness and consripation and he\\n had coffee grounds emesis x 2 in ambulance and subsequently in ED. He\\n also reprots hematuria since stents and foley placed 4 days prior.\\n Denies any prior h/o GIB or similar symptoms.\\n .\\n In the emergency department, initial vitals were: 97.8 91 142/79 16\\n 98%RA. NG lavage was positive for hemoccult positive coffee grounds\\n which did not clear after 1L. He was guaiac negative but was noted to\\n have abdominal tenderness so CT abdomen/pelvis was obtained and\\n revealed distended small and large bowel with air fluid levels\\n suggestive of gastroenteritis. GI and Surgery evaluated patient and\\n recommended decompressing from above with NGT and enemas from below but\\n no urgent indication for scope since HD stable. UA was positive and\\n blood cx x 2 were drawn. He received 1LNS, pantoprazole, levofloxacin,\\n flagyl and Zofran. Labs significant for HCT 34 from baseline 32 and Cr\\n 1.7 from baseline 2.0.\\n .\\n Vitals prior to transfer were: 77 131/78 16 95%RA\\n .\\n REVIEW OF SYSTEMS:\\n (+)ve: Urinary urgency since foley catheter placed.\\n (-)ve: As above. Denies fever, chills, night sweats, loss of appetite,\\n weight loss, palpitations, nasal congestion, cough, sputum production,\\n hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, focal\\n numbness, focal weakness, myalgias, arthralgias\\n Patient admitted from: ER\\n History obtained from Patient, Family / Friend\\n Allergies:\\n Known Drug Allergies\\n Last dose of Antibiotics:\\n Ciprofloxacin - 08:11 PM\\n Infusions:\\n Pantoprazole (Protonix) - 8 mg/hour\\n Other ICU medications:\\n Other medications:\\n Home Meds:\\n Lipitor 10mg PO daily\\n Flomax 0.4mg PO daily\\n Keflex 500mg PO TID since \\n Tylenol #3 prn\\n Lisinopril 10mg PO daily\\n Effexor XR 37.5mg PO daily\\n Colace 100mg PO TID\\n Mag citrate prn\\n OFF AGGRENOX x 1 week\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Colon cancer, stage IIIB, status post hemicolectomy on in\\n the setting of bowel obstruction, received 7 cycles of Xeloda, stopped\\n concern for progression of disease\\n 2. Bilateral ureteral obstruction s/p b/l stent placement ;\\n unclear etiology of obstruction per review of notes\\n 3. CVA with residual R sided weakness and R facial droop\\n 4. Hypertension\\n 5. Diabetes (diet controlled)\\n 6. Hyperlipidemia\\n 7. Prostate cancer s/p treatment with external beam radiation \\\"many\\n years ago\\\" -\\n NC\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: He is married with two children. He is a retired\\n electrician from in and currently lives in ,\\n MA with wife. denies tobacco, alcohol or drug abuse.\\n Review of systems:\\n Flowsheet Data as of 11:32 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.4\\n Tcurrent: 37.2\\nC (98.9\\n HR: 84 (77 - 86) bpm\\n BP: 134/70(85) {132/70(85) - 157/91(103)} mmHg\\n RR: 14 (12 - 24) insp/min\\n SpO2: 97%\\n Total In:\\n 601 mL\\n PO:\\n TF:\\n IVF:\\n 601 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 250 mL\\n Urine:\\n 250 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 351 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n GENERAL: Pleasant, well appearing elderly gentleman in NAD\\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\\n icterus. PERRLA/EOMI. Dry MM. OP clear with dried blood in posterior\\n OP. NGT in place with gastroccult positive coffee grounds material in\\n canister.\\n Neck: Supple, No LAD, No thyromegaly.\\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\\n murmur heard best RUSB. No rubs or . JVP=7-8cm\\n LUNGS: CTAB, good air movement biaterally.\\n ABDOMEN: Distended abdomen. Well healed midline scar. Hyperactive BS.\\n Palpable peristalsis. TTP with involuntary guarding LLQ. No rebound or\\n HSM\\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\\n pulses. Scar R knee\\n SKIN: No rashes/lesions, ecchymoses.\\n NEURO: A&Ox3. Speech slow and deliberate. Initially reported was in\\n but later reoriented to in , MA. Oriented\\n to self and wife and able to relate her phone number. Oriented to month\\n and year but not date. Appropriate. CN 2-12 intact. 5/5 strength\\n throughout. + reflexes, equal BL. Gait assessment deferred\\n PSYCH: Listens and responds to questions appropriately, pleasant\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: CT A/P:Distended large and small bowel suggestive of\\n gastroenteritis\\n CXR: (my read): NGT in stomach. No infiltrate or effusion. Normal\\n cardiac silhouette. Large stomach gas bubble and dilated loops of bowel\\n with elevated left hemidiaphragm. Blunted rigth costophrenic angle\\n Microbiology: Urine cx: Pending\\n Blood cx x 2 pending\\n ECG: ECG:NSR HR 75. Normal axis and intervals with slight IVCD QRS\\n 90msec. Q waves in V5-V6. No acute ST or T wave changes. ? U waves\\n Assessment and Plan\\n ASSESSMENT AND PLAN:\\n 75 year old man with colon cancer s/p hemicolectomy and s/p\\n bilateral ureteral stent placement now admitted to with UGIB in\\n setting of constipation and hematuria\\n #. UGIB: Patient presented with coffee grounds emesis in setting of\\n constipation. Differential diagnosis includes gastritis, \\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\\n prior history of varices or liver disease. He is guaiac negative from\\n below and has been constipated which would be atypical for brisk GIB\\n especially given still passing flatus and no clear obstruction on CT\\n scan. Most likely scenario would be constipation leading to nausea and\\n vomiting and possible tear related to emesis. Remains HD\\n stable without current evidence of active bleed and HCT as well as BUN\\n are currently improved from baseline. He denies recent NSAID or steroid\\n use that would increase risk of bleeding.\\n - continue PPI drip for now, change to dosing in am\\n - maintain PIVs x 2\\n - monitor HCT q8, next HCT likely to be lower since has received IVF\\n but transfuse for HCT <27 or active bleed\\n - maintain NPO with IVF\\n - appreciate GI recommendations, possible EGD in am\\n - guaiac all stool\\n - continue NGT to wall suction\\n - NS bolus x 1 L now\\n #. Constipation: Likely related to chronic constipation (reports\\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\\n codeine use as well as dehydration given dry appearance on exam. Per\\n surgery, no signs of obstruction on CT related to -enteric\\n anastamoses and has fluid passing through. He continues to pass flatus\\n so not fully obstructed and is relatively asymptomatic.\\n - NGT to wall suction to decompress from above\\n - tap water enema and bisacodyl suppository, continue colace\\n - appreciate surgery recs\\n - serial abdominal exams\\n - avoid narcotics\\n #. Hematuria: Likely related to foley and recent stent placement\\n - appreciate urology recommendations who will see in am\\n # ?UTI: Patient has foley catheter in place and positive UA although is\\n asymptomatic other than urinary urgency related to foley catheter. WBC\\n mildly elevated which may be related to UTI\\n - cipro for now as below\\n - follow up urine cx\\n - continue keflex, ? for stent placement, will d/w urology\\n #. Ureteral obstruction: Cr improved since placement of bilateral\\n stents and passing adequate UOP\\n - continue to monitor\\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\\n diarrhea or fever or chills. Appearance may just be secondary to\\n inflammation from obstruction and/or ileus.\\n - continue cipro/flagyl for now, likely d/c if no further evidence of\\n infection\\n # s/p CVA: Continue to hold aggrenox in setting of GIB\\n #. HTN: Hold antihypertensives in setting of GIB\\n #. Hyperlipidemia: Continue statin\\n # Diabetes: Diet controlled.\\n - FS QID and HISS\\n #. h/o prostate cancer\\n - hold flomax given GIB, consider restart in am if HD stable\\n FEN: NPO with IVF\\n PPX:\\n -DVT ppx with pneumoboots in setting of GIB\\n -Bowel regimen with enemas, home regimen\\n -Pain management with tylenol\\n ACCESS: PIV's\\n .\\n CODE STATUS: DNR/DNI\\n .\\n EMERGENCY CONTACT: Wife \\n .\\n DISPOSITION: ICU for now, likely call out if stable in am\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 08:25 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: DNR / DNI\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2201-02-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 252773,\n \"text\": \"Sinus rhythm. Tracing may be within normal limits but unstable baseline makes\\nassessment difficult. Since the previous tracing of there may be no\\nsignificant change but unstable baseline makes comparison difficult.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-02-03 00:00:00.000\",\n \"description\": \"CT PELVIS W/O CONTRAST\",\n \"row_id\": 1118239,\n \"text\": \" 2:08 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: eval for obstruction\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with left sided abdominal pain\\n REASON FOR THIS EXAMINATION:\\n eval for obstruction\\n CONTRAINDICATIONS for IV CONTRAST:\\n creatinine;\\n ______________________________________________________________________________\\n WET READ: ASpf 4:36 PM\\n Distended small and large bowel with air fluid levels suggestive of\\n gastroenteritis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT SCAN OF THE ABDOMEN AND PELVIS PERFORMED ON .\\n\\n CLINICAL HISTORY: 75-year-old male with left-sided abdominal pain, question\\n obstruction.\\n\\n Comparison is made with a prior CT abdomen and pelvis dated .\\n\\n TECHNIQUE: MDCT was used to obtain contiguous axial images through the\\n abdomen and pelvis without oral or IV contrast material. IV contrast was\\n withheld due to patient's elevated creatinine. Coronal and sagittal\\n reformations were provided.\\n\\n FINDINGS:\\n\\n LUNG BASES: There is slight interval increase in the layering\\n simple-appearing right-sided pleural effusion. Mild compressive atelectasis\\n is also noted at the right lung base. There is a 3-mm focus of nodularity\\n along the major fissure on series 2, image 10. Additional tiny vague areas of\\n nodularity in the right middle lobe are seen on series 2, image 12, likely as\\n well as image 14, which may be inflammatory. An NG tube courses into the\\n upper abdomen with the distal side-port at the level of the GE junction. A\\n small hiatal hernia is noted. Coronary artery calcifications are noted.\\n\\n ABDOMEN: Non-contrast appearance of the liver is unremarkable. There is a\\n small amount of perihepatic free fluid. Gallbladder is collapsed. The spleen\\n is unremarkable. Adrenal glands appear normal bilaterally. The pancreas is\\n grossly normal. Kidneys have been internally decompressed with bilateral\\n ureteral stents in place with proximal coils well positioned in the bilateral\\n renal pelves and distal coils in the urinary bladder. Nonspecific perinephric\\n stranding is stable. The abdominal aorta contains atherosclerotic\\n calcifications notably at the origin of the major branch vessel. There is no\\n aneurysm seen. Retroperitoneal lymph nodes do not appear enlarged.\\n\\n The stomach is decompressed. The duodenum appears grossly unremarkable.\\n\\n PELVIS: There is diffuse fluid distention of small bowel with numerous\\n air-fluid levels and bowel measuring up to 3.4 cm in diameter. There is no\\n (Over)\\n\\n 2:08 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: eval for obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n point of transition seen. An anastomosis in the right mid abdomen is noted in\\n this patient with prior right colonic resection. Distal to the anastomosis\\n there is gaseous distention and mild dilation of the large bowel without\\n discrete point of obstruction though note is made of the significant fecal\\n loading of the sigmoid colon. There is no gross bowel wall thickening seen.\\n The urinary bladder is decompressed with a Foley catheter in place. Small\\n amount of free fluid extends into the pelvis.\\n\\n BONES: Degenerative changes are noted in the lower lumbar spine. Significant\\n facet arthropathy is also noted at the lumbosacral junction.\\n\\n IMPRESSION:\\n 1. Diffuse distention and mild dilation of small and large bowel without\\n transition and with numerous air-fluid levels seen. Overall, the\\n configuration suggests a diagnosis of gastroenteritis, though clinical\\n correlation is strongly advised.\\n 2. Slight interval increase in right-sided simple-appearing pleural effusion.\\n 3. Stable volume of small abdominal ascites.\\n 4. Interval placement of bilateral ureteral stents with resolution of\\n previously noted hydronephrosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-02-16 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 1120454,\n \"text\": \" 3:23 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: r picc 50cm\\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n G I bleed\\n REASON FOR THIS EXAMINATION:\\n r picc 50cm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 75-year-old male with right-sided PICC placement, evaluate for\\n PICC placement.\\n\\n COMPARISON: Portable chest radiograph, at 12:53 p.m.\\n\\n TECHNIQUE: Portable chest radiograph, at 15:33 p.m.\\n\\n FINDINGS: The left-sided PICC line has been removed in the interim. A new\\n right-sided PICC line tip terminates within the mid SVC. Opacification within\\n the right lower lobe is most likely due to layering right-sided pleural\\n effusion. The cardiac, mediastinal, and hilar contours appear unchanged from\\n most recent prior and are normal.\\n\\n IMPRESSION: Right-sided PICC tip projects over the mid SVC. IV nurse, \\n , was notified of the results on . Dr. was\\n also notified of the results at 17:11 on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-02-16 00:00:00.000\",\n \"description\": \"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\",\n \"row_id\": 1120422,\n \"text\": \" 12:29 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: MR enterography - ? mass, stricture\\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with h/o colon cancer, now with obstruction seen on\\n colonoscopy. Please perform MR enterography\\n REASON FOR THIS EXAMINATION:\\n MR enterography - ? mass, stricture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): MON 9:58 PM\\n 1. Markedly dilated small bowel and large bowel loops compatible with\\n obstruction. Apparent transition point at colosigmoid junction. Distal\\n collapse of bowel demonstrates markedly thickened wall - however, difficult to\\n delineate for underlying discrete mass or stricture. ? adhesions.\\n 2. Right hemicolectomy changes area of anastomosis in right mid abdomen\\n appears okay.\\n 3. Moderate ascites. Further evaluation for bowel perforation would be\\n better assessed on upright x-ray or CT.\\n ______________________________________________________________________________\\n FINAL REPORT\\n MR ABDOMEN WITHOUT AND WITH CONTRAST\\n\\n INDICATION: 75-year-old male with history of colon cancer with right\\n hemicolectomy in and remote history of prostate cancer with external beam\\n radiation treatment presents with obstruction seen on colonoscopy. Evaluate\\n for underlying mass or stricture.\\n\\n COMPARISON: CT abdomen and pelvis exam date .\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained on a 1.5\\n Tesla magnet including dynamic 3D imaging obtained prior to, during, and after\\n the uneventful IV administration of 0.1 mmol/kg of gadolinium-DTPA (17 cc\\n Magnevist). A total of 1800 ml VoLumen was orally administered. No\\n intramuscular glucagon was given. Multiplanar 2D and 3D reformations and\\n subtraction images were generated on an independent workstation.\\n\\n FINDINGS: Right hemicolectomy changes are noted. Extensive and diffuse\\n dilated small bowel and colon is identified with apparent transition point at\\n the colosigmoid junction deep within the pelvis. In the pelvis, multiple\\n collapsed and clustered bowel loops are noted with extensive wall thickening\\n and vague enhancement. Regional inflammatory changes and enhancement are seen\\n in the pelvis with some areas of nodular enhancement in the adjacent\\n peritoneum. Note is made on dynamic SSFSE images of diffusely sluggish bowel\\n motility, but with virtually none in these abnormal-appearing pelvic loops.\\n These findings are suggestive of an obstruction of unclear etiology. Given\\n the peritoneal enhancement and lack of FDG avidity in this region upon\\n correlation with recent PET exam findings suggest a fibrotic process, possibly\\n from prior radiation treatment with, or without changes due to prior ischemic\\n episodes.\\n (Over)\\n\\n 12:29 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: MR enterography - ? mass, stricture\\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n A few prominent pelvic lymph nodes are noted, the largest seen anteromedial to\\n the left psoas, measuring 12 mm. None of these are accessible for biopsy due\\n to location, with surrounding dilated bowel loops as well as osseous\\n structures.\\n\\n A moderate amount of ascites is present. Bilateral renal cysts are noted.\\n The bladder wall is diffusely thickened measuring 4 mm. Ureteral stents are\\n not clearly visualized, but is as expected for MRI.\\n\\n 2D reformations and 3D volume rendered images were reviewed at interpretation,\\n supporting these findings.\\n\\n IMPRESSION:\\n\\n 1. Extensive dilated loops of small bowel and colon with apparent transition\\n deep in the pelvis at distal colon. Diffuse surrounding enhancement and\\n suggestion of wall thickening of the colon is of unclear etiology, but given\\n the lack of preferential FDG uptake on PET findings, this more likely is\\n attributed to a fibrotic process from prior radiation treatment and/or\\n stricturing from superimposed ischemic episodes than a high grade tumor.\\n However, given the presumed recent onset of these findings, with the\\n remoteness of regional radiation treatment, neoplasm as a cause of this\\n stricture cannot be excluded based on imaging.\\n\\n A dedicated MRI pelvis with rectal contrast and glucagon to reduce bowel\\n motion artifacts may be considered in attempts obtain higher resolution\\n imaging of the abnormal pelvic loops.\\n\\n 2. Prominent pelvic lymph nodes, inaccessible for biopsy.\\n\\n 3. Bilateral renal cysts.\\n\\n 4. Right hemicolectomy changes.\\n\\n Findings discussed with Dr. at 1115hrs via telephone\\n report by Dr. .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2201-02-16 00:00:00.000\",\n \"description\": \"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\",\n \"row_id\": 1120423,\n \"text\": \", N. MED 11R 12:29 PM\\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: MR enterography - ? mass, stricture\\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with h/o colon cancer, now with obstruction seen on\\n colonoscopy. Please perform MR enterography\\n REASON FOR THIS EXAMINATION:\\n MR enterography - ? mass, stricture\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Markedly dilated small bowel and large bowel loops compatible with\\n obstruction. Apparent transition point at colosigmoid junction. Distal\\n collapse of bowel demonstrates markedly thickened wall - however, difficult to\\n delineate for underlying discrete mass or stricture. ? adhesions.\\n 2. Right hemicolectomy changes area of anastomosis in right mid abdomen\\n appears okay.\\n 3. Moderate ascites. Further evaluation for bowel perforation would be\\n better assessed on upright x-ray or CT.\\n\\n\"\n }\n]"}}},{"rowIdx":789,"cells":{"subject_id":{"kind":"number","value":13545,"string":"13,545"},"hadm_id":{"kind":"number","value":156780,"string":"156,780"},"target_text":{"kind":"string","value":"On the the patient was brought to the Operating Room where he underwent an aortic valve replacement with a #25 prosthetic valve and coronary artery bypass grafting with saphenous vein graft to the posterior descending coronary artery. He tolerated the operation well and was transferred to the Operating Room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period. he was weaned from all cardioactive drugs. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated on postoperative day one. The patient continued to do well. His chest tubes were removed and he was transferred from the Cardiothoracic Intensive Care Unit to Far Two for continuing postoperative care and cardiac rehabilitation. Over the next several days the patient continued to do well on the floor. He was assisted with his physical activity by physical therapy and the nursing staff. He gradually improved to the point where on postoperative day four it was deemed that he was stable and ready for discharge to home."},"extractive_notes_summ":{"kind":"string","value":"of residual pnuemothorax. Sinus rhythmRight bundle branch blockInferior/lateral ST-T changes may be due to myocardial ischemia - clinicalcorrelation is suggestedLeft atrial abnormalitySince previous tracing of : no significant change Sinus rhythmConduction defect of RBBB typeAnterolateral ST-T changes may be due to myocardial ischemia - clinicalcorrelation is suggestedLeft atrial abnormalitySince previous tracing of : probably no significant change Baseline artifactSinus rhythmConduction defect of RBBB typeAnterolateral ST-T changes may be due to myocardial ischemia - clinicalcorrelation is suggestedConsider left atrial abnormalitySince previous tracing : further ST-T wave changes present and QRSvoltage less prominent Sinus rhythm- premature ventricular contractionsLeft atrial abnormalityRight bundle branch blockLateral ST-T changes may be due to myocardial ischemia - clinical correlationis suggestedSince previous tracing of : no significant change S/P aortic valve replacement. There is a retrocardiac opacity which likely represents atelectasis. Minimal left subcutaneous emphysema. S/P CABG/AVRNSR. ETT SUCTIONED FOR SOME THICK SECRETIONS ~ 1HR PRIOR TO EXTUBATION. PRBC ORDERED BY DR. .BREATHSOUNDS CLEAR. FINAL REPORT INDICATION: Crepitus over left chest, evaluate for residual pneumothorax. WEANED FROM VENTILATOR AND EXTUBATED @ 2100. CHEST, PA AND LATERAL: The patient is s/p aortic valve replacement. There is a small amount of subcutaneous emphysema on the left. H/O PROLONGED QT INTERVAL. There is blunting of both costophrenic angles posteriorly and laterally suggesting small pleural effusions. IMPRESSION: Small bilateral pleural effusions. A chest tube and mediastinal drain are present. NTG GTT TITRATED TO KEEP MBP <90. 2 LITERS LR GIVEN EARLIER. NEURO ALERT ORIENTED NO DEFECITS NOTEDC/V APACED WITH FREQ PVCS A NOT ALWAYS SENSING CORRECTLY SENSITIVITY DECREASE TO .8 WITH LITTLE EFFECT CONTINUES TO NOT SENSE AT TIMES 4AM INCREASE DIFFICULTY WITH SENSING NOT SENSING CORRECTLY FREQ POLARITY CHANGED WITH NO EFFECT PACER DECREASE TO BACKUP RATE OF 50 WITH LOWEST MA SETTING TO USE AS NEEDED MP NSR SB HR 55-66 OCC PVC MAG REPLACED B/P STABLE ON NITRO 2MCGS B/P INREASE TO MAP 88 5AM WITH NO B/P CHANGE WITH HR CHANGE NTG INCREASE TO 2.2MCG MS GIVEN WITH GOOD EFFECTRESP NC 4L SATS 98% NONPRODUCTIVE LUNGS CLEAR CHEST TUBES PATENT 10-20CC SEROSANGACTIVITY TURNING IN BED WITH ONE ASSIST TOL WELLPLAN CONTINUE TO MONITOR FOR HEMODYNAMIC STABLITY ? PLAN TO MONITOR QT INTERVAL. IMPRESSION: 1) No pneumothorax. Comparison is made to the prior study from . SEMI-UPRIGHT AP CHEST RADIOGRAPH: A right internal jugular Swan-Ganz catheter is present with the tip in the main pulmonary artery. 63 PKG/YR SMOKING HISTORY NOTED IN CHART. DIFFICULTY GETTING V WIRE TO SENSE APPROPRIATELY. PLAN TO CHECK K/ION CA/ Q/4HRS TONIGHT PER DR. . HR DOWN TO 55 (SINUS) TONIGHT. NO NAUSEA TONIGHT.FOLEY DRAINING CLEAR YELLOW.PT DENIES PAIN BUT ADMITS TO A SENSATION OF HEAVINESS IN HIS INCISIONAL AREA.ORIENTED X 3. SHE WILL CHECK IN BY PHONE.GLASSES AND UPPER PLATE AND BRIDGE LEFT AT BEDSIDE.PLAN TO RECHECK PRBC AND ELECTROLYTES. 8:28 AM CHEST (PORTABLE AP) Clip # Reason: s/p CABG and now has crepitus over left chest despite presen MEDICAL CONDITION: 75 year old man with s/p CABG/AVR REASON FOR THIS EXAMINATION: s/p CABG and now has crepitus over left chest despite presence of CT, please evaluate adequacy of chest tube and ? A PACING INITIATED @ 80. HCT DOWN TO ~22 BUT IMMEDIATE REPEAT ^25. Sternal wires are present. METABOLIC ACIDOSIS NOTED AND TREATED WITH IV VOLUME.OGT DRAINING GREEN BILIOUS PRIOR TO REMOVAL. 2) Moderate congestive heart failure, increased since the prior study. CI GOOD. SEEN BY EPS LAB HERE AT . The heart and vascularity are normal. There is increased cardiomegaly, along with increased lung opacity indicating worsening congestive heart failure. 10:54 AM CHEST (PA & LAT) Clip # Reason: s/p chest tubes out MEDICAL CONDITION: 75 year old man with critical AS pre op REASON FOR THIS EXAMINATION: s/p chest tubes out FINAL REPORT INDICATION: S/P chest tube removal. MAE. OOB TO CHAIR TODAY The osseous structures are unremarkable. There is no pneumothorax. No pneumothorax is seen. NAPPING MOST OF SHIFT.WIFE IN TO VISIT."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2140-12-28 00:00:00.000","description":"CHEST (PA & LAT)","row_id":777608,"text":" 10:54 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p chest tubes out\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with critical AS pre op\n\n REASON FOR THIS EXAMINATION:\n s/p chest tubes out\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P chest tube removal.\n\n CHEST, PA AND LATERAL: The patient is s/p aortic valve replacement.\n There is blunting of both costophrenic angles posteriorly and laterally\n suggesting small pleural effusions. No pneumothorax is seen. There is a\n small amount of subcutaneous emphysema on the left. The heart and vascularity\n are normal.\n\n IMPRESSION: Small bilateral pleural effusions. Minimal left subcutaneous\n emphysema. S/P aortic valve replacement.\n\n"},{"category":"Radiology","chartdate":"2140-12-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":777508,"text":" 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG and now has crepitus over left chest despite presen\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p CABG/AVR\n REASON FOR THIS EXAMINATION:\n s/p CABG and now has crepitus over left chest despite presence of CT, please\n evaluate adequacy of chest tube and ? of residual pnuemothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Crepitus over left chest, evaluate for residual pneumothorax.\n\n Comparison is made to the prior study from .\n\n SEMI-UPRIGHT AP CHEST RADIOGRAPH: A right internal jugular Swan-Ganz catheter\n is present with the tip in the main pulmonary artery. A chest tube and\n mediastinal drain are present. Sternal wires are present. There is no\n pneumothorax. There is increased cardiomegaly, along with increased lung\n opacity indicating worsening congestive heart failure. There is a\n retrocardiac opacity which likely represents atelectasis. The osseous\n structures are unremarkable.\n\n IMPRESSION:\n 1) No pneumothorax.\n 2) Moderate congestive heart failure, increased since the prior study.\n\n"},{"category":"ECG","chartdate":"2140-12-29 00:00:00.000","description":"Report","row_id":172828,"text":"Sinus rhythm\nRight bundle branch block\nInferior/lateral ST-T changes may be due to myocardial ischemia - clinical\ncorrelation is suggested\nLeft atrial abnormality\nSince previous tracing of : no significant change\n\n"},{"category":"ECG","chartdate":"2140-12-28 00:00:00.000","description":"Report","row_id":172829,"text":"Sinus rhythm\n- premature ventricular contractions\nLeft atrial abnormality\nRight bundle branch block\nLateral ST-T changes may be due to myocardial ischemia - clinical correlation\nis suggested\nSince previous tracing of : no significant change\n\n"},{"category":"ECG","chartdate":"2140-12-27 00:00:00.000","description":"Report","row_id":172830,"text":"Sinus rhythm\nConduction defect of RBBB type\nAnterolateral ST-T changes may be due to myocardial ischemia - clinical\ncorrelation is suggested\nLeft atrial abnormality\nSince previous tracing of : probably no significant change\n\n"},{"category":"ECG","chartdate":"2140-12-26 00:00:00.000","description":"Report","row_id":172831,"text":"Baseline artifact\nSinus rhythm\nConduction defect of RBBB type\nAnterolateral ST-T changes may be due to myocardial ischemia - clinical\ncorrelation is suggested\nConsider left atrial abnormality\nSince previous tracing : further ST-T wave changes present and QRS\nvoltage less prominent\n\n"},{"category":"Nursing/other","chartdate":"2140-12-27 00:00:00.000","description":"Report","row_id":1438525,"text":"NEURO ALERT ORIENTED NO DEFECITS NOTED\n\nC/V APACED WITH FREQ PVCS A NOT ALWAYS SENSING CORRECTLY SENSITIVITY DECREASE TO .8 WITH LITTLE EFFECT CONTINUES TO NOT SENSE AT TIMES 4AM INCREASE DIFFICULTY WITH SENSING NOT SENSING CORRECTLY FREQ POLARITY CHANGED WITH NO EFFECT PACER DECREASE TO BACKUP RATE OF 50 WITH LOWEST MA SETTING TO USE AS NEEDED MP NSR SB HR 55-66 OCC PVC MAG REPLACED B/P STABLE ON NITRO 2MCGS B/P INREASE TO MAP 88 5AM WITH NO B/P CHANGE WITH HR CHANGE NTG INCREASE TO 2.2MCG MS GIVEN WITH GOOD EFFECT\n\nRESP NC 4L SATS 98% NONPRODUCTIVE LUNGS CLEAR CHEST TUBES PATENT 10-20CC SEROSANG\n\nACTIVITY TURNING IN BED WITH ONE ASSIST TOL WELL\n\nPLAN CONTINUE TO MONITOR FOR HEMODYNAMIC STABLITY ? OOB TO CHAIR TODAY\n"},{"category":"Nursing/other","chartdate":"2140-12-26 00:00:00.000","description":"Report","row_id":1438524,"text":"S/P CABG/AVR\nNSR. HR DOWN TO 55 (SINUS) TONIGHT. A PACING INITIATED @ 80. NTG GTT TITRATED TO KEEP MBP <90. DIFFICULTY GETTING V WIRE TO SENSE APPROPRIATELY. H/O PROLONGED QT INTERVAL. SEEN BY EPS LAB HERE AT . PLAN TO CHECK K/ION CA/ Q/4HRS TONIGHT PER DR. . CI GOOD. 2 LITERS LR GIVEN EARLIER. HCT DOWN TO ~22 BUT IMMEDIATE REPEAT ^25. PRBC ORDERED BY DR. .\n\nBREATHSOUNDS CLEAR. WEANED FROM VENTILATOR AND EXTUBATED @ 2100. ETT SUCTIONED FOR SOME THICK SECRETIONS ~ 1HR PRIOR TO EXTUBATION. 63 PKG/YR SMOKING HISTORY NOTED IN CHART. METABOLIC ACIDOSIS NOTED AND TREATED WITH IV VOLUME.\n\nOGT DRAINING GREEN BILIOUS PRIOR TO REMOVAL. NO NAUSEA TONIGHT.\n\nFOLEY DRAINING CLEAR YELLOW.\n\nPT DENIES PAIN BUT ADMITS TO A SENSATION OF HEAVINESS IN HIS INCISIONAL AREA.\n\nORIENTED X 3. MAE. NAPPING MOST OF SHIFT.\n\nWIFE IN TO VISIT. SHE REPORTED THAT SHE WILL NOT BE IN TO VISIT BECAUSE SHE DOES NOT DRIVE IN THE CITY. SHE WILL CHECK IN BY PHONE.\n\nGLASSES AND UPPER PLATE AND BRIDGE LEFT AT BEDSIDE.\n\nPLAN TO RECHECK PRBC AND ELECTROLYTES. PLAN TO MONITOR QT INTERVAL.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-12-28 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 777608,\n \"text\": \" 10:54 AM\\n CHEST (PA & LAT) Clip # \\n Reason: s/p chest tubes out\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with critical AS pre op\\n\\n REASON FOR THIS EXAMINATION:\\n s/p chest tubes out\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: S/P chest tube removal.\\n\\n CHEST, PA AND LATERAL: The patient is s/p aortic valve replacement.\\n There is blunting of both costophrenic angles posteriorly and laterally\\n suggesting small pleural effusions. No pneumothorax is seen. There is a\\n small amount of subcutaneous emphysema on the left. The heart and vascularity\\n are normal.\\n\\n IMPRESSION: Small bilateral pleural effusions. Minimal left subcutaneous\\n emphysema. S/P aortic valve replacement.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-12-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 777508,\n \"text\": \" 8:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p CABG and now has crepitus over left chest despite presen\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old man with s/p CABG/AVR\\n REASON FOR THIS EXAMINATION:\\n s/p CABG and now has crepitus over left chest despite presence of CT, please\\n evaluate adequacy of chest tube and ? of residual pnuemothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Crepitus over left chest, evaluate for residual pneumothorax.\\n\\n Comparison is made to the prior study from .\\n\\n SEMI-UPRIGHT AP CHEST RADIOGRAPH: A right internal jugular Swan-Ganz catheter\\n is present with the tip in the main pulmonary artery. A chest tube and\\n mediastinal drain are present. Sternal wires are present. There is no\\n pneumothorax. There is increased cardiomegaly, along with increased lung\\n opacity indicating worsening congestive heart failure. There is a\\n retrocardiac opacity which likely represents atelectasis. The osseous\\n structures are unremarkable.\\n\\n IMPRESSION:\\n 1) No pneumothorax.\\n 2) Moderate congestive heart failure, increased since the prior study.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 172828,\n \"text\": \"Sinus rhythm\\nRight bundle branch block\\nInferior/lateral ST-T changes may be due to myocardial ischemia - clinical\\ncorrelation is suggested\\nLeft atrial abnormality\\nSince previous tracing of : no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-12-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 172829,\n \"text\": \"Sinus rhythm\\n- premature ventricular contractions\\nLeft atrial abnormality\\nRight bundle branch block\\nLateral ST-T changes may be due to myocardial ischemia - clinical correlation\\nis suggested\\nSince previous tracing of : no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 172830,\n \"text\": \"Sinus rhythm\\nConduction defect of RBBB type\\nAnterolateral ST-T changes may be due to myocardial ischemia - clinical\\ncorrelation is suggested\\nLeft atrial abnormality\\nSince previous tracing of : probably no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 172831,\n \"text\": \"Baseline artifact\\nSinus rhythm\\nConduction defect of RBBB type\\nAnterolateral ST-T changes may be due to myocardial ischemia - clinical\\ncorrelation is suggested\\nConsider left atrial abnormality\\nSince previous tracing : further ST-T wave changes present and QRS\\nvoltage less prominent\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1438525,\n \"text\": \"NEURO ALERT ORIENTED NO DEFECITS NOTED\\n\\nC/V APACED WITH FREQ PVCS A NOT ALWAYS SENSING CORRECTLY SENSITIVITY DECREASE TO .8 WITH LITTLE EFFECT CONTINUES TO NOT SENSE AT TIMES 4AM INCREASE DIFFICULTY WITH SENSING NOT SENSING CORRECTLY FREQ POLARITY CHANGED WITH NO EFFECT PACER DECREASE TO BACKUP RATE OF 50 WITH LOWEST MA SETTING TO USE AS NEEDED MP NSR SB HR 55-66 OCC PVC MAG REPLACED B/P STABLE ON NITRO 2MCGS B/P INREASE TO MAP 88 5AM WITH NO B/P CHANGE WITH HR CHANGE NTG INCREASE TO 2.2MCG MS GIVEN WITH GOOD EFFECT\\n\\nRESP NC 4L SATS 98% NONPRODUCTIVE LUNGS CLEAR CHEST TUBES PATENT 10-20CC SEROSANG\\n\\nACTIVITY TURNING IN BED WITH ONE ASSIST TOL WELL\\n\\nPLAN CONTINUE TO MONITOR FOR HEMODYNAMIC STABLITY ? OOB TO CHAIR TODAY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1438524,\n \"text\": \"S/P CABG/AVR\\nNSR. HR DOWN TO 55 (SINUS) TONIGHT. A PACING INITIATED @ 80. NTG GTT TITRATED TO KEEP MBP <90. DIFFICULTY GETTING V WIRE TO SENSE APPROPRIATELY. H/O PROLONGED QT INTERVAL. SEEN BY EPS LAB HERE AT . PLAN TO CHECK K/ION CA/ Q/4HRS TONIGHT PER DR. . CI GOOD. 2 LITERS LR GIVEN EARLIER. HCT DOWN TO ~22 BUT IMMEDIATE REPEAT ^25. PRBC ORDERED BY DR. .\\n\\nBREATHSOUNDS CLEAR. WEANED FROM VENTILATOR AND EXTUBATED @ 2100. ETT SUCTIONED FOR SOME THICK SECRETIONS ~ 1HR PRIOR TO EXTUBATION. 63 PKG/YR SMOKING HISTORY NOTED IN CHART. METABOLIC ACIDOSIS NOTED AND TREATED WITH IV VOLUME.\\n\\nOGT DRAINING GREEN BILIOUS PRIOR TO REMOVAL. NO NAUSEA TONIGHT.\\n\\nFOLEY DRAINING CLEAR YELLOW.\\n\\nPT DENIES PAIN BUT ADMITS TO A SENSATION OF HEAVINESS IN HIS INCISIONAL AREA.\\n\\nORIENTED X 3. MAE. NAPPING MOST OF SHIFT.\\n\\nWIFE IN TO VISIT. SHE REPORTED THAT SHE WILL NOT BE IN TO VISIT BECAUSE SHE DOES NOT DRIVE IN THE CITY. SHE WILL CHECK IN BY PHONE.\\n\\nGLASSES AND UPPER PLATE AND BRIDGE LEFT AT BEDSIDE.\\n\\nPLAN TO RECHECK PRBC AND ELECTROLYTES. PLAN TO MONITOR QT INTERVAL.\\n\"\n }\n]"}}},{"rowIdx":790,"cells":{"subject_id":{"kind":"number","value":43450,"string":"43,450"},"hadm_id":{"kind":"number","value":177207,"string":"177,207"},"target_text":{"kind":"string","value":"40F unknown past medical history with Insulin dependant DM2 transferred to for severe acidosis and hypokalemia in setting of DKA. Patient managed in the MICU for 6 days with resolution of her acidosis noted. Patient was called out to the floor on hospital day 6 after being stable on SubQ insulin. Course complicated by new sensory-motor polyneuropathy of left upper extremity and bilateral lower extremities. Transfered to neurology service after EMG concerning for axonal neuropathy on hospital day 11, ultimately determined to be a compressive neuropathy vs. multiple root radiculopathy. # Severe acidosis likely DKA Patient has severe acidosis on ABG with both primary metabolic non-gap and gap acidoses with superimposed respiratory acidosis. Etiology of primary metabolic non-gap acidosis may be from NS volume resuscitation, diarrhea, or other etiologies. The likely cause of the anion gap acidosis is DKA with no other apparent MUDPILES etiologies based on urine/serum toxicology. Osmolar gap initially 51, so methanol, polyethylene glycol or other exogenous substance may explain extra osmoles that would not be accounted for by DKA alone. Patient started on Insulin drip and Bicarb which were rate limited so as not to drop K+ faster than it could be repleted. Over the course of hospital day 1 patient was noted to have progressive improvement of her acidosis. In setting of severe acidosis and osmolar gap, patient received a single episode of hemodialysis. In the evening of hospital day 1 the patient's anion gap was noted to re-open to 24, patient was given additional IV fluids and insulin drip was continued with resolution of anion gap noted on repeat Chem7. Patient tolerated a PO diet on hospital day 4 and was started on SubQ insulin. Following initiation of SubQ insulin the insulin drip was discontinued. The patient was observed in the MICU following discontinuation of the insulin drip and her anion gap was noted to remain closed. Once the patient was fully awake she endorsed poor medication compliance with regards to her insulin. She states that she was on vacation prior to onset of DKA and that she did not utilize her insulin at all during a period of time during her vacation making medication non-compliance the most likely etiology of her DKA. After transfer to the general medicine, her blood sugars remained in the 120-250 range and she was kept on Lantus 50 units in the am and humalog sliding scale. She was followed closely by the service. Insulin dose on discharge was Lantus 40qam and 16qhs along with sliding scale. Instructed patient about importance of insulin compliance and establishing care with a primary care doctor upon return to . # Leukocytosis/hypothermia/MRSA bacteremia Initial concern for hypothermic sepsis given marked leukocytosis. Careful skin exam did not reveal any skin/soft tissue infection. CXR showing ? atelectasis vs. developing LL infiltrate after fluid resuscitation. CT Abdomen could suggest colitis although indefinite. Host factors include DM2 - no recent healthcare exposure- vancomycin/cefepime/flagyl given empirically as patient critically ill pending culture results. Patient's antibiotics discontinued on hospital day 3 as all cultures acquired were negative. On hospital day 5, repeat CXR concerning for new pneumonia and UA concerning for UTI. Repeat cultures sent and patient re-started on vanc and cefepime. Cultures sendt noted to grow out gram positive cocci in clusters, central line discontinued and patient continued on vanc and cefepime. She remained on Vancomycin after confirmed MRSA bacteremia to complete a 2 week course ending . A PICC was placed via IR guidance after an initial failed attempt. She also had a TTE which did not show evidence of vegetation, thus low suspicion of endocarditis. She completed a course of Vancomycin per recommendations of the infectious disease team on . # ? Pancreatitis The patient had elevated pancreatic enzymes, which may reflect either pancreatitis or increased pancreatic enzyme activities in the setting of DKA. Her abdominal exam appears to be bengin. A CT Abd/pelvis showed bowel wall thickening mainly involving the proximal small bowel (duodenum and jejunum) which could represent peristalsis, enteritis (such as infectious, inflammatory or ischemic) with mild blurring of pancreatic margins with minimal mesenteric stranding. It also shows multiple transient intussusception of jejenum, little bit of fluid in mesenetery and pancreas consistent with ? focal pancreatitis. Patient was evaluated by surgery for questionable CT abdomen findings, no surgical intervention indicated per surgery. TG mildly elevated, but unclear if high enough to have precipitated pancreatitis. Ca within normal limits; no evidence of CBG/gallstone pancreatitis on CT Abd. As patient's mental status improved appeared to be in pain with apparent tenderness to palpation of epigastrum, in setting of elevated lipase we have increased suspiscion of pancreatitis as cause of pain and possibly as etiology of DKA. Treated with IV Dilaudid PRN pain. Patient subsequently noted to have improvement of pain and tenderness likely representing resolution of acute pancreatitis episode. There was no further abdominal pain/tenderness while on the floor. # Respiratory failure Patient was intubated secondary to depressed mental status for airway protection. Patient passed spontaneous breathing test on hospital day two and was extubated. No further respiratory distress. # Shock Patient likely had septic shock from underlying infection, hypovolemic shock from osmotic diuresis in setting of DKA. Doubt cardiogenic or distributive shock. Her opening CVP was 11 with good urine output, normal lactate, and exam consistent with good perfusion. ScVO2 is ~ 90 suggestive of likely tissue mitochondrial dysfunction in setting of severe acidosis. She has been responsive to IVF resuscitation. By hospital day 2 patient was noted to have improvement in hemodynamics and was weaned off of phenylephrine. # Elevated LFTs Patient had mild elevated LFTs at OSH and on admission at . Uncertain etiology - abdominal CT not showed elevated Tbili or other overt abnormalities. Could be from toxidrome vs. early shock liver given hypotension or other causes. Patient's LFTs were trended and returned to baseline. # Thrombocytopenia Admission platelets with thrombocytopenia. Etiology is likely marrow suppresion from acute sepsis/illness. No evidence of sequestration or destruction - firinogen and coagulation is within normal limits speaking against DIC. Was noted to have improvement of platelet count during ICU stay. Normal platelet counts while on the floor. She was seen by heme/onc who recommended a skeletal survey which was normal. Also recommended HIV, which is pending at time of discharge. Considered bone marrow biopsy, but deferred given abnormalities likely in setting of acute illness. Asked patient to seen a hematologist/oncologist in 3 months and have them re-check SPEP, free kappa/lambda chains. Also, re-consider a bone marrow biopsy if values have not normalized."},"extractive_notes_summ":{"kind":"string","value":"COMPARISON: Non-contrast CT head on . Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. Minimal fluid is noted extending in the pericholecystic region, however the gallbladder is within normal limits. The mitral valve appears structurally normal withtrivial mitral regurgitation. The mitral valve appears structurally normal withtrivial mitral regurgitation. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. IMPRESSION: Very minimal disc buldge of L5-S1. Cannot assess RA pressure.LEFT VENTRICLE: Normal LV wall thickness and cavity size. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. The sacroiliac joints are grossly within normal limits. There is no pericardial effusion.IMPRESSION: Normal biventricular cavity sizes with preserved regional andhyperdynamic global biventricular systolic function. There is minimal spurring at the anterior aspect of several lower thoracic vertebral bodies. Minimal spurring at the L4 and L5 vertebral bodies are seen anteriorly. Hypoinflation of the lungs is unchanged. A small disc buldge is present at L5-S1 with very minimal compression of the thecal sac, but no contact with traversing nerve roots. There is a trace of free pelvic fluid, within physiologic limits for age. Left ventricular wall thicknesses arenormal. IMPRESSION: Tip of a right-sided PICC line remains in the left brachiocephalic vein. Sepsis.Height: (in) 60Weight (lb): 186BSA (m2): 1.81 m2BP (mm Hg): 91/43HR (bpm): 118Status: InpatientDate/Time: at 10:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. mild gallbladder wall edema. Tissue Doppler imaging suggests anormal left ventricular filling pressure (PCWP<12mmHg). No restingLVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Normal aortic valve leaflets (?#). FINDINGS: As compared to the previous radiograph, the previously placed left internal jugular vein catheter has been removed. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 62Weight (lb): 186BSA (m2): 1.86 m2BP (mm Hg): 110/80HR (bpm): 104Status: InpatientDate/Time: at 14:42Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. The left ventricular cavity size is normal. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aortic stenosisor aortic regurgitation. IMPRESSION: No acute intracranial pathology. Normal regional LVsystolic function. TECHNIQUE: Contiguous axial images were obtained through the head without the administration of IV contrast. There is trace fluid in the right maxillary sinus and right mastoid air cells and sphenoid sinuses but the remaining paranasal sinuses are clear. Left ventricular wall thicknesses andcavity size are normal. LowQRS voltages in the precordial leads. ST-T wave changes in the anterior andlateral leads are non-specific. AP PELVIS AND BILATERAL FEMORA: No focal lytic or blastic lesions are seen. The aortic valve leaflets (?#) appear structurally normalwith good leaflet excursion. Regional left ventricular wall motion is normal. Minimal edema within the fat in the groove between the pancreas and duodenum which may represent focal acute pancreatitis with extension of edema to the pericholecystic region. The patient is mechanicallyventilated. Right ventricularchamber size and free wall motion are normal. Right ventricular chamber size and free wallmotion are normal. There is evidence of minimal edema within the fat in the groove between the pancreas and duodenum which may represent focal pancreatitis. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). FINDINGS: A single semi-erect portable chest radiograph is obtained. Normal LV cavity size. Bilateral hip joint spaces demonstrate mild spurring in the superolateral aspect, consistent with early degenerative changes. Tricuspid valve not wellvisualized. FINDINGS: In comparison with the earlier study of this date, there has been placement of a left IJ catheter that extends to about the junction with the superior vena cava. There is a small mucus retention cyst in the left sphenoid sinus. THORACIC SPINE: No compression deformities are seen. Ventricles and sulci are normal in size and configuration. Vertebral body heights are maintained and show normal signal. TECHNIQUE: MR of the lumbar spine without contrast. COMPARISON: PORTABLE AP CHEST RADIOGRAPH: Bilateral low lung volumes are noted with crowding of bronchovascular markings. The ventricles and sulci are normal in size and symmetric in configuration. T wave abnormalities persist. There are no new abnormal cardiac or mediastinal contours. 2. mild blurring of pancreatic margins with minimal mesenteric straning, very early pancreatitis cannot be excluded, although no CT evidence of florid pancreatitis or pancreatitis related complications. IMPRESSION: No evidence of acute intracranial pathology. Multiple transient intussceptions are noted along the jejunum (uncertain significance). Multiple transient intussceptions are noted along the jejunum (uncertain significance). Visualized osseous structures show no suspicious lesions. Diffuse ST-T wave changes that are non-specific. Otherwise, the radiograph is unremarkable. No valvular pathology orpathologic flow identified.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Evaluate for cerebral edema. If there is concern for polyneuritis, post gadolineum imaging can be obtained. There is no pericardial effusion.No vegetation seen (cannot definitively exclude).Compared with the prior study (images reviewed) of , findings aresimilar. LATERAL SKULL: No focal lytic or blastic lesions are seen. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Feeding tube is noted in the post-pyloric position with tip not clearly visualized. Low voltage throughout. No pleural effusion, or pneumothorax. Voltage is lesspriominent. The uterus appears unremarkable. Left IJ catheter extends to the mid-to-lower portion of the SVC. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). Probable sinus tachycardia. Tip of a right-sided PICC line is positioned more centrally within the left brachiocephalic vein."},"n_notes":{"kind":"number","value":17,"string":"17"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2156-09-21 00:00:00.000","description":"Report","row_id":60118,"text":"PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 62\nWeight (lb): 186\nBSA (m2): 1.86 m2\nBP (mm Hg): 110/80\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 14:42\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: 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 Doppler imaging suggests a\nnormal left ventricular filling pressure (PCWP<12mmHg). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic stenosis\nor aortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no pericardial effusion.\n\nNo vegetation seen (cannot definitively exclude).\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar. The heart rate is now slower.\n\n\n"},{"category":"Echo","chartdate":"2156-09-14 00:00:00.000","description":"Report","row_id":60121,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Sepsis.\nHeight: (in) 60\nWeight (lb): 186\nBSA (m2): 1.81 m2\nBP (mm Hg): 91/43\nHR (bpm): 118\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The patient is mechanically\nventilated. Cannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. Estimated cardiac index is high\n(>4.0L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Tricuspid valve not well\nvisualized. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%). The estimated cardiac\nindex is high (>4.0L/min/m2). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (?#) appear structurally normal\nwith good leaflet excursion. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved regional and\nhyperdynamic global biventricular systolic function. No valvular pathology or\npathologic flow identified.\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":"2156-09-18 00:00:00.000","description":"Report","row_id":108882,"text":"Baseline artifact. Sinus tachycardia. ST-T wave changes in the anterior and\nlateral leads are non-specific. Repeat tracing is suggested given the baseline\nartifact. Compared to the previous tracing of the lateral precordial\nST-T wave changes are slightly more pronounced. The sinus rate has increased\nby 8 beats per minute.\n\n"},{"category":"ECG","chartdate":"2156-09-14 00:00:00.000","description":"Report","row_id":108883,"text":"Probable sinus tachycardia. Low voltage throughout. T wave abnormalities.\nSince the previous tracing of the rate is faster. Voltage is less\npriominent. ST segments have improved. T wave abnormalities persist.\n\n"},{"category":"ECG","chartdate":"2156-09-14 00:00:00.000","description":"Report","row_id":108884,"text":"Sinus rhythm. Diffuse ST-T wave changes that are non-specific. Low\nQRS voltages in the precordial leads. No previous tracing available for\ncomparison.\n\n\n"},{"category":"Radiology","chartdate":"2156-09-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1251957,"text":" 3:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe DKA now with signs concerning for new infection\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe DKA with signs concerning for new infection.\n\n FINDINGS: In comparison with the study of , all of the monitoring and\n support devices have been removed except for the left IJ catheter, which\n extends to the mid portion of the SVC. Very low lung volumes may account for\n the prominence of interstitial markings, though some elevation of pulmonary\n venous pressure could be present. Some atelectatic changes are seen at the\n bases.\n\n\n"},{"category":"Radiology","chartdate":"2156-09-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1251391,"text":" 3:48 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for right IJ\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 40F with right IJ\n REASON FOR THIS EXAMINATION:\n eval for right IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ catheter.\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 about the junction with the\n superior vena cava. Otherwise, little change.\n\n\n"},{"category":"Radiology","chartdate":"2156-09-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1251381,"text":" 12:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for pancreatitis, ICH, cerebral edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 40F with intubated, sedated; likely pancreatitis\n REASON FOR THIS EXAMINATION:\n eval for pancreatitis, ICH, cerebral edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 1:47 AM\n no acute ich\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female who presented to Hospital with rapid\n deterioration in mental status and hypotension. Now intubated, sedated, with\n possible pancreatitis. Evaluate for intracranial pathology and cerebral edema.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained through the head without the\n administration of IV contrast. Multiplanar reformats were generated and\n reviewed.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass\n effect or loss of /white matter differentiation. Ventricles and sulci are\n normal in size and configuration. Basal cisterns are not compressed.\n\n Bilateral mastoid air cells and pneumatized petrous apices are well aerated.\n There are secretions within the nasopharynx, likely secondary to intubation\n and supine positioning. There is a small mucus retention cyst in the left\n sphenoid sinus.\n\n IMPRESSION: No evidence of acute intracranial pathology.\n DFDkq\n\n"},{"category":"Radiology","chartdate":"2156-09-14 00:00:00.000","description":"CT ABD & PELVIS WITH CONTRAST","row_id":1251382,"text":" 12:56 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for pancreatitis, ICH, cerebral edema\n Field of view: 50 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 40F with intubated, sedated; likely pancreatitis\n REASON FOR THIS EXAMINATION:\n eval for pancreatitis, ICH, cerebral edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 2:17 AM\n 1. bowel wall thickening mainly invol the prox small bowel (duod and jejunum),\n while this may represent peristalsis, enteritis (infectious, inflammatory,\n ischemia cannot be excluded).\n 2. mild blurring of pancreatic margins with minimal mesenteric straning, very\n early pancreatitis cannot be excluded, although no CT evidence of florid\n pancreatitis or pancreatitis related complications.\n 3. pericholecystic fluid. mild gallbladder wall edema.\n 4. fatty deposition within the liver.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female intubated, sedated, likely pancreatitis.\n Evaluate for pancreatitis.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis\n with the administration of IV contrast. Multiplanar reformats were generated\n and reviewed.\n\n FINDINGS:\n\n CT OF THE ABDOMEN: Bilateral breast prostheses are noted. The visualized\n lung bases show bilateral trace pleural effusions with adjacent opacification\n which likely represents predominantly atelectasis; however, a component of\n aspiration versus infectious process such as pneumonia cannot be completely\n excluded. A nasogastric tube is seen within the post-pyloric stomach.\n\n The liver demonstrates diffuse and significant fatty change. The spleen is\n unremarkable. Note is made of a tiny splenule. There is evidence of minimal\n edema within the fat in the groove between the pancreas and duodenum which may\n represent focal pancreatitis. Minimal fluid is noted extending in the\n pericholecystic region, however the gallbladder is within normal limits.\n Bilateral adrenal glands and both kidneys enhance and excrete contrast\n symmetrically. A hypodensity within the interpolar region of the left kidney\n measuring 17 x 15 mm likely represents a renal cyst.\n\n Multiple transient intussceptions are noted along the jejunum (uncertain\n significance). There is no free air or free fluid within the abdomen.\n Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for\n pathology.\n (Over)\n\n 12:56 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for pancreatitis, ICH, cerebral edema\n Field of view: 50 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS: The rectum and sigmoid colon appear unremarkable. Mild\n prominance of the colonic wall may be secondary to third-spacing. A Foley\n catheter is present within the bladder. Air within the bladder likely relates\n to Foley. The uterus appears unremarkable. There is a trace of free pelvic\n fluid, within physiologic limits for age. Pelvic lymph nodes do not meet CT\n size criteria for pathology.\n\n Visualized osseous structures show no suspicious lesions.\n\n IMPRESSION:\n\n 1. Visualized lung bases show bilateral trace pleural effusions with adjacent\n opacification which likely represents atelectasis; however, a component of\n aspiration versus infectious process such as pneumonia cannot be completely\n excluded.\n 2. Minimal edema within the fat in the groove between the pancreas and\n duodenum which may represent focal acute pancreatitis with extension of edema\n to the pericholecystic region.\n 3. Multiple transient intussceptions are noted along the jejunum (uncertain\n significance).\n 4. Significantly fatty liver.\n\n Updated findings were discussed with Dr. at 9:12 am on \n via telephone.\n\n"},{"category":"Radiology","chartdate":"2156-09-14 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1251461,"text":" 12:48 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Evaluate line placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with new central line placed\n REASON FOR THIS EXAMINATION:\n Evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: No previous images. Right IJ sheath extends to the lower portion\n of the SVC. Left IJ catheter extends to the mid-to-lower portion of the SVC.\n Nasogastric tube extends to at least the distal stomach.\n\n There are low lung volumes. Hazy opacification at the right base raises the\n possibility of consolidation. Probable atelectatic changes at the left base.\n\n\n"},{"category":"Radiology","chartdate":"2156-09-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1251388,"text":" 2:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 40F with attempted left subclavian\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female with attempted left subclavian, evaluate for\n pneumothorax.\n\n COMPARISON:\n\n PORTABLE AP CHEST RADIOGRAPH: Bilateral low lung volumes are noted with\n crowding of bronchovascular markings. No pleural effusion, or pneumothorax.\n Opacification at the left lung base may represent atelectasis, less likely\n infection. ET tube is noted approximately 2.8 cm above the carina with chin in\n raised position, recommend pulling ETT back by another 1cm to prevent it\n touching the carina with neck flexion. Feeding tube is noted in the\n post-pyloric position with tip not clearly visualized.\n\n Findings discussed with RN, Israeli Demenezes at 9:15am and Dr. at 9:20\n am on via telephone.\n\n"},{"category":"Radiology","chartdate":"2156-09-15 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1251553,"text":" 11:13 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for cerebral edema\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with DKA, profound acidemia, now with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for cerebral edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman, with DKA and profound acidemia. Now with altered\n mental status. Evaluate for cerebral edema.\n\n COMPARISON: Non-contrast CT head on .\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\n major vascular territorial infarct. The ventricles and sulci are normal in\n size and symmetric in configuration. Basal cisterns are patent. There is no\n shift of normally midline structures. The -white matter differentiation\n is preserved. The visualized mastoid air cells are clear. There is trace\n fluid in the right maxillary sinus and right mastoid air cells and sphenoid\n sinuses but the remaining paranasal sinuses are clear. No acute skull\n fracture is noted. This study is essentially unchanged from the study one day\n before.\n\n IMPRESSION: No acute intracranial pathology. Unchanged exam from yesterday.\n If clinical concerns remain high, consider MRI brain to further assess.\n\n"},{"category":"Radiology","chartdate":"2156-09-22 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1252358,"text":" 9:47 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 44cm iv \n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r picc 44cm iv \n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Right PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the previously placed left\n internal jugular vein catheter has been removed. New is a right PICC line.\n The line crosses the midline and the tip projects over the left subclavian\n vein. This malposition requires replacement of the PICC line. There is no\n evidence of complication, notably no pneumothorax. Otherwise, the radiograph\n is unremarkable. The observation was made on 8:26 a.m., on .\n At 8:27 a.m., on the same day, the referring physician, . , was paged\n for notification.\n\n\n"},{"category":"Radiology","chartdate":"2156-10-01 00:00:00.000","description":"SKELETAL SURVEY (INCLUD LONG BONES)","row_id":1253453,"text":" 10:05 AM\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \n Reason: please assess for bone involvement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with IgG elevation, c/f MGUS vs myeloma. New anemia\n REASON FOR THIS EXAMINATION:\n please assess for bone involvement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Skeletal survey, .\n\n CLINICAL HISTORY: 40-year-old woman with IgG elevation, history of MGUS\n versus myeloma, now with new anemia.\n\n FINDINGS: No previous studies skeletal survey-wise for a direct comparison.\n Comparison is made to the scan from .\n\n LATERAL SKULL: No focal lytic or blastic lesions are seen.\n\n BILATERAL HUMERI: There is a portion of a central venous catheter seen in the\n right arm. There are no focal lytic or blastic lesions or significant\n degenerative changes.\n\n THORACIC SPINE: No compression deformities are seen. There is minimal\n spurring at the anterior aspect of several lower thoracic vertebral bodies.\n Visualized lung fields are clear. There is a central venous catheter with\n distal lead tip at the cavoatrial junction.\n\n LUMBAR SPINE: There are five non-rib-bearing lumbar-type vertebral bodies.\n There is no compression deformity. Minimal spurring at the L4 and L5\n vertebral bodies are seen anteriorly.\n\n AP PELVIS AND BILATERAL FEMORA: No focal lytic or blastic lesions are seen.\n The sacroiliac joints are grossly within normal limits. Bilateral hip joint\n spaces demonstrate mild spurring in the superolateral aspect, consistent with\n early degenerative changes.\n\n IMPRESSION:\n\n No focal lytic or blastic lesions in the skeleton to indicate definite\n myelomatous deposits.\n\n"},{"category":"Radiology","chartdate":"2156-09-22 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1252372,"text":" 11:25 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 44cm crossed chest, pulled back 2cm, power flushed. r\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r picc 44cm crossed chest, pulled back 2cm, power flushed. repeat x-ray iv \n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old woman with right-sided PICC line.\n\n COMPARISON: 10 a.m. this morning.\n\n FINDINGS: A single semi-erect portable chest radiograph is obtained. Tip of\n a right-sided PICC line is positioned more centrally within the left\n brachiocephalic vein. Hypoinflation of the lungs is unchanged. There is no\n new consolidation, effusion, or pneumothorax. There are no new abnormal\n cardiac or mediastinal contours.\n\n IMPRESSION: Tip of a right-sided PICC line remains in the left\n brachiocephalic vein.\n\n"},{"category":"Radiology","chartdate":"2156-09-22 00:00:00.000","description":"EXCH PERPHERAL W/O PORT","row_id":1252421,"text":" 4:05 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC line\n Admitting Diagnosis: PANCREATITIS\n Contrast: OMNIPAQUE Amt: 5\n This is a power pick\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with hx of MRSA bacteremia and DKA who had failed bedside\n picc today.\n REASON FOR THIS EXAMINATION:\n please place PICC line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old woman with history of MRSA bacteremia and DKA, failed\n bedside PICC.\n\n RADIOLOGISTS: Dr. (resident), Dr. (fellow), Dr. \n (attending).\n\n PICC LINE EXCHANGE/REPOSITIONING\n The procedure was explained to the patient. A timeout was performed.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling right arm PICC line, and subsequently into the\n SVC under fluoroscopic guidance. The old PICC line was then removed and a\n peel-away sheath was placed over the guidewire. A new single-lumen PICC line\n measuring 42 cm in length was then placed through the peel-away sheath with\n its tip positioned in the SVC. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a\n new 4 French single-lumen PICC line. Final internal length is 42 cm, with the\n tip positioned in the SVC. The line is ready to use.\n\n"},{"category":"Radiology","chartdate":"2156-09-23 00:00:00.000","description":"MR L SPINE W/O CONTRAST","row_id":1252586,"text":" 9:37 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Evaluate for radiculopathy\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman who presented with DKA requiring intubation, now with severe\n acute axonal sensory-motor polyneuropathy by EMG.\n REASON FOR THIS EXAMINATION:\n Evaluate for radiculopathy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman presenting with DKA, requiring intubation, now with\n acute axonal sensory and motor polyneuropathy by EMG. Please evaluate for\n radiculopathy.\n\n COMPARISON: None.\n\n TECHNIQUE: MR of the lumbar spine without contrast.\n\n FINDINGS: Intervertebral disc heights and signals are maintained. There is\n no signal abnormality in the cord. Vertebral body heights are maintained and\n show normal signal. Imaged portions of the soft tissues are unremarkable. A\n small disc buldge is present at L5-S1 with very minimal compression of the\n thecal sac, but no contact with traversing nerve roots.\n\n IMPRESSION: Very minimal disc buldge of L5-S1. If there is concern for\n polyneuritis, post gadolineum imaging can be obtained.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2156-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 60118,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Endocarditis.\\nHeight: (in) 62\\nWeight (lb): 186\\nBSA (m2): 1.86 m2\\nBP (mm Hg): 110/80\\nHR (bpm): 104\\nStatus: Inpatient\\nDate/Time: at 14:42\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\\nnormal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting\\nLVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: 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 Doppler imaging suggests a\\nnormal left ventricular filling pressure (PCWP<12mmHg). Right ventricular\\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\\nappear structurally normal with good leaflet excursion and no aortic stenosis\\nor aortic regurgitation. The mitral valve appears structurally normal with\\ntrivial mitral regurgitation. There is no pericardial effusion.\\n\\nNo vegetation seen (cannot definitively exclude).\\n\\nCompared with the prior study (images reviewed) of , findings are\\nsimilar. The heart rate is now slower.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2156-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 60121,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Sepsis.\\nHeight: (in) 60\\nWeight (lb): 186\\nBSA (m2): 1.81 m2\\nBP (mm Hg): 91/43\\nHR (bpm): 118\\nStatus: Inpatient\\nDate/Time: at 10:00\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The patient is mechanically\\nventilated. Cannot assess RA pressure.\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\\nsystolic function. Hyperdynamic LVEF >75%. Estimated cardiac index is high\\n(>4.0L/min/m2). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Tricuspid valve not well\\nvisualized. Indeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\\n\\nConclusions:\\nThe left atrium is normal in size. Left ventricular wall thicknesses and\\ncavity size are normal. Regional left ventricular wall motion is normal. Left\\nventricular systolic function is hyperdynamic (EF>75%). The estimated cardiac\\nindex is high (>4.0L/min/m2). Right ventricular chamber size and free wall\\nmotion are normal. The aortic valve leaflets (?#) appear structurally normal\\nwith good leaflet excursion. There is no aortic valve stenosis. No aortic\\nregurgitation is seen. The mitral valve appears structurally normal with\\ntrivial mitral regurgitation. The pulmonary artery systolic pressure could not\\nbe determined. There is no pericardial effusion.\\n\\nIMPRESSION: Normal biventricular cavity sizes with preserved regional and\\nhyperdynamic global biventricular systolic function. No valvular pathology or\\npathologic flow identified.\\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\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2156-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 108882,\n \"text\": \"Baseline artifact. Sinus tachycardia. ST-T wave changes in the anterior and\\nlateral leads are non-specific. Repeat tracing is suggested given the baseline\\nartifact. Compared to the previous tracing of the lateral precordial\\nST-T wave changes are slightly more pronounced. The sinus rate has increased\\nby 8 beats per minute.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2156-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 108883,\n \"text\": \"Probable sinus tachycardia. Low voltage throughout. T wave abnormalities.\\nSince the previous tracing of the rate is faster. Voltage is less\\npriominent. ST segments have improved. T wave abnormalities persist.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2156-09-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 108884,\n \"text\": \"Sinus rhythm. Diffuse ST-T wave changes that are non-specific. Low\\nQRS voltages in the precordial leads. No previous tracing available for\\ncomparison.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1251957,\n \"text\": \" 3:30 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? PNA\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with severe DKA now with signs concerning for new infection\\n REASON FOR THIS EXAMINATION:\\n ? PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Severe DKA with signs concerning for new infection.\\n\\n FINDINGS: In comparison with the study of , all of the monitoring and\\n support devices have been removed except for the left IJ catheter, which\\n extends to the mid portion of the SVC. Very low lung volumes may account for\\n the prominence of interstitial markings, though some elevation of pulmonary\\n venous pressure could be present. Some atelectatic changes are seen at the\\n bases.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1251391,\n \"text\": \" 3:48 AM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval for right IJ\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 40F with right IJ\\n REASON FOR THIS EXAMINATION:\\n eval for right IJ\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Right IJ catheter.\\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 about the junction with the\\n superior vena cava. Otherwise, little change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1251381,\n \"text\": \" 12:54 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for pancreatitis, ICH, cerebral edema\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 40F with intubated, sedated; likely pancreatitis\\n REASON FOR THIS EXAMINATION:\\n eval for pancreatitis, ICH, cerebral edema\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: TUE 1:47 AM\\n no acute ich\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40-year-old female who presented to Hospital with rapid\\n deterioration in mental status and hypotension. Now intubated, sedated, with\\n possible pancreatitis. Evaluate for intracranial pathology and cerebral edema.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Contiguous axial images were obtained through the head without the\\n administration of IV contrast. Multiplanar reformats were generated and\\n reviewed.\\n\\n FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass\\n effect or loss of /white matter differentiation. Ventricles and sulci are\\n normal in size and configuration. Basal cisterns are not compressed.\\n\\n Bilateral mastoid air cells and pneumatized petrous apices are well aerated.\\n There are secretions within the nasopharynx, likely secondary to intubation\\n and supine positioning. There is a small mucus retention cyst in the left\\n sphenoid sinus.\\n\\n IMPRESSION: No evidence of acute intracranial pathology.\\n DFDkq\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-14 00:00:00.000\",\n \"description\": \"CT ABD & PELVIS WITH CONTRAST\",\n \"row_id\": 1251382,\n \"text\": \" 12:56 AM\\n CT ABD & PELVIS WITH CONTRAST Clip # \\n Reason: eval for pancreatitis, ICH, cerebral edema\\n Field of view: 50 Contrast: OMNIPAQUE Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 40F with intubated, sedated; likely pancreatitis\\n REASON FOR THIS EXAMINATION:\\n eval for pancreatitis, ICH, cerebral edema\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: TUE 2:17 AM\\n 1. bowel wall thickening mainly invol the prox small bowel (duod and jejunum),\\n while this may represent peristalsis, enteritis (infectious, inflammatory,\\n ischemia cannot be excluded).\\n 2. mild blurring of pancreatic margins with minimal mesenteric straning, very\\n early pancreatitis cannot be excluded, although no CT evidence of florid\\n pancreatitis or pancreatitis related complications.\\n 3. pericholecystic fluid. mild gallbladder wall edema.\\n 4. fatty deposition within the liver.\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40-year-old female intubated, sedated, likely pancreatitis.\\n Evaluate for pancreatitis.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis\\n with the administration of IV contrast. Multiplanar reformats were generated\\n and reviewed.\\n\\n FINDINGS:\\n\\n CT OF THE ABDOMEN: Bilateral breast prostheses are noted. The visualized\\n lung bases show bilateral trace pleural effusions with adjacent opacification\\n which likely represents predominantly atelectasis; however, a component of\\n aspiration versus infectious process such as pneumonia cannot be completely\\n excluded. A nasogastric tube is seen within the post-pyloric stomach.\\n\\n The liver demonstrates diffuse and significant fatty change. The spleen is\\n unremarkable. Note is made of a tiny splenule. There is evidence of minimal\\n edema within the fat in the groove between the pancreas and duodenum which may\\n represent focal pancreatitis. Minimal fluid is noted extending in the\\n pericholecystic region, however the gallbladder is within normal limits.\\n Bilateral adrenal glands and both kidneys enhance and excrete contrast\\n symmetrically. A hypodensity within the interpolar region of the left kidney\\n measuring 17 x 15 mm likely represents a renal cyst.\\n\\n Multiple transient intussceptions are noted along the jejunum (uncertain\\n significance). There is no free air or free fluid within the abdomen.\\n Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for\\n pathology.\\n (Over)\\n\\n 12:56 AM\\n CT ABD & PELVIS WITH CONTRAST Clip # \\n Reason: eval for pancreatitis, ICH, cerebral edema\\n Field of view: 50 Contrast: OMNIPAQUE Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n CT OF THE PELVIS: The rectum and sigmoid colon appear unremarkable. Mild\\n prominance of the colonic wall may be secondary to third-spacing. A Foley\\n catheter is present within the bladder. Air within the bladder likely relates\\n to Foley. The uterus appears unremarkable. There is a trace of free pelvic\\n fluid, within physiologic limits for age. Pelvic lymph nodes do not meet CT\\n size criteria for pathology.\\n\\n Visualized osseous structures show no suspicious lesions.\\n\\n IMPRESSION:\\n\\n 1. Visualized lung bases show bilateral trace pleural effusions with adjacent\\n opacification which likely represents atelectasis; however, a component of\\n aspiration versus infectious process such as pneumonia cannot be completely\\n excluded.\\n 2. Minimal edema within the fat in the groove between the pancreas and\\n duodenum which may represent focal acute pancreatitis with extension of edema\\n to the pericholecystic region.\\n 3. Multiple transient intussceptions are noted along the jejunum (uncertain\\n significance).\\n 4. Significantly fatty liver.\\n\\n Updated findings were discussed with Dr. at 9:12 am on \\n via telephone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-14 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1251461,\n \"text\": \" 12:48 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: Evaluate line placement\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with new central line placed\\n REASON FOR THIS EXAMINATION:\\n Evaluate line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Central line placement.\\n\\n FINDINGS: No previous images. Right IJ sheath extends to the lower portion\\n of the SVC. Left IJ catheter extends to the mid-to-lower portion of the SVC.\\n Nasogastric tube extends to at least the distal stomach.\\n\\n There are low lung volumes. Hazy opacification at the right base raises the\\n possibility of consolidation. Probable atelectatic changes at the left base.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1251388,\n \"text\": \" 2:35 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for pneumothorax\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 40F with attempted left subclavian\\n REASON FOR THIS EXAMINATION:\\n eval for pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40-year-old female with attempted left subclavian, evaluate for\\n pneumothorax.\\n\\n COMPARISON:\\n\\n PORTABLE AP CHEST RADIOGRAPH: Bilateral low lung volumes are noted with\\n crowding of bronchovascular markings. No pleural effusion, or pneumothorax.\\n Opacification at the left lung base may represent atelectasis, less likely\\n infection. ET tube is noted approximately 2.8 cm above the carina with chin in\\n raised position, recommend pulling ETT back by another 1cm to prevent it\\n touching the carina with neck flexion. Feeding tube is noted in the\\n post-pyloric position with tip not clearly visualized.\\n\\n Findings discussed with RN, Israeli Demenezes at 9:15am and Dr. at 9:20\\n am on via telephone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-15 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1251553,\n \"text\": \" 11:13 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: evaluate for cerebral edema\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with DKA, profound acidemia, now with altered mental status\\n REASON FOR THIS EXAMINATION:\\n evaluate for cerebral edema\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 40-year-old woman, with DKA and profound acidemia. Now with altered\\n mental status. Evaluate for cerebral edema.\\n\\n COMPARISON: Non-contrast CT head on .\\n\\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\\n\\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\\n major vascular territorial infarct. The ventricles and sulci are normal in\\n size and symmetric in configuration. Basal cisterns are patent. There is no\\n shift of normally midline structures. The -white matter differentiation\\n is preserved. The visualized mastoid air cells are clear. There is trace\\n fluid in the right maxillary sinus and right mastoid air cells and sphenoid\\n sinuses but the remaining paranasal sinuses are clear. No acute skull\\n fracture is noted. This study is essentially unchanged from the study one day\\n before.\\n\\n IMPRESSION: No acute intracranial pathology. Unchanged exam from yesterday.\\n If clinical concerns remain high, consider MRI brain to further assess.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-22 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1252358,\n \"text\": \" 9:47 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r picc 44cm iv \\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with picc\\n REASON FOR THIS EXAMINATION:\\n r picc 44cm iv \\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Right PICC line placement.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the previously placed left\\n internal jugular vein catheter has been removed. New is a right PICC line.\\n The line crosses the midline and the tip projects over the left subclavian\\n vein. This malposition requires replacement of the PICC line. There is no\\n evidence of complication, notably no pneumothorax. Otherwise, the radiograph\\n is unremarkable. The observation was made on 8:26 a.m., on .\\n At 8:27 a.m., on the same day, the referring physician, . , was paged\\n for notification.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-10-01 00:00:00.000\",\n \"description\": \"SKELETAL SURVEY (INCLUD LONG BONES)\",\n \"row_id\": 1253453,\n \"text\": \" 10:05 AM\\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \\n Reason: please assess for bone involvement\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with IgG elevation, c/f MGUS vs myeloma. New anemia\\n REASON FOR THIS EXAMINATION:\\n please assess for bone involvement\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Skeletal survey, .\\n\\n CLINICAL HISTORY: 40-year-old woman with IgG elevation, history of MGUS\\n versus myeloma, now with new anemia.\\n\\n FINDINGS: No previous studies skeletal survey-wise for a direct comparison.\\n Comparison is made to the scan from .\\n\\n LATERAL SKULL: No focal lytic or blastic lesions are seen.\\n\\n BILATERAL HUMERI: There is a portion of a central venous catheter seen in the\\n right arm. There are no focal lytic or blastic lesions or significant\\n degenerative changes.\\n\\n THORACIC SPINE: No compression deformities are seen. There is minimal\\n spurring at the anterior aspect of several lower thoracic vertebral bodies.\\n Visualized lung fields are clear. There is a central venous catheter with\\n distal lead tip at the cavoatrial junction.\\n\\n LUMBAR SPINE: There are five non-rib-bearing lumbar-type vertebral bodies.\\n There is no compression deformity. Minimal spurring at the L4 and L5\\n vertebral bodies are seen anteriorly.\\n\\n AP PELVIS AND BILATERAL FEMORA: No focal lytic or blastic lesions are seen.\\n The sacroiliac joints are grossly within normal limits. Bilateral hip joint\\n spaces demonstrate mild spurring in the superolateral aspect, consistent with\\n early degenerative changes.\\n\\n IMPRESSION:\\n\\n No focal lytic or blastic lesions in the skeleton to indicate definite\\n myelomatous deposits.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-22 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1252372,\n \"text\": \" 11:25 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r picc 44cm crossed chest, pulled back 2cm, power flushed. r\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with picc\\n REASON FOR THIS EXAMINATION:\\n r picc 44cm crossed chest, pulled back 2cm, power flushed. repeat x-ray iv \\n \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40-year-old woman with right-sided PICC line.\\n\\n COMPARISON: 10 a.m. this morning.\\n\\n FINDINGS: A single semi-erect portable chest radiograph is obtained. Tip of\\n a right-sided PICC line is positioned more centrally within the left\\n brachiocephalic vein. Hypoinflation of the lungs is unchanged. There is no\\n new consolidation, effusion, or pneumothorax. There are no new abnormal\\n cardiac or mediastinal contours.\\n\\n IMPRESSION: Tip of a right-sided PICC line remains in the left\\n brachiocephalic vein.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-22 00:00:00.000\",\n \"description\": \"EXCH PERPHERAL W/O PORT\",\n \"row_id\": 1252421,\n \"text\": \" 4:05 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: please place PICC line\\n Admitting Diagnosis: PANCREATITIS\\n Contrast: OMNIPAQUE Amt: 5\\n This is a power pick\\n ********************************* CPT Codes ********************************\\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman with hx of MRSA bacteremia and DKA who had failed bedside\\n picc today.\\n REASON FOR THIS EXAMINATION:\\n please place PICC line\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 40-year-old woman with history of MRSA bacteremia and DKA, failed\\n bedside PICC.\\n\\n RADIOLOGISTS: Dr. (resident), Dr. (fellow), Dr. \\n (attending).\\n\\n PICC LINE EXCHANGE/REPOSITIONING\\n The procedure was explained to the patient. A timeout was performed.\\n\\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\\n advanced through the indwelling right arm PICC line, and subsequently into the\\n SVC under fluoroscopic guidance. The old PICC line was then removed and a\\n peel-away sheath was placed over the guidewire. A new single-lumen PICC line\\n measuring 42 cm in length was then placed through the peel-away sheath with\\n its tip positioned in the SVC. Position of the catheter was confirmed by a\\n fluoroscopic spot film of the chest.\\n The peel-away sheath and guidewire were then removed. The catheter was\\n secured to the skin, flushed, and a sterile dressing applied.\\n\\n The patient tolerated the procedure well. There were no immediate\\n complications.\\n\\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a\\n new 4 French single-lumen PICC line. Final internal length is 42 cm, with the\\n tip positioned in the SVC. The line is ready to use.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-09-23 00:00:00.000\",\n \"description\": \"MR L SPINE W/O CONTRAST\",\n \"row_id\": 1252586,\n \"text\": \" 9:37 PM\\n MR L SPINE W/O CONTRAST Clip # \\n Reason: Evaluate for radiculopathy\\n Admitting Diagnosis: PANCREATITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 40 year old woman who presented with DKA requiring intubation, now with severe\\n acute axonal sensory-motor polyneuropathy by EMG.\\n REASON FOR THIS EXAMINATION:\\n Evaluate for radiculopathy\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 40-year-old woman presenting with DKA, requiring intubation, now with\\n acute axonal sensory and motor polyneuropathy by EMG. Please evaluate for\\n radiculopathy.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: MR of the lumbar spine without contrast.\\n\\n FINDINGS: Intervertebral disc heights and signals are maintained. There is\\n no signal abnormality in the cord. Vertebral body heights are maintained and\\n show normal signal. Imaged portions of the soft tissues are unremarkable. A\\n small disc buldge is present at L5-S1 with very minimal compression of the\\n thecal sac, but no contact with traversing nerve roots.\\n\\n IMPRESSION: Very minimal disc buldge of L5-S1. If there is concern for\\n polyneuritis, post gadolineum imaging can be obtained.\\n\\n\"\n }\n]"}}},{"rowIdx":791,"cells":{"subject_id":{"kind":"number","value":26156,"string":"26,156"},"hadm_id":{"kind":"number","value":184187,"string":"184,187"},"target_text":{"kind":"string","value":"Patient was managed in the CCU for the embolic stroke, which occurred during her cardiac catheterization. She was started on a Heparin drip. A Neuro consult, which was called during the cardiac catheterization continued to follow her progress. However, the patient continued to have an oxygen requirement. She did have a pulmonary capillary wedge pressure less than 18, pAO2/FIO2 of less than 200, which was consistent with an ARDS picture. For this, she was transferred to the Medical Intensive Care Unit for further management of possible ARDS. The etiology of this ARDS was initially unclear. It was possibly related to amiodarone, which she had been on for quite a long time. She also has extensive smoking history and COPD. This could also have been maybe secondary to a sepsis in the setting of possible pneumonia. She did have a bronchoscopy done, which was unrevealing and with diuresis, her pulmonary status improved dramatically. She was quickly weaned off oxygen, and it was believed that her pulmonary function was secondary to pulmonary edema and not an ARDS picture. The amiodarone continued to be held and her Solu-Medrol, which was initially started of COPD was discontinued. She did have a repeat head CT for further evaluation of the stroke. That repeat head CT showed a hypodensity and loss of the -white differentiation in the left frontal lobe. There was no evidence of shift of midline structures or ventricular dilation. These findings were consistent with an evolving infarct within the distribution of the superior division of the left middle cerebral artery. For this, the patient was continued on her Heparin drip, her aspirin, and she was started on Coumadin. Patient does have atrial fibrillation and this could be predisposition for stroke. The patient did have improvement of her neurological status. She did regain some ability of speech and she was seen by the Speech and Swallow service. Her verbal abilities have been improving slowly. Speech and Swallow evaluation was done, and they felt that she was not aspirating at this time. They did recommend soft solids as her dentures were not available here. Once the patient was euvolemic with diuresis, her diuresis was held in the setting of her aortic stenosis as she is preload dependent. She did complete a full course of ceftazidime for UTI and hydronephrosis in the setting of placement of her ureteral stent in . In terms of her cardiac status, she was continued on her beta-blocker, her ACE inhibitor, her calcium-channel blocker, and she was also started on a statin in the setting of her stroke and her known coronary artery disease. She was also restarted on her amiodarone for her atrial fibrillation once ARDS and her pulmonary status had resolved. Patient will need outpatient followup for her cardiac disease including her aortic stenosis. Patient will also followup with Dr. with the Clinic here at the . She was also instructed to followup with her primary care provider weeks. Of note, the patient did have Hemoccult positive stools in the setting of her therapeutic INR, however, her hematocrit had remained stable during the course of her hospitalization on anticoagulation. Patient obviously needs to be continued on her anticoagulation in the setting of her stroke and her atrial fibrillation. On the day of discharge, her INR was therapeutic at 2.4 and her Heparin drip was discontinued."},"extractive_notes_summ":{"kind":"string","value":"Nebs by RT x1 s/p bronch. vea, am lytes pnd. on ceftaz.RESP: LS clear, dim. ?d/c in am. Conts on Heparin/Coumadin. S/P bronch . ccu npn 7p-7aS: incomprehensible soundsO: Please see carevue for VS and objective data.CVS: Hemodynamically stable with HR 70's NSR no vea noted. RR 23-31. shallow breathes. Heparin dc'd for bronch in amResp - ls are clear, and decreased upper. am Na pnd. abd soft +BS. TO BE TACHYPNEIC WITH RR 32-38 & SHALLOW. PA line remains in R fem. On lopressor + lisinopril - new parameters - hold if BP <130. to start clear liquids in am. Copd. Cont to monitor resp. Right groin D/I with dsg. \"O: Please see carevue for VS and objective data.CVS: Hemodynamically stable with HR 60-70's NSR, rare APC noted, no sign. Hct 29.9Resp; s/p bronch from previous shift. Decreased Fio2 requirement this shift. +BS. Pt. Pt. Pt. Pt. Pt. Pt. ON CEFTAZADIME IV FOR UTI.ENDO: BS 156->137. SPONT. BS+. CONT. CONT. Distal pulses palp. Encouraged Pt. PTT 70.GI: NPO. keep SBP >130. Resp status stable. PERL. Again seen within the subcortical white matter are multiple regions of hypodensity, unchanged from the previous examination and most likely represent small vessel ischemic changes. REMAINS NPO. There has been interval removal of a Swan-Ganz catheter and nasogastric tube. HEPARIN GTT INFUS- ING AT 1750U/HR. Moving UE equally. solumedrol d/ced.GU: urine no longer bloody now that heparin is off. RR 20, HR 67. Cont on Lopressor and Lisinopril. initially with normal speech, as above statement. U/O 50-75CC/HR.ID: AFEBRILE. Small brown, formed stool x1, guaic positive.ID: afebrile on IV Ceftazidime q 12hours. 7.42/39/249. Frequent observations.A: stable, neuro assessment varies, at times with clear speech, other times aphasic. BP 142-162/59-68. Please r/o evolving ichemia/bleed. Boop vs Amiodarone toxicity. WBC 6.7Neuro: Pt. Is only oriented x1 at this time. NGT CLAMPED FOR MEDS. Lungs coarse to clear with diminished breathe sounds in bases. +gag/cough. APHASIC. BP 138-156/60. ABD. COMPARISONS: . con't abx. The ventricles are symmetric and nondilated. remains calm.ID: afebrile. Respiratory Care:Patient given Albuterol/Atrovent nebs X 2 this shift. pt encouraged to cough. taken off NRB and placed on NC but desatted to mid 80s. pt does nod head and obeys simple commands - inconsistently. NGT patent for meds.PLAN: wean O2 as tolerated. Awaiting results of bronch from . K+3.5 GIVEN 60 MEQ PO KCL. ??? Follow up with am labs, pnd. RR 30's. BP ranges via right radial aline 140-160's/60's. pulling on foley. Tolerating meds as ordered. TECHNIQUE: Noncontrast CT of the head. status closely. BP ranges via right radial aline 150-160/60's. only received lisinopril and lopressor not norvasc.Resp: lungs clear diminshed at bases. BS COARSE BUT DIMINISHED AT BASES. to notify RN for bedpan, Pt. leaving in place, am abg 140/41/7.41/27/1 96%, therefore face tent removed, Pt. amount urine, therefore dc'd. found to be incont. to con't to wean in am. At 2am, pt found to be oob, despite side rales up, self dc'd ngt and was steady on her feet. There is moderateaortic valve stenosis. Anterior, septal, apicial andposterior hypokinesis is present.3. In comparison with prior chest radiographs, this appears to be an acute process. Mild (1+) aortic regurgitation is seen.4. Mild (1+) mitral regurgitation is seen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. Mild (1+) aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Prior inferior myocardial infarction.Q-T interval prolongation. COMPARISON: SINGLE VIEW CHEST, AP SEMIUPRIGHT: There has been interval formation of diffuse interstitial and alveolar opacification within both lungs. Overallleft ventricular systolic function is moderately depressed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are moderately thickened. occ wheeze noted. FINDINGS: The patient is status post median sternotomy. Left ventricular function.BP (mm Hg): 158/72HR (bpm): 80Status: InpatientDate/Time: at 09:51Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity is moderately dilated. lytes replaced this am. There ismoderate aortic valve stenosis. The patient is status-post median sternotomy and CABG. There is mildmitral annular calcification. recheck lytes tonite. Small pericardial effusion and small bilateral pleural effusions. The patient is status post median sternotomy and CABG. Delayed precordial R wave progression consistentwith prior anterior myocardial infarction. Cont to follow and cov with SS Reg.A/P: pt remains tachypneic, sl improvement in po2, Enc C&DB, IV solumedrol, hemodynamically stable, neuro status somewhat improved, now verbalizing, head CT consistant with stroke, awaiting official report, check PTT at 1AM. Mild (1+) mitralregurgitation is seen.5. Levo d/c'd. 2) Interval re- positioning of the NG tube which now extends beyond the limits of the radiograph in the stomach. Levoflox changed to Ceftazidime. placement checked by xray + auscultation. The patient is status post CABG. AP SUPINE VIEW OF THE CHEST: There is an NG tube with the tip located in the esophagocardiac junction. A small pericardial effusion is present. monitor resp status. There is again noted a Swan-Ganz catheter in unchanged position. ?stroke + encephalopathy? There is a calcified granuloma at the right lung base. There is mild pulmonary artery systolic hypertension.6. CT CHEST WITHOUT CONTRAST: There is moderate polychamber cardiac enlargement. The NG tube was re-positioned and now extends beyond the limitations of the radiograph in the stomach. The left atrium is mildly dilated.2. admin meds via ngt. Sinus rhythm. Calm, cooperative, wrist restraints removed.CV: HR 70's NSR, BP 150-160's/60, up to 170-180's right before Lopressor dose due. repeat lytes this pm.GI/GU: foley patent, cloudy/sediment dk urine. The left ventricular cavity is moderately dilated. There are multiple lacunar infarcts unchanged from MRI of . The thoracic aorta is enfolded with vascular calcifications. Findings are consistent with pulmonary edema. There is mildpulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. IMPRESSION: 1) There is slight interval improvement in the lung inflation and possibly in the diffuse bilateral pulmonary infiltrates."},"n_notes":{"kind":"number","value":22,"string":"22"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2159-04-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":821739,"text":" 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess infiltrates/chf\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for\n change\n REASON FOR THIS EXAMINATION:\n please assess infiltrates/chf\n ______________________________________________________________________________\n FINAL REPORT\n Compared to .\n\n CLINICAL INDICATION: Pulmonary edema.\n\n There has been interval removal of a Swan-Ganz catheter and nasogastric tube.\n The cardiac silhouette is mildly enlarged. The previously present pattern of\n pulmonary edema has significantly improved with residual areas of perihilar\n haziness and peribronchial cuffing remaining. No new or worsening areas of\n opacification are observed.\n\n IMPRESSION: Resolving congestive heart failure pattern.\n\n"},{"category":"Radiology","chartdate":"2159-04-10 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":821400,"text":" 6:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o stroke progression\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n FINAL ADDENDUM\n There is moderate mucosal thickening in the right sphenoid air cell, also seen\n on the prior study, likely inflammatory in origin.\n\n\n\n 6:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o stroke progression\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new aphasia after cardiac cath. would not tolerate MRI.\n Please r/o evolving ichemia/bleed.\n REASON FOR THIS EXAMINATION:\n r/o stroke progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New aphasia after cardiac cath cannot tolerate MRI please evaluate\n for evolving ischemia or hemorrhage.\n\n COMPARISONS: .\n\n TECHNIQUE: Noncontrast CT of the head.\n\n CT OF THE HEAD WITHOUT CONTRAST: Within the left frontal lobe, there is a 3 by\n 5cm area of loss of / white differentiation and hypodensity consistent\n with a subacute infarct. This extends to involve the left insular region.\n There is mass effect upon the sulci of the left frontal lobe and insula;\n however, there is no shift of normally midline structures. The ventricles are\n symmetric and nondilated. There is no intracranial hemorrhage. No other areas\n of loss of / white differentiation are identified. Again seen within the\n subcortical white matter are multiple regions of hypodensity, unchanged from\n the previous examination and most likely represent small vessel ischemic\n changes. The density values of the brain parenchyma are otherwise within\n normal limits. The surrounding osseous structures appear unremarkable, without\n evidence of fracture. The paranasal sinuses and mastoid air cells are normally\n pneumatized.\n\n IMPRESSION: Hypodensity and loss of white differentiation within the left\n frontal lobe extending to the left insula, with local mass effect but without\n evidence of shift of midline structures or ventricular dilatation. These\n findings are consistent with an evolving infarct within the distribution of\n the superior division of the left middle cerebral artery. No acute hemorrhage.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2159-04-13 00:00:00.000","description":"Report","row_id":1603427,"text":"CCU NPN: Please see flowsheet for objective data\n\nCardiac: HR 60's NSR BP 140-170's/50-68 BP did drop transiently to 90's/when ambulated to chair with PT. only received lisinopril and lopressor not norvasc.\n\nResp: lungs clear diminshed at bases. sats mid 90's on 4l. bronched in afternoon recieved 2mg versed and 25mcg fent,now wearing 50% CN with 4l NP. solumedrol d/ced.\n\nGU: urine no longer bloody now that heparin is off. uo 35-50cc/hr -190cc.\n\nGI: NPO prior to bronch. was able to swallow pills without difficulty prior to bronch. no stool. +BS. attempt po meds and diet once versed and fent wear off\n\nID: afebrile continues on ceftazidine\n\nEndocrine: has not required any insulin\n\nNeuro: equal strength in all ext. ambulates with minimal assistance.has cognitive deficits,when asked someones name,gave a phone number. asked her name,spells her name. oriented x1\nfollows commands. when she does speak her speech is clear. answering more questions verbally today than yesterday.\n\nSocial: daughter in visiting today.\n\nA/P: to restart heparin at 9pm\n wean O2 as tolerated\n provide for safety,did climb out of bed last night\n\n"},{"category":"Nursing/other","chartdate":"2159-04-14 00:00:00.000","description":"Report","row_id":1603428,"text":"ccu npn micu border 7p-7a\nS:\"I'm home, I'm in Nashau.\"\n\nO: Please see carevue for VS and objective data.\n\nCVS: Hemodynamically stable with HR 60-70's NSR, rare APC noted, no sign. vea, am lytes pnd. BP ranges via right radial aline 140-160's/60's. Tolerating meds as ordered. IV Heparin restarted at 1100u/hour at as ordered without bolus, PTT at 0230 56.5, Pt. started on 5mg po Coumadin at . am PT 14.2. Hct 29.9\n\nResp; s/p bronch from previous shift. Initially on 5l n/c with cool neb at 70%, however, Pt. cont to remove face mask and sats 90-93% on n/c, therefore changed to 5L n/c with face tent at 50%. Pt. leaving in place, am abg 140/41/7.41/27/1 96%, therefore face tent removed, Pt. now on 5l n/c with sats 96-98%. Lungs coarse to clear with diminished breathe sounds in bases. Nebs by RT x1 s/p bronch. RR 23-31. shallow breathes. Weak, non-productive cough.\n\nGI:GU: Taking free H20 with meds, +gag, swallowing pills without any difficultly, sipping independently from straw in cup. Unable to give free h20 bolus secondary to no NGT, encouraged to drink H20. MICU team aware. am Na pnd. Pt. to start clear liquids in am. At change of shift, foley catheter noted to be leaking urine around insertion, ? Pt. pulling on foley. Attempted to add sterile H20 to balloon, foley cont'd to leak mod. amount urine, therefore dc'd. Encouraged Pt. to notify RN for bedpan, Pt. found to be incont. of moderate amount urine, therefore foley replaced with 16Fr, urine pink with sediment, irrigated with sterile H20, no clots noted. U/O 10-80cc/hour. Small brown, formed stool x1, guaic positive.\n\nID: afebrile on IV Ceftazidime q 12hours. WBC 6.7\n\nNeuro: Pt. initially with normal speech, as above statement. Alert and oriented to person only, stated she was at home and month was , unable to name president or current events. Unaware she is in the hospital. At times speech is clear but confused, repetitive statements. \"It all happened around the corner\" Unable to elaborate or explain. Other times Pt. is aphasic, focusing on RN, nodding head appropriately to simple questions but not able to speak, despite encouragement; this was during the middle of the night, when Pt. was woken from sleep for labs and neuro assessment. Micu team aware. Pt. MAE, following commands. PERL 3mm, . +gag/cough. Sleeping comfortably most of night, no attempts to get OOB. Frequent observations.\n\nA: stable, neuro assessment varies, at times with clear speech, other times aphasic. Confused at baseline.\n\nP: Cont to monitor neuro status closely. Maintain safety measures. Conts on Heparin/Coumadin. Follow up with am labs, pnd. Awaiting results of bronch from . Cont to monitor resp. status and hemodynamics. Comfort and emotional support to Pt. and family\n\n\n"},{"category":"Nursing/other","chartdate":"2159-04-14 00:00:00.000","description":"Report","row_id":1603429,"text":"Respiratory Care:\n\nPatient given Albuterol/Atrovent nebs X 2 this shift. Bs remain clear bilaterally. RR 20, HR 67. Decreased Fio2 requirement this shift. Pt. weaned to 5lpm nasal prongs. O2 sats 98%. Resp status stable. Copd. S/P bronch . ? Boop vs Amiodarone toxicity. No change with bronchodilator rx's. Plan: Will follow and re evaluate frequency of therapy.\n"},{"category":"Nursing/other","chartdate":"2159-04-11 00:00:00.000","description":"Report","row_id":1603423,"text":"ccu npn 7p-7a\nS: incomprehensible sounds\n\nO: Please see carevue for VS and objective data.\n\nCVS: Hemodynamically stable with HR 70's NSR no vea noted. BP ranges via right radial aline 150-160/60's. Tolerated 25mg po Lopressor at . Right groin D/I with dsg. Distal pulses palp. IV Heparin at 1750u/hour with PTT pnd.\n\nResp; Sats 92-95% on 50% face tent. Lungs coarse and diminished in bases. RR 30's. To have chest CT tonight.\n\nGI:GU: NPO, meds via NGT in good placement. Abdomen soft with active bowel sounds. No stool. Foley to drainage with amber urine, total I/O per flow.\n\nID: afebrile\n\nNeuro: Pt. alert, aphasic, some incomprehensible sounds noted when changing IV site for rountine change. Nodding head appropriately to simple questions. States she hears nurse and understands. Denied pain. PERL 2-3mm. Weak non-productive cough. Follows simple commands, weak hand grasp but equal, wiggles toes, lifts and holds LE. Moving UE equally. Does not attempt to pull off mask or NGT. Resting comfortably when left alone.\n\nA: stable, awaiting chest CT for pulmonary w/u.\n\nP: Cont to assess neuro status, monitor hemodynamics and resp. status closely. Pt. to have chest CT tonight. Comfort and emotional support to PT. and family. Dr. called daughter this shift to inform her of plan for chest CT.\n"},{"category":"Nursing/other","chartdate":"2159-04-12 00:00:00.000","description":"Report","row_id":1603425,"text":"CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 60-70's BP 155-180's/55-74 norvasc increased to 10mg and lisinopril increased to 20mg.lopressor 25mg .\n\nFluid/electrolytes: K 3.2 this am repleted with 80po KCL.repeat 4.6,NA 147 in am now 144.free water boluses now 250 q4. UO has been 60-150/hr +56cc.\n\nRenal: BUN/Creat 43/0.7.had been diuresed initially\n\nResp: on 50% face tent with sats 88-98. lungs coarse and diminished at bases. CT of chest today,poor study and bronch tomorrow.weak non productive cough,tachypnic at times rr 32-36.ASA d/ced to do bronch\n\nActivity: OOB to chair at 5pm with PT,minimal assist. did not seem to understand all directions,bending knees only partly,then resisted when PT attemped to bend her knees more.\n\nNeuro: alert and oriented x1,when she does speak her speech is clear. repeats questions when asked,called the window a wall. with encouragement is able to answer questions.\n\nID: afebrile,on ceftazidine for e-coli UTI\n\nHeme: PTT in am 86.6,hep gtt decreased to 1600,repeat at 4pm PTT 80 heparin drip decreased to 1450 at 5pm. urine is red with clots\n\nEndocrine: no insulin coverage required\n\nGI: TF's started at 2pm promote with fiber at 10cc/hr,residuals checked at 6pm,less than 10cc.TF rate increased to 20/hr. goal is 60/hr. has one small loose OB- stool\n\nSocial: daughter visited and team called daughter . signed consent for bronch.\n\nA/P: encourage to speak\n check PTT at 11pm\n follow uo and I&O's\n provide emotional support to pt and family\n NPO after midnight for bronch\n"},{"category":"Nursing/other","chartdate":"2159-04-13 00:00:00.000","description":"Report","row_id":1603426,"text":"CCU NURSING PROGRESS NOTE 7PM-7AM\nS: I'm in the hospital\n\nO: Through eve, pt is oriented x2 (-time), is pleasant and cooperative. She is encouraged to verbalize, rather than nod her head and does so with encouragement. MAE purposefully. At 2am, pt found to be oob, despite side rales up, self dc'd ngt and was steady on her feet. She was attempting to look out the window. Pt back to bed with 2 nurse assist. Is only oriented x1 at this time. Pt sleeping through most of shift.\n\nAfebrile - cont on Ceftazadime\nCV - HR 60's nsr with no vea. BP 138-156/60. Cont on Lopressor and Lisinopril. Heparin dose changed from 1450u/ to 1300u/hr, for PTT 79. Heparin dc'd for bronch in am\nResp - ls are clear, and decreased upper. non productive cough. O2 had been on with face tent at 50%, but pt is taking off. Sats down to 82% on ra. O2 placed at 4ln/p and sats up to 97-100%\ngi- TF off at 12 am d/t NPO for bronch\nGU - uo cont bloody @ 40-75cc/hr\nDM - Fingersticks wnl\n\nA: Improved neuro status early in evening. Increased confusion during night resulting in dc/ing of NGT\n\nP: NPO for bronch, Restart Heparin post, ? possible replacement of NGT vs. assessment of swallow, Increase activity as pt tolerates, cont to reorient as necessary and encourage verbalization by pt, Maintain safe environment.\n\n"},{"category":"Nursing/other","chartdate":"2159-04-12 00:00:00.000","description":"Report","row_id":1603424,"text":"NEURO: AWAKE & ALERT. MAKES EYE CONTACT & TRACTS WITH EYES. PERL.\n APHASIC. FOLLOWS SIMPLE COMMANDS CONSISTENTLY. MAE. ABLE TO\n LIFT & HOLD LE. PURPOSEFUL MOVEMENTS WITH UE. HAND GRASPS = BUT\n WEAK.\nRESP: O2->50% OFT. O2 SATS 94-98%. BS COARSE BUT DIMINISHED AT BASES.\n CONT. TO BE TACHYPNEIC WITH RR 32-38 & SHALLOW. WEAK NON-PROD-\n UCTIVE COUGH.\nCARDIAC: HR 65-73 SR, NO ECTOPY. BP 142-162/59-68. HEPARIN GTT INFUS-\n ING AT 1750U/HR. PTT 70.\nGI: NPO. NGT CLAMPED FOR MEDS. ABD. SOFT. BS+. NO STOOL.\nGU: FOLEY->CD PATENT & DRAINING BLOOD-TINGED URINE. U/O 50-75CC/HR.\nID: AFEBRILE. CONT. ON CEFTAZADIME IV FOR UTI.\nENDO: BS 156->137. INSULIN PER SLIDING SCALE.\nAM LABS PENDING.\n\nPLAN: CHEST CT EARLY THIS AM, THEN ?????BRONCH DEPENDING WHAT IS SEEN\n ON CT SCAN.\n"},{"category":"Nursing/other","chartdate":"2159-04-11 00:00:00.000","description":"Report","row_id":1603421,"text":"CCU progress note 11p-7a MICU team\nNEURO: pt remains aphasic, occasionally saying words. unable to assess orientation. pt does nod head and obeys simple commands - inconsistently. wrist restraints remain off, pt occasionally taking off face mask but leaves in NGT, pt not tugging at lines. remains calm.\n\nID: afebrile. on ceftaz.\n\nRESP: LS clear, dim. continues to have shallow rapid breathing. 7.42/39/249. taken off NRB and placed on NC but desatted to mid 80s. placed on 5L w/ 70% cool neb face tent for sats >98%. to con't to wean in am. pt encouraged to cough. CXR due in am - last CXR showed ARDS.\n\nCARDIAC: SR 60-70s. On lopressor + lisinopril - new parameters - hold if BP <130. Neuro goal BP >130. PA line remains in R fem. PADs 15. ?d/c in am. R radial Aline patent - maps >80. Heparin gtt increased to 1550u at 2am - repeat PTT at 8am.\n\nGI/GU: foley patent, cloudy amber urine ~ 30cc/hr. abd soft +BS. no BM. NGT patent for meds.\n\nPLAN: wean O2 as tolerated. keep SBP >130. monitor neuro status. con't abx. recheck PTT at 8am.\n"},{"category":"Nursing/other","chartdate":"2159-04-11 00:00:00.000","description":"Report","row_id":1603422,"text":"NURSING PROGRESS NOTE 0700-1500\nNEURO---MUCH IMPROVED NEURO STATUS SINCE 0700. PT IS ABLE TO CLEARLY SAY A FEW WORDS INCLUDING HER NAME. SHE HAS PROBLEMS WITH REPETITION. WHEN ASK PT TO COUGH AND DEMONSTRATION IS SHOWN, SHE WILL SAY THE WORDS 'COUGH,COUGH' IN THE SAME CADENCE THAT SHE IS HEARING . BILAT ARM STR IS 5+ . SHE HAS A WEAK GRASP. NOT ABLE TO FOLLOW ACTION COMMANDS,\"TOUCH YR NOSE,POINT TO LIGHT\".BILAT LE LIFT AND HOLD ON BED. SHE MOVES ALL 4 EXT. SPONT. SPEECH AT TIMES IS CLEAR, OTHER TIMES IT IS GARBLED. PEARL AT 3-4 MM.\n\nCARDIAC--SBP 150-160. HR SR 70'S WITH OCCAS UNIFOCAL PVC. RECEIVED ALL ANTI HTN DRUGS. K+3.5 GIVEN 60 MEQ PO KCL. ON HEPARIN GTT AT 1550. PTT TO BE CHECKED AT 1400.\n\nRESP--O2 WEANED DOWN TO 50% FACE TENT. SPONT RESP 34-42. LUNGS COARSE BILATERALLY AND DECREASED IN UPPER LOBES. PT COUGHS SPONT AND IT IS PRODUCTIVE. SAO2 90-95%.\n\nGI--NGT PATENT. REMAINS NPO. NO STOOL AT PRESENT.\n\nGU--FOLEY CATH PATENT DRAINING >40 CC HR OF CLOUDY URINE.\n\nENDO--NO SSRI COVERAGE NEEDED.\n\nSKIN--GROSSLY INTACT.\n\nID--AFEBRILE AT PRESENT. ON ABX FOR E COLI IN URINE.\n\n RN HAS SPOKEN WITH DAUGHTER , AND HAS UPDATED HER REGARDING HER CONDITION AND PLANS FOR THE DAY. SHE WOULD LIKE TO BE CALLED PRIOR TO ANY TESTS THAT WILL BE DONE. PT HAS NODDED IN THE AFFIRMATIVE WHEN ASKED IF SHE IS FRIGHTENED. SHE DOES WELL WITH REINFORCEMENT.\n\nA--IMPROVED NEURO STATUS. AFEBRILE.\n\nP--CON'T TO ASSESS NEURO STATUS. PROVIDE SAFETY AND REASSURANCE TO PT. OFFER SUPPORT TO FAMILY AND PT. CHECK RESULTS OF LABS DRAWN AT 1400.\n"},{"category":"Echo","chartdate":"2159-04-10 00:00:00.000","description":"Report","row_id":69585,"text":"PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Coronary artery disease. H/O cardiac surgery. Left ventricular function.\nBP (mm Hg): 158/72\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 09:51\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 mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity is moderately dilated. Overall\nleft ventricular systolic function is moderately depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is\nmoderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. The left ventricular cavity is moderately dilated. Overall left ventricular\nsystolic function is moderately depressed. Anterior, septal, apicial and\nposterior hypokinesis is present.\n3. The aortic valve leaflets are moderately thickened. There is moderate\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n5. There is mild pulmonary artery systolic hypertension.\n6. Compared with the findings of the prior study (tape reviewed) of ,\nthere is no significant change.\n\n\n"},{"category":"Radiology","chartdate":"2159-04-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":821430,"text":" 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: am CXR to be done for 730am Rounds.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for\n change\n REASON FOR THIS EXAMINATION:\n am CXR to be done for 730am Rounds.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with coronary artery disease and acute\n pulmonary edema. Please evaluate for change.\n\n COMPARISON: .\n\n FINDINGS: AP portable supine single view of the chest. There is cardiomegaly\n which is stable. Mediastinal and hilar contours are stable when compared to\n the previous study. In the interval, there is slight improvement in the lung\n inflation and possibly in the bilateral diffuse infiltrates. The Swan-Ganz\n catheter is in an unchanged position. There is a new central line with the\n tip in the left brachiocephalic vein. The NG tube was re-positioned and now\n extends beyond the limitations of the radiograph in the stomach. The patient\n is status-post median sternotomy and CABG.\n\n IMPRESSION: 1) There is slight interval improvement in the lung inflation and\n possibly in the diffuse bilateral pulmonary infiltrates. 2) Interval re-\n positioning of the NG tube which now extends beyond the limits of the\n radiograph in the stomach.\n\n"},{"category":"Radiology","chartdate":"2159-04-09 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":821289,"text":" 6:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for evidence of ICH.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new aphasia after cardiac cath.\n REASON FOR THIS EXAMINATION:\n Evaluate for evidence of ICH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 year old, aphasia post-cath.\n\n CT SCAN of the brain(following cardiac catheterization)\n\n Findings: Contrast enhancement is seen in the circle of vessels\n consistent with the patient's post-cath status. There are no extra or\n intracranial hemorrhage, shift of normally mid- line structures, or\n hydrocephalus. - white differentiation is preserved. There are multiple\n lacunar infarcts unchanged from MRI of . The osseous structures are\n unremarkable. The mastoid air cells are clear. Mucosal thickening is seen in\n the sphenoid sinus. The remaining visualized paranasal sinuses are clear.\n\n IMPRESSION: No acute hemorrhage.\n\n"},{"category":"Radiology","chartdate":"2159-04-12 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":821543,"text":" 7:55 AM\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for interstitial lung disease. ?ARDS vs, amio lung tox\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with incr. O2 req, bilat infil on CXR, PaO2/FiO2 of 60.\n\n REASON FOR THIS EXAMINATION:\n eval for interstitial lung disease. ?ARDS vs, amio lung toxicitiy.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increasing oxygen requirement, bilateral infiltrates on chest\n radiographs, evaluate for ARDS versus amiodarone lung toxicity.\n\n TECHNIQUE: Contiguous axial images were obtained through the chest without IV\n contrast. Additional images in expiration were obtained. Coronal reformations\n were performed.\n\n CT CHEST WITHOUT CONTRAST: There is moderate polychamber cardiac enlargement.\n Dense coronary arterial and aortic calcifications are present. Scattered nodes\n are noted throughout the mediastinum which do not meet CT criteria for\n pathologic enlargement. The NG tube extends into the stomach. A small\n pericardial effusion is present. There are bilateral small pleural effusions.\n Within the imaged portion of the upper abdomen, the liver is noted to be of\n high attenuation, measuring up to 79 Hounsfield units. Multiple splenic\n granulomas are identified.\n\n Lung windows demonstrate diffuse lung disease with relative sparring of the\n lung bases. There are diffuse areas of ground glass attenuation as well the\n presence of intralobular septal thickening. In comparison with prior chest\n radiographs, this appears to be an acute process. There is evidence for\n moderate air trapping. There is a calcified granuloma at the right lung base.\n\n Bone windows demonstrate no suspicious lytic or sclerotic abnormalities. The\n patient is status post CABG.\n\n IMPRESSION:\n 1. Diffuse lung disease with extensive areas of ground glass opacification as\n well as centrilobular septal thickening. There is relative sparring of the\n bases. Differential considerations are broad and include pulmonary edema,\n cryptogenic organizing pneumonia, chronic eosinophylic pneumonia, vasculitis,\n desquamative interstitial pneumonitis, drug-induced lung disease, diffuse\n alveolar damage secondary to amiodarone, and pulmonary alveolar proteinosis.\n Less likely considerations include bronchiol-alveolar cell carcinoma and\n lymphoma.\n 2. Small pericardial effusion and small bilateral pleural effusions.\n 3. Evidence for prior granulomatous disease.\n\n (Over)\n\n 7:55 AM\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for interstitial lung disease. ?ARDS vs, amio lung tox\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2159-04-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":821309,"text":" 6:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for change\n REASON FOR THIS EXAMINATION:\n please eval for change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 71 y/o woman with coronary artery disease and acute pulmonary\n edema.\n\n PORTABLE AP CHEST: Comparison is made to the study from at 9:15 p.m.\n\n FINDINGS: The patient is status post median sternotomy. There is again noted a\n Swan-Ganz catheter in unchanged position. There are diffuse bilateral alveolar\n opacities consistent with pulmonary edema. It is possibly slightly\n improved when compared to the previous study. There is slight blunting of the\n left costophrenic angle that could represent a small pleural effusion. The\n cardiac, mediastinal and hilar contours are unchanged.\n\n IMPRESSION: There is possible slight improvement in the pulmonary edema in the\n interval. The findings are consistent with pulmonary edema. Correlate with\n Swan-Ganz measurements.\n\n"},{"category":"Radiology","chartdate":"2159-04-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":821294,"text":" 8:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulm edema/infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema\n REASON FOR THIS EXAMINATION:\n assess for pulm edema/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, shortness of breath.\n\n COMPARISON: \n\n SINGLE VIEW CHEST, AP SEMIUPRIGHT: There has been interval\n formation of diffuse interstitial and alveolar opacification within both\n lungs. There has also been interval placement of a right femoral Swan-Ganz\n catheter with the tip lying within the left interlobar pulmonary artery. No\n pleural effusions are identified. The patient is status post median\n sternotomy and CABG. The cardiac size is enlarged with left ventricular\n prominence. The thoracic aorta is enfolded with vascular calcifications.\n\n IMPRESSION:\n 1. Interval placement of right femoral Swan-Ganz catheter with the tip lying\n within the left interlobar artery.\n 2. Marked interstitial and alveolar opacification within both lung fields.\n Findings are consistent with pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2159-04-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":821332,"text":" 8:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ngt placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for change\n\n REASON FOR THIS EXAMINATION:\n evaluate for ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n COMPARISON: X ray done 1 hour and ago.\n\n AP SUPINE VIEW OF THE CHEST: There is an NG tube with the tip located in the\n esophagocardiac junction. There is 1 side hole of the NG tube that is located\n in the distal esophagus. Recommend advancing the NG tube approximately 7 cm.\n Otherwise the appearance of the chest radiograph is essentially unchanged.\n\n"},{"category":"Nursing/other","chartdate":"2159-04-10 00:00:00.000","description":"Report","row_id":1603419,"text":"CCU progress note 7a-3p\nNEURO: PERLA 3mm , , normal strength, obeys commands inconsistently. opens eyes to voice. occasional garbled sounds, unable to speak, shakes head no when asked to speak. startles very easily. nods head yes and no inconsistently to commands. Neuro on consult. ?stroke + encephalopathy? pt to have MRI if she stays calm/unmoving for scan or repeat CT of head without contrast for diagnostic purposes.\n\nID: afebrile. Tmax 98.8 ax. Levo d/c'd. to be started on Ceftaz. +ecoli UTI. urine cx sent today for legionella screen. need to obtain induced sputum cx and nasal swabs this evening. Pan Cx . no skin breakdown noted.\n\nRESP: LS clear, dim. occ wheeze noted. CXR shows ARDS. Tachypneic 20-30s. sats 96-99% on NRB 100%. attempted to wean off to 6L n/c but sats dropped to 87%.\n\nCARDIAC: SR 70s. given lopressor 25mg as ordered via NGT today. Heparin gtt increased to 1250u/hr - next PTT due after 3pm. R fem PA line intact. stable BP. PA 43/19 Pasat 69% CO 6.4 CI 3.03. con't to have R leg immobilizer on d/t PA line in R fem. palpable pedal pulses. lytes replaced this am. repeat lytes this pm.\n\nGI/GU: foley patent, cloudy/sediment dk urine. >60cc/hr. abd soft distended. +BS. NGT inserted today for po meds. placement checked by xray + auscultation. no BM. remains NPO.\n\nSOCIAL: daughters called multiple times during day. RN + HO talked to family. keep up to date. family to call back this evening w/ med list.\n\n\nPLAN: con't monitoring hemodynamics/vs. admin meds via ngt. monitor resp status. keep pt from getting out of bed - R leg immobilizer on. less agitated during day shift today. rechekc PTT after 3pm. recheck lytes tonite. con't abx. keep pt comfortable.\n\n"},{"category":"Nursing/other","chartdate":"2159-04-10 00:00:00.000","description":"Report","row_id":1603420,"text":"CCU NPN 3-11pm\nNeuro: alert, following commands consistantly, nodding appropriately, PERL, MAE and has normal strength. By later in shift becoming more verbal. Asked daughters where her washing machine was. When I encouraged her to cough, she wouldn't saying oh, it will be alright. Would not answer orientation questions. Had head CT this eve. Calm, cooperative, wrist restraints removed.\n\nCV: HR 70's NSR, BP 150-160's/60, up to 170-180's right before Lopressor dose due. Denies any pain. Swan-ganz in R fem, PA 40/17-20. Daughter brought in all meds from home, list given to resident. A-line placed in R radial. Hep gtt increased to 1450U/hr for PTT 37.\n\nResp: LS crackles in upper lobes, clear at bases bilaterally. cont on 100% NRB with sats 90-100%, ABG improved with po2 in 80's. Weak cough, sounds conjested at times, unable to expectorate. Cont tachypneic with RR high 30's-40, shallow.\n\nGI: NPO, no stool.\n\nID: afebrile. Levoflox changed to Ceftazidime. Nasal swabs sent for culture and viral tests.\n\nSkin: intact.\n\nEndocrine: BS 148, no coverage required. Cont to follow and cov with SS Reg.\n\nA/P: pt remains tachypneic, sl improvement in po2, Enc C&DB, IV solumedrol, hemodynamically stable, neuro status somewhat improved, now verbalizing, head CT consistant with stroke, awaiting official report, check PTT at 1AM.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2159-04-10 00:00:00.000","description":"Report","row_id":1603418,"text":"CCU NSG ADMIT/PROGRESS NOTE 7:30P- 7A/ RESP DISTRESS\n\nS- NONVERBAL\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT ARRIVED TO CCU S/P CATH WITH BILATERAL SHEATHS IN PLACE AND 100% NR ON FOR 02 SATS MID 86%.\nINITIALLY ON TNG GTT FOR PRELOAD REDUCTION R/O PULMONARY EDEMA- ONCE CXR INDICATED ARDS- WEANED TO OFF.\nRT FEMORAL ALINE D/C AND LEFT IN PA LINE- HEPARIN GTT 1100U NO BOLUS STARTED 1AM 4 HOURS AFTER SHEATH D/C.\nHEMODYNAMICS STABLE- HR- 70'S SR, MINIMAL VEA- BP- 140/60-150/70'S.\nUNABLE TO GIVE PO B BLOCKERS/MEDS D/T ALTERED MENTAL STATUS.\n\nMS- SEE PT NONVERBAL, STARTED ON HEPARIN GTT PER NEURO TEAM FOR R/O EMBOLIC STROKE, R/O PE FOR ACUTE RESP DISTRESS.\nPT LOOKING BUT NO WORDS, UNABLE TO ASSESS LEVEL OF ORIENTATION\nNO CHANGE IN NEURO SIGNS THIS SHIFT.\nBILATERAL WRIST RESTRAINTS AND POSEY AND NEED FOR CLOSE MONITORING FOR AGITATION. ATTEMPTING OOB AND TRYING TO PULL AT PA LINE. PULL OFF O2 MASK WITH O2 SATS DROPPING TO 68%.\nDAUGHTER IN TO SPEAK WITH TEAM/STAFF AND REINFORCED THIS BEHAVIOR IS NEW.\n\n PT INITIALLY ON 100%- INCREASED TO 100% NR AND 6L NP- ABLE TO WEAN OFF NC- KEEPING O2 SATS >93%- SOME WHEEZING- STARTED NEBS AND STRESS DOSE STEROIDS TID.\nNO COUGH, DROPPING SATS WHEN SELF D/C MASK IN SPITE OF REPEATED WRIST RESTRAINING..REQUIRING CLOSE WATCH.\n\nID- AFEBRILE- RESUMED DAY LEVO FOR (+) ECOLI UTI.\nPAN CULTURED THIS EVE\n\nGU- GOOD REPSONSE TO CATH LAB LASIX AND REPEATED 40 LASIX 12AM- 1 LITER OUT TO THAT DOSE\nCXR REVEALING ARDS PICTURE.\nI/O EVEN AS OF MN IN SPITE OF GOOD DIURESIS AND PAD # LOW NORMAL.\n\nGI- NPO- TOO SOMNOLENT (+) BS\n\n\nLYTES- REPLETED K AND CA WITH 40 KCL AND 2 AMPS CA GLUC\n\nLINES- BILATERAL HEPLOCKS, RT FEMORAL PA LINE WITH VENOUS SIDEARM.\n\nA/ PT ADMITTED TO CCU S/P CATH WITH CHF VS COPD FLARE VS ARDS\n\n\nCONTINUE TO CLOSELY MONITOR NEURO STATUS, NOTE ANY CHANGE IN MS.\nSAFETY- WRIST RESTRAINTS, POSEY, ATTEMPT TO REORIENT.\nPLAN FOR MRI TODAY\nCONTINUE HEPARIN.\nDISCUSS NEED FOR NG TUBE FOR PO MEDS.\nDISCUSS POSSIBILITY TO D/C PA LINE WITH NO CHANGE IN PA # OR CO/CI\nAND IN SETTING OF AGITATED PT.\nCHECK PTT 7AM ON 1100U HEPARIN.\nCONTINUE TO DIURESE AS NEEDED AND REPLETE LYTES.\nCONTINUE ANTIBX AS ORDERED.KEEP NPO UNTIL MS CLEARS, LESS SOMNOLENT.\n"},{"category":"ECG","chartdate":"2159-04-15 00:00:00.000","description":"Report","row_id":164113,"text":"Sinus rhythm. A-V conduction delay. Prior inferior myocardial infarction.\nQ-T interval prolongation. Delayed precordial R wave progression consistent\nwith prior anterior myocardial infarction. Compared to the previous tracing\nof the rate has increased. Otherwise, no diagnostic interim change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2159-04-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 821739,\n \"text\": \" 7:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please assess infiltrates/chf\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for\\n change\\n REASON FOR THIS EXAMINATION:\\n please assess infiltrates/chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n Compared to .\\n\\n CLINICAL INDICATION: Pulmonary edema.\\n\\n There has been interval removal of a Swan-Ganz catheter and nasogastric tube.\\n The cardiac silhouette is mildly enlarged. The previously present pattern of\\n pulmonary edema has significantly improved with residual areas of perihilar\\n haziness and peribronchial cuffing remaining. No new or worsening areas of\\n opacification are observed.\\n\\n IMPRESSION: Resolving congestive heart failure pattern.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2159-04-10 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 821400,\n \"text\": \" 6:03 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o stroke progression\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n FINAL ADDENDUM\\n There is moderate mucosal thickening in the right sphenoid air cell, also seen\\n on the prior study, likely inflammatory in origin.\\n\\n\\n\\n 6:03 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o stroke progression\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with new aphasia after cardiac cath. would not tolerate MRI.\\n Please r/o evolving ichemia/bleed.\\n REASON FOR THIS EXAMINATION:\\n r/o stroke progression\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: New aphasia after cardiac cath cannot tolerate MRI please evaluate\\n for evolving ischemia or hemorrhage.\\n\\n COMPARISONS: .\\n\\n TECHNIQUE: Noncontrast CT of the head.\\n\\n CT OF THE HEAD WITHOUT CONTRAST: Within the left frontal lobe, there is a 3 by\\n 5cm area of loss of / white differentiation and hypodensity consistent\\n with a subacute infarct. This extends to involve the left insular region.\\n There is mass effect upon the sulci of the left frontal lobe and insula;\\n however, there is no shift of normally midline structures. The ventricles are\\n symmetric and nondilated. There is no intracranial hemorrhage. No other areas\\n of loss of / white differentiation are identified. Again seen within the\\n subcortical white matter are multiple regions of hypodensity, unchanged from\\n the previous examination and most likely represent small vessel ischemic\\n changes. The density values of the brain parenchyma are otherwise within\\n normal limits. The surrounding osseous structures appear unremarkable, without\\n evidence of fracture. The paranasal sinuses and mastoid air cells are normally\\n pneumatized.\\n\\n IMPRESSION: Hypodensity and loss of white differentiation within the left\\n frontal lobe extending to the left insula, with local mass effect but without\\n evidence of shift of midline structures or ventricular dilatation. These\\n findings are consistent with an evolving infarct within the distribution of\\n the superior division of the left middle cerebral artery. No acute hemorrhage.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603427,\n \"text\": \"CCU NPN: Please see flowsheet for objective data\\n\\nCardiac: HR 60's NSR BP 140-170's/50-68 BP did drop transiently to 90's/when ambulated to chair with PT. only received lisinopril and lopressor not norvasc.\\n\\nResp: lungs clear diminshed at bases. sats mid 90's on 4l. bronched in afternoon recieved 2mg versed and 25mcg fent,now wearing 50% CN with 4l NP. solumedrol d/ced.\\n\\nGU: urine no longer bloody now that heparin is off. uo 35-50cc/hr -190cc.\\n\\nGI: NPO prior to bronch. was able to swallow pills without difficulty prior to bronch. no stool. +BS. attempt po meds and diet once versed and fent wear off\\n\\nID: afebrile continues on ceftazidine\\n\\nEndocrine: has not required any insulin\\n\\nNeuro: equal strength in all ext. ambulates with minimal assistance.has cognitive deficits,when asked someones name,gave a phone number. asked her name,spells her name. oriented x1\\nfollows commands. when she does speak her speech is clear. answering more questions verbally today than yesterday.\\n\\nSocial: daughter in visiting today.\\n\\nA/P: to restart heparin at 9pm\\n wean O2 as tolerated\\n provide for safety,did climb out of bed last night\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603428,\n \"text\": \"ccu npn micu border 7p-7a\\nS:\\\"I'm home, I'm in Nashau.\\\"\\n\\nO: Please see carevue for VS and objective data.\\n\\nCVS: Hemodynamically stable with HR 60-70's NSR, rare APC noted, no sign. vea, am lytes pnd. BP ranges via right radial aline 140-160's/60's. Tolerating meds as ordered. IV Heparin restarted at 1100u/hour at as ordered without bolus, PTT at 0230 56.5, Pt. started on 5mg po Coumadin at . am PT 14.2. Hct 29.9\\n\\nResp; s/p bronch from previous shift. Initially on 5l n/c with cool neb at 70%, however, Pt. cont to remove face mask and sats 90-93% on n/c, therefore changed to 5L n/c with face tent at 50%. Pt. leaving in place, am abg 140/41/7.41/27/1 96%, therefore face tent removed, Pt. now on 5l n/c with sats 96-98%. Lungs coarse to clear with diminished breathe sounds in bases. Nebs by RT x1 s/p bronch. RR 23-31. shallow breathes. Weak, non-productive cough.\\n\\nGI:GU: Taking free H20 with meds, +gag, swallowing pills without any difficultly, sipping independently from straw in cup. Unable to give free h20 bolus secondary to no NGT, encouraged to drink H20. MICU team aware. am Na pnd. Pt. to start clear liquids in am. At change of shift, foley catheter noted to be leaking urine around insertion, ? Pt. pulling on foley. Attempted to add sterile H20 to balloon, foley cont'd to leak mod. amount urine, therefore dc'd. Encouraged Pt. to notify RN for bedpan, Pt. found to be incont. of moderate amount urine, therefore foley replaced with 16Fr, urine pink with sediment, irrigated with sterile H20, no clots noted. U/O 10-80cc/hour. Small brown, formed stool x1, guaic positive.\\n\\nID: afebrile on IV Ceftazidime q 12hours. WBC 6.7\\n\\nNeuro: Pt. initially with normal speech, as above statement. Alert and oriented to person only, stated she was at home and month was , unable to name president or current events. Unaware she is in the hospital. At times speech is clear but confused, repetitive statements. \\\"It all happened around the corner\\\" Unable to elaborate or explain. Other times Pt. is aphasic, focusing on RN, nodding head appropriately to simple questions but not able to speak, despite encouragement; this was during the middle of the night, when Pt. was woken from sleep for labs and neuro assessment. Micu team aware. Pt. MAE, following commands. PERL 3mm, . +gag/cough. Sleeping comfortably most of night, no attempts to get OOB. Frequent observations.\\n\\nA: stable, neuro assessment varies, at times with clear speech, other times aphasic. Confused at baseline.\\n\\nP: Cont to monitor neuro status closely. Maintain safety measures. Conts on Heparin/Coumadin. Follow up with am labs, pnd. Awaiting results of bronch from . Cont to monitor resp. status and hemodynamics. Comfort and emotional support to Pt. and family\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603429,\n \"text\": \"Respiratory Care:\\n\\nPatient given Albuterol/Atrovent nebs X 2 this shift. Bs remain clear bilaterally. RR 20, HR 67. Decreased Fio2 requirement this shift. Pt. weaned to 5lpm nasal prongs. O2 sats 98%. Resp status stable. Copd. S/P bronch . ? Boop vs Amiodarone toxicity. No change with bronchodilator rx's. Plan: Will follow and re evaluate frequency of therapy.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603423,\n \"text\": \"ccu npn 7p-7a\\nS: incomprehensible sounds\\n\\nO: Please see carevue for VS and objective data.\\n\\nCVS: Hemodynamically stable with HR 70's NSR no vea noted. BP ranges via right radial aline 150-160/60's. Tolerated 25mg po Lopressor at . Right groin D/I with dsg. Distal pulses palp. IV Heparin at 1750u/hour with PTT pnd.\\n\\nResp; Sats 92-95% on 50% face tent. Lungs coarse and diminished in bases. RR 30's. To have chest CT tonight.\\n\\nGI:GU: NPO, meds via NGT in good placement. Abdomen soft with active bowel sounds. No stool. Foley to drainage with amber urine, total I/O per flow.\\n\\nID: afebrile\\n\\nNeuro: Pt. alert, aphasic, some incomprehensible sounds noted when changing IV site for rountine change. Nodding head appropriately to simple questions. States she hears nurse and understands. Denied pain. PERL 2-3mm. Weak non-productive cough. Follows simple commands, weak hand grasp but equal, wiggles toes, lifts and holds LE. Moving UE equally. Does not attempt to pull off mask or NGT. Resting comfortably when left alone.\\n\\nA: stable, awaiting chest CT for pulmonary w/u.\\n\\nP: Cont to assess neuro status, monitor hemodynamics and resp. status closely. Pt. to have chest CT tonight. Comfort and emotional support to PT. and family. Dr. called daughter this shift to inform her of plan for chest CT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603425,\n \"text\": \"CCU NPN: please see flowsheet for objective data\\n\\nCardiac: HR 60-70's BP 155-180's/55-74 norvasc increased to 10mg and lisinopril increased to 20mg.lopressor 25mg .\\n\\nFluid/electrolytes: K 3.2 this am repleted with 80po KCL.repeat 4.6,NA 147 in am now 144.free water boluses now 250 q4. UO has been 60-150/hr +56cc.\\n\\nRenal: BUN/Creat 43/0.7.had been diuresed initially\\n\\nResp: on 50% face tent with sats 88-98. lungs coarse and diminished at bases. CT of chest today,poor study and bronch tomorrow.weak non productive cough,tachypnic at times rr 32-36.ASA d/ced to do bronch\\n\\nActivity: OOB to chair at 5pm with PT,minimal assist. did not seem to understand all directions,bending knees only partly,then resisted when PT attemped to bend her knees more.\\n\\nNeuro: alert and oriented x1,when she does speak her speech is clear. repeats questions when asked,called the window a wall. with encouragement is able to answer questions.\\n\\nID: afebrile,on ceftazidine for e-coli UTI\\n\\nHeme: PTT in am 86.6,hep gtt decreased to 1600,repeat at 4pm PTT 80 heparin drip decreased to 1450 at 5pm. urine is red with clots\\n\\nEndocrine: no insulin coverage required\\n\\nGI: TF's started at 2pm promote with fiber at 10cc/hr,residuals checked at 6pm,less than 10cc.TF rate increased to 20/hr. goal is 60/hr. has one small loose OB- stool\\n\\nSocial: daughter visited and team called daughter . signed consent for bronch.\\n\\nA/P: encourage to speak\\n check PTT at 11pm\\n follow uo and I&O's\\n provide emotional support to pt and family\\n NPO after midnight for bronch\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603426,\n \"text\": \"CCU NURSING PROGRESS NOTE 7PM-7AM\\nS: I'm in the hospital\\n\\nO: Through eve, pt is oriented x2 (-time), is pleasant and cooperative. She is encouraged to verbalize, rather than nod her head and does so with encouragement. MAE purposefully. At 2am, pt found to be oob, despite side rales up, self dc'd ngt and was steady on her feet. She was attempting to look out the window. Pt back to bed with 2 nurse assist. Is only oriented x1 at this time. Pt sleeping through most of shift.\\n\\nAfebrile - cont on Ceftazadime\\nCV - HR 60's nsr with no vea. BP 138-156/60. Cont on Lopressor and Lisinopril. Heparin dose changed from 1450u/ to 1300u/hr, for PTT 79. Heparin dc'd for bronch in am\\nResp - ls are clear, and decreased upper. non productive cough. O2 had been on with face tent at 50%, but pt is taking off. Sats down to 82% on ra. O2 placed at 4ln/p and sats up to 97-100%\\ngi- TF off at 12 am d/t NPO for bronch\\nGU - uo cont bloody @ 40-75cc/hr\\nDM - Fingersticks wnl\\n\\nA: Improved neuro status early in evening. Increased confusion during night resulting in dc/ing of NGT\\n\\nP: NPO for bronch, Restart Heparin post, ? possible replacement of NGT vs. assessment of swallow, Increase activity as pt tolerates, cont to reorient as necessary and encourage verbalization by pt, Maintain safe environment.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603424,\n \"text\": \"NEURO: AWAKE & ALERT. MAKES EYE CONTACT & TRACTS WITH EYES. PERL.\\n APHASIC. FOLLOWS SIMPLE COMMANDS CONSISTENTLY. MAE. ABLE TO\\n LIFT & HOLD LE. PURPOSEFUL MOVEMENTS WITH UE. HAND GRASPS = BUT\\n WEAK.\\nRESP: O2->50% OFT. O2 SATS 94-98%. BS COARSE BUT DIMINISHED AT BASES.\\n CONT. TO BE TACHYPNEIC WITH RR 32-38 & SHALLOW. WEAK NON-PROD-\\n UCTIVE COUGH.\\nCARDIAC: HR 65-73 SR, NO ECTOPY. BP 142-162/59-68. HEPARIN GTT INFUS-\\n ING AT 1750U/HR. PTT 70.\\nGI: NPO. NGT CLAMPED FOR MEDS. ABD. SOFT. BS+. NO STOOL.\\nGU: FOLEY->CD PATENT & DRAINING BLOOD-TINGED URINE. U/O 50-75CC/HR.\\nID: AFEBRILE. CONT. ON CEFTAZADIME IV FOR UTI.\\nENDO: BS 156->137. INSULIN PER SLIDING SCALE.\\nAM LABS PENDING.\\n\\nPLAN: CHEST CT EARLY THIS AM, THEN ?????BRONCH DEPENDING WHAT IS SEEN\\n ON CT SCAN.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603421,\n \"text\": \"CCU progress note 11p-7a MICU team\\nNEURO: pt remains aphasic, occasionally saying words. unable to assess orientation. pt does nod head and obeys simple commands - inconsistently. wrist restraints remain off, pt occasionally taking off face mask but leaves in NGT, pt not tugging at lines. remains calm.\\n\\nID: afebrile. on ceftaz.\\n\\nRESP: LS clear, dim. continues to have shallow rapid breathing. 7.42/39/249. taken off NRB and placed on NC but desatted to mid 80s. placed on 5L w/ 70% cool neb face tent for sats >98%. to con't to wean in am. pt encouraged to cough. CXR due in am - last CXR showed ARDS.\\n\\nCARDIAC: SR 60-70s. On lopressor + lisinopril - new parameters - hold if BP <130. Neuro goal BP >130. PA line remains in R fem. PADs 15. ?d/c in am. R radial Aline patent - maps >80. Heparin gtt increased to 1550u at 2am - repeat PTT at 8am.\\n\\nGI/GU: foley patent, cloudy amber urine ~ 30cc/hr. abd soft +BS. no BM. NGT patent for meds.\\n\\nPLAN: wean O2 as tolerated. keep SBP >130. monitor neuro status. con't abx. recheck PTT at 8am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603422,\n \"text\": \"NURSING PROGRESS NOTE 0700-1500\\nNEURO---MUCH IMPROVED NEURO STATUS SINCE 0700. PT IS ABLE TO CLEARLY SAY A FEW WORDS INCLUDING HER NAME. SHE HAS PROBLEMS WITH REPETITION. WHEN ASK PT TO COUGH AND DEMONSTRATION IS SHOWN, SHE WILL SAY THE WORDS 'COUGH,COUGH' IN THE SAME CADENCE THAT SHE IS HEARING . BILAT ARM STR IS 5+ . SHE HAS A WEAK GRASP. NOT ABLE TO FOLLOW ACTION COMMANDS,\\\"TOUCH YR NOSE,POINT TO LIGHT\\\".BILAT LE LIFT AND HOLD ON BED. SHE MOVES ALL 4 EXT. SPONT. SPEECH AT TIMES IS CLEAR, OTHER TIMES IT IS GARBLED. PEARL AT 3-4 MM.\\n\\nCARDIAC--SBP 150-160. HR SR 70'S WITH OCCAS UNIFOCAL PVC. RECEIVED ALL ANTI HTN DRUGS. K+3.5 GIVEN 60 MEQ PO KCL. ON HEPARIN GTT AT 1550. PTT TO BE CHECKED AT 1400.\\n\\nRESP--O2 WEANED DOWN TO 50% FACE TENT. SPONT RESP 34-42. LUNGS COARSE BILATERALLY AND DECREASED IN UPPER LOBES. PT COUGHS SPONT AND IT IS PRODUCTIVE. SAO2 90-95%.\\n\\nGI--NGT PATENT. REMAINS NPO. NO STOOL AT PRESENT.\\n\\nGU--FOLEY CATH PATENT DRAINING >40 CC HR OF CLOUDY URINE.\\n\\nENDO--NO SSRI COVERAGE NEEDED.\\n\\nSKIN--GROSSLY INTACT.\\n\\nID--AFEBRILE AT PRESENT. ON ABX FOR E COLI IN URINE.\\n\\n RN HAS SPOKEN WITH DAUGHTER , AND HAS UPDATED HER REGARDING HER CONDITION AND PLANS FOR THE DAY. SHE WOULD LIKE TO BE CALLED PRIOR TO ANY TESTS THAT WILL BE DONE. PT HAS NODDED IN THE AFFIRMATIVE WHEN ASKED IF SHE IS FRIGHTENED. SHE DOES WELL WITH REINFORCEMENT.\\n\\nA--IMPROVED NEURO STATUS. AFEBRILE.\\n\\nP--CON'T TO ASSESS NEURO STATUS. PROVIDE SAFETY AND REASSURANCE TO PT. OFFER SUPPORT TO FAMILY AND PT. CHECK RESULTS OF LABS DRAWN AT 1400.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2159-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 69585,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Aortic valve disease. Congestive heart failure. Coronary artery disease. H/O cardiac surgery. Left ventricular function.\\nBP (mm Hg): 158/72\\nHR (bpm): 80\\nStatus: Inpatient\\nDate/Time: at 09:51\\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 mildly dilated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\\n\\nLEFT VENTRICLE: The left ventricular cavity is moderately dilated. Overall\\nleft ventricular systolic function is moderately depressed.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is normal in diameter.\\n\\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is\\nmoderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\\n\\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is mild\\npulmonary artery systolic hypertension.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\\n\\nConclusions:\\n1. The left atrium is mildly dilated.\\n2. The left ventricular cavity is moderately dilated. Overall left ventricular\\nsystolic function is moderately depressed. Anterior, septal, apicial and\\nposterior hypokinesis is present.\\n3. The aortic valve leaflets are moderately thickened. There is moderate\\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\\nregurgitation is seen.\\n5. There is mild pulmonary artery systolic hypertension.\\n6. Compared with the findings of the prior study (tape reviewed) of ,\\nthere is no significant change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2159-04-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 821430,\n \"text\": \" 7:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: am CXR to be done for 730am Rounds.\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for\\n change\\n REASON FOR THIS EXAMINATION:\\n am CXR to be done for 730am Rounds.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old woman with coronary artery disease and acute\\n pulmonary edema. Please evaluate for change.\\n\\n COMPARISON: .\\n\\n FINDINGS: AP portable supine single view of the chest. There is cardiomegaly\\n which is stable. Mediastinal and hilar contours are stable when compared to\\n the previous study. In the interval, there is slight improvement in the lung\\n inflation and possibly in the bilateral diffuse infiltrates. The Swan-Ganz\\n catheter is in an unchanged position. There is a new central line with the\\n tip in the left brachiocephalic vein. The NG tube was re-positioned and now\\n extends beyond the limitations of the radiograph in the stomach. The patient\\n is status-post median sternotomy and CABG.\\n\\n IMPRESSION: 1) There is slight interval improvement in the lung inflation and\\n possibly in the diffuse bilateral pulmonary infiltrates. 2) Interval re-\\n positioning of the NG tube which now extends beyond the limits of the\\n radiograph in the stomach.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2159-04-09 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 821289,\n \"text\": \" 6:35 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Evaluate for evidence of ICH.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with new aphasia after cardiac cath.\\n REASON FOR THIS EXAMINATION:\\n Evaluate for evidence of ICH.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71 year old, aphasia post-cath.\\n\\n CT SCAN of the brain(following cardiac catheterization)\\n\\n Findings: Contrast enhancement is seen in the circle of vessels\\n consistent with the patient's post-cath status. There are no extra or\\n intracranial hemorrhage, shift of normally mid- line structures, or\\n hydrocephalus. - white differentiation is preserved. There are multiple\\n lacunar infarcts unchanged from MRI of . The osseous structures are\\n unremarkable. The mastoid air cells are clear. Mucosal thickening is seen in\\n the sphenoid sinus. The remaining visualized paranasal sinuses are clear.\\n\\n IMPRESSION: No acute hemorrhage.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2159-04-12 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 821543,\n \"text\": \" 7:55 AM\\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: eval for interstitial lung disease. ?ARDS vs, amio lung tox\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with incr. O2 req, bilat infil on CXR, PaO2/FiO2 of 60.\\n\\n REASON FOR THIS EXAMINATION:\\n eval for interstitial lung disease. ?ARDS vs, amio lung toxicitiy.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Increasing oxygen requirement, bilateral infiltrates on chest\\n radiographs, evaluate for ARDS versus amiodarone lung toxicity.\\n\\n TECHNIQUE: Contiguous axial images were obtained through the chest without IV\\n contrast. Additional images in expiration were obtained. Coronal reformations\\n were performed.\\n\\n CT CHEST WITHOUT CONTRAST: There is moderate polychamber cardiac enlargement.\\n Dense coronary arterial and aortic calcifications are present. Scattered nodes\\n are noted throughout the mediastinum which do not meet CT criteria for\\n pathologic enlargement. The NG tube extends into the stomach. A small\\n pericardial effusion is present. There are bilateral small pleural effusions.\\n Within the imaged portion of the upper abdomen, the liver is noted to be of\\n high attenuation, measuring up to 79 Hounsfield units. Multiple splenic\\n granulomas are identified.\\n\\n Lung windows demonstrate diffuse lung disease with relative sparring of the\\n lung bases. There are diffuse areas of ground glass attenuation as well the\\n presence of intralobular septal thickening. In comparison with prior chest\\n radiographs, this appears to be an acute process. There is evidence for\\n moderate air trapping. There is a calcified granuloma at the right lung base.\\n\\n Bone windows demonstrate no suspicious lytic or sclerotic abnormalities. The\\n patient is status post CABG.\\n\\n IMPRESSION:\\n 1. Diffuse lung disease with extensive areas of ground glass opacification as\\n well as centrilobular septal thickening. There is relative sparring of the\\n bases. Differential considerations are broad and include pulmonary edema,\\n cryptogenic organizing pneumonia, chronic eosinophylic pneumonia, vasculitis,\\n desquamative interstitial pneumonitis, drug-induced lung disease, diffuse\\n alveolar damage secondary to amiodarone, and pulmonary alveolar proteinosis.\\n Less likely considerations include bronchiol-alveolar cell carcinoma and\\n lymphoma.\\n 2. Small pericardial effusion and small bilateral pleural effusions.\\n 3. Evidence for prior granulomatous disease.\\n\\n (Over)\\n\\n 7:55 AM\\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: eval for interstitial lung disease. ?ARDS vs, amio lung tox\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2159-04-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 821309,\n \"text\": \" 6:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval for change\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for change\\n REASON FOR THIS EXAMINATION:\\n please eval for change\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 71 y/o woman with coronary artery disease and acute pulmonary\\n edema.\\n\\n PORTABLE AP CHEST: Comparison is made to the study from at 9:15 p.m.\\n\\n FINDINGS: The patient is status post median sternotomy. There is again noted a\\n Swan-Ganz catheter in unchanged position. There are diffuse bilateral alveolar\\n opacities consistent with pulmonary edema. It is possibly slightly\\n improved when compared to the previous study. There is slight blunting of the\\n left costophrenic angle that could represent a small pleural effusion. The\\n cardiac, mediastinal and hilar contours are unchanged.\\n\\n IMPRESSION: There is possible slight improvement in the pulmonary edema in the\\n interval. The findings are consistent with pulmonary edema. Correlate with\\n Swan-Ganz measurements.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2159-04-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 821294,\n \"text\": \" 8:08 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for pulm edema/infiltrate\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CAD, acute pulm edema\\n REASON FOR THIS EXAMINATION:\\n assess for pulm edema/infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Coronary artery disease, shortness of breath.\\n\\n COMPARISON: \\n\\n SINGLE VIEW CHEST, AP SEMIUPRIGHT: There has been interval\\n formation of diffuse interstitial and alveolar opacification within both\\n lungs. There has also been interval placement of a right femoral Swan-Ganz\\n catheter with the tip lying within the left interlobar pulmonary artery. No\\n pleural effusions are identified. The patient is status post median\\n sternotomy and CABG. The cardiac size is enlarged with left ventricular\\n prominence. The thoracic aorta is enfolded with vascular calcifications.\\n\\n IMPRESSION:\\n 1. Interval placement of right femoral Swan-Ganz catheter with the tip lying\\n within the left interlobar artery.\\n 2. Marked interstitial and alveolar opacification within both lung fields.\\n Findings are consistent with pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2159-04-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 821332,\n \"text\": \" 8:36 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for ngt placement\\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for change\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate for ngt placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: NG tube placement.\\n\\n COMPARISON: X ray done 1 hour and ago.\\n\\n AP SUPINE VIEW OF THE CHEST: There is an NG tube with the tip located in the\\n esophagocardiac junction. There is 1 side hole of the NG tube that is located\\n in the distal esophagus. Recommend advancing the NG tube approximately 7 cm.\\n Otherwise the appearance of the chest radiograph is essentially unchanged.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603419,\n \"text\": \"CCU progress note 7a-3p\\nNEURO: PERLA 3mm , , normal strength, obeys commands inconsistently. opens eyes to voice. occasional garbled sounds, unable to speak, shakes head no when asked to speak. startles very easily. nods head yes and no inconsistently to commands. Neuro on consult. ?stroke + encephalopathy? pt to have MRI if she stays calm/unmoving for scan or repeat CT of head without contrast for diagnostic purposes.\\n\\nID: afebrile. Tmax 98.8 ax. Levo d/c'd. to be started on Ceftaz. +ecoli UTI. urine cx sent today for legionella screen. need to obtain induced sputum cx and nasal swabs this evening. Pan Cx . no skin breakdown noted.\\n\\nRESP: LS clear, dim. occ wheeze noted. CXR shows ARDS. Tachypneic 20-30s. sats 96-99% on NRB 100%. attempted to wean off to 6L n/c but sats dropped to 87%.\\n\\nCARDIAC: SR 70s. given lopressor 25mg as ordered via NGT today. Heparin gtt increased to 1250u/hr - next PTT due after 3pm. R fem PA line intact. stable BP. PA 43/19 Pasat 69% CO 6.4 CI 3.03. con't to have R leg immobilizer on d/t PA line in R fem. palpable pedal pulses. lytes replaced this am. repeat lytes this pm.\\n\\nGI/GU: foley patent, cloudy/sediment dk urine. >60cc/hr. abd soft distended. +BS. NGT inserted today for po meds. placement checked by xray + auscultation. no BM. remains NPO.\\n\\nSOCIAL: daughters called multiple times during day. RN + HO talked to family. keep up to date. family to call back this evening w/ med list.\\n\\n\\nPLAN: con't monitoring hemodynamics/vs. admin meds via ngt. monitor resp status. keep pt from getting out of bed - R leg immobilizer on. less agitated during day shift today. rechekc PTT after 3pm. recheck lytes tonite. con't abx. keep pt comfortable.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603420,\n \"text\": \"CCU NPN 3-11pm\\nNeuro: alert, following commands consistantly, nodding appropriately, PERL, MAE and has normal strength. By later in shift becoming more verbal. Asked daughters where her washing machine was. When I encouraged her to cough, she wouldn't saying oh, it will be alright. Would not answer orientation questions. Had head CT this eve. Calm, cooperative, wrist restraints removed.\\n\\nCV: HR 70's NSR, BP 150-160's/60, up to 170-180's right before Lopressor dose due. Denies any pain. Swan-ganz in R fem, PA 40/17-20. Daughter brought in all meds from home, list given to resident. A-line placed in R radial. Hep gtt increased to 1450U/hr for PTT 37.\\n\\nResp: LS crackles in upper lobes, clear at bases bilaterally. cont on 100% NRB with sats 90-100%, ABG improved with po2 in 80's. Weak cough, sounds conjested at times, unable to expectorate. Cont tachypneic with RR high 30's-40, shallow.\\n\\nGI: NPO, no stool.\\n\\nID: afebrile. Levoflox changed to Ceftazidime. Nasal swabs sent for culture and viral tests.\\n\\nSkin: intact.\\n\\nEndocrine: BS 148, no coverage required. Cont to follow and cov with SS Reg.\\n\\nA/P: pt remains tachypneic, sl improvement in po2, Enc C&DB, IV solumedrol, hemodynamically stable, neuro status somewhat improved, now verbalizing, head CT consistant with stroke, awaiting official report, check PTT at 1AM.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2159-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1603418,\n \"text\": \"CCU NSG ADMIT/PROGRESS NOTE 7:30P- 7A/ RESP DISTRESS\\n\\nS- NONVERBAL\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\n PT ARRIVED TO CCU S/P CATH WITH BILATERAL SHEATHS IN PLACE AND 100% NR ON FOR 02 SATS MID 86%.\\nINITIALLY ON TNG GTT FOR PRELOAD REDUCTION R/O PULMONARY EDEMA- ONCE CXR INDICATED ARDS- WEANED TO OFF.\\nRT FEMORAL ALINE D/C AND LEFT IN PA LINE- HEPARIN GTT 1100U NO BOLUS STARTED 1AM 4 HOURS AFTER SHEATH D/C.\\nHEMODYNAMICS STABLE- HR- 70'S SR, MINIMAL VEA- BP- 140/60-150/70'S.\\nUNABLE TO GIVE PO B BLOCKERS/MEDS D/T ALTERED MENTAL STATUS.\\n\\nMS- SEE PT NONVERBAL, STARTED ON HEPARIN GTT PER NEURO TEAM FOR R/O EMBOLIC STROKE, R/O PE FOR ACUTE RESP DISTRESS.\\nPT LOOKING BUT NO WORDS, UNABLE TO ASSESS LEVEL OF ORIENTATION\\nNO CHANGE IN NEURO SIGNS THIS SHIFT.\\nBILATERAL WRIST RESTRAINTS AND POSEY AND NEED FOR CLOSE MONITORING FOR AGITATION. ATTEMPTING OOB AND TRYING TO PULL AT PA LINE. PULL OFF O2 MASK WITH O2 SATS DROPPING TO 68%.\\nDAUGHTER IN TO SPEAK WITH TEAM/STAFF AND REINFORCED THIS BEHAVIOR IS NEW.\\n\\n PT INITIALLY ON 100%- INCREASED TO 100% NR AND 6L NP- ABLE TO WEAN OFF NC- KEEPING O2 SATS >93%- SOME WHEEZING- STARTED NEBS AND STRESS DOSE STEROIDS TID.\\nNO COUGH, DROPPING SATS WHEN SELF D/C MASK IN SPITE OF REPEATED WRIST RESTRAINING..REQUIRING CLOSE WATCH.\\n\\nID- AFEBRILE- RESUMED DAY LEVO FOR (+) ECOLI UTI.\\nPAN CULTURED THIS EVE\\n\\nGU- GOOD REPSONSE TO CATH LAB LASIX AND REPEATED 40 LASIX 12AM- 1 LITER OUT TO THAT DOSE\\nCXR REVEALING ARDS PICTURE.\\nI/O EVEN AS OF MN IN SPITE OF GOOD DIURESIS AND PAD # LOW NORMAL.\\n\\nGI- NPO- TOO SOMNOLENT (+) BS\\n\\n\\nLYTES- REPLETED K AND CA WITH 40 KCL AND 2 AMPS CA GLUC\\n\\nLINES- BILATERAL HEPLOCKS, RT FEMORAL PA LINE WITH VENOUS SIDEARM.\\n\\nA/ PT ADMITTED TO CCU S/P CATH WITH CHF VS COPD FLARE VS ARDS\\n\\n\\nCONTINUE TO CLOSELY MONITOR NEURO STATUS, NOTE ANY CHANGE IN MS.\\nSAFETY- WRIST RESTRAINTS, POSEY, ATTEMPT TO REORIENT.\\nPLAN FOR MRI TODAY\\nCONTINUE HEPARIN.\\nDISCUSS NEED FOR NG TUBE FOR PO MEDS.\\nDISCUSS POSSIBILITY TO D/C PA LINE WITH NO CHANGE IN PA # OR CO/CI\\nAND IN SETTING OF AGITATED PT.\\nCHECK PTT 7AM ON 1100U HEPARIN.\\nCONTINUE TO DIURESE AS NEEDED AND REPLETE LYTES.\\nCONTINUE ANTIBX AS ORDERED.KEEP NPO UNTIL MS CLEARS, LESS SOMNOLENT.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2159-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 164113,\n \"text\": \"Sinus rhythm. A-V conduction delay. Prior inferior myocardial infarction.\\nQ-T interval prolongation. Delayed precordial R wave progression consistent\\nwith prior anterior myocardial infarction. Compared to the previous tracing\\nof the rate has increased. Otherwise, no diagnostic interim change.\\n\\n\"\n }\n]"}}},{"rowIdx":792,"cells":{"subject_id":{"kind":"number","value":6854,"string":"6,854"},"hadm_id":{"kind":"number","value":123406,"string":"123,406"},"target_text":{"kind":"string","value":"She was admitted preoperatively for cardiac cath which showed patent bypass grafts x 3. She was then taken to the operating toom on where she underwent a redo-sternotomy, excision of left atrial mass/myxoma. She was tranferred to the SICU in critical but stable condition. A CXR immediately post operatively showed right sided collapse for which she underwent a bronchoscopy which showed secretions, a post bronch xray showed marked improvement. She was extubated and weaned from her vasoactive drips by POD #1. She was transferred to the floor on POD #2. She did well postoperatively, and was ready for discharge on ."},"extractive_notes_summ":{"kind":"string","value":"Normaldescending aorta diameter. Normal ascending aorta diameter. Aorta intact post decannulation. Right ventricular conduction delay. Cardiomediastinal silhouette has a normal postoperative appearance and mediastinal vasculature is less engorged. Normal regional LVsystolic function. Sternal drsg w/old serosang drng small amt.Resp: Lungs clear and diminished in the bases. repleted lytes prn. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There are simple atheroma in the descending thoracic aorta.6. PERCOCET FOR PAIN.CV: SR, NO ECTOPY. Mediastinal and hilar contours are normal. NO CT.RESP: L/S CLEAR WITH DIM BASES. Small bilateral pleural effusions unchanged. IMPRESSION: Slight increase and small right pleural effusion. A small focus of air is present in the retrosternal region, likely postoperative. Biventricular systolic function is unchanged.2. Left atrial myxoma has been resected.3. Standard position of tubes and lines. Chest tubes removed. CSRU NPNNEURO: GROSSLY INTACT. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). Right ventricular chamber size and free wall motion are normal.4. Has peripheral IV. B/P STABLE. vital signs stable. Right upper lobe atelectasis. No AR.MITRAL VALVE: Normal mitral valve leaflets. Peripheral pulses palpable. The mediastinal drain tip is just above the right hemidiaphragm. No resp distress noted, = rise and fall of chest. by m.d. Reexpansion of collapse part of right upper lung. sl gen edemaresp: ls diminished rll, crackes lll. PEARRLACV: RSR w/o ectopy. Normal LV wall thicknesses and cavity size. Heart size is borderline normal. Mild (1+) mitralregurgitation is seen.8. CHEST, TWO VIEWS: There are median sternotomy wires and mediastinal clips in place. Probable mild pulmonary edema. nursing 7a-3ppt neurologically intact. Monitor, tx, support, and comfort. There is resolution of bilateral reticular opacities of the lung. pt post op for sm-mod amt of clear secretions. Discrete atelectasis is limited to the right lower lobe. skin w/d. calm, cooperativeid: afebrile, p/o atbcv: apaced at 70. bp good. ROS:Neuro: A+O x's 3. Overall left ventricular systolic functionis normal (LVEF>55%).3. Left ventricular wall thicknesses and cavity size are normal. The right lower lung is clear. Regional leftventricular wall motion is normal. Lungs otherwise clear. The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation.7. The overall cardiac size is normal. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. INDICATION: Status post myxoma resection. IMPRESSION: 1. IMPRESSION: 1. Pulmonary toileting. The mitral valve leaflets are structurally normal. pulm toilet. palapabled pulses. There is no pericardial effusion.Post Bypass1. Postioned for comfort. no distressgi: tol sip cl liquid w/o difficultyendo: con't insulin gttgu: adquate huowound: chest wound dsd w sm amt serosang drg. Compared to the previoustracing of no major change. PULMONARY HYGIENE. provide support/tlc to pta/p: s/p excision of l atrial mass/myxoma. Sinus bradycardia. percocet for pain control w/ good effect. for little secretions but repeat cxr much improved. maex 4 to command, no deficit. The patient appears to be in sinus rhythm. good index. 3LNC. Sinus bradycardiaIncomplete RBBBNo previous tracing available for comparison provided w cough pillow & cognizant of use.pain controlled w morphine,repositioned freq. There are mild degenerative changes of the spine. Improving heart failure. bronch d/t r lung collapse ->atelectasis.Deline. FINDINGS: There has been resolution of collapse of right upper lung with complete aeration. no apparent skin breakdowncomfort: medicated w morphine prn w adequate sternal incis pain relief. Endotracheal tube is 3.7 cm above carina. The patient was under general anesthesia throughout theprocedure. vss, a paced for underlying sb 50's with decreased bp,great svo2,ci. The heart size is normal as well as the pulmonary vascularity. MAE x's 4. support. NG tube has its tip in the distal stomach. Portable AP chest radiograph compared to the preoperative study from , . IMPRESSION: AP chest compared to and 27: Lung volumes are lower since following extubation. A patent foramen ovale is present which wasdemonstrated with bubble study using valsalva.2. extubated on to np's w/o incident. closely monitor -> ? midazolam given & precedex planned for extubation attempt. HISTORY: Myxoma resection. for lt. shoulder discomfort. Itmeasure 3.6 cms.5. 3. 3. I certifyI was present in compliance with HCFA regulations. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for left atrial myxoma resectionHeight: (in) 66Weight (lb): 208BSA (m2): 2.04 m2BP (mm Hg): 134/78HR (bpm): 86Status: InpatientDate/Time: at 09:37Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV. cooperative w deep breathing,coughing. PFO is present.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. The left lung is grossly clear, and there is no left pleural effusion. No AS. a line inadvertently removed by patient while drinking,cuff bp acceptable.pacing rate adjusted as indicated for bp support or control,stable hemodynamics. Left atrial myxoma seen with pedicle attached to the interatrial septum. + BS, NO BM.GU: AUTODIURESING, > 150CC/HR.ENDO: CSRU SSRI.PLAN: TRANSFER TO 2. 2. 2. ^diet and act. Plan at this time is to lighten sedation and wean to extuabe at tolerated while monitoring ABGs to maintain adequate oxygenation and ventilkation. pain control. The Swan-Ganz tip is in the pulmonary outflow tract. no ectopies. Resp CarePt intubated with 7.5 ETT 20 @lip on SIMV+ PS. continues with underlying of sb 50's.see flow sheet. shift cover 2300-0700neuro: pt a+ox3. There is perihilar haziness on the left with some engorgement of the pulmonary vessels, which may represent a mild asymmetric pulmonary edema. OOB > CHAIR. Results were personallyreviewed with the MD caring for the patient.Conclusions:Prebypass1. addenum:Lower body w scatter sm areas of pink coloration, groin and abd fold sl red -> powder dry, use non-bleach linens. Overall normal LVEF (>55%). cco svo2 recal high 60s-70, ci>2.5."},"n_notes":{"kind":"number","value":16,"string":"16"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2148-07-04 00:00:00.000","description":"Report","row_id":1353000,"text":"extubated on to np's w/o incident. cooperative w deep breathing,coughing. provided w cough pillow & cognizant of use.pain controlled w morphine,repositioned freq. for lt. shoulder discomfort. a line inadvertently removed by patient while drinking,cuff bp acceptable.pacing rate adjusted as indicated for bp support or control,stable hemodynamics. continues with underlying of sb 50's.see flow sheet.\n"},{"category":"Nursing/other","chartdate":"2148-07-05 00:00:00.000","description":"Report","row_id":1353001,"text":"shift cover 2300-0700\n\nneuro: pt a+ox3. maex 4 to command, no deficit. calm, cooperative\n\nid: afebrile, p/o atb\n\ncv: apaced at 70. bp good. no ectopies. repleted lytes prn. cco svo2 recal high 60s-70, ci>2.5. skin w/d. palapabled pulses. sl gen edema\n\nresp: ls diminished rll, crackes lll. sat>96% on 4lnc. is reinforced->pt used ^500ml. no distress\ngi: tol sip cl liquid w/o difficulty\nendo: con't insulin gtt\ngu: adquate huo\nwound: chest wound dsd w sm amt serosang drg. no apparent skin breakdown\ncomfort: medicated w morphine prn w adequate sternal incis pain relief. no family call. provide support/tlc to pt\n\na/p: s/p excision of l atrial mass/myxoma. good index. bronch d/t r lung collapse ->atelectasis.\n\nDeline. pulm toilet. ^diet and act. pain control. support. to f2 today\n"},{"category":"Nursing/other","chartdate":"2148-07-05 00:00:00.000","description":"Report","row_id":1353002,"text":"addenum:\n\nLower body w scatter sm areas of pink coloration, groin and abd fold sl red -> powder dry, use non-bleach linens. closely monitor -> ? need miconazole powder order\n\ndeline per am team round. to f2 today\n"},{"category":"Nursing/other","chartdate":"2148-07-05 00:00:00.000","description":"Report","row_id":1353003,"text":"nursing 7a-3p\npt neurologically intact. vital signs stable. percocet for pain control w/ good effect. can be anxious at times. awaiting bed on 2. see nursing transfer note in chart.\n"},{"category":"Nursing/other","chartdate":"2148-07-05 00:00:00.000","description":"Report","row_id":1353004,"text":"ROS:\n\nNeuro: A+O x's 3. MAE x's 4. Postioned for comfort. PEARRLA\n\nCV: RSR w/o ectopy. Epicardial wires and pacer in place no pacing requirments. Peripheral pulses palpable. Has peripheral IV. Sternal drsg w/old serosang drng small amt.\n\nResp: Lungs clear and diminished in the bases. No resp distress noted, = rise and fall of chest. O2 3 L NP, sats 95% or >.\n\nGI: Taking diet and po fluids w/o c/o NV. Soft form stool.\n\nGU: Foley patent draining clear y ellow urine in QS.\n\nSocial: Friend this eveining.\n\nPlan: Await floor bed. Mobilize. Pulmonary toileting. Monitor, tx, support, and comfort.\n"},{"category":"Nursing/other","chartdate":"2148-07-06 00:00:00.000","description":"Report","row_id":1353005,"text":"CSRU NPN\nNEURO: GROSSLY INTACT. PERCOCET FOR PAIN.\n\nCV: SR, NO ECTOPY. B/P STABLE. NO VASOACTIVE GTTS. NO CT.\n\nRESP: L/S CLEAR WITH DIM BASES. 3LNC. CONGESTED COUGH, OCCASIONALLY PRODUCTIVE WHITE SPUTUM.\n\nGI: TOLERATING CLEAR LIQUIDS W/O NAUSEA. + BS, NO BM.\n\nGU: AUTODIURESING, > 150CC/HR.\n\nENDO: CSRU SSRI.\n\nPLAN: TRANSFER TO 2. OOB > CHAIR. PAIN MANAGEMENT. PULMONARY HYGIENE.\n"},{"category":"Nursing/other","chartdate":"2148-07-04 00:00:00.000","description":"Report","row_id":1352998,"text":"vss, a paced for underlying sb 50's with decreased bp,great svo2,ci. waking thru high dose propofol even at rest with decreased svo2 into the 50's,high pip's,biting on ett,thrashing. midazolam given & precedex planned for extubation attempt. son reports prior difficult extubation with severe agitation after 1st cabg in req. sitters & physical restraint.cxr revealed rll collapse with decreased breath breath sounds rt > lt. recently(this month)quit smoking. by m.d. for little secretions but repeat cxr much improved. plan to initiate weaning soon.glucoses treated w protocol,see flow sheet.\n"},{"category":"Nursing/other","chartdate":"2148-07-04 00:00:00.000","description":"Report","row_id":1352999,"text":"Resp Care\nPt intubated with 7.5 ETT 20 @lip on SIMV+ PS. pt post op for sm-mod amt of clear secretions. Plan at this time is to lighten sedation and wean to extuabe at tolerated while monitoring ABGs to maintain adequate oxygenation and ventilkation.\n"},{"category":"Echo","chartdate":"2148-07-04 00:00:00.000","description":"Report","row_id":81225,"text":"PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for left atrial myxoma resection\nHeight: (in) 66\nWeight (lb): 208\nBSA (m2): 2.04 m2\nBP (mm Hg): 134/78\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 09:37\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA.\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: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thicknesses and cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Mild (1+) 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: 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. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPrebypass\n\n1. No spontaneous echo contrast or thrombus is seen in the body of the left\natrium or left atrial appendage. A patent foramen ovale is present which was\ndemonstrated with bubble study using valsalva.\n\n2. Left ventricular wall thicknesses and cavity size are normal. Regional left\nventricular wall motion is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\n3. Right ventricular chamber size and free wall motion are normal.\n\n4. Left atrial myxoma seen with pedicle attached to the interatrial septum. It\nmeasure 3.6 cms.\n\n5. There are simple atheroma in the descending thoracic aorta.\n\n6. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation.\n\n7. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen.\n\n8. There is no pericardial effusion.\n\n\nPost Bypass\n\n1. Biventricular systolic function is unchanged.\n\n2. Left atrial myxoma has been resected.\n\n3. Aorta intact post decannulation.\n\n\n"},{"category":"ECG","chartdate":"2148-07-04 00:00:00.000","description":"Report","row_id":200926,"text":"Sinus bradycardia. Right ventricular conduction delay. Compared to the previous\ntracing of no major change.\n\n"},{"category":"ECG","chartdate":"2148-07-03 00:00:00.000","description":"Report","row_id":200927,"text":"Sinus bradycardia\nIncomplete RBBB\nNo previous tracing available for comparison\n\n"},{"category":"Radiology","chartdate":"2148-07-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":921708,"text":" 2:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval collapse, s/p bronch\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman scheduled for myxoma resection \n\n REASON FOR THIS EXAMINATION:\n eval collapse, s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE STUDY: Evaluation for collapse and status post bronchoscopy in\n a patient that is prescheduled for myxoma resection.\n\n TECHNIQUE: Chest portable PA view, and this study is compared to the previous\n study done on same day three hours earlier.\n\n FINDINGS: There has been resolution of collapse of right upper lung with\n complete aeration. The right internal jugular Swan-Ganz catheter has its tip\n in right ventricle and needs to be advanced at least 5cm in order to be in\n main pulmonary artery . Endotracheal tube is 3.7 cm above carina. NG tube\n has its tip in the distal stomach. There are no pleural effusion or\n pneumothoraxes. Heart size is borderline normal. There is resolution of\n bilateral reticular opacities of the lung.\n\n IMPRESSION:\n\n 1. Reexpansion of collapse part of right upper lung.\n\n 2. Right internal jugular Swan-Ganz catheter in right ventricle and needs to\n be advanced further.\n\n 3. Improving heart failure.\n\n\n"},{"category":"Radiology","chartdate":"2148-07-03 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":921590,"text":" 8:23 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman scheduled for myxoma resection \n REASON FOR THIS EXAMINATION:\n pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for myxoma resection on .\n\n There are no prior studies for comparison.\n\n CHEST, TWO VIEWS: There are median sternotomy wires and mediastinal clips in\n place. The overall cardiac size is normal. Mediastinal and hilar contours\n are normal. No consolidation or vascular congestion within the lungs. No\n pleural effusions or pneumothorax. There are mild degenerative changes of the\n spine.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2148-07-08 00:00:00.000","description":"CHEST (PA & LAT)","row_id":922152,"text":" 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: eval post op\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s.p myxoma resection\n REASON FOR THIS EXAMINATION:\n eval post op\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW, CHEST X-RAY, \n\n COMPARISON: .\n\n INDICATION: Status post myxoma resection.\n\n Midline surgical staples overlie the sternotomy site. The heart size is\n normal as well as the pulmonary vascularity. A small right pleural effusion\n appears slightly larger, but the degree of right basilar atelectasis has\n improved. The left lung is grossly clear, and there is no left pleural\n effusion. A small focus of air is present in the retrosternal region, likely\n postoperative.\n\n IMPRESSION: Slight increase and small right pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2148-07-04 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":921660,"text":" 12:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx, effusion\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with s/p Redo Sternotomy, Removal of Left Atrial Myxoma\n REASON FOR THIS EXAMINATION:\n ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Immediate postoperative evaluation in a patient after\n a removal of left atrial myxoma.\n\n Portable AP chest radiograph compared to the preoperative study from , .\n\n The ET tube tip is 4 cm above the carina. The Swan-Ganz tip is in the\n pulmonary outflow tract. The NG tube is within the stomach. The mediastinal\n drain tip is just above the right hemidiaphragm. There is complete\n atelectasis of the right upper lobe, most probably due to muceous plugg. The\n right lower lung is clear. There is perihilar haziness on the left with some\n engorgement of the pulmonary vessels, which may represent a mild asymmetric\n pulmonary edema. There is no pleural effusion or pneumothorax.\n\n IMPRESSION:\n\n 1. Right upper lobe atelectasis. These findings were discussed with Dr.\n .\n\n 2. Standard position of tubes and lines.\n\n 3. Probable mild pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2148-07-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":921830,"text":" 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman scheduled for myxoma resection \n\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest 10:36 a.m. on .\n\n HISTORY: Myxoma resection. Chest tubes removed.\n\n IMPRESSION: AP chest compared to and 27:\n\n Lung volumes are lower since following extubation. Discrete\n atelectasis is limited to the right lower lobe. Lungs otherwise clear. Small\n bilateral pleural effusions unchanged. Cardiomediastinal silhouette has a\n normal postoperative appearance and mediastinal vasculature is less engorged.\n No pneumothorax.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1353000,\n \"text\": \"extubated on to np's w/o incident. cooperative w deep breathing,coughing. provided w cough pillow & cognizant of use.pain controlled w morphine,repositioned freq. for lt. shoulder discomfort. a line inadvertently removed by patient while drinking,cuff bp acceptable.pacing rate adjusted as indicated for bp support or control,stable hemodynamics. continues with underlying of sb 50's.see flow sheet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1353001,\n \"text\": \"shift cover 2300-0700\\n\\nneuro: pt a+ox3. maex 4 to command, no deficit. calm, cooperative\\n\\nid: afebrile, p/o atb\\n\\ncv: apaced at 70. bp good. no ectopies. repleted lytes prn. cco svo2 recal high 60s-70, ci>2.5. skin w/d. palapabled pulses. sl gen edema\\n\\nresp: ls diminished rll, crackes lll. sat>96% on 4lnc. is reinforced->pt used ^500ml. no distress\\ngi: tol sip cl liquid w/o difficulty\\nendo: con't insulin gtt\\ngu: adquate huo\\nwound: chest wound dsd w sm amt serosang drg. no apparent skin breakdown\\ncomfort: medicated w morphine prn w adequate sternal incis pain relief. no family call. provide support/tlc to pt\\n\\na/p: s/p excision of l atrial mass/myxoma. good index. bronch d/t r lung collapse ->atelectasis.\\n\\nDeline. pulm toilet. ^diet and act. pain control. support. to f2 today\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1353002,\n \"text\": \"addenum:\\n\\nLower body w scatter sm areas of pink coloration, groin and abd fold sl red -> powder dry, use non-bleach linens. closely monitor -> ? need miconazole powder order\\n\\ndeline per am team round. to f2 today\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1353003,\n \"text\": \"nursing 7a-3p\\npt neurologically intact. vital signs stable. percocet for pain control w/ good effect. can be anxious at times. awaiting bed on 2. see nursing transfer note in chart.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1353004,\n \"text\": \"ROS:\\n\\nNeuro: A+O x's 3. MAE x's 4. Postioned for comfort. PEARRLA\\n\\nCV: RSR w/o ectopy. Epicardial wires and pacer in place no pacing requirments. Peripheral pulses palpable. Has peripheral IV. Sternal drsg w/old serosang drng small amt.\\n\\nResp: Lungs clear and diminished in the bases. No resp distress noted, = rise and fall of chest. O2 3 L NP, sats 95% or >.\\n\\nGI: Taking diet and po fluids w/o c/o NV. Soft form stool.\\n\\nGU: Foley patent draining clear y ellow urine in QS.\\n\\nSocial: Friend this eveining.\\n\\nPlan: Await floor bed. Mobilize. Pulmonary toileting. Monitor, tx, support, and comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1353005,\n \"text\": \"CSRU NPN\\nNEURO: GROSSLY INTACT. PERCOCET FOR PAIN.\\n\\nCV: SR, NO ECTOPY. B/P STABLE. NO VASOACTIVE GTTS. NO CT.\\n\\nRESP: L/S CLEAR WITH DIM BASES. 3LNC. CONGESTED COUGH, OCCASIONALLY PRODUCTIVE WHITE SPUTUM.\\n\\nGI: TOLERATING CLEAR LIQUIDS W/O NAUSEA. + BS, NO BM.\\n\\nGU: AUTODIURESING, > 150CC/HR.\\n\\nENDO: CSRU SSRI.\\n\\nPLAN: TRANSFER TO 2. OOB > CHAIR. PAIN MANAGEMENT. PULMONARY HYGIENE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1352998,\n \"text\": \"vss, a paced for underlying sb 50's with decreased bp,great svo2,ci. waking thru high dose propofol even at rest with decreased svo2 into the 50's,high pip's,biting on ett,thrashing. midazolam given & precedex planned for extubation attempt. son reports prior difficult extubation with severe agitation after 1st cabg in req. sitters & physical restraint.cxr revealed rll collapse with decreased breath breath sounds rt > lt. recently(this month)quit smoking. by m.d. for little secretions but repeat cxr much improved. plan to initiate weaning soon.glucoses treated w protocol,see flow sheet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2148-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1352999,\n \"text\": \"Resp Care\\nPt intubated with 7.5 ETT 20 @lip on SIMV+ PS. pt post op for sm-mod amt of clear secretions. Plan at this time is to lighten sedation and wean to extuabe at tolerated while monitoring ABGs to maintain adequate oxygenation and ventilkation.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2148-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 81225,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Intraoperative TEE for left atrial myxoma resection\\nHeight: (in) 66\\nWeight (lb): 208\\nBSA (m2): 2.04 m2\\nBP (mm Hg): 134/78\\nHR (bpm): 86\\nStatus: Inpatient\\nDate/Time: at 09:37\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \\nLAA.\\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: Wall thickness and cavity dimensions were obtained from 2D\\nimages. Normal LV wall thicknesses and cavity size. Normal regional LV\\nsystolic function. Overall normal LVEF (>55%). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\\ndescending aorta diameter. Simple atheroma in descending aorta.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Mild (1+) 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: 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. No TEE related\\ncomplications. The patient was under general anesthesia throughout the\\nprocedure. The patient appears to be in sinus rhythm. Results were personally\\nreviewed with the MD caring for the patient.\\n\\nConclusions:\\nPrebypass\\n\\n1. No spontaneous echo contrast or thrombus is seen in the body of the left\\natrium or left atrial appendage. A patent foramen ovale is present which was\\ndemonstrated with bubble study using valsalva.\\n\\n2. Left ventricular wall thicknesses and cavity size are normal. Regional left\\nventricular wall motion is normal. Overall left ventricular systolic function\\nis normal (LVEF>55%).\\n\\n3. Right ventricular chamber size and free wall motion are normal.\\n\\n4. Left atrial myxoma seen with pedicle attached to the interatrial septum. It\\nmeasure 3.6 cms.\\n\\n5. There are simple atheroma in the descending thoracic aorta.\\n\\n6. The aortic valve leaflets (3) appear structurally normal with good leaflet\\nexcursion and no aortic regurgitation.\\n\\n7. The mitral valve leaflets are structurally normal. Mild (1+) mitral\\nregurgitation is seen.\\n\\n8. There is no pericardial effusion.\\n\\n\\nPost Bypass\\n\\n1. Biventricular systolic function is unchanged.\\n\\n2. Left atrial myxoma has been resected.\\n\\n3. Aorta intact post decannulation.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2148-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 200926,\n \"text\": \"Sinus bradycardia. Right ventricular conduction delay. Compared to the previous\\ntracing of no major change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2148-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 200927,\n \"text\": \"Sinus bradycardia\\nIncomplete RBBB\\nNo previous tracing available for comparison\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-07-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 921708,\n \"text\": \" 2:26 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval collapse, s/p bronch\\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\\\RE-DO STERNOTOMY, MYXOMA RESECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman scheduled for myxoma resection \\n\\n REASON FOR THIS EXAMINATION:\\n eval collapse, s/p bronch\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR THE STUDY: Evaluation for collapse and status post bronchoscopy in\\n a patient that is prescheduled for myxoma resection.\\n\\n TECHNIQUE: Chest portable PA view, and this study is compared to the previous\\n study done on same day three hours earlier.\\n\\n FINDINGS: There has been resolution of collapse of right upper lung with\\n complete aeration. The right internal jugular Swan-Ganz catheter has its tip\\n in right ventricle and needs to be advanced at least 5cm in order to be in\\n main pulmonary artery . Endotracheal tube is 3.7 cm above carina. NG tube\\n has its tip in the distal stomach. There are no pleural effusion or\\n pneumothoraxes. Heart size is borderline normal. There is resolution of\\n bilateral reticular opacities of the lung.\\n\\n IMPRESSION:\\n\\n 1. Reexpansion of collapse part of right upper lung.\\n\\n 2. Right internal jugular Swan-Ganz catheter in right ventricle and needs to\\n be advanced further.\\n\\n 3. Improving heart failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-07-03 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 921590,\n \"text\": \" 8:23 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: CORONARY ARTERY ARTHROSCLEROSIS\\\\RE-DO STERNOTOMY, MYXOMA RESECTION\\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\\\RE-DO STERNOTOMY, MYXOMA RESECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman scheduled for myxoma resection \\n REASON FOR THIS EXAMINATION:\\n pleural effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Preop for myxoma resection on .\\n\\n There are no prior studies for comparison.\\n\\n CHEST, TWO VIEWS: There are median sternotomy wires and mediastinal clips in\\n place. The overall cardiac size is normal. Mediastinal and hilar contours\\n are normal. No consolidation or vascular congestion within the lungs. No\\n pleural effusions or pneumothorax. There are mild degenerative changes of the\\n spine.\\n\\n IMPRESSION: No evidence of acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-07-08 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 922152,\n \"text\": \" 10:01 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval post op\\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\\\RE-DO STERNOTOMY, MYXOMA RESECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman s.p myxoma resection\\n REASON FOR THIS EXAMINATION:\\n eval post op\\n ______________________________________________________________________________\\n FINAL REPORT\\n TWO VIEW, CHEST X-RAY, \\n\\n COMPARISON: .\\n\\n INDICATION: Status post myxoma resection.\\n\\n Midline surgical staples overlie the sternotomy site. The heart size is\\n normal as well as the pulmonary vascularity. A small right pleural effusion\\n appears slightly larger, but the degree of right basilar atelectasis has\\n improved. The left lung is grossly clear, and there is no left pleural\\n effusion. A small focus of air is present in the retrosternal region, likely\\n postoperative.\\n\\n IMPRESSION: Slight increase and small right pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-07-04 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 921660,\n \"text\": \" 12:30 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: ptx, effusion\\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\\\RE-DO STERNOTOMY, MYXOMA RESECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with s/p Redo Sternotomy, Removal of Left Atrial Myxoma\\n REASON FOR THIS EXAMINATION:\\n ptx, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Immediate postoperative evaluation in a patient after\\n a removal of left atrial myxoma.\\n\\n Portable AP chest radiograph compared to the preoperative study from , .\\n\\n The ET tube tip is 4 cm above the carina. The Swan-Ganz tip is in the\\n pulmonary outflow tract. The NG tube is within the stomach. The mediastinal\\n drain tip is just above the right hemidiaphragm. There is complete\\n atelectasis of the right upper lobe, most probably due to muceous plugg. The\\n right lower lung is clear. There is perihilar haziness on the left with some\\n engorgement of the pulmonary vessels, which may represent a mild asymmetric\\n pulmonary edema. There is no pleural effusion or pneumothorax.\\n\\n IMPRESSION:\\n\\n 1. Right upper lobe atelectasis. These findings were discussed with Dr.\\n .\\n\\n 2. Standard position of tubes and lines.\\n\\n 3. Probable mild pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-07-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 921830,\n \"text\": \" 10:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o ptx s/p ct's removed\\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\\\RE-DO STERNOTOMY, MYXOMA RESECTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman scheduled for myxoma resection \\n\\n REASON FOR THIS EXAMINATION:\\n r/o ptx s/p ct's removed\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: AP chest 10:36 a.m. on .\\n\\n HISTORY: Myxoma resection. Chest tubes removed.\\n\\n IMPRESSION: AP chest compared to and 27:\\n\\n Lung volumes are lower since following extubation. Discrete\\n atelectasis is limited to the right lower lobe. Lungs otherwise clear. Small\\n bilateral pleural effusions unchanged. Cardiomediastinal silhouette has a\\n normal postoperative appearance and mediastinal vasculature is less engorged.\\n No pneumothorax.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":793,"cells":{"subject_id":{"kind":"number","value":17544,"string":"17,544"},"hadm_id":{"kind":"number","value":186843,"string":"186,843"},"target_text":{"kind":"string","value":"The patient was admitted to the ICU. Aspirin was held as per Stroke Team management as was heparin while the patient was in the ICU. A TEE was ordered to rule out emboli with head of the bed greater than 30 degrees and blood pressure control to keep the systolic blood pressure less than 185. Given the patient's history of medical problems, the patient has hypercholesterolemia, hypertension, and anxiety with a 40-80 pack year history of tobacco. The patient had high pretest probability for an ischemic event. Repeat MRI of the head was performed in the ICU with resumption of Coumadin after the patient was cleared for any bleed on repeat MRI of the head. The patient had a TEE negative for any thrombus. The transesophageal echocardiogram did show a small PFO with a left-to-right shunt. In addition, there were hypermobile atheromata in the aorta Cardiology was then consulted for a clam shell to close the patent foramen ovale. The patient also was very anxious during this admission and outpatient medications were continued with p.r.n. Ativan having to be written for episodes of anxiety. A Psychiatry consult was also obtained with the suggestion to workup anxiety and check up TSH which was normal before discharge. The patient was continued on Celexa and Klonopin after psychiatry consultation. The patient's physical examination and neurologic examination improved status post TPA administration and the patient had increased strength in the left upper extremity and lower extremity prior to discharge. The patent foramen ovale was found on transesophageal echocardiogram. Heparin IV was started. The patient could leave on therapeutic Coumadin INR. The patient was scheduled for TEE on Monday but the patient was frustrated that she was not being discharged sooner than her expectations and the patient refused the examinations and was noncompliant with the advice of the neurologic team. The patient then agreed to be discharged on Monday, with Coumadin follow-up for PFO and follow-up with Dr. in the Clinic on and follow-up with primary care physician for INR to keep between 2 and 2.5. An outpatient TEE was scheduled on . The patient was advised to consider Wellbutrin instead of Celexa to assist with smoking cessation to reduce risk factors for further stroke. The patient then had follow-up with Dr. of Cardiology for TEE on Thursday, . The patient also had follow-up with Dr. for PFO evaluation for which the patient was given the phone number. The patient then had follow-up with Dr. for Coumadin monitoring on Wednesday, , and finally follow-up with Dr. on Thursday, at 1:00 p.m. in the Clinic in office clinical center."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: 1) Normal bilateral venous studies of lower extremities without evidence of deep venous thrombosis. Physiologic mitral regurgitation is seen (withinnormal limits).TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:1. Regional left ventricular wall motion isnormal.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are mildly thickened. TECHNIQUE: Routine noncontrast head CT. FINDINGS: Duplex and color Doppler demonstrate normal carotid systems bilaterally. No significant changes are seen in the right MCA distribution, corresponding to the diffusion abnormality seen by recent MRI. Source of embolism.Height: (in) 65Weight (lb): 150BSA (m2): 1.75 m2BP (mm Hg): 158/79Status: InpatientDate/Time: at 11:19Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. MAE'S AND HAS STRONG GRASP NOTED, SLIGHT UNCORDINATION NOTED IN UPPER EXT'S. FINDINGS: The right common femoral vein, greater saphenous vein, superficial femoral vein, lesser saphenous vein and popliteal vein are normal in flow and compressibility with normal response to augmentation. bleed No contraindications for IV contrast FINAL REPORT INDICATION: Acute stroke, status post TPA. The mediastinal and hilar contours are normal. IMPRESSION: Resolution of previously seen areas of signal loss in the right middle cerebral artery possibly secondary to resolution of a thrombus. There are two small areas of low attenuation in the region of the right caudate head and thalamus, which could relate to prior lacunar infarcts. MRA OF THE HEAD: The head MRA demonstrates resolution of previously seen filling defect within the right middle cerebral artery. CONCLUSION: Right insular cortex and adjacent white matter acute infarction with stenosis or embolus at the right MCA bifurcation. IS A/A/O AND C/O FRONTAL HEADACHE AT A SCORE OF \"\" CT SCAN PERFORMED WITH NO BLEED EVIDENT. The area of restricted diffusion in the occipital region appears to be in the watershed distribution between the right middle cerebral and posterior cerebral arteries. Regional left ventricular wall motion is normal.2. FINDINGS BRAIN MRI: On diffusion weighted images again restricted diffusion is seen in the right insular cortex indicating acute right middle cerebral artery infarct. IVF OF NORMAL SALINE IS INFUSING AT 100CC/HR.SKIN: IS BENIGN IN ASSESSMENT, WITH NO BREAKDOWN NOTED. There is mildmitral annular calcification. No new significant abnormalities on the MRA of the head. The left common femoral vein, greater saphenous vein, superficial femoral vein, deep femoral vein, and popliteal veins are also normal in flow and compressibility with normal response to augmentation. Normal sinus rhythm. acute stroke vs bleed ? A patentforamen ovale is present.LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%). In addition, several new small areas of restricted diffusion are identified in the right posterior temporal parietal and occipital regions. The acute infarct involving the right MCA distribution seen by diffusion- weighted imaging on the recent MRI is not well visualized by CT. IMPRESSION: No significant abnormalities identified. stenosis FINAL REPORT HISTORY: Acute CVA. FINDINGS: There is no intra- or extra-axial hemorrhage. In addition, there is normal antegrade flow in both vertebral arteries. There is mild polypoid mucosal thickening of the visualized portion of the maxillary sinuses. These findings are compatible with a stenosis, or embolus, at the MCA bifurcation with severe reduction in flow in the superior division and a resulting insular infarction. Possible small infarct in the left cerebellar hemisphere. There is a focus of hyperintensity on the diffusion-weighted images in the anterior left cerebellar hemisphere. Normal tracing. The pulmonary vasculature is unremarkable. ASSESSMENT BENIGN.G.U: FOLEY CATHETER INPLACE WHILE DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE.I.V: PT. The right deep femoral vein also is normal in flow and compressibility. FINDINGS: The diffusion images demonstrate hyperintensity in the right insular cortex and right frontal and parietal white matter suggesting acute ischemia. The lungs are clear and there are no pleural effusions. No osseous abnormalities are identified. HAS BEEN NSR WITH RATE IN THE 60-70'S WITH NO NOTED ECTOPY. Hyperlipidemia question stroke of hemorrhage. PORTABLE CHEST: The heart size is normal. TECHNIQUE: T1 sagittal and axial, and FLAIR, T2, susceptibility and diffusion axial images of the brain were obtained. The above mentioned infarcts are in the distribution of the right middle cerebral artery. No abnormalities are detected in this region on the FLAIR images. A tiny PFO is seen (a few bubbles) with cough manuevers on contrastechocardiography. HAS EXHIBITED LOW GRADE TEMP. The MRA images demonstrate a filling defect at the MCA bifurcation with severe attenuation of the superior division of the MCA. Improved visualization of sylvian branches of right middle cerebral artery. Comparison was made with the previous MRI study of . BOTH LOWER EXT'S ARE STRONG, WITH PT. 3D time of flight MRA of the circle of was acquired. PATIENT/TEST INFORMATION:Indication: Cerebrovascular event/TIA. NEURO: PT. PULSES REMAIN STRONG.RESP: LUNGS ARE CLEAR THROUGHOUT AND O2 SATS ARE 100% on 2l/Min via nasal cannula.G.I: PT. Evaluate for hemorrhage. There is improved visualization of the sylvian branches of the right middle cerebral artery. ABLE TO LIFT AND HOLD LOWER EXTREMITIES, WITHOUT DIFFICULTIES. Again, this may represent a small focus of infarction, perhaps embolic. The visualized osseous structures are unremarkable. The mitral valve leaflets are mildly thickened.3."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2188-06-05 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":795200,"text":" 9:25 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: ACUTE SX OF LEFT FACIAL, SLURRED SPEECH AND LEFT HEMIPARESIS FACE ARM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with hyperlipidemia\n ? acute stroke vs bleed ? MCA clot\n REASON FOR THIS EXAMINATION:\n 59 y/o woman with pmh high cholesterol and anxiety now with acute sx of left\n facial, slurred speech and left hemiparesis face and arm > leg\n ACUTE STROKE PROTOCOL thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left facial weakness, slurred speech and left hemiparesis.\n Hyperlipidemia question stroke of hemorrhage.\n\n Diffusion imaging was performed through the brain. In addition, axial gradient\n echo images for susceptibility contrast and axial FLAIR imaging was performed.\n A three-dimensional time of flight arteriogram was performed. No prior studies\n are available for comparison.\n\n FINDINGS: The diffusion images demonstrate hyperintensity in the right insular\n cortex and right frontal and parietal white matter suggesting acute ischemia.\n No abnormalities are detected in this region on the FLAIR images. The MRA\n images demonstrate a filling defect at the MCA bifurcation with severe\n attenuation of the superior division of the MCA. These findings are compatible\n with a stenosis, or embolus, at the MCA bifurcation with severe reduction in\n flow in the superior division and a resulting insular infarction. There is no\n evidence of hemorrhage.\n\n There is a focus of hyperintensity on the diffusion-weighted images in the\n anterior left cerebellar hemisphere. Again, this may represent a small focus\n of infarction, perhaps embolic.\n\n CONCLUSION: Right insular cortex and adjacent white matter acute infarction\n with stenosis or embolus at the right MCA bifurcation. Possible small infarct\n in the left cerebellar hemisphere.\n\n"},{"category":"Radiology","chartdate":"2188-06-06 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":795211,"text":" 12:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MVA\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with acute stroke s/p tpa, right MCA ? bleed\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute stroke, status post TPA. Evaluate for hemorrhage.\n\n TECHNIQUE: Routine noncontrast head CT.\n\n COMPARISON: MRI from four hours earlier.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage. There is no mass\n effect or shift of the normally midline structures. There are two small areas\n of low attenuation in the region of the right caudate head and thalamus, which\n could relate to prior lacunar infarcts. No significant changes are seen in\n the right MCA distribution, corresponding to the diffusion abnormality seen by\n recent MRI. The ventricles, cisterns, and sulci are unremarkable, without\n effacement. There is mild polypoid mucosal thickening of the visualized\n portion of the maxillary sinuses. The visualized osseous structures are\n unremarkable.\n\n IMPRESSION:\n 1. No evidence for hemorrhage.\n 2. The acute infarct involving the right MCA distribution seen by diffusion-\n weighted imaging on the recent MRI is not well visualized by CT.\n\n\n"},{"category":"Radiology","chartdate":"2188-06-05 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":795205,"text":" 10:46 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pt w/ acute stroke\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n pt w/ acute stroke\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute stroke.\n\n PORTABLE CHEST: The heart size is normal. The mediastinal and hilar contours\n are normal. The lungs are clear and there are no pleural effusions. The\n pulmonary vasculature is unremarkable. No osseous abnormalities are\n identified.\n\n IMPRESSION: No significant abnormalities identified.\n\n\n"},{"category":"Radiology","chartdate":"2188-06-06 00:00:00.000","description":"CAROTID SERIES COMPLETE","row_id":795249,"text":" 9:58 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: ACUTE STROKE, S/P TPA\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with acute stroke s/p tpa\n REASON FOR THIS EXAMINATION:\n ? stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute CVA.\n\n FINDINGS: Duplex and color Doppler demonstrate normal carotid systems\n bilaterally. In addition, there is normal antegrade flow in both vertebral\n arteries.\n\n"},{"category":"Radiology","chartdate":"2188-06-09 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":795557,"text":" 2:30 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please evaluate for DVT.\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with R embolic CVA s/p tpa with patent PFO\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT.\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND OF THE BILATERAL LOWER EXTREMITIES:\n\n HISTORY: This is a 59 year old female with a right embolic cerebral vascular\n accident, s/p thrombolytic therapy.\n\n FINDINGS: The right common femoral vein, greater saphenous vein, superficial\n femoral vein, lesser saphenous vein and popliteal vein are normal in flow and\n compressibility with normal response to augmentation. The right deep femoral\n vein also is normal in flow and compressibility.\n\n The left common femoral vein, greater saphenous vein, superficial femoral\n vein, deep femoral vein, and popliteal veins are also normal in flow and\n compressibility with normal response to augmentation.\n\n IMPRESSION:\n 1) Normal bilateral venous studies of lower extremities without evidence of\n deep venous thrombosis.\n\n"},{"category":"Radiology","chartdate":"2188-06-06 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":795325,"text":" 9:25 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: please do mri head with perfusion and dwi to assess for any\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with right mca stroke had tpa administration\n REASON FOR THIS EXAMINATION:\n please do mri head with perfusion and dwi to assess for any bleed or new\n infarct\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with right MCA infarct status post TPA\n administration for assessment of bleed or new infarct.\n\n TECHNIQUE: T1 sagittal and axial, and FLAIR, T2, susceptibility and diffusion\n axial images of the brain were obtained. 3D time of flight MRA of the circle\n of was acquired. Comparison was made with the previous MRI study of\n .\n\n FINDINGS\n\n BRAIN MRI:\n\n On diffusion weighted images again restricted diffusion is seen in the right\n insular cortex indicating acute right middle cerebral artery infarct. In\n addition, several new small areas of restricted diffusion are identified in\n the right posterior temporal parietal and occipital regions. The area of\n restricted diffusion in the occipital region appears to be in the watershed\n distribution between the right middle cerebral and posterior cerebral\n arteries. No evidence of hemorrhage is seen in these areas or other parts of\n the brain. No evidence of mass effect midline shift or hydrocephalus is\n identified.\n\n IMPRESSION: Several new areas of acute infarct are now appreciated on the\n diffusion weighted images since the previous study of . No evidence of\n hemorrhage is seen. The above mentioned infarcts are in the distribution of\n the right middle cerebral artery.\n\n MRA OF THE HEAD:\n\n The head MRA demonstrates resolution of previously seen filling defect within\n the right middle cerebral artery. There is improved visualization of the\n sylvian branches of the right middle cerebral artery.\n\n IMPRESSION: Resolution of previously seen areas of signal loss in the right\n middle cerebral artery possibly secondary to resolution of a thrombus.\n Improved visualization of sylvian branches of right middle cerebral artery. No\n new significant abnormalities on the MRA of the head.\n (Over)\n\n 9:25 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: please do mri head with perfusion and dwi to assess for any\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Echo","chartdate":"2188-06-06 00:00:00.000","description":"Report","row_id":102513,"text":"PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Source of embolism.\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 158/79\nStatus: Inpatient\nDate/Time: at 11:19\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: Saline\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. A patent\nforamen ovale is present.\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.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Physiologic mitral regurgitation is seen (within\nnormal limits).\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The mitral valve leaflets are mildly thickened.\n3. A tiny PFO is seen (a few bubbles) with cough manuevers on contrast\nechocardiography.\n\n\n"},{"category":"ECG","chartdate":"2188-06-06 00:00:00.000","description":"Report","row_id":292756,"text":"Normal sinus rhythm. Normal tracing. No previous tracing available for\ncomparison.\n\n"},{"category":"Nursing/other","chartdate":"2188-06-06 00:00:00.000","description":"Report","row_id":1492185,"text":"NEURO: PT. IS A/A/O AND C/O FRONTAL HEADACHE AT A SCORE OF \"\" CT SCAN PERFORMED WITH NO BLEED EVIDENT. PT. MAE'S AND HAS STRONG GRASP NOTED, SLIGHT UNCORDINATION NOTED IN UPPER EXT'S. BOTH LOWER EXT'S ARE STRONG, WITH PT. ABLE TO LIFT AND HOLD LOWER EXTREMITIES, WITHOUT DIFFICULTIES. PT. HAS EXHIBITED LOW GRADE TEMP. WITH TMAX 100.4. PT. HAS NOT BEEN CULTURED AT THIS TIME.\n\nC.V: PT. HAS BEEN NSR WITH RATE IN THE 60-70'S WITH NO NOTED ECTOPY. SBP HAS BEEN 130-180'S WITH LABETOLOL GTT STARTED FOR SBP>180 AND THEN SHUT OFF AFTER 20 MINS DUE TO SBP DROPPING INTO THE 130'S. PULSES REMAIN STRONG.\n\nRESP: LUNGS ARE CLEAR THROUGHOUT AND O2 SATS ARE 100% on 2l/Min via nasal cannula.\n\nG.I: PT. REMAINS NPO, WITH ABD. ASSESSMENT BENIGN.\n\nG.U: FOLEY CATHETER INPLACE WHILE DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE.\n\nI.V: PT. HAS BILAT #18'S IN LEFT WRIST AND RIGHT AC. IVF OF NORMAL SALINE IS INFUSING AT 100CC/HR.\n\nSKIN: IS BENIGN IN ASSESSMENT, WITH NO BREAKDOWN NOTED.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-06-05 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 795200,\n \"text\": \" 9:25 PM\\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \\n Reason: ACUTE SX OF LEFT FACIAL, SLURRED SPEECH AND LEFT HEMIPARESIS FACE ARM\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with hyperlipidemia\\n ? acute stroke vs bleed ? MCA clot\\n REASON FOR THIS EXAMINATION:\\n 59 y/o woman with pmh high cholesterol and anxiety now with acute sx of left\\n facial, slurred speech and left hemiparesis face and arm > leg\\n ACUTE STROKE PROTOCOL thanks\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Left facial weakness, slurred speech and left hemiparesis.\\n Hyperlipidemia question stroke of hemorrhage.\\n\\n Diffusion imaging was performed through the brain. In addition, axial gradient\\n echo images for susceptibility contrast and axial FLAIR imaging was performed.\\n A three-dimensional time of flight arteriogram was performed. No prior studies\\n are available for comparison.\\n\\n FINDINGS: The diffusion images demonstrate hyperintensity in the right insular\\n cortex and right frontal and parietal white matter suggesting acute ischemia.\\n No abnormalities are detected in this region on the FLAIR images. The MRA\\n images demonstrate a filling defect at the MCA bifurcation with severe\\n attenuation of the superior division of the MCA. These findings are compatible\\n with a stenosis, or embolus, at the MCA bifurcation with severe reduction in\\n flow in the superior division and a resulting insular infarction. There is no\\n evidence of hemorrhage.\\n\\n There is a focus of hyperintensity on the diffusion-weighted images in the\\n anterior left cerebellar hemisphere. Again, this may represent a small focus\\n of infarction, perhaps embolic.\\n\\n CONCLUSION: Right insular cortex and adjacent white matter acute infarction\\n with stenosis or embolus at the right MCA bifurcation. Possible small infarct\\n in the left cerebellar hemisphere.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-06-06 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 795211,\n \"text\": \" 12:24 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: MVA\\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with acute stroke s/p tpa, right MCA ? bleed\\n REASON FOR THIS EXAMINATION:\\n ? bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Acute stroke, status post TPA. Evaluate for hemorrhage.\\n\\n TECHNIQUE: Routine noncontrast head CT.\\n\\n COMPARISON: MRI from four hours earlier.\\n\\n FINDINGS: There is no intra- or extra-axial hemorrhage. There is no mass\\n effect or shift of the normally midline structures. There are two small areas\\n of low attenuation in the region of the right caudate head and thalamus, which\\n could relate to prior lacunar infarcts. No significant changes are seen in\\n the right MCA distribution, corresponding to the diffusion abnormality seen by\\n recent MRI. The ventricles, cisterns, and sulci are unremarkable, without\\n effacement. There is mild polypoid mucosal thickening of the visualized\\n portion of the maxillary sinuses. The visualized osseous structures are\\n unremarkable.\\n\\n IMPRESSION:\\n 1. No evidence for hemorrhage.\\n 2. The acute infarct involving the right MCA distribution seen by diffusion-\\n weighted imaging on the recent MRI is not well visualized by CT.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-06-05 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 795205,\n \"text\": \" 10:46 PM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: pt w/ acute stroke\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with\\n REASON FOR THIS EXAMINATION:\\n pt w/ acute stroke\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Acute stroke.\\n\\n PORTABLE CHEST: The heart size is normal. The mediastinal and hilar contours\\n are normal. The lungs are clear and there are no pleural effusions. The\\n pulmonary vasculature is unremarkable. No osseous abnormalities are\\n identified.\\n\\n IMPRESSION: No significant abnormalities identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-06-06 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 795249,\n \"text\": \" 9:58 AM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: ACUTE STROKE, S/P TPA\\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with acute stroke s/p tpa\\n REASON FOR THIS EXAMINATION:\\n ? stenosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Acute CVA.\\n\\n FINDINGS: Duplex and color Doppler demonstrate normal carotid systems\\n bilaterally. In addition, there is normal antegrade flow in both vertebral\\n arteries.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-06-09 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 795557,\n \"text\": \" 2:30 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: Please evaluate for DVT.\\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with R embolic CVA s/p tpa with patent PFO\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for DVT.\\n ______________________________________________________________________________\\n FINAL REPORT\\n ULTRASOUND OF THE BILATERAL LOWER EXTREMITIES:\\n\\n HISTORY: This is a 59 year old female with a right embolic cerebral vascular\\n accident, s/p thrombolytic therapy.\\n\\n FINDINGS: The right common femoral vein, greater saphenous vein, superficial\\n femoral vein, lesser saphenous vein and popliteal vein are normal in flow and\\n compressibility with normal response to augmentation. The right deep femoral\\n vein also is normal in flow and compressibility.\\n\\n The left common femoral vein, greater saphenous vein, superficial femoral\\n vein, deep femoral vein, and popliteal veins are also normal in flow and\\n compressibility with normal response to augmentation.\\n\\n IMPRESSION:\\n 1) Normal bilateral venous studies of lower extremities without evidence of\\n deep venous thrombosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2188-06-06 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 795325,\n \"text\": \" 9:25 PM\\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \\n Reason: please do mri head with perfusion and dwi to assess for any\\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\\n Contrast: MAGNEVIST Amt: 20CC\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 59 year old woman with right mca stroke had tpa administration\\n REASON FOR THIS EXAMINATION:\\n please do mri head with perfusion and dwi to assess for any bleed or new\\n infarct\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: Patient with right MCA infarct status post TPA\\n administration for assessment of bleed or new infarct.\\n\\n TECHNIQUE: T1 sagittal and axial, and FLAIR, T2, susceptibility and diffusion\\n axial images of the brain were obtained. 3D time of flight MRA of the circle\\n of was acquired. Comparison was made with the previous MRI study of\\n .\\n\\n FINDINGS\\n\\n BRAIN MRI:\\n\\n On diffusion weighted images again restricted diffusion is seen in the right\\n insular cortex indicating acute right middle cerebral artery infarct. In\\n addition, several new small areas of restricted diffusion are identified in\\n the right posterior temporal parietal and occipital regions. The area of\\n restricted diffusion in the occipital region appears to be in the watershed\\n distribution between the right middle cerebral and posterior cerebral\\n arteries. No evidence of hemorrhage is seen in these areas or other parts of\\n the brain. No evidence of mass effect midline shift or hydrocephalus is\\n identified.\\n\\n IMPRESSION: Several new areas of acute infarct are now appreciated on the\\n diffusion weighted images since the previous study of . No evidence of\\n hemorrhage is seen. The above mentioned infarcts are in the distribution of\\n the right middle cerebral artery.\\n\\n MRA OF THE HEAD:\\n\\n The head MRA demonstrates resolution of previously seen filling defect within\\n the right middle cerebral artery. There is improved visualization of the\\n sylvian branches of the right middle cerebral artery.\\n\\n IMPRESSION: Resolution of previously seen areas of signal loss in the right\\n middle cerebral artery possibly secondary to resolution of a thrombus.\\n Improved visualization of sylvian branches of right middle cerebral artery. No\\n new significant abnormalities on the MRA of the head.\\n (Over)\\n\\n 9:25 PM\\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \\n Reason: please do mri head with perfusion and dwi to assess for any\\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\\n Contrast: MAGNEVIST Amt: 20CC\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2188-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 102513,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Cerebrovascular event/TIA. Source of embolism.\\nHeight: (in) 65\\nWeight (lb): 150\\nBSA (m2): 1.75 m2\\nBP (mm Hg): 158/79\\nStatus: Inpatient\\nDate/Time: at 11:19\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: Saline\\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. A patent\\nforamen ovale is present.\\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.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\\ngood leaflet excursion and no aortic regurgitation.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\\nmitral annular calcification. Physiologic mitral regurgitation is seen (within\\nnormal limits).\\n\\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\\ntricuspid regurgitation.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\\nstructurally normal with physiologic pulmonic regurgitation.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\n1. Left ventricular wall thickness, cavity size, and systolic function are\\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\\n2. The mitral valve leaflets are mildly thickened.\\n3. A tiny PFO is seen (a few bubbles) with cough manuevers on contrast\\nechocardiography.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2188-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 292756,\n \"text\": \"Normal sinus rhythm. Normal tracing. No previous tracing available for\\ncomparison.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2188-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1492185,\n \"text\": \"NEURO: PT. IS A/A/O AND C/O FRONTAL HEADACHE AT A SCORE OF \\\"\\\" CT SCAN PERFORMED WITH NO BLEED EVIDENT. PT. MAE'S AND HAS STRONG GRASP NOTED, SLIGHT UNCORDINATION NOTED IN UPPER EXT'S. BOTH LOWER EXT'S ARE STRONG, WITH PT. ABLE TO LIFT AND HOLD LOWER EXTREMITIES, WITHOUT DIFFICULTIES. PT. HAS EXHIBITED LOW GRADE TEMP. WITH TMAX 100.4. PT. HAS NOT BEEN CULTURED AT THIS TIME.\\n\\nC.V: PT. HAS BEEN NSR WITH RATE IN THE 60-70'S WITH NO NOTED ECTOPY. SBP HAS BEEN 130-180'S WITH LABETOLOL GTT STARTED FOR SBP>180 AND THEN SHUT OFF AFTER 20 MINS DUE TO SBP DROPPING INTO THE 130'S. PULSES REMAIN STRONG.\\n\\nRESP: LUNGS ARE CLEAR THROUGHOUT AND O2 SATS ARE 100% on 2l/Min via nasal cannula.\\n\\nG.I: PT. REMAINS NPO, WITH ABD. ASSESSMENT BENIGN.\\n\\nG.U: FOLEY CATHETER INPLACE WHILE DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE.\\n\\nI.V: PT. HAS BILAT #18'S IN LEFT WRIST AND RIGHT AC. IVF OF NORMAL SALINE IS INFUSING AT 100CC/HR.\\n\\nSKIN: IS BENIGN IN ASSESSMENT, WITH NO BREAKDOWN NOTED.\\n\"\n }\n]"}}},{"rowIdx":794,"cells":{"subject_id":{"kind":"number","value":48391,"string":"48,391"},"hadm_id":{"kind":"number","value":128847,"string":"128,847"},"target_text":{"kind":"string","value":"80yo F presented to on w/ n/v, ataxia, and disorientation several days following a suspected MI. She collapsed and was found to be in shock. After reperfusing an occluded circumflex in cathlab she remained in cardiogenic shock. A TEE revealed a left ventricular free wall rupture. In Cardiothoracic OR she underwent clot evacuation without any identifiable bleeding source, surmising a contained rupture. She was post-operatively managed on CCU for the following problems: #Delayed presentation of posterior wall STEMI: The patient had endorsed several days of pain radiation to the jaw. She initally presented to an OSH where she was found to be in cardiogenic shock. She was intubated and placed on pressors and transfered to where she was taken to the cardiac cath lab where she was found to have a fully occuled LCx artery and a free wall rupture of the LV. She was taken to the OR by CT surgery who performed an emergent mediastinal re-exploration and drainage of pericardial effusion. They discovered a clot that tampanaded the free wall rupture. She was taken to the ICU following surgery where the patient SBPs were initially in the 80s and continued to require pressor support. She had an IABP that had been placed at time of cardiac cath and she was maintained on pressor support and IABP. She developed shock liver and her renal function deteriorated. Her cardiac output initially worsened but were stabilized with the addition of inotropic support. In this setting she was able to be weaned off the IABP. Following the removal she became hypertensive and became less reactive to stimuli. There was growing concern for a septic component to shock as WBC count bumped and temp persisted. Sputum culture notable for gram neg rods and WBC increased to 19 so pt started on renally dosed cefepime and vancomycin. On after a family meeting and in keeping with the patients wishes and given the clinical status of the patient the decision was made to make her CMO. She was extubated and given fentanyl and morphine. The family was present and the patient passed peacefully on . # Ventricular Rupture. Good hemostasis achieved in OR, w/CT placement then removed . Repeat echo confirmed effusion-free and good hemostasis. Clopidogrel held due to rebleeding risk. CXR showed vascular congestion. Patient diuresed furosemide and metolazone. After several liters removed, diuretics were scaled back with target net negative .5L daily. A repeat echo on showed continued hemostasis with no new effusion. There was no observed pulsus paradoxis. He recovery was complicated by the above issues issues."},"extractive_notes_summ":{"kind":"string","value":"There is left atrial diastolic collapse.Drs. Normalascending aorta diameter. There is evidence of a lateral free wallrupture and contained hematoma.4. There is mildregional left ventricular systolic dysfunction with severe hypokinesis of thebasal inferolateral wall. Regional left ventricular systolicdysfunction c/w CAD. Left ventricularhypertrophy. No PS.Physiologic PR.PERICARDIUM: Moderate pericardial effusion. Shortness of breath.Status: InpatientDate/Time: at 17:17Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: LA not well visualized. Mildlydepressed LVEF.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque. There is mild regional left ventricularsystolic dysfunction with severe hypo/akinesis of the basal inferolateral wallwith a discontuity and the basal wall at the annulus level with apparentcommunication with the pericardial space. There is moderate symmetric left ventricular hypertrophy. The Swan-Ganz catheter inserted through the right internal jugular approach terminates at the level of the low right ventricle. Mild regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferolateral - akinetic; mid inferolateral - hypo;PERICARDIUM: Moderate pericardial effusion. Normal aortic arch diameter. Normal aortic diameter at the sinus level. There is mild symmetric left ventricularhypertrophy with normal cavity size. Right precordial ST segment depression. An ET tube is present, grossly unchanged in position, with its tip at the lower level of the clavicular heads. Aortic contour is normal postdecannulation. Suboptimal image quality.Conclusions:The posterior and lateral walls of the left ventricle are akinetic. Compared to the previous tracing of atrial ectopy hasappeared. There is ST segment elevation inleads I and aVL and ST segment depression in leads V1-V4 consistent withanterolateral ischemia, rule out infarction. Left atrial abnormality. Left atrial abnormality. Right thoracostomy and mediastinal drains. A right IJ sheath is present, tip overlying the lower IJ proximal to the SVC, at the level of the thoracic inlet. No AS.PERICARDIUM: Moderate pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. There is unchanged evidence of bilateral pleural fluid collections and relatively extensive retrocardiac atelectasis. Suboptimal image quality - poor echo windows.Conclusions:Left ventricular wall thicknesses and cavity size are normal. Reduced size of pericardial effusionwith significant compression of left atrium. Right ventricular function. Intubated.Height: (in) 64Weight (lb): 170BSA (m2): 1.83 m2BP (mm Hg): 130/60HR (bpm): 91Status: InpatientDate/Time: at 13:35Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Left ventricular function. There is a moderate sized circumferentialpericardial effusion. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The Swan-Ganz catheter is terminating in the proximal right ventricular outflow tract. FINDINGS: Compared to the previous radiograph, there is a newly appeared mild to moderate right pleural effusion and an increasing left pleural effusion. Endotracheal tube seats 2.5 cm above the carina and appears unchanged, however, the cuff appears to be overinflated. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. Left pleural effusion and left lower lung consolidation is noted. Stable pulmonary vascular congestion and pleural effusions. There is a moderate sized pericardial effusion. FINDINGS: In comparison with the earlier study of this date, the endotracheal tube has been removed. The mediastinal drains and the right chest tube has been removed. S-G terminating at the proximal right ventricular outflow tract. Mild regional LVsystolic dysfunction. Small left pleural effusion. These findings arenew as compared to the previous tracing of and are consistent withactive posterolateral ischemic process, rule out myocardial infarction. Emergency study.Conclusions:The left atrium is normal in size. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Moderate symmetric LVH. The possibility of a small right apical pneumothorax cannot be excluded. Mild regional LVsystolic dysfunction.RIGHT VENTRICLE: RV not well seen. Frequent atrial ectopy. However, dilated vascular structures suggest the presence of mild to moderate pulmonary edema. Resting tachycardia (HR>100bpm). Tamponade.Height: (in) 64Weight (lb): 170BSA (m2): 1.83 m2BP (mm Hg): 212/59HR (bpm): 104Status: InpatientDate/Time: at 14:43Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. ST segment depressions in leads V3-V6 which are worrisome formyocardial ischemia. The ET tube tip is grossly unchanged at the level of lower clavicular heads. Suboptimalimage quality - ventilator. PATIENT/TEST INFORMATION:Indication: s/p clot removal, lv ruptureHeight: (in) 64Weight (lb): 151BSA (m2): 1.74 m2BP (mm Hg): 105/38HR (bpm): 95Status: InpatientDate/Time: at 15:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: LV pseudoaneursym.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferolateral - akinetic; mid inferolateral - akinetic; basal anterolateral -akinetic; mid anterolateral - akinetic;MITRAL VALVE: MR present but cannot be quantified.GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads orelectrodes. A right IJ sheath is present, tip overlying lower IJ above the level of the clavicle. No RVdiastolic collapse.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. There is obscuration of the right inferior lung likely reflecting combination of pleural fluid and underlying collapse and/or consolidation. Probable small left effusion. The effusion appearsloculated. PATIENT/TEST INFORMATION:Indication: s/p ventricular rumpture. No definite extravasation of blood is identified.IMPRESSION: Suboptimal image quality. REASON FOR THIS EXAMINATION: Please assess for any consolidation, pnumothorax, pleural effusions. Normal RV chamber size.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets. Pericardial effusion.Height: (in) 65Weight (lb): 151BSA (m2): 1.76 m2BP (mm Hg): 153/70HR (bpm): 84Status: InpatientDate/Time: at 15:01Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: OptisonTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Normal LV wall thickness and cavity size."},"n_notes":{"kind":"number","value":19,"string":"19"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2134-08-17 00:00:00.000","description":"Report","row_id":70571,"text":"PATIENT/TEST INFORMATION:\nIndication: s/p clot removal, lv rupture\nHeight: (in) 64\nWeight (lb): 151\nBSA (m2): 1.74 m2\nBP (mm Hg): 105/38\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 15:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: LV pseudoaneursym.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - akinetic; mid inferolateral - akinetic; basal anterolateral -\nakinetic; mid anterolateral - akinetic;\n\nMITRAL VALVE: MR present but cannot be quantified.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality as the patient was difficult to position.\nSuboptimal image quality - ventilator. Suboptimal image quality.\n\nConclusions:\nThe posterior and lateral walls of the left ventricle are akinetic. Findings\nare suggestive of a pseudoaneurysm at the basal posterolateral wall. Mitral\nregurgitation is present but cannot be quantified. The overall left\nventricular ejection fraction is relatively well-preserved despite the\nposterior and lateral akinesis.\n\n\n"},{"category":"Echo","chartdate":"2134-08-16 00:00:00.000","description":"Report","row_id":70647,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. S/p Arrest. Intubated.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 130/60\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 13:35\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction.\n\nRIGHT VENTRICLE: RV not well seen. Normal RV chamber size.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.\n\nPERICARDIUM: Moderate pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Emergency study.\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 severe hypo/akinesis of the basal inferolateral wall\nwith a discontuity and the basal wall at the annulus level with apparent\ncommunication with the pericardial space. Color flow Doppler is inadequate to\ndefine flow. The remaining segments contract normally (LVEF = 45-50 %). Right\nventricular chamber size is normal. The free wall is not well seen. The aortic\nvalve leaflets are mildly thickened (?#). There is no aortic valve stenosis.\nThere is a moderate sized circumferential pericardial effusion. Tamponade\ncould not be assessed.\n\n\n"},{"category":"Echo","chartdate":"2134-08-20 00:00:00.000","description":"Report","row_id":70561,"text":"PATIENT/TEST INFORMATION:\nIndication: s/p ventricular rumpture. Pericardial effusion.\nHeight: (in) 65\nWeight (lb): 151\nBSA (m2): 1.76 m2\nBP (mm Hg): 153/70\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 15:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Optison\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. Mild-moderate regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - hypo; mid inferolateral - hypo;\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Suboptimal image quality - poor echo windows.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with severe hypokinesis of the\nbasal inferolateral wall. The remaining segments contract normally (LVEF >50\n%). The mitral valve leaflets are not well seen. There is no definite\npericardial effusion. No definite extravasation of blood is identified.\n\nIMPRESSION: Suboptimal image quality. Regional left ventricular systolic\ndysfunction c/w CAD. No definite pericardial effusion identified.\n\n\n"},{"category":"Echo","chartdate":"2134-08-16 00:00:00.000","description":"Report","row_id":70612,"text":"PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Tamponade.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 212/59\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 14:43\nTest: TTE (Focused views)\nDoppler: Limited 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 VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - akinetic; mid inferolateral - hypo;\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No RV\ndiastolic collapse.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator. Resting tachycardia (HR>100bpm). Emergency study\nperformed by the cardiology fellow on call. Results were personally reviewed\nwith the MD caring for the patient.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is mild regional left ventricular systolic dysfunction with akinesis of\nthe basal inferolateral wall. There appears to be a rupture of the basal\ninferolateral wall immediately apical to the mitral annulus with color flow\nDoppler through this area in to the pericardial space. The remaining segments\ncontract normally (LVEF = 55 %). There is a moderate sized circumferential\npericardial effusion. No right ventricular diastolic collapse is seen.\n\nCompared with the prior study (images reviewed) of earlier in the day of\n, the pericardial effusion is slightly larger and flow from the left\nventricle into the pericardial space is now more clearly defined.\n\n\n"},{"category":"Echo","chartdate":"2134-08-16 00:00:00.000","description":"Report","row_id":70572,"text":"PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. Left ventricular function. Pericardial effusion. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 17:17\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: LA not well visualized. No spontaneous echo contrast is seen in\nthe LAA. No thrombus in the LAA. All four pulmonary veins not identified.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mildly\ndepressed LVEF.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal aortic diameter at the sinus level. Normal\nascending aorta diameter. Normal aortic arch diameter. Normal descending aorta\ndiameter.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion is loculated. \n collapse.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The patient received antibiotic\nprophylaxis. The TEE probe was passed with assistance from the anesthesioology\nstaff using a laryngoscope. No TEE related complications. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-CPB:The patient was brought to the operating room on IABP with infusions\nof norepinephrine and dopamine.\n1. No spontaneous echo contrast is seen in the left atrial appendage. No\nthrombus is seen in the left atrial appendage.\n2. No atrial septal defect is seen by 2D or color Doppler.\n3. There is moderate symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed (LVEF= 50 %). There is evidence of a lateral free wall\nrupture and contained hematoma.\n4. Right ventricular chamber size and free wall motion are normal.\n5. The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque. The IABP is in good positoipn 3\ncm below the LSCA.\n6. There are three aortic valve leaflets. There is no aortic valve stenosis.\nNo aortic regurgitation is seen.\n7. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral doppler evidence for mitral stenosis.\n8. There is a moderate sized pericardial effusion. The effusion appears\nloculated. There is left atrial diastolic collapse.\nDrs. and notified in person of the results.\n\nPOST CPB: On infusion of epinephrine. Reduced size of pericardial effusion\nwith significant compression of left atrium. The lateral free wall has a\nsmaller rupture than pre bypass. LVEF = 60%. Aortic contour is normal post\ndecannulation.\n\n\n"},{"category":"Echo","chartdate":"2134-08-16 00:00:00.000","description":"Report","row_id":70573,"text":"PATIENT/TEST INFORMATION:\nIndication: s/p myocardial infarction with concern for ventricular wall rupture. Pericardial effusion.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 212/59\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 14:55\nTest: Portable TEE (Unsuccessful Placement) (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nSedation per cath lab team. Unsuccessful TEE as unable to pass probe past the\nposterior pharynx.\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). The patient was under general anesthesia throughout the procedure.\nUnsuccessful esophageal intubation.\n\nConclusions:\nThe TEE probe could not be passed into the esophagus due to resistance in the\nposterior pharynx.\n\n\n"},{"category":"Radiology","chartdate":"2134-08-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1249291,"text":" 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for intrathoracic pathology and line placement\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with LV rupture now with IABP\n REASON FOR THIS EXAMINATION:\n Please eval for intrathoracic pathology and line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Left ventricular rupture, evaluation for placement of monitoring\n devices.\n\n COMPARISON: , 7:19 p.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Extensive bilateral parenchymal opacities with pleural effusions and\n moderate cardiomegaly are constant. The monitoring and support devices,\n including the aortic balloon pump and Swan-Ganz catheter, are in virtually\n unchanged position. There is no evidence of pneumothorax or other new\n complication. The sternal wires show unchanged alignment.\n\n\n"},{"category":"Radiology","chartdate":"2134-08-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1249200,"text":" 9:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with S/P tamponade evac\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Tamponade, evaluation for pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is little overall\n change. The mediastinal drains and the right chest tube has been removed.\n There is unchanged evidence of bilateral pleural fluid collections and\n relatively extensive retrocardiac atelectasis. The position of the\n intraaortic balloon pump is constant. No newly appeared parenchymal\n opacities. No convincing evidence for pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2134-08-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1249263,"text":" 7:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate line placement\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with ventricular rupture, s/p sterotomy and evacuation\n REASON FOR THIS EXAMINATION:\n please evaluate line placement\n ______________________________________________________________________________\n WET READ: LLTc WED 9:02 PM\n ET tube 3.9 cm above the carina. S-G terminating at the proximal right\n ventricular outflow tract. OG tube within the stomach. Intraaortic balloon\n pump remains appropriately positioned.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Ventricular rupture, status post sternotomy, evaluation of line\n placement.\n\n COMPARISON: , 9:59 a.m.\n\n FINDINGS: The tip of the endotracheal tube projects 3.9 cm above the carina.\n The Swan-Ganz catheter is terminating in the proximal right ventricular\n outflow tract. The nasogastric tube is within the stomach. The intra-aortic\n balloon pump remains approximately positioned at a distance of 6 cm from the\n top of the aortic arch. The appearance of the lung parenchyma and of the\n heart show no substantial change. No evidence of pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2134-08-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1249052,"text":" 9:07 PM\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \n -76 BY SAME PHYSICIAN; CHEST (PORTABLE AP)\n -76 BY SAME PHYSICIAN\n : check swan placement\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with `MI\n REASON FOR THIS EXAMINATION:\n check swan placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with Swan-Ganz placement,\n assessment for position.\n\n AP radiograph of the chest\n\n As compared to prior study obtained the same day earlier, the Swan-Ganz\n catheter has been slightly advanced with its tip currently at the level of the\n upper portion of the right ventricle close to the right ventricle outflow\n tract. The intra-aortic balloon pump remains low. No other changes have been\n demonstrated except for minimal interval development of interstitial pulmonary\n edema.\n\n"},{"category":"Radiology","chartdate":"2134-08-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1249181,"text":" 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm edema\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with s/p tamponade evac/myocardial rupture\n REASON FOR THIS EXAMINATION:\n pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post tamponade, myocardial rupture, evaluation for\n pulmonary edema.\n\n COMPARISON: .\n\n FINDINGS: Compared to the previous radiograph, there is a newly appeared mild\n to moderate right pleural effusion and an increasing left pleural effusion.\n The appearance of the cardiac silhouette is unchanged. However, dilated\n vascular structures suggest the presence of mild to moderate pulmonary edema.\n The position of the tubes and lines is constant. Unchanged alignment of the\n sternal wires.\n\n\n"},{"category":"Radiology","chartdate":"2134-08-16 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1249043,"text":" 7:48 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p Repair of RV Rupture\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n WET READ: LLTc MON 8:53 PM\n Right IJ catheter terminating within the right ventricle. ET tube 3.4 cm above\n the carina. OG tube extending to at least the stomach. Right thoracostomy and\n mediastinal drains. No pneumothorax. Left basilar opacity may reflect severe\n atelectasis. Small left pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after repair of the right\n ventricular rupture.\n\n AP radiograph of the chest was reviewed in comparison to .\n\n The ET tube tip is approximately 4.3 cm above the carina. The intra-aortic\n balloon pump is very low, at least 8 cm below the roof of the aortic arch.\n Mediastinal drains are in place. The Swan-Ganz catheter inserted through the\n right internal jugular approach terminates at the level of the low right\n ventricle. Right chest tube is in place. Mediastinal drains are in place.\n Heart size and mediastinum are grossly stable. Left pleural effusion and left\n lower lung consolidation is noted.\n\n\n"},{"category":"ECG","chartdate":"2134-08-22 00:00:00.000","description":"Report","row_id":161611,"text":"Atrial fibrillation with rapid ventricular response. Left ventricular\nhypertrophy. ST segment depressions in leads V3-V6 which are worrisome for\nmyocardial ischemia. The atrial fibrillation is new compared to the previous\ntracing of , as are the ST segment abnormalities. Clinical correlation\nis highly suggested.\n\n\n"},{"category":"ECG","chartdate":"2134-08-18 00:00:00.000","description":"Report","row_id":161612,"text":"Sinus rhythm. Left atrial abnormality. Frequent atrial ectopy. Low limb lead\nvoltage. Compared to the previous tracing of atrial ectopy has\nappeared. The A-V interval has decreased. There is ST segment elevation in\nleads I and aVL and ST segment depression in leads V1-V4 consistent with\nanterolateral ischemia, rule out infarction. Followup and clinical correlation\nare suggested.\n\n"},{"category":"ECG","chartdate":"2134-08-16 00:00:00.000","description":"Report","row_id":161613,"text":"Sinus rhythm. Left atrial abnormality. A-V conduction delay. Diminished\nvoltage as compared to the previous tracing of and increase in rate.\nThere is ST segment elevation in leads I and aVL with biphasic T waves in\nleads I and aVL. Right precordial ST segment depression. These findings are\nnew as compared to the previous tracing of and are consistent with\nactive posterolateral ischemic process, rule out myocardial infarction. There\nis Q-T interval prolongation. Clinical correlation is suggested.\n\n"},{"category":"Radiology","chartdate":"2134-08-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1249579,"text":" 12:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for edema/effusion or infectious process\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with STEMI c/b ventricular rupture and \n REASON FOR THIS EXAMINATION:\n Please eval for edema/effusion or infectious process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: STEMI, complicated by ventricular rupture and .\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n An ET tube is present, tip approximately 5.9 cm above the carina. NG tube is\n present, tip extends beneath the diaphragm, off the film. A right IJ sheath\n is present, tip overlying lower IJ above the level of the clavicle.\n\n The patient is status post sternotomy, with a prominent cardiomediastinal\n silhouette. There is upper zone redistribution and diffuse vascular blurring,\n asymmetrically more pronounced on the right. There is obscuration of the\n right inferior lung likely reflecting combination of pleural fluid and\n underlying collapse and/or consolidation. There is increased retrocardiac\n density, consistent with left lower lobe collapse and/or consolidation, likely\n with a small amount of pleural fluid. Some subcutaneous emphysema is noted\n over the right greater than left chest. The possibility of a small right\n apical pneumothorax cannot be excluded. Linear lucency traversing the right\n posterior third rib may represent artifact due to subcutaneous emphysema, but\n the differential diagnosis would include a non-displaced rib fracture.\n\n Compared with at 8:27 a.m., lung findings are similar. Right apical\n pneumothorax and possible right posterior third rib fracture, if real, are\n new.\n\n Findings discussed with Dr. at ~11:23 am on .\n\n"},{"category":"Radiology","chartdate":"2134-08-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1249528,"text":" 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: position of tubes and lines\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with MI, intubated and sedated\n REASON FOR THIS EXAMINATION:\n position of tubes and lines\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MI, intubated, check tubes and lines.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n An ET tube is present, grossly unchanged in position, with its tip at the\n lower level of the clavicular heads. The crania itself is not well\n demonstrated. An NG tube is present, tip extending beneath diaphragm off film.\n A right IJ sheath is present, tip overlying the lower IJ proximal to the SVC,\n at the level of the thoracic inlet. The ET tube tip is grossly unchanged at\n the level of lower clavicular heads.\n\n The patient is status post sternotomy. The cardiomediastinal silhouette is\n prominent, but unchanged. There is upper zone redistribution and diffuse\n vascular blurring, with patchy alveolar opacities, consistent with CHF and\n pulmonary edema. There is increased retrocardiac density, consistent with\n left lower lobe collapse and/or consolidation. Probable small left effusion.\n Likely also right effusion, with underlying collapse and/or consolidation.\n\n Overall, the appearance is similar to at 16:39 p.m. CHF\n findings may be very slightly worse.\n\n"},{"category":"Radiology","chartdate":"2134-08-20 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":1249465,"text":" 4:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess for any consolidation, pnumothorax, pleural ef\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock. Currently on ventilation with high\n o2 requirement.\n REASON FOR THIS EXAMINATION:\n Please assess for any consolidation, pnumothorax, pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiogenic shock.\n\n FINDINGS: In comparison with the earlier study of this date, the endotracheal\n tube has been removed. The Swan-Ganz catheter has been removed and replaced\n with a jugular shunt. Nasogastric tube remains in place. IABP has been\n removed.\n\n There are still hazy opacifications bilaterally, more prominent on the right,\n consistent with bilateral pleural effusions and pulmonary vascular congestion.\n\n No evidence of acute pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2134-08-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1249392,"text":" 7:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess placement of IABP.\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenci shock now on IABP.\n REASON FOR THIS EXAMINATION:\n Please assess placement of IABP.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with cardiogenic shock, now on IABP. Please\n assess placement of IABP.\n\n COMPARISON: .\n\n FINDINGS: Portable AP radiograph of the chest is obtained. Endotracheal tube\n seats 2.5 cm above the carina and appears unchanged, however, the cuff appears\n to be overinflated. Swan-Ganz tip is in the pulmonary outflow tract and also\n remains unchanged. Tip of the intra-aortic balloon pump is seen in the mid\n descending thoracic aorta approximately 7 cm below the arch. A more desirable\n location for this device would be 3-4 cm higher. Cardiomediastinal silhouette\n and pulmonary vascular congestion is stable. Small pleural effusions and no\n pneumothorax.\n\n IMPRESSION:\n 1. IABP sits 7 cm below the aortic arch; 3-4 cm below its desirable location.\n 2. Endotracheal tube cuff is overinflated, stretching the tracheal wall and\n needs to be slightly deflated.\n 3. Stable pulmonary vascular congestion and pleural effusions.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2134-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70571,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: s/p clot removal, lv rupture\\nHeight: (in) 64\\nWeight (lb): 151\\nBSA (m2): 1.74 m2\\nBP (mm Hg): 105/38\\nHR (bpm): 95\\nStatus: Inpatient\\nDate/Time: at 15:27\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT VENTRICLE: LV pseudoaneursym.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\\ninferolateral - akinetic; mid inferolateral - akinetic; basal anterolateral -\\nakinetic; mid anterolateral - akinetic;\\n\\nMITRAL VALVE: MR present but cannot be quantified.\\n\\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\\nelectrodes. Suboptimal image quality as the patient was difficult to position.\\nSuboptimal image quality - ventilator. Suboptimal image quality.\\n\\nConclusions:\\nThe posterior and lateral walls of the left ventricle are akinetic. Findings\\nare suggestive of a pseudoaneurysm at the basal posterolateral wall. Mitral\\nregurgitation is present but cannot be quantified. The overall left\\nventricular ejection fraction is relatively well-preserved despite the\\nposterior and lateral akinesis.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2134-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70647,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Right ventricular function. S/p Arrest. Intubated.\\nHeight: (in) 64\\nWeight (lb): 170\\nBSA (m2): 1.83 m2\\nBP (mm Hg): 130/60\\nHR (bpm): 91\\nStatus: Inpatient\\nDate/Time: at 13:35\\nTest: Portable TTE (Focused views)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\\nsystolic dysfunction.\\n\\nRIGHT VENTRICLE: RV not well seen. Normal RV chamber size.\\n\\nAORTA: Normal aortic diameter at the sinus level.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.\\n\\nPERICARDIUM: Moderate pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\\nimage quality - body habitus. Emergency study.\\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 severe hypo/akinesis of the basal inferolateral wall\\nwith a discontuity and the basal wall at the annulus level with apparent\\ncommunication with the pericardial space. Color flow Doppler is inadequate to\\ndefine flow. The remaining segments contract normally (LVEF = 45-50 %). Right\\nventricular chamber size is normal. The free wall is not well seen. The aortic\\nvalve leaflets are mildly thickened (?#). There is no aortic valve stenosis.\\nThere is a moderate sized circumferential pericardial effusion. Tamponade\\ncould not be assessed.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2134-08-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70561,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: s/p ventricular rumpture. Pericardial effusion.\\nHeight: (in) 65\\nWeight (lb): 151\\nBSA (m2): 1.76 m2\\nBP (mm Hg): 153/70\\nHR (bpm): 84\\nStatus: Inpatient\\nDate/Time: at 15:01\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: Optison\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\\nsystolic dysfunction. Mild-moderate regional LV systolic dysfunction.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\\ninferolateral - hypo; mid inferolateral - hypo;\\n\\nMITRAL VALVE: Mitral valve leaflets not well seen.\\n\\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\\nagitated normal saline at rest. Suboptimal image quality - poor echo windows.\\n\\nConclusions:\\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\\nregional left ventricular systolic dysfunction with severe hypokinesis of the\\nbasal inferolateral wall. The remaining segments contract normally (LVEF >50\\n%). The mitral valve leaflets are not well seen. There is no definite\\npericardial effusion. No definite extravasation of blood is identified.\\n\\nIMPRESSION: Suboptimal image quality. Regional left ventricular systolic\\ndysfunction c/w CAD. No definite pericardial effusion identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2134-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70612,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Pericardial effusion. Tamponade.\\nHeight: (in) 64\\nWeight (lb): 170\\nBSA (m2): 1.83 m2\\nBP (mm Hg): 212/59\\nHR (bpm): 104\\nStatus: Inpatient\\nDate/Time: at 14:43\\nTest: TTE (Focused views)\\nDoppler: Limited 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 VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\\nsystolic dysfunction.\\n\\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\\ninferolateral - akinetic; mid inferolateral - hypo;\\n\\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No RV\\ndiastolic collapse.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\\nimage quality - ventilator. Resting tachycardia (HR>100bpm). Emergency study\\nperformed by the cardiology fellow on call. Results were personally reviewed\\nwith the MD caring for the patient.\\n\\nConclusions:\\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\\nThere is mild regional left ventricular systolic dysfunction with akinesis of\\nthe basal inferolateral wall. There appears to be a rupture of the basal\\ninferolateral wall immediately apical to the mitral annulus with color flow\\nDoppler through this area in to the pericardial space. The remaining segments\\ncontract normally (LVEF = 55 %). There is a moderate sized circumferential\\npericardial effusion. No right ventricular diastolic collapse is seen.\\n\\nCompared with the prior study (images reviewed) of earlier in the day of\\n, the pericardial effusion is slightly larger and flow from the left\\nventricle into the pericardial space is now more clearly defined.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2134-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70572,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. Left ventricular function. Pericardial effusion. Shortness of breath.\\nStatus: Inpatient\\nDate/Time: at 17:17\\nTest: TEE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: LA not well visualized. No spontaneous echo contrast is seen in\\nthe LAA. No thrombus in the LAA. All four pulmonary veins not identified.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mildly\\ndepressed LVEF.\\n\\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\\natherosclerotic plaque. Normal aortic diameter at the sinus level. Normal\\nascending aorta diameter. Normal aortic arch diameter. Normal descending aorta\\ndiameter.\\n\\nAORTIC VALVE: Three aortic valve leaflets. No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Moderate pericardial effusion. Effusion is loculated. \\n collapse.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was under\\ngeneral anesthesia throughout the procedure. The patient received antibiotic\\nprophylaxis. The TEE probe was passed with assistance from the anesthesioology\\nstaff using a laryngoscope. No TEE related complications. Results were\\npersonally reviewed with the MD caring for the patient.\\n\\nConclusions:\\nPRE-CPB:The patient was brought to the operating room on IABP with infusions\\nof norepinephrine and dopamine.\\n1. No spontaneous echo contrast is seen in the left atrial appendage. No\\nthrombus is seen in the left atrial appendage.\\n2. No atrial septal defect is seen by 2D or color Doppler.\\n3. There is moderate symmetric left ventricular hypertrophy. The left\\nventricular cavity size is normal. Overall left ventricular systolic function\\nis mildly depressed (LVEF= 50 %). There is evidence of a lateral free wall\\nrupture and contained hematoma.\\n4. Right ventricular chamber size and free wall motion are normal.\\n5. The ascending, transverse and descending thoracic aorta are normal in\\ndiameter and free of atherosclerotic plaque. The IABP is in good positoipn 3\\ncm below the LSCA.\\n6. There are three aortic valve leaflets. There is no aortic valve stenosis.\\nNo aortic regurgitation is seen.\\n7. The mitral valve appears structurally normal with trivial mitral\\nregurgitation. There is no mitral doppler evidence for mitral stenosis.\\n8. There is a moderate sized pericardial effusion. The effusion appears\\nloculated. There is left atrial diastolic collapse.\\nDrs. and notified in person of the results.\\n\\nPOST CPB: On infusion of epinephrine. Reduced size of pericardial effusion\\nwith significant compression of left atrium. The lateral free wall has a\\nsmaller rupture than pre bypass. LVEF = 60%. Aortic contour is normal post\\ndecannulation.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2134-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70573,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: s/p myocardial infarction with concern for ventricular wall rupture. Pericardial effusion.\\nHeight: (in) 64\\nWeight (lb): 170\\nBSA (m2): 1.83 m2\\nBP (mm Hg): 212/59\\nHR (bpm): 104\\nStatus: Inpatient\\nDate/Time: at 14:55\\nTest: Portable TEE (Unsuccessful Placement) (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nSedation per cath lab team. Unsuccessful TEE as unable to pass probe past the\\nposterior pharynx.\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. The patient was monitored\\nby a nurse throughout the procedure. The patient was sedated for\\nthe TEE. Medications and dosages are listed above (see Test Information\\nsection). The patient was under general anesthesia throughout the procedure.\\nUnsuccessful esophageal intubation.\\n\\nConclusions:\\nThe TEE probe could not be passed into the esophagus due to resistance in the\\nposterior pharynx.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1249291,\n \"text\": \" 7:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for intrathoracic pathology and line placement\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with LV rupture now with IABP\\n REASON FOR THIS EXAMINATION:\\n Please eval for intrathoracic pathology and line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Left ventricular rupture, evaluation for placement of monitoring\\n devices.\\n\\n COMPARISON: , 7:19 p.m.\\n\\n FINDINGS: As compared to the previous radiograph, there is no relevant\\n change. Extensive bilateral parenchymal opacities with pleural effusions and\\n moderate cardiomegaly are constant. The monitoring and support devices,\\n including the aortic balloon pump and Swan-Ganz catheter, are in virtually\\n unchanged position. There is no evidence of pneumothorax or other new\\n complication. The sternal wires show unchanged alignment.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1249200,\n \"text\": \" 9:48 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PTX\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with S/P tamponade evac\\n REASON FOR THIS EXAMINATION:\\n PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Tamponade, evaluation for pneumothorax.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is little overall\\n change. The mediastinal drains and the right chest tube has been removed.\\n There is unchanged evidence of bilateral pleural fluid collections and\\n relatively extensive retrocardiac atelectasis. The position of the\\n intraaortic balloon pump is constant. No newly appeared parenchymal\\n opacities. No convincing evidence for pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1249263,\n \"text\": \" 7:17 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please evaluate line placement\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with ventricular rupture, s/p sterotomy and evacuation\\n REASON FOR THIS EXAMINATION:\\n please evaluate line placement\\n ______________________________________________________________________________\\n WET READ: LLTc WED 9:02 PM\\n ET tube 3.9 cm above the carina. S-G terminating at the proximal right\\n ventricular outflow tract. OG tube within the stomach. Intraaortic balloon\\n pump remains appropriately positioned.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Ventricular rupture, status post sternotomy, evaluation of line\\n placement.\\n\\n COMPARISON: , 9:59 a.m.\\n\\n FINDINGS: The tip of the endotracheal tube projects 3.9 cm above the carina.\\n The Swan-Ganz catheter is terminating in the proximal right ventricular\\n outflow tract. The nasogastric tube is within the stomach. The intra-aortic\\n balloon pump remains approximately positioned at a distance of 6 cm from the\\n top of the aortic arch. The appearance of the lung parenchyma and of the\\n heart show no substantial change. No evidence of pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1249052,\n \"text\": \" 9:07 PM\\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \\n -76 BY SAME PHYSICIAN; CHEST (PORTABLE AP)\\n -76 BY SAME PHYSICIAN\\n : check swan placement\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with `MI\\n REASON FOR THIS EXAMINATION:\\n check swan placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the patient with Swan-Ganz placement,\\n assessment for position.\\n\\n AP radiograph of the chest\\n\\n As compared to prior study obtained the same day earlier, the Swan-Ganz\\n catheter has been slightly advanced with its tip currently at the level of the\\n upper portion of the right ventricle close to the right ventricle outflow\\n tract. The intra-aortic balloon pump remains low. No other changes have been\\n demonstrated except for minimal interval development of interstitial pulmonary\\n edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1249181,\n \"text\": \" 7:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pulm edema\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with s/p tamponade evac/myocardial rupture\\n REASON FOR THIS EXAMINATION:\\n pulm edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post tamponade, myocardial rupture, evaluation for\\n pulmonary edema.\\n\\n COMPARISON: .\\n\\n FINDINGS: Compared to the previous radiograph, there is a newly appeared mild\\n to moderate right pleural effusion and an increasing left pleural effusion.\\n The appearance of the cardiac silhouette is unchanged. However, dilated\\n vascular structures suggest the presence of mild to moderate pulmonary edema.\\n The position of the tubes and lines is constant. Unchanged alignment of the\\n sternal wires.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-16 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1249043,\n \"text\": \" 7:48 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman s/p Repair of RV Rupture\\n REASON FOR THIS EXAMINATION:\\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\\n ______________________________________________________________________________\\n WET READ: LLTc MON 8:53 PM\\n Right IJ catheter terminating within the right ventricle. ET tube 3.4 cm above\\n the carina. OG tube extending to at least the stomach. Right thoracostomy and\\n mediastinal drains. No pneumothorax. Left basilar opacity may reflect severe\\n atelectasis. Small left pleural effusion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the patient after repair of the right\\n ventricular rupture.\\n\\n AP radiograph of the chest was reviewed in comparison to .\\n\\n The ET tube tip is approximately 4.3 cm above the carina. The intra-aortic\\n balloon pump is very low, at least 8 cm below the roof of the aortic arch.\\n Mediastinal drains are in place. The Swan-Ganz catheter inserted through the\\n right internal jugular approach terminates at the level of the low right\\n ventricle. Right chest tube is in place. Mediastinal drains are in place.\\n Heart size and mediastinum are grossly stable. Left pleural effusion and left\\n lower lung consolidation is noted.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 161611,\n \"text\": \"Atrial fibrillation with rapid ventricular response. Left ventricular\\nhypertrophy. ST segment depressions in leads V3-V6 which are worrisome for\\nmyocardial ischemia. The atrial fibrillation is new compared to the previous\\ntracing of , as are the ST segment abnormalities. Clinical correlation\\nis highly suggested.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 161612,\n \"text\": \"Sinus rhythm. Left atrial abnormality. Frequent atrial ectopy. Low limb lead\\nvoltage. Compared to the previous tracing of atrial ectopy has\\nappeared. The A-V interval has decreased. There is ST segment elevation in\\nleads I and aVL and ST segment depression in leads V1-V4 consistent with\\nanterolateral ischemia, rule out infarction. Followup and clinical correlation\\nare suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2134-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 161613,\n \"text\": \"Sinus rhythm. Left atrial abnormality. A-V conduction delay. Diminished\\nvoltage as compared to the previous tracing of and increase in rate.\\nThere is ST segment elevation in leads I and aVL with biphasic T waves in\\nleads I and aVL. Right precordial ST segment depression. These findings are\\nnew as compared to the previous tracing of and are consistent with\\nactive posterolateral ischemic process, rule out myocardial infarction. There\\nis Q-T interval prolongation. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1249579,\n \"text\": \" 12:18 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for edema/effusion or infectious process\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with STEMI c/b ventricular rupture and \\n REASON FOR THIS EXAMINATION:\\n Please eval for edema/effusion or infectious process\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: STEMI, complicated by ventricular rupture and .\\n\\n CHEST, SINGLE AP PORTABLE VIEW.\\n\\n An ET tube is present, tip approximately 5.9 cm above the carina. NG tube is\\n present, tip extends beneath the diaphragm, off the film. A right IJ sheath\\n is present, tip overlying lower IJ above the level of the clavicle.\\n\\n The patient is status post sternotomy, with a prominent cardiomediastinal\\n silhouette. There is upper zone redistribution and diffuse vascular blurring,\\n asymmetrically more pronounced on the right. There is obscuration of the\\n right inferior lung likely reflecting combination of pleural fluid and\\n underlying collapse and/or consolidation. There is increased retrocardiac\\n density, consistent with left lower lobe collapse and/or consolidation, likely\\n with a small amount of pleural fluid. Some subcutaneous emphysema is noted\\n over the right greater than left chest. The possibility of a small right\\n apical pneumothorax cannot be excluded. Linear lucency traversing the right\\n posterior third rib may represent artifact due to subcutaneous emphysema, but\\n the differential diagnosis would include a non-displaced rib fracture.\\n\\n Compared with at 8:27 a.m., lung findings are similar. Right apical\\n pneumothorax and possible right posterior third rib fracture, if real, are\\n new.\\n\\n Findings discussed with Dr. at ~11:23 am on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1249528,\n \"text\": \" 7:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: position of tubes and lines\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with MI, intubated and sedated\\n REASON FOR THIS EXAMINATION:\\n position of tubes and lines\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: MI, intubated, check tubes and lines.\\n\\n CHEST, SINGLE AP PORTABLE VIEW.\\n\\n An ET tube is present, grossly unchanged in position, with its tip at the\\n lower level of the clavicular heads. The crania itself is not well\\n demonstrated. An NG tube is present, tip extending beneath diaphragm off film.\\n A right IJ sheath is present, tip overlying the lower IJ proximal to the SVC,\\n at the level of the thoracic inlet. The ET tube tip is grossly unchanged at\\n the level of lower clavicular heads.\\n\\n The patient is status post sternotomy. The cardiomediastinal silhouette is\\n prominent, but unchanged. There is upper zone redistribution and diffuse\\n vascular blurring, with patchy alveolar opacities, consistent with CHF and\\n pulmonary edema. There is increased retrocardiac density, consistent with\\n left lower lobe collapse and/or consolidation. Probable small left effusion.\\n Likely also right effusion, with underlying collapse and/or consolidation.\\n\\n Overall, the appearance is similar to at 16:39 p.m. CHF\\n findings may be very slightly worse.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-20 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1249465,\n \"text\": \" 4:26 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: Please assess for any consolidation, pnumothorax, pleural ef\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock. Currently on ventilation with high\\n o2 requirement.\\n REASON FOR THIS EXAMINATION:\\n Please assess for any consolidation, pnumothorax, pleural effusions.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cardiogenic shock.\\n\\n FINDINGS: In comparison with the earlier study of this date, the endotracheal\\n tube has been removed. The Swan-Ganz catheter has been removed and replaced\\n with a jugular shunt. Nasogastric tube remains in place. IABP has been\\n removed.\\n\\n There are still hazy opacifications bilaterally, more prominent on the right,\\n consistent with bilateral pleural effusions and pulmonary vascular congestion.\\n\\n No evidence of acute pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2134-08-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1249392,\n \"text\": \" 7:37 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please assess placement of IABP.\\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenci shock now on IABP.\\n REASON FOR THIS EXAMINATION:\\n Please assess placement of IABP.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 79-year-old woman with cardiogenic shock, now on IABP. Please\\n assess placement of IABP.\\n\\n COMPARISON: .\\n\\n FINDINGS: Portable AP radiograph of the chest is obtained. Endotracheal tube\\n seats 2.5 cm above the carina and appears unchanged, however, the cuff appears\\n to be overinflated. Swan-Ganz tip is in the pulmonary outflow tract and also\\n remains unchanged. Tip of the intra-aortic balloon pump is seen in the mid\\n descending thoracic aorta approximately 7 cm below the arch. A more desirable\\n location for this device would be 3-4 cm higher. Cardiomediastinal silhouette\\n and pulmonary vascular congestion is stable. Small pleural effusions and no\\n pneumothorax.\\n\\n IMPRESSION:\\n 1. IABP sits 7 cm below the aortic arch; 3-4 cm below its desirable location.\\n 2. Endotracheal tube cuff is overinflated, stretching the tracheal wall and\\n needs to be slightly deflated.\\n 3. Stable pulmonary vascular congestion and pleural effusions.\\n\\n\"\n }\n]"}}},{"rowIdx":795,"cells":{"subject_id":{"kind":"number","value":92287,"string":"92,287"},"hadm_id":{"kind":"number","value":106961,"string":"106,961"},"target_text":{"kind":"string","value":"59 year old male with a past medical history of systolic congestive heart failure (last EF 55-60%), atrial fibrillation on coumadin, transaminitis secondary to cirrhosis, chronic lower extremity stasis dermatitis (recent admission for cellulitis on ), history of pulmonary embolus and atrial thrombus who presented from clinic with with a significant hyponatremia, elevated lactate, and acute kidney injury."},"extractive_notes_summ":{"kind":"string","value":"Atrial fibrillation with a controlled ventricular response. Compared to the previous tracingof the anterolateral ST segment abnormality is slightly more prominent.No other significant change.TRACING #1 Compared to theprevious tracing the anterolateral ST segment abnormality is less prominent.TRACING #3 Atrial fibrillation with fast ventricular response. Hyponatremia. Mild cardiomegaly is unchanged. Atrial fibrillation with rapid ventricular response. FINDINGS AND IMPRESSION: The lungs are clear. Non-specificanterolateral ST segment depression. Compared to the previoustracing there is no diagnostic change.TRACING #2 COMPARISON: Multiple prior examinations, most recent dated . No pleural effusion, pulmonary edema or pneumothorax is present. TECHNIQUE: Two views of the chest."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2173-08-03 00:00:00.000","description":"Report","row_id":194737,"text":"Atrial fibrillation with a controlled ventricular response. Compared to the\nprevious tracing the anterolateral ST segment abnormality is less prominent.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2173-08-03 00:00:00.000","description":"Report","row_id":194738,"text":"Atrial fibrillation with fast ventricular response. Compared to the previous\ntracing there is no diagnostic change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2173-08-03 00:00:00.000","description":"Report","row_id":194995,"text":"Atrial fibrillation with rapid ventricular response. Non-specific\nanterolateral ST segment depression. Compared to the previous tracing\nof the anterolateral ST segment abnormality is slightly more prominent.\nNo other significant change.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2173-08-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1249758,"text":" 12:58 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 59M with hyponatremia, leukocytosis\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Leukocytosis. Hyponatremia.\n\n TECHNIQUE: Two views of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS AND IMPRESSION: The lungs are clear. No pleural effusion, pulmonary\n edema or pneumothorax is present. Mild cardiomegaly is unchanged.\n\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2173-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 194737,\n \"text\": \"Atrial fibrillation with a controlled ventricular response. Compared to the\\nprevious tracing the anterolateral ST segment abnormality is less prominent.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2173-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 194738,\n \"text\": \"Atrial fibrillation with fast ventricular response. Compared to the previous\\ntracing there is no diagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2173-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 194995,\n \"text\": \"Atrial fibrillation with rapid ventricular response. Non-specific\\nanterolateral ST segment depression. Compared to the previous tracing\\nof the anterolateral ST segment abnormality is slightly more prominent.\\nNo other significant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2173-08-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1249758,\n \"text\": \" 12:58 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 59M with hyponatremia, leukocytosis\\n REASON FOR THIS EXAMINATION:\\n eval for pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Leukocytosis. Hyponatremia.\\n\\n TECHNIQUE: Two views of the chest.\\n\\n COMPARISON: Multiple prior examinations, most recent dated .\\n\\n FINDINGS AND IMPRESSION: The lungs are clear. No pleural effusion, pulmonary\\n edema or pneumothorax is present. Mild cardiomegaly is unchanged.\\n\\n\"\n }\n]"}}},{"rowIdx":796,"cells":{"subject_id":{"kind":"number","value":87949,"string":"87,949"},"hadm_id":{"kind":"number","value":167925,"string":"167,925"},"target_text":{"kind":"string","value":"73 RHM with recently diagnosed PD started on Sinemet 1 month before admission, HTN, HLD, CAD s/p CABG and multiple stents, right hand weakness, s/p C5 corpectomy and C4-C6 instrumented fusion, T2DM on insulin presented with acute onset of left sided weakness and aphasia, found to have hypodensities in the R superior frontal lobe on NCHCT (unable to do an MRI given PPM) which were felt to be old. He was markedly hypertensive and this was controlled initially with an IV nicardipine drip and latterly with po medications. LP was unremarkable and infectious studies and cytology were negative. He had fevers for which no source was found, and one episode of possible seizure with no clear epileptiform changes on EEG telemetry. Left sided weakness resolved and were felt likely due to a seizure. He was commenced on AEDs and these were decreased during his course and discharged on keppra. He was found to have dysphagia and placed on a modified diet. He initially required ICU level care and was admitted on and transferred to the floor on , discharged to rehab on . Pending issues are persistent hyperextension and diabetes control. . . # Neurology: Patient had recently been diagnosed with possible PD for bilateral tremor (not present here) and gait disturbance by Dr at and started on Sinemet 1 month prior to admission. Patient presented initially to an OSH with acute left sides weakness and confusion as well as language difficulties and intermittent chest pain and was transferred to the on for possible tPA. He was markedly hypertensive on admission with SBP >200 and he was given labetalol 10mg IV with decrease in BP. He required ICU level care due to his poor conscious level. Initial concern was for stroke and initial examination revealed that he was inattentive, could not repeat, speech was slightly dysarthric and was nonsensical. There was also evidence of left arm>leg hemiparesis. Initial NIHSS was 16. CT head showed likely old hypodensities in the right thalamus and right occipital lobe. CTA showed no significant vessel abnormalities. Due to the presence of chest pain in the ED he had a CT- revealed no aortic dissection or aneurysm or PE and multiple subcentimeter thyroid nodules with trace bilateral effusions. BP was treated with an IV nicardipine infusion while in the ICU and latterly was managed with po antihypertensives on transfer to the floor. He was felt to be very encephalopathic with a WCC that increased to maximum 20 (no source found) and returned to and the concern was then for infective encephalitis. He was therefore initially started on vanc/ceftriaxone/ampicillin/acyclovir. LP was performed and CSF results were negative with 1 RBC 1 WBC Pr 47 and normal Glc. HSV/entero/VZV PCR were negative as was cryptococcal Ag and cultures. Cytology was negative. Abx and antiviral were then stopped. The patient had an episode of right sided gaze deviation and rhythmic shaking of his R arm and leg suspicious for a seizure on admission to the ICU and he was placed on EEG telemetry. He was commenced on IV phenytoin->fosphenytoin and due to low phenytoin levels fosphenytoin was increased to 150mg Q8H in addition to IV keppra 1g . EEG was initially obscured by artifact and latterly showed changes compatible with encephalopathy with no epileptiform features seen. As his hospital course progressed, his EEG became less encephalopathic in tandem with his improving conscious level. He was also assessed by speech and swallow who found aspiration and he went on to have a video swallow which showed intermittent aspiration with thin liquids as well as penetration with thin liquids and nectar. He was placed on a modified diet and this will have to be reviewed at rehab for possible advancement. On he was persistently agitated, requiring IV haloperidol. He also had one episode of fever to 101.3 and blood and urine cultures were sent which returned negative. His agitation subsequently improved and by , his mental status was improving. He was still somewhat lethargic but oriented x with fluent speech and able to follow commands. Still with some LUE weakness, neuro exam otherwise intact. He was transferred to the floor on . In the ICU he was also found to have apneic episodes and desaturations on sleeping and was presumptively started on CPAP at night and subsequently did well. He had an inpatient sleep study and was seen by sleep medicine. The results of this are pending. He was continued on CPAP at night for likely OSA. On the floor, his conscious level cleared and normalised per family. He was still hypertensive and had no episodes of agitation. Patient noted painful calves and doppler U/S showed no DVTs bilaterally. The likely cause of his symptoms was felt to be hypertensive encephalopathy causing seizures given encephalopathy without infective features on LP and markedly high BP with left hemiparesis which completely resolved. It is unclear what impact his Sinemet had on this but due to temporal relationship and no clear Parkinsonian features, Sinemet was not continued during his hospital stay. His anti-hypertensives were uptitrated and this will have to be further uptitrated as necessary at rehab. He also had variable BGlc levels and his HISS was changed. Due to no epileptiform changes on EEG and no further seizures, his phenytoin was tapered and stopped on and will continue keppra until advised in neurology clinic. He was assessed by PT, OT and S&S and was deemed to require rehab. He will have to be reassessed by Speech and Swallow at rehab with the hopes that his diet can be advanced. He was discharged to rehab on . He has neurology follow-up and should see his PCP on discharge from rehab. . # CVS: Patient was very hypertensive initially requiring IV nicardipine. Cardiology were consulted for pacer interrogation and found a normally functioning dual chamber pacemaker and he was not pacemaker dependent. We continued aspirin 325mg daily and clopidogrel 75mg daily for CAD/stents. He was monitored on tele. CE's were negative. Echo showed no source of cardioembolism and a normal EF. Lipid profile revealed Chol 127 TGCs 125 LDL 61 and were continued home simvastatin 20mg qd and fenofibrate. Patient initially had a dose reduction of his losartan and this was uptitrated to his home dose of 100mg qd on discharge. We changed metoprolol XL to metoprolol tartrate 25mg tid. Due to persistent hypertension we added amlodipine 5mg qd on and he will need his anti-HTN uptitrated at rehab an closely monitor BP and goal is normotension. . # PULM: In the ICU he was also found to have apneic episodes and desaturations (70s-80s) on sleeping and was presumptively started on CPAP at night and subsequently did well. He had an inpatient sleep study 1/5-6 and was seen by sleep medicine. The results of this are pending. He was continued on CPAP at night for likely OSA. His respiratory status was stable on discharge. Dr will follow-up these results and will coordinate follow-up. . # ID: Patient had one fever as above and was otherwise afebrile. WBC initially peaked at 20 and fell without treatment (following discontinuation of Abx and anti-virals) to normal range 10.2 on discharge and had no further fevers. The reason for this rise is unclear and may be reactive but is quite high for this. All microbiology was unremarkable. CSF infection studies were all negative. . # ENDO: Patient has T2DM on 70/30 and Januvia in the community. His BGlc was difficult to control in house and required a considerable sliding scale. He was seen by endocrinologists on and recommended a change to his sliding scale given am hypoglycemic events. He was discharged on Lantus 20 units and this will need to be uptitrated based on his diabetic control. Januvia and 70/30 were held. HbA1C 9.8%. We continued home levothyroxine 75mcg daily . # Psych: We held Cymbalta in house and this can be restarted as felt necessary by his PCP. . Transitional issues: Patient to continue keppra as an outpatient unless directed to stop this after his neurology follow-up with Dr . He will need sleep follow-up which will be coordinated by Dr is still hypertensive and his anti-hypertensives will need to be uptitrated at rehab. Patient has poor diabetic control and his insulin regimen will have to be uptitrated at rehab. Patient will need reassessment by speech and swallow at rehab with a view to advancing his diet. Patient had low phosphate and was started on neutraphos and PO4 will need to be monitored at rehab. Patient was started on a trial of sinemet in the community and this was stopped in house and should not be restarted given temporal association to his admission symptoms. . Pending labs: One pending blood cultures and all other cultures negative"},"extractive_notes_summ":{"kind":"string","value":"Unchanged hypodensities in the right thalamus and right occipital region which likely represent subacute infarcts. Hypodensities within the right thalamus and in the right occipital region appear unchanged compared to recent prior examinations and likely reflect infarcts that are probably subacute. Mild (1+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. There is a trivial/physiologic pericardial effusion.IMPRESSION: Suboptimal image quality. Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Right-sided PICC line present, tip not optimally visualized but likely overlying the distal SVC near the RA junction. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) mitral regurgitation is seen. Trace left pleural effusion is present (2:63). Left atrial abnormality. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. No resting LVOT gradient.RIGHT VENTRICLE: RV not well seen.AORTIC VALVE: Mildly thickened aortic valve leaflets. Low precordial lead voltage isnew. Limited head CT shows hypodensity in the right thalamus and right occipital region due to infarcts of undetermined age. The thoracic aorta demonstrates minimal atherosclerotic calcification, and is normal in caliber. There is symmetric left ventricularhypertrophy. Two ventricular premature beats are noted.A-V conduction delay. Suboptimal image quality - patient unable to cooperate.Conclusions:The left atrium is mildly dilated. Cardiomediastinal silhouette is prominent,but unchanged. Mild mitral annularcalcification. Trace left pleural effusion with adjacent atelectasis. Chronic parietal lobe focal encephalomalacia unchanged from the reference CT exam performed earlier. Chronic parietal lobe focal encephalomalacia unchanged from the reference CT exam performed earlier. There is unchanged moderate proportional enlargement of the ventricles and sulci, findings consistent with age-related cortical atrophy. Since the prior radiograph, there has been resolution of the right pleural effusion. Compared to the previous tracing of the rate is slowerand ventricular ectopy is no longer present. Possible small left pleural effusion. Resolution of right pleural effusion. The mitral valve leaflets are mildlythickened. FINDINGS: There is hypodensity in the right thalamus and right occipital lobe which could be due to infarcts of undetermined age. Left atrialabnormality. Allowing for low lung volumes, I doubt overt CHF. Mild-to-moderate cardiomegaly and mild mediastinal vascular engorgement are unchanged. FINAL REPORT INDICATION: Left-sided weakness and neglect with concerning EKG changes and chest tightness. PATIENT/TEST INFORMATION:Indication: Cerebrovascular event/TIA.Height: (in) 66Weight (lb): 231BSA (m2): 2.13 m2BP (mm Hg): 135/93HR (bpm): 129Status: InpatientDate/Time: at 10:22Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Symmetric LVH. Q waves in the anterior leads consistent with myocardialinfarction. No obvious area of hemorrhage noted. Left DVT REASON FOR THIS EXAMINATION: ? Persistent left pleural effusion. Moderate atherosclerotic calcification of the coronary vessels is seen. The pulmonary artery systolic pressure couldnot be determined. No PE detected to the subsegmental levels. Please note that multiple leads and tubes overlie the neck and superior mediastinum, which are of unknown etiology or significance. No acute hemorrhage. No acute hemorrhage. No obvious intracardiac source ofthromboembolism identified in the setting of very limited echocardiographicviews. Suboptimal technicalquality, a focal LV wall motion abnormality cannot be fully excluded. Low voltage in theprecordial leads. Normal caliber main pulmonary arteries, with no pulmonary embolus detected to the subsegmental levels. Q waves in leads V1-V3indicating an anterior myocardial infarction of undetermined age. FINDINGS: The PICC ends at the junction of the upper and middle SVC, and has been pulled back since the prior radiograph. OSSEOUS STRUCTURES: There is no acute fracture. Tricuspid regurgitation ispresent but cannot be quantified. Right lower chest and lateral right hemidiaphragm excluded from the film. PICC ends at upper to mid SVC. Scattered axillary and mediastinal lymph nodes do not meet CT criteria for lymphadenopathy. Pleural effusion is small if any. Increased retrocardiac density and atelectasis in the right cardiophrenic region are unchanged compared with at 4:27 a.m. Cervical fusion hardware again noted. Small left pleural effusion is probably present. Frequent single ventricular premature beats.Probable old anteroseptal myocardial infarction. TECHNIQUE: Axial images of the head were obtained without contrast. CHEST, SINGLE AP PORTABLE VIEW, LORDOTIC POSITIONING: The extreme left costophrenic angle and left lung base are excluded from the film. Possible non-specific ST-T wave changes. CHEST, SINGLE AP PORTABLE VIEW. interval change No contraindications for IV contrast WET READ: GMSj 5:24 PM -No acute intracranial process -Stable hypodensities in the right thalamic and occipital regions - likely infarcts of indeterminate age -No hemorrhage, midline shift or acute large territorial infarction -Moderate mucosal thickening of the ethmoid air cells and sphenoid sinuses (R>L). A PICC line is present -- the tip is not optimally visualized due to underpenetration. There are low inspiratory volumes. TR present - cannot bequantified. NCCT: No acute territorial infarct detected. NCCT: No acute territorial infarct detected. Suboptimal image quality - poorsuprasternal views. COMMENT: This report provided without the availability of 3D reformatted images. No pulmonary embolus is detected to the subsegmental levels. IMPRESSION: No evidence of deep vein thrombosis in either leg. A left-sided pacemaker generator projects leads into the right atrium and ventricle. The left ventricular cavity size is normal. Otherwise, I doubt significant interval change. The intracranial anterior circulation demonstrates patency without stenosis, occlusion or an aneurysm greater than 3 mm in size. FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, femoral, popliteal and tibial veins. Mild central pulmonary vascular congestion with mild interstitial edema. There is mild dependent atelectasis bilaterally, slightly worse at the left base, where there is is pleural thickening and calcifications, probably reflecting chronic post-surgical hemothorax (2:56). Status post sternotomy with mediastinal clips. The aorticvalve leaflets are mildly thickened (?#). Suboptimalimage quality - poor subcostal views. There is marked left ventricular hypertrophy with rapid thinning at the apex. Transvenous right atrial and right ventricular pacer leads are in standard placements. Check Dobbhoff tube placement. No pneumothorax. No pneumothorax. There is mild-to-moderate vallecular residue with solids."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2189-01-25 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1222040,"text":" 3:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 w poss encephalitis\n REASON FOR THIS EXAMINATION:\n ? interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GMSj 5:24 PM\n -No acute intracranial process\n -Stable hypodensities in the right thalamic and occipital regions - likely\n infarcts of indeterminate age\n -No hemorrhage, midline shift or acute large territorial infarction\n -Moderate mucosal thickening of the ethmoid air cells and sphenoid sinuses\n (R>L).\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with possible encephalitis. Evaluation for\n interval change.\n\n COMPARISON: CTA of the head and neck from at 4:25 a.m. and\n outside hospital head CT from at 1:09 a.m.\n\n TECHNIQUE: 64 MDCT axial images of the brain were obtained without\n intravenous contrast.\n\n NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass, pr mass\n effect. Hypodensities within the right thalamus and in the right occipital\n region appear unchanged compared to recent prior examinations and likely\n reflect infarcts that are probably subacute. There is unchanged moderate\n proportional enlargement of the ventricles and sulci, findings consistent with\n age-related cortical atrophy. There is no shift of the usually midline\n structures. The suprasellar and basilar cisterns are widely patent. There is\n no scalp hematoma or acute skull fractures. There is moderate mucosal\n thickening of the ethmoid air cells and bilateral sphenoid sinuses, right\n greater than left. The mastoid air cells are well aerated.\n\n IMPRESSION:\n 1. Unchanged hypodensities in the right thalamus and right occipital region\n which likely represent subacute infarcts.\n 2. No evidence of hemorrhage.\n 3. Moderate mucosal thickening of the ethmoid air cells and sphenoid sinuses,\n right greater than left.\n\n"},{"category":"Radiology","chartdate":"2189-01-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1221995,"text":" 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with acute altered mental status, rising WBC\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:59 A.M. \n\n HISTORY: Altered mental status. Rising white count.\n\n IMPRESSION: AP chest compared to :\n\n Low lung volumes and supine positioning make it difficult to say whether mild\n interstitial edema has developed, but I doubt it. Leftward rotation probably\n accounts for increase in size and change in contour of the cardiomediastinal\n silhouette, but mild cardiomegaly is presumed. Transvenous right atrial and\n right ventricular pacer leads are in standard placements. Small left pleural\n effusion is probably present. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2189-01-28 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1222371,"text":" 3:40 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: BILAT LEG PAIN, R/O DVT\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with tenderness in left calf and on foot dorsiflexion.\n Previously had left sided weakness and has been bed bound for several days. ?\n Left DVT\n REASON FOR THIS EXAMINATION:\n ? Left DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 73-year-old man with left calf tenderness and extended bed\n bound. Evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral\n common femoral, femoral, popliteal and tibial veins. Normal flow,\n compression, and augmentation is seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n"},{"category":"Radiology","chartdate":"2189-01-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1222132,"text":" 3:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval placement of new Dobhoff tube\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with delirium\n REASON FOR THIS EXAMINATION:\n Eval placement of new Dobhoff tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Delirium, evaluate the new placement of Dobbhoff tube.\n\n CHEST, 1 VW\n\n Compared with earlier the same day, the Dobbhoff tube has been replaced. The\n radiopaque tip now lies in the region of the gastric fundus and GE junction.\n Otherwise, I doubt significant interval change. Please note that multiple\n leads and tubes overlie the neck and superior mediastinum, which are of\n unknown etiology or significance.\n\n"},{"category":"Radiology","chartdate":"2189-01-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1222082,"text":" 4:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 M w/ aseptic meningitis\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aseptic meningitis. Question interval change.\n\n CHEST, SINGLE AP PORTABLE VIEW, LORDOTIC POSITIONING:\n\n The extreme left costophrenic angle and left lung base are excluded from the\n film.\n\n A PICC line is present -- the tip is not optimally visualized due to\n underpenetration. A left-sided dual-lead pacemaker is present, with lead tips\n over right atrium and right ventricle.\n\n There are low inspiratory volumes. The patient is status post sternotomy, with\n mediastinal clips. There is increased retrocardiac density, consistent with\n left lower lobe collapse and/or consolidation and patchy opacity in the right\n cardiophrenic region. Mild prominence of pulmonary vasculature is noted, but\n likely accentuated due to technique and low lung volumes. Possible small left\n pleural effusion. Incidental note is made of fusion hardware in the lower\n cervical spine.\n\n Compared with at 10:07 a.m., I doubt significant interval change.\n\n"},{"category":"Echo","chartdate":"2189-01-26 00:00:00.000","description":"Report","row_id":90008,"text":"PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA.\nHeight: (in) 66\nWeight (lb): 231\nBSA (m2): 2.13 m2\nBP (mm Hg): 135/93\nHR (bpm): 129\nStatus: Inpatient\nDate/Time: at 10:22\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: Symmetric LVH. Normal LV cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Overall\nnormal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. TR present - cannot be\nquantified. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality - poor\nsuprasternal views. Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is mildly dilated. There is 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%). The aortic\nvalve leaflets are mildly thickened (?#). There is no aortic valve stenosis.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is\npresent but cannot be quantified. The pulmonary artery systolic pressure could\nnot be determined. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. No obvious intracardiac source of\nthromboembolism identified in the setting of very limited echocardiographic\nviews.\n\n\n"},{"category":"Radiology","chartdate":"2189-01-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1222512,"text":" 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: To assess line position\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with PICC on right now 3cm out ? Midline vs central\n REASON FOR THIS EXAMINATION:\n To assess line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess PICC line.\n\n COMPARISONS: Chest radiograph, .\n\n FINDINGS: The PICC ends at the junction of the upper and middle SVC, and has\n been pulled back since the prior radiograph. A pacemaker is in place with the\n leads seen in the left ventricle and right atrium. Sternal wires are intact\n and midline. Multiple clips are seen within the mediastinum. Since the prior\n radiograph, there has been resolution of the right pleural effusion.\n Opacification of the left base likely represents a persistent left effusion.\n There is no evidence of pulmonary edema.\n\n IMPRESSION:\n 1. PICC ends at upper to mid SVC.\n 2. Persistent left pleural effusion. Resolution of right pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2189-01-24 00:00:00.000","description":"CTA NECK W&W/OC & RECONS","row_id":1221885,"text":" 4:25 AM\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \n Reason: Dissection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with symptoms of left-sided weakness and neglect along with\n concerning EKG changes and chest tightness\n REASON FOR THIS EXAMINATION:\n Dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SAT 4:57 AM\n Limited examination due to patient motion. NCCT: No acute territorial infarct\n detected. Chronic parietal lobe focal encephalomalacia unchanged from the\n reference CT exam performed earlier. No acute hemorrhage. CTA: No dissection,\n flow limiting stenosis, or aneurysm detected. Multiple subcentimeter thyroid\n nodules. 3D reconstructions pending.\n WET READ VERSION #1 LLTc SAT 4:56 AM\n Limited examination due to patient motion. NCCT: No acute territorial infarct\n detected. Chronic parietal lobe focal encephalomalacia unchanged from the\n reference CT exam performed earlier. No acute hemorrhage. CTA: No dissection,\n flow limiting stenosis, or aneurysm detected. 3D reconstructions pending.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CTA of the head and neck.\n\n CLINICAL INFORMATION: Patient with left-sided weakness and neglect concerning\n for EKG changes, for further evaluation.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Following this using departmental protocol CT angiography of the head and neck\n was acquired.\n\n FINDINGS: There is hypodensity in the right thalamus and right occipital lobe\n which could be due to infarcts of undetermined age. The examination is\n limited due to patient motion, evaluation for the upper part of the brain is\n limited. Moderate to severe brain and medial temporal atrophy seen. No\n obvious area of hemorrhage noted.\n\n CT ANGIOGRAPHY OF THE NECK: There is a tortuous proximal left vertebral\n artery seen. Both vertebral arteries otherwise are patent of the neck with\n normal appearance of the distal intracranial vertebral and basilar arteries.\n\n\n The carotid arteries are patent bilaterally without stenosis, occlusion or\n dissection. There are post-operative changes identified in the neck.\n\n The intracranial anterior circulation demonstrates patency without stenosis,\n occlusion or an aneurysm greater than 3 mm in size.\n\n IMPRESSION:\n 1. Limited head CT shows hypodensity in the right thalamus and right\n occipital region due to infarcts of undetermined age. MRI could provide more\n (Over)\n\n 4:25 AM\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \n Reason: Dissection\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n information but patient may not likely be able to get it secondary to presence\n of a pacemaker. Followup study could be helpful.\n 2. CT angiography of the head and neck demonstrates no evidence of high-grade\n stenosis or occlusion. Vascular calcifications seen.\n 3. Tracheal calcifications and post-operative changes in cervical spine are\n noted in the neck.\n\n COMMENT: This report provided without the availability of 3D reformatted\n images. When these images are available and if additional information is\n obtained, an addendum will be given to this report.\n\n"},{"category":"Radiology","chartdate":"2189-01-24 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1221886,"text":" 4:25 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evidence of dissection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with symptoms of left-sided weakness and neglect along with\n concerning EKG changes and chest tightness\n REASON FOR THIS EXAMINATION:\n Evidence of dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SAT 5:27 AM\n 1. No dissection. No PE detected to the subsegmental levels.\n 2. Trace left pleural effusion with adjacent atelectasis.\n 3. Mild central pulmonary vascular congestion with mild interstitial edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left-sided weakness and neglect with concerning EKG changes and\n chest tightness.\n\n No comparison studies available.\n\n TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were obtained\n following the uneventful administration of 70 mL of Omnipaque intravenous\n contrast. Coronal and sagittal reformations were performed at 5-mm slice\n thickness.\n\n CHEST CT WITH IV CONTRAST:\n Multiple subcentimeter thyroid nodules are present (2:5). The thyroid gland\n is not enlarged. Scattered axillary and mediastinal lymph nodes do not meet\n CT criteria for lymphadenopathy.\n\n A left-sided pacemaker generator projects leads into the right atrium and\n ventricle. There is marked left ventricular hypertrophy with rapid thinning\n at the apex. Moderate atherosclerotic calcification of the coronary vessels is\n seen. There is no pericardial effusion. The left atrium is mildly enlarged.\n\n The thoracic aorta demonstrates minimal atherosclerotic calcification, and is\n normal in caliber. There is no dissection. The main pulmonary arteries are\n normal in caliber. No pulmonary embolus is detected to the subsegmental\n levels.\n\n Trace left pleural effusion is present (2:63). There is mild dependent\n atelectasis bilaterally, slightly worse at the left base, where there is is\n pleural thickening and calcifications, probably reflecting chronic\n post-surgical hemothorax (2:56). There is no pneumothorax.\n\n The patient is status post cholecystectomy. Included views of the liver,\n pancreas, stomach, spleen, adrenal glands, and splenic flexure are normal.\n\n OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or\n lytic lesions are identified. Extensive bridging anterior osteophytosis\n throughout thoracic spine is compatible with DISH (401B:27).\n (Over)\n\n 4:25 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evidence of dissection\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No aortic dissection or aneurysm. Normal caliber main pulmonary arteries,\n with no pulmonary embolus detected to the subsegmental levels.\n 2. Multiple subcentimeter thyroid nodules.\n\n"},{"category":"Radiology","chartdate":"2189-01-25 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1222019,"text":" 10:14 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 47 cm Picc in right brachial vein, need Picc tip placement\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 47 cm Picc in right brachial vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:07 A.M., \n\n HISTORY: Evaluate PICC line placement.\n\n IMPRESSION: AP chest compared to at 4:59 a.m.\n\n New right PICC line ends in the mid SVC. Mild-to-moderate cardiomegaly and\n mild mediastinal vascular engorgement are unchanged. Lungs are low in volume\n but clear. Pleural effusion is small if any. No pneumothorax. No pulmonary\n edema.\n\n\n"},{"category":"Radiology","chartdate":"2189-01-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1222109,"text":" 11:35 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Check placement of Dobhoff tube\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with confusion, agitation, weakness, unable to take PO.\n REASON FOR THIS EXAMINATION:\n Check placement of Dobhoff tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Confusion, agitation, weakness. Check Dobbhoff tube placement.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Right lower chest and lateral right hemidiaphragm excluded from the film.\n\n Dobbhoff tube is present. However, it is looped over the level of the fundus,\n with the radiopaque tip now superimposed over the lower neck and\n it requires repositioning.\n\n Right-sided PICC line present, tip not optimally visualized but likely\n overlying the distal SVC near the RA junction.\n\n Dual-lead left-sided pacemaker present with lead tips over right atrium and\n right ventricle. Status post sternotomy with mediastinal clips.\n Cardiomediastinal silhouette is prominent,but unchanged. Allowing for low\n lung volumes, I doubt overt CHF. Increased retrocardiac density and\n atelectasis in the right cardiophrenic region are unchanged compared with\n at 4:27 a.m. Cervical fusion hardware again noted.\n\n IMPRESSION:\n\n Abnormal placement of Dobbhoff tube -- the tube reaches the gastric fundus,\n where there is a \"hairpin\" bend of the tube, then courses back up the\n esophagus, so that the radiopaque tube tip overlies the neck.\n\n Findings discussed with Dr. at approximately 1:45 p.m. on\n the day of the exam (, phone).\n\n"},{"category":"Radiology","chartdate":"2189-01-28 00:00:00.000","description":"VIDEO OROPHARYNGEAL SWALLOW","row_id":1222338,"text":" 1:23 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for aspiration\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with 73 year old man with acute mental status change, clinical\n evidence of aspiration\n REASON FOR THIS EXAMINATION:\n eval for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute mental status change and clinical evidence of aspiration.\n\n SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing videofluoroscopy was\n performed in conjunction with speech and swallow division. Multiple\n consistencies of barium were administered. There was intermittent aspiration\n of thin liquids as well as penetration with thin and nectar thin liquids and\n nectar. There is mild-to-moderate vallecular residue with solids.\n\n IMPRESSION: Intermittent aspiration with thin liquids as well as penetration\n with thin liquids and nectar. For details, please refer to speech and swallow\n note in OMR.\n\n\n"},{"category":"ECG","chartdate":"2189-01-29 00:00:00.000","description":"Report","row_id":237317,"text":"Artifact is present. Sinus rhythm. The P-R interval is prolonged. Left atrial\nabnormality. Q waves in the anterior leads consistent with myocardial\ninfarction. Possible non-specific ST-T wave changes. Low voltage in the\nprecordial leads. Compared to the previous tracing of the rate is slower\nand ventricular ectopy is no longer present. Low precordial lead voltage is\nnew.\n\n"},{"category":"ECG","chartdate":"2189-01-26 00:00:00.000","description":"Report","row_id":237550,"text":"Regular supraventricular rhythm - because of baseline artifact, atrial activity\ncannot be clearly determined. Frequent single ventricular premature beats.\nProbable old anteroseptal myocardial infarction. Compared to the previous\ntracing of rate is faster.\n\n"},{"category":"ECG","chartdate":"2189-01-24 00:00:00.000","description":"Report","row_id":237551,"text":"Sinus rhythm. Baseline artifact. Two ventricular premature beats are noted.\nA-V conduction delay. Left atrial abnormality. Q waves in leads V1-V3\nindicating an anterior myocardial infarction of undetermined age. The baseline\nartifact makes further interpretation difficult. Compared to the previous\ntracing the Q waves in leads V1 and V2 are new but could be again related to\nlead placement. Previously, only Q waves in lead V1 were noted. The\npreviously noted Q waves in leads III and aVF are there but difficult to\ndiscern due to the baseline artifact.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-25 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1222040,\n \"text\": \" 3:08 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 w poss encephalitis\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: GMSj 5:24 PM\\n -No acute intracranial process\\n -Stable hypodensities in the right thalamic and occipital regions - likely\\n infarcts of indeterminate age\\n -No hemorrhage, midline shift or acute large territorial infarction\\n -Moderate mucosal thickening of the ethmoid air cells and sphenoid sinuses\\n (R>L).\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 73-year-old male with possible encephalitis. Evaluation for\\n interval change.\\n\\n COMPARISON: CTA of the head and neck from at 4:25 a.m. and\\n outside hospital head CT from at 1:09 a.m.\\n\\n TECHNIQUE: 64 MDCT axial images of the brain were obtained without\\n intravenous contrast.\\n\\n NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass, pr mass\\n effect. Hypodensities within the right thalamus and in the right occipital\\n region appear unchanged compared to recent prior examinations and likely\\n reflect infarcts that are probably subacute. There is unchanged moderate\\n proportional enlargement of the ventricles and sulci, findings consistent with\\n age-related cortical atrophy. There is no shift of the usually midline\\n structures. The suprasellar and basilar cisterns are widely patent. There is\\n no scalp hematoma or acute skull fractures. There is moderate mucosal\\n thickening of the ethmoid air cells and bilateral sphenoid sinuses, right\\n greater than left. The mastoid air cells are well aerated.\\n\\n IMPRESSION:\\n 1. Unchanged hypodensities in the right thalamus and right occipital region\\n which likely represent subacute infarcts.\\n 2. No evidence of hemorrhage.\\n 3. Moderate mucosal thickening of the ethmoid air cells and sphenoid sinuses,\\n right greater than left.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1221995,\n \"text\": \" 5:00 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for pneumonia\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with acute altered mental status, rising WBC\\n REASON FOR THIS EXAMINATION:\\n evaluate for pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 4:59 A.M. \\n\\n HISTORY: Altered mental status. Rising white count.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Low lung volumes and supine positioning make it difficult to say whether mild\\n interstitial edema has developed, but I doubt it. Leftward rotation probably\\n accounts for increase in size and change in contour of the cardiomediastinal\\n silhouette, but mild cardiomegaly is presumed. Transvenous right atrial and\\n right ventricular pacer leads are in standard placements. Small left pleural\\n effusion is probably present. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-28 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1222371,\n \"text\": \" 3:40 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: BILAT LEG PAIN, R/O DVT\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with tenderness in left calf and on foot dorsiflexion.\\n Previously had left sided weakness and has been bed bound for several days. ?\\n Left DVT\\n REASON FOR THIS EXAMINATION:\\n ? Left DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 73-year-old man with left calf tenderness and extended bed\\n bound. Evaluate for DVT.\\n\\n COMPARISON: No previous exam for comparison.\\n\\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral\\n common femoral, femoral, popliteal and tibial veins. Normal flow,\\n compression, and augmentation is seen in all of the vessels.\\n\\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1222132,\n \"text\": \" 3:15 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: Eval placement of new Dobhoff tube\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with delirium\\n REASON FOR THIS EXAMINATION:\\n Eval placement of new Dobhoff tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Delirium, evaluate the new placement of Dobbhoff tube.\\n\\n CHEST, 1 VW\\n\\n Compared with earlier the same day, the Dobbhoff tube has been replaced. The\\n radiopaque tip now lies in the region of the gastric fundus and GE junction.\\n Otherwise, I doubt significant interval change. Please note that multiple\\n leads and tubes overlie the neck and superior mediastinum, which are of\\n unknown etiology or significance.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1222082,\n \"text\": \" 4:30 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 M w/ aseptic meningitis\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Aseptic meningitis. Question interval change.\\n\\n CHEST, SINGLE AP PORTABLE VIEW, LORDOTIC POSITIONING:\\n\\n The extreme left costophrenic angle and left lung base are excluded from the\\n film.\\n\\n A PICC line is present -- the tip is not optimally visualized due to\\n underpenetration. A left-sided dual-lead pacemaker is present, with lead tips\\n over right atrium and right ventricle.\\n\\n There are low inspiratory volumes. The patient is status post sternotomy, with\\n mediastinal clips. There is increased retrocardiac density, consistent with\\n left lower lobe collapse and/or consolidation and patchy opacity in the right\\n cardiophrenic region. Mild prominence of pulmonary vasculature is noted, but\\n likely accentuated due to technique and low lung volumes. Possible small left\\n pleural effusion. Incidental note is made of fusion hardware in the lower\\n cervical spine.\\n\\n Compared with at 10:07 a.m., I doubt significant interval change.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2189-01-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 90008,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Cerebrovascular event/TIA.\\nHeight: (in) 66\\nWeight (lb): 231\\nBSA (m2): 2.13 m2\\nBP (mm Hg): 135/93\\nHR (bpm): 129\\nStatus: Inpatient\\nDate/Time: at 10:22\\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: Symmetric LVH. Normal LV cavity size. Suboptimal technical\\nquality, a focal LV wall motion abnormality cannot be fully excluded. Overall\\nnormal LVEF (>55%). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: RV not well seen.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\\ncalcification. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized. TR present - cannot be\\nquantified. Indeterminate PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\\nimage quality - poor subcostal views. Suboptimal image quality - poor\\nsuprasternal views. Suboptimal image quality - patient unable to cooperate.\\n\\nConclusions:\\nThe left atrium is mildly dilated. There is 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%). The aortic\\nvalve leaflets are mildly thickened (?#). There is no aortic valve stenosis.\\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\\nthickened. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is\\npresent but cannot be quantified. The pulmonary artery systolic pressure could\\nnot be determined. There is a trivial/physiologic pericardial effusion.\\n\\nIMPRESSION: Suboptimal image quality. No obvious intracardiac source of\\nthromboembolism identified in the setting of very limited echocardiographic\\nviews.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1222512,\n \"text\": \" 1:24 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: To assess line position\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with PICC on right now 3cm out ? Midline vs central\\n REASON FOR THIS EXAMINATION:\\n To assess line position\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Assess PICC line.\\n\\n COMPARISONS: Chest radiograph, .\\n\\n FINDINGS: The PICC ends at the junction of the upper and middle SVC, and has\\n been pulled back since the prior radiograph. A pacemaker is in place with the\\n leads seen in the left ventricle and right atrium. Sternal wires are intact\\n and midline. Multiple clips are seen within the mediastinum. Since the prior\\n radiograph, there has been resolution of the right pleural effusion.\\n Opacification of the left base likely represents a persistent left effusion.\\n There is no evidence of pulmonary edema.\\n\\n IMPRESSION:\\n 1. PICC ends at upper to mid SVC.\\n 2. Persistent left pleural effusion. Resolution of right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-24 00:00:00.000\",\n \"description\": \"CTA NECK W&W/OC & RECONS\",\n \"row_id\": 1221885,\n \"text\": \" 4:25 AM\\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \\n Reason: Dissection\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with symptoms of left-sided weakness and neglect along with\\n concerning EKG changes and chest tightness\\n REASON FOR THIS EXAMINATION:\\n Dissection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: LLTc SAT 4:57 AM\\n Limited examination due to patient motion. NCCT: No acute territorial infarct\\n detected. Chronic parietal lobe focal encephalomalacia unchanged from the\\n reference CT exam performed earlier. No acute hemorrhage. CTA: No dissection,\\n flow limiting stenosis, or aneurysm detected. Multiple subcentimeter thyroid\\n nodules. 3D reconstructions pending.\\n WET READ VERSION #1 LLTc SAT 4:56 AM\\n Limited examination due to patient motion. NCCT: No acute territorial infarct\\n detected. Chronic parietal lobe focal encephalomalacia unchanged from the\\n reference CT exam performed earlier. No acute hemorrhage. CTA: No dissection,\\n flow limiting stenosis, or aneurysm detected. 3D reconstructions pending.\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: CTA of the head and neck.\\n\\n CLINICAL INFORMATION: Patient with left-sided weakness and neglect concerning\\n for EKG changes, for further evaluation.\\n\\n TECHNIQUE: Axial images of the head were obtained without contrast.\\n Following this using departmental protocol CT angiography of the head and neck\\n was acquired.\\n\\n FINDINGS: There is hypodensity in the right thalamus and right occipital lobe\\n which could be due to infarcts of undetermined age. The examination is\\n limited due to patient motion, evaluation for the upper part of the brain is\\n limited. Moderate to severe brain and medial temporal atrophy seen. No\\n obvious area of hemorrhage noted.\\n\\n CT ANGIOGRAPHY OF THE NECK: There is a tortuous proximal left vertebral\\n artery seen. Both vertebral arteries otherwise are patent of the neck with\\n normal appearance of the distal intracranial vertebral and basilar arteries.\\n\\n\\n The carotid arteries are patent bilaterally without stenosis, occlusion or\\n dissection. There are post-operative changes identified in the neck.\\n\\n The intracranial anterior circulation demonstrates patency without stenosis,\\n occlusion or an aneurysm greater than 3 mm in size.\\n\\n IMPRESSION:\\n 1. Limited head CT shows hypodensity in the right thalamus and right\\n occipital region due to infarcts of undetermined age. MRI could provide more\\n (Over)\\n\\n 4:25 AM\\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \\n Reason: Dissection\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n information but patient may not likely be able to get it secondary to presence\\n of a pacemaker. Followup study could be helpful.\\n 2. CT angiography of the head and neck demonstrates no evidence of high-grade\\n stenosis or occlusion. Vascular calcifications seen.\\n 3. Tracheal calcifications and post-operative changes in cervical spine are\\n noted in the neck.\\n\\n COMMENT: This report provided without the availability of 3D reformatted\\n images. When these images are available and if additional information is\\n obtained, an addendum will be given to this report.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-24 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1221886,\n \"text\": \" 4:25 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: Evidence of dissection\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with symptoms of left-sided weakness and neglect along with\\n concerning EKG changes and chest tightness\\n REASON FOR THIS EXAMINATION:\\n Evidence of dissection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: LLTc SAT 5:27 AM\\n 1. No dissection. No PE detected to the subsegmental levels.\\n 2. Trace left pleural effusion with adjacent atelectasis.\\n 3. Mild central pulmonary vascular congestion with mild interstitial edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Left-sided weakness and neglect with concerning EKG changes and\\n chest tightness.\\n\\n No comparison studies available.\\n\\n TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were obtained\\n following the uneventful administration of 70 mL of Omnipaque intravenous\\n contrast. Coronal and sagittal reformations were performed at 5-mm slice\\n thickness.\\n\\n CHEST CT WITH IV CONTRAST:\\n Multiple subcentimeter thyroid nodules are present (2:5). The thyroid gland\\n is not enlarged. Scattered axillary and mediastinal lymph nodes do not meet\\n CT criteria for lymphadenopathy.\\n\\n A left-sided pacemaker generator projects leads into the right atrium and\\n ventricle. There is marked left ventricular hypertrophy with rapid thinning\\n at the apex. Moderate atherosclerotic calcification of the coronary vessels is\\n seen. There is no pericardial effusion. The left atrium is mildly enlarged.\\n\\n The thoracic aorta demonstrates minimal atherosclerotic calcification, and is\\n normal in caliber. There is no dissection. The main pulmonary arteries are\\n normal in caliber. No pulmonary embolus is detected to the subsegmental\\n levels.\\n\\n Trace left pleural effusion is present (2:63). There is mild dependent\\n atelectasis bilaterally, slightly worse at the left base, where there is is\\n pleural thickening and calcifications, probably reflecting chronic\\n post-surgical hemothorax (2:56). There is no pneumothorax.\\n\\n The patient is status post cholecystectomy. Included views of the liver,\\n pancreas, stomach, spleen, adrenal glands, and splenic flexure are normal.\\n\\n OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or\\n lytic lesions are identified. Extensive bridging anterior osteophytosis\\n throughout thoracic spine is compatible with DISH (401B:27).\\n (Over)\\n\\n 4:25 AM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: Evidence of dissection\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n IMPRESSION:\\n 1. No aortic dissection or aneurysm. Normal caliber main pulmonary arteries,\\n with no pulmonary embolus detected to the subsegmental levels.\\n 2. Multiple subcentimeter thyroid nodules.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-25 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1222019,\n \"text\": \" 10:14 AM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: 47 cm Picc in right brachial vein, need Picc tip placement\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with new picc\\n REASON FOR THIS EXAMINATION:\\n 47 cm Picc in right brachial vein, need Picc tip placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 10:07 A.M., \\n\\n HISTORY: Evaluate PICC line placement.\\n\\n IMPRESSION: AP chest compared to at 4:59 a.m.\\n\\n New right PICC line ends in the mid SVC. Mild-to-moderate cardiomegaly and\\n mild mediastinal vascular engorgement are unchanged. Lungs are low in volume\\n but clear. Pleural effusion is small if any. No pneumothorax. No pulmonary\\n edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1222109,\n \"text\": \" 11:35 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: Check placement of Dobhoff tube\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with confusion, agitation, weakness, unable to take PO.\\n REASON FOR THIS EXAMINATION:\\n Check placement of Dobhoff tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Confusion, agitation, weakness. Check Dobbhoff tube placement.\\n\\n CHEST, SINGLE AP PORTABLE VIEW.\\n\\n Right lower chest and lateral right hemidiaphragm excluded from the film.\\n\\n Dobbhoff tube is present. However, it is looped over the level of the fundus,\\n with the radiopaque tip now superimposed over the lower neck and\\n it requires repositioning.\\n\\n Right-sided PICC line present, tip not optimally visualized but likely\\n overlying the distal SVC near the RA junction.\\n\\n Dual-lead left-sided pacemaker present with lead tips over right atrium and\\n right ventricle. Status post sternotomy with mediastinal clips.\\n Cardiomediastinal silhouette is prominent,but unchanged. Allowing for low\\n lung volumes, I doubt overt CHF. Increased retrocardiac density and\\n atelectasis in the right cardiophrenic region are unchanged compared with\\n at 4:27 a.m. Cervical fusion hardware again noted.\\n\\n IMPRESSION:\\n\\n Abnormal placement of Dobbhoff tube -- the tube reaches the gastric fundus,\\n where there is a \\\"hairpin\\\" bend of the tube, then courses back up the\\n esophagus, so that the radiopaque tube tip overlies the neck.\\n\\n Findings discussed with Dr. at approximately 1:45 p.m. on\\n the day of the exam (, phone).\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2189-01-28 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 1222338,\n \"text\": \" 1:23 PM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: eval for aspiration\\n Admitting Diagnosis: QUESTION OF STROKE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 73 year old man with 73 year old man with acute mental status change, clinical\\n evidence of aspiration\\n REASON FOR THIS EXAMINATION:\\n eval for aspiration\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Acute mental status change and clinical evidence of aspiration.\\n\\n SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing videofluoroscopy was\\n performed in conjunction with speech and swallow division. Multiple\\n consistencies of barium were administered. There was intermittent aspiration\\n of thin liquids as well as penetration with thin and nectar thin liquids and\\n nectar. There is mild-to-moderate vallecular residue with solids.\\n\\n IMPRESSION: Intermittent aspiration with thin liquids as well as penetration\\n with thin liquids and nectar. For details, please refer to speech and swallow\\n note in OMR.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2189-01-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 237317,\n \"text\": \"Artifact is present. Sinus rhythm. The P-R interval is prolonged. Left atrial\\nabnormality. Q waves in the anterior leads consistent with myocardial\\ninfarction. Possible non-specific ST-T wave changes. Low voltage in the\\nprecordial leads. Compared to the previous tracing of the rate is slower\\nand ventricular ectopy is no longer present. Low precordial lead voltage is\\nnew.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2189-01-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 237550,\n \"text\": \"Regular supraventricular rhythm - because of baseline artifact, atrial activity\\ncannot be clearly determined. Frequent single ventricular premature beats.\\nProbable old anteroseptal myocardial infarction. Compared to the previous\\ntracing of rate is faster.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2189-01-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 237551,\n \"text\": \"Sinus rhythm. Baseline artifact. Two ventricular premature beats are noted.\\nA-V conduction delay. Left atrial abnormality. Q waves in leads V1-V3\\nindicating an anterior myocardial infarction of undetermined age. The baseline\\nartifact makes further interpretation difficult. Compared to the previous\\ntracing the Q waves in leads V1 and V2 are new but could be again related to\\nlead placement. Previously, only Q waves in lead V1 were noted. The\\npreviously noted Q waves in leads III and aVF are there but difficult to\\ndiscern due to the baseline artifact.\\n\\n\"\n }\n]"}}},{"rowIdx":797,"cells":{"subject_id":{"kind":"number","value":21202,"string":"21,202"},"hadm_id":{"kind":"number","value":104041,"string":"104,041"},"target_text":{"kind":"string","value":"57-year-old man with AML s/p matched unrelated allogeneic stem cell transplant in , complicated by GVHD on chronic prednisone with multiple admission for infections now presents with somnolence in the setting if increased sedative medication use, hypercarbic respiratory distress, cough and CXR with LLL consolidation found to have segmental PE."},"extractive_notes_summ":{"kind":"string","value":"Mild symmetric left ventricular hypertrophy withpreserved global biventricular systolic function.Compared with the prior study (images reviewed) of , the rightventricular cavity is now dilated with free wall hypokinesis c/w an acutepulmonary process (e.g., pulmonary embolism, bronchospasm, etc. Bilateral small pleural effusions, left greater than right, with bilateral lower lobe compressive atelectasis are redemonstrated. The right ventricular cavity is mildly dilated with moderateglobal free wall hypokinesis. Resting tachycardia(HR>100bpm).Conclusions:The left atrium is mildly dilated. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - ventilator. Dual-channel right supraclavicular central venous set ends close to the superior cavoatrial junction. Sinus tachycardia persists. Incidental note of retro-aortic left renal vein is made. Hepatic steatosis. Hepatic steatosis. Regular narrow complex rhythm, probably sinus or atrialtachycardia. Right ventricular cavity dilation withfree wall hypokinesis. There appears to bemore ST segment depression in leads V3-V6 without diagnostic interim change. Extensive bilateral consolidation and peribronchovascular nodular opacities consistent with multifocal infection and aspiration and bilateral small effusions have not significantly changed since the prior study. Bilateral small effusions and right lower lobe pulmonary emboli. Moderate coronary arterial calcification is present. The liver demonstrates diffuse hypoattenuation, consistent with hepatic steatosis. Moderate body wall edema, and asymmetric left lateral abdominal wall edema, relate to third spacing. FINDINGS: In comparison with the study of , the diffuse bilateral pulmonary opacification is essentially unchanged, presenting a pattern of multifocal pneumonia. Bilateral small pleural effusions have slightly worsened. Bilateral femoral head avascular necrosis is unchanged. Pulmonary emboli within the right lower lobar and segmental arteries are redemonstrated. Coronary arteries are moderately calcified. An infrarenal IVC filter is present. No resting LVOT gradient.RIGHT VENTRICLE: Mildly dilated RV cavity. Stable lung base findings include, lingular pneumonia and bibasal peribronchovascular nodular opacities suggestive of aspiration. Known right lower lobe pulmonary emboli not evaluated on this examination. 2:52 PM CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # Reason: VENOGRAM to eval IVC filter Admitting Diagnosis: ALTERED MENTAL STATUS MEDICAL CONDITION: RLL PE REASON FOR THIS EXAMINATION: VENOGRAM to eval IVC filter No contraindications for IV contrast WET READ: FRI 7:03 PM 1. Moderate global RV free wallhypokinesis.AORTIC VALVE: Normal aortic valve leaflets (?#). TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal notch to the upper abdomen without administration of IV contrast and 1.25 mm slice collimation. Pulmonary edema is less likely. New confluent ground-glass opacities in the apical right and left upper lobes. Areas of consolidation in the left upper lobe, lingula, and lower lobes has not worsened; however, there is developing bronchiectasis in lower lobes consistent with post-infectious bronchiectasis. FINDINGS: Status post removal of right subclavian vascular catheter. FINDINGS: Right sided dialysis catheter tip terminates in the low SVC. Dual-channel right supraclavicular central venous set ends in the region of the superior cavoatrial junction. Filling defects compatible with pulmonary embolism are seen in a lobar, segmental and subsegmental level in the right lower lobe. FINAL REPORT CHEST CTA WITH CONTRAST INDICATION: Patient with AML, tachycardia, hypotension, somnolence, rule out PE. COMPARISON: Left lower extremity venous ultrasound of . TECHNIQUE: Bilateral lower extremity venous ultrasound. Mild bronchial wall thickening and interstitial abnormalities secondary to GVHD persist. Mild enlargement of the main pulmonary arteries. There is near-complete opacification of the right and partial opacification of the left mastoid air cells. PE Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OMNIPAQUE Amt: 100 FINAL REPORT (Cont) Small bilateral pleural effusions are new. FINDINGS: Grayscale, color, and spectral Doppler images were obtained of the right and left common femoral, femoral, and popliteal veins. Both the initial and repeat images were degraded by patient motion artifact . FINDINGS: Portable radiograph of the chest demonstrates a new right subclavian line in standard position, terminating in the upper-to-mid SVC. Slight interval improvement in previously noted airspace disease within the right upper lobe. The most proximal portion of the pulmonary embolus is peripheral raising the question if this pulmonary embolism could be chronic. PE No contraindications for IV contrast WET READ: KKgc WED 11:41 PM Pulmonary emboli seen in the right lower lobar pulmonary artery extending into two segmental arteries. CONCLUSION: New right PICC line in standard position, terminating in the mid-to-upper SVC. DVT FINAL REPORT INDICATION: Tachycardia and hypoxemia, evaluate for DVT. Smaller region of consolidation in the right lower lung medially is either a second focus of pneumonia or atelectasis. Right lower lobe lobar to subsegmental pulmonary acute embolism. COMPARISON: Head CT dated . OSSEOUS STRUCTURES: Post-surgical changes and compression deformities of the thoracic spine are stable. There is fluid in the bilateral mastoid air cells as well as mucosal thickening in the right maxillary sinus, in the anterior ethmoid air cells and mild mucosal thickening in the frontal sinuses. Paranasal sinus disease and bilateral mastoid air cell fluid. Also, bilateral pleural effusions, with left greater than right, are again demonstrated on this study. Small left and possible small right pleural effusions are unchanged. Mild mucosal thickening is seen in both maxillary, ethmoid and frontal sinuses. Mild mid thoracic vertebral compressions and thoracic spine fixation hardware, stable."},"n_notes":{"kind":"number","value":21,"string":"21"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2148-10-02 00:00:00.000","description":"Report","row_id":84148,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary embolus. Right ventricular function.\nHeight: (in) 64\nWeight (lb): 250\nBSA (m2): 2.15 m2\nBP (mm Hg): 101/70\nHR (bpm): 125\nStatus: Inpatient\nDate/Time: at 15:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npt supine, intubated on vent\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator. Resting tachycardia\n(HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. The right ventricular cavity is mildly dilated with moderate\nglobal free wall hypokinesis. The aortic valve leaflets (?#) appear\nstructurally normal with good leaflet excursion. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The pulmonary artery\nsystolic pressure could not be determined. There is an anterior space which\nmost likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Right ventricular cavity dilation with\nfree wall hypokinesis. Mild symmetric left ventricular hypertrophy with\npreserved global biventricular systolic function.\n\nCompared with the prior study (images reviewed) of , the right\nventricular cavity is now dilated with free wall hypokinesis c/w an acute\npulmonary process (e.g., pulmonary embolism, bronchospasm, etc.).\n\n\n"},{"category":"Radiology","chartdate":"2148-10-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256591,"text":" 1:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fluid overload vs. pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57-year-old man with AML s/p matched unrelated allogeneic stem cell transplant\n in , complicated by GVHD on chronic prednisone with multiple admission for\n infections now presents with somnolence in the setting if increased sedative\n medication use, hypercarbic respiratory distress, cough and CXR with LLL\n consolidation.\n REASON FOR THIS EXAMINATION:\n fluid overload vs. pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:58 P.M. ON \n\n HISTORY: 57-year-old man with AML and stem cell transplant.\n Graft-versus-host disease, on prednisone. Now somnolent.\n\n IMPRESSION: AP chest compared to :\n\n Progressive heterogeneous opacification in the left mid and lower lung zone is\n most likely pneumonia worsening since . There could be a second\n focus of right infrahilar pneumonia, also advancing. Cardiomediastinal\n silhouette is essentially unchanged over several years. Dual-channel right\n supraclavicular central venous set ends close to the superior cavoatrial\n junction. No pneumothorax.\n\n\n"},{"category":"ECG","chartdate":"2148-10-09 00:00:00.000","description":"Report","row_id":225516,"text":"Baseline artifact. Regular narrow complex rhythm, probably sinus or atrial\ntachycardia. Borderline intraventricular conduction delay. Probable\nST-T wave abnormalities. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2148-10-06 00:00:00.000","description":"Report","row_id":225517,"text":"Sinus tachycardia persists. Diffuse non-specific ST-T wave changes. No\nsignificant change compared to previous tracing of .\n\n"},{"category":"ECG","chartdate":"2148-10-02 00:00:00.000","description":"Report","row_id":225518,"text":"Sinus tachycardia with increase in rate as compared to the previous tracing\nof . Diffuse non-specific ST-T wave changes are more prominent in the\ncontext of wandering baseline and much baseline artifact. There appears to be\nmore ST segment depression in leads V3-V6 without diagnostic interim change.\n\n"},{"category":"Radiology","chartdate":"2148-10-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256959,"text":" 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with likely fungal PNA.\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Likely fungal pneumonia, to assess for change.\n\n FINDINGS: In comparison with the study of , the diffuse bilateral\n pulmonary opacification is essentially unchanged, presenting a pattern of\n multifocal pneumonia. Some element of elevated pulmonary venous pressure may\n be present.\n\n Extensive fixation devices about the cervical and upper thoracic spine are\n again seen.\n\n IMPRESSION: Little change.\n\n\n"},{"category":"Radiology","chartdate":"2148-10-04 00:00:00.000","description":"CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS","row_id":1256771,"text":" 2:52 PM\n CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # \n Reason: VENOGRAM to eval IVC filter\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n RLL PE\n REASON FOR THIS EXAMINATION:\n VENOGRAM to eval IVC filter\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 7:03 PM\n 1. No evidence of IVC or iliac vein thrombosis. IVC filter in place.\n 2. Extensive bilateral consolidation and peribronchovascular nodular\n opacities consistent with multifocal infection and aspiration and bilateral\n small effusions have not significantly changed since the prior study.\n 3. Hepatic steatosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with pulmonary embolism with an IVC filter in\n place, to assess for IVC thrombosis.\n\n COMPARISON: CT abdomen and pelvis without contrast and CTA of the\n chest .\n\n DLP: .80 mGy-cm.\n\n TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained\n prior to and after the intravenous administration of 150 cc of Omnipaque\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: Multiple heterogeneous areas of consolidation in the lingula, is\n most suggestive of pneumonia. Peribronchial nodular opacities in both lung\n bases are likely due to aspiration. Bilateral small pleural effusions, left\n greater than right, with bilateral lower lobe compressive atelectasis are\n redemonstrated. Pulmonary emboli within the right lower lobar and segmental\n arteries are redemonstrated. These findings have not significantly changed\n since the prior study. Moderate coronary arterial calcification is present.\n There is no pericardial effusion.\n\n The liver demonstrates diffuse hypoattenuation, consistent with hepatic\n steatosis. There is no intra- or extra-hepatic biliary dilatation.\n Hyperdense material within the gallbladder may reflect vicarious excretion of\n contrast or gallbladder sludge. The adrenal glands, spleen, and pancreas are\n normal. Mild fat stranding in the retroperitoneum, likely relates to third\n spacing. An infrarenal IVC filter is present. The IVC is patent throughout\n without evidence of thrombosis. The common iliac and external iliac veins are\n patent, without evidence of deep venous thrombosis. Incidental note of\n retro-aortic left renal vein is made. The stomach, small and large bowel\n loops, including the appendix is normal. There is no intra-abdominal free\n fluid or air. Moderate body wall edema, and asymmetric left lateral abdominal\n wall edema, relate to third spacing.\n (Over)\n\n 2:52 PM\n CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # \n Reason: VENOGRAM to eval IVC filter\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is decompressed with\n wall thickening. Small locules of air within the bladder relates to the Foley\n catheter. The prostate, rectum, and sigmoid colon are unremarkable. No\n significant pelvic lymphadenopathy or free fluid is seen.\n\n BONES AND SOFT TISSUES: Multiple bilateral healing rib fractures are seen in\n the imaged lower ribs. Dense sclerosis at the right iliac , likely a bone\n island is unchanged. Old fractures of bilateral inferior pubic rami are seen.\n Multiple thoracic and lumbar vertebral body compressions involving L3, L1,\n T12, and T7 vertebral bodies are similar. Post-vertebroplasty changes are\n seen in L5 vertebra. Bilateral femoral head avascular necrosis is unchanged.\n\n IMPRESSION:\n 1. No evidence of IVC or iliac vein thrombosis. IVC filter in place.\n 2. Stable lung base findings include, lingular pneumonia and bibasal\n peribronchovascular nodular opacities suggestive of aspiration. Bilateral\n small effusions and right lower lobe pulmonary emboli.\n 3. Hepatic steatosis.\n\n"},{"category":"Radiology","chartdate":"2148-10-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256909,"text":" 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with intubation\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation.\n\n FINDINGS: In comparison with the study of , there may be further\n increase in the bilateral pulmonary opacifications, especially at the right\n base. The findings are again consistent with widespread pneumonia, though\n there could be some element of vascular congestion. Extensive spinal fixation\n devices are again seen.\n\n\n"},{"category":"Radiology","chartdate":"2148-10-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256827,"text":" 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA vs Edema\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p air embolism, continued poor respiratory status\n REASON FOR THIS EXAMINATION:\n PNA vs Edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Radiograph of one day earlier.\n\n FINDINGS: Widespread combined alveolar and interstitial opacities affecting\n the left lung to a greater degree than the right have progressed in the\n interval, particularly in the right lower lung where there is also an\n increasing pleural effusion with adjacent consolidation and/or atelectasis.\n Small left pleural effusion also appears increased from prior radiograph.\n\n"},{"category":"Radiology","chartdate":"2148-10-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256838,"text":" 11:21 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate for rib fracture, pneumothorax\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man immunocompromised with pneumonia, s/p air embolism ,\n continued poor respiratory status now with sudden L sharp chest pain with\n movement reproducable with palpation\n REASON FOR THIS EXAMINATION:\n please evaluate for rib fracture, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, WITH COMPARISON STUDY OF EARLIER THE SAME\n DATE\n\n FINDINGS: Right pleural effusion has decreased in size with associated\n improvement in adjacent right basilar atelectasis. Multifocal areas of\n heterogeneous consolidation involving the left lung to a greater degree than\n the right, have slightly improved. A small hyperlucency is present in the\n periphery of the left upper lobe at the level of the second and third anterior\n ribs, but no discrete visceral pleural line is identified. This may represent\n an area of spared lung parenchyma from the presumed multifocal pneumonia, but\n attention to this area on short-term followup radiograph may be helpful to\n exclude an atypical presentation of pneumothorax, given clinical suspicion for\n this entity.\n\n\n"},{"category":"Radiology","chartdate":"2148-10-06 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1256851,"text":" 5:45 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please evaluate for fungal pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man immunocompromised with PE, pneumonia, and respiratory distress\n REASON FOR THIS EXAMINATION:\n please evaluate for fungal pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GMSj SUN 8:01 PM\n rogressive multilobar consolidation concerning for worsening pneumonia. New\n confluent ground-glass opacities in the apical right and left upper lobes.\n New tree-in- opacities predominantly in the right upper and right middle\n lobe. Persistent bibasilar consolidation may be a combination of pneumonia\n and atelectasis given signs of volume loss. Unchanged small bilateral pleural\n effusions. Known right lower lobe pulmonary emboli not evaluated on this\n examination. Findings are non-specific for a particular pathogen and overall\n reflect endobronchial spread of infection. Fungal pneumonia remains within\n the differential though CT findings are non-specific. The presence of pleural\n effusions makes PCP much less likely. D/w Dr. at 7:55 pm on\n by telephone. GSenapati \n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITHOUT CONTRAST\n\n INDICATION: Patient immunocompromised with PE, pneumonia, respiratory\n distress, evaluation for fungal pneumonia.\n\n COMPARISON: Multiple chest CTs from to recent CTA of .\n\n TECHNIQUE:\n\n Axial helical MDCT images were obtained from the suprasternal notch to the\n upper abdomen without administration of IV contrast and 1.25 mm slice\n collimation. Multiplanar reformatted images in coronal and sagittal axes were\n generated.\n\n FINDINGS:\n\n LUNG AND AIRWAYS:\n\n There is increase of ground-glass opacities with interlobular septal\n thickening, mainly in upper lobes but also in the lingula.\n\n Bilateral widespread tree-in- has also increased.\n\n Areas of consolidation in the left upper lobe, lingula, and lower lobes has\n not worsened; however, there is developing bronchiectasis in lower lobes\n consistent with post-infectious bronchiectasis.\n\n (Over)\n\n 5:45 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please evaluate for fungal pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Secretions are seen in the airways, but the airways are patent until\n subsegmental level.\n\n MEDIASTINUM:\n\n There is no pathologic superclavicular, mediastinal, or axillary lymph node\n enlargement by CT size criteria, all the small lymph nodes are unchanged.\n\n Mediastinal lipomatosis is probably explained by corticosteroid. Bilateral\n small pleural effusions have slightly worsened. There is no pericardial\n effusion. Coronary arteries are moderately calcified.\n\n UPPER ABDOMEN: Liver steatosis is severe. The spleen is not enlarged.\n\n OSSEOUS STRUCTURES: Multiple costal fractures and compression fractures of\n the spine are stable. There is no new lesion.\n\n CONCLUSION:\n\n Patient is known with AML and fever.\n\n 1. Bilateral ground-glass opacities with interlobular septal thickening have\n significantly worsened since . They are predominant in upper\n lobes. The most likely diagnosis is an infectious process (pneumocystis,\n viral) considering that they were already present on , /.\n Pulmonary edema is less likely. Although bacterial or fungal infection cannot\n be excluded, the radiologic features are not classic for those pathogens.\n\n 2. Developing post-infectious bronchiectasis are new in lower lobes.\n\n"},{"category":"Radiology","chartdate":"2148-10-07 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1256882,"text":" 1:06 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 42cm right basilic. \n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 42cm right basilic. \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with new right PICC placement.\n\n COMPARISON: Comparison is made to same-day radiograph of the chest from 8\n hours prior. This study is read in conjunction with CT of the chest from\n .\n\n FINDINGS: Portable radiograph of the chest demonstrates a new right\n subclavian line in standard position, terminating in the upper-to-mid SVC.\n There is no pneumothorax. Low lung volumes persist and are unchanged since\n the prior study along with widespread bilateral opacifications with the left\n greater than right. Also, bilateral pleural effusions, with left greater than\n right, are again demonstrated on this study.\n\n CONCLUSION: New right PICC line in standard position, terminating in the\n mid-to-upper SVC. Otherwise, unchanged since the prior radiograph.\n\n The above findings were communicated to IV nurse, , at 13:38 via\n telephone by Dr. , at the time of discovery.\n\n"},{"category":"Radiology","chartdate":"2148-10-02 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1256635,"text":" 12:49 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with tachycardia, hypoxemia\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachycardia and hypoxemia, evaluate for DVT.\n\n COMPARISON: Left lower extremity venous ultrasound of .\n\n TECHNIQUE: Bilateral lower extremity venous ultrasound.\n\n FINDINGS: Grayscale, color, and spectral Doppler images were obtained of the\n right and left common femoral, femoral, and popliteal veins. Normal flow,\n compressibility, augmentation, and waveforms are demonstrated. No\n intraluminal thrombus is identified. Normal color flow is visualized in the\n posterior tibial and peroneal veins bilaterally. Visualization of the\n peroneal veins is somewhat limited due to calf edema and limited acoustic\n penetration.\n\n IMPRESSION: No deep venous thrombosis in right or left lower extremity.\n Bilateral calf edema.\n\n\n"},{"category":"Radiology","chartdate":"2148-10-07 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1256892,"text":" 3:21 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: ? fungal process\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: GADAVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with fungemia, HA, decreased hearing\n REASON FOR THIS EXAMINATION:\n ? fungal process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 58-year-old man with fungemia, headache, decreased\n hearing. Question of fungal process.\n\n COMPARISON: Head CT dated .\n\n TECHNIQUE: MRI of the head was performed prior to and following the\n intravenous administration of 10 mL Gadovist utilizing standard department\n protocol.\n\n FINDINGS: There is a small punctate focus of slow diffusion in the left\n parietal lobe deep white matter. Elsewhere, there are a few scattered\n punctate foci of FLAIR signal abnormality in the periventricular and\n subcortical white matter bilaterally which are non-specific. There is no\n evidence of hemorrhage. The images are degraded by motion artifact,\n particularly on the post-contrast sequences, but there is no obvious area of\n abnormal enhancement.\n\n There is fluid in the bilateral mastoid air cells as well as mucosal\n thickening in the right maxillary sinus, in the anterior ethmoid air cells and\n mild mucosal thickening in the frontal sinuses. The orbital contents are\n unremarkable.\n\n IMPRESSION:\n 1. Punctate focus of slow diffusion in the left parietal lobe deep white\n matter compatible with infarct.\n 2. Images are degraded by motion artifact, but there is no evidence for\n abnormal enhancement. No definite findings to suggest fungal infection.\n 3. Paranasal sinus disease and bilateral mastoid air cell fluid.\n\n"},{"category":"Radiology","chartdate":"2148-09-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256522,"text":" 11:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pneumonia vs chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 58M with sob\n REASON FOR THIS EXAMINATION:\n eval pneumonia vs chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n TECHNIQUE: Upright AP view of the chest.\n\n COMPARISON: Chest radiograph and chest CTA from .\n\n FINDINGS:\n\n Right sided dialysis catheter tip terminates in the low SVC. Lung volumes are\n low. Heart size is normal. The mediastinal and hilar contours are unchanged.\n There is crowding of the bronchovascular structures, but no frank pulmonary\n edema is present. Previously noted patchy opacities in the right upper lobe\n have improved. There is worsening ill-defined opacification within the left\n lung base. No large pleural effusion or pneumothorax is demonstrated.\n Bronchial wall thickening is most pronounced within the left lung base and\n likely reflective of bronchitis. Areas of callus formation are noted\n involving multiple bilateral ribs. Partially imaged is fusion hardware within\n the cervical and thoracic spine.\n\n IMPRESSION:\n\n 1. Worsening opacification in the left lung base with associated bronchial\n wall thickening concerning for infection.\n\n 2. Slight interval improvement in previously noted airspace disease within the\n right upper lobe.\n\n 3. No definite pulmonary edema.\n\n DFDdp\n\n"},{"category":"Radiology","chartdate":"2148-10-05 00:00:00.000","description":"REMOVE TUNNELED CENTRAL W/O PORT","row_id":1256901,"text":" 6:27 PM\n DIALYSIS REMOVE Clip # \n Reason: Please remove tunnel line. Patient had placed in by\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old BMT patient in FOR THIS EXAMINATION:\n Please remove tunnel line. Patient had placed in by IR. Must be\n removed for yeast growing in blood, sputum and urine.\n ______________________________________________________________________________\n FINAL REPORT\n 15:15\n Request for a triple lumen tunneled line removal for septic\n patient was placed on evening. As patient was on heparin,\n and this has to be stopped for procedure, arrangements were made\n to stop it morning . Case was discussed with attending Dr\n , who suggested to remove the line on the\n floor. The case was reviewed, as well as potential complications.\n\n After the heparin was stopped for 3.5 hours on the 20th, I came\n into the ICU for removal of the line. Procedure was explained for the patient.\n\n\n Steril field was created, 10 ml of local lidocaine were injected for\n anesthesia, and blunt dissection with was performed around the cuff.\n Singificant fibrosis was noted and gentle traction was applied.\n As the traction was applied, I continued dissection with the\n . At a point, the catheter ripped, and the proximal piece\n just came out. Imediatelly pressure was applied in the distal\n burried fragment, at the level of the clavicle. Following,\n oxygen saturation of the patient dropped, and a nurse came in and\n also helped holding the burried piece of the catheter. Patient\n was placed on left lateral decubitus (right side up). Dr was\n immediately informed. Following, oxygen saturation of the patient improved\n and sat was 98% on oxygen mask. Vascular surgery was also\n immediately contact who came in and perfomed blunt dissection and\n the whole catheter was removed. Tip was sent to culture. Catheter piece was\n sent to analysis.\n\n\n\n"},{"category":"Radiology","chartdate":"2148-10-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256610,"text":" 10:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Worsening/new infiltrate?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pneumonia, now febrile, somnolent most of day after pain\n meds so concern for aspiration.\n REASON FOR THIS EXAMINATION:\n Worsening/new infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:22 P.M. ON \n\n HISTORY: 58-year-old man with pneumonia, febrile and somnolent.\n\n IMPRESSION: AP chest compared to , 1:58 p.m.:\n\n Previous pulmonary vascular congestion has improved, but there is still very\n extensive consolidation in the left lung due to pneumonia, without\n improvement, possibly worsened. Smaller region of consolidation in the right\n lower lung medially is either a second focus of pneumonia or atelectasis.\n Mild cardiomegaly is stable. Dual-channel right supraclavicular central\n venous set ends in the region of the superior cavoatrial junction. No\n pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2148-10-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256813,"text":" 5:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: air embolism, line location\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with AML had hypoxia during right tunnelled line removal\n REASON FOR THIS EXAMINATION:\n air embolism, line location\n ______________________________________________________________________________\n WET READ: MDAg SAT 7:39 PM\n no evidence of retained fragment. bilateral opacities L>R may be edema or\n infection\n -MAgarwal d/w Dr. by phone at 7:30pm .\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n FINDINGS: Status post removal of right subclavian vascular catheter.\n Widespread heterogeneous combined alveolar and interstitial opacities\n affecting the left lung to a greater degree than the right, have progressed in\n the interval, and may represent a multifocal pneumonia with or without\n coexisting pulmonary edema. Pulmonary hemorrhage is also possible in the\n appropriate clinical setting.\n\n"},{"category":"Radiology","chartdate":"2148-10-02 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1256667,"text":" 9:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? hemorrhage or mass lesion\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with AML, headaches, tachycardia, hypotension, somnolence, TTE\n with large hypokinetic RV concerning for PE\n REASON FOR THIS EXAMINATION:\n ? hemorrhage or mass lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:40 AM\n 1. Extremely limited study due to motion artifact, within this limitation, no\n acute intracranial pathology.\n 2. Multifocal paranasal sinus and bilateral mastoid air cell opacification.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with AML, tachycardia, hypotension and\n somnolence.\n\n COMPARISON: CT head without contrast, .\n\n TECHNIQUE: Multidetector CT imaging of the head was obtained without\n intravenous contrast. Sagittal and coronal reformations were performed and\n reviewed. Both the initial and repeat images were degraded by patient motion\n artifact\n .\n FINDINGS: Limited study due to motion artifact. Within this limitation,\n there is no large intracranial hemorrhage, edema, mass or mass effect. The\n -white matter differentiation is preserved. The ventricles and sulci are\n mildly enlarged, consistent with mild involutional changes. Basal cisterns\n are normal. Mild mucosal thickening is seen in both maxillary, ethmoid and\n frontal sinuses. Bilateral symmetric exophthalmos is unchanged. Bilateral\n intraocular lens implants are noted.\n There is near-complete opacification of the right and partial opacification of\n the left mastoid air cells.\n\n IMPRESSION:\n 1. Limited study due to motion artifact, within this limitation, no acute\n intracranial pathology.\n 2. Multifocal paranasal sinus and bilateral mastoid air cell opacification.\n\n"},{"category":"Radiology","chartdate":"2148-10-02 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1256669,"text":" 10:48 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with AML, tachycardia, hypotension, somnolence, TTE with large\n hypokinetic RV concerning for PE\n REASON FOR THIS EXAMINATION:\n ? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc WED 11:41 PM\n Pulmonary emboli seen in the right lower lobar pulmonary artery extending into\n two segmental arteries. Assessment of upper lobe vessels significantly limited\n by motion. No evidence of right heart strain. Mild enlargement of the main\n pulmonary arteries. Multifocal new areas of heterogeneous parenchymal\n consolidation seen in both lungs,predominantly the left lung, are worrisome\n for infection. Dense bilateral lower lobe consolidations with small pleural\n effusions. Mild bronchial wall thickening and interstitial abnormalities\n secondary to GVHD persist. Bilateral healing rib fractures. Mild mid thoracic\n vertebral compressions and thoracic spine fixation hardware, stable.\n Kkaliannan d/w Dr. at 11:35 p.m, immediately after discovery.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CTA WITH CONTRAST\n\n INDICATION: Patient with AML, tachycardia, hypotension, somnolence, rule out\n PE.\n\n COMPARISON: Multiple chest CTs from to .\n\n TECHNIQUE:\n\n Axial helical MDCT images were obtained from the suprasternal notch to the\n upper abdomen with administration of IV contrast following the CTPA protocol.\n Multiplanar reformatted images were generated.\n\n FINDINGS:\n\n HEART AND GREAT VESSELS:\n\n Multiple motion artifacts are mostly in bilateral upper lobe arteries.\n Filling defects compatible with pulmonary embolism are seen in a lobar,\n segmental and subsegmental level in the right lower lobe. The most proximal\n portion of the pulmonary embolus is peripheral raising the question if this\n pulmonary embolism could be chronic. This is new since . There is\n no dilatation of main pulmonary artery or right heart chamber. There is no\n acute aortic syndrome. Coronary artery calcification is stable. There is no\n pericardial effusion.\n\n MEDIASTINUM:\n (Over)\n\n 10:48 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Small bilateral pleural effusions are new. There is no pathologic\n superclavicular, mediastinal or axillary lymph node enlargement by CT size\n criteria. Mediastinal lipomatosis is unchanged.\n\n LUNGS AND AIRWAYS:\n\n Worsening of multifocal consolidations, more severe in left upper lobe and\n bilateral lower lobes, is compatible with an infectious process. Small\n residual nodules in right middle lobe and right lower lobe described on\n previous exam is hard to assess throughout those changes.\n\n The airways are patent to the subsegmental level.\n\n UPPER ABDOMEN:\n\n This study is not tailored for assessment for intra-abdominal organs. Liver\n steatosis is severe. The spleen is not enlarged.\n\n OSSEOUS STRUCTURES:\n\n Post-surgical changes and compression deformities of the thoracic spine are\n stable. There are also bilateral rib fractures.\n\n CONCLUSION:\n\n 1. Right lower lobe lobar to subsegmental pulmonary acute embolism. The most\n proximal portion of the filling defect is peripheral in the artery raising the\n question if this could be chronic but new since . There is no\n dilatation of main pulmonary artery or right heart .\n\n 2. Worsening of bilateral multifocal pneumonia.\n\n"},{"category":"Radiology","chartdate":"2148-10-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1256859,"text":" 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for worsening pna vs. pulmonary edema\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man immunocompromised with pneumonia, s/p air embolism, continued\n poor respiratory status. Worsening CXR on .\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening pna vs. pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: Radiograph of one day earlier.\n\n FINDINGS: Lung volumes are slightly lower compared to prior study.\n Cardiomediastinal contours are stable in appearance allowing for this factor.\n Widespread heterogeneous pulmonary opacities affecting the left lung to a\n greater degree than the right have worsened in the lower lung since the prior\n study, and likely represent a multilobar pneumonia. Small left and possible\n small right pleural effusions are unchanged.\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2148-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 84148,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Pulmonary embolus. Right ventricular function.\\nHeight: (in) 64\\nWeight (lb): 250\\nBSA (m2): 2.15 m2\\nBP (mm Hg): 101/70\\nHR (bpm): 125\\nStatus: Inpatient\\nDate/Time: at 15:10\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\npt supine, intubated on vent\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\\nabnormality cannot be fully excluded. No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\\nhypokinesis.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\nIndeterminate PA systolic pressure.\\n\\nPERICARDIUM: There is an anterior space which most likely represents a fat\\npad, though a loculated anterior pericardial effusion cannot be excluded.\\n\\nGENERAL COMMENTS: Suboptimal image quality - ventilator. Resting tachycardia\\n(HR>100bpm).\\n\\nConclusions:\\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\\nfully excluded. The right ventricular cavity is mildly dilated with moderate\\nglobal free wall hypokinesis. The aortic valve leaflets (?#) appear\\nstructurally normal with good leaflet excursion. There is no aortic valve\\nstenosis. No aortic regurgitation is seen. The mitral valve appears\\nstructurally normal with trivial mitral regurgitation. The pulmonary artery\\nsystolic pressure could not be determined. There is an anterior space which\\nmost likely represents a prominent fat pad.\\n\\nIMPRESSION: Suboptimal image quality. Right ventricular cavity dilation with\\nfree wall hypokinesis. Mild symmetric left ventricular hypertrophy with\\npreserved global biventricular systolic function.\\n\\nCompared with the prior study (images reviewed) of , the right\\nventricular cavity is now dilated with free wall hypokinesis c/w an acute\\npulmonary process (e.g., pulmonary embolism, bronchospasm, etc.).\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256591,\n \"text\": \" 1:34 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: fluid overload vs. pneumonia\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57-year-old man with AML s/p matched unrelated allogeneic stem cell transplant\\n in , complicated by GVHD on chronic prednisone with multiple admission for\\n infections now presents with somnolence in the setting if increased sedative\\n medication use, hypercarbic respiratory distress, cough and CXR with LLL\\n consolidation.\\n REASON FOR THIS EXAMINATION:\\n fluid overload vs. pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 1:58 P.M. ON \\n\\n HISTORY: 57-year-old man with AML and stem cell transplant.\\n Graft-versus-host disease, on prednisone. Now somnolent.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Progressive heterogeneous opacification in the left mid and lower lung zone is\\n most likely pneumonia worsening since . There could be a second\\n focus of right infrahilar pneumonia, also advancing. Cardiomediastinal\\n silhouette is essentially unchanged over several years. Dual-channel right\\n supraclavicular central venous set ends close to the superior cavoatrial\\n junction. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2148-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 225516,\n \"text\": \"Baseline artifact. Regular narrow complex rhythm, probably sinus or atrial\\ntachycardia. Borderline intraventricular conduction delay. Probable\\nST-T wave abnormalities. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2148-10-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 225517,\n \"text\": \"Sinus tachycardia persists. Diffuse non-specific ST-T wave changes. No\\nsignificant change compared to previous tracing of .\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2148-10-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 225518,\n \"text\": \"Sinus tachycardia with increase in rate as compared to the previous tracing\\nof . Diffuse non-specific ST-T wave changes are more prominent in the\\ncontext of wandering baseline and much baseline artifact. There appears to be\\nmore ST segment depression in leads V3-V6 without diagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256959,\n \"text\": \" 5:17 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? Interval change\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with likely fungal PNA.\\n REASON FOR THIS EXAMINATION:\\n ? Interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Likely fungal pneumonia, to assess for change.\\n\\n FINDINGS: In comparison with the study of , the diffuse bilateral\\n pulmonary opacification is essentially unchanged, presenting a pattern of\\n multifocal pneumonia. Some element of elevated pulmonary venous pressure may\\n be present.\\n\\n Extensive fixation devices about the cervical and upper thoracic spine are\\n again seen.\\n\\n IMPRESSION: Little change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-04 00:00:00.000\",\n \"description\": \"CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS\",\n \"row_id\": 1256771,\n \"text\": \" 2:52 PM\\n CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # \\n Reason: VENOGRAM to eval IVC filter\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n RLL PE\\n REASON FOR THIS EXAMINATION:\\n VENOGRAM to eval IVC filter\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: FRI 7:03 PM\\n 1. No evidence of IVC or iliac vein thrombosis. IVC filter in place.\\n 2. Extensive bilateral consolidation and peribronchovascular nodular\\n opacities consistent with multifocal infection and aspiration and bilateral\\n small effusions have not significantly changed since the prior study.\\n 3. Hepatic steatosis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 58-year-old man with pulmonary embolism with an IVC filter in\\n place, to assess for IVC thrombosis.\\n\\n COMPARISON: CT abdomen and pelvis without contrast and CTA of the\\n chest .\\n\\n DLP: .80 mGy-cm.\\n\\n TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained\\n prior to and after the intravenous administration of 150 cc of Omnipaque\\n intravenous contrast. Sagittal and coronal reformats were generated and\\n reviewed.\\n\\n FINDINGS: Multiple heterogeneous areas of consolidation in the lingula, is\\n most suggestive of pneumonia. Peribronchial nodular opacities in both lung\\n bases are likely due to aspiration. Bilateral small pleural effusions, left\\n greater than right, with bilateral lower lobe compressive atelectasis are\\n redemonstrated. Pulmonary emboli within the right lower lobar and segmental\\n arteries are redemonstrated. These findings have not significantly changed\\n since the prior study. Moderate coronary arterial calcification is present.\\n There is no pericardial effusion.\\n\\n The liver demonstrates diffuse hypoattenuation, consistent with hepatic\\n steatosis. There is no intra- or extra-hepatic biliary dilatation.\\n Hyperdense material within the gallbladder may reflect vicarious excretion of\\n contrast or gallbladder sludge. The adrenal glands, spleen, and pancreas are\\n normal. Mild fat stranding in the retroperitoneum, likely relates to third\\n spacing. An infrarenal IVC filter is present. The IVC is patent throughout\\n without evidence of thrombosis. The common iliac and external iliac veins are\\n patent, without evidence of deep venous thrombosis. Incidental note of\\n retro-aortic left renal vein is made. The stomach, small and large bowel\\n loops, including the appendix is normal. There is no intra-abdominal free\\n fluid or air. Moderate body wall edema, and asymmetric left lateral abdominal\\n wall edema, relate to third spacing.\\n (Over)\\n\\n 2:52 PM\\n CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # \\n Reason: VENOGRAM to eval IVC filter\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is decompressed with\\n wall thickening. Small locules of air within the bladder relates to the Foley\\n catheter. The prostate, rectum, and sigmoid colon are unremarkable. No\\n significant pelvic lymphadenopathy or free fluid is seen.\\n\\n BONES AND SOFT TISSUES: Multiple bilateral healing rib fractures are seen in\\n the imaged lower ribs. Dense sclerosis at the right iliac , likely a bone\\n island is unchanged. Old fractures of bilateral inferior pubic rami are seen.\\n Multiple thoracic and lumbar vertebral body compressions involving L3, L1,\\n T12, and T7 vertebral bodies are similar. Post-vertebroplasty changes are\\n seen in L5 vertebra. Bilateral femoral head avascular necrosis is unchanged.\\n\\n IMPRESSION:\\n 1. No evidence of IVC or iliac vein thrombosis. IVC filter in place.\\n 2. Stable lung base findings include, lingular pneumonia and bibasal\\n peribronchovascular nodular opacities suggestive of aspiration. Bilateral\\n small effusions and right lower lobe pulmonary emboli.\\n 3. Hepatic steatosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256909,\n \"text\": \" 4:32 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with intubation\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Intubation.\\n\\n FINDINGS: In comparison with the study of , there may be further\\n increase in the bilateral pulmonary opacifications, especially at the right\\n base. The findings are again consistent with widespread pneumonia, though\\n there could be some element of vascular congestion. Extensive spinal fixation\\n devices are again seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256827,\n \"text\": \" 5:07 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PNA vs Edema\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man s/p air embolism, continued poor respiratory status\\n REASON FOR THIS EXAMINATION:\\n PNA vs Edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n COMPARISON: Radiograph of one day earlier.\\n\\n FINDINGS: Widespread combined alveolar and interstitial opacities affecting\\n the left lung to a greater degree than the right have progressed in the\\n interval, particularly in the right lower lung where there is also an\\n increasing pleural effusion with adjacent consolidation and/or atelectasis.\\n Small left pleural effusion also appears increased from prior radiograph.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256838,\n \"text\": \" 11:21 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please evaluate for rib fracture, pneumothorax\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man immunocompromised with pneumonia, s/p air embolism ,\\n continued poor respiratory status now with sudden L sharp chest pain with\\n movement reproducable with palpation\\n REASON FOR THIS EXAMINATION:\\n please evaluate for rib fracture, pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, WITH COMPARISON STUDY OF EARLIER THE SAME\\n DATE\\n\\n FINDINGS: Right pleural effusion has decreased in size with associated\\n improvement in adjacent right basilar atelectasis. Multifocal areas of\\n heterogeneous consolidation involving the left lung to a greater degree than\\n the right, have slightly improved. A small hyperlucency is present in the\\n periphery of the left upper lobe at the level of the second and third anterior\\n ribs, but no discrete visceral pleural line is identified. This may represent\\n an area of spared lung parenchyma from the presumed multifocal pneumonia, but\\n attention to this area on short-term followup radiograph may be helpful to\\n exclude an atypical presentation of pneumothorax, given clinical suspicion for\\n this entity.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-06 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1256851,\n \"text\": \" 5:45 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: please evaluate for fungal pneumonia\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man immunocompromised with PE, pneumonia, and respiratory distress\\n REASON FOR THIS EXAMINATION:\\n please evaluate for fungal pneumonia\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: GMSj SUN 8:01 PM\\n rogressive multilobar consolidation concerning for worsening pneumonia. New\\n confluent ground-glass opacities in the apical right and left upper lobes.\\n New tree-in- opacities predominantly in the right upper and right middle\\n lobe. Persistent bibasilar consolidation may be a combination of pneumonia\\n and atelectasis given signs of volume loss. Unchanged small bilateral pleural\\n effusions. Known right lower lobe pulmonary emboli not evaluated on this\\n examination. Findings are non-specific for a particular pathogen and overall\\n reflect endobronchial spread of infection. Fungal pneumonia remains within\\n the differential though CT findings are non-specific. The presence of pleural\\n effusions makes PCP much less likely. D/w Dr. at 7:55 pm on\\n by telephone. GSenapati \\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST WITHOUT CONTRAST\\n\\n INDICATION: Patient immunocompromised with PE, pneumonia, respiratory\\n distress, evaluation for fungal pneumonia.\\n\\n COMPARISON: Multiple chest CTs from to recent CTA of .\\n\\n TECHNIQUE:\\n\\n Axial helical MDCT images were obtained from the suprasternal notch to the\\n upper abdomen without administration of IV contrast and 1.25 mm slice\\n collimation. Multiplanar reformatted images in coronal and sagittal axes were\\n generated.\\n\\n FINDINGS:\\n\\n LUNG AND AIRWAYS:\\n\\n There is increase of ground-glass opacities with interlobular septal\\n thickening, mainly in upper lobes but also in the lingula.\\n\\n Bilateral widespread tree-in- has also increased.\\n\\n Areas of consolidation in the left upper lobe, lingula, and lower lobes has\\n not worsened; however, there is developing bronchiectasis in lower lobes\\n consistent with post-infectious bronchiectasis.\\n\\n (Over)\\n\\n 5:45 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: please evaluate for fungal pneumonia\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n Secretions are seen in the airways, but the airways are patent until\\n subsegmental level.\\n\\n MEDIASTINUM:\\n\\n There is no pathologic superclavicular, mediastinal, or axillary lymph node\\n enlargement by CT size criteria, all the small lymph nodes are unchanged.\\n\\n Mediastinal lipomatosis is probably explained by corticosteroid. Bilateral\\n small pleural effusions have slightly worsened. There is no pericardial\\n effusion. Coronary arteries are moderately calcified.\\n\\n UPPER ABDOMEN: Liver steatosis is severe. The spleen is not enlarged.\\n\\n OSSEOUS STRUCTURES: Multiple costal fractures and compression fractures of\\n the spine are stable. There is no new lesion.\\n\\n CONCLUSION:\\n\\n Patient is known with AML and fever.\\n\\n 1. Bilateral ground-glass opacities with interlobular septal thickening have\\n significantly worsened since . They are predominant in upper\\n lobes. The most likely diagnosis is an infectious process (pneumocystis,\\n viral) considering that they were already present on , /.\\n Pulmonary edema is less likely. Although bacterial or fungal infection cannot\\n be excluded, the radiologic features are not classic for those pathogens.\\n\\n 2. Developing post-infectious bronchiectasis are new in lower lobes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-07 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1256882,\n \"text\": \" 1:06 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: 42cm right basilic. \\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with new picc\\n REASON FOR THIS EXAMINATION:\\n 42cm right basilic. \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 58-year-old man with new right PICC placement.\\n\\n COMPARISON: Comparison is made to same-day radiograph of the chest from 8\\n hours prior. This study is read in conjunction with CT of the chest from\\n .\\n\\n FINDINGS: Portable radiograph of the chest demonstrates a new right\\n subclavian line in standard position, terminating in the upper-to-mid SVC.\\n There is no pneumothorax. Low lung volumes persist and are unchanged since\\n the prior study along with widespread bilateral opacifications with the left\\n greater than right. Also, bilateral pleural effusions, with left greater than\\n right, are again demonstrated on this study.\\n\\n CONCLUSION: New right PICC line in standard position, terminating in the\\n mid-to-upper SVC. Otherwise, unchanged since the prior radiograph.\\n\\n The above findings were communicated to IV nurse, , at 13:38 via\\n telephone by Dr. , at the time of discovery.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-02 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1256635,\n \"text\": \" 12:49 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: ? DVT\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with tachycardia, hypoxemia\\n REASON FOR THIS EXAMINATION:\\n ? DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Tachycardia and hypoxemia, evaluate for DVT.\\n\\n COMPARISON: Left lower extremity venous ultrasound of .\\n\\n TECHNIQUE: Bilateral lower extremity venous ultrasound.\\n\\n FINDINGS: Grayscale, color, and spectral Doppler images were obtained of the\\n right and left common femoral, femoral, and popliteal veins. Normal flow,\\n compressibility, augmentation, and waveforms are demonstrated. No\\n intraluminal thrombus is identified. Normal color flow is visualized in the\\n posterior tibial and peroneal veins bilaterally. Visualization of the\\n peroneal veins is somewhat limited due to calf edema and limited acoustic\\n penetration.\\n\\n IMPRESSION: No deep venous thrombosis in right or left lower extremity.\\n Bilateral calf edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-07 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1256892,\n \"text\": \" 3:21 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: ? fungal process\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n Contrast: GADAVIST Amt: 10\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with fungemia, HA, decreased hearing\\n REASON FOR THIS EXAMINATION:\\n ? fungal process\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: 58-year-old man with fungemia, headache, decreased\\n hearing. Question of fungal process.\\n\\n COMPARISON: Head CT dated .\\n\\n TECHNIQUE: MRI of the head was performed prior to and following the\\n intravenous administration of 10 mL Gadovist utilizing standard department\\n protocol.\\n\\n FINDINGS: There is a small punctate focus of slow diffusion in the left\\n parietal lobe deep white matter. Elsewhere, there are a few scattered\\n punctate foci of FLAIR signal abnormality in the periventricular and\\n subcortical white matter bilaterally which are non-specific. There is no\\n evidence of hemorrhage. The images are degraded by motion artifact,\\n particularly on the post-contrast sequences, but there is no obvious area of\\n abnormal enhancement.\\n\\n There is fluid in the bilateral mastoid air cells as well as mucosal\\n thickening in the right maxillary sinus, in the anterior ethmoid air cells and\\n mild mucosal thickening in the frontal sinuses. The orbital contents are\\n unremarkable.\\n\\n IMPRESSION:\\n 1. Punctate focus of slow diffusion in the left parietal lobe deep white\\n matter compatible with infarct.\\n 2. Images are degraded by motion artifact, but there is no evidence for\\n abnormal enhancement. No definite findings to suggest fungal infection.\\n 3. Paranasal sinus disease and bilateral mastoid air cell fluid.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-09-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256522,\n \"text\": \" 11:39 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval pneumonia vs chf\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 58M with sob\\n REASON FOR THIS EXAMINATION:\\n eval pneumonia vs chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Shortness of breath.\\n\\n TECHNIQUE: Upright AP view of the chest.\\n\\n COMPARISON: Chest radiograph and chest CTA from .\\n\\n FINDINGS:\\n\\n Right sided dialysis catheter tip terminates in the low SVC. Lung volumes are\\n low. Heart size is normal. The mediastinal and hilar contours are unchanged.\\n There is crowding of the bronchovascular structures, but no frank pulmonary\\n edema is present. Previously noted patchy opacities in the right upper lobe\\n have improved. There is worsening ill-defined opacification within the left\\n lung base. No large pleural effusion or pneumothorax is demonstrated.\\n Bronchial wall thickening is most pronounced within the left lung base and\\n likely reflective of bronchitis. Areas of callus formation are noted\\n involving multiple bilateral ribs. Partially imaged is fusion hardware within\\n the cervical and thoracic spine.\\n\\n IMPRESSION:\\n\\n 1. Worsening opacification in the left lung base with associated bronchial\\n wall thickening concerning for infection.\\n\\n 2. Slight interval improvement in previously noted airspace disease within the\\n right upper lobe.\\n\\n 3. No definite pulmonary edema.\\n\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-05 00:00:00.000\",\n \"description\": \"REMOVE TUNNELED CENTRAL W/O PORT\",\n \"row_id\": 1256901,\n \"text\": \" 6:27 PM\\n DIALYSIS REMOVE Clip # \\n Reason: Please remove tunnel line. Patient had placed in by\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ********************************* CPT Codes ********************************\\n * REMOVE TUNNELED CENTRAL W/O PO *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old BMT patient in FOR THIS EXAMINATION:\\n Please remove tunnel line. Patient had placed in by IR. Must be\\n removed for yeast growing in blood, sputum and urine.\\n ______________________________________________________________________________\\n FINAL REPORT\\n 15:15\\n Request for a triple lumen tunneled line removal for septic\\n patient was placed on evening. As patient was on heparin,\\n and this has to be stopped for procedure, arrangements were made\\n to stop it morning . Case was discussed with attending Dr\\n , who suggested to remove the line on the\\n floor. The case was reviewed, as well as potential complications.\\n\\n After the heparin was stopped for 3.5 hours on the 20th, I came\\n into the ICU for removal of the line. Procedure was explained for the patient.\\n\\n\\n Steril field was created, 10 ml of local lidocaine were injected for\\n anesthesia, and blunt dissection with was performed around the cuff.\\n Singificant fibrosis was noted and gentle traction was applied.\\n As the traction was applied, I continued dissection with the\\n . At a point, the catheter ripped, and the proximal piece\\n just came out. Imediatelly pressure was applied in the distal\\n burried fragment, at the level of the clavicle. Following,\\n oxygen saturation of the patient dropped, and a nurse came in and\\n also helped holding the burried piece of the catheter. Patient\\n was placed on left lateral decubitus (right side up). Dr was\\n immediately informed. Following, oxygen saturation of the patient improved\\n and sat was 98% on oxygen mask. Vascular surgery was also\\n immediately contact who came in and perfomed blunt dissection and\\n the whole catheter was removed. Tip was sent to culture. Catheter piece was\\n sent to analysis.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256610,\n \"text\": \" 10:20 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: Worsening/new infiltrate?\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with pneumonia, now febrile, somnolent most of day after pain\\n meds so concern for aspiration.\\n REASON FOR THIS EXAMINATION:\\n Worsening/new infiltrate?\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 10:22 P.M. ON \\n\\n HISTORY: 58-year-old man with pneumonia, febrile and somnolent.\\n\\n IMPRESSION: AP chest compared to , 1:58 p.m.:\\n\\n Previous pulmonary vascular congestion has improved, but there is still very\\n extensive consolidation in the left lung due to pneumonia, without\\n improvement, possibly worsened. Smaller region of consolidation in the right\\n lower lung medially is either a second focus of pneumonia or atelectasis.\\n Mild cardiomegaly is stable. Dual-channel right supraclavicular central\\n venous set ends in the region of the superior cavoatrial junction. No\\n pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256813,\n \"text\": \" 5:55 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: air embolism, line location\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with AML had hypoxia during right tunnelled line removal\\n REASON FOR THIS EXAMINATION:\\n air embolism, line location\\n ______________________________________________________________________________\\n WET READ: MDAg SAT 7:39 PM\\n no evidence of retained fragment. bilateral opacities L>R may be edema or\\n infection\\n -MAgarwal d/w Dr. by phone at 7:30pm .\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n COMPARISON: .\\n\\n FINDINGS: Status post removal of right subclavian vascular catheter.\\n Widespread heterogeneous combined alveolar and interstitial opacities\\n affecting the left lung to a greater degree than the right, have progressed in\\n the interval, and may represent a multifocal pneumonia with or without\\n coexisting pulmonary edema. Pulmonary hemorrhage is also possible in the\\n appropriate clinical setting.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-02 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1256667,\n \"text\": \" 9:24 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? hemorrhage or mass lesion\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with AML, headaches, tachycardia, hypotension, somnolence, TTE\\n with large hypokinetic RV concerning for PE\\n REASON FOR THIS EXAMINATION:\\n ? hemorrhage or mass lesion\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 12:40 AM\\n 1. Extremely limited study due to motion artifact, within this limitation, no\\n acute intracranial pathology.\\n 2. Multifocal paranasal sinus and bilateral mastoid air cell opacification.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 80-year-old man with AML, tachycardia, hypotension and\\n somnolence.\\n\\n COMPARISON: CT head without contrast, .\\n\\n TECHNIQUE: Multidetector CT imaging of the head was obtained without\\n intravenous contrast. Sagittal and coronal reformations were performed and\\n reviewed. Both the initial and repeat images were degraded by patient motion\\n artifact\\n .\\n FINDINGS: Limited study due to motion artifact. Within this limitation,\\n there is no large intracranial hemorrhage, edema, mass or mass effect. The\\n -white matter differentiation is preserved. The ventricles and sulci are\\n mildly enlarged, consistent with mild involutional changes. Basal cisterns\\n are normal. Mild mucosal thickening is seen in both maxillary, ethmoid and\\n frontal sinuses. Bilateral symmetric exophthalmos is unchanged. Bilateral\\n intraocular lens implants are noted.\\n There is near-complete opacification of the right and partial opacification of\\n the left mastoid air cells.\\n\\n IMPRESSION:\\n 1. Limited study due to motion artifact, within this limitation, no acute\\n intracranial pathology.\\n 2. Multifocal paranasal sinus and bilateral mastoid air cell opacification.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-02 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1256669,\n \"text\": \" 10:48 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: ? PE\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n Contrast: OMNIPAQUE Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man with AML, tachycardia, hypotension, somnolence, TTE with large\\n hypokinetic RV concerning for PE\\n REASON FOR THIS EXAMINATION:\\n ? PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KKgc WED 11:41 PM\\n Pulmonary emboli seen in the right lower lobar pulmonary artery extending into\\n two segmental arteries. Assessment of upper lobe vessels significantly limited\\n by motion. No evidence of right heart strain. Mild enlargement of the main\\n pulmonary arteries. Multifocal new areas of heterogeneous parenchymal\\n consolidation seen in both lungs,predominantly the left lung, are worrisome\\n for infection. Dense bilateral lower lobe consolidations with small pleural\\n effusions. Mild bronchial wall thickening and interstitial abnormalities\\n secondary to GVHD persist. Bilateral healing rib fractures. Mild mid thoracic\\n vertebral compressions and thoracic spine fixation hardware, stable.\\n Kkaliannan d/w Dr. at 11:35 p.m, immediately after discovery.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST CTA WITH CONTRAST\\n\\n INDICATION: Patient with AML, tachycardia, hypotension, somnolence, rule out\\n PE.\\n\\n COMPARISON: Multiple chest CTs from to .\\n\\n TECHNIQUE:\\n\\n Axial helical MDCT images were obtained from the suprasternal notch to the\\n upper abdomen with administration of IV contrast following the CTPA protocol.\\n Multiplanar reformatted images were generated.\\n\\n FINDINGS:\\n\\n HEART AND GREAT VESSELS:\\n\\n Multiple motion artifacts are mostly in bilateral upper lobe arteries.\\n Filling defects compatible with pulmonary embolism are seen in a lobar,\\n segmental and subsegmental level in the right lower lobe. The most proximal\\n portion of the pulmonary embolus is peripheral raising the question if this\\n pulmonary embolism could be chronic. This is new since . There is\\n no dilatation of main pulmonary artery or right heart chamber. There is no\\n acute aortic syndrome. Coronary artery calcification is stable. There is no\\n pericardial effusion.\\n\\n MEDIASTINUM:\\n (Over)\\n\\n 10:48 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: ? PE\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n Contrast: OMNIPAQUE Amt: 100\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n Small bilateral pleural effusions are new. There is no pathologic\\n superclavicular, mediastinal or axillary lymph node enlargement by CT size\\n criteria. Mediastinal lipomatosis is unchanged.\\n\\n LUNGS AND AIRWAYS:\\n\\n Worsening of multifocal consolidations, more severe in left upper lobe and\\n bilateral lower lobes, is compatible with an infectious process. Small\\n residual nodules in right middle lobe and right lower lobe described on\\n previous exam is hard to assess throughout those changes.\\n\\n The airways are patent to the subsegmental level.\\n\\n UPPER ABDOMEN:\\n\\n This study is not tailored for assessment for intra-abdominal organs. Liver\\n steatosis is severe. The spleen is not enlarged.\\n\\n OSSEOUS STRUCTURES:\\n\\n Post-surgical changes and compression deformities of the thoracic spine are\\n stable. There are also bilateral rib fractures.\\n\\n CONCLUSION:\\n\\n 1. Right lower lobe lobar to subsegmental pulmonary acute embolism. The most\\n proximal portion of the filling defect is peripheral in the artery raising the\\n question if this could be chronic but new since . There is no\\n dilatation of main pulmonary artery or right heart .\\n\\n 2. Worsening of bilateral multifocal pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2148-10-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1256859,\n \"text\": \" 4:26 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for worsening pna vs. pulmonary edema\\n Admitting Diagnosis: ALTERED MENTAL STATUS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 58 year old man immunocompromised with pneumonia, s/p air embolism, continued\\n poor respiratory status. Worsening CXR on .\\n REASON FOR THIS EXAMINATION:\\n please evaluate for worsening pna vs. pulmonary edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST\\n\\n COMPARISON: Radiograph of one day earlier.\\n\\n FINDINGS: Lung volumes are slightly lower compared to prior study.\\n Cardiomediastinal contours are stable in appearance allowing for this factor.\\n Widespread heterogeneous pulmonary opacities affecting the left lung to a\\n greater degree than the right have worsened in the lower lung since the prior\\n study, and likely represent a multilobar pneumonia. Small left and possible\\n small right pleural effusions are unchanged.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":798,"cells":{"subject_id":{"kind":"number","value":7136,"string":"7,136"},"hadm_id":{"kind":"number","value":194998,"string":"194,998"},"target_text":{"kind":"string","value":"Upon admission to the the patient went immediately to cardiac catheterization. At that time his cardiac output was 4.3, a cardiac index of 2.47, pulmonary capillary wedge pressure of 7, pulmonary artery pressure of 22/16, left ventricular end-diastolic pressure of 11, right atrium of 10, right ventricle of 23/10, AO of 122/75. His ejection fraction was calculated at 40% with anterior apical dyskinesis. His coronaries showed the left anterior descending artery had mild haziness in the mid portion but no focal stenosis. His left circumflex and right coronary arteries had no disease. The patient was extubated on without complications and started on a steroid taper for his chronic obstructive pulmonary disease flare. He was continued on his 10-day course of levofloxacin started at for presumed community-acquired bronchitis. He responded well to these therapies with a respiratory examination significant for good air movement and only occasional wheezes by the time of discharge. After catheterization, the patient was given post catheterization heparin for approximately 48 hours to treat for presumed unstable angina in the setting of no occlusion noted on catheterization. He tolerated the institution of beta blocker well and was discharged on p.o. atenolol without evidence of bronchospasm."},"extractive_notes_summ":{"kind":"string","value":"PT S/P CATH- RT GROIN STABLE/PULSES PALPABLE- VSS.HR- 60-70'S SR, BP- 118-126/65.REMAINS ON CAPTOPRIL 6.25/LOPRESSOR 12.5/ASA.CYCLING CPK'S. ECG done. EXTUBATE THIS AM AS CHF/COPD/ABG'S ALLOW. DeepT wave inversions in leads V1-V6 consistent with anterior ischemia.TRACING #1 The tip of the orogastric tube is again seen to be well past mid-line, possibly post-pyloric. remains intubated and on vent. Q-T interval prolongation. Q-T interval prolongation. albuterol/atrovent given for copd hx. Heart size and mediastinal and hilar contours are within normal limits. First degree A-V block. First degree A-V block. Given Ativan 1mg x 1 for discomfort from ETT.Neuro: A&Ox3, cooperative. Found to be in hypercarbic resp failure ABG: 241/66/7.27, improved initially on Bipap, then again had increased SOB, required intubation. CCU NSG PROGRESS NOTE 11P-7A/ R/I MI; S/P CATHS- INUTUBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA. EKG changes found on evaluation of SOB, T wave changes seen, ruled in for MI by and Troponin level. resp. PT REMAINS REMAINS STABLE ON PRESSURE SUPPORT.MINIMAL SUCTIONING - BRONCHOSPASTIC WITH ANY SX.I/E WHEEZES.CHANGED TO ELIXIR , REMAIN ON NEBS/O2 SATS 99-100% CURRENTLY.GOOD U.O-= NO DIURESIS THIS SHIFT.GU- SEE ABOVE= UO- 50-60/HOUR.IVF S/P CATH DECREASED TO 75/HOUR.ID AFEBRILE. IMPRESSION: 1) Satisfactory position of ET tube. carept. weaned to psv 10/5 with good vols. Heart size and mediastinal and hilar contours are within normal limits and stable. Cath today showed questionable lesion in LAD otherwise clean.PMH: HTN, COPDAll: NKDAReview of systems:CV: returned from cath lab, alert, VS stable,(see careveiw for objective data), R groin with venous and art sheath, pulled at 7PM. PORTABLE CHEST: The endotracheal tube is in satisfactory position, unchanged. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. 2) NG tube tip may be post-pyloric. Started on captopril and will get lopressor at MN. Deep T wave inversions inthe limb leads and V2-V6. The orogastric tube courses below the diaphragm and crosses mid-line, with the tip possibly in the post-pyloric position. bbs wheezes. HEPARIN GTT RESTARTED AFTER SHEATH PULL.HEMODYNAMICS STABLE CURRENTLY.RECEIVED 80 KCL FOR K- 2.9 ON EVES. Intubated at OSH for COPD flare. BP 110/60, HR 60. Marked Q-T interval prolongation.Compared to the previous tracing of the Q-T interval has diminished butremains markedly prolonged.TRACING #2 Pulses palpable. FINAL REPORT HISTORY: COPD, intubated for respiratory distress. PT VERY ALERT= ASKING FOR MEDICATION FOR SLEEP- GIVEN 1 ATIVAN- SHORT ACTING.ASKING FOR BEDPAN LATER IN SHIFT- NO SUCCESS.GI- NEW OG TUBE PLACED- OLD ONE GUMMED OUT.CXR (+) GOOD PLACEMENT.A/ PT HEMODYNAMICALLY STABLE S/P CARDIAC CATH.R/I FOR MIPLAN TO ?INTERVENE ON HAZY LAD. Soft restraints for protection of tubes.GI: ogt in place. plan to wean and possible extubate this a.m. PORTABLE CHEST: The endotracheal tube is in satisfactory position approximately 3-4 cm above the carina. Suctioned for minimal white secretions. FINAL REPORT HISTORY: 81-year-old male with COPD flair, endotracheal and orogastric tube placement. IMPRESSION: 1) Stomach is distended with gas, possibly due to post-pyloric positioning of orogastric tube tip. Was presumed to have bronchitis, treated with abx and steroids. Denies CP/SOB. K+ 2.9, 40 mEq in maintainance fluid, 40 mEq po x2 to be given.Resp: Vented initially on AC, changed to PS 15/5PEEP, RR 16-20 with VT 5-600. CONTINUE TO MAXIMIZE RPP - INCREASE CAPTOPRIL AS TOLERATED.KEEP PT COMFORTABLE/SAFE.INFORM PT/FAMILY AS TO PLAN OF CARE/PROGRESS.INCREASE ACTIVITY PER R/O MI PROTOCOL ONCE EXTUBATED. Left axis deviation. The stomach is distended with gas. Comparison to prior study from . The lungs are clear and there are no effusions. The lungs are clear and there are no effusions. REASON FOR THIS EXAMINATION: SP OGT placement in man with COPD intubated for resp distres. Compared to the previous tracingof there are no diagnostic interim changes. Wife in this eve.Status: full code. No complications. BS(+)GU: foleySoc: married, no children. very much awake and following commands. 3) No evidence of pneumonia. Please evaluate for ET/OG tube placement and evidence of pneumonia. 2) No evidence of failure, pneumonia or other acute cardiopulmonary disease. The right costophrenic angle is off the film and cannot be evaluated. REASON FOR THIS EXAMINATION: 81 yo man admitted to CCU from cath lab. 6:16 PM CHEST (PORTABLE AP) Clip # Reason: 81 yo man admitted to CCU from cath lab. 1:20 AM CHEST (PORTABLE AP) Clip # Reason: SP OGT placement in man with COPD intubated for resp distres MEDICAL CONDITION: 81 year old man with COPD flare and acute coronary syndrome. Intubated at OSH fo MEDICAL CONDITION: 81 year old man with COPD flare and acute coronary syndrome. There are no prior studies for comparison. No stool."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2143-08-16 00:00:00.000","description":"Report","row_id":1357281,"text":"resp. care\npt. remains intubated and on vent. weaned to psv 10/5 with good vols. very much awake and following commands. albuterol/atrovent given for copd hx. bbs wheezes. plan to wean and possible extubate this a.m.\n"},{"category":"Nursing/other","chartdate":"2143-08-15 00:00:00.000","description":"Report","row_id":1357279,"text":"CCU Nursing Adm note:\n81 yr old male transfered from Hospital today for cath, S/P non Q-wave MI, adm to OSH on after 3-4 days of cough and increased SOB. Found to be in hypercarbic resp failure ABG: 241/66/7.27, improved initially on Bipap, then again had increased SOB, required intubation. EKG changes found on evaluation of SOB, T wave changes seen, ruled in for MI by and Troponin level. Was presumed to have bronchitis, treated with abx and steroids. Cath today showed questionable lesion in LAD otherwise clean.\n\nPMH: HTN, COPD\n\nAll: NKDA\n\nReview of systems:\n\nCV: returned from cath lab, alert, VS stable,(see careveiw for objective data), R groin with venous and art sheath, pulled at 7PM. Pulses palpable. No complications. Denies CP/SOB. ECG done. Started on captopril and will get lopressor at MN. BP 110/60, HR 60. K+ 2.9, 40 mEq in maintainance fluid, 40 mEq po x2 to be given.\n\nResp: Vented initially on AC, changed to PS 15/5PEEP, RR 16-20 with VT 5-600. Suctioned for minimal white secretions. Given Ativan 1mg x 1 for discomfort from ETT.\n\nNeuro: A&Ox3, cooperative. Soft restraints for protection of tubes.\n\nGI: ogt in place. No stool. BS(+)\n\nGU: foley\n\nSoc: married, no children. Wife in this eve.\n\nStatus: full code.\n\n\n"},{"category":"Nursing/other","chartdate":"2143-08-16 00:00:00.000","description":"Report","row_id":1357280,"text":"CCU NSG PROGRESS NOTE 11P-7A/ R/I MI; S/P CATH\n\nS- INUTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT S/P CATH- RT GROIN STABLE/PULSES PALPABLE- VSS.\nHR- 60-70'S SR, BP- 118-126/65.\nREMAINS ON CAPTOPRIL 6.25/LOPRESSOR 12.5/ASA.\nCYCLING CPK'S. HEPARIN GTT RESTARTED AFTER SHEATH PULL.\nHEMODYNAMICS STABLE CURRENTLY.RECEIVED 80 KCL FOR K- 2.9 ON EVES.\n\n PT REMAINS REMAINS STABLE ON PRESSURE SUPPORT.\nMINIMAL SUCTIONING - BRONCHOSPASTIC WITH ANY SX.\nI/E WHEEZES.CHANGED TO ELIXIR , REMAIN ON NEBS/\nO2 SATS 99-100% CURRENTLY.\nGOOD U.O-= NO DIURESIS THIS SHIFT.\n\nGU- SEE ABOVE= UO- 50-60/HOUR.\nIVF S/P CATH DECREASED TO 75/HOUR.\n\nID AFEBRILE.\n\n PT VERY ALERT= ASKING FOR MEDICATION FOR SLEEP- GIVEN 1 ATIVAN- SHORT ACTING.\nASKING FOR BEDPAN LATER IN SHIFT- NO SUCCESS.\n\nGI- NEW OG TUBE PLACED- OLD ONE GUMMED OUT.\nCXR (+) GOOD PLACEMENT.\n\nA/ PT HEMODYNAMICALLY STABLE S/P CARDIAC CATH.\nR/I FOR MI\n\nPLAN TO ?INTERVENE ON HAZY LAD. EXTUBATE THIS AM AS CHF/COPD/ABG'S ALLOW. CONTINUE TO MAXIMIZE RPP - INCREASE CAPTOPRIL AS TOLERATED.\nKEEP PT COMFORTABLE/SAFE.\nINFORM PT/FAMILY AS TO PLAN OF CARE/PROGRESS.\nINCREASE ACTIVITY PER R/O MI PROTOCOL ONCE EXTUBATED.\n"},{"category":"ECG","chartdate":"2143-08-17 00:00:00.000","description":"Report","row_id":152773,"text":"Normal sinus rhythm. Q-T interval prolongation. Deep T wave inversions in\nthe limb leads and V2-V6. Left axis deviation. Compared to the previous tracing\nof there are no diagnostic interim changes.\n\n"},{"category":"ECG","chartdate":"2143-08-16 00:00:00.000","description":"Report","row_id":152774,"text":"Normal sinus rhythm. First degree A-V block. Marked Q-T interval prolongation.\nCompared to the previous tracing of the Q-T interval has diminished but\nremains markedly prolonged.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2143-08-15 00:00:00.000","description":"Report","row_id":152775,"text":"Normal sinus rhythm. First degree A-V block. Q-T interval prolongation. Deep\nT wave inversions in leads V1-V6 consistent with anterior ischemia.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2143-08-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":743098,"text":" 6:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 81 yo man admitted to CCU from cath lab. Intubated at OSH fo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with COPD flare and acute coronary syndrome.\n REASON FOR THIS EXAMINATION:\n 81 yo man admitted to CCU from cath lab. Intubated at OSH for COPD flare.\n Please evaluate for ET/OG tube placement and evidence of pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old male with COPD flair, endotracheal and orogastric tube\n placement.\n\n There are no prior studies for comparison.\n\n PORTABLE CHEST: The endotracheal tube is in satisfactory position\n approximately 3-4 cm above the carina. The orogastric tube courses below the\n diaphragm and crosses mid-line, with the tip possibly in the post-pyloric\n position. Heart size and mediastinal and hilar contours are within normal\n limits. The lungs are clear and there are no effusions.\n\n IMPRESSION:\n\n 1) Satisfactory position of ET tube.\n\n 2) NG tube tip may be post-pyloric.\n\n 3) No evidence of pneumonia.\n\n"},{"category":"Radiology","chartdate":"2143-08-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":743110,"text":" 1:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SP OGT placement in man with COPD intubated for resp distres\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with COPD flare and acute coronary syndrome.\n REASON FOR THIS EXAMINATION:\n SP OGT placement in man with COPD intubated for resp distres.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD, intubated for respiratory distress.\n\n Comparison to prior study from .\n\n PORTABLE CHEST: The endotracheal tube is in satisfactory position, unchanged.\n The tip of the orogastric tube is again seen to be well past mid-line,\n possibly post-pyloric. The stomach is distended with gas. Heart size and\n mediastinal and hilar contours are within normal limits and stable. The lungs\n are clear and there are no effusions. The right costophrenic angle is off the\n film and cannot be evaluated.\n\n IMPRESSION:\n\n 1) Stomach is distended with gas, possibly due to post-pyloric positioning of\n orogastric tube tip.\n\n 2) No evidence of failure, pneumonia or other acute cardiopulmonary disease.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2143-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1357281,\n \"text\": \"resp. care\\npt. remains intubated and on vent. weaned to psv 10/5 with good vols. very much awake and following commands. albuterol/atrovent given for copd hx. bbs wheezes. plan to wean and possible extubate this a.m.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2143-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1357279,\n \"text\": \"CCU Nursing Adm note:\\n81 yr old male transfered from Hospital today for cath, S/P non Q-wave MI, adm to OSH on after 3-4 days of cough and increased SOB. Found to be in hypercarbic resp failure ABG: 241/66/7.27, improved initially on Bipap, then again had increased SOB, required intubation. EKG changes found on evaluation of SOB, T wave changes seen, ruled in for MI by and Troponin level. Was presumed to have bronchitis, treated with abx and steroids. Cath today showed questionable lesion in LAD otherwise clean.\\n\\nPMH: HTN, COPD\\n\\nAll: NKDA\\n\\nReview of systems:\\n\\nCV: returned from cath lab, alert, VS stable,(see careveiw for objective data), R groin with venous and art sheath, pulled at 7PM. Pulses palpable. No complications. Denies CP/SOB. ECG done. Started on captopril and will get lopressor at MN. BP 110/60, HR 60. K+ 2.9, 40 mEq in maintainance fluid, 40 mEq po x2 to be given.\\n\\nResp: Vented initially on AC, changed to PS 15/5PEEP, RR 16-20 with VT 5-600. Suctioned for minimal white secretions. Given Ativan 1mg x 1 for discomfort from ETT.\\n\\nNeuro: A&Ox3, cooperative. Soft restraints for protection of tubes.\\n\\nGI: ogt in place. No stool. BS(+)\\n\\nGU: foley\\n\\nSoc: married, no children. Wife in this eve.\\n\\nStatus: full code.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2143-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1357280,\n \"text\": \"CCU NSG PROGRESS NOTE 11P-7A/ R/I MI; S/P CATH\\n\\nS- INUTUBATED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\n PT S/P CATH- RT GROIN STABLE/PULSES PALPABLE- VSS.\\nHR- 60-70'S SR, BP- 118-126/65.\\nREMAINS ON CAPTOPRIL 6.25/LOPRESSOR 12.5/ASA.\\nCYCLING CPK'S. HEPARIN GTT RESTARTED AFTER SHEATH PULL.\\nHEMODYNAMICS STABLE CURRENTLY.RECEIVED 80 KCL FOR K- 2.9 ON EVES.\\n\\n PT REMAINS REMAINS STABLE ON PRESSURE SUPPORT.\\nMINIMAL SUCTIONING - BRONCHOSPASTIC WITH ANY SX.\\nI/E WHEEZES.CHANGED TO ELIXIR , REMAIN ON NEBS/\\nO2 SATS 99-100% CURRENTLY.\\nGOOD U.O-= NO DIURESIS THIS SHIFT.\\n\\nGU- SEE ABOVE= UO- 50-60/HOUR.\\nIVF S/P CATH DECREASED TO 75/HOUR.\\n\\nID AFEBRILE.\\n\\n PT VERY ALERT= ASKING FOR MEDICATION FOR SLEEP- GIVEN 1 ATIVAN- SHORT ACTING.\\nASKING FOR BEDPAN LATER IN SHIFT- NO SUCCESS.\\n\\nGI- NEW OG TUBE PLACED- OLD ONE GUMMED OUT.\\nCXR (+) GOOD PLACEMENT.\\n\\nA/ PT HEMODYNAMICALLY STABLE S/P CARDIAC CATH.\\nR/I FOR MI\\n\\nPLAN TO ?INTERVENE ON HAZY LAD. EXTUBATE THIS AM AS CHF/COPD/ABG'S ALLOW. CONTINUE TO MAXIMIZE RPP - INCREASE CAPTOPRIL AS TOLERATED.\\nKEEP PT COMFORTABLE/SAFE.\\nINFORM PT/FAMILY AS TO PLAN OF CARE/PROGRESS.\\nINCREASE ACTIVITY PER R/O MI PROTOCOL ONCE EXTUBATED.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2143-08-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 152773,\n \"text\": \"Normal sinus rhythm. Q-T interval prolongation. Deep T wave inversions in\\nthe limb leads and V2-V6. Left axis deviation. Compared to the previous tracing\\nof there are no diagnostic interim changes.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2143-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 152774,\n \"text\": \"Normal sinus rhythm. First degree A-V block. Marked Q-T interval prolongation.\\nCompared to the previous tracing of the Q-T interval has diminished but\\nremains markedly prolonged.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2143-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 152775,\n \"text\": \"Normal sinus rhythm. First degree A-V block. Q-T interval prolongation. Deep\\nT wave inversions in leads V1-V6 consistent with anterior ischemia.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2143-08-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 743098,\n \"text\": \" 6:16 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 81 yo man admitted to CCU from cath lab. Intubated at OSH fo\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old man with COPD flare and acute coronary syndrome.\\n REASON FOR THIS EXAMINATION:\\n 81 yo man admitted to CCU from cath lab. Intubated at OSH for COPD flare.\\n Please evaluate for ET/OG tube placement and evidence of pneumonia.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 81-year-old male with COPD flair, endotracheal and orogastric tube\\n placement.\\n\\n There are no prior studies for comparison.\\n\\n PORTABLE CHEST: The endotracheal tube is in satisfactory position\\n approximately 3-4 cm above the carina. The orogastric tube courses below the\\n diaphragm and crosses mid-line, with the tip possibly in the post-pyloric\\n position. Heart size and mediastinal and hilar contours are within normal\\n limits. The lungs are clear and there are no effusions.\\n\\n IMPRESSION:\\n\\n 1) Satisfactory position of ET tube.\\n\\n 2) NG tube tip may be post-pyloric.\\n\\n 3) No evidence of pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2143-08-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 743110,\n \"text\": \" 1:20 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: SP OGT placement in man with COPD intubated for resp distres\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old man with COPD flare and acute coronary syndrome.\\n REASON FOR THIS EXAMINATION:\\n SP OGT placement in man with COPD intubated for resp distres.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: COPD, intubated for respiratory distress.\\n\\n Comparison to prior study from .\\n\\n PORTABLE CHEST: The endotracheal tube is in satisfactory position, unchanged.\\n The tip of the orogastric tube is again seen to be well past mid-line,\\n possibly post-pyloric. The stomach is distended with gas. Heart size and\\n mediastinal and hilar contours are within normal limits and stable. The lungs\\n are clear and there are no effusions. The right costophrenic angle is off the\\n film and cannot be evaluated.\\n\\n IMPRESSION:\\n\\n 1) Stomach is distended with gas, possibly due to post-pyloric positioning of\\n orogastric tube tip.\\n\\n 2) No evidence of failure, pneumonia or other acute cardiopulmonary disease.\\n\\n\"\n }\n]"}}},{"rowIdx":799,"cells":{"subject_id":{"kind":"number","value":75001,"string":"75,001"},"hadm_id":{"kind":"number","value":181537,"string":"181,537"},"target_text":{"kind":"string","value":"63 y/o F w/ CAD on /, hx ovarian CA, hep C, BRCA s/p modified radical mastectomy c/b hematoma, on wound vac."},"extractive_notes_summ":{"kind":"string","value":"Left ventricular conduction delay withleft axis deviation. Non-specific ST-T wave changewith QTc interval prolongation. Left atrial abnormality. Right axillary clips are visualized. Compared to the previous tracing of atrialfibrillation is not seen. rt axillary surgical clips. Baseline artifact. Lt presumed chest wall drain. coronary stent. , M.D. , M.D. Intraventricular conductiondelay with QRS duration of 122 milliseconds. Sinus bradycardia. minimal pleuroparenchymal scarring at apices. Clinicalcorrelation is suggested. REASON FOR THIS EXAMINATION: New afib with RVR. Leftward axis at minus 26 degrees.Left bundle-branch block. Coronary stent is visualized. Slow R wave progression could be due to theintraventricular conduction delay, although underlying anterior wall myocardialinfarction is not excluded. Compared to the previous tracing of thepatient has gone from sinus bradycardia at 58 per minute to atrialfibrillation. Atrial fibrillation, average ventricular rate 134. The heart is upper limits normal in size. There is some minimal biapical scarring. 7:36 PM CHEST (PORTABLE AP) Clip # Reason: New afib with RVR. Approved: MON 3:26 PM RADLINE ; A radiology consult service. The above described findings are consistent with no evidence of metastatic osseous lesions. A drain is seen overlying the left anterior chest. QTc interval prolongation is more apparent. IMPRESSION: No evidence for metastatic osseous lesions. There is mild focus of uptake around bilateral shoulder joints and along the left knee consistent with degenerative changes. To hear preliminary results, prior to transcription, call the Radiology Listen Line . FINAL REPORT CHEST ON HISTORY: Modified radical mastectomy with AFib FINDINGS: There are no old films available for comparison. The kidneys and urinary bladder are visualized, the normal route of tracer excretion. There is no other diagnostic interval change. INTERPRETATION: Whole body images of the skeleton were obtained in anterior and posterior projections There is mild scoliosis with stress related degenerative changes. WET READ: AGLc SUN 12:52 AM no pna or pulm edema seen. There is no infiltrate or effusion. No comparisons are available. Admitting Diagnosis: LEFT BREAST CANCER/SDA MEDICAL CONDITION: 63 year old woman with modified radical mastectomy, now with afib with RVR."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2178-05-08 00:00:00.000","description":"BONE SCAN","row_id":1137799,"text":"BONE SCAN Clip # \n Reason: 63 YR OLD WOMAN WITH BREAST CANCER STAGING\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 20.5 mCi Tc-m MDP ();\n HISTORY: 63 yo woman with breast cancer staging.\n\n INTERPRETATION:\n\n Whole body images of the skeleton were obtained in anterior and posterior\n projections\n There is mild scoliosis with stress related degenerative changes. There is mild\n focus of uptake around bilateral shoulder joints and along the left knee\n consistent with degenerative changes.\n\n The above described findings are consistent with no evidence of metastatic\n osseous lesions.\n\n No comparisons are available.\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n IMPRESSION: No evidence for metastatic osseous lesions.\n\n\n\n\n\n , M.D.\n , M.D. Approved: MON 3:26 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":"2178-04-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1135991,"text":" 7:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: New afib with RVR.\n Admitting Diagnosis: LEFT BREAST CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with modified radical mastectomy, now with afib with RVR.\n REASON FOR THIS EXAMINATION:\n New afib with RVR.\n ______________________________________________________________________________\n WET READ: AGLc SUN 12:52 AM\n no pna or pulm edema seen. minimal pleuroparenchymal scarring at apices. rt\n axillary surgical clips. Lt presumed chest wall drain. coronary stent.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Modified radical mastectomy with AFib\n\n FINDINGS: There are no old films available for comparison. A drain is seen\n overlying the left anterior chest. Coronary stent is visualized. There is\n some minimal biapical scarring. Right axillary clips are visualized. The\n heart is upper limits normal in size. There is no infiltrate or effusion.\n\n\n"},{"category":"ECG","chartdate":"2178-05-08 00:00:00.000","description":"Report","row_id":231062,"text":"Baseline artifact. Sinus bradycardia. Left ventricular conduction delay with\nleft axis deviation. Left atrial abnormality. Non-specific ST-T wave change\nwith QTc interval prolongation. Slow R wave progression could be due to the\nintraventricular conduction delay, although underlying anterior wall myocardial\ninfarction is not excluded. Compared to the previous tracing of atrial\nfibrillation is not seen. QTc interval prolongation is more apparent. Clinical\ncorrelation is suggested.\n\n"},{"category":"ECG","chartdate":"2178-04-25 00:00:00.000","description":"Report","row_id":231266,"text":"Atrial fibrillation, average ventricular rate 134. Intraventricular conduction\ndelay with QRS duration of 122 milliseconds. Leftward axis at minus 26 degrees.\nLeft bundle-branch block. Compared to the previous tracing of the\npatient has gone from sinus bradycardia at 58 per minute to atrial\nfibrillation. There is no other diagnostic interval change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-05-08 00:00:00.000\",\n \"description\": \"BONE SCAN\",\n \"row_id\": 1137799,\n \"text\": \"BONE SCAN Clip # \\n Reason: 63 YR OLD WOMAN WITH BREAST CANCER STAGING\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n RADIOPHARMACEUTICAL DATA:\\n 20.5 mCi Tc-m MDP ();\\n HISTORY: 63 yo woman with breast cancer staging.\\n\\n INTERPRETATION:\\n\\n Whole body images of the skeleton were obtained in anterior and posterior\\n projections\\n There is mild scoliosis with stress related degenerative changes. There is mild\\n focus of uptake around bilateral shoulder joints and along the left knee\\n consistent with degenerative changes.\\n\\n The above described findings are consistent with no evidence of metastatic\\n osseous lesions.\\n\\n No comparisons are available.\\n\\n The kidneys and urinary bladder are visualized, the normal route of tracer\\n excretion.\\n\\n IMPRESSION: No evidence for metastatic osseous lesions.\\n\\n\\n\\n\\n\\n , M.D.\\n , M.D. Approved: MON 3:26 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\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-04-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1135991,\n \"text\": \" 7:36 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: New afib with RVR.\\n Admitting Diagnosis: LEFT BREAST CANCER/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old woman with modified radical mastectomy, now with afib with RVR.\\n REASON FOR THIS EXAMINATION:\\n New afib with RVR.\\n ______________________________________________________________________________\\n WET READ: AGLc SUN 12:52 AM\\n no pna or pulm edema seen. minimal pleuroparenchymal scarring at apices. rt\\n axillary surgical clips. Lt presumed chest wall drain. coronary stent.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON \\n\\n HISTORY: Modified radical mastectomy with AFib\\n\\n FINDINGS: There are no old films available for comparison. A drain is seen\\n overlying the left anterior chest. Coronary stent is visualized. There is\\n some minimal biapical scarring. Right axillary clips are visualized. The\\n heart is upper limits normal in size. There is no infiltrate or effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-05-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 231062,\n \"text\": \"Baseline artifact. Sinus bradycardia. Left ventricular conduction delay with\\nleft axis deviation. Left atrial abnormality. Non-specific ST-T wave change\\nwith QTc interval prolongation. Slow R wave progression could be due to the\\nintraventricular conduction delay, although underlying anterior wall myocardial\\ninfarction is not excluded. Compared to the previous tracing of atrial\\nfibrillation is not seen. QTc interval prolongation is more apparent. Clinical\\ncorrelation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-04-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 231266,\n \"text\": \"Atrial fibrillation, average ventricular rate 134. Intraventricular conduction\\ndelay with QRS duration of 122 milliseconds. Leftward axis at minus 26 degrees.\\nLeft bundle-branch block. Compared to the previous tracing of the\\npatient has gone from sinus bradycardia at 58 per minute to atrial\\nfibrillation. There is no other diagnostic interval change.\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":7,"numItemsPerPage":100,"numTotalItems":24993,"offset":700,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMDMxNjE4OSwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMDMxOTc4OSwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.tICK1M6Yk5IhVY2YUWJ4cPOnYBTcYDO7v6K35B8jkC4KxDRnNWMpp4vMjNG7BHLXUMu9kFPNZKHz2eftLhIpAA","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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18,942 | 130,772 | The patient was admitted on for coronary artery bypass grafting directly to the Operating Room. Please see the operative report for full details. In summary, the patient had coronary artery bypass grafting times two with LIMA to the left anterior descending and saphenous vein graft to the obtuse marginal. His bypass time was 122 min with a cross-clamp time of 100 min. He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was in sinus rhythm with a mean arterial pressure of 80, PA of 25/15. He had Neo-Synephrine at 0.5 mcg/kg/min. He did well in the immediate postoperative period. His anesthesia was reversed, and he was successfully extubated. On postoperative day #1, the patient remained hemodynamically stable, and he was transferred to ................ for continuing postoperative care and cardiac rehabilitation. His chest tubes remained in place on postoperative day #1, as he had a significant amount of drainage. On postoperative day #2, the patient was noted to have rapid atrial fibrillation with a ventricular response of 140-160 and a blood pressure ranging from 90-110, not associated with any dizziness, shortness of breath, or chest pain. At that time, the patient was started on Amiodarone, and by on postoperative day #3, the patient had converted to normal sinus rhythm. Over the next several days, the patient had an uneventful postoperative course. He did however, have an additional episode of atrial fibrillation on postoperative day #4, and at that time, he was started on Heparin infusion, and Coumadin was begun. The patient again converted to normal sinus rhythm and has been in normal sinus rhythm since that time. With the assistance of the nursing staff and Physical Therapy, the patient's activity level was gradually increased, and now on postoperative day #7, the patient is stable and ready to be discharged to home. | SUPINE AP PORTABLE CHEST: There has been interval removal of the ET tube and NG tube. 3) Resolving left apical pneumothorax. Median sternotomy wires and endotracheal tubes are visualized. There has been interval removal of a left sided chest tube. huge huo w low fp's,stable hemodynamics,neo requirements resolved after volume.multifocal pvc's improved after k+ & mg++ replacement.extubated w/o incident to np's. CLINICAL INDICATION: Chest tube removal. A tiny left apical pneumothorax is noted. Atrial fibrillation with rapid ventricular responseDiffuse nonspecific ST-T wave abnormalitiesClinical correlation is suggestedSince previous tracing of , sinus rhythm absent and ST-T wave changesseen 2) Bibasilar atelectasis and small pleural effusions, with interval improvement in aeration in the left lung base. APPEARS COMFORTABLE AFTER MSO4 IV GIVEN..K/CA WNL.. Stable appearance of the heart and mediastinum status post CABG. A tiny left apical pneumothorax is noted and improved in the interval from recent study. The patient is s/p recent CABG with sternotomy wires, vascular clips and mediastinal drain. IMPRESSION: 1) Small left hydropneumothorax. The line was placed through the right brachial vein and terminates in the SVC. Under fluoroscopic guidance a 0.018 guidewire was advanced into the SVC. There is bibasilar atelectasis and elevation of both diaphragms. 3) NGT port in the esophagus, recommend advancement. There is minimal atelectasis at the left lung base and right cardiophrenic angle. AP UPRIGHT CHEST: Comparison with one day prior shows interval removal of the right PA catheter. REASON FOR THIS EXAMINATION: s/p chest tube removal eval for pneumo FINAL REPORT PORTABLE CHEST ON . IMPRESSION: 1) Resolving bibasilar atelectatic changes. The heart size and mediastinal contours are within normal limits. RECEIVING MSO4 2MG IV APPROX. The right-sided pulmonary artery catheter is again present in stable position. IMPRESSION: Minimal if any cardiac failure. Pt has a note f Admitting Diagnosis: CORONARY ARTERY DISEASE\CORONARY ARTERY BYPASS GRAFT/SDA ********************************* CPT Codes ******************************** * CVL/PICC UD GUID FOR NEEDLE PLACMENT * * C1751 CATH ,/CENT/MID(NOT D * **************************************************************************** MEDICAL CONDITION: 56 year old man s/p CABG REASON FOR THIS EXAMINATION: Need PICC line for hep gtt and blood draws. There has been interval improvement in the degree of bibasilar atelectasis with minor atelectatic changes remaining. Small pleural effusions are again demonstrated. Removal of the PA catheter. REASON FOR THIS EXAMINATION: s/p CABG FINAL REPORT INDICATION: CABG. AP PORTABLE SUPINE CHEST: A right PA catheter tip is located in the pulmonary outflow tract. REASON FOR THIS EXAMINATION: RO PTX FINAL REPORT HISTORY: CABG. The NGT port is in the esophagus, therefore advancement is recommended. REASON FOR THIS EXAMINATION: ASSESS EFFUSIONS/INFILTRATES FINAL REPORT INDICATION: CAD. PROCEDURE: The patient's right upper extremity was prepped and draped in the usual sterile fashion. 50CC/HR FROM CTS.. ENDO--BS ELEVATED TITRATING DRIP UP AS NEEDED.. mso4 given w poor relief per pt. Baseline artifactSinus rhythmModest nonspecific T wave changesSince previous tracing of : ST-T wave changes decreased and ventricularectopy not seen Bibasilar atelectatic changes show slight improvement in the left lung base in the interval. 2) Small bilateral pleural effusions. IMPRESSION: Decreases lung volumes following extubation and worsened bibasilar atelectasis. Normal pulmonary vascularity. COMPARISON: CXR on . 2) PA catheter within the pulmonary outflow tract. REASON FOR THIS EXAMINATION: s/p CABG - patient needs to travel with tele FINAL REPORT INDICATION: Status post coronary artery bypass surgery. toradol added & percocet started. Q3HRS, WITH GOOD RESULTS.... GU AS NOTED U/O IN THE 30-40 RANGE AS NIGHT PROGRESSED NEED REPEAT HESPAN/OR DEPENDING ON PA NUMBERS GENTLE DIURESIS, WGT UP!!!. The lungs are slightly less inflated following extubation. S/P CABG. Since no suitable superficial vein was seen, ultrasound was used to identify a patent and compressible right brachial vein. The patient is status post median sternotomy and coronary artery bypass surgery. clear liqs.plan f2 in a.m. 1% Lidocaine was injected for local analgesia. The cardiac and mediastinal contours are stable. COMPARISONS: A right PICC line is in satisfactory position. Assess effusions,infiltrates. GOOD CI.. ON 3LNP WITH SATS 95% OR BETER, ENCOURAGED TO TAKE DEEP BREATHED/COUGH WITJ PILLOW. Both ports flushed and aspirated normally. position changes performed for chronic back pain.tol. Under son guidance the right brachial vein was cannulated with a 21 gauge needle. PLAN OOB TO CHAIR /D/C PSE LINES THIS AM.. AM LABS SENT WITH HCT PENDING.. PATIENT SLEEPING COMFORTABLE AFTER MSO4 IV 2MG GIVEN.. REPOSTIONED ONTO LEFT SIDE, DRAINING APPROX. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2131-01-08 00:00:00.000",
"description": "Report",
"row_id": 1510976,
"text": "huge huo w low fp's,stable hemodynamics,neo requirements resolved after volume.multifocal pvc's improved after k+ & mg++ replacement.extubated w/o incident to np's. reluctant to perform deep breathing due to pain. mso4 given w poor relief per pt. falls asleep instantly unless stimulated then wakes up & c/o pain. toradol added & percocet started. freq. position changes performed for chronic back pain.tol. clear liqs.plan f2 in a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-01-09 00:00:00.000",
"description": "Report",
"row_id": 1510977,
"text": "PATIENT STARTED ON 2U INSULIN DRIP FOR BS OF 151, GIVEN 2U BOLUS AS WELL. TOLERATED BEING TURNED TO OTHER SIDE. APPEARS COMFORTABLE AFTER MSO4 IV GIVEN..K/CA WNL..\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-01-09 00:00:00.000",
"description": "Report",
"row_id": 1510978,
"text": "PATIENT IN NSR WITH RARE PVC, DESPITE GOOD CI, PLAN TO GIVE 500CC HESPAN FOR LOW U/O DROPS IN PAPSE, ALSO DROPS IN SBP TO LOW 80'S. AM LABS SENT WITH HCT PENDING.. PATIENT SLEEPING COMFORTABLE AFTER MSO4 IV 2MG GIVEN.. REPOSTIONED ONTO LEFT SIDE, DRAINING APPROX. 50CC/HR FROM CTS.. ENDO--BS ELEVATED TITRATING DRIP UP AS NEEDED..\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-01-09 00:00:00.000",
"description": "Report",
"row_id": 1510979,
"text": "PATIENT RECEIVED 500CC HESPAN WITH MODERATE RESPONSE IMPROVED SBP 95 OR GREATER BUT U/O STILL IN THE 30'S, NO ECTOPY, PLAN TO GIVE 2GM MAGSO4. GOOD CI.. ON 3LNP WITH SATS 95% OR BETER, ENCOURAGED TO TAKE DEEP BREATHED/COUGH WITJ PILLOW. PLAN OOB TO CHAIR /D/C PSE LINES THIS AM.. RECEIVING MSO4 2MG IV APPROX. Q3HRS, WITH GOOD RESULTS.... GU AS NOTED U/O IN THE 30-40 RANGE AS NIGHT PROGRESSED NEED REPEAT HESPAN/OR DEPENDING ON PA NUMBERS GENTLE DIURESIS, WGT UP!!!. ENDO BS ELEVATED, WELL CONTROLLED ON INSULIN DRIP AT 4U/HR..\n"
},
{
"category": "Radiology",
"chartdate": "2131-01-13 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 815939,
"text": " 11:52 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p CABG\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with severe PVD, CAD, htn s/p carotid stent .\n\n REASON FOR THIS EXAMINATION:\n s/p CABG - patient needs to travel with tele\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post coronary artery bypass surgery.\n\n COMPARISONS: \n\n A right PICC line is in satisfactory position. The patient is status post\n median sternotomy and coronary artery bypass surgery. The heart size and\n mediastinal contours are within normal limits. There has been interval\n improvement in the degree of bibasilar atelectasis with minor atelectatic\n changes remaining. Small pleural effusions are again demonstrated. A tiny left\n apical pneumothorax is noted and improved in the interval from recent study.\n\n IMPRESSION: 1) Resolving bibasilar atelectatic changes.\n 2) Small bilateral pleural effusions.\n 3) Resolving left apical pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-01-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815355,
"text": " 2:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: RO PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with CAD s/p CABG.\n\n REASON FOR THIS EXAMINATION:\n RO PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n COMPARISON: .\n\n AP PORTABLE SUPINE CHEST: A right PA catheter tip is located in the pulmonary\n outflow tract. The NGT port is in the esophagus, therefore advancement is\n recommended. There is minimal atelectasis at the left lung base and right\n cardiophrenic angle. No pneumothorax or definite pleural effusion. Median\n sternotomy wires and endotracheal tubes are visualized. There is satisfactory\n position of the ETT. Normal pulmonary vascularity.\n\n IMPRESSION:\n 1) No definite pneumothorax on this supine view.\n 2) PA catheter within the pulmonary outflow tract.\n 3) NGT port in the esophagus, recommend advancement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-01-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815566,
"text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with CAD s/p CABG.\n\n REASON FOR THIS EXAMINATION:\n s/p CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CABG.\n\n AP UPRIGHT CHEST: Comparison with one day prior shows interval removal of the\n right PA catheter. There is no change in position of the chest tube.\n Allowing for postural differences, there is no change in the pulmonary\n vasculature. There is bibasilar atelectasis and elevation of both diaphragms.\n Stable appearance of the heart and mediastinum status post CABG. No\n pneumothorax or new focal infiltrates.\n\n IMPRESSION: Minimal if any cardiac failure. Removal of the PA catheter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-01-12 00:00:00.000",
"description": "CVL/PICC",
"row_id": 815866,
"text": " 3:35 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Need PICC line for hep gtt and blood draws. Pt has a note f\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n Need PICC line for hep gtt and blood draws. Pt has a note from IV nurse that\n he has no peripheral access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Heparin and multiple medications. No peripheral access. IV\n therapy cannot place PICC.\n\n PHYSICIANS: Dr and were present for the procedure\n with Dr. supervising.\n\n PROCEDURE: The patient's right upper extremity was prepped and draped in the\n usual sterile fashion. Since no suitable superficial vein was seen,\n ultrasound was used to identify a patent and compressible right brachial vein.\n 1% Lidocaine was injected for local analgesia. Under son guidance the\n right brachial vein was cannulated with a 21 gauge needle. Under fluoroscopic\n guidance a 0.018 guidewire was advanced into the SVC. Using the markers on\n the wire a length of 40 cm was determined to be appropriate. A 5 French dual\n lumen PICC was trimmed to 40 cm and inserted into the SVC through a 5 French\n peel-away sheath. The sheath was subsequently removed. Both ports flushed and\n aspirated normally. The line is ready for use.\n\n IMPRESSION: Successful placement of a 5 French dual lumen PICC measuring 40\n cm. The line was placed through the right brachial vein and terminates in the\n SVC. The line is ready for use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-01-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815430,
"text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS EFFUSIONS/INFILTRATES\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with CAD s/p CABG.\n\n REASON FOR THIS EXAMINATION:\n ASSESS EFFUSIONS/INFILTRATES\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CAD. S/P CABG. Assess effusions,infiltrates.\n\n COMPARISON: CXR on .\n\n SUPINE AP PORTABLE CHEST: There has been interval removal of the ET tube and\n NG tube. The right-sided pulmonary artery catheter is again present in stable\n position. The patient is s/p recent CABG with sternotomy wires, vascular\n clips and mediastinal drain. The lungs are slightly less inflated following\n extubation. There is slight upper zone vascular redistribution which could be\n secondary to posture. There is worsened bilateral atelectasis greater on the\n left base.\n\n IMPRESSION: Decreases lung volumes following extubation and worsened\n bibasilar atelectasis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-01-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 815696,
"text": " 9:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal eval for pneumo\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with CAD s/p CABG.\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal eval for pneumo\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON .\n\n CLINICAL INDICATION: Chest tube removal.\n\n Comparison is made to previous study of one day earlier.\n\n There has been interval removal of a left sided chest tube. A tiny left\n apical pneumothorax is noted. The cardiac and mediastinal contours are\n stable. Bibasilar atelectatic changes show slight improvement in the left\n lung base in the interval. Small pleural effusions are not significantly\n changed in the interval.\n\n IMPRESSION: 1) Small left hydropneumothorax. In retrospect, this is\n unchanged since the previous study of one day earlier.\n\n 2) Bibasilar atelectasis and small pleural effusions, with interval\n improvement in aeration in the left lung base.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-01-10 00:00:00.000",
"description": "Report",
"row_id": 196441,
"text": "Atrial fibrillation with rapid ventricular response\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of , sinus rhythm absent and ST-T wave changes\nseen\n\n"
},
{
"category": "ECG",
"chartdate": "2131-01-08 00:00:00.000",
"description": "Report",
"row_id": 196442,
"text": "Baseline artifact\nSinus rhythm\nModest nonspecific T wave changes\nSince previous tracing of : ST-T wave changes decreased and ventricular\nectopy not seen\n\n"
}
] |
15,637 | 101,960 | The patient underwent cardiac surgery on . The patient underwent CABG times three with a LIMA to LAD, saphenous vein graft to OM, saphenous vein graft to PDA. The patient tolerated the procedure well and was transferred to the CSRU, not on any drips. The patient had an endovein harvest on the left thigh. Postoperatively the patient did well and was extubated successfully the evening of his surgery. On postoperative day #1 he was started on Lasix, Lopressor and Aspirin and was transferred to the floor. The patient received Vancomycin as perioperative antibiotic. The patient was noted on interoperative TEE to have an EF of 55-60%. The patient was seen by physical therapy and was noted to benefit from short term stay at rehab. The patient continued to do well but on the evening of postoperative day #1 was noted to be in atrial fibrillation with rapid ventricular response. This was controlled by IV Lopressor and patient was started on Amiodarone. The patient did convert to normal sinus rhythm, however, on the evening of postoperative day #2 he did have another second episode of atrial fibrillation that was converted to normal sinus rhythm after 10 mg of IV Lopressor. The patient, on postoperative day #3, had third episode of atrial fibrillation that converted spontaneously to normal sinus rhythm, however, at this point after three episodes of atrial fibrillation, it was decided to start the patient on Coumadin with a goal INR of 2.0. On discharge patient is doing well, he is afebrile, all vital signs stable, he is in normal sinus rhythm with heart rate in the high 50's to low 60's, his blood pressure is 140/80 and his O2 sats are 96% on room air. On exam patient is in no apparent distress, his heart is regular, his sternal wound is clean, dry and intact, his sternum is stable, his lungs are clear to auscultation bilaterally, his abdomen is soft, nontender, non distended, his extremities are warm and his incisions are clean, dry and intact. | Dopplerable DP/PT bilat. PT HAS ECZEMA. Area of eczema on back of right leg dng this am-DSD in place and currently dry.Activity/Comfort: Needs much encouragement to increase activity-i.e. MSO4 FOR DISCOMFORT W/ RELIEF. DIURESING WELLSKIN~ SM AMT OF DRAINAGE NOTE FROM RIGHT SHIN. MED W/ MSO4 2MG Q 2/HRS FOR INCISIONAL DISCOMFORT W/ GOOD EFFECT. Htn. SBP ^130'S. OR and CSRU courses stable hemodynamically. SBP 130'S~140'S.POS PULSES BILAT W/ DOPPLER.RESP~WEANED TO 2L NP SATS: 100% LUNGS CLEAR UPPER DIMINISHED IN BASES. Pt is slightly below pre op weight. Femoral a line d/c'd without difficulty. PO lasix started per PA request. + ETT. Hct 31. Requires 2 more doses of Vancomycin post op.Skin: Intact to back/buttocks. Aware of probably transfer to 6 today.A/P Hemodynamically stable. TOLERATED WELL W/ STABLE BP. Normal EF. A demand pacer at . Pain med as ordered. INS . Went to OR for CABG 3 with LIMA to LAD. NEEDS CONSTANT REASSURANCE THAT HE IS DOING WELL.CARDIAC~REMAINS IN SR IN 70'S,PACER BACK A-DEMAND 60. Minimal IVF post op. I and O. Early precordial R wave transition.Non-specific ST-T wave changes in leads III and aVF. CSRU TRANSFER NOTEMr. Changed to percocet and started toradol-pt reports much improved pain relief w/ these meds. ADDENDUMOOB TO CHAIR W/ 2 ASSIST. NEURO~A+OX3, MAE, C/O BEING STIFF AND ACHES. Cath showed 3 VD. DLCL d/c'd without difficulty. feeding self. Did respond well to discussion regarding progress and his ability to do things for himself post op which he perceives as limited.CV: HR 70's NSR, APC's noted this am. SBP 90-110's. + BS PASSING GAS.ADEQUAATE U/O.NITRO BRIEFLY FOR SBP ^140'S MAP 89. Pt reports that he is a "type A" person and anxious at baseline.Allergies: PCN-anaphylaxis, "multiple chemical sensitivity".PMH Psoriasis, s/p bilat CEA, PVD, s/p MI 1 month ago. PACER V DEMAND OF 60 IN NSR IN 70'S.SCANT DRAINAGE NOTED FROM R LOWER SHIN, PT STATES THAT HE HAS ECZEMA AND THIS OCC HAPPENS. No c/o sob.GI/GU: Abd soft, hypoactive BS. Difficulty w/ pain management. Received 25 mg Lopressor this am. Atrial paced ventricular sensed rhythm. Emotional support to decrease anxiety. MAE w/ equal strength with lots of encouragement. WEAK COUGH.GI/GU~TOL SIPS OF WATER NO C/O NAUSEA + BS. DSD APPLIEDMOBILITY~PT HAS LEFT FOOT DEFORMITY, WEARS SPECIAL SHOES. Encourage pulmonary hygiene. NEURO REVERSED PROPOFOL OFF AWAKE ALERT FOLLOWING ALL COMMANDS MOVES ALL EXTREMETIESC/V A PACED WITH EPISODES OF PACING DIAPHRAM MA DECREASE A WIRES WITH GOOD EFFECT V WIRES NON CAPTURE B/P STABLE GOOD PULSES CHEST TUBE INTACT UNDERLYING RHYTHM SB 50S NO ECT DSG CD&IRESP WEANED AND EXTRUBATED PLACED ON 50% AEROSOL MASK SATS 99% NONPRODUCTIVE COUGH C/O PAIN WITH INSPIRATION MS 2MG X2 GIVEN WITH FAIR EFFECT RR 14-16 WITH NO DISTRESSGI/GU TOL ICE CHIPS WELL GOOD U/OLABS CA LOW AWAITING CA GLUCONATE FOR BOLUSPLAN CONTINUE TO ASSESS RESP STATUS INCREASE PO MONITOR MS FOR PAIN Smoker, fusion of left foot (polio)- revision of fusion, ' cataract surgery.Neuro: Alert and oriented. c/o pain at incision and inbetween shoulder blades this am. READY FOR TRANSFER TO 6. R LEG ELEVATED ON PILLOW C/O HEEL PAIN. Anxious. BUN/Cr wnl.Endo: Received 3 u SC reg insulin this am for glucose of 142.ID: Afebrile. K+ 4.5.Resp: BS diminished at bases, left more than right. Increase activity as tolerated. u/o down to 15cc x 1 hour. Currently on bedrest until 1130 d/t removal of left femoral a line.Social: Family called and in visiting. Monitor glucose per protocol. Skin warm, dry. Site dry. NEURO RECIEVED FROM OR PROPOFOL 20MCGS UNRESPONSIVE PUPILS PINPOINTC/V APACED WITH UNDERLYING HR 42 SB NONCAPTURE OF V WIRES UP TO 11 A PACER BACK ON WILL REASSSESS CURRENTLY A PACED WITH 100% SENSING AND CAPTURE GOOD BILAT PEDAL PULSES BY DOPPLER TEMP 96.7 BEAR HUGGER ON B/P STABLE SL ELEVATED PACER DECREASE FROM 88 TO 78 CT INTACT SMALL BLOODY DRAINAGE DSG CD&IRESP FROM OR ON 700/10/100% 5/5 ABGS DONE SETTINGS ADJUSTED DECREASE TO 50% TOL WELL SATS 100% BREATH SOUNDS CLEAR BILAT NO SECRETIONSLABS K 3.9 REPLACED 40 KCLPLAN CONTINUE TO WEAN VENT AS TOL IF REMAINS STABLE REVERSE AND WEAN PROPOFOL Transfer to 6 today. O2 sats 96% or greater on 2l np. TOL ICE CHIPS WELL ADVANCED TO SIPS OF WATER TOL WELL. Tolerated all of banana and of milk this am. FAMILY TO BRING THEM IN TODAY.A/P~PERCOCET WHEN EATING FOR PAIN MGT. OOB TO CHAIR TODAY PLAN TO TRANS TO 6 TODAY. HAD POLIO AS A CHILD. No previous tracingavailable for comparison. Brown areas noted throughout skin which pt reports is due to eczema. STATED HE HAD BEEN SCRATCHING HIS LEGS ALOT PRIOR TO SURGERY. | 7 | [
{
"category": "ECG",
"chartdate": "2183-11-06 00:00:00.000",
"description": "Report",
"row_id": 153056,
"text": "Atrial paced ventricular sensed rhythm. Early precordial R wave transition.\nNon-specific ST-T wave changes in leads III and aVF. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-11-06 00:00:00.000",
"description": "Report",
"row_id": 1465085,
"text": "NEURO RECIEVED FROM OR PROPOFOL 20MCGS UNRESPONSIVE PUPILS PINPOINT\n\nC/V APACED WITH UNDERLYING HR 42 SB NONCAPTURE OF V WIRES UP TO 11 A PACER BACK ON WILL REASSSESS CURRENTLY A PACED WITH 100% SENSING AND CAPTURE GOOD BILAT PEDAL PULSES BY DOPPLER TEMP 96.7 BEAR HUGGER ON B/P STABLE SL ELEVATED PACER DECREASE FROM 88 TO 78 CT INTACT SMALL BLOODY DRAINAGE DSG CD&I\n\nRESP FROM OR ON 700/10/100% 5/5 ABGS DONE SETTINGS ADJUSTED DECREASE TO 50% TOL WELL SATS 100% BREATH SOUNDS CLEAR BILAT NO SECRETIONS\n\nLABS K 3.9 REPLACED 40 KCL\n\nPLAN CONTINUE TO WEAN VENT AS TOL IF REMAINS STABLE REVERSE AND WEAN PROPOFOL\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-11-06 00:00:00.000",
"description": "Report",
"row_id": 1465086,
"text": "NEURO REVERSED PROPOFOL OFF AWAKE ALERT FOLLOWING ALL COMMANDS MOVES ALL EXTREMETIES\n\nC/V A PACED WITH EPISODES OF PACING DIAPHRAM MA DECREASE A WIRES WITH GOOD EFFECT V WIRES NON CAPTURE B/P STABLE GOOD PULSES CHEST TUBE INTACT UNDERLYING RHYTHM SB 50S NO ECT DSG CD&I\n\nRESP WEANED AND EXTRUBATED PLACED ON 50% AEROSOL MASK SATS 99% NONPRODUCTIVE COUGH C/O PAIN WITH INSPIRATION MS 2MG X2 GIVEN WITH FAIR EFFECT RR 14-16 WITH NO DISTRESS\n\nGI/GU TOL ICE CHIPS WELL GOOD U/O\n\nLABS CA LOW AWAITING CA GLUCONATE FOR BOLUS\n\nPLAN CONTINUE TO ASSESS RESP STATUS INCREASE PO MONITOR MS FOR PAIN\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-11-07 00:00:00.000",
"description": "Report",
"row_id": 1465087,
"text": "MED W/ MSO4 2MG Q 2/HRS FOR INCISIONAL DISCOMFORT W/ GOOD EFFECT. TOL ICE CHIPS WELL ADVANCED TO SIPS OF WATER TOL WELL. + BS PASSING GAS.\nADEQUAATE U/O.\nNITRO BRIEFLY FOR SBP ^140'S MAP 89. SBP ^130'S. PACER V DEMAND OF 60 IN NSR IN 70'S.\nSCANT DRAINAGE NOTED FROM R LOWER SHIN, PT STATES THAT HE HAS ECZEMA AND THIS OCC HAPPENS. R LEG ELEVATED ON PILLOW C/O HEEL PAIN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-11-07 00:00:00.000",
"description": "Report",
"row_id": 1465088,
"text": "NEURO~A+OX3, MAE, C/O BEING STIFF AND ACHES. MSO4 FOR DISCOMFORT W/ RELIEF. NEEDS CONSTANT REASSURANCE THAT HE IS DOING WELL.\nCARDIAC~REMAINS IN SR IN 70'S,PACER BACK A-DEMAND 60. SBP 130'S~140'S.\nPOS PULSES BILAT W/ DOPPLER.\nRESP~WEANED TO 2L NP SATS: 100% LUNGS CLEAR UPPER DIMINISHED IN BASES. WEAK COUGH.\nGI/GU~TOL SIPS OF WATER NO C/O NAUSEA + BS. DIURESING WELL\nSKIN~ SM AMT OF DRAINAGE NOTE FROM RIGHT SHIN. PT HAS ECZEMA. STATED HE HAD BEEN SCRATCHING HIS LEGS ALOT PRIOR TO SURGERY. DSD APPLIED\nMOBILITY~PT HAS LEFT FOOT DEFORMITY, WEARS SPECIAL SHOES. HAD POLIO AS A CHILD. FAMILY TO BRING THEM IN TODAY.\nA/P~PERCOCET WHEN EATING FOR PAIN MGT. INS . OOB TO CHAIR TODAY PLAN TO TRANS TO 6 TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-11-07 00:00:00.000",
"description": "Report",
"row_id": 1465089,
"text": "CSRU TRANSFER NOTE\n\nMr. is a 74 year old man who was worked for c/o chest pressure w/ elevated HR approx 2 weeks ago. + ETT. Cath showed 3 VD. Normal EF. Went to OR for CABG 3 with LIMA to LAD. OR and CSRU courses stable hemodynamically. Minimal IVF post op. Difficulty w/ pain management. Pt reports that he is a \"type A\" person and anxious at baseline.\n\nAllergies: PCN-anaphylaxis, \"multiple chemical sensitivity\".\n\nPMH Psoriasis, s/p bilat CEA, PVD, s/p MI 1 month ago. Htn. Smoker,\n fusion of left foot (polio)- revision of fusion, '\n cataract surgery.\n\nNeuro: Alert and oriented. MAE w/ equal strength with lots of encouragement. Anxious. Did respond well to discussion regarding progress and his ability to do things for himself post op which he perceives as limited.\n\nCV: HR 70's NSR, APC's noted this am. SBP 90-110's. Received 25 mg Lopressor this am. Skin warm, dry. Dopplerable DP/PT bilat. Femoral a line d/c'd without difficulty. Site dry. Hct 31. A demand pacer at . DLCL d/c'd without difficulty. K+ 4.5.\n\nResp: BS diminished at bases, left more than right. O2 sats 96% or greater on 2l np. No c/o sob.\n\nGI/GU: Abd soft, hypoactive BS. Tolerated all of banana and of milk this am. u/o down to 15cc x 1 hour. PO lasix started per PA request. Pt is slightly below pre op weight. BUN/Cr wnl.\n\nEndo: Received 3 u SC reg insulin this am for glucose of 142.\n\nID: Afebrile. Requires 2 more doses of Vancomycin post op.\n\nSkin: Intact to back/buttocks. Brown areas noted throughout skin which pt reports is due to eczema. Area of eczema on back of right leg dng this am-DSD in place and currently dry.\n\nActivity/Comfort: Needs much encouragement to increase activity-i.e. feeding self. c/o pain at incision and inbetween shoulder blades this am. Changed to percocet and started toradol-pt reports much improved pain relief w/ these meds. Currently on bedrest until 1130 d/t removal of left femoral a line.\n\nSocial: Family called and in visiting. Aware of probably transfer to 6 today.\n\nA/P Hemodynamically stable. Encourage pulmonary hygiene. I and O. Monitor glucose per protocol. Pain med as ordered. Emotional support to decrease anxiety. Increase activity as tolerated. Transfer to 6 today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-11-07 00:00:00.000",
"description": "Report",
"row_id": 1465090,
"text": "ADDENDUM\n\nOOB TO CHAIR W/ 2 ASSIST. TOLERATED WELL W/ STABLE BP. READY FOR TRANSFER TO 6.\n"
}
] |
11,051 | 150,770 | Pt was admitted to the icu for close observation and neuro checks. His repeat imaging was stable and his exam non focal. He wishes to go home today. Social work was asked to see pt prior to discharge for history of physical altercations and alcohol intoxication on admission. He was later discharged to home. | IMPRESSION: No acute cardiopulmonary abnormality. The cardiac silhouette is unchanged. FINDINGS: There is stable appearance of subtle hyperattenuating focus in the right temporal , likely an area of focal contusion, with no significant interval change. No acute fracture is seen. No new hemorrhage. There is no pericardial effusion. There is no large area of hemorrhage. No displaced fracture is identified. FINDINGS: There is no focal consolidation or pleural effusion at the lung bases. No retroperitoneal or mesenteric lymphadenopathy. There is no evidence of bowel obstruction. FINDINGS: Single AP upright portable view of the chest was obtained. The gallbladder appears normal. No intravenous contrast was administered. No intravenous contrast was administered. No oral contrast was administered. There is no shift of midline structures. There is no shift of midline structures. No evidence of acute injury in the abdomen or pelvis. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. Mild prominence of the superior mediastinum is without significant change since the prior study and likely relates to AP technique. Visualized portion of paranasal sinus and mastoid air cells are within normal limits. Visualized portion of paranasal sinuses and mastoid air cells are within normal limits. COMPARISON: No prior. Ventricles and sulci are normal in size and configuration. Heart size is normal. Subtle hyperattenuating focus in the right temporal , unchanged over the 7 hour interval, may represent either very small contusion or diffuse axonal injury. No evidence of hydrocephalus. The ventricles and sulci are normal in size and configuration. The urinary bladder, rectum, sigmoid, prostate and seminal vesicles appear normal. There is no evidence of hydrocephalus. There is no pelvic free fluid or free air. Small focus of hydperdensity in the right temporal , be due to small contusion or relate to diffuse axonal injury. CT PELVIS: A normal appendix is seen in the right lower quadrant. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. There is no free fluid or free air. There are relatively low lung volumes. There is soft tissue edema in the right parietal area. please scan abdomen and pelvis with and without IV contrast No contraindications for IV contrast WET READ: IPf SUN 11:02 PM no evidence of acute injury on ct FINAL REPORT HISTORY: Trauma. please take at 6am No contraindications for IV contrast WET READ: IPf MON 6:11 AM No significant interval change FINAL REPORT HISTORY: Skull fracture status post assault. Incidental finding of cisterna magna. The liver, spleen, pancreas, adrenal glands, kidneys, loops of large and small bowel appear unremarkable. 10:07 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: eval for acute process. Tubular hyperdense material at the right posterior fossa, likely blood in the transverse venous sinus; less likely, given its stability (including since the Hospital study of 10 hours earlier), is small focal subdural hemorrhage. OSSEOUS STRUCTURES: There is old fracture of the right posterolateral 10th rib. Old fracture of the posterolateral right 10th rib. 10:06 PM CT HEAD W/O CONTRAST Clip # Reason: eval for IPH, fx MEDICAL CONDITION: 45 year old man s/p assault with depressed skull fx by OSH report REASON FOR THIS EXAMINATION: eval for IPH, fx No contraindications for IV contrast WET READ: IPf SUN 10:59 PM soft tissue edema R parietal area squamous portion of the temporal bone fracture R depressed 4-5 mm 2:13 focal area of contusion with high dense material, could be small area of blood, could be DIA, with no significant interval change mri can be done to evaluate futher FINAL REPORT HISTORY: Trauma. Further evaluation with MRI can be done if clinically warranted, and if there is no contraindication for MRI. 2. 2. 2. 3. There is cisterna magna, (2:5). TECHNIQUE: CT abdomen and pelvis with IV contrast. There is soft tissue edema in the right parietal area with associated comminuted fracture of the squamosal portion of the right temporal bone, with 4-5 mm depression of bony fragments. Persistent soft tissue edema at right parietal area with underlying comminuted fracture of the squamous portion of the right temporal bone, with 4-5 mm depression of bony fragments, as before. COMPARISON: . There is a comminuted fracture with 4-5 mm depressed bony fragments at the squamous portion of the temporal bone. COMPARISON: Compared to CT head from at 22:39 p.m. Soft tissue edema at the parietal area, with a comminuted fracture of the squamous portion of the right temporal bone with 4-5 mm of depression of bony fragments. 5:17 AM CT HEAD W/O CONTRAST Clip # Reason: evaluate for interval change. | 4 | [
{
"category": "Radiology",
"chartdate": "2148-05-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1137271,
"text": " 5:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change. please take at 6am \n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with 4-5mm depressed skull fracture s/p assault\n REASON FOR THIS EXAMINATION:\n evaluate for interval change. please take at 6am \n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf MON 6:11 AM\n No significant interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Skull fracture status post assault.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: Compared to CT head from at 22:39 p.m.\n\n FINDINGS: There is stable appearance of subtle hyperattenuating focus\n in the right temporal , likely an area of focal contusion, with no\n significant interval change. There is no shift of midline structures. There\n is no evidence of hydrocephalus. The ventricles and sulci are normal in size\n and configuration. Incidental finding of cisterna magna.\n\n There is soft tissue edema in the right parietal area with associated\n comminuted fracture of the squamosal portion of the right temporal bone, with\n 4-5 mm depression of bony fragments. Visualized portion of paranasal sinuses\n and mastoid air cells are within normal limits.\n\n Tubular hyperdense material at the right posterior fossa, likely blood in the\n transverse venous sinus; less likely, given its stability (including since\n the Hospital study of 10 hours earlier), is small focal subdural\n hemorrhage.\n\n IMPRESSION:\n 1. Persistent soft tissue edema at right parietal area with underlying\n comminuted fracture of the squamous portion of the right temporal bone, with\n 4-5 mm depression of bony fragments, as before.\n 2. Subtle hyperattenuating focus in the right temporal , unchanged over\n the 7 hour interval, may represent either very small contusion or diffuse\n axonal injury.\n 3. No new hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-19 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1137245,
"text": " 9:59 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE UPRIGHT AP PORTABLE VIEW\n\n CLINICAL INFORMATION: 51-year-old male with history of trauma.\n\n COMPARISON: .\n\n FINDINGS: Single AP upright portable view of the chest was obtained. There\n are relatively low lung volumes. Mild prominence of the superior mediastinum\n is without significant change since the prior study and likely relates to AP\n technique. The cardiac silhouette is unchanged. No focal consolidation,\n pleural effusion, or evidence of pneumothorax is seen.\n\n No displaced fracture is identified.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1137246,
"text": " 10:06 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for IPH, fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p assault with depressed skull fx by OSH report\n REASON FOR THIS EXAMINATION:\n eval for IPH, fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 10:59 PM\n soft tissue edema R parietal area\n squamous portion of the temporal bone fracture R depressed 4-5 mm\n 2:13 focal area of contusion with high dense material, could be small area of\n blood, could be DIA, with no significant interval change\n mri can be done to evaluate futher\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: Outside CT from , at 8:10 p.m.\n\n FINDINGS: There is a focal area of high dense material in the right temporal\n , likely area of focal contusion, could be due to diffuse axonal injury.\n There is no large area of hemorrhage. There is no shift of midline\n structures. Ventricles and sulci are normal in size and configuration. No\n evidence of hydrocephalus. There is cisterna magna, (2:5).\n\n There is soft tissue edema in the right parietal area. There is a comminuted\n fracture with 4-5 mm depressed bony fragments at the squamous portion of the\n temporal bone. Visualized portion of paranasal sinus and mastoid air cells\n are within normal limits.\n\n IMPRESSION:\n 1. Soft tissue edema at the parietal area, with a comminuted fracture of the\n squamous portion of the right temporal bone with 4-5 mm of depression of bony\n fragments.\n 2. Small focus of hydperdensity in the right temporal , be due to\n small contusion or relate to diffuse axonal injury. Further evaluation with\n MRI can be done if clinically warranted, and if there is no contraindication\n for MRI.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-19 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1137247,
"text": " 10:07 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for acute process. please scan abdomen and pelvis with\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p assault with depressed skull fx by OSH report\n REASON FOR THIS EXAMINATION:\n eval for acute process. please scan abdomen and pelvis with and without IV\n contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 11:02 PM\n no evidence of acute injury on ct\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n TECHNIQUE: CT abdomen and pelvis with IV contrast. No oral contrast was\n administered.\n\n COMPARISON: No prior.\n\n FINDINGS: There is no focal consolidation or pleural effusion at the lung\n bases. There is no pericardial effusion. Heart size is normal. The liver,\n spleen, pancreas, adrenal glands, kidneys, loops of large and small bowel\n appear unremarkable. The gallbladder appears normal. There is no evidence of\n bowel obstruction. There is no free fluid or free air. No retroperitoneal or\n mesenteric lymphadenopathy.\n\n CT PELVIS: A normal appendix is seen in the right lower quadrant. The\n urinary bladder, rectum, sigmoid, prostate and seminal vesicles appear normal.\n There is no pelvic free fluid or free air.\n\n OSSEOUS STRUCTURES: There is old fracture of the right posterolateral 10th\n rib. No acute fracture is seen.\n\n IMPRESSION:\n 1. No evidence of acute injury in the abdomen or pelvis.\n 2. Old fracture of the posterolateral right 10th rib.\n\n"
}
] |
88,726 | 189,805 | Pt was admitted to Neurosurgery for Dr. , floor w/o telemetry for Q4 hr neuro checks. He was started on Decadron 4mg Q6 hrs and Keppra 500mg and ordered for a brain MRI +/- as soon as possible. This was performed and revealed a brain lesion in the basal ganglia/3rd ventricle. On Neuro and Radiation Oncology were consulted and Metastatic work up was initiated. On the patient was brought to the operating room and underwent stereotactic biopsy and EVD placement. Surgery was without complication. Post op Head CT revealed expected post-operative changes. On he had left eye edema, was full strength, and was nauseaus and vomiting. HisEVD was draining CSF that was pink On he was lethargic but easily arousable and his IV pain meds began to be titrated On 2.28 he was stable in the SDU while awaiting further management and final pathology results. on 3.1 Dr met with the patients family to discuss surgical resection of the lesion. it was deemed appropriate that he would go to the operating room on for surgical resection On 3.2 he remained stable in the SDU with improvement of his left drift, facial droop, and mental status while awaiting surgery on On he was taken to the OR and underwent a right craniotomy and mass resection. His EVD catheter was also replaced. This was done without complication and he tolerated it well. He was admitted to the ICU for close monitoring. Post op CT revealed no hemorrhage and adequate catheter placement. On he remained neurologically stable. EVD cont at 10 cm H20. Decadron wean was initated and his SBP was liberalized to 160. An MRI was obtained which revealed expected post-operative changes with pneumocephalus. On he was noted to have what was believed to be ICU delirium, family at the bedsidce, not sleeping much, ambien and benadryl tried without much effect. On his EVD was clamped and his Decadron was discontinued and he was seen by Psych as he continued with psychosis. Psych recommended discontinuing his Keppra. Also on he had a head CT which shwoed his ventircles were very minimally enlarged. His drain continued to be clamped and he recieed Haldol overnight for agitation. It was felt that he may have had a seziure versus dystonic reaction to the haldol as his RUE was extending. He had an EEG placed on the mornign of and his mental status was much improved compared to during the weekend. Another head CT was done which showed no hydrocephalus and as such his EVD was pulled. On the patient remained neurologically well. EEG was removed and preliminary negative for seizure activity that could correlate with his episode of delerium. He was transferred to the stepdown unit. On PT and OT were ordered for assistance with discharge planning. on he was doing well and PT/OT felt he would benefit from outpatient services. On he was deemed fit for discharge and was given instructions for follow-up | Since the prior head CT the pneumocephalus has been resolved, there is a large unchanged mild lesion with heterogeneous signal, predominantly midline and to the right of the region of the third ventricle with similar characteristics as the prior examination dated . Since the prior head CT the pneumocephalus has been resolved, there is a large unchanged mild lesion with heterogeneous signal, predominantly midline and to the right of the region of the third ventricle with similar characteristics as the prior examination dated . Unchanged mildly dilated ventricles compared to , and hypodnese areas in the right frontal lobe adjacent to the prior ventricular tract allowing for technical differences and pneumocephalus. IMPRESSION: Unchanged intracranial mass lesion centered in the midline towards the right and adjacent to the third ventricle. FINDINGS: Non-contrast head CT was performed with axial, coronal, sagittal reformations. An unchanged intracranial mass lesion is redemonstrated predominantly midline and to the right in the region of the third ventricle, right anterior thalamus, internal capsule and displacing the surrounding structures. FINDINGS: CT HEAD: The hyperdense mass abutting and displacing the third ventricle in the region of the right thalamus is unchanged in size, appearance and mass effect. FINAL REPORT NON-CONTRAST HEAD CT PERFORMED ON . FINDINGS: There has been interval placement of an external ventricular drain from a right frontal approach. Minimal pneumocephalus and a focus of air within the frontal of the right lateral ventricle are a normal post-procedual expected appearance. Moderate prominence of the lateral ventricular system is unchanged compared with the most recent prior CT of the head dated . LESIONAL VOLUMETRY PLEASE No contraindications for IV contrast PFI REPORT Status post resection of right basal thalamic lesion likely a cavernous malformation since the previous MRI of . FINDINGS: A right frontal approach ventriculostomy catheter projects from the craniotomy site, terminating within the anterior of the right lateral ventricle (301B:19), unchanged in position and orientation since the prior examination of . Hyperdense blood within the occipital of the right lateral ventricle (301B:22) is now less conspicuous. In comparison with the prior head CT, the pneumocephalus has been resolved in the right frontal area. There has been interval removal of the right frontal ventriculostomy catheter. Unchanged appearance of the heterogenous mass adjacent to the third ventricle. The orbits and periorbital soft tissues are unremarkable.The pituitary gland and suprasellar cystern is normal in appearance. CTA HEAD: The internal carotid arteries and branches are normal in contrast opacification and caliber. There is local mass effect and the lateral ventricles are mildly prominent, without evidence of transependymal CSF flow. Of note, The lateral ventricles are mildly promenent without evidence of transependymal CSF flow. Of note, The lateral ventricles are mildly promenent without evidence of transependymal CSF flow. Of note, The lateral ventricles are mildly promenent without evidence of transependymal CSF flow. IMPRESSION: Status post partial resection of right thalamic lesion with similar appearance and mass effect. The lesion in the region of the right thalamus is unchanged in size, appearance and mass effect. Vasogenic edema in right frontal lobe along proximal tract of removed catheter is not significantly changed. The degree of compression of the third ventricle is unchanged. FINDINGS: Allowing for differences in technique, there is no significant change in the size of the residual lesion with blood products in the right thalamus with extension into the 3rd ventricle. Moderate degree of pneumocephalus overlying the frontal lobes and within the anterior of the left lateral ventricle appears stable. Stable appearance of the residual lesion andblood products in the right thalamus with similar mass effect on the third ventricle. Unchanged large heterogeneous mass located to the right of the third ventricle. FINDINGS: The patient is status post interval placement of an external ventricular drain via right frontal approach. Slight prominennce in ventricules compared to last MR could be due to different head position during CT and diff modality. Interval removal of the right frontal ventriculostomy catheter. Blood products within the right basal ganglia (301B:20) are unchanged. The lateral ventricles are mildly prominent, most notably the temporal horns without evidence of transependymal CSF flow. Expected post-procedural changes including mild pneumocephalus. Expected post-procedural changes including mild pneumocephalus. IMPRESSION: Right craniotomy and right thalamic resection post-surgical changes, stable since . IMPRESSION: Status post resection of right thalamic lesion, likely a cavernous malformation since the previous MRI of . COMPARISON: CT head from . TECHNIQUE: MDCT-acquired axial images of the head were obtained without the use of IV contrast. Follwo up as clinically indicated. The ventricles are mildly dilated, but are not significantly changed in size or configuration compared to , allowing for technical differences and pneumocephalus. TECHNIQUE: Axial, sagittal and coronal T1-weighted sequences after the administration of contrast were obtained. There are no abnormal vessels in the region of the previously described lesion in the region of the right thalamus. COMPARISON: CT head and MR . TECHNIQUE: MR of the brain was performed utilizing sagittal and axial T1, axial T2, axial FLAIR, axial gradient and diffusion with ADC map sequences without intravenous contrast. Normal thymus gland is noted. LESIONAL VOLUMETRY PLEASE No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 12:49 PM Status post resection of right basal thalamic lesion likely a cavernous malformation since the previous MRI of . Bilateral opacification of mastoid air cells is noted. Blood products are seen in the medial portion but resection is identified on the lateral anterior portion of the previously noted lesion. Blood products are seen in the medial portion but resection is identified on the lateral anterior portion of the previously noted lesion. | 15 | [
{
"category": "Radiology",
"chartdate": "2138-03-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1180544,
"text": " 7:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 22 year old man s/p EVD removal . Eval for interval \n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p EVD removal . Eval for interval changes.\n REASON FOR THIS EXAMINATION:\n 22 year old man s/p EVD removal . Eval for interval changes.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:37 AM\n Blood products within the right basal ganglia are not significantly changed\n compared to . No new intracranial hemorrhage. Interval removal\n of the right frontal ventriculostomy catheter. No significant change in\n ventricular size or configuration compared to . Vasogenic edema\n in right frontal lobe along proximal tract of removed catheter is not\n significantly changed. No evidence of central herniation. No acute large\n vascular territorial infarction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post EVD removal on . Evaluate for interval\n changes.\n\n TECHNIQUE: Sequential axial images were acquired through the head without\n administration of intravenous contrast.\n\n COMPARISON: Multiple CT head studies extending back to ,\n including the most recent study from .\n\n FINDINGS: Allowing for differences in technique, there is no significant\n change in the size of the residual lesion with blood products in the right\n thalamus with extension into the 3rd ventricle. No new intracranial\n hemorrhage is seen. There has been interval removal of the right frontal\n ventriculostomy catheter. Slight evolution of white matter hypodensities\n along the proximal portion of the catheter tract are noted and may relate to\n edema/injury. The ventricles are mildly dilated, but are not significantly\n changed in size or configuration compared to , allowing for\n technical differences and pneumocephalus. The degree of compression of the\n third ventricle is unchanged. There is no evidence of herniation or acute\n large vascular territorial infarction. Decreased pneumocephalus is noted.\n The visualized portions of the paranasal sinuses and mastoid air cells are\n well aerated. Aside from a right frontal craniotomy, there are no fractures\n identified.\n\n IMPRESSION:\n\n 1. Stable appearance of the residual lesion andblood products in the right\n thalamus with similar mass effect on the third ventricle.\n\n 2. Unchanged mildly dilated ventricles compared to , and\n hypodnese areas in the right frontal lobe adjacent to the prior ventricular\n tract allowing for technical differences and pneumocephalus.\n (Over)\n\n 7:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 22 year old man s/p EVD removal . Eval for interval \n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3. No new intracranial hemorrhage identified.\n Follwo up as clinically indicated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1179978,
"text": " 9:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 22 year old man s/p crani for resection, EVD clamped, please\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man s/p crani for resection, EVD clamped, please evalute for\n interval changes\n REASON FOR THIS EXAMINATION:\n 22 year old man s/p crani for resection, EVD clamped, please evalute for\n interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: IPf SUN 10:33 AM\n Similar apperance of the right basal ganglia mass, with blood product at the\n surgical bed, and pneumocephalus.\n Blood in the posterior horns; similar to prior.\n Slight prominennce in ventricules compared to last MR could be due to\n different head position during CT and diff modality.\n If continuous clinical concern, close follow-up can be considered.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post craniotomy for resection, EVD clamped; evaluate for\n interval change.\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: The patient is status post partial resection of the lesion in the\n right basal ganglia, with residual post-surgical pneumocephalus. There is\n similar appearance of residual lesion in the right basal ganglia with\n heterogeneous appearance and blood products in the medial inferior portion,\n with similar mass effect on the third ventricle. There is a drain extending\n from the right frontal lobe into the frontal of the right lateral\n ventricle. The ventricles appear similar in configuration; however, slightly\n prominent compared to MR, could be due to difference in modality and\n positioning. There is blood layering in the posterior of the right\n lateral ventricle.\n\n IMPRESSION:\n Status post partial resection of right thalamic lesion with similar appearance\n and mass effect.\n Blood layering in the posterior of the right lateral ventricle.\n Ventricles similar in configuration and slightly more prominent compared to MR\n from ; however, could be due to positioning and difference in\n modality.\n\n If continuous clinical concern, please consider close followup.\n (Over)\n\n 9:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: 22 year old man s/p crani for resection, EVD clamped, please\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1180060,
"text": " 4:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for ventriculmegaly, EVD capped\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with s/p brain mass excision and EVD placed\n REASON FOR THIS EXAMINATION:\n assess for ventriculmegaly, EVD capped\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc MON 6:03 AM\n . s/p right thalamic lesion resectionn, Postoperative changes are stable since\n the 10:00AM exam. No evidence of new hemorrhage, mass effect, or large\n vascular territorial infarction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old male status post brain mass excision with EVD placed.\n\n COMPARISON: CT available from .\n\n TECHNIQUE: MDCT-acquired axial images of the head were obtained without the\n use of IV contrast. Coronal and sagittal reformations were performed with\n 2-mm slice thickness.\n\n FINDINGS: A right frontal approach ventriculostomy catheter projects from the\n craniotomy site, terminating within the anterior of the right lateral\n ventricle (301B:19), unchanged in position and orientation since the prior\n examination of . The ventricles are unchanged in configuration.\n Blood products within the right basal ganglia (301B:20) are unchanged.\n Hyperdense blood within the occipital of the right lateral ventricle\n (301B:22) is now less conspicuous. Moderate degree of pneumocephalus\n overlying the frontal lobes and within the anterior of the left lateral\n ventricle appears stable.\n\n No new hemorrhage, mass effect, or infarction is seen.\n\n IMPRESSION:\n Right craniotomy and right thalamic resection post-surgical changes, stable\n since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-21 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1179800,
"text": " 8:30 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 22 year old man with cavernous malformation s/p craniotomy a\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with cavernous malformation s/p craniotomy and resection. Eval\n post op\n REASON FOR THIS EXAMINATION:\n 22 year old man with cavernous malformation s/p craniotomy and resection. Eval\n post op. LESIONAL VOLUMETRY PLEASE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 12:49 PM\n Status post resection of right basal thalamic lesion likely a cavernous\n malformation since the previous MRI of . Blood products are seen in\n the medial portion but resection is identified on the lateral anterior portion\n of the previously noted lesion. There is no new hemorrhage seen. No\n hydrocephalus. Pneumocephalus noted.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with cavernous malformation, status post\n surgery.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images obtained before gadolinium. T1 axial and MP-RAGE sagittal images\n acquired following gadolinium. Comparison was made with the previous MRI\n examination of .\n\n FINDINGS: Since the previous study, the patient has undergone partial\n resection of the lesion in the right basal ganglia region. There is evidence\n of a surgical defect in the lateral portion of previously identified lesion\n which appears to be resected. A small area of blood products remains in the\n medial inferior portion. There remains some mass effect on the third\n ventricle. There is no hydrocephalus. There is a drain identified from the\n right frontal region. There is pneumocephalus. There is no acute infarct\n seen. Small amount of blood products are seen within the ventricles.\n Suprasellar and craniocervical are unremarkable.\n\n IMPRESSION: Status post resection of right thalamic lesion, likely a\n cavernous malformation since the previous MRI of . Blood products are\n seen in the medial portion but resection is identified on the lateral anterior\n portion of the previously noted lesion. There is no new hemorrhage seen. No\n hydrocephalus. Pneumocephalus noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-21 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1179801,
"text": ", M. NSURG SICU-B 8:30 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: 22 year old man with cavernous malformation s/p craniotomy a\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with cavernous malformation s/p craniotomy and resection. Eval\n post op\n REASON FOR THIS EXAMINATION:\n 22 year old man with cavernous malformation s/p craniotomy and resection. Eval\n post op. LESIONAL VOLUMETRY PLEASE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Status post resection of right basal thalamic lesion likely a cavernous\n malformation since the previous MRI of . Blood products are seen in\n the medial portion but resection is identified on the lateral anterior portion\n of the previously noted lesion. There is no new hemorrhage seen. No\n hydrocephalus. Pneumocephalus noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-13 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1178500,
"text": " 5:35 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: 22 year old man with new brain mass; left sided facial droop\n Admitting Diagnosis: BRAIN MASS\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with new brain mass; left sided facial droop\n REASON FOR THIS EXAMINATION:\n 22 year old man with new brain mass; left sided facial droop\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New brain mass. Left-sided facial droop.\n\n TECHNIQUE: Continuous axial images were obtained through the brain without\n contrast material. Subsequently, rapid axial imaging was performed from the\n skull base to the vertex during the infusion of intravenous contrast. Images\n were processed on a separate workstation with display of curved reformats, 3D\n volume-rendered images and maximum intensity projection images.\n\n COMPARISON: CT of the head , MR of the brain . No prior CTA of the head for comparison.\n\n FINDINGS:\n CT HEAD: The hyperdense mass abutting and displacing the third ventricle in\n the region of the right thalamus is unchanged in size, appearance and mass\n effect. The moderate prominence of the lateral ventricles is not\n significantly changed. No new lesions are identified. The cerebral sulci are\n stable in appearance without effacement. -white matter differentiation is\n maintained. The basal cisterns are patent.\n\n CTA HEAD: The internal carotid arteries and branches are normal in contrast\n opacification and caliber. The vertebrobasilar arteries and branches are also\n normal in caliber and post-contrast enhancement. There are no abnormal\n vessels in the region of the previously described lesion in the region of the\n right thalamus. No evidence of aneurysm, stenosis, occlusion, arteriovenous\n malformation or AV fistula is identified.\n\n IMPRESSION:\n 1. No evidence of aneurysm, arteriovenous malformation or AV fistula.\n\n 2. The lesion in the region of the right thalamus is unchanged in size,\n appearance and mass effect.\n\n 3. Moderate prominence of the lateral ventricular system is unchanged\n compared with the most recent prior CT of the head dated .\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-13 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1178501,
"text": " 5:36 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONSClip # \n Reason: 22 year old man with brain mass; left sided facial droop, on\n Admitting Diagnosis: BRAIN MASS\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with new brain mass; left sided facial droop, oncology workup\n REASON FOR THIS EXAMINATION:\n 22 year old man with brain mass; left sided facial droop, oncology workup\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 8:38 PM\n Normal CT of the chest abdomen and pelvis. \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old with brain mass. Evaluate for malignancy.\n\n COMPARISON: Brain MRI .\n\n TECHNIQUE: Multidetector helical scanning of the chest, abdomen and pelvis\n was performed following the administration of oral and 90 cc of IV Optiray\n contrast. Non-contrast and three-minute delayed images were obtained through\n the abdomen. Coronal and sagittal reformats were displayed.\n\n CT OF THE CHEST: The lungs are clear and the bronchi are patent to the\n subsegmental level. The heart, pericardium and great vessels are normal.\n There is no pleural or pericardial effusion. Normal thymus gland is noted.\n No axillary, mediastinal, or hilar lymphadenopathy.\n\n CT OF THE ABDOMEN: The liver, spleen, gallbladder, pancreas, and adrenal\n glands are normal. The kidneys enhance and excrete contrast symmetrically.\n The small and large bowel loops are normal. There is no ascites. The\n abdominal aorta is normal in caliber. There is no mesenteric or\n retroperitoneal lymphadenopathy. The appendix is normal.\n\n CT OF THE PELVIS: The sigmoid colon, rectum, prostate, and bladder are\n normal. There is no pelvic free fluid or lymphadenopathy.\n\n No concerning lytic or sclerotic lesions.\n\n IMPRESSION: Normal CT of the chest, abdomen, and pelvis, with no evidence of\n malignancy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-20 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 1179496,
"text": " 5:12 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-operative planning. obtain prior to 5am on as patien\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with ependymoma\n REASON FOR THIS EXAMINATION:\n pre-operative planning. obtain prior to 5am on as patient is first case for\n OR at 7am\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 1:13 PM\n PFI: No significant changes are demonstrated in the interval, the patient is\n status post interval placement of an external ventricular drain via right\n frontal approach. Since the prior head CT the pneumocephalus has been\n resolved, there is a large unchanged mild lesion with heterogeneous signal,\n predominantly midline and to the right of the region of the third ventricle\n with similar characteristics as the prior examination dated .\n Fiducial markers are in place.\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE HEAD WITH CONTRAST, WAND PROTOCOL\n\n COMPARISON: Prior head CT dated and MRI of the brain dated\n .\n\n TECHNIQUE: Axial, sagittal and coronal T1-weighted sequences after the\n administration of contrast were obtained. Axial MP-RAGE and multiplanar\n reconstructions were provided.\n\n FINDINGS: The patient is status post interval placement of an external\n ventricular drain via right frontal approach. In comparison with the prior\n head CT, the pneumocephalus has been resolved in the right frontal area. An\n unchanged intracranial mass lesion is redemonstrated predominantly midline and\n to the right in the region of the third ventricle, right anterior thalamus,\n internal capsule and displacing the surrounding structures. Again complex\n signal in the mass lesion is redemonstrated with significant T1 intrinsic\n hyperintensity with fluid levels and areas of low signal. Whether this mass\n arises from the third ventricle or the brain parenchyma adjacent to the third\n ventricle is indeterminate. The size of this lesion is unchanged and measures\n approximately 3 x 3 cm in size. There is no evidence of hydrocephalus or new\n lesions in the interval.\n\n IMPRESSION: Unchanged intracranial mass lesion centered in the midline\n towards the right and adjacent to the third ventricle. The differential\n diagnosis for this mass is broad, some considerations are possible cavernoma\n arising adjacent to the third ventricle, however other differential\n considerations including neoplasm adjacent to the third ventricle or\n hypothalamic region are not completely excluded.\n\n Fiducial markers are in place and no new lesions are demonstrated in the\n (Over)\n\n 5:12 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-operative planning. obtain prior to 5am on as patien\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n interval.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1179573,
"text": " 1:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 22 year old man with cavernous malformation s/p craniotomy a\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with cavernous malformation s/p craniotomy and resection. Eval\n post op\n REASON FOR THIS EXAMINATION:\n 22 year old man with cavernous malformation s/p craniotomy and resection. Eval\n post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:27 PM\n Pneumocephalus with mass effect and displacement of the frontal lobes is\n concerning for tension pneumocephalus in the appropriate clinical setting.\n Hyperdense mass adjacent to the third ventricle is decreased in size compared\n to .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post craniotomy and resection of a cavernous malformation.\n Evaluate postoperative changes.\n\n TECHNIQUE: Sequential axial images were acquired through the head without\n administration of intravenous contrast.\n\n COMPARISON: CT head from . MR head from .\n\n FINDINGS: A moderate degree of pneumocephalus causes mass effect and\n displacement of the bilateral frontal lobes, to correlate for possibility of\n tension pneumocephalus in the appropriate clinical setting. The hyperdense\n mass along the right portion of the third ventricle is decreased in size\n compared to CT from , an expected finding given the surgical\n resection earlier today. Minimal focal hemorrhage at the site of the\n resection bed cannot be excluded, but there is no definite intracerebral\n hemorrhage. A catheter extends from a right frontal approach, terminating\n near the third ventricle. There is no evidence of acute infarction. The\n visualized portions of the paranasal sinuses are clear. Bilateral\n opacification of mastoid air cells is noted. Aside from a defect in the right\n frontal bone to allow passage of the intraventricular catheter, the bony\n calvarium appears intact. Small dense focus at the vertex on the right side is\n noted on the earliest study available done on and relates to\n calcification/ossification. ( se 2, im 28 and 29)\n\n IMPRESSION:\n\n 1. Increased pneumocephalus with mass effect and displacement of the frontal\n lobes bilaterally is concerning for possible tension pneumocephalus in the\n appropriate clinical setting. Correlate clinically. D/w Dr. by Dr.\n on at 1pm.\n\n 2. Decreased size of the hyperdense mass felt to represent a cavenroma\n adjacent to the third ventricle in the setting of recent resection.\n (Over)\n\n 1:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 22 year old man with cavernous malformation s/p craniotomy a\n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-20 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 1179497,
"text": ", M. NSURG FA11 5:12 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: pre-operative planning. obtain prior to 5am on as patien\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with ependymoma\n REASON FOR THIS EXAMINATION:\n pre-operative planning. obtain prior to 5am on as patient is first case for\n OR at 7am\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No significant changes are demonstrated in the interval, the patient is\n status post interval placement of an external ventricular drain via right\n frontal approach. Since the prior head CT the pneumocephalus has been\n resolved, there is a large unchanged mild lesion with heterogeneous signal,\n predominantly midline and to the right of the region of the third ventricle\n with similar characteristics as the prior examination dated .\n Fiducial markers are in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1178675,
"text": " 4:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: 22 year old man with 3rd ventricle/basal ganglia mass s/p \n Admitting Diagnosis: BRAIN MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with 3rd ventricle/basal ganglia mass s/p biopsy and EVD\n placement. eval post op\n REASON FOR THIS EXAMINATION:\n 22 year old man with 3rd ventricle/basal ganglia mass s/p biopsy and EVD\n placement. eval post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 4:55 PM\n Interval placement of an external ventricular drain from a right frontal\n approach. Expected post-procedural changes including mild pneumocephalus. No\n evidence of intracranial hemorrhage. Unchanged appearance of the heterogenous\n mass adjacent to the third ventricle. Unchanged mild hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Third ventricle/basal ganglia mass status post biopsy and\n external ventricular drain placement. Evaluate postoperative changes.\n\n TECHNIQUE: Sequential axial images were acquired through the head without\n administration of intravenous contrast.\n\n COMPARISON: CT head from at 11:29 a.m.\n\n FINDINGS: There has been interval placement of an external ventricular drain\n from a right frontal approach. The tip of the drain ends near the third\n ventricle. Minimal pneumocephalus and a focus of air within the frontal \n of the right lateral ventricle are a normal post-procedual expected\n appearance. As previously noted, there is a heterogeneous mass to the right\n of midline adjacent to the third ventricle. Mild hydrocephalus is unchanged.\n There is no evidence of intracranial hemorrhage. Aside from a small channel\n in the right frontal bone for passage of the ventricular drain, the bony\n calvarium is intact.\n\n IMPRESSION:\n\n 1. Expected post-procedural changes including mild pneumocephalus.\n\n 2. No evidence of intraventricular hemorrhage.\n\n 3. External ventricular drain from a right frontal approach with its tip near\n the third ventricle.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-14 00:00:00.000",
"description": "CT STEREOTAXIS W/ CONTRAST",
"row_id": 1178619,
"text": " 11:05 AM\n CT STEREOTAXIS W/ CONTRAST Clip # \n Reason: Post stereotactic frame placement approximately 0800 \n Admitting Diagnosis: BRAIN MASS\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with brain mass\n REASON FOR THIS EXAMINATION:\n Post stereotactic frame placement approximately 0800 \n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 3:24 PM\n Unchanged right-sided hyperdense mass adjacent to the third ventricle. Mild\n hydrocephalus is not significantly changed. A stereotactic frame is in place.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Brain mass, presenting for stereotactic biopsy.\n\n TECHNIQUE: MDCT axial images were acquired through the head following\n administration of intravenous contrast. A stereotactic frame was in place.\n\n COMPARISON: CTA head from . MR head from .\n\n FINDINGS: Again seen is a large mass measuring 3.4 x 2.8 cm that is located\n to the right of midline adjacent to the third ventricle. The mass is\n predominantly hyperdense although it does contain areas of low attenuation.\n There is unchanged mild hydrocephalus. No additional masses are identified.\n The visualized portions of the paranasal sinuses and mastoid air cells are\n well aerated. The bony calvarium is intact. A stereotactic frame is in\n place.\n\n IMPRESSION:\n 1. Unchanged large heterogeneous mass located to the right of the third\n ventricle. Please see the recent MR head from for\n additional details.\n\n 2. Unchanged mild hydrocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1178328,
"text": " 9:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute process, mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with facial droop, uncoordination, gait instability\n REASON FOR THIS EXAMINATION:\n eval for acute process, mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa WED 11:24 PM\n Heterogeneously dense, 2.3 x 2.6 cm mass lesion centered in the right basal\n ganglia, concerning for neoplastic process including glioma. Mass effect on\n adjacent parenchyma. Recommend MRI with gado to further characterize.\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT PERFORMED ON .\n\n COMPARISON: None.\n\n CLINICAL HISTORY: 22-year-old man with facial droop, ptosis, lack of\n coordination, gait instability, question acute process, evaluate for mass.\n\n FINDINGS: Non-contrast head CT was performed with axial, coronal, sagittal\n reformations. There is a predominantly hyperdense mass abutting the third\n ventricle, likely intra-axial, measuring approximately 2.8 (AP) x 3.1\n (transverse) x 3.2 (craniocaudal) cm. There is internal heterogeneity with\n possible internal areas of hemorrhage noted. Surrounding edema is present.\n There is no overt hydrocephalus though given the position of this mass\n adjacent to the third ventricle, the patient is at imminent risk for\n development of hydrocephalus. No additional abnormalities are detected. The\n paranasal sinuses, mastoid air cells and middle ear cavities are well aerated.\n The bony calvarium is intact.\n\n IMPRESSION: Predominantly hyperdense intra-axial mass abutting the third\n ventricle which is concerning for malignancy and correlation with MRI is\n advised to further evaluate/characterize. Internal hyperdensity with apparent\n fluid level suggests the possibility of internal hemorrhage. Findings were\n discussed with Dr. at the time of initial review.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-13 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1178341,
"text": " 1:29 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval R brain mass\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with R brain mass seen on CT\n REASON FOR THIS EXAMINATION:\n eval R brain mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:43 PM\n IMPRESSION:\n There is a large mass predominantly midline and to the right in the region of\n the third ventricle, right anterior thalamus, internal capsule and displacing\n surrounding structures. Whether this mass arises from the third ventricle or\n the brain parenchyma adjacent to the third ventricle is indeterminate. The\n signal of the mass is complex with significant T1 intrinsic hyperintensity and\n significant gradient signal abnormality involving the entire lesion. There\n are also focal areas of fluid-fluid levels and T2 isointensity of the lesion\n itself. Given the complex signal characteristics, the differential diagnosis\n is broad although a cavernoma arising adjacent to the third ventricle is\n favored. Other differential considerations include third ventricular tumors\n such as pineal tumors. Less likely, a craniopharyngioma can extend into the\n third ventricle, but there is no suprasellar cistern extension.\n\n Of note, The lateral ventricles are mildly promenent without evidence of\n transependymal CSF flow.\n\n The above findings were discussed with Dr. by Dr. on the morning\n of the exam.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 22-year-old male with right brain mass on CT.\n\n TECHNIQUE: MR of the brain was performed utilizing sagittal and axial T1,\n axial T2, axial FLAIR, axial gradient and diffusion with ADC map sequences\n without intravenous contrast. After the administration of intravenous\n contrast, axial T1 and sagittal MP-RAGE with coronal and axial MP-RAGE\n reconstructions were performed.\n\n COMPARISON: No prior MR examination for comparison. Prior CT of the head\n performed was reviewed.\n\n FINDINGS: There is a mass measuring 2.5 cm in greatest AP dimension, 3.1 cm\n in greatest transverse dimension and 2.6 cm in greatest superior-inferior\n dimension which is located centrally within the brain along the midline to the\n right of midline which displaces and involves the right thalamus, right\n internal capsule, and the third ventricle. The globus pallidus and putamen\n are displaced laterally.\n\n The mass is complex in its MR of T1 intrinsic hyperintensity,\n (Over)\n\n 1:29 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval R brain mass\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n T1 hypointensity, predominantly FLAIR and T2 isointense with the surrounding\n areas of FLAIR and T2 hypointensity and central collections of T2\n hyperintensity with fluid-fluid levels, the largest measuring 1.5 cm in\n greatest transverse dimension. Given the intrinsic T1 hyperintensity, it is\n difficult to say whether this lesion demonstrate post-contrast enhancement.\n The gradient sequence demonstrates extensive and near-complete gradient\n artifact associated with the lesion with the exception of some focal areas of\n hyperintensity centrally in the of the fluid-fluid levels. The local\n surrounding mass effect as described above is moderate in severity. There is\n left to right shift of midline structures locally, more specifically involving\n the third ventricle.\n\n The lateral ventricles are mildly prominent, most notably the temporal horns\n without evidence of transependymal CSF flow. The fourth ventricle is not\n significantly enlarged. There is no evidence of slow diffusion involving the\n mass. No other lesions are identified. There is local mass effect and the\n lateral ventricles are mildly prominent, without evidence of transependymal\n CSF flow.\n\n No other abnormal lesions are identified. The parenchymal -white matter\n differentiation is maintained. No evidence of acute infarction is identified.\n The major intracranial flow voids are present. The paranasal sinuses and\n mastoid air cells are clear. The orbits and periorbital soft tissues are\n unremarkable.The pituitary gland and suprasellar cystern is normal in\n appearance.\n\n IMPRESSION:\n There is a large mass predominantly midline and to the right in the region of\n the third ventricle, right anterior thalamus, internal capsule and displacing\n surrounding structures. Whether this mass arises from the third ventricle or\n the brain parenchyma adjacent to the third ventricle is indeterminate. The\n signal of the mass is complex with significant T1 intrinsic hyperintensity and\n significant gradient signal abnormality involving the entire lesion. There\n are also focal areas of fluid-fluid levels and T2 isointensity of the lesion\n itself. Given the complex signal characteristics, the differential diagnosis\n is broad although a cavernoma arising adjacent to the third ventricle is\n favored. Other differential considerations include third ventricular tumors.\n Less likely, a craniopharyngioma can extend into the third ventricle, but\n there is no suprasellar cistern extension.\n\n Of note, The lateral ventricles are mildly promenent without evidence of\n transependymal CSF flow.\n\n The above findings were discussed with Dr. by Dr. on the morning\n of the exam.\n (Over)\n\n 1:29 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval R brain mass\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-03-13 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1178342,
"text": ", M. NSURG FA11 1:29 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: eval R brain mass\n Admitting Diagnosis: BRAIN MASS\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with R brain mass seen on CT\n REASON FOR THIS EXAMINATION:\n eval R brain mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION:\n There is a large mass predominantly midline and to the right in the region of\n the third ventricle, right anterior thalamus, internal capsule and displacing\n surrounding structures. Whether this mass arises from the third ventricle or\n the brain parenchyma adjacent to the third ventricle is indeterminate. The\n signal of the mass is complex with significant T1 intrinsic hyperintensity and\n significant gradient signal abnormality involving the entire lesion. There\n are also focal areas of fluid-fluid levels and T2 isointensity of the lesion\n itself. Given the complex signal characteristics, the differential diagnosis\n is broad although a cavernoma arising adjacent to the third ventricle is\n favored. Other differential considerations include third ventricular tumors\n such as pineal tumors. Less likely, a craniopharyngioma can extend into the\n third ventricle, but there is no suprasellar cistern extension.\n\n Of note, The lateral ventricles are mildly promenent without evidence of\n transependymal CSF flow.\n\n The above findings were discussed with Dr. by Dr. on the morning\n of the exam.\n\n"
}
] |
15,018 | 185,503 | 1. Respiratory. The patient is stable on room air from the time of birth. No ventilatory or oxygen assistance required. 2. Cardiovascular. Stable no issues. No history of hypotension. 3. Fluid, electrolytes and nutrition. The patient has transitioned to full p.o. feeds for greater than 72 hours with consistent weight gain over the past week. The patient takes breast milk fortified, 24 kcal/oz with Similac powder. The patient's weight on the day of discharge was 2735 with an average of 25-30 g of weight gain per day over the past week. 4. GI. The patient had a maximum bilirubin level of 6.3 on day of life 3. No other issues. 5. Hematology. The patient's hematocrit on admission was 51.7 with normal white count and platelets of 13.5 and 334. 6. Infectious disease. The patient underwent 48 hours of ampicillin and gentamicin until blood cultures were negative. No significant issues since that time. 7. Neurology, no issues. 8. Sensory. Audiology hearing screening was performed with automated auditory brain responses on , with normal results. 9. Ophthalmology. The patient did not undergo ophthalmologic exam. 10. Psychosocial. Not applicable. | sounds clear with no increase work ofbreathing noted.#3O: Wt. Abdomen benign.PO/PG. BS clear= with mildretractions. cx remain neg. cx remain neg. CV stable.Wt 2175 down 40. NPN DAYSAGREE WITH ABOVE ASSESSMENT AND PLAN. G/D: Temps are stable and swaddled in air set at29.3 C. HOB raised for Hx of spits. Occassionally wakes for cares. time increased andn no further spits.#4O: Temp stable in heated covered isolette, swadddled withhat on. ComfortableWt up. 2. in RA, color pink, BBS equal, clear, occas mild scretractions, RR30-50, no spells so far this shift A: stablein RA P: continue to monitor and document.3. soft, active BS, noloops, Voiding and stooling qs#4 dev:O; Temps stable in low heated , AFSOF.A/P: Cont to support dev.#5 parenting:O: Mom in and becoming more independent with caes. Gav. Will d/cantibx this am if bld. Abd benign, girths 23.5-24cm. Abd benign, girths 23.5-24cm. Alert and active withcares, likes pacifier.#5O: No contact. NObradys so far this shift. sounds clear.#3O: Wt. NeonatologyDoing well. Abd is soft and round; voiding andstooling(g-). Resp: Infant remains on RA. Lungs are clear andequal, mild subcostal retractions. Min. Bottles fairly well withsome uncoordination noted. bld. Bld. Minimal aspirates. Toleratign feeds at 80 cc/k/d. NPN Agree w/ above note by , PCA. Sepsis O: Pt. P: Cont d/cteaching. PT PULLED OUT NGT. NP-ExamAFOF, sutures overriding. Bottledwell x 1, otherwise gav. Passed trace positive stool again. Respiratory O: Pt. fed, min. A:alt in FEN P: Cont offer bf ad lib. Bottling well. BOTTLING WELL. NPN 1100-2300#1 SEPSIS O: Infant remains on AMpi and Gent, CBC neg. Continue w/ IV Amp+Gent per schedule.#2. wt q day. LSclear/=. Will continue to encourage PO intakeENV'T: Stable temp cobedding with sib. Softw/active BS. V+S heme trace positive. A: Pt. NPN2 Alt in Respiration3. Abd benign. A: stable resp P:cont to assess for increased wob, monitor and document allspells.#3 FEN O: Infant remains on TF 60c/k/day of IVF D10W viaPIV. is tolerateing current nutritionalplan. Cont support. Wakes forsome feeds. NPN#2 resp:O: Remains in RA with sats 98-100. P: Continue w/ current feeding plan. Offered bottle all carestoday. Abdomen benign.Temp stable on warmer.Abx for 48 h r/o. sounds clear with mild SCretractions.#3O: Wt. A+A w/cares. nares instilled and sx'ed smal white 2. in RA, color pink, BBS equal, clear, RR30-50's, occasmild sc retractions, no spells A: stable in RA P; continueto monitor for apnea and bradycardia, desats.3. Mild S/C rtxs noted. Stable.Cont. A&A withcares and settles well in between. sounds clear with occ.mild SC retractions.#2O: Wt. Noincreased WOB noted. STill req gavage. NoA&B's noted this shift. Respiratory O: Pt. Respiratory O: Pt. Settles well between cares. Cont to monior andsupport resp status.FenInfant PO/PG and BF BM24. fed. LSclear/=. LSclear/=. A: Pt. A: Pt. A: Pt. A: Pt. A/A for cares. Fontanellesoft/flat. MAEs.FS&F. Bottled of 1feed, otherwise gav. Min. Min. to supportdev. LS clear and =. with min. Monitor for s/s ofintolerance. br. br. Br. HOB ^45deg forspitting.Continue to support needs.5. AGA. AGA. and nospits today. Asking appropriatequestions. Asking appropriatequestions. He is voidng well, passing guiac -stool QS. Did have 1spontaneous brady, quick self-resolved. Independant with cares. Nobradys. remains swaddled in aservo-controlled , temps stable. asp. asp. asp. in and up to date.A: Stable. LSC. to offer po's as tolerated. Cont. Cont. Active BS. Continue to monitor andsupport.DEV - Temps remains stable swaddled in an OAC. mae, afsf. Likespacifier. tolerated well. Bottle attempted, not muchinterest, gav. Active withcares, likes pacifier and being swaddled.#4O: No contact. tf150/k, BM/sc24, po/pg. P: Continuew/ current feeding plan. Min aspirate.Abdomen benign. Settles wellin between cares. remainder with min. MildSCR noted. Temp stable swaddled and cobedding w/sib in OC. Gav. Bottling well. Updatedby RN. Abd benign. Min aspirate. NPN 11p-7a#2 LS clear. Updated by RN. to monitor resp. Br. A+A w/cares. V+Sw/each diaper. sounds clearwith mild SC retractions.#3O: Wt. P:Cont. P: Cont. P: Cont. Alt PO/PG. AGA. AGA. MAE well. Mild retractions. Mild retractions. AltPO/PG. BFx2 so far this shift. Mild subcostal retractions. Mild subcostal retractions. Wakesfor feeds. A/A with cares.Waking for most cares. Lung sounds clear/=. A/AGA. A/AGA. Asking appropriatequestions. Mature breathing control evident most recently. Updated at thebedside. asp. BFx2. A/A with cares.Occasionaly waking for cares. Independent with cares. PCA Progress NoteRESP: O/Infant remains in RA. Passes intermittently heme positive stool. Abdomen benign. Likespacifier. PCA Progress NoteRESP: O/Infant remaisn in RA. MAE,AFSF. MAE, AFSF. P/Continue to support dev. Infant was started on ferinsol.P: Cont. BFx1 and PO 30cc so far this shift. P/Continue tosupoort and encourage PO feeds.DEV: O/Temps stable, swaddled in OAC. Benign abdomen. Benign abdomen. Benign abdomen. Benign abdomen. A/Tolerating feeds well. A/Tolerating feeds well. On BM24. to support and update . Well saturated. up to date. A/Breathing comfortably in RA. Abd benign, voiding and stooling hemeneg. P: Continue to update, support andeducate.REVISIONS TO PATHWAY: 1 Infant with Potential Sepsis; resolved is tolerateing currentnutritional plan. Anus patent.A Well apeparing preterm infantw ithout resp distress during initial portion of transitional period.P Admit NICU Clinicla and non-invasive monitoring of CV and resp status. VNA referral has beenwritten. Cor Nl s1s2 w/o murmurs. Respiratory O: Pt. temp stable swaddled in heated - tempweaned slightly, active and alert with cares. Gave Fe andMultivits. NPO for now with IV hydration. A: Pt.is tolerateing current nutritional plan. P: Continue w/current feeding plan. HEENT WNL. Given BBo2 and stim. are active and independent in cares, askingappropriate questions. continue toupdate and offer support. given handouts on circ care and safe travels. A: occ drifting P: monitor#3 remains on 100cc/k/d BM/SC20. both pleasewith infant's progress, discussed possibility ofphototherapy A: involved family P: cont to inform andsupport LSclear/=. 2. in RA, color pink, BBs clear, equal, mild sc retractions,RR30-50, sats 90-100. no brady so far-please see flow sheetfor current details. A: Pt. A: Pt. also breastfeedswell. Mom will make pedi appt. Parents aware of status and plan. P: Continue to monitor respiratory status. | 99 | [
{
"category": "Nursing/other",
"chartdate": "2186-10-13 00:00:00.000",
"description": "Report",
"row_id": 1887841,
"text": "Nursing\n\n\n#2O: Ampi given as ordered. Bld. cx remain neg. Will d/c\nantibx this am if bld. cx remain neg. No s/s sepsis.\nA: Neg. bld. cx to date with no s/s sepsis P: check bld\ncx and d/c antibx if cx remain neg.\n#2O: In room air with O2 sats > 95% with no noted desats or\nbradys. br. sounds clear.\n#3O: Wt. down 40g on 80cc/kg, SSC q 4 hrs. Belly soft, 1\n6cc asp. that was refed and infant placed in prone position\nwith no further asp. voiding and passing meconium. D-s 76.\nWent to breast x 1, latched and did well. Gav. with spits,\nfdg. time increased andn no further spits.\n#4O: Temp stable in heated covered isolette, swadddled with\nhat on. Likes pacifier and being swaddled. Active with\ncares.\n#5O: Parents up for 1 cares, took temp, changed diaper and\nheld.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-13 00:00:00.000",
"description": "Report",
"row_id": 1887842,
"text": "NeonatologyDoing well. REmains in rA.\nNo spells.\nCOmfortable apeparing. CV stable.\n\nWt 2175 down 40. Toleratign feeds at 80 cc/k/d. Abdomen benign.\nPO/PG. Will increase TF to 100 cc/k/d and monitor tolerance.\n\nAbx to be dced after 48 h r/o.\n\ntemp stable.\n\n\nBili 5.5 this am. Will repeat in am.\nFamily meeting for this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-13 00:00:00.000",
"description": "Report",
"row_id": 1887843,
"text": "Neonatology NP Note\nPE\nswaddled in open crib\nAFOF, sutures approximated\nminimal subcostal retractions in room air,lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\ne-tox rash\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-13 00:00:00.000",
"description": "Report",
"row_id": 1887844,
"text": "2. RESP-Infant is in RA with RR 30-50's. Lungs are clear and\nequal, mild subcostal retractions. O2 sats are 95-100%. NO\nbradys so far this shift. Continue to monitor infants\nrespiratory status.\n\n3. FEN-TF=100cc/kg (up today from 80cc/kg) of SC/BM 20 or\n38cc q4hrs. Infant put to breast and gavaged full feeds at\neach care. Abd benign, girths 23.5-24cm. Voiding and\nstooling meconium stools. Minimal aspirates. Had medium spit\nduring first gavage, increased time of gavage to 75 minutes.\nContinue to support nutritional needs.\n\n4. DEV-Infant has stable temperatures swaddled in air\nisolette. Occassionally wakes for cares. Continue to support\ndevelopmental needs.\n\n5. PARENTS-Mom in for first two cares. Did temp, diaper and\nput infant to breast. Loving, asking appropriate questions.\nContinue to educate and support parents.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-13 00:00:00.000",
"description": "Report",
"row_id": 1887845,
"text": "NPN DAYS\nAGREE WITH ABOVE ASSESSMENT AND PLAN. CONTINUE TO MONITOR ALL SYSTEMS CLOSELY. MONITOR FOR ANY FEEDING INTOLERANCE. CONTINUE TO SUPPORT AND UPDATE PARENTS. FAMILY MEETING TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-16 00:00:00.000",
"description": "Report",
"row_id": 1887857,
"text": "NPn\n\n\n#2 resp:\nO: Remaisn in RA with sats 95-100. RR 40-50, no spells noted\nA?P: Cont to monitor for immature breathing control\n\n#3 FEN:\nO: wt 2.175 (+ 10) On 120cc/k/d BM. Abd. soft, active BS, no\nloops, Voiding and stooling qs\n\n#4 dev:\nO; Temps stable in low heated , AFSOF.\nA/P: Cont to support dev.\n\n#5 parenting:\nO: Mom in and becoming more independent with caes. Mom\nplacing infant to breast\nA/P: Cont to support and inform\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-16 00:00:00.000",
"description": "Report",
"row_id": 1887858,
"text": "Nursing Addendum\nInfant had a spontaneous brady to 72, desat 84 mild stim\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-16 00:00:00.000",
"description": "Report",
"row_id": 1887859,
"text": "PCA note 0700-1900\n\n\n1. Resp: Infant remains on RA. RR 30-40's. O2 Sats 94-98%.\nLS clear/=. No episodes of apnea or desats noted thus far\nthis shift. Occasional drifts in O2 Sat into 80's during\nfeed. QSR. P: Continue to monitor respiratory status.\n\n2. FEN: TF raised to 140cc/kg BM or SC 20. At 0930 BF for\n5-10 min and was gavaged 50cc. At 1330 Bottled 21cc, gavaged\n32cc. Tolerating feeds well; abdomen benign, good BS, one\nsmall spit. Voiding and stooling heme negative. P: Continue\nto support nutritional needs.\n\n3. G/D: Temps are stable and swaddled in air set at\n29.3 C. HOB raised for Hx of spits. Alert and active with\ncares. MAE well. AFSF. AGA. P: Continue to support\ndevelopmental needs.\n\n4. Parenting: Mom in to visit and BF in am. Loving and\ninvolved. Updated on infant's condition at bedside by RN. P:\nContinue to support and update parents.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-16 00:00:00.000",
"description": "Report",
"row_id": 1887860,
"text": "Fellow evaluation note\nAddendum - Neonatology Attending\n\nI have reviewed the interim history and physical examination, discussed all with the medical team and agree with Dr. assessment and plan for management as detailed above. 34-5/7 week GA twin with feeding and respiratory immaturity. COntinue cardiorespiratory monitoring and advance enteral feed volume as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-16 00:00:00.000",
"description": "Report",
"row_id": 1887861,
"text": "Fellow evaluation note\nDOL5, CGA 35 3/7 weeks\n\nIn RA, RR 30-40, 2 spells last 24 hrs\nHR 110-140, no murmur, BP 78/48 (59)\n\nFeeds: on 120 mls/kg/d of po/pg feeds BM/Sim20\nwt 2175g (+10)\nvoiding, stooling\n\nO/E: looks well\nResp: comfortably breathing in RA, B/L good aeration\nCVS: pink, well perfused, S1S2 normal, no murmur\n: soft, non distended\nNeuro; tone normal, handles well\n\nAssessnment & plan: 5days old ex 34 5/7 weeks with feeding immaturity and mild AOP\n-establish po feeding\n-watch spells\n-increase feeds to 140 mls/kg/d\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-16 00:00:00.000",
"description": "Report",
"row_id": 1887862,
"text": "Nursing\nI have read and agree with , PCA note above. Infant doing well in , alert and feeding well. No murmur. Continue with plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-17 00:00:00.000",
"description": "Report",
"row_id": 1887863,
"text": "2. RESP-Infant is in RA with RR 30-40s. Lungs are clear and\nequal, no retractions. O2 sats are 94-100%. No bradys so far\nthis shift. Continue to monitor infants respiratory status.\n\n3. FEN-TF=140cc/kg of BM/Sim20 or 53cc q4hrs. Full feeds are\nbeing gavaged over 90 minutes for spits. Infant was gavaged\nat both cares. Abd benign, girths 23.5-24cm. Voiding and\nstooling heme negative. One small spit and minimal\naspirates. Continue to support nutritional needs.\n\n4. DEV-Infant has stable temperatures swaddled in air\n. Alert and active during cares. Waking for cares,\nsleeping well in between. Bili checked this shift. Continue\nto assess developmental needs.\n\n5. PARENT-No contact so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-20 00:00:00.000",
"description": "Report",
"row_id": 1887881,
"text": "Felllow evaluation note\nDOL 9, CGA 36 weeks\n\nIn RA, RR 20-50, 2 self resolving bradys\nHR 120-150, 85/51 (63), no murmur\n\nNutrition:\nwt 2285 (+65)\non 150 mls/kg/d of BM/SC24, pg over 1.5 hr, + BF\nvoiding, stooling\n\nO/E well, alert, active\nResp: comfortably breathing in RA, B/L good aeration\nCVS: pink, well perfused, S1S2 normal, no murmur\n: soft, non distended\nNeuro: active, tone normal\n\nImpression & plan: 9 days old ex 34 5/7 weeks, now 36 weeks corrected age baby with feeding and some respiratory immaturity\n-Await maturation of oral feeding skills\n-Transition to open cot\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-20 00:00:00.000",
"description": "Report",
"row_id": 1887882,
"text": "2. in RA, color pink, BBS equal, clear, occas mild sc\nretractions, RR30-50, no spells so far this shift A: stable\nin RA P: continue to monitor and document.\n3. TF 150cc/k/d BM24/SC24 57cc q4h, breast fed well this am\nfollowed by 40cc pg, abd soft, active bowel sounds, no\nloops, spit x1, voiding and passing stool P: continue to\nencourage breast/bottle as tolerated.\n4. temp stable swaddled in low heat -now off, active\nwith cares A: AGA P: to open crib soon, cont to support\ndevelopmental needs.\n5.Parents here this am-to return for next cares, very loving\nand involved, signed consents for hep b P: continue to\nupdate and offer support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-20 00:00:00.000",
"description": "Report",
"row_id": 1887883,
"text": "Neonatology\nRA. Intermitetnt spells. Comfortable\n\nWt up. Toleratign feeds. Still requring gavage.\n\nContinue to await maturation of feeds and resp contol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-21 00:00:00.000",
"description": "Report",
"row_id": 1887884,
"text": "Nursing\n\n\n#2O: In room air with O2 sats 94 - 97% with no noted desats\nor spells. br. sounds clear with no increase work of\nbreathing noted.\n#3O: Wt. up 20g on 150cc/kg, BM24, q 4 hr. feeds. belly\nsoft, voiding and stooling. Min. asp. and no spits tonite.\nBottled of 1 feed, gav. other feeds.\n#4O: Temp stable in off , and moved to a crib with\nlast cares. Hepatitis vaccine given. Alert and active with\ncares, likes pacifier.\n#5O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-21 00:00:00.000",
"description": "Report",
"row_id": 1887885,
"text": "Neonatology NP note\nPe\nswaddled in \nAFOF\ncomfortable respirations in room air, lungs clear/=\nRRr, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-21 00:00:00.000",
"description": "Report",
"row_id": 1887886,
"text": "Neo Attend\nDay 10, now 36.1 wkpma\nrespr: ra, clear=bs, rr 20-40s.\nno spells in past 24 hr.\nCV: no murmur, hr 130-150s, bp 72/39, mean 51\nruddy, well perfused.\nFEN: wt 2305 gm, up 20 gm\n150 cc/kg/day BM24. bf x . gavaged mostly.\nabd wnl, uop and stool wnl.\ntemp stable in crib. alert, active.\nHad Hep B immunization.\n\nAssessment/Plan: Stable premature infant learning to po feed.\nPlan continue current regimen.\nPt evaluated and discussed with team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-24 00:00:00.000",
"description": "Report",
"row_id": 1887899,
"text": "NPN\n\n\n#2\nInfant remains in RA with sats >94%. BS clear= with mild\nretractions. Color is pink; well perfused. No spells noted\nthus far tonight. Murmer not audible.\n\n#3\nInfant continues on TF=150cc/k of BM24 q4 hours. Infant has\ntolerated feeds well without any spits and only small\nnon-bilious aspirates. Abd is soft and round; voiding and\nstooling(g-). Infant has bottled x1 thus far tonight and\ntook ~30cc; remainder of feeds via gavage over 90 minutes.\nWt is up 70gms-2450.\n\n#4\nInfant remains in an open crib swaddled with boundaries; now\ncobedding with his brother. has been stable. Infant\nis alert with cares; at times waking prior to feedings and\nsucking eagerly on the pacifier. Bottles fairly well with\nsome uncoordination noted. Sleeps well between cares.\n\n#5\nNo contact thus far tonight from the .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-24 00:00:00.000",
"description": "Report",
"row_id": 1887900,
"text": "Fellow evaluation note\nAddendum - Neonatology Attending\n\nI have reviewed the interim history and physical examination, discussed all with the medical team and agree with Dr. assessment and plan for management as detailed above. 34-5/7 week GA twin with feeding immaturity. Continue to encourage development of oral feeding skills.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-24 00:00:00.000",
"description": "Report",
"row_id": 1887901,
"text": "Fellow evaluation note\nDOL 13 CGA 36 4/7 weeks\n\nIn RA, RR 30-50\nHR 140-160 BP 54/38(46), no murmur\n\nwt 2450 (+70)\nOn 150/kg of BM24, po/pg alternate\nvoiding, stooling\nIn open crib\n\nO/E: well, see below\n\nImpression & plan: 13 days old ex 34 now 36 4/7 weeks corrected age baby with feeding immaturity\n-Establish po feeding skills\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-24 00:00:00.000",
"description": "Report",
"row_id": 1887902,
"text": "2. in RA, color pink, BBS equal, clear, RR30-50's, occas\nmild sc retractions, no spells A: stable in RA P; continue\nto monitor for apnea and bradycardia, desats.\n3. TF 150cc/k/d BM24 61cc q4h, breast feeding very well\nx2/shift with ~30cc pg, abd soft, active bowel sounds, no\nloops, no spits, voiding and passing stool A: tolerating\nfeedings, learning to breast and bottle feed P: continue to\nalt po/pg.\n4. temp stable swaddled in open crib with brother, waking\nfor some feedings, active and very alert with cares, quiet\nawake periods, sleeping well in between feedings A: AGA P:\ncontinue to assess and support growth and developmental\nneeds.\n5. Mom and GM here ~0830, Mom to return for 1630,\nbreastfeeding both babies, very good milk supply A: very\ninvolved and loving Mom P: continue to update and offer\nsuppport.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-24 00:00:00.000",
"description": "Report",
"row_id": 1887903,
"text": "Examination note\nGen: active, alert, looks well\nResp: comfortably breathing in RA, B/L good aeration\nCVS: pink, well perfused, S1S2 normal, no murmur\n: soft, non distended\nNeuro: tone normal, handles well\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-25 00:00:00.000",
"description": "Report",
"row_id": 1887904,
"text": "Nursing\n\n\n#2O: In room air with O2 sats > 91% with occ. drift, self\nresolved into the 80's. Br. sounds clear with mild SC\nretractions.\n#3O: Wt. up 50g on 150cc/kg, BM24, q 4 hr. feeds. Bottled\nwell x 1, otherwise gav. fed, min. asp. and no spits. D-s\n71.\n#4O: Co-bedding with brother, stable temp. Active with\ncares. 14 day PKU done.\n#5O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-28 00:00:00.000",
"description": "Report",
"row_id": 1887916,
"text": "NPN\n\n2 Alt in Respiration\n\n3. FEN: WT 2.565kg, up 10gr. Tf at 150cc/kg of BM 24 64cc\nq4hr PO/PG. Took 48-50cc PO, waking for feeds, eager to eat.\nMin. aspirates, no spits, burping well, abd soft, active BS,\nvoiding, stooled x2 yellow heme pos., no frank blood.\nUnclear if there is an anal fissure, desitin to buttocks no\nexcoriation.\nA/P: Tolerating feeds, gaining wt, bottle qfeed infant is\nawake and eager. Monitor stools, further assess for fissure.\n\n4. Dev; Infant swaddled co-bedding with brother, temps WNL.\nWaking for feeds, active and alert, fixes and follows,\nsleeps in between cares.\nA/P; AGA, cont to support dev. needs.\n\n5. Parenting: in this eve, bottle feeding twins.\nIndependent with infants, following feeding cues.\nA/P: Updated and loving , plan to come in the am.\n\n\nREVISIONS TO PATHWAY:\n\n 2 Alt in Respiration; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-28 00:00:00.000",
"description": "Report",
"row_id": 1887917,
"text": "NICU Attending note\n\nDOL # 17 = 37 1/7 weeks PMA learning to PO feed.\n\nCVR/RESP: RRR without murmur, skin pink and well perufsed, BS clear/=, no increased WOB, no A/B, not on caffeine. Will conntinue to monitor.\n\nFEN: Abd benign, weight 2565 gm, up 10 gm, on TF of 150 mL/kg/day, MM 24, PO/PG, but improving. Heme trace stool with small fissure seen recently. Will continue to encourage PO intake\n\nENV'T: Stable temp cobedding with sib.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-28 00:00:00.000",
"description": "Report",
"row_id": 1887918,
"text": "NPN \n\n\n\n #3. TF 150cc/k/d BM 24 (64cc q4h). Offered bottle all cares\ntoday. Taking ~50cc/feed or BF x10min well. Well coordinated\nand eager to bottle but tires out at the end and falls\nasleep. Gavaging remainder of feeds. Abd benign. Soft\nw/active BS. No spits. V+S heme trace positive. Applying\ndesitin to butt for ?fissure. A: Premie learning to po feed.\nP: Cont to offer bottle w/each care.\n\n #4. Temp stable swaddled and cobedding w/sibling. Wakes for\nsome feeds. A+A w/cares. A: AGA P: Cont d/c planning. Needs\ncirc scheduled. Carseat test and hearing screen.\n\n #5. in this am. Independent w/cares. To get bath\n this eve. Mom gave correctly this am. P: Cont d/c\nteaching. Cont support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-29 00:00:00.000",
"description": "Report",
"row_id": 1887919,
"text": "NNP Physical Exam\nPE: pink, AFOF, breath sounds clear/equal with easy WOB, no m;urmur, abd soft, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-29 00:00:00.000",
"description": "Report",
"row_id": 1887920,
"text": "#3 TF 150CC/KG BM24. PT PULLED OUT NGT. ALL VOLUME TAKEN PO\nTHUS FAR. WAKING TO FEED. BOTTLING WELL. VOIDING AND\nSTOOLING WITH EACH CARE. WEIGHT INCREASE 50GM.\n#4 TEMPS ARE STABLE IN OPEN CRIB. WAKING TO FEED. FEEDING\nWELL. SLEEPING AFTER CARES.\n#5 NO CONTACT FROM FAMILY THIS SHIFT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-29 00:00:00.000",
"description": "Report",
"row_id": 1887921,
"text": "Neonatology Attending\n\nDay 18 PMA 37 wks\n\nRemains in RA. No bradycardia. No murmur. HR 130-150. BP mean 62. Pink. Weight 2615g (+50). On BM 24. Pulled feeding tube out. Took 133/kg and breast fed twice yesterday. Passed trace positive stool again. Stable temperature in open crib.\n\nDoing well. Will put on 130 ml/kg minimum volume. Discontinuing HMF and starting formula powder supplementation for 24 cals/oz feeds. Will put on minimum volume of 120 ml/kg. Needs circumcision. be ready for discharge on Tuesday if continues to do well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-11 00:00:00.000",
"description": "Report",
"row_id": 1887837,
"text": "NPN 1100-2300\n\n\n#1 SEPSIS O: Infant remains on AMpi and Gent, CBC neg. blood\ncultures neg. to date. Temp stable, alert and active infant.\nNo signs of sepsis A: r/o sepsis P: cont to assess for signs\nof sepsis, Cont with antibiotics as ordered.\n#2 RESP O: Infant remains on RA, 02 sats >95%, BBS equal and\nclear, no spells. No increased wob noted. A: stable resp P:\ncont to assess for increased wob, monitor and document all\nspells.\n#3 FEN O: Infant remains on TF 60c/k/day of IVF D10W via\nPIV. d/s stable. abd soft and nondistended, voiding and\nstooling. Mom put infant to breast, infant did not latch. A:\nalt in FEN P: Cont offer bf ad lib. wt q day. maintain IVF\nas ordered.\n#5 PARENTING O: Mom and dad in to visit, asking appropriate\nquestions and updated on infant's progress. P: cont to\ninform and support family as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-12 00:00:00.000",
"description": "Report",
"row_id": 1887838,
"text": "NeonatologyDoing well. REmains in RA. No spells.\nComfortable apeparing\n\nwt 2215 down 45. Tf at 60 cc/k/d. Bottling well. IV stopped. Will imcrease TF to 80 cc/k/d. gavage as needed. Abdomen benign.\n\nTemp stable on warmer.\n\nAbx for 48 h r/o. BC remains negative.\n\nBili to be followed.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-12 00:00:00.000",
"description": "Report",
"row_id": 1887839,
"text": "NNP On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant on open warmer, room air\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nChest:breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; active bowel sounds; cord on/drying\nGU: normal male, testes not fully descended; palpable in canals bilaterally\nExt: moves all\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-12 00:00:00.000",
"description": "Report",
"row_id": 1887840,
"text": "Nursing NICU Note\n\n\n#1. Sepsis O: Pt. is alert, active and acting\nappropriate. CBC-, blood cult -to date. He is on IV\nAmp+Gent for 48hr R/O. A: stable P: Continue to monitor\nfor s/s of infection. Continue w/ IV Amp+Gent per schedule.\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~96-99%.\nRR ~30-50's, no increase work of breathing noted. LS\nclear/=. No A&B's noted this shift thus far. A: Pt.\nremains stable in RA. P: Continue to monitor respiratory\nstatus. Monitor for A&B's.\n\n#3. FEN O: TF 80cc/kg/d of BM/Sim20 =30cc Q 4hrs. He has\ntaken ~22cc/27cc PO thus far. Patient also breastfeeds and\nwill supplement with the bottle after. Abdomen is soft,\npink, +bs, no loops/spits noted. Abdominal girth is\n~22.5-23.5cm. He is voidng well, passing meconium stool w/\nQ diaper change. A: Pt. is tolerateing current nutritional\nplan. P: Continue w/ current feeding plan. Monitor for\ns/s of intolerance. Continue to encourage oral feeds as pt.\nlooks interated and tolerates.\n\n#4. Growth/Development O: Pt. is swaddled w/ hat on an\nopen warmer, temps stable. He is laert and active w/ cares,\nsleeps well in bwteen. Fontanelle soft/flat. He loves to\nuse his pacifier, brings hands to face. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopemnt. Plan to place infant into crib tonight if\nphoto therapy is not indicated.\n\n#5. Parents O: Parents in to visit throughout the shift\nfor cares. They were updated at bedside on pt's current\nstatus and daily plan of care. Parents are involved in\ncares, asking approrpriate questions. A: AGA P: Continue\nto provide environment appropriate for growth and\ndevelopment.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-15 00:00:00.000",
"description": "Report",
"row_id": 1887850,
"text": "NPN\n\n\n#2 resp:\nO: Remains in RA with sats 98-100. RR 40's, cl=. no\nretractions or spells\nA/P: Cont to monitor\n\n#3 FEN:\nO: wt 2.165 (- 5 gms0 On min 100cc/k/d BM/ 20. abd soft,\nactive BS, no loops. nursed fair X1, po attepmted, did\npoorly although infant appeared eager, voiding and stooling\nqs\nA/P: Cont to monitor growth\n\n#4 Dev:\nO: Temps stable in low heat , , AFSOF, waking for\ncares.\nA/P: Cont to support dev\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-15 00:00:00.000",
"description": "Report",
"row_id": 1887851,
"text": "NP-Exam\n\nAFOF, sutures overriding. Breath sounds clear and equal. NL S1S2, no audible murmur. Pink and jaundiced. ABd benign, no HSM. Active bowel sounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-15 00:00:00.000",
"description": "Report",
"row_id": 1887852,
"text": "addendum to above NPN\nInfant had period of desaturation to lo 80's with circumoral cyanosis. nares instilled and sx'ed smal white\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-15 00:00:00.000",
"description": "Report",
"row_id": 1887853,
"text": "Neonatology\nDOL #4, CGA 35 wks.\n\nCVR: Remains in RA, O2sats > 96%, RR 40-60s, mild intermittent retractions. Occasional saturation drifts with crying/feeding. Hemodynamically stable, no murmur.\n\nFEN: Wt 2165, down 5 grams. TF 100 cc/kg/day, BM/Sim20, PG, minimal PO intake. Voiding/stooling, occasional small aspirates/spits, abdomen soft.\n\nGI: Bili 6/0.3 yesterday.\n\nDEV: In .\n\nIMP: Former 34+ wk twin, overall stable, still with immaturity of respiratory control, feeding, and temp regulation. Some spits, but abdominal exam benign.\n\nPLANS:\n- Continue monitoring resp status.\n- Monitor for spells.\n- Advance TF to 120.\n- Advance PO as able.\n- Monitor jaundice clinically.\n- Wean to crib as able.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-17 00:00:00.000",
"description": "Report",
"row_id": 1887864,
"text": "NPN Agree w/ above note by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-17 00:00:00.000",
"description": "Report",
"row_id": 1887865,
"text": "Fellow evaluation note\nAddendum - Neonatology Attending\n\nI have reviewed the interim history and physical examination, discussed all with the medical team and agree with Dr. assessment and plan for management as detailed above. 34-5/7 week GA infant with feeding immaturity. Continue to advance enteral intake to full volume.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-17 00:00:00.000",
"description": "Report",
"row_id": 1887866,
"text": "Fellow evaluation note\nDOL 6, CGA 35 4/7 weeks\n\nIn RA, RR 20-40, no bradys\nHR 120-150, BP stable, no murmur\n\nOn 140 mls/kg/d of BM/ 20, po/pg\nwt (+20g)\nvoiding, stooling\nIn air \n\n0/E:\nlooks well, alert, active\nResp: comfortably breathing in RA, B/L good aeration\nCVS: pink, well perfused, S1S2 normal, no murmur\n: soft, non distended\nNeuro: tone normal, handles well\n\nAssessment & plan: 6 days old ex 35 4/7 weeks gestation baby with feeding immaturity\n-Increase feeds to 150 mls/kg/d. consider increasing caloric density tomorrow\n-wean off to open crib\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-15 00:00:00.000",
"description": "Report",
"row_id": 1887854,
"text": "Nursing\n\n\n#2O: In room air with occ. desat after crying. Did have 1\nspontaneous brady, quick self-resolved. br. sounds clear\nwith mild SC retractions.\n#3O: Increased to 120cc/kg, BM/ q 4 hrs. Belly soft,\nvoiding and stooling, stools guaiac neg. Min. asp. and no\nspits today. Put to breast x 1, did not really latch today.\n#4O: Temp stable in heated , unable to wean today.\nActive with cares, comforts easily with pacifier and being\ntitely swaddled.\n#5O: Parents and mother's parents visited. Parents\nattended family mtg. with Dr. . Given info sheet on\nHep B vaccine.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-16 00:00:00.000",
"description": "Report",
"row_id": 1887855,
"text": "NPN\nThis NPN is incorrect for this patient and should be noted for sibling.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-16 00:00:00.000",
"description": "Report",
"row_id": 1887856,
"text": "NPN\n\n\n#2 Resp:\n Ol Remaisn in RA with sats 95-100. RR 30-40, cl=, no spells\nA/P: Cont to monitor for resp problems\n\n#3 FEN:\nO: wt 2.190 (- 15) On 120cc/k/d BM abd soft, active Bs, no\nloops. gavage fed over 1 hr. Mom placed to breast and infant\njust nuzzled\nA/P: Cont to monitor wt chages, offer po/ breastfeeding\n\n#4 Dev:\nO: temps stable in heayed . MAE ant font soft and\nflat\nA/P: Cont to support dev\n\n#5 parenting:\nO: Mom in and placed to breast. Did cares.Mom discharge\n in rooming in room\nA/P: Cont to support and inform\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-19 00:00:00.000",
"description": "Report",
"row_id": 1887875,
"text": "NPN 1900-0700\n\n\n2. RA, rr20-50's, cl/=, no WOB. No a/b's thus far this\nshift.\nContinue to monitor resp status in RA.\n\n3. Wt up 5g. tf150/k, BM/sc24, po/pg. Offered bottle and\ntook 10cc. Not vigorous with bottle. Otherwise gavaged\nover 1.5hrs for one lg spit overnight. max asp 3.2cc.\nVoid/stooling heme neg.\nContinue to offer bottle once overnight, infant breastfeeds\nw/mom during day.\n\n4. Temp stable in low air , swaddled w/hat.\nAlert/active w/cares. Mellow temperament. HOB ^45deg for\nspitting.\nContinue to support needs.\n\n5. No contact .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-19 00:00:00.000",
"description": "Report",
"row_id": 1887876,
"text": "Fellow evaluation note\nDOl 8, CGA 35 6/7 weeks\n\nIn RA, RR 20-40s, no spells\nHR 130-150, BP 70/48 (55)\n\nOn 150 mls/kg/d of BM/SC24, pg over 1hr 15min\nwt 2220(+5g)\nvoiding, stooling\nIn low air \n\no/E: looks well, see below\n\nAssessment & plan: 8 days old ex 34 5/7 weeks now 35 6/7 weeks corrected age baby with feeding immaturity\n-establish po feeding & watch wt gain\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-19 00:00:00.000",
"description": "Report",
"row_id": 1887877,
"text": "Fellow examination note\nGen: looks well, alert, active\nResp: comfotably breathing in RA, B/L good aeration\nCVS: pink, well perfused, S1S2 normal, no murmur\n: soft, non distended\nNeuro: tone normal, handles well\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-19 00:00:00.000",
"description": "Report",
"row_id": 1887878,
"text": "Neonatology\nRA. No spells. Comfortable appearing., No murmur.\n\nTolerating feeds.. STill req gavage. Abdomen benign.\n\nActive and alert.\n\nAwaiting maturation of feeding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-17 00:00:00.000",
"description": "Report",
"row_id": 1887867,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~ 93-99%.\nRR ~20-50's, no increase work of breathing noted. LS\nclear/=. He has had occcasional periods of O2 sat drifts to\nthe upper 80's/ lower 90's that have self resolved. No\nA&B's noted this shift. A: Pt. remains stable in RA. P:\nContinue to monitor respiraory status. Monitor for A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM/Sim20 =57cc Q 4hrs,\ngavaged over 90 min. tolerated well. He also breastfeeds ~\n5 min+ w/ a supplemental gavage feed. Abdomen is soft,\npink, +bs, no loops/spits noted. Abdominal girth is\n~23.5cm. He is voiding well, passing trace amount of yellow\nstool. A: Pt. is tolerateing current nutritional plan. P:\n Continue w/ current feeding plan. Monitor for s/s of\nintolerance. Continue to encourage oral feeds as pt. looks\ninterested and tolerates.\n\n#4. Growth/Development O: Pt. remains swaddled in a\nservo-controlled , temps stable. He is alert and\nactive w/ cares, sleeps well in between. Fontanelle\nsoft/flat. He loves to use his pacifier, brings hands to\nface. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n#5. Parents O: Parents in to visit for cares throughout\nthe shift. They were updated at bedside on pt's current\nstatus and daily plan of care. Parents are active and\nindependent in cares, asking approrpriate questions. A:\nFamily is loving and involved. P: Continue to update,\nsupport and educate.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-18 00:00:00.000",
"description": "Report",
"row_id": 1887868,
"text": "Nursing\n\n\n#2O: In room air with O2 sats > 92% with 3 bradys,\nself-resolved. br. sounds clear with very mild SC\nretractions.\n#3O: Wt. up 20g on 150cc/kg, BM, q 4 hrs. Bottled of 1\nfeed, otherwise gav. fed. belly soft, voiding and stooling,\nstools, guaiac neg. Min. asp. and no spits.\n#4O: Stable temp in heated covered . Active with\ncares, likes pacifier and being swaddled.\n#4O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-21 00:00:00.000",
"description": "Report",
"row_id": 1887887,
"text": "NPN\n\n\nRESP- Infant remains stable on RA. LS clear and =. No\nincreased WOB noted. No spells thus far. Continue to\nmonitor.\n\nFEN - TF 150cc/kg/d of BM24=58cc q4h gavaged over 90 min.\nInfant breast fed fairly for 10 min, recieved partial\ngavage. Tolerating feeds fairly with one small spit and\nminimal aspirates thus far. Abd is benign with no visible\nloops and +BS. V&S heme negative. Continue to monitor and\nsupport.\n\nDEV - Temps remains stable swaddled in an OAC. A&A with\ncares and settles well in between. Brings hands to face and\nsucks on pacifier for comfort. Continue to support\ndevelopmental growth.\n\nPAR - Mom and dad in for first care. Asking appropriate\nquestions. Independant with cares. Updated by RN.\nReviewed Back to sleep, tummy time, activities for first\nyear, and immunization booklets with parents. Both parents\ncurrently taking CPR class. Continue to support and prepare\nfor d/c.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-21 00:00:00.000",
"description": "Report",
"row_id": 1887888,
"text": "NICU Infant CPR Class Note\n\nO: Both parents present for Infant CPR class at 1500. Please see note in Boy 1's chart for details of class.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-19 00:00:00.000",
"description": "Report",
"row_id": 1887879,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~95-100%.\nRR ~30-50's, no increase work of breathing noted. LS\nclear/=. No A&B's noted this shift. A: Pt. remains stable\nin RA. P: Continue to monitor respiratory status. Monitor\nfor A&B's.\n\n#3. FEN O: TF 150cc/kg/d of BM/SC24 =57cc Q 4hrs gavaged\nover 1hr 40min, tolerated well. He also breastfeeds and\nreceives ~40cc of supplemantal gavage feed. Abdomen is\nsoft, pink, +bs, no loops/spits noted. Abdominal girth is\n~24-24.5cm. He is voidng well, passing guiac -stool QS. A:\n Pt. is tolerteing current nutritional plan. P: Continue\nw/ current feeding plan. Monitor for s/s of intolerance.\nContinue to encourage oral feeds as pt. looks interested and\ntolerates.\n\n#4. Growth/Development O: Pt. remains swaddled in a low\nair mode , temps stable. He is alert and active w/\ncares, sleeps well in between. Fontanelle soft/flat. He\nloves to use his pacifier, brings hands to face. A: AGA\nP: Continue to provide environment approrpriate for growth\nand development.\n\n#5. Parents O: Parents in to visit for cares throughout\nthe shift. They were updated at bedside on pt's current\nstatus and daily plan of care. Parents are active and\nindependent in cares, asking appropriate questions. A:\nFamily is loving and involved. P: Continue to update,\nsupport and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-20 00:00:00.000",
"description": "Report",
"row_id": 1887880,
"text": "Nursing\n\n\n#1O; In room air with O2 sats > 94% with 1 brady,\nself-resolved, no noted desats. Br. sounds clear with occ.\nmild SC retractions.\n#2O: Wt. up 65g on 150cc/kg, BM24, q 4 hr. feeds. belly\nsoft, voiding and stooling. Bottle attempted, not much\ninterest, gav. with min. asp. and no spits.\n#4O: Temp stable in heated (27.1C) covered .\nActive with cares, likes pacifier.\n#5O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-22 00:00:00.000",
"description": "Report",
"row_id": 1887893,
"text": "NPN 7a7p\n\n\nResp\nInfant in RA. Mild S/C rtxs noted. RR 30-60s. LSC. No\nbradys. Did drift with bottling but recovered quickly as\nsoon as nipple removed from his mouth. Cont to monior and\nsupport resp status.\nFen\nInfant PO/PG and BF BM24. Bottled 10 cc for Dad this am.\n(Dad's first time ever bottling a baby.) Midday feed gavaged\nand plan for BF this afternoon. Abd soft with some soft\nloops. Stooling with every diaper, heme -. Active BS. Min\nasps and no spits. Infant learning to PO. Offer bottle when\nawake and interested. Monitor weight and exam.\nG/D\nInfant in OAC with stable temps. A/A for cares. Likes\npacifier. Settles well between cares. Hands to face. MAEs.\nFS&F. AGA. Monitor and support G/D.\nParenting\nBoth in for cares and pictures. Asking appropriate\nquestions. Mom appearing more confident and independent then\nFOB. Cont to support and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-23 00:00:00.000",
"description": "Report",
"row_id": 1887894,
"text": "Nursing Progress Note\n\n\n#2 Resp: RA, 30-40, lungs clear, mild sc, no spells. Stable.\nCont. to monitor. #3 FEN: wt 2380 (^60). TF150cc/kg of BM24.\n Abd soft, no loops, active bs, voiding, stooling. Bottled\n20cc's, well coordinated, tired easily. No spits, minimal\naspirates. Stable. Cont. to offer po's as tolerated. #4 DEV:\n's temps are stable in oac. He is alert/active w/ cares.\nSettles well w/ pacifier. mae, afsf. AGA. Cont. to support\ndev. needs. #5 Parenting: no contact this shift. See\nflowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-22 00:00:00.000",
"description": "Report",
"row_id": 1887889,
"text": "NPN\n\n\n2. Resp: Infant remains in RA, BS clear, no retractions, RR\n40-60's, no drifts or spells, sats >94%.\nA/P: Stable resp exam, cont to monitor for spells.\n\n3. FEN: WT 2.320, up 15gr. TF at 150cc/kg of BM24, 58cc q4hr\nPO/PG. Infant took 35cc PO, the rest of feeds were given\ngavage. Eager to eat but tiring, fed for 25 min. Small spit\nduring feed, needing to burp. Abd soft, min aspirates,\nvoiding, stooled x1 lg yellow heme neg.\nA/P: Tolerating feeds, learning to PO feed, offer BF/PO\nfeeds every other feed as tol. Gaining wt, monitor.\n\n4. Dev: Infant swaddled in crib, temps WNL. Sleeps in\nbetween feeds, occasional wakes, settles with pacifier.\nAlert and active with cares.\nA/P: AGA premie twins, cont to support dev. needs. Co-bed\nwhen large bed is available.\n\n5. Parenting: No contact from , plan on coming this\nam.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-22 00:00:00.000",
"description": "Report",
"row_id": 1887890,
"text": "Neonatology Np Note\nPE\nswaddled in open crib\nAFOF\ncomfortable respirations in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-22 00:00:00.000",
"description": "Report",
"row_id": 1887891,
"text": "Pe Addendum\ncolor ruddy/face and trunk mildly jaundiced\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-22 00:00:00.000",
"description": "Report",
"row_id": 1887892,
"text": "Neonatology Attending\n\nDOL 11 PMA 36 2/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 79/45 mean 57\n\nOn 150 ml/kg/d BM 24 po/pg. Voiding. Stooling. Wt 2320 grams (up 15).\n\n in and up to date.\n\nA: Stable. No spells. Needs to learn to feed.\n\nP: Monitor\n Encourage pos as tolerated\n Circ this week\n Home when feeding well\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-25 00:00:00.000",
"description": "Report",
"row_id": 1887905,
"text": "Neonatology Attending\n\nDay 14 PMA 36 wks\n\nRemains in RA. Sats > 91%. Occasional mild saturation drift. No murmur. HR 140-150s. Pink, well-perfused. BP mean 46. Weight 2500g (+50). TF at 150 ml/kg/d- BM 24. Blood glucose 71. Took full bottle last night. Put to breast daily. Stable temperature in open crib- co-bedding. Repeat newborn screen yesterday.\n\nDoing well overall with mild respiratory immaturity. Will continue to monitor closely. Gaining weight well overall. Encouraging po feeding. Will meet family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-25 00:00:00.000",
"description": "Report",
"row_id": 1887906,
"text": "Exam Note\nGEN - lying in crib, calm\nHEENT - oropharynx clear, AFSFO, NGT present\nCV - RRR, s1+s2, no murmur\nPULM - CTAB, no g/f/r\nABD - soft, NT, ND, no mass\nGU - nl male external genitalia, testes descended bilat\nEXT - WWP, CR < 2 sec, MAE\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-23 00:00:00.000",
"description": "Report",
"row_id": 1887895,
"text": "fellow examination note\nAddendum - Neonatology Attending\n\nI have reviewed the interim history and physical examination, discussed all with the medical team and agree with Dr. assessment and plan for management as detailed above. Continue to await maturation of oral feeding skills.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-23 00:00:00.000",
"description": "Report",
"row_id": 1887896,
"text": "fellow examination note\nDOL 12, CGA 36 \n\nRA 30-40, no spells\nHR 140-160, no murmur, BP 72/45 (55)\n\nwt 2380 (+60)\n150/kg/d of BM 24, po/pg over 1hr, alternate po\nvoiding, stooling\n\nO/E well, see, below\n\nImpression & plan: 12 days old 34 5/7 weeks now 36 6/7 weeks corrected age baby with feeding immaturity\n-Establish po feeding\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-23 00:00:00.000",
"description": "Report",
"row_id": 1887897,
"text": "Examination note\nGen: alert, active, looks well\nResp: comfortably breathing in RA, B/L good aeration\nCVS: pink, well perfused, S1S2 normal, no murmur\n: soft, non distended\nNeuro: tone normal, handles well\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-23 00:00:00.000",
"description": "Report",
"row_id": 1887898,
"text": "PCA Progress Note\n\n\nRESP: O/Infant remaisn in RA. RR 30-50's. Sat's >96%. Lungs\nare clear and equal. Mild subcostal retractions. No spell so\nfar this shift. A/Breathing comfortably in RA. P/Will\ncontinue to monitor.\n\nFEN: O/Infant on 150cc per kilo BM 24, 58cc q4 gavaged over\n90min. Alt PO/PG. BFx1 and PO 30cc so far this shift. No\nspits. Min aspirate. Abdomen benign. Voiding and stooling\nheme negative. A/Tolerating feeds well. P/Continue to\nsupoort and encourage PO feeds.\n\nDEV: O/Temps stable, swaddled in OAC. A/A with cares.\nOccasionaly waking for cares. Resting comfortably in\nbetween. MAE, AFSF. A/AGA. P/Will continue to support dev.\nneeds.\n\nPAR: Mom and dad in x2 Mom 1 and dad bottledx1. Updated\nby RN. Will continue to keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-26 00:00:00.000",
"description": "Report",
"row_id": 1887911,
"text": "PCA Progress Note\n\n\nRESP: O/Infant remains in RA. RR 30-60's. Lungs are clear\nand equal. Mild subcostal retractions. Sat monitor D/C\ntoday. A/Breathing comfortably in RA. P/Continue to monitor.\n\nFEN: O/Infant remains on 150cc per kilo, BM 24, 63ccq4. Alt\nPO/PG. BFx2 so far this shift. No spits. Min aspirate.\nAbdomen benign. Voiding, stoolingx3, 1 heme positive this\nshift. A/Tolerating feeds well. P/Continue to support and\nencourage PO feeds.\n\nDEV: O/Temps stable, swaddled, co-bedding. A/A with cares.\nWaking for most cares. Resting comfortably in Between. MAE,\nAFSF. A/AGA. P/Continue to support dev. needs.\n\nPAR: Mom and dad in for morning cares. Mom and again for\naftrernoon cares. BFx2. Independent with cares. Very loving\nand involved. Updated by RN. Will continue to support dev.\nneeds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-27 00:00:00.000",
"description": "Report",
"row_id": 1887912,
"text": "Nursing\n\n\n#2O: In room air with no noted spells. Br. sounds clear\nwith mild SC retractions.\n#3O: Wt. up 60g on 150cc/kg, BM24, q 4 hr. Bottle offered\nx 2, did well 1st time and 2nd time, took a little more than\n. Gav. remainder with min. asp. and no spits. Belly\nsoft, void and stooling 2 stools neg, 1 stool guaiac +, no\nvisible bld.\n#4O: Co-bedding with brother, stable temp. Active with\ncares, likes pacifier and being swaddled.\n#5O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-25 00:00:00.000",
"description": "Report",
"row_id": 1887907,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 93%. Lung sounds clear/=. RR 30-50's. Mild\nSCR noted. No bradys noted thus far. Occ drifts noted to\nmid 80's. P: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 150 cc/kg/day of BM24. Infant\nbreastfed x 1 thus far and latched and did well. Tolerating\nfeedings well; abd exam benign, no spits, min asp. Voiding\nqs and stooling heme neg. Infant was started on ferinsol.\nP: Cont. to support nutritional needs.\n\n3. G/D: Temps stable swaddled cobedding in open crib with\nsiblings. Infant is alert/active with cares. Settles well\nin between cares. Appropriately brings hands to face and\nsucks on pacifier to comfort self. AFSF. AGA. P: Cont. to\nsupport developmental needs.\n\n4. : Mom and dad in for 09 cares. Updated at bedside\non infant's condition and plan of care. Asking appropriate\nquestions. Independent with cares and handling infants.\nWill be in for 17 cares. Loving, involved . P:\nCont. to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-26 00:00:00.000",
"description": "Report",
"row_id": 1887908,
"text": "NPN 11p-7a\n\n\n#2 LS clear. Well saturated. No resp distress or spells A:\nstable P; follow\n\n#3 TF's 150cc/k=63cc of BM24 q 4hrs. Full gavage offered 1hr\nat 0100. PO fed 50cc at 0500 without difficulty and then\ntired. Abdominal exam unremarkable. Voiding and stooling\nheme neg stool. A: tolerating feeds P: support feeding as\ntol\n\n#4 Temps stable cobedding with sibling. Sleeps well. Likes\npacifier. Working on bottling skills. A: AGA P: support\ndevelopmental needs\n\n#5 No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-26 00:00:00.000",
"description": "Report",
"row_id": 1887909,
"text": "Neonatology Attending\n\nDay 15 PMA 36 wks\n\nRemains in RA. RR 30-40s. Mild retractions. No murmur. HR 140-150s. BP mean 46. Pink, well-perfused. Weight 2495g (-5). On BM 24 at 150 ml/kg/d. Alternating po/pg feeds. Breast feeds during days. Taking 25-55 ml per bottle feed. Passes intermittently heme positive stool. Stable temperature in open crib. Spoke with yesterday. Received hepatitis B vaccine.\n\nDoing well overall. Mature breathing control evident most recently. Will discontinue oximeter. Monitoring cardio-respiratory status closely. Encouraging po feeds. Gaining weight well overall.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-26 00:00:00.000",
"description": "Report",
"row_id": 1887910,
"text": "NICU FELLOW PE NOTE\nGen- WD/WN M alert in NAD\nHEENT- NCAT, AFOF, nares patent, oropharynx clear, MMM\nCardiac- RRR, nl s1,s2, no murmur appreciated\nLungs- CTAB, no retractions\nAbdomen- +BS, soft, ND, no mass\nExtrem- FROM x4\nSkin- no rash\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-29 00:00:00.000",
"description": "Report",
"row_id": 1887922,
"text": "NPN \n\n\n\n #3. Infant changed to ad lib min 130cc/k BM24 made w/\npowder. He has been waking every 4hrs and taking 70-90cc\neach time. Abd benign. Soft w/active BS. No spits. V+S\nw/each diaper. Desitin appliec to butt for hx fissure.\nInfant conts on and was started on multivits today. P:\nCont to support nutritional needs.\n\n #4. Temp stable swaddled and cobedding w/sib in OC. Wakes\nfor feeds. A+A w/cares. AFSF. P: Cont to support dev needs.\n\n\n #5. in for am cares. Independent. Updated at the\nbedside. Asking approp questions about d/c. Mom to call OB\nin am to set up circ. P: Cont d/c teaching.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-27 00:00:00.000",
"description": "Report",
"row_id": 1887913,
"text": "Neonatology Attending\n\nDay 16 PMA 37 0/7 wks\n\nRemains in RA. RR 30-60s. Mild retractions. HR 130-160s. No murmur. BP mean 56. Weight 2555g (+60). TF at 150 ml/kg/d- BM24. Taking bottles. Benign abdomen. Passed heme positive stool yesterday. No gross blood. Benign abdomen. Stool now negative. Stable temperature in open crib.\n\nDoing overall. Will continue to monitor respiratory control closely. Tolerating feeds and gaining weight. No changes for today. up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-27 00:00:00.000",
"description": "Report",
"row_id": 1887914,
"text": "2. in RA, color pink, BBs equal, clear, RR40-60, mild sc\nretractions, no spells A: stable in RA P:cont to monitor.\n3. TF 150cc/k/d Bm24 =64cc q4h, breast fed well this am ,\ntook 40cc po ~1300, abd soft, stable, no spits, minimal\naspirates, voiding and passing stool, on ferinsol. A:\nlearning to breast and bottle feed P: cont present care.\n4. active and alert with cares, starting to wake for some\nfeedings, sleeping well in between, temps stable swaddled in\nopen crib with brother A:AGA P: cont to support needs for\ngrowth and develoment.\n5. Mom here this am with MGM, shown how to draw up ferinsol,\nrequsting bath for tomorrow A: loving and involved\nfamily P: continue to provide updates and dc teaching.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-27 00:00:00.000",
"description": "Report",
"row_id": 1887915,
"text": "Fellow PE Note\nGen: NAD\nHEENT: NCAT, AFOF, nares patent\nCardiac: rrr, nl S1S2, no murmur appreciated\nLungs: CTA B w/o retractions\nAbd: +BS, soft NT/ND, no masses appreciated\nExt: FROM x 4\nNeuro: alert, nl tone\nGenital: nl male genitalia\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-31 00:00:00.000",
"description": "Report",
"row_id": 1887927,
"text": "PCA note 1900-0700\n\n\n1. FEN: TF 130cc/kg BM 24 with powder. New weight 2.735\nkg, up 35g. At 2100 bottled 70cc. At 0100 bottled 60cc.\nTolerating feeds well; abdomen benign, good BS, only one sm\nspit. Voiding and stooling heme negative. P: Continue to\nsupport nutritional needs.\n\n2. G/D: Temps are stable and swaddled in co-bed. Alert and\nactive with cares. Wakes for feeds. MAE well. AFSF. AGA. Had\ncircumcision done on day shift; vaseline and gauze applied\nto site a/o. P: Continue to support developmental needs.\n\n3. Parenting: in during day shift. Mom called to\ncheck on infant's condition this shift; updated by RN.\nLoving and involved. P: Continue to support and update\n.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-31 00:00:00.000",
"description": "Report",
"row_id": 1887928,
"text": "Neonatology Attending\n\nDay 20 PMA 37 wks\n\nRemains in RA. RR 30-50s. Clear breath sounds. No murmur, bradycardia. HR 150--170s. BP mean 53. Weight 2735g (+35). On BM24. Took 155 ml/kg yesterday. Benign abdomen. Had circumcision yesterday. Passed hearing screen and car seat study. Stable temperature in crib.\n\nDoing well overall. Ready for discharge on and vitamin E. F/U appointment with Dr. tomorrow at 1100.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-30 00:00:00.000",
"description": "Report",
"row_id": 1887923,
"text": "Nursing\n\n\n#3O: Wt. up 85g, taking in 184cc/kg, of BM 24 made\nwith powder. Wakes q 4 hrs., bottles well. Belly soft,\nvoiding and stooling. To have circ today.\n#4O: Cobedding with brother, stable temp. Active with\ncares, likes pacifier and being swaddled. Passed car seat\nsafety screen.\n#5O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-30 00:00:00.000",
"description": "Report",
"row_id": 1887924,
"text": "Neonatology Attending\n\nDay 19 PMA 37 wks\n\nRemains in RA. RR 30-50s. Pink, well-perfused. Weight 2700g (+85). On BM 24 with Similac powder. Bottling well. Benign abdomen. Passed car seat position study. Stable temperature.\n\nDoing well overall. Will continue to monitor. Feeding much improved over weekend. Needs circumcision and hearing screen. Hope to discharge home tomorrow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-30 00:00:00.000",
"description": "Report",
"row_id": 1887925,
"text": "Nursing NICU Note\n\n\n#3. FEN O: TF Min 130cc/kg/d of BM24 w/ powder =59cc Q\n4hrs. He wakes independently to feed q 3-4hrs, and has\ntaken ~60cc PO without difficulty. Pt. also breastfeeds\nwell. Abdomen is soft, pink, +bs, no loops/spits noted. He\nis voiding/stooling QS. A: Pt. is tolerateing current\nnutritional plan. P: Continue w/ current feeding plan.\nMonitor for s/s of intolerance.\n\n#4. Growth/Development O: Pt. remains swaddled in an open\ncrib, co-bedding w/ twin. Temps stable. He is alert and\nactive w/ cares, sleeping well in between. Fontanelle\nsoft/flat. He loves to use his pacifier, brings hands to\nface. A: AGA P: Continue to provide environment\nappropriate for growth and development.\n\n#5. O: Mom in to visit this am for cares. Mom\nupdated at bedside on pt's current status and daily plan of\ncare. are active and independent in cares, asking\nappropriate questions. A: Family is very loving and\ninvolved. P: Continue to update, support and educate.\nContinue w/ discharge teaching. D/C planned for tomorrow.\nPatient to have circumcision this afternoon, hearing screen\nto be done this evening. Mom will make pedi appt. \nhave not decided if they want VNA. VNA referral has been\nwritten.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-30 00:00:00.000",
"description": "Report",
"row_id": 1887926,
"text": "Exam Note\nGEN - active, alert\nHEENT - AFSFO, oropharynx clearn, nares patent\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - recently circumcised penis, no active bleeding, otherwise normal male external genitalia\nEXT - WWP, cr < 2 sec\nNEURO - responsive to touch, MAE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-31 00:00:00.000",
"description": "Report",
"row_id": 1887929,
"text": "PCA Progress Note \n\n\n#3 FEN: TF min 130cc/kg/day BM24 with powder (60cc\nq4hours). Ad lib demand infant waking q3-5 hours for feeds,\nand taking 60-75cc. Abd benign, voiding and stooling heme\nneg. No spits, no loops, +BS. Tolerating feeds. Continue to\nfollow nutritional plan.\n\n#4 DEV: Temps stable swaddled cobedding with twin brother.\n and active with cares, sleeping well between. MAE.\nAFSF. Brings hands to face, enjoys pacifier. AGA. Continue\nto support developmental needs.\n\n#5 SOC: Mom in for morning cares. Independent. Gave Fe and\nMultivits. Appropriately excited for discharge to home this\nevening. Will return later this afternoon with father to\nprepare for discharge. Continue to educate and support.\n\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-31 00:00:00.000",
"description": "Report",
"row_id": 1887930,
"text": "I have examined and agree with above note by , PCA. Mom given 24cal recipe and prepared milk at bedside with RN assistance, reviewed signs of illness and preventing infection. given handouts on circ care and safe travels.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-31 00:00:00.000",
"description": "Report",
"row_id": 1887931,
"text": "Exam Note\nGEN - sleeping, calm\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genitalia, recently circ with wound c/d/i and no active bleeding\nEXT - wwp, cr < 2 sec\nNEURO - reactive, MAE\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-31 00:00:00.000",
"description": "Report",
"row_id": 1887932,
"text": " here ~1800, dc papers reviewed and signed, dc'd to home in infant car seat accompanied by \n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-11 00:00:00.000",
"description": "Report",
"row_id": 1887834,
"text": "Nursing;\nMOm32y, G1P0, 34 weeks gestation,ivf twins, bete complete,c/s for breech, apgar 8,8, admitted to NICu, placed on the warmer, v/s as recorded. BBS coarse to clear, mid subcostal retractions present at admission,cbc with def, blood culture sent, d'stix063,78.PIV placed, IVF D10 started at 60cc/kg/day, infusing at PIV,parents visited, mom held the baby, CBC results, .5,poly's 28,bands1,HCt51.7,platelets 334.baby care meds given, amp+ gent given as ordered.no desats noted thus far this shift.kept NPO.BS+, no loops, no void or stool thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-11 00:00:00.000",
"description": "Report",
"row_id": 1887835,
"text": "1 Infant with Potential Sepsis\n2 Alt in Respiration\n3 Alt in Fen\n4 Alt in Development\n5 Alt in parenting\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Alt in Respiration; added\n Start date: \n 3 Alt in Fen; added\n Start date: \n 4 Alt in Development; added\n Start date: \n 5 Alt in parenting; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-11 00:00:00.000",
"description": "Report",
"row_id": 1887836,
"text": "Neonatology\nPatient is 2.26 kg product of 34 wk gestation born to primiparous woman after pregnancy notable for fibroids and iVF.\n\nPrenatal screens complete and unremarkable. GBS +. No other sepsis risk factros.\n\nAt delivery attended by Dr , patient emerged vigorous. Apgars 8,8. Given BBo2 and stim. Brought to NICU after visting with parents.\n\nOn exam pink active non-dysmorphic infant. Well saturated and perfused in RA. HEENT WNL. Lungs clear. Abdomen benign. Cor Nl s1s2 w/o murmurs. Neuro non-focal and age appropriate. Spine intact. Hips normal. Neuro non-focal and age appropriate. genitalia normal male. Anus patent.\n\nA_ Well apeparing preterm infantw ithout resp distress during initial portion of transitional period.\n\n\nP Admit NICU\n Clinicla and non-invasive monitoring of CV and resp status.\n NPO for now with IV hydration.\n CBC diff bC\n Abx for 48 h r/o pending cx results and clincial course.\n Usual attention to metabolic issues and bili.\n Parents aware of status and plan.\n PMD will be Dr .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-14 00:00:00.000",
"description": "Report",
"row_id": 1887846,
"text": "NPN 7p-7a\n\n\n#1 infant with no S/S sepsis, VSS, Bld cx neg, antibiotics\ndc'd, A: no sepsis P: dc problem\n#2 Remains in rm air with RR 30-50, color pink, LS clear and\nequal, mild subcostal retractions. has had some very quick\ndrifts in SaO2 to mid 80's. A: occ drifting P: monitor\n#3 remains on 100cc/k/d BM/SC20. to breast once, little\ninterest, trialed bottle at 00:30 feed, took 10cc. tol pg's\nwell over 90 min but has has 2 small spits. abd benign,\nsoft, +BS, no loops or distention, vdg qs, stool each care,\nheme neg. weight down 15 grams. A: tol feeds, P: no change\nat present, off occ po feeds.\n#4 stable in low heat isolette, waking for feeds, poor at po\nnow, does suck some on pacifier. calm with cares, sleeping\nwell between feeds, A: AGA P: cont to support development\n#5 mom and dad here early in shift. handling infants well,\nmom tried each baby at breast with brief latch. both please\nwith infant's progress, discussed possibility of\nphototherapy A: involved family P: cont to inform and\nsupport\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-14 00:00:00.000",
"description": "Report",
"row_id": 1887847,
"text": "Neonatology Attending Note\nDay 3, PMA 35 1\n\nRA. RR30-40s. 1 brady. No murmur. HR 110-140s. BP 61/40, 46. Bili 6.0/0.3. Wt 2170, down 5 gms. TF 100 SC20. PO/PG. Tol well. Nl voiding and stooling. In air isolette.\n\nA/P:\nPreterm infant with immature feeding abilities and temperature regulation. Cont current management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-14 00:00:00.000",
"description": "Report",
"row_id": 1887848,
"text": "Nursing NICU Note\n\n1 Infant with Potential Sepsis\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~94-98%.\nRR ~20-40's, no increase work of breathing noted. LS\nclear/=. No A&B's noted this shift thus far. Pt. has an\noccasional O2 sat drift while useing pacifier and once while\nattempting to breastfeed. A: Pt. remains stable in RA. P:\n Continue to monitor respiratory status. Monitor for A&B's.\n\n#3. FEN O: TF 100cc/kg/d of BM/Sim20 =38cc Q 4hrs,\ngavaged over 90 min, tolerated well. He also attempt to\nbreastfeed w/ a supplemental gavage feed as well. Abdomen\nis soft, pink, +bs, no loops/spits noted. Abdominal girth\nis ~24cm. He is voiding, passing guiac- stool QS. A: Pt.\nis tolerateing current nutritional plan. P: Continue w/\ncurrent feeding plan. Monitor for s/s of intolerance.\nContinue to encourage oral feeds as pt. looks interested and\ntolerates.\n\n#4. Growth/Development o: Pt. remains swaddled in an air\nmode isolette. Temps stable. He is alert and active w/\ncares, sleeps well in between. Fontanelle soft/flat. He\nuses his pacifier well for comfort, brings hands to face.\nA: AGA P: Continue to provide environment appropriate for\ngrowth and development.\n\n#5. Parents O: Mom in to visit for cares throughout the\nshift. She was updated at bedside on pt's current status\nand daily plan of care. Mom participates in cares\nindependently, asking appropriate questions. A: Family is\nloving and involved. P: Continue to update, support and\neducate.\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-14 00:00:00.000",
"description": "Report",
"row_id": 1887849,
"text": "NNP ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in isolette, room air\nSKin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur; normla S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds\nExt: moving all\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-18 00:00:00.000",
"description": "Report",
"row_id": 1887869,
"text": "Fellow evaluation note\nDOL 7 CGA 35 \n\nRA 30-60, 3 bradys last night to 70s\nHR 120-140, no murmur, BP 76/52 (60)\n\nwt 2215 (+20g)\n150 mls/kg/d BM/ 20, po/pg\nvoiding, stooling\n\nO/E: well, see below\n\nImpression & plan : 7 days old ex 34 5/7 weeks baby with feeding immaturity\n-Increase to BM/SC 24\n-establish po feeding skills\n-lactation consult today\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-18 00:00:00.000",
"description": "Report",
"row_id": 1887870,
"text": "Fellow evaluation note\nAddendum - Neonatology Attending\n\nI have reviewed the interim history and physical examination, discussed the patient with the medical team and agree with Dr. assessment and plan for management as detailed above. 34-5/7 week GA twin with feeding and respiratory immaturity, doing well. We will advance caloric density and continue to await maturation of oral feeding skills and respiratory drive.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-18 00:00:00.000",
"description": "Report",
"row_id": 1887871,
"text": "Fellow examination note\nGen: looks well, alert, active\nResp: comfortably breathing in RA, B/L good aeration\nCVS: pink, well perfused, S1S2 normal, no murmur\n: soft, non distended GU normal\nNeuro: tone normal, handles well\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-18 00:00:00.000",
"description": "Report",
"row_id": 1887872,
"text": "Lactation Consult 0900\nMet w/ family to assess positioning, latch and milk supply.\nInfant held cross cradle position w/ support pillow. Mom is using a nipple shield and had an immediate letdown reflex. Infant latched well but did have some periods of shallow breathing and drifts on O2sat to 88-90% which were self resolving. There was some discoordination of suck/swallow/breathe but infant did nurse fairly well. He was then held by kangaroo care and gavage fed full feeding.\nPlan to continue to provide support for mom's breastfeeding efforts. Will check in w/ family by next Weds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-18 00:00:00.000",
"description": "Report",
"row_id": 1887873,
"text": "2. in RA, color pink, BBs clear, equal, mild sc retractions,\nRR30-50, sats 90-100. no brady so far-please see flow sheet\nfor current details. continue to monitor.\n3. TF 150cc/k/d Bm24/Sim24 57cc q4h, breast fed fairly well\nthis am plus pg full volume and pg fed at 1300 in\nanticipation of BF again at 1700, abd soft, no loops, active\nbowel sounds, minimal aspirates, no spits, voiding and\npassing guiac neg stool A: learning to breast and bottle\nfeed, tolerating feedings, advancing in calories P: offer po\non night shift, cont to monitor/assess.\n4. temp stable swaddled in heated - temp\nweaned slightly, active and alert with cares. loves to suck\non pacifier, sleeping well between feedings. continue to\nsupport developmental needs.\n5. Parents here this am, Mom met with G, LC. Parents\nvery loving, planning to return for next cares. continue to\nupdate and offer support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-10-18 00:00:00.000",
"description": "Report",
"row_id": 1887874,
"text": "correction to above note: feedings are BM24 or SC24.\n\n\n"
}
] |
65,417 | 133,094 | The patient was admitted on and underwent CABGx3(LIMA->LAD, SVG->OM, Diag. The cross clamp time was 44 minutes, total bypass time was 65 minutes. He tolerated the procedure well and was transferred to the CVICU on Propofol in stable condition. He was extubated on the post op night and his chest tubes were discontinued on POD#1. He was transferred to the floor on POD#2 and his epicardial pacing wires were discontinued on POD#3. He continued to progress and was discharged to home on POD#4 in stable condition. | Normal interatrial septum. Normal aortic arch diameter. Physiologic(normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The left ventricular cavity sizeis normal. Trivial mitral regurgitationis seen.There is no pericardial effusion.POSTBYPASSThe patient is A-paced on a phenylephrine infusion.Biventricular systolic function is preserved.Trace aortic regurgitation and trace mitral regurgitation persist.The thoracic aorta is intact after aortic decannulation.Dr. Mild global RV free wallhypokinesis.AORTA: Normal aortic diameter at the sinus level. Aortic valve mass.No AS. No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body ofthe RA. Normal descending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mildly dilated ascendingaorta. Overall left ventricular systolic function is normal (LVEF>55%).The right ventricular cavity is mildly dilated with mild global free wallhypokinesis.The ascending aorta is mildly dilated.The aortic valve leaflets (3) are mildly thickened. No atrial septal defect is seen by 2Dor color Doppler.Left ventricular wall thicknesses are normal. Coronary artery disease.Status: InpatientDate/Time: at 15:51Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Normal LV cavity size. Early transition.Compared to the previous tracing of no diagnostic interval change.Consider prior inferior myocardial infarction. There is a focalcalcification on one of the aortic valve leaflets, either the non-coronary orthe left-coronary leaflet. No spontaneous echo contrast in the body of the LAA. No spontaneous echo contrastis seen in the body of the right atrium. There is no aortic valve stenosis. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No TEE related complications. Prior inferior myocardial infarction. Thepatient appears to be in sinus rhythm. No spontaneous echo contrast is seen in thebody of the left atrium or left atrial appendage. Trace aorticregurgitation is seen.The mitral valve leaflets are mildly thickened. Trivial MR.TRICUSPID VALVE: Tricuspid valve not well visualized. Sinus rhythm. Results were personally reviewed withthe MD caring for the patient.Conclusions:PREBYPASSThe left atrium is normal in size. Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. The patient was undergeneral anesthesia throughout the procedure. A-V conduction delay. Overallnormal LVEF (>55%).RIGHT VENTRICLE: Mildly dilated RV cavity. I certifyI was present in compliance with HCFA regulations. Compared to the previous tracing of the findings are similar. Sinus bradycardia, rate 56. Q waves in leads II, III and aVF. was notified in person of the results at the time of the study. | 3 | [
{
"category": "Echo",
"chartdate": "2117-11-12 00:00:00.000",
"description": "Report",
"row_id": 98039,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Coronary artery disease.\nStatus: Inpatient\nDate/Time: at 15:51\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the body of the\n LAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of\nthe RA. Normal interatrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter. Normal descending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Aortic valve mass.\nNo AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic\n(normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPREBYPASS\nThe left atrium is normal in size. No spontaneous echo contrast is seen in the\nbody of the left atrium or left atrial appendage. No spontaneous echo contrast\nis seen in the body of the right atrium. No atrial septal defect is seen by 2D\nor color Doppler.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is normal (LVEF>55%).\nThe right ventricular cavity is mildly dilated with mild global free wall\nhypokinesis.\nThe ascending aorta is mildly dilated.\nThe aortic valve leaflets (3) are mildly thickened. There is a focal\ncalcification on one of the aortic valve leaflets, either the non-coronary or\nthe left-coronary leaflet. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\nThere is no pericardial effusion.\n\nPOSTBYPASS\nThe patient is A-paced on a phenylephrine infusion.\nBiventricular systolic function is preserved.\nTrace aortic regurgitation and trace mitral regurgitation persist.\nThe thoracic aorta is intact after aortic decannulation.\n\nDr. was notified in person of the results at the time of the study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2117-11-12 00:00:00.000",
"description": "Report",
"row_id": 268988,
"text": "Sinus rhythm. A-V conduction delay. Compared to the previous tracing of \nthe findings are similar. Prior inferior myocardial infarction.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-11-08 00:00:00.000",
"description": "Report",
"row_id": 268989,
"text": "Sinus bradycardia, rate 56. Q waves in leads II, III and aVF. Early transition.\nCompared to the previous tracing of no diagnostic interval change.\nConsider prior inferior myocardial infarction.\n\n"
}
] |
53,759 | 112,935 | 85 yo M with DM2, HTN, vascular dementia, presents with lethargy in the setting of severe dehydration, hyperglycemia, and hypernatremia, consistent with hyperosmolar hyperglycemic state. . # Hyperosmolar hyperglycemic state/DM2: The patient presented with marked hyperglycemia and was started on an insulin drip. With improvement in his hyperglycemia, he was transitioned to subcutaneous insulin. Metformin was held. He was started on lantus while needing D5W. When his D5W was stopped after his sodium was corrected, his insulin was adjusted and his sugars were mildly well-controlled. Insulin sliding scale was eventually stopped and patient was restarted on metformin. He was switched to metformin 500mg twice a day. . # Hypernatremia: The patient presented with profound hypernatremia, with sodium 177-180. His free water deficit was greater than 10 L. During a period of several days, his free water deficit was gradually repleted with good effect. Last serum sodium checked prior to discharge was 140. As patient's labs were stable, they were not checked daily. . # Acute renal failure: The patient presented with creatinine 2.2, significantly elevated from his baseline of 0.9. This was felt to be pre-renal in setting of severe dehydration. However, given the patient's history of urinary retention, obstruction may have also contributed, a Foley catheter was placed. The patient was treated with IV fluids and Foley placement and his creatinine slowly improved. At the time of discharge his creatinine was 1.2. His mixed picture has resolved and he will need to follow up with Urology. . # Urinary tract infection: U/A was positive. The patient was started on empiric ceftriaxone and Vancomycin given gram positive cultures in the past. Cultures grew out coagulase positive staph aureus. Blood cultures were negative. He was continued on vancomycin until he was able to tolerate oral medications and then switched to bactrim for a total of 14 days. Last dose is on . . # Constipation: Patient appeared to be having some abdominal discomfort and hard bowel movements. He was started on a more aggressive bowel regimen and received a tap water enema the day prior to admission. He should receive all constipation medications until he is having soft, regular bowel movements. If he does not have a bowel movement after 2 days, he should receive a tap water enema. . # EKG changes: The patient had some lateral ST depression, which were reviewed with cardiology and felt to be most consistent with left ventricular hypertrophy with strain. . # Goals of care: Patient will be transitioned to hospice care when he returns to . . # CODE STATUS: DNR/DNI | There has been right lens surgery. Prominence of ventricles and sulci is consistent with moderate parenchymal atrophy. Clinical correlation issuggested. There is a well defined small hypodensity in the right caudate head, consistent with a chronic infarct, new since . Visualized paranasal sinuses and mastoid air cells are well aerated. Sinus rhythm at upper limits of normal rate. Again seen is mild cephalization of the pulmonary vasculature. Compared to the previous tracingof possible atrial pacing is now present. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the right brachial venous approach. Small chronic infarct in the right caudate head, new since . Currently, the PICC line tip is at the level of left brachiocephalic vein, pulled back as compared to the prior position at least for 10 cm. Evaluate for acute process. Evaluate for acute process. Diffusenon-diagnostic repolarization abnormalities. A timeout was performed. Lungs are essentially clear except for minimal atelectasis at the right lung base, new. Probable left ventricularhypertrophy with ST-T wave abnormalities of strain and/or ischemia. Please secure with extra tape/gauze and patient tends to pull at lines. Final internal length is 46 cm, with the tip positioned in SVC. The aorta is mildly tortuous, but unchanged. COMPARISON: Head CT of and head MRI of . ST-T wave abnormalities are more marked. FINAL REPORT PICC LINE PLACEMENT INDICATION: IV access needed for venous access. DFDkq REASON FOR THIS EXAMINATION: Please place PICC. Mediastinum is normal. Please secure with extra tape/gauze and p Admitting Diagnosis: HYPERNATREMIA ********************************* CPT Codes ******************************** * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. FINDINGS: In comparison with the earlier study of this date, there has been placement of a left subclavian PICC line that extends to the lower portion of the SVC. FINAL REPORT HISTORY: PICC placement. TECHNIQUE: MDCT-acquired images were obtained through the head without contrast. IMPRESSION: Mild pulmonary vascular congestion, unchanged. Portable AP chest radiograph was compared to . Position of the catheter was confirmed by a fluoroscopic spot film of the chest. Size remains at the upper limits of normal. Coronal and sagittal reformatted images were also displayed. IMPRESSION: 1. 4:43 PM PICC LINE PLACMENT SCH Clip # Reason: Please place PICC. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access are on file. The line is ready to use. COMPARISON: . SINGLE FRONTAL VIEW OF THE CHEST: Lungs are clear bilaterally. 2:46 PM CHEST PORT. Heart size is normal. This information has been telephoned to at his request. The catheter was secured to the skin, flushed, and a sterile dressing applied. High-density material within the external auditory canals bilaterally is consistent with cerumen. Since theprevious tracing of the rate is now slower. Possible atrial pacing with frequent atrial premature depolarizations andbaseline artifact precluding definitive rhythm analysis. The QRS voltage is moreprominent. Otherwise, little change. RADIOLOGIST: Dr. and Dr. performed the procedure. TECHNIQUE: Using sterile technique and local anesthesia, the patent right brachial vein was punctured under direct ultrasound guidance using a micropuncture set. The procedure was explained to the patient. The peel-away sheath and guidewire were then removed. A peel-away sheath was then placed over a guidewire and a double lumen PICC line measuring 46 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. FINDINGS: A portion of the study was repeated due to motion artifacts, but evaluation remains slightly limited. PICC came out completely during attempt to exchange PICC over wire. The patient tolerated the procedure well. 2. There were no immediate complications. FINAL REPORT INDICATION: 85-year-old man with altered mental status. 10:31 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Pulled PICC out partially, eval placement/location Admitting Diagnosis: HYPERNATREMIA MEDICAL CONDITION: 85 year old who presented w/ UTI, hyperglycemic, hypernatremic, altered REASON FOR THIS EXAMINATION: Pulled PICC out partially, eval placement/location FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with urinary infection, hyperglycemic, and hypernatremic, with unclear position of PICC line. No acute intrathoracic process. 4:02 AM CT HEAD W/O CONTRAST Clip # Reason: please eval r/o acute process MEDICAL CONDITION: 85 year old man with altered mental status REASON FOR THIS EXAMINATION: please eval r/o acute process No contraindications for IV contrast WET READ: JKSd TUE 5:29 AM no acute intracranial process. No evidence of an acute intracranial process. There is no pleural effusion or pneumothorax. ACCESS * **************************************************************************** MEDICAL CONDITION: 85 year old man with left PICC who began agitated and pulled PICC back into left brachiocephalic. | 7 | [
{
"category": "Radiology",
"chartdate": "2129-04-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1190737,
"text": " 2:46 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: L picc 56cm \n Admitting Diagnosis: HYPERNATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with new picc\n REASON FOR THIS EXAMINATION:\n L picc 56cm \n ______________________________________________________________________________\n WET READ: KKgc TUE 4:35 PM\n LUE PICC ends in the lower SVC. Kkaliann d/w Ms. (IV access team) at\n 4:30 p.m.\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 left subclavian PICC line that extends to the lower portion of\n the SVC. Otherwise, little change.\n\n This information has been telephoned to at his request.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-27 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1190883,
"text": " 4:43 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC. Please secure with extra tape/gauze and p\n Admitting Diagnosis: HYPERNATREMIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with left PICC who began agitated and pulled PICC back into\n left brachiocephalic. PICC came out completely during attempt to exchange PICC\n over wire.\n REASON FOR THIS EXAMINATION:\n Please place PICC. Please secure with extra tape/gauze and patient tends to\n pull at lines.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for venous access.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. and Dr. performed the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the patent right\n brachial vein was punctured under direct ultrasound guidance using a\n micropuncture set. Hard copies of ultrasound images were obtained before and\n immediately after establishing intravenous access are on file. A peel-away\n sheath was then placed over a guidewire and a double lumen PICC line measuring\n 46 cm in length was then placed through the peel-away sheath with its tip\n positioned in the SVC under fluoroscopic guidance. Position of the catheter\n was confirmed by a fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided double lumen\n PICC line placement via the right brachial venous approach. Final internal\n length is 46 cm, with the tip positioned in SVC. The line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190777,
"text": " 10:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Pulled PICC out partially, eval placement/location\n Admitting Diagnosis: HYPERNATREMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old who presented w/ UTI, hyperglycemic, hypernatremic, altered\n REASON FOR THIS EXAMINATION:\n Pulled PICC out partially, eval placement/location\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with urinary infection,\n hyperglycemic, and hypernatremic, with unclear position of PICC line.\n\n Portable AP chest radiograph was compared to .\n\n Currently, the PICC line tip is at the level of left brachiocephalic vein,\n pulled back as compared to the prior position at least for 10 cm. Heart size\n is normal. Mediastinum is normal. Lungs are essentially clear except for\n minimal atelectasis at the right lung base, new.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190651,
"text": " 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with lethargy\n REASON FOR THIS EXAMINATION:\n please eval r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old man with lethargy. Evaluate for acute process.\n\n COMPARISON: .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Lungs are clear bilaterally. Again seen is\n mild cephalization of the pulmonary vasculature. There is no pleural effusion\n or pneumothorax. The aorta is mildly tortuous, but unchanged. Size remains\n at the upper limits of normal.\n\n IMPRESSION: Mild pulmonary vascular congestion, unchanged. No acute\n intrathoracic process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1190652,
"text": " 4:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n please eval r/o acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKSd TUE 5:29 AM\n no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old man with altered mental status. Evaluate for acute\n process.\n\n COMPARISON: Head CT of and head MRI of .\n\n TECHNIQUE: MDCT-acquired images were obtained through the head without\n contrast. Coronal and sagittal reformatted images were also displayed.\n\n FINDINGS: A portion of the study was repeated due to motion artifacts, but\n evaluation remains slightly limited. There is no evidence of acute\n intracranial hemorrhage, edema, or mass effect. There is a well defined small\n hypodensity in the right caudate head, consistent with a chronic infarct, new\n since . Prominence of ventricles and sulci is consistent with moderate\n parenchymal atrophy.\n\n Visualized paranasal sinuses and mastoid air cells are well aerated.\n High-density material within the external auditory canals bilaterally is\n consistent with cerumen. There has been right lens surgery.\n\n IMPRESSION:\n 1. No evidence of an acute intracranial process.\n 2. Small chronic infarct in the right caudate head, new since .\n DFDkq\n\n"
},
{
"category": "ECG",
"chartdate": "2129-04-27 00:00:00.000",
"description": "Report",
"row_id": 124104,
"text": "Possible atrial pacing with frequent atrial premature depolarizations and\nbaseline artifact precluding definitive rhythm analysis. Diffuse\nnon-diagnostic repolarization abnormalities. Compared to the previous tracing\nof possible atrial pacing is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2129-04-26 00:00:00.000",
"description": "Report",
"row_id": 124105,
"text": "Sinus rhythm at upper limits of normal rate. Probable left ventricular\nhypertrophy with ST-T wave abnormalities of strain and/or ischemia. Since the\nprevious tracing of the rate is now slower. The QRS voltage is more\nprominent. ST-T wave abnormalities are more marked. Clinical correlation is\nsuggested.\n\n"
}
] |
94,977 | 177,518 | HOSPITAL COURSE This is a 63yo female PMHx COPD and CHF, multiple prior admissions for respiratory failure, who presented w hypercarbic respiratory failure requiring Bipap in MICU, thought to be secondary to COPD and CHF, diuresed and started on steroid pulse with improved respiratory status to baseline, discharged back to . . ACTIVE # Acute sCHF and COPD Exacerbation - Patient a/w hypercarbic respiratory failure requiring Bipap (usually on CPAP at home), thought to be CHF and COPD exacerbations. Exacerbating factors were potential medication non-compliance, worsening of pulmonary HTN (noted on TTE during this hospitalization), cigarette smoking. COPD was treated with azithro x5d and extended prednisone taper; CHF with diuresis. She improved to baseline respiratory status, and was cleared by PT to return to . Given prior non-compliance with O2, and recommendation from PCP in prior note, patient was not discharged on home O2. She was given script for prednisone taper. Home inhalers (spiriva, symbicort, albuterol, fluticasone/salmeterol) were continued and patient was counseled on smoking cessation. Lasix dose was increased to dosing for improved diuresis and will need to be followed up in outpatient setting. . # Hypertension: Continued lisinopril. Given borderline admission blood pressure, isosorbide mononitrate was held. Pressures remained well-controlled and it was not restarted at discharge; could be restarted as outpatient if blood pressures become difficult to control . INACTIVE # CAD: Continued , , simvastatin, metoprolol . # DM 2: Continued metformin . # Depression Continued abilify and fluoxetine . TRANSITIONAL 1. Code status: Full code for duration of the admission 2. Pending: No labs/studied were pending at time of discharge 3. Transfer of Care: Patient reported that provided at-home PCP . Discharge summary faxed to . 4. Barriers to Care: Recurrent readmissions with respiratory distress are concerning for potential medication non-compliance or environmental exacerbating factor. | Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is mild symmetric leftventricular hypertrophy. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. There is noaortic valve stenosis. Compared to theprevious tracing of sinus tachycardia with atrial premature beats isnew. Moderate global RV free wall hypokinesis.Cannot assess regional RV systolic function.AORTA: Normal aortic diameter at the sinus level. No resting LVOT gradient.RIGHT VENTRICLE: Dilated RV cavity. Theright ventricular cavity is dilated with moderate global free wallhypokinesis. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , the rightventricle may now be more dilated and hypokinetic (however views aresuboptimal for comparison). Estimated pulmonary artery systolic pressure isnow higher. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There ismoderate pulmonary artery systolic hypertension. Normal IVC diameter(<2.1cm) with >55% decrease during respiration (estimated RA pressure(0-5mmHg).LEFT VENTRICLE: Mild symmetric LVH. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor apical views. The right atrium is moderately dilated. The mitral valveappears structurally normal with trivial mitral regurgitation. Suboptimalimage quality - patient unable to cooperate.Conclusions:The left atrium is dilated. The left ventricular cavity size is normal. Sinus tachycardia. Diffuse T wave inversions, especially in the anterior leads, are nowimproved. PATIENT/TEST INFORMATION:Indication: Evaluate worsening cardiac function given respiratory distressHeight: (in) 69Weight (lb): 288BSA (m2): 2.41 m2BP (mm Hg): 117/66HR (bpm): 85Status: InpatientDate/Time: at 10:56Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal LV cavity size. Theestimated right atrial pressure is 0-5 mmHg. The aortic valve leaflets (3) are mildly thickened. Suboptimaltechnical quality, a focal LV wall motion abnormality cannot be fullyexcluded. Frequent premature atrial contractions. Overall left ventricular systolic function is normal (LVEF>55%). Due tosuboptimal technical quality, a focal wall motion abnormality cannot be fullyexcluded. Findings are suggestive of pulmonary embouls or other intercurrentpulmonary process. Overall normal LVEF (>55%). No AS. No aortic regurgitation is seen. | 2 | [
{
"category": "Echo",
"chartdate": "2194-02-25 00:00:00.000",
"description": "Report",
"row_id": 98000,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate worsening cardiac function given respiratory distress\nHeight: (in) 69\nWeight (lb): 288\nBSA (m2): 2.41 m2\nBP (mm Hg): 117/66\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 10:56\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: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal IVC diameter\n(<2.1cm) with >55% decrease during respiration (estimated RA pressure\n(0-5mmHg).\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%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Moderate global RV free wall hypokinesis.\nCannot assess regional RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial 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 - poor apical views. Suboptimal\nimage quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is dilated. The right atrium is moderately dilated. The\nestimated right atrial pressure is 0-5 mmHg. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is normal (LVEF>55%). The\nright ventricular cavity is dilated with moderate global free wall\nhypokinesis. The aortic valve leaflets (3) are mildly thickened. There is no\naortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , the right\nventricle may now be more dilated and hypokinetic (however views are\nsuboptimal for comparison). Estimated pulmonary artery systolic pressure is\nnow higher. Findings are suggestive of pulmonary embouls or other intercurrent\npulmonary process.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2194-02-24 00:00:00.000",
"description": "Report",
"row_id": 268046,
"text": "Sinus tachycardia. Frequent premature atrial contractions. Compared to the\nprevious tracing of sinus tachycardia with atrial premature beats is\nnew. Diffuse T wave inversions, especially in the anterior leads, are now\nimproved. Clinical correlation is suggested.\n\n"
}
] |
8,767 | 127,196 | RESPIRATORY FAILURE: The patient presented with right-sided pneumonia and some pulmonary edema. She developed ARDS and became extremely difficult to oxygenate on the ventilator. She was initially treated with ceftazidime, gentamicin, and vancomycin. Gentamicin was held. On , her sputum culture came back as Acinetobacter which was sensitive only to Zosyn. The patient was switched over to Zosyn. However, throughout the day she became extremely difficult to oxygenate, saturating only in the 80s on 100 percent FI02 on the ventilator. The ventilator settings had a high respiratory rate and a low tidal volume to match the ARDSNet protocol. In the end, her oxygenation tailed off during the day up until her death. | Since theprevious tracing of atrial fibrillation is now present. There has been interval intubation with ET tube terminating several cm above the carina in satisfactory position. Since theprevious tracing of the ventricular response rate has slowed somewhat.Deeper T wave inversions are seen again in leads I, II, aVF and across thelateral precordium.TRACING #2 Sinus tachycardiaLow QRS voltages in limb leadsNonspecific ST-T wave changesSince previous tracing, atrial fibrillation is gone ID: DC'd sepsis protocol..afebrile..lactate down to 1.6..multilple antibiotics.. Endo: Following bs q4-6hrs.. SSRI Neuro: Post intubation..pt unarousable..by late am..able to open eyes to name..nod appropriately to yes/no questions. There remains vascular engorgement and perihilar haziness. IMPRESSION: Change in distribution of bilateral alveolar pattern, now worse in the left perihilar region and somewhat improved in the right lung. Note is made of underlying emphysema within the upper lobes. Allowing for technique, there has been interval worsening of chf with increased interstitial markings in both apices consistent with worsening CHF. Atrial fibrillation with an average ventricular response, 151. Previously described abnormalitiespersist. IMPRESSION: Pulmonary edema and bilateral pleural effusions. Atrial fibrillation with an average ventricular response, rate 104. rate 80's..still with pvcBP low 70's to 110/..requireing levo for support. Supraventricular tachycardiaLow QRS voltages in limb leadsNonspecific ST-T wave changesSince previous tracing, supraventricular tachycardia is new IMPRESSION; Placement of ET tube and right IJ central venous catheter in satisfactory position. deep sulcus L REASON FOR THIS EXAMINATION: look for pneumothorax FINAL REPORT INDICATION: COPD AND chf, post-intubation. 4 ICU nursing progress note: Respiratory: Remains intubated and vented..slowly decreasing fio2 and increased ventilation to correct initial acidosis..see care view labs..occassional spont rr.. Sats 90-95%. The T waveinversions previously noted are less impressive.TRACING #1 Cardiac silhouette is upper limits of normal in size and stable. Atrial fibrillation with a rapid ventricular response. Needed to titrate up as high as .05mic/kg/min..to keep map ^60. An endotracheal tube is in satisfactory position as well as a central venous catheter. To continue to wean fio2 as po2 tolerates.. Cardiac: Most of day in af..80-120's..occassional pvc..by 1600 converted to nsr spontaneously. Recent pneumonia. There are increased vascular markings and bilateral perihilar opacities consistent with pulmonary edema. There is persistent congestive heart failure. U/O poor..7-15cc/hr. Persistent chf. There has also been placement of a central venous catheter terminating in mid-SVC. The cardiac silhouette is partially obscured. A nasogastric tube is in place and courses below the diaphragm. Confluent areas of alveolar opacification have changed in distribution in the interval, and are now worse in the left perihilar region that the right. History of COPD and lung cancer status-post lobectomy. Assess ET tube. RESP CARE: Pt remains intubated on vent. The diaphragms are also obscured, consistent with pleural effusions bilaterally. Moderate right and small left pleural effusions are unchanged. ALBUTEROLAND ATROVENT MDI'S GIVEN. Lactate level =1.0. W/ 7.0 ORAL ETT IN PLACE.CURRENTLY ON AC MODE 32/380/.60/10. Albuterol/Atrovent MDI's added. Ceftaz and Gent dc'ed. Sxnd q3/hr. W/ 7.0 ORAL ETT IN PLACE.REMAINS ON AC MODE 32/380/1.0/10. PR: 0.20 QRS: 0.06 QT: 0.28. Hypoactive BS. HYPOTENSION W/ ATRIALFIBRILLATION TODAY REQUIRING LEVOPHED. Resp Care,Pt. AM ABG: 7.26/46/64/-. remains intubated on A/C overnoc. Lytes WNL. NPO, OGT in place, patent.GU: Foley C/D/I. B/L BS clear, diminished R base. Repleted w/ KCL 40meq IV, Mag 3gm IV, Calcium 2gm IV.HEM: HCT 28.5 from 36. See carevue for ABG's. PMH LUL WEDGE RESECTION. ATTEMPTTO WEAN FIO2 BACK TO .60 AS TOLERATED. Lactic acid 3.1, up from 1.1. on IV abx.GI: Abd soft, +BS X4. CVP=. +PP. +PP. Vent settings almost maxed. PMHX RU lobectomy. Appropiate, calm, understands dx, treatment. MAE, generalized weakness.RESP: OETT, 7fr, 20 at lip. EkG on patient at time of tachy episode: ?Af. abg acidotic, 1L D5W with 150MEQNAHCO3 bolus given. FOR TAN SPUTUM.UO MINIMAL. Repleted w/ Calcium 2gm IV. As per HO possibly dilutional. Piperacillin and Vanco ordered according to sensitivities. AM K+, Mg+ WNL. B/L BS clear to auscultation. Pt given fentanyl and versed prior for comfort. Weaned levo to off since . , RRT , RRT Wet, prod cough.CV: NSR, occasional multifocal PVC's. AC/32/60%/380/10. RESPIRATORY CARE: PT. altered resp statusd: pt intubated but mouthing words and appears alert and oriented. HO aware.ID: WBC 21.8, up from 12. afebrile. Dilt 10mg iv given x2 with moderate shortlived effect. CXR taken this am.GI: ABd, flat, soft. Anasarca, pitting. BUN 28, Cr 0.8, HCT 21; indicates pt dehydrated. SX. SX. GrathRN RN Pt aphonic, able to communicate approp. atn. HR at 950 145 with bp 68/45. HCT 31.2, up from 28.5. This AM labs: BUN 29, Cr 1.0, HCO3= 22. AM K+=3.3, Mg+=1.7, Ca++=6.5. ABG PENDING.WORSENING OXYGENATION TODAY DESPITE SX/LAVAGE/MORE PEEP/RECRUITMENT MANEUVER. AM ABG unchanged WNL, 7.34/44/64/-. Following same , pt's HR 150-160, Dopa shut off. RESPIRATORY CARE SERVICE: PT. Occasional PVC's, PAC's. Amio held. 2300 ABG done, settings unchanged. FOR TAN SPUTUM. on 60%/350/ac 28 with 10 peep abg=7.23/52/70/23/-6. PH 7.06 on latest abg, 2 more amps NAHCO3 given. C/W VENTILATORY SUPPORT. C/W VENTILATORY SUPPORT. Patient repositioned and Versed 1mg iv given. on abx.GI: Abd soft, +BSX4, no BM. MAE, generalized wekaness.RESP: OETT, marked at 20cm at lip, repositioned, tape changed. CVP 9-12. Amio ordered to attempt to control rate and rhythmn and just prior to receiving same pt's hr returned to 90's. Ca++=7.6, ionized calcium=1.10. No BM.GU: Foley, C/D/I, patent. IF SHE WILL STAY ON LACTACT NOW IS 1.6. RAPID AF SEEMED TORESOLVE ON OWN. AM cardiac enzymes WNL. no other active issues at this present time.gi:ogt in place and pt now started on tube fdgs of probalance at 10 cc's/hr. LAST ABG C/W A COMBINED METABOLIC ANDRESPIRATORY ACIDOSIS. abd soft and nontender with pos bowel sounds on auscultation. Pt in partially compensated metabolic acidosis. Pt stuperous at start of shift. | 21 | [
{
"category": "Radiology",
"chartdate": "2111-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 827216,
"text": " 1:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB - respir distress\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with COPD, lung ca s/p lobectomy, recent PNA\n REASON FOR THIS EXAMINATION:\n SOB - respir distress\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress. History of COPD and lung cancer status-post\n lobectomy. Recent pneumonia.\n\n FINDINGS: AP portable upright view. There are increased vascular markings and\n bilateral perihilar opacities consistent with pulmonary edema. The cardiac\n silhouette is partially obscured. The diaphragms are also obscured, consistent\n with pleural effusions bilaterally. The effusions are increased since the\n prior study. The superior mediastinum appears unremarkable. The visualized\n osseous structures are stable.\n\n IMPRESSION: Pulmonary edema and bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 827467,
"text": " 12:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax, worsening infiltrates\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with COPD, pneumonia, s/p intubation w/ new hypotension,\n hypoxia\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax, worsening infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Hypoxia.\n\n An endotracheal tube is in satisfactory position as well as a central venous\n catheter. A nasogastric tube is in place and courses below the diaphragm.\n Cardiac silhouette is upper limits of normal in size and stable. There\n remains vascular engorgement and perihilar haziness. Confluent areas of\n alveolar opacification have changed in distribution in the interval, and are\n now worse in the left perihilar region that the right. Moderate right and\n small left pleural effusions are unchanged. Note is made of underlying\n emphysema within the upper lobes.\n\n IMPRESSION: Change in distribution of bilateral alveolar pattern, now worse\n in the left perihilar region and somewhat improved in the right lung. Such a\n rapid shift in distribution favors pulmonary edema, but developing pneumonia\n or aspiration event in the left lung cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 827220,
"text": " 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: look for pneumothorax\n Admitting Diagnosis: SEPSIS,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with COPD, pneumonia, s/p intubation w/ ? deep sulcus L\n REASON FOR THIS EXAMINATION:\n look for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: COPD AND chf, post-intubation. Assess ET tube.\n\n PORTABLE SUPINE FRONTAL RADIOGRAPH: Comparison is made to study of one hour\n prior. There has been interval intubation with ET tube terminating several cm\n above the carina in satisfactory position. There has also been placement of\n a central venous catheter terminating in mid-SVC. No pneumothorax is\n identified on this supine film. There is persistent congestive heart failure.\n Cardiac and mediastinal contours are unchanged.\n\n IMPRESSION; Placement of ET tube and right IJ central venous catheter in\n satisfactory position. No ptx on this supine radiograph identified.\n Persistent chf.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 827218,
"text": " 1:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation/central line\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with COPD, lung ca s/p lobectomy, recent PNA\n\n REASON FOR THIS EXAMINATION:\n s/p intubation/central line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess line placement.\n\n PORTABLE SUPINE FRONTAL CHEST: Comparison made to studies of one and two\n hours prior.\n\n Allowing for technique, there has been interval worsening of chf with\n increased interstitial markings in both apices consistent with worsening CHF.\n Lines and tubes are unchanged.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2111-06-18 00:00:00.000",
"description": "Report",
"row_id": 139296,
"text": "Atrial fibrillation with an average ventricular response, rate 104. Since the\nprevious tracing of the ventricular response rate has slowed somewhat.\nDeeper T wave inversions are seen again in leads I, II, aVF and across the\nlateral precordium.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2111-06-18 00:00:00.000",
"description": "Report",
"row_id": 139297,
"text": "Atrial fibrillation with an average ventricular response, 151. Since the\nprevious tracing of atrial fibrillation is now present. The T wave\ninversions previously noted are less impressive.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2111-06-20 00:00:00.000",
"description": "Report",
"row_id": 139293,
"text": "Supraventricular tachycardia\nLow QRS voltages in limb leads\nNonspecific ST-T wave changes\nSince previous tracing, supraventricular tachycardia is new\n\n"
},
{
"category": "ECG",
"chartdate": "2111-06-20 00:00:00.000",
"description": "Report",
"row_id": 139294,
"text": "Sinus tachycardia\nLow QRS voltages in limb leads\nNonspecific ST-T wave changes\nSince previous tracing, atrial fibrillation is gone\n\n"
},
{
"category": "ECG",
"chartdate": "2111-06-19 00:00:00.000",
"description": "Report",
"row_id": 139295,
"text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing of the rate is increased. Previously described abnormalities\npersist.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-18 00:00:00.000",
"description": "Report",
"row_id": 1378028,
"text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented..slowly decreasing fio2 and increased ventilation to correct initial acidosis..see care view labs..occassional spont rr.. Sats 90-95%. Suctioned for small amt thick brownish sputum..sent for culture. To continue to wean fio2 as po2 tolerates..\n Cardiac: Most of day in af..80-120's..occassional pvc..by 1600 converted to nsr spontaneously. rate 80's..still with pvc\nBP low 70's to 110/..requireing levo for support. Needed to titrate up as high as .05mic/kg/min..to keep map ^60. Has recieved 3500cc ns in fluid boluses to support bp and u/o. CVP 11-13..unchanged despite fluid. U/O poor..7-15cc/hr. Lytes/culture sent.\n ID: DC'd sepsis protocol..afebrile..lactate down to 1.6..multilple antibiotics..\n Endo: Following bs q4-6hrs.. SSRI\n Neuro: Post intubation..pt unarousable..by late am..able to open eyes to name..nod appropriately to yes/no questions. c/o back pain..given 25mic of fent with relief..hands restrainded for saftey..\nDr and Dr spoke with pt about aggressiveness of care..she indicated that she wants to be intubated at this time and to continue with treatment.\n Social: Pt husband is deceased..has nephew and wife..he is the spokesperson..#on black book..met with Dr ..updated on pts condition..is going to get intouch with other neice/nephews..\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-19 00:00:00.000",
"description": "Report",
"row_id": 1378029,
"text": "RESP CARE: Pt remains intubated on vent. No vent changes this shift. RSBI-114. Pt sxd copious amounts thick secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-19 00:00:00.000",
"description": "Report",
"row_id": 1378030,
"text": "NPN SHIFT 1900-0700:\n\nNEURO: Pt intermittently dozing sec to PRN versed and fentanyl. Easily arousable to verbal or tactile stimulus. Pt OX3, able to communicate aphonically. Appropiate, calm, understands dx, treatment. Occasional pain to intubation site relieved w/ fentanyl. PERRLA, 4 brisk. MAE, generalized wekaness.\n\nRESP: OETT, marked at 20cm at lip, repositioned, tape changed. No chnaged in settings. CMV/20/.50/450/8. AM ABG unchanged WNL, 7.34/44/64/-. Lactate level =1.0. O2 sat 92-98%. Suctioned frequently copious, thick, tan secretions. B/L BS clear to auscultation. Wet, prod cough.\n\nCV: NSR, occasional multifocal PVC's. Inverted T-waves. Weaned levo to off since . MAP >65. CVP 9-12. Anasarca, pitting. +PP. AM K+=3.3, Mg+=1.7, Ca++=6.5. Repleted w/ KCL 40meq IV, Mag 3gm IV, Calcium 2gm IV.\n\nHEM: HCT 28.5 from 36. As per HO possibly dilutional. Will monitor. Pt w/ ecchymosis to LLE, hip sec to fall at rehab. No progression noted. HO aware.\n\nID: WBC 21.8, up from 12. afebrile. on abx.\n\nGI: Abd soft, +BSX4, no BM. NPO, OGT in place, patent.\n\nGU: Foley C/D/I. Urine concentrated, yellow, cloudy, <30cc/hr. HO aware. BUN 28, Cr 0.8, HCT 21; indicates pt dehydrated. NS bolus tot 2.5 liters for shift without results. No more boluses as MD to prevent failure/pulmonary edema. This AM labs: BUN 29, Cr 1.0, HCO3= 22. No additional boluses unless hemodynamics unstable.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-19 00:00:00.000",
"description": "Report",
"row_id": 1378031,
"text": "altered resp status\nd: pt intubated but mouthing words and appears alert and oriented. able to follow simple commands appropriately. mae's. as the day has progressed pt has required more pain med for c/o back ache and versed for restlessness. this afternoon pt does open eyes to tactile and verbal stimulation. will continue to offer pain meds and sedate pt as needed while she is intubated.\n\nresp: orally intubated and at 0830 o2 sats down to 84%. sutioned after lavaging for mod amts of thick tan sputum.recruitment breath and vent changes made. on 60%/350/ac 28 with 10 peep abg=7.23/52/70/23/-6. so present vent settings=60%/380/ac 32 with 10 peep and o2 sats have been 90-93%. diminished bs to l lung and coarse bs to r lung with diminshed bs at the base. suctioned ett for thick tan sputum. pt presently about 10 l pos fluid balance. continue to follow abg's as ordered and follow resp status.\n\ncv: electrolytes repleted on previous shift. will follow electrolytes as ordered and replete as needed. hemodynamically stable. hr 90-100's and sbp 90-136. goal is to keep map>60. no other active issues at this present time.\n\ngi:ogt in place and pt now started on tube fdgs of probalance at 10 cc's/hr. her goal rate is 50cc's/hr. continue to check residuals and hold for residuals > 150cc's. abd soft and nontender with pos bowel sounds on auscultation. hct stable at 28.5.\n\ngu: uo poor tday and has only put out 700cc's of urine this ahift.? atn. pt medicated with a total of 30 mg ivp lasix with poor effect. will hold off witf fluid boluses for now since she is pos by approx 10 l and now has 3+ edema to her 4 extremities. follw bun and creat on daily basis.\n\nid: max tmep=98.8 and wbc elevated at 12.8. vanco level this am =22.8 and so vancomycin does held today and will dose on daily basis depending on her random vanco level. continues on ceftazidine.\n\nsocail: pt is dnr but would use pressors for bp support. pt's niec and nephew have called today and have been updated. will continue to keep them well informed on daily basis and will offfer emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-18 00:00:00.000",
"description": "Report",
"row_id": 1378027,
"text": "ADMIT NOTE\n72 Y/O FEMALE ADMITTED THIS AM FROM ER, SHE WAS BROUGHT INTO THE ER FROM YOUVILL WITH DIFFICULTY BREATHING AND SOB, WAS INTUBATED IN THE ER, LACTACT 2.1 ON ADMISSION, WAS PLACED ON SEPSIS PROTOCOL, ? IF SHE WILL STAY ON LACTACT NOW IS 1.6. SEE FHP FOR PAST MEDICAL HISTORY, PT IS ON LEVOPHED .03MCG/KG/MIN BP IS 86/50'S MAP 65. SEE FLOW SHEET FOR VENT SETTINGS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-20 00:00:00.000",
"description": "Report",
"row_id": 1378038,
"text": "NURSING NOTE :\n\nPt deceased at . Pt comfortable and surrounded by family. Other family members updated by family and HO. Pt's prognosis was terminal despite maximal medical interventions. Pt very involved in care and updated by Ho throughout the day. Pt was DNR; family proxy verbalized there was to be no escalation in care accordinmg to the wishes of the patient and requested to made pt comfortable. Religious services was offered and declined. Pt stuperous at start of shift. Pt given fentanyl and versed prior for comfort. Pt displaying no s/s of pain nor distress. Remained on supportive measures till end and passed away on her own. Provided emotional support to family. Information given to family about transfer of body to morgue. Pt's family will make funeral arrangements.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-20 00:00:00.000",
"description": "Report",
"row_id": 1378036,
"text": "Nursing Progress Note: 7am-\n\nNeuro: Patient awake and nodding head and obeying commands this am. As day progressed patient has become more lethargic, not obeying commands now. Has received sedation throughout the day, boluses of Fent and Versed. Appears comfortable at time of writing.\n\nCV: Labile. HR at 950 145 with bp 68/45. Sat had also been dropping to 88 prior to this event. abg acidotic, 1L D5W with 150MEQNAHCO3 bolus given. Bp stable following same map >60 but hr remained tachy 140's. EkG on patient at time of tachy episode: ?Af. Dilt 10mg iv given x2 with moderate shortlived effect. Levo started at 1100 and has remained on throughout the day. At .3mcg.kg/min most of the pm but just increased same to .4 recently. Amio ordered to attempt to control rate and rhythmn and just prior to receiving same pt's hr returned to 90's. Amio held. Dopa started at 1700 to aid bp, tol same did not have rebound tachy with same. PH 7.06 on latest abg, 2 more amps NAHCO3 given. Following same , pt's HR 150-160, Dopa shut off. No intervention taken with tachy, hr gradually decreased back to 90's currentlyNSR. CVP 9-15.\n\nResp: Vent settings: AC36/380 P10 Fio2 100%. Desaturated this am to 88 when turned on her rt side. Increased to 70% transiently but then placed on 100% when hypotensive and tachycardial.\nWill continue note.\n\n RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-20 00:00:00.000",
"description": "Report",
"row_id": 1378037,
"text": "Nursing Progress Note (Contd):\n\nNeuro: Patient became extremely agitated , flung her rt arm into me, appeared very distressed. Patient repositioned and Versed 1mg iv given. Shortly after same, bp dropped dramatically with map's mid 40's. MD's aware. Md's agree patient needs to be kept comfortable and are calling the family to update them re patient's distress. Pressors maxed: Levo at .5mcg/kg/min. Dopa at 5mcg/kg/min. Appears to be slowly pulling up her bp map's 55's now.\n\nResp: Moderate amounts of creamy secretions . Sxnd q3/hr. Remains with mixed acidosis, poor oxygenation. Vent settings almost maxed. Patient did not tolerate attempt to increase PEEP from 10 to 12, sats dropped with same. CXR taken this am.\n\nGI: ABd, flat, soft. Hypoactive BS. TF ProBalance at 50 goal.\n\nGU: Anuric.\n\nID: Bld cx's x2 sent. Ceftaz and Gent dc'ed. Piperacillin and Vanco ordered according to sensitivities. Await same from pharmacy.\n\nEndo: Started on insulin drip at 1300, currently at 8.5u/hr.\n\nSocial: Family are away camping this weekend, but were contact by cell phone. Aware of situation and deterioration.\n\n GrathRN\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-19 00:00:00.000",
"description": "Report",
"row_id": 1378032,
"text": "RESPIRATORY CARE: PT. W/ 7.0 ORAL ETT IN PLACE.\nCURRENTLY ON AC MODE 32/380/.60/10. ABG PENDING.\nWORSENING OXYGENATION TODAY DESPITE SX/LAVAGE/\nMORE PEEP/RECRUITMENT MANEUVER. SX. FOR TAN SPUTUM.\nUO MINIMAL. LAST ABG C/W A COMBINED METABOLIC AND\nRESPIRATORY ACIDOSIS. C/W VENTILATORY SUPPORT.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-20 00:00:00.000",
"description": "Report",
"row_id": 1378033,
"text": "Resp Care,\nPt. remains intubated on A/C overnoc. No vent changes this shift. Albuterol/Atrovent MDI's added. See carevue for ABG's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-20 00:00:00.000",
"description": "Report",
"row_id": 1378034,
"text": "NPN SHIFT 1900-0700:\n\nNEURO: A&OX3. Frequent periods of anxiety, pain relieved w/ PRN fentanyl/versed. Pt aphonic, able to communicate approp. HO aware, no con't sedation for risk of hypotension. PERRLA, 4 brisk. MAE, generalized weakness.\n\nRESP: OETT, 7fr, 20 at lip. AC/32/60%/380/10. O2 sat 85-96%, desaturates when agitated. PMHX RU lobectomy. B/L BS clear, diminished R base. Wet, prod cough. Suctioned Q2hr mod-copious thick, tan sputum. 2300 ABG done, settings unchanged. AM ABG: 7.26/46/64/-. Serum HCO3=20. Pt in partially compensated metabolic acidosis. HO made aware, verbalized no changes to be implemented till rounds.\n\nCV: NSR-ST. Occasional PVC's, PAC's. Occasional atrial bigeminy and 8 beat run of PAC's at 2200. No change in BP noted. Pt verbalized no c/o chest pain. HO made aware. Lytes WNL. PR: 0.20 QRS: 0.06 QT: 0.28. AM cardiac enzymes WNL. Anasarca, pitting, third spacing, weeping. CVP=. AM K+, Mg+ WNL. Ca++=7.6, ionized calcium=1.10. Repleted w/ Calcium 2gm IV. +PP. HCT 31.2, up from 28.5. HCO3=20; intrasvascularly dry. +10L so far. Wt up 5 kg.\n\nID: afebrile. WBC 44.4, up from 24. Lactic acid 3.1, up from 1.1. on IV abx.\n\nGI: Abd soft, +BS X4. OGT in place, TF at target 50cc/hr. Tol well, no residuals, no s/s of aspiration. No BM.\n\nGU: Foley, C/D/I, patent. Urine <15cc/hr, concentrated, sediment. HO aware. Pt in acute renal failure, Cr 1.6, up from 1.0. BUN=44.Does not respond to lasix or boluses.\n\nSTATUS: DNR, +pressors, no CPR, no prolonged intubation.\n\nPLAN: Balloon studies. Possible implementation of sepsis protocol. family meeting to be scheduled for plan of care.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-20 00:00:00.000",
"description": "Report",
"row_id": 1378035,
"text": "RESPIRATORY CARE SERVICE: PT. W/ 7.0 ORAL ETT IN PLACE.\nREMAINS ON AC MODE 32/380/1.0/10. ABG C/W A COMBINED\nMETABOLIC-RESPIRATORY ACIDOSIS AND POOR TO MARGINAL\nOXYGENATION. PLATEAU P MARGINAL AT 28-30 CM H2O BUT\nONLY MINIMAL AUTOPEEP OF CM H2O DESPITE HIGH RR.\nUO MINIMAL THIS SHIFT. HYPOTENSION W/ ATRIAL\nFIBRILLATION TODAY REQUIRING LEVOPHED. RAPID AF SEEMED TO\nRESOLVE ON OWN. WBC 44.4. PNEUMONIA INVOLVING BOTH LUNGS\nR>L. PMH LUL WEDGE RESECTION. SX. FOR TAN SPUTUM. ALBUTEROL\nAND ATROVENT MDI'S GIVEN. C/W VENTILATORY SUPPORT. ATTEMPT\nTO WEAN FIO2 BACK TO .60 AS TOLERATED. NOT MUCH ROOM LEFT\nTO INCREASE PEEP/RR/OR TIDAL VOLUME. DO BETTER IN TERMS\nOF GAS EXCHANGE POSITIONED ON LEFT SIDE OR BETTER LUNG DOWN.\n\n , RRT\n\n"
}
] |
12,347 | 156,595 | The patient was initially admitted to the Coronary Care Unit Service after cardiac catheterization. Cardiac catheterization showed a proximal 100% left anterior descending coronary artery lesion, left circumflex was 70% proximal 100% mid occlusions, right coronary artery with 100% proximal and patent saphenous vein graft to obtuse marginal grafts, 70% left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to ramus and posterior descending coronary artery totally occluded. An left ventriculogram showed an EF of approximately 40%. Her right sided filling pressures were markedly elevated with a right atrial pressure of 97/20, right ventricular 98/10, pulmonary capillary wedge pressure of 32 and 45 mm peak to peak pressure. Her aortic valve area was measured as .55 cm square. She was subsequently given 120 cc of intravenous Lasix in the catheterization laboratory and received a total of 276 cc of contrast during this cardiac catheterization. Given these catheterization results it was decided that the patient may benefit from an aortic valve replacement with an accompanying coronary artery bypass graft. As such Dr. of CT Surgery was consulted. Within 24 hours of cardiac catheterization the patient's creatinine began to rise and urine output fall. Her creatinine peaked on at 4.6 and she was evaluated by the renal team. It was believed that her acute renal failure was secondary to contrast nephropathy on top of a chronic renal insufficiency caused by her diabetes and hypertension. By the time of discharge her renal failure was resolving with her creatinine falling to 3.3 and continuing to trend down. As part of her surgical evaluation a copy of her CT scan from the outside hospital was obtained, which showed 1 to 2 cm hilar and peritracheal adenopathy. This scan was reviewed with the Pulmonary Service who performed lymph node biopsy and bronchoscopy. This biopsy did not reveal any malignant cells and instead showed a hypocellular specimen with a few group of bronchial cells, pulmonary macrophages, lymphocytes, red blood cells and neutrophils. The pulmonary team recommended that she have a repeat CT scan in approximately eight weeks time to examine for any changes in her lymphadenopathy. The patient also has a known anemia, which may be secondary to her chronic renal insufficiency and required transfusion of 2 units of packed red blood cells during this hospitalization. After transfusion her hematocrit was stable and was approximately 28 at the time of discharge. Given the problems listed above full surgical evaluation was deferred until her renal function returns to baseline and her pulmonary process is completely worked up as described. The patient will follow up with Dr. on Tuesday . At that time it is expected that after checking a repeat chem 7 and her renal function that a number of her medications that were held secondary to her renal failure will be able to be reinstituted. These medications include her ace inhibitor, Digoxin and diuretic. The patient will also follow up with her primary care physician . within the next few weeks. After her repeat CT scan she will again be evaluated at her cardiologist's discretion for possible AVR and coronary artery bypass graft. | AWARE, PT 40MG OF IV LASIX.HCT 26 DR. PT 40MG OF IV LASIX LAST NOC. AWARE, PT 40MG OF IVP LASIX AT 1330, AWAIT DIURESIS. PA PRESSURES 80-90/25-30. CO 5.4 CI 3.12. Normal sinus rhythmAnterior myocardial infarction- age indeterminateleft ventricular hypertrophyConsider inferior myocardial infarctionNondiagnostic ST-T changesNo previous report available for comparison PAS 79-91 PAD 25-28 WEDGE 22 DR. , DR. PCWP 32.+ AS 45MMHG PEAK TO PEAK. KCL 40 MEQ PO X1 FOR K 3.6. RIGHT GRION SWAN/CORDIS D/C'D BY DR. . RT FEMORAL PA LINE, PULSES GOOD. PT TRANSFERRED TO ON FOR CARDIAC CATH SHOWED:100% LAD, LCX 70% PROX, 100% MID, RCA 100% PROX: PATENT SVG OM, 70% LIMA TO LAD PATENT BUT 70% STENOSIS, SVG TO RAMUS AND SVG TO PDA OCCULDED. HR SB, LOPRESSOR HELD. AT 1500 IF URINE OUTPUT NOT 100CC, PT TO 80MG OF IV LASIX PER DR. , PT 80MG OF IV LASIX AWAIT DIUREISIS. RESP: PT ON 4LNP 02SAT 93-95%, 02SAT GOES DOWN TO 84% ON RA DR. . MG 1.5 2GM OF MG SULFATE. transfer note: PT IS 67YR. PA NUMBERS TODAY 79-84, PAD 25-28 WEDGE 22 THIS MORNING. K 3.9 40MEQ KCL, K TO BE CHECKED AT , GLUCOSE 236 2UNITS OF REGULAR PER SLIDING SCALE. LV GRAM 40%. Sinus bradycardia - first degree A-V blockLeft axis deviationProbable inferior infarct - age undeterminedAnterolateral myocardial infarct, age indeterminateleft ventricular hypertrophySince previous tracing, no significant change CARDS: PT IN SB, PO LOPRESSOR HELD THIS MORNING SECONDARY TO HR IN 50'S, DR. ON NTG DRIP AT 33 MCG/MIN FOR 2 HRS, THEN D/C'D. GU: URINEOUPUT FOR 1300 ONLY 25CC, DR. FOCUS: CARDIACDATA: VSS. RIGHT SIDED FILLING PRESSURES ELEVATED. PT IS BEING TO 3. PT 120MG OF IV LASIX DOWN CATH TRANSFERRED TO NSICU FROM CATH LAB FOR HEMODYNAMIC MONITORING. LASIX 40 IV X 1 WITH GOOD RESPONSE, BUT PAS REMAINS QUITE ELEVATED. OLD FEMALE WITH PMH CAD, CABG , CHF, AS,HTN, HYPOTHRIOD, INCREASE CHOL, TYPE II DM INSULIN DEPENDANT. LUNGS PT WITH CRACKLES ON RIGHT BASE,OTHERWISE CLEAR. BP HAS BEEN 125-130/50. GI: PT TOLERATING REGULAR DIET. RIGHT FEMEROL SWAN D/C'D TODAY.NUERO: PT ALERT AND ORIENTED X3, PLEASANT, PT DENIES ANY C/O PAIN.PT FOLLOWING COMMANDS. AWARE OF PT CHF STATUS. AWARE, PT TO ONE UNIT OF BLOOD ON FLOOR PER DR. AND DR. PT TO 120MG OF IV LASIX PRIOR TO BLOOD TRANSFUSION, DR. AND DR. ADD. ETIOLOGY , ADMITTED TO HOSPITAL ON WITH INCREASE LEG EDEMA. PT DENIED CP AT TIME,PT WAS TX WITH IV BUMEX, NORVASC, DIG. MEDIASINAL LAD ? GROINS OK. SLEPT WELL. | 5 | [
{
"category": "ECG",
"chartdate": "2111-02-11 00:00:00.000",
"description": "Report",
"row_id": 176129,
"text": "Sinus bradycardia\n - first degree A-V block\nLeft axis deviation\nProbable inferior infarct - age undetermined\nAnterolateral myocardial infarct, age indeterminate\nleft ventricular hypertrophy\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2111-02-06 00:00:00.000",
"description": "Report",
"row_id": 176130,
"text": "Normal sinus rhythm\nAnterior myocardial infarction- age indeterminate\nleft ventricular hypertrophy\nConsider inferior myocardial infarction\nNondiagnostic ST-T changes\nNo previous report available for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-07 00:00:00.000",
"description": "Report",
"row_id": 1423972,
"text": "FOCUS: CARDIAC\nDATA: VSS. HR SB, LOPRESSOR HELD. PA PRESSURES 80-90/25-30. ON NTG DRIP AT 33 MCG/MIN FOR 2 HRS, THEN D/C'D. LASIX 40 IV X 1 WITH GOOD RESPONSE, BUT PAS REMAINS QUITE ELEVATED. KCL 40 MEQ PO X1 FOR K 3.6. RT FEMORAL PA LINE, PULSES GOOD. GROINS OK. SLEPT WELL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-07 00:00:00.000",
"description": "Report",
"row_id": 1423973,
"text": "transfer note:\n\n PT IS 67YR. OLD FEMALE WITH PMH CAD, CABG , CHF, AS,HTN, HYPOTHRIOD, INCREASE CHOL, TYPE II DM INSULIN DEPENDANT. MEDIASINAL LAD ? ETIOLOGY , ADMITTED TO HOSPITAL ON WITH INCREASE LEG EDEMA. PT DENIED CP AT TIME,PT WAS TX WITH IV BUMEX, NORVASC, DIG. PT TRANSFERRED TO ON FOR CARDIAC CATH SHOWED:\n100% LAD, LCX 70% PROX, 100% MID, RCA 100% PROX: PATENT SVG OM, 70% LIMA TO LAD PATENT BUT 70% STENOSIS, SVG TO RAMUS AND SVG TO PDA OCCULDED. LV GRAM 40%. RIGHT SIDED FILLING PRESSURES ELEVATED. PCWP 32.+ AS 45MMHG PEAK TO PEAK. PT 120MG OF IV LASIX DOWN CATH TRANSFERRED TO NSICU FROM CATH LAB FOR HEMODYNAMIC MONITORING. PT 40MG OF IV LASIX LAST NOC. PA NUMBERS TODAY 79-84, PAD 25-28 WEDGE 22 THIS MORNING. CO 5.4 CI 3.12. RIGHT FEMEROL SWAN D/C'D TODAY.\nNUERO: PT ALERT AND ORIENTED X3, PLEASANT, PT DENIES ANY C/O PAIN.PT FOLLOWING COMMANDS. RESP: PT ON 4LNP 02SAT 93-95%, 02SAT GOES DOWN TO 84% ON RA DR. . LUNGS PT WITH CRACKLES ON RIGHT BASE,OTHERWISE CLEAR. CARDS: PT IN SB, PO LOPRESSOR HELD THIS MORNING SECONDARY TO HR IN 50'S, DR. AWARE. BP HAS BEEN 125-130/50. PAS 79-91 PAD 25-28 WEDGE 22 DR. , DR. AWARE, PT 40MG OF IVP LASIX AT 1330, AWAIT DIURESIS. RIGHT GRION SWAN/CORDIS D/C'D BY DR. . GI: PT TOLERATING REGULAR DIET. GU: URINEOUPUT FOR 1300 ONLY 25CC, DR. AWARE, PT 40MG OF IV LASIX.HCT 26 DR. AWARE, PT TO ONE UNIT OF BLOOD ON FLOOR PER DR. AND DR. PT TO 120MG OF IV LASIX PRIOR TO BLOOD TRANSFUSION, DR. AND DR. AWARE OF PT CHF STATUS. K 3.9 40MEQ KCL, K TO BE CHECKED AT , GLUCOSE 236 2UNITS OF REGULAR PER SLIDING SCALE. MG 1.5 2GM OF MG SULFATE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-02-07 00:00:00.000",
"description": "Report",
"row_id": 1423974,
"text": "ADD. AT 1500 IF URINE OUTPUT NOT 100CC, PT TO 80MG OF IV LASIX PER DR. , PT 80MG OF IV LASIX AWAIT DIUREISIS. PT IS BEING TO 3.\n"
}
] |
11,961 | 136,082 | # Hypotension: Resolved with IV hydration. Given the patient's history, was likely due to overmedication with with sublingual nitroglycerin. BP was normal on the floor and gradually metoprolol and were introduced at lower doses, with good response. Isordil was not started given the recent hypotensive episode. This can be restarted in clinic if the patient can tolerate it. No further chest pain occured in the hospital and no cardiac enzyme changes or ECG changes were noted. A work-up for infection related sepsis was also done - except for UTI no clear source of infection found. Blood cultures were negative at discharge. | SINGLE AP UPRIGHT PORTABLE CHEST: Compared to PA and lateral chest of and chest CTA of the same day. Low QRS voltage in the precordial leads.Compared to the previous tracing of atrially paced rhythm has changedto atrial fibrillation. LS CLEAR AND DIMINISHED AT THE BASES.NO SOB OR ANY BREATHING DIFFICULTIES.CVS: IN NSR, HR 60-70/MIN. IMPRESSION: 1) Stable cardiomegaly without evidence of overt congestive heart failure. DENIES ANY PAIN.RESP: O2 2L/MIN VIA NC AND O2 SATS 95-98%. There may be upper zone redistribution, which is unchanged from multiple prior radiographs. There remains a subtle ill-defined opacity in the right mid lung zone, which is better seen on the prior chest CT. A& RN report though pt's dgt not present upon arrival. 2) Subtle right mid lung zone opacity, better seen on the chest CTA of . Left-sided axillary ICD with its leads unchanged in position and intact. The subtler tree-in- opacity is seen on the prior chest CTA are not appreciable on the current radiograph. NO C/O CP ALL THROUGHT NIGHT.SBP 100-120MMHG AND NO FLUID BOLOUS INDICATED THIS SHIFT.GU/GI: ABD SOFT, BS PRESENT, ON REGULAR DIET. TOOK MEDICATION SIMILAR TO SL NTG(RUSSIAN MED) AND WAS CP FREE.PATIENT TOOK DOUBLE DOSE OF COZAAR, IN ED BP WAS IN 70'S, AND ^SED TO 80'S AFTER 750CC OF FLUID BOLOUS.NEURO: RUSSIAN SPEAKING, PER DAUGHTER ALERT, ORIENTED X3 AND FOLLOWING COMMANDS. WAS IN A FIB CURRENTLY CONTROLED AND WAS ON COUMADIN, INR 5.2. Heart remains mildly enlarged. URINE VIA FOLEY'S CATHAND PASSING 30-100 ML/HR.AFEBRILE, NO ANTIBIOTICS.SKIN INTACT.ACCESS: PIV X2 ON RT HAND.ENDO: INSULIN ON SS.SOCIAL: VISITED BY DAUGHTER AND UPDATED BY MD.FULL CODEPLAN: CALL OUT TODAY, F/U CULTURE RESULTS, MONITOR FOR CP AND HYPOTESION. Diffuse ST-T waveabnormalities which are non-specific. BP 129/48 HR 70 SR. O2sats 98% on 2L N/C. NURSING NOTES 1900-0700 EDTREVIEW CAREVUE FOR ALL OBJECTIVE DATA YO F AMITTED YESTERDAY VIA ED WITH PMH PAF,CAD S/P MI, CHF40%, HTN,P/W CHEST PAIN AND HYPOTENSION. No specific evidence of congestive heart failure. Plan to monitor overnight. 12:45 PM CHEST (PORTABLE AP) Clip # Reason: R/o Pericardial Effusion/CHF MEDICAL CONDITION: year old woman with hypotension, SOB, fever REASON FOR THIS EXAMINATION: R/o Pericardial Effusion/CHF FINAL REPORT INDICATION: -year-old with hypoxia, fever, and hypotension. YO Russian speaking woman, with h/o AF,CAD, HTN,CHF,PM, admitted w/ hypotention and intermittent CP s/p double dose of Cozaar per her dgt. PACEMAKER IN PLACE. Clinical correlation is suggested. Atrial fibrillation with rapid ventricular response. No CP. MICU EAST ADMIT NOTE 1830-1900Please see admit/FHPA and flowsheet for further details. MAE WITH NO STRENGTH. Pt appears alert. | 4 | [
{
"category": "ECG",
"chartdate": "2153-11-19 00:00:00.000",
"description": "Report",
"row_id": 127528,
"text": "Atrial fibrillation with rapid ventricular response. Diffuse ST-T wave\nabnormalities which are non-specific. Low QRS voltage in the precordial leads.\nCompared to the previous tracing of atrially paced rhythm has changed\nto atrial fibrillation. Clinical correlation is suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-11-19 00:00:00.000",
"description": "Report",
"row_id": 1419234,
"text": "MICU EAST ADMIT NOTE 1830-1900\n\n\nPlease see admit/FHPA and flowsheet for further details.\n\n\n YO Russian speaking woman, with h/o AF,CAD, HTN,CHF,PM, admitted w/ hypotention and intermittent CP s/p double dose of Cozaar per her dgt. A& RN report though pt's dgt not present upon arrival. Pt appears alert. No CP. BP 129/48 HR 70 SR. O2sats 98% on 2L N/C. Plan to monitor overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-11-20 00:00:00.000",
"description": "Report",
"row_id": 1419235,
"text": "NURSING NOTES 1900-0700 EDT\nREVIEW CAREVUE FOR ALL OBJECTIVE DATA\n YO F AMITTED YESTERDAY VIA ED WITH PMH PAF,CAD S/P MI, CHF40%, HTN,P/W CHEST PAIN AND HYPOTENSION. AS PER PATIENTS REPORTS PATIENT HAD INTERMITTENT SSCP A/W BILATERAL FLANK PAIN THE NIGHT PRIOR TO PRESENTATION. TOOK MEDICATION SIMILAR TO SL NTG(RUSSIAN MED) AND WAS CP FREE.PATIENT TOOK DOUBLE DOSE OF COZAAR, IN ED BP WAS IN 70'S, AND ^SED TO 80'S AFTER 750CC OF FLUID BOLOUS.\n\nNEURO: RUSSIAN SPEAKING, PER DAUGHTER ALERT, ORIENTED X3 AND FOLLOWING COMMANDS. MAE WITH NO STRENGTH. DENIES ANY PAIN.\n\nRESP: O2 2L/MIN VIA NC AND O2 SATS 95-98%. LS CLEAR AND DIMINISHED AT THE BASES.NO SOB OR ANY BREATHING DIFFICULTIES.\n\nCVS: IN NSR, HR 60-70/MIN. WAS IN A FIB CURRENTLY CONTROLED AND WAS ON COUMADIN, INR 5.2. PACEMAKER IN PLACE. NO C/O CP ALL THROUGHT NIGHT.\nSBP 100-120MMHG AND NO FLUID BOLOUS INDICATED THIS SHIFT.\n\nGU/GI: ABD SOFT, BS PRESENT, ON REGULAR DIET. URINE VIA FOLEY'S CATHAND PASSING 30-100 ML/HR.\n\nAFEBRILE, NO ANTIBIOTICS.\nSKIN INTACT.\nACCESS: PIV X2 ON RT HAND.\nENDO: INSULIN ON SS.\nSOCIAL: VISITED BY DAUGHTER AND UPDATED BY MD.\nFULL CODE\nPLAN: CALL OUT TODAY, F/U CULTURE RESULTS, MONITOR FOR CP AND HYPOTESION.\n"
},
{
"category": "Radiology",
"chartdate": "2153-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930867,
"text": " 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/o Pericardial Effusion/CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with hypotension, SOB, fever\n\n REASON FOR THIS EXAMINATION:\n R/o Pericardial Effusion/CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old with hypoxia, fever, and hypotension.\n\n SINGLE AP UPRIGHT PORTABLE CHEST: Compared to PA and lateral chest of \n and chest CTA of the same day. Left-sided axillary ICD with its leads\n unchanged in position and intact. Heart remains mildly enlarged. No specific\n evidence of congestive heart failure. There remains a subtle ill-defined\n opacity in the right mid lung zone, which is better seen on the prior chest\n CT. The subtler tree-in- opacity is seen on the prior chest CTA are not\n appreciable on the current radiograph. There may be upper zone\n redistribution, which is unchanged from multiple prior radiographs.\n\n IMPRESSION:\n 1) Stable cardiomegaly without evidence of overt congestive heart failure.\n 2) Subtle right mid lung zone opacity, better seen on the chest CTA of\n .\n\n\n"
}
] |
53,086 | 143,522 | This is an 82 year old woman who had a recent endoscopic ultrasound (EUS) with FNA of a pancreatic mass with cytology that was positive for adenocarcinoma. She presented with continued abdominal pain, nausea, lightheartedness, and weakness. She had evidence of dehydration. The patient recieved IV hydration, adequate pain control with long/short acting medications, Zofran, and GI/hepatobiliary surgery consultation to discuss treatment options. She has microcytic anemia but no records regarding the etiology or previous colonoscopy. She has hypokalemia related to Lasix which can contribute to her weakness. For unknown reasons, she stopped Benicar but was continued Lasix. Her elevated Lipase and Amylase levels are related to the pancreatic mass without evidence of pancreatitis. Ms. was admitted to on after fall on 11 resulting in intraparenchymal and subdural hemorrhages. Patient requireed frequent neurologic assessment and close mental status evaluation. She denied any LOC before or after incident or dizziness/lightheadedness on standing. Patient was also on multiple psychiatric medications and narcotics, which surely altered her mental status. Ms. is usure of exactly what precipitated fall, but believes that she simply slipped in front of her roommate's bed as they were talking. She was transferred to the ICU for Q1hr neuro checks, and her neuro exam remained stable. A repeat Head CT in the AM did not show significant progression of bleed. Heparin was held, and she was loaded with fosphenytoin then maintained with phenytoin tid. Dilantin levels were checked. She was evaluated frequently for change in mental status. Sedating or altering drugs were minimized. She was evaluated by neurosurgery, who felt that her head CT and neuro exam remained stable; they recommended maintenance on dilantin until f/u with them in one month. She will need repeat head CT at that time. She was transferred to transplant surgery on for further work-up of her pancreatic adenocarcinoma. On further study of her CT scan it was decided that Ms. was not an operative candidate. Patient was seen by hematology/oncology and advised to follow-up with them in clinic for further treatment. She will also follow-up with as an outpatient for change of her stent to a metal stent. She was discharged home on into the care of her daughter. 24 hour care was suggested as a precaution as Ms. still has some residual unsteadiness following her fall. | Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Pt was transferred to for q 1 hr neuro checks.being followed by neurosurgery. --Appreciate neurosurgery recommendations --Transfer to ICU for Q1hr neuro checks --CT in AM or earlier if neuro exam changes --Hold Heparin SC --Fosphenytoin 20mg/kg IV load, and Phenytoin 100 TID maintenance starting in morning --Dilantin levels QAM on and in AM --Minimize benzodiazipines, other sedating medications for now . Disposition: ICU for Q1 hour neurologic checks. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Intracranial Hemorrhage-Is likely mechanical fall in the setting of sedating medications -Will continue to monitor neuro exam closely -Will check follow up coagulation studies -Will minimize pain medications and optimize fall risk minimization -Dilantin to continuewill follow levels -Repeat CT scan performed this morning and will confirm final there to aid in guide for management PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN) CANCER (MALIGNANT NEOPLASM), PANCREAS SUBDURAL HEMORRHAGE (SDH) INTRACEREBRAL HEMORRHAGE (ICH) ANXIETY ICU Care Nutrition: NPO Glycemic Control: Lines / Intubation: 20 Gauge - 01:30 AM Comments: Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: Transfer to floor with neurosurgery comfortable with stability over time Total time spent: 34 minutes Action: Checked neuro vs q 1 hr. Action: Checked neuro vs q 1 hr. Action: Checked neuro vs q 1 hr. Action: Checked neuro vs q 1 hr. Action: Checked neuro vs q 1 hr. Action: Checked neuro vs q 1 hr. ADENOCARCINOMA: Patient with planed surgery on for GI malignancy. She was seen by neurosurgy who recommended conservative treatment with fosphenytoin load and phenytoin for maintenance. Glycemic Control: Lines: 20 Gauge - 01:30 AM Prophylaxis: DVT: Pneumobots Stress ulcer: Lansoprazole VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU for now Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Fell today & developed bilateral parasagital subdural hematomas. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. Transferred to ICU for q 1 hr neuro vs checks. PATIENT/TEST INFORMATION:Indication: LV/RV FXN, Pre-opHeight: (in) 65Weight (lb): 157BSA (m2): 1.79 m2BP (mm Hg): 124/99HR (bpm): 94Status: OutpatientDate/Time: at 15:27Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. To be done when patient has been transferred to No contraindications for IV contrast PFI REPORT 1. Subdural hemorrhage (SDH) Assessment: Neuro vss. Subdural hemorrhage (SDH) Assessment: Neuro vss. There is diffuse osteopenia. There is diffuse osteopenia. Hiatal hernia. Hiatal hernia. Action: Repeat head ct done this am. Action: Repeat head ct done this am. Action: Repeat head ct done this am. FINDINGS: There is unchanged appearance of the anterior falcine, more to the left side, and bilateral frontal acute subdural hemorrhages with blood seen tracking down the falx posteriorly. There is mildpulmonary artery systolic hypertension. Action: Checked neuro vs q 1 hr. Action: Checked neuro vs q 1 hr. Again seen is hypoattenuation of the periventricular white matter consistent with small-vessel ischemic disease. PLEASE DO arterial, venous and Admitting Diagnosis: ABDOMINAL PAIN Field of view: 39.6 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) IMPRESSION: 1. Splenomegaly and the spleen demonstrates a hypoattenuating band in the superior pole which could represent infarct, but is otherwise unremarkable. This mass narrows the SMA in its most proximal course without occluding, invading it and likely reflects a conglomerate adenopathy in the setting of malignancy. IMPRESSION: Multiple areas of acute subdural hemorrhage, as described above, without significant change. Pt was transferred to for q 1 hr neuro checks.being followed by neurosurgery. Pt was transferred to for q 1 hr neuro checks.being followed by neurosurgery. Pt was transferred to for q 1 hr neuro checks.being followed by neurosurgery. To be done when patient has been transferred to No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb WED 10:47 PM 1. | 24 | [
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715495,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro vss. Some difficulty remembering which hospital she was in ,\n after falling asleep & being woken up.\n Action:\n Checked neuro vs q 1 hr.\n Response:\n As above.\n Plan:\n MRI planned for today. Check list was faxed from 11R.\n Pain control (acute pain, chronic pain)\n Assessment:\n Had abdominal pain since mid . Being treated w/10mg oxycontin\n here w/oxycodone 5mg for breakthrough pain.\n Action:\n Oxycontin held this evening as were xanax 0.25mg & zyprexa 5mg po this\n evening, all per MICU resident.\n Response:\n Plan:\n Medicate w/oxycodone prn pain.\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715496,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro vss. Some difficulty remembering which hospital she was in ,\n after falling asleep & being woken up.\n Action:\n Checked neuro vs q 1 hr.\n Response:\n As above.\n Plan:\n Head CT w/o contrast planned for today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Had abdominal pain since mid . Being treated w/10mg oxycontin\n & oxycodone 5mg for breakthrough pain.\n Action:\n Oxycontin held this evening as were xanax 0.25mg & zyprexa 5mg po this\n evening, all per MICU resident so as not to cloud neuro presentation.\n Response:\n Plan:\n Medicate w/oxycodone prn pain.\n"
},
{
"category": "Physician ",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 715575,
"text": "Chief Complaint: Intracranial hemorrhage-SDH and intraparencymal\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with fall while ambulating in hospital room with CT scan\n showing multiple small foci of bleeding.\n She was then admitted to the ICU for closer monitoring and frequent\n neuro checks\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n Anxiety\n APPY and Tonsilectomy\n Non-contributory for falls or ICH\n Occupation: Ret'd\n Drugs: None\n Tobacco: None\n Alcohol: Social Only\n Other:\n Review of systems:\n Constitutional: Fatigue\n Gastrointestinal: Abdominal pain\n Pain: Mild\n Pain location: Headache\n Flowsheet Data as of 09:43 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 92 (83 - 96) bpm\n BP: 123/69(82) {95/48(59) - 137/81(94)} mmHg\n RR: 15 (13 - 19) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 2,905 mL\n 40 mL\n PO:\n 400 mL\n TF:\n IVF:\n 105 mL\n 40 mL\n Blood products:\n Total out:\n 700 mL\n 600 mL\n Urine:\n 200 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,205 mL\n -560 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Mild hematoma on head\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: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, bruises in area of\n previous injections\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person and place, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 182 K/uL\n 29.5 %\n 9.8 g/dL\n 112 mg/dL\n 0.5 mg/dL\n 11 mg/dL\n 25 mEq/L\n 110 mEq/L\n 3.2 mEq/L\n 144 mEq/L\n 5.0 K/uL\n [image002.jpg]\n 03:27 AM\n WBC\n 5.0\n Hct\n 29.5\n Plt\n 182\n Cr\n 0.5\n Glucose\n 112\n Other labs: PT / PTT / INR:1.3/23.7-PTT from \n Imaging: CT Scan-\n Assessment and Plan\n 82 yo female with new diagnosis of adenocarcinoma in region of pancreas\n which led to admission to hospital. Now patient to ICU with ICH\n following fall.\n Intracranial Hemorrhage-Is likely mechanical fall in the setting of\n sedating medications\n -Will continue to monitor neuro exam closely\n -Will check follow up coagulation studies\n -Will minimize pain medications and optimize fall risk minimization\n -Dilantin to continue\nwill follow levels\n -Repeat CT scan performed this morning and will confirm final \n there to aid in guide for management\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n CANCER (MALIGNANT NEOPLASM), PANCREAS\n SUBDURAL HEMORRHAGE (SDH)\n INTRACEREBRAL HEMORRHAGE (ICH)\n ANXIETY\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 01:30 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: Transfer to floor with neurosurgery comfortable with\n stability over time\n Total time spent: 34 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715491,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass nest to bile duct\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715545,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro vss. Some difficulty remembering which hospital she was in ,\n after falling asleep & being woken up, improved as night progressed\n into morning.\n Action:\n Checked neuro vs q 1 hr. Was NPO since Mn. Received 1580mg loading\n dose of phosphenytoin IV @ 2330.\n Response:\n As above.\n Plan:\n Head CT w/o contrast planned for today. Draw dilantin level before\n giving 0800 dose dilantin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Had abdominal pain since mid . Being treated w/10mg oxycontin\n & oxycodone 5mg for breakthrough pain.\n Action:\n Oxycontin held this evening as were xanax 0.25mg & zyprexa 5mg po this\n evening, all per MICU resident so as not to cloud neuro presentation.\n Response:\n Patient denied pain all night , & she was surprised to do so.\n Plan:\n Medicate w/Tylenol q 6 hrs (not prn).\n Cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Patient was scheduled for GI surgery on @ .\n Action:\n Kept NPO for possible procedure.\n Response:\n Plan is for eventual GI surgery.\n Plan:\n Once neuosurgically stable, to be transferred to \nmay be\n today.\n"
},
{
"category": "Physician ",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 715546,
"text": "Chief Complaint: Intracranial bleed\n 24 Hour Events:\n --Patient stabilized in with Q1 hour neuro checks\n --No focal changes on neuro exam\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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 90 (83 - 96) bpm\n BP: 117/59(73) {95/48(59) - 134/81(94)} mmHg\n RR: 15 (13 - 17) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 2,905 mL\n 64 mL\n PO:\n 400 mL\n TF:\n IVF:\n 105 mL\n 64 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,205 mL\n 64 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 182 K/uL\n 9.8 g/dL\n 112 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.2 mEq/L\n 11 mg/dL\n 110 mEq/L\n 144 mEq/L\n 29.5 %\n 5.0 K/uL\n [image002.jpg]\n 03:27 AM\n WBC\n 5.0\n Hct\n 29.5\n Plt\n 182\n Cr\n 0.5\n Glucose\n 112\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n CANCER (MALIGNANT NEOPLASM), PANCREAS\n SUBDURAL HEMORRHAGE (SDH)\n INTRACEREBRAL HEMORRHAGE (ICH)\n ANXIETY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:30 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": "2113-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 715548,
"text": "Chief Complaint: Intracranial bleed\n 24 Hour Events:\n --Patient stabilized in with Q1 hour neuro checks\n --No focal changes on neuro exam\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 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 90 (83 - 96) bpm\n BP: 117/59(73) {95/48(59) - 134/81(94)} mmHg\n RR: 15 (13 - 17) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 2,905 mL\n 64 mL\n PO:\n 400 mL\n TF:\n IVF:\n 105 mL\n 64 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,205 mL\n 64 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 182 K/uL\n 9.8 g/dL\n 112 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.2 mEq/L\n 11 mg/dL\n 110 mEq/L\n 144 mEq/L\n 29.5 %\n 5.0 K/uL\n [image002.jpg]\n 03:27 AM\n WBC\n 5.0\n Hct\n 29.5\n Plt\n 182\n Cr\n 0.5\n Glucose\n 112\n Assessment and Plan\n Assessment/Plan: This is an 82-year-old female with probable\n adenocarcinoma of pancreas, admitted to after fall on 11 \n resulting in intraparenchymal and subdural hemorrhages. Patient\n requires frequent neurologic assessment and close mental status\n evaluation.\n .\n HEAD TRAUMA: Patient with recent fall in hospital room after getting\n up from bed. She denies any LOC before or after incident or\n dizziness/lightheadedness on standing, but we must still be cognizant\n of physiologic reasons for fall (i.e. orthostatic hypotension,\n arrythmia, seizure\nthough unlikely). Patient is also on multiple\n psychiatric medications and narcotics, which surely alter her mental\n status. Ms. is usure of exactly what precipitated fall, but\n believes that she simply slipped in front of her roommate's bed as they\n were talking.\n --CT this morning to evaluate for interval change\n --Continue to hold heparin\n --Fosphenytoin 20mg/kg IV load last night, and Phenytoin 100 TID\n maintenance now\n --Dilantin levels QAM on and in AM\n --Minimize benzodiazipines, other sedating medications for now\n .\n ADENOCARCINOMA: Patient with planed surgery on for GI\n malignancy.\n --Touch base with West 1 Surgery\n --CT abdomen arterial, venous, and portal venous phases when stabilized\n --NPO for now\n --Treat pain, though hold narcotics tonight as not to cloud mental\n status.\n .\n ANXIETY/DEPRESSION: Patient with long-standing anxiety and depression,\n followed by outpatient PCP.\n Sertraline 50mg QD\n --Hold Xanax and Olanzapine for now, though be wary of benzo withdrawal\n .\n GERD/ABDOMINAL UPSET: Patient with abdominal pain, bloating for the\n past 3 months.\n --Continue lansoprazole, ondansteron, bisacodyl, and milk of magnesia\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines:\n 20 Gauge - 01:30 AM\n Prophylaxis:\n DVT: Pneumobots\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 715653,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Intracranial hemorrhage most likely mechanical fall in the setting of\n sedating meds. Head ct done post fall showed multiple small foci of\n bleeding. Pt was transferred to for q 1 hr neuro checks.being\n followed by neurosurgery. Pt a&o x3. pleasant and cooperative. Pt\n denies ha,n/v,blurred vision. Pupils equal bil and briskly reactive to\n light.\n Action:\n Repeat head ct done this am. Neuro checks q 1 hr. receiving dilantin\n 100mg ivpb q 8 hrs. kept npo and all sedative meds were held except for\n her 50mg po Zoloft. Tte done at the bedside. Dilantin now changed to\n po route\n Response:\n Stable neurologically. No seizure activity. Head ct unchanged from\n previous study.\n Plan:\n Continue to assess pt\ns neurological status. Being followed by\n neurosurgery and according to t hem pt no longer needs q 1 hr\n neurochecks.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has had abd pain since mid . Had been receiving oxycontin and\n oxycodone for pain control but all meds have been on hold since t he\n mechanical fall because of the potential for altering effects on her m\n ental status. Pt has been pain free all day.\n Action:\n Pt drinking baricat in preparation for triple series abd ct. pt being\n followed by gastroenterology and surgery. Pt otherwise npo till ct is\n completed. At 1645 pt transported to radiology for abd ct with po\n contrast\n Response:\n Pt remains pain free.\n Plan:\n Continue to assess pt\ns level of pain and if needed for now medicate\n with Tylenol po q 6 hrs. plan is for eventual gi surgery. Pt being\n transferred to 10 floor under transplant surgery.\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 77.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: GERD, depression, anxiety, insomnia\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:158\n D:138\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,260 mL\n 24h total out:\n 1,700 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 03:27 AM\n Potassium:\n 3.2 mEq/L\n 03:27 AM\n Chloride:\n 110 mEq/L\n 03:27 AM\n CO2:\n 25 mEq/L\n 03:27 AM\n BUN:\n 11 mg/dL\n 03:27 AM\n Creatinine:\n 0.5 mg/dL\n 03:27 AM\n Glucose:\n 112 mg/dL\n 03:27 AM\n Hematocrit:\n 29.5 %\n 03:27 AM\n Finger Stick Glucose:\n 105\n 06:00 PM\n Valuables / Signature\n Patient valuables: Glasses, Dentures: (Upper )\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: \n Transferred to: 10\n Date & time of Transfer: 22:00 pM\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715541,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro vss. Some difficulty remembering which hospital she was in ,\n after falling asleep & being woken up, improved as night progressed\n into morning.\n Action:\n Checked neuro vs q 1 hr. Was NPO since Mn. Received 1580mg loading\n dose of phosphenytoin IV @ 2330.\n Response:\n As above.\n Plan:\n Head CT w/o contrast planned for today. Draw dilantin level before\n giving 0800 dose dilantin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Had abdominal pain since mid . Being treated w/10mg oxycontin\n & oxycodone 5mg for breakthrough pain.\n Action:\n Oxycontin held this evening as were xanax 0.25mg & zyprexa 5mg po this\n evening, all per MICU resident so as not to cloud neuro presentation.\n Response:\n Patient denied pain all night , & she was surprised to do so.\n Plan:\n Medicate w/Tylenol q 6 hrs (not prn).\n Cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Patient was scheduled for GI surgery on @ .\n Action:\n Kept NPO for possible procedure.\n Response:\n Plan is for eventual GI surgery.\n Plan:\n Once neuosurgically stable, to be transferred to \nmay be\n today.\n"
},
{
"category": "Physician ",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 715486,
"text": "Chief Complaint: Intraparenchymal and subdural hemorrhages status-post\n fall.\n HPI:\n This is an 82-year-old woman with suspected adenocarcinoma of the\n pancreas, scheduled for GI surgery on , who fell in the hospital,\n sustained ICH, and is now transferred from 11 to the for\n Q1 hour neuro checks. Patient states that after her dinner she was\n walking out of her room when she slipped in front of her roommate's\n bed; she hit her head and needed assistance getting up off the floor.\n Ms. loss of consciousness, change in vision, or neck/back\n pain. She does endorse two episodes of vomiting, immediately after\n fall and during subsequent CT scan, but attributes this to eating a\n large meal. Patient reports a headache on the left, which has resolved\n with pain medication. She any recollection of falls or head\n injuries.\n A CT scan done immediately after eventshowed multiple parasagital\n hemorrhages and parasagitalsubdural hematomas bilaterally. She was\n seen by neurosurgy who recommended conservative treatment with\n fosphenytoin load and phenytoin for maintenance.\n ROS: Patient change in vision, change in mentation, chest pain,\n shortness of breath, abdominal pain, urine/bowel incontinence, or any\n other concerning sign or symptoms. She does endorse a \"bump\" on the\n left side of her head where she fell.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Medications on admission:\n Milk of Magnesia 30 mL PO/NG \n Bisacodyl 10 mg PO DAILY\n Oxycodone SR (OxyconTIN) 10 mg PO Q12H\n Ondansetron ODT 4 mg PO/NG Q8H:PRN nausea\n Sertraline 50 mg PO/NG DAILY\n Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY\n Alprazolam 0.25 mg PO/NG \n Olanzapine 5 mg PO HS\n Acetaminophen 1000 mg PO/NG 8 HOURS\n OxycoDONE Liquid 5 mg PO/NG Q6H:PRN pain\n Past medical history:\n Family history:\n Social History:\n HTN (resolved with unintentional recent 30lb weight loss)\n Anxiety\n Appendectomy\n Tonsillectomy\n Mother with HTN\n Father died of rectal CA at age 54\n Other: Married for 65 years. Has 2 children, 2 grand-children, and 4\n great-grandchildren. Works in her daughter's bakery when she is\n feeling well. Patient quit smoking 25 years ago (with 35\n pack-year-history); drinks alcohol socially. She lives with her\n husband in .\n Review of systems: As above.\n Flowsheet Data as of 12:55 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: 36.3\nC (97.3\n HR: 87 (83 - 87) bpm\n BP: 95/54(64) {95/54(64) - 117/70(82)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 2,400 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,700 mL\n 0 mL\n Respiratory\n SpO2: 91%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Ecchymosis on right\n side from subcu injection\n Skin: Warm\n Neurologic: Attentive, Responds to: Verbal stimuli, Movement:\n Purposeful, Tone: Normal, Neuro: CN II-XII intact bilaterally. Smile\n droops down a bit on left, but patient says this is chronic as her\n bridge doesn't fit well.\n Labs / Radiology: TO BE DRAWN.\n [image002.jpg]\n Imaging: CT Head : Head CT showed multiple parasagital\n hemorrhages and also parasagital subdural hematomas bilaterally. There\n is little mass effect and no herniation.\n Assessment and Plan\n Assessment/Plan: This is an 82-year-old female with probable\n adenocarcinoma of pancreas, admitted to after fall on 11 \n resulting in intraparenchymal and subdural hemorrhages. Patient\n requires frequent neurologic assessment and close mental status\n evaluation.\n .\n HEAD TRAUMA: Patient with recent fall in hospital room after getting\n up from bed. She any LOC before or after incident or\n dizziness/lightheadedness on standing, but we must still be cognizant\n of physiologic reasons for fall (i.e. orthostatic hypotension,\n arrythmia, seizure). Patient is also on multiple psychiatric\n medications and narcotics, which surely alter her mental status. Ms.\n is usure of exactly what precipitated fall, but believes that she\n simply slipped in front of her roommate's bed as they were talking.\n --Appreciate neurosurgery recommendations\n --Transfer to ICU for Q1hr neuro checks\n --CT in AM or earlier if neuro exam changes\n --Hold Heparin SC\n --Fosphenytoin 20mg/kg IV load, and Phenytoin 100 TID maintenance\n starting in morning\n --Dilantin levels QAM on and in AM\n --Minimize benzodiazipines, other sedating medications for now\n .\n ADENOCARCINOMA: Patient was supposed to be transferred to \n surgery service this evening for further work-up of GI cancer.\n --Touch base with West 1 Surgery\n --CT abdomen arterial, venous, and portal venous phases when stabilized\n --NPO overnight for possible procedure tomorrow\n --Treat pain, though hold narcotics tonight as not to cloud mental\n status.\n .\n ANXIETY/DEPRESSION: Patient with long-standing anxiety and depression,\n followed by outpatient PCP.\n Sertraline 50mg QD\n --Hold Xanax and Olanzapine tonight as not to cloud neuro exam\n .\n GERD/ABDOMINAL UPSET: Patient with abdominal pain, bloating for the\n past 3 months.\n --Continue lansoprazole, ondansteron, bisacodyl, and milk of magnesia\n ICU Care\n Nutrition: Regular diet, but NPO overnight on for possible\n procedures.\n Lines:\n 20 Gauge - 10:00 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Lanzoprazole\n VAP:\n Comments:\n Communication: Comments: , husband. Phone:\n .\n Code status: Presumed full.\n Disposition: ICU for Q1 hour neurologic checks.\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715539,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro vss. Some difficulty remembering which hospital she was in ,\n after falling asleep & being woken up, improved as night progressed\n into morning.\n Action:\n Checked neuro vs q 1 hr. Was NPO since Mn. Received 1580mg loading\n dose of phosphenytoin IV @ 2330.\n Response:\n As above.\n Plan:\n Head CT w/o contrast planned for today. Draw dilantin level before\n giving 0800 dose dilantin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Had abdominal pain since mid . Being treated w/10mg oxycontin\n & oxycodone 5mg for breakthrough pain.\n Action:\n Oxycontin held this evening as were xanax 0.25mg & zyprexa 5mg po this\n evening, all per MICU resident so as not to cloud neuro presentation.\n Response:\n Patient denied pain all night , & she was surprised to do so.\n Plan:\n Medicate w/Tylenol q 6 hrs (not prn).\n Cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Patient was scheduled for GI surgery on @ .\n Action:\n Kept NPO for possible procedure.\n Response:\n Plan is for eventual GI surgery.\n Plan:\n Once neuosurgically stable, to be transferred to \nmay be\n today.\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715534,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro vss. Some difficulty remembering which hospital she was in ,\n after falling asleep & being woken up, improved as night progressed\n into morning.\n Action:\n Checked neuro vs q 1 hr. Was NPO since Mn.\n Response:\n As above.\n Plan:\n Head CT w/o contrast planned for today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Had abdominal pain since mid . Being treated w/10mg oxycontin\n & oxycodone 5mg for breakthrough pain.\n Action:\n Oxycontin held this evening as were xanax 0.25mg & zyprexa 5mg po this\n evening, all per MICU resident so as not to cloud neuro presentation.\n Response:\n Patient denied pain all night , & she was surprised to do so.\n Plan:\n Medicate w/Tylenol q 6 hrs (not prn).\n Cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Action:\n Kept NPO for possible procedure.\n Response:\n Plan:\n Once neuosurgically stable, to be transferred to for\n procedure\nmay be today.\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715535,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro vss. Some difficulty remembering which hospital she was in ,\n after falling asleep & being woken up, improved as night progressed\n into morning.\n Action:\n Checked neuro vs q 1 hr. Was NPO since Mn.\n Response:\n As above.\n Plan:\n Head CT w/o contrast planned for today. Draw dilantin level before\n giving 0800 dose dilantin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Had abdominal pain since mid . Being treated w/10mg oxycontin\n & oxycodone 5mg for breakthrough pain.\n Action:\n Oxycontin held this evening as were xanax 0.25mg & zyprexa 5mg po this\n evening, all per MICU resident so as not to cloud neuro presentation.\n Response:\n Patient denied pain all night , & she was surprised to do so.\n Plan:\n Medicate w/Tylenol q 6 hrs (not prn).\n Cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Action:\n Kept NPO for possible procedure.\n Response:\n Plan is for eventual GI surgery.\n Plan:\n Once neuosurgically stable, to be transferred to \nmay be\n today.\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715537,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Subdural hemorrhage (SDH)\n Assessment:\n Neuro vss. Some difficulty remembering which hospital she was in ,\n after falling asleep & being woken up, improved as night progressed\n into morning.\n Action:\n Checked neuro vs q 1 hr. Was NPO since Mn. Received 1580mg loading\n dose of phosphenytoin IV @ 2330.\n Response:\n As above.\n Plan:\n Head CT w/o contrast planned for today. Draw dilantin level before\n giving 0800 dose dilantin.\n Pain control (acute pain, chronic pain)\n Assessment:\n Had abdominal pain since mid . Being treated w/10mg oxycontin\n & oxycodone 5mg for breakthrough pain.\n Action:\n Oxycontin held this evening as were xanax 0.25mg & zyprexa 5mg po this\n evening, all per MICU resident so as not to cloud neuro presentation.\n Response:\n Patient denied pain all night , & she was surprised to do so.\n Plan:\n Medicate w/Tylenol q 6 hrs (not prn).\n Cancer (Malignant Neoplasm), Pancreas\n Assessment:\n Action:\n Kept NPO for possible procedure.\n Response:\n Plan is for eventual GI surgery.\n Plan:\n Once neuosurgically stable, to be transferred to \nmay be\n today.\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715626,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Intracranial hemorrhage most likely mechanical fall in the setting of\n sedating meds. Head ct done post fall showed multiple small foci of\n bleeding. Pt was transferred to for q 1 hr neuro checks.being\n followed by neurosurgery. Pt a&o x3. pleasant and cooperative. Pt\n denies ha,n/v,blurred vision. Pupils equal bil and briskly reactive to\n light.\n Action:\n Repeat head ct done this am. Neuro checks q 1 hr. receiving dilantin\n 100mg ivpb q 8 hrs. kept npo and all sedative meds were held except for\n her 50mg po Zoloft. Tte done at the bedside.\n Response:\n Stable neurologically. No seizure activity. Head ct unchanged from\n previous study.\n Plan:\n Continue to assess pt\ns neurological status. Being followed bu\n neurosurgery and according to t hem pt no longer needs q 1 hr\n neurochecks.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has had abd pain since mid . Had been receiving oxycontin and\n oxycodone for pain control but all meds have been on hold since t he\n mechanical fall because of the potential for altering effects on her m\n ental status. Pt has been pain free all day.\n Action:\n Pt drinking baricat in preparation for triple series abd ct. pt being\n followed by gastroenterology and surgery. Pt otherwise npo till sct is\n completed.\n Response:\n Pt remains pain free.\n Plan:\n Conintue to assess pt\ns level of pain and if needed for now medicate\n with Tylenol po q 6 hrs. plan is for eventual gi surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 715628,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Intracranial hemorrhage most likely mechanical fall in the setting of\n sedating meds. Head ct done post fall showed multiple small foci of\n bleeding. Pt was transferred to for q 1 hr neuro checks.being\n followed by neurosurgery. Pt a&o x3. pleasant and cooperative. Pt\n denies ha,n/v,blurred vision. Pupils equal bil and briskly reactive to\n light.\n Action:\n Repeat head ct done this am. Neuro checks q 1 hr. receiving dilantin\n 100mg ivpb q 8 hrs. kept npo and all sedative meds were held except for\n her 50mg po Zoloft. Tte done at the bedside. Dilantin now changed to\n po route\n Response:\n Stable neurologically. No seizure activity. Head ct unchanged from\n previous study.\n Plan:\n Continue to assess pt\ns neurological status. Being followed bu\n neurosurgery and according to t hem pt no longer needs q 1 hr\n neurochecks.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has had abd pain since mid . Had been receiving oxycontin and\n oxycodone for pain control but all meds have been on hold since t he\n mechanical fall because of the potential for altering effects on her m\n ental status. Pt has been pain free all day.\n Action:\n Pt drinking baricat in preparation for triple series abd ct. pt being\n followed by gastroenterology and surgery. Pt otherwise npo till ct is\n completed. At 1645 pt transported to radiology for abd ct with po\n contrast\n Response:\n Pt remains pain free.\n Plan:\n Continue to assess pt\ns level of pain and if needed for now medicate\n with Tylenol po q 6 hrs. plan is for eventual gi surgery. Pt being\n transferred to 10 floor under transplant surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 715629,
"text": "82 yr old woman was admitted to 11R w/abdominal pain, wgt loss &\n 1X1 cm mass next to bile duct. Fell today & developed bilateral\n parasagital subdural hematomas. No LOC or change in baseline neuro\n vs. Transferred to ICU for q 1 hr neuro vs checks.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Intracranial hemorrhage most likely mechanical fall in the setting of\n sedating meds. Head ct done post fall showed multiple small foci of\n bleeding. Pt was transferred to for q 1 hr neuro checks.being\n followed by neurosurgery. Pt a&o x3. pleasant and cooperative. Pt\n denies ha,n/v,blurred vision. Pupils equal bil and briskly reactive to\n light.\n Action:\n Repeat head ct done this am. Neuro checks q 1 hr. receiving dilantin\n 100mg ivpb q 8 hrs. kept npo and all sedative meds were held except for\n her 50mg po Zoloft. Tte done at the bedside. Dilantin now changed to\n po route\n Response:\n Stable neurologically. No seizure activity. Head ct unchanged from\n previous study.\n Plan:\n Continue to assess pt\ns neurological status. Being followed bu\n neurosurgery and according to t hem pt no longer needs q 1 hr\n neurochecks.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt has had abd pain since mid . Had been receiving oxycontin and\n oxycodone for pain control but all meds have been on hold since t he\n mechanical fall because of the potential for altering effects on her m\n ental status. Pt has been pain free all day.\n Action:\n Pt drinking baricat in preparation for triple series abd ct. pt being\n followed by gastroenterology and surgery. Pt otherwise npo till ct is\n completed. At 1645 pt transported to radiology for abd ct with po\n contrast\n Response:\n Pt remains pain free.\n Plan:\n Continue to assess pt\ns level of pain and if needed for now medicate\n with Tylenol po q 6 hrs. plan is for eventual gi surgery. Pt being\n transferred to 10 floor under transplant surgery.\n"
},
{
"category": "Physician ",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 715584,
"text": "Chief Complaint: Intracranial bleed\n 24 Hour Events:\n --Patient stabilized in with Q1 hour neuro checks\n --No focal changes on neuro exam\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: None.\n Review of systems is unchanged from admission except as noted below\n Review of systems: None.\n Flowsheet Data as of 06:32 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 90 (83 - 96) bpm\n BP: 117/59(73) {95/48(59) - 134/81(94)} mmHg\n RR: 15 (13 - 17) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 2,905 mL\n 64 mL\n PO:\n 400 mL\n TF:\n IVF:\n 105 mL\n 64 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,205 mL\n 64 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General: Well-appearing, no acute distress\n Chest: CTA b/l, no wheezes, rales, or rhonchi\n Cardiac: RRR, normal S1 and S2\n Abdomen: +BS, soft, non-tender, non-distended\n Extremities: In pneumaboots, warm, well-perfused.\n Labs / Radiology\n 182 K/uL\n 9.8 g/dL\n 112 mg/dL\n 0.5 mg/dL\n 25 mEq/L\n 3.2 mEq/L\n 11 mg/dL\n 110 mEq/L\n 144 mEq/L\n 29.5 %\n 5.0 K/uL\n [image002.jpg]\n 03:27 AM\n WBC\n 5.0\n Hct\n 29.5\n Plt\n 182\n Cr\n 0.5\n Glucose\n 112\n Assessment and Plan\n Assessment/Plan: This is an 82-year-old female with probable\n adenocarcinoma of pancreas, admitted to after fall on 11 \n resulting in intraparenchymal and subdural hemorrhages. Patient\n requires frequent neurologic assessment and close mental status\n evaluation.\n .\n HEAD TRAUMA: Patient with recent fall in hospital room after getting\n up from bed. Denies syncope before or after event. Most likely,\n patient had mechanical fall (with psychiatric and pain med contributing\n to unsteadiness).\n --CT this morning to evaluate for interval change\n --Coags this AM\n --Continue to hold heparin\n --Fosphenytoin 20mg/kg IV load last night, and Phenytoin 100 TID\n maintenance now\n --Dilantin levels QAM on and in AM\n --Minimize benzodiazipines, other sedating medications for now\n .\n ADENOCARCINOMA: Patient with planed work up on for GI\n malignancy.\n --Touch base with GI\n --CT abdomen arterial, venous, and portal venous phases when stabilized\n --NPO for now until we touch base with GI\n --Treat pain, though hold narcotics tonight as not to cloud mental\n status.\n .\n ANXIETY/DEPRESSION: Patient with long-standing anxiety and depression,\n followed by outpatient PCP.\n Sertraline 50mg QD\n --Hold Xanax and Olanzapine for now, though be wary of benzo withdrawal\n .\n GERD/ABDOMINAL UPSET: Patient with abdominal pain, bloating for the\n past 3 months.\n --Continue lansoprazole, ondansteron, bisacodyl, and milk of magnesia\n ICU Care\n Nutrition: NPO for now.\n Glycemic Control:\n Lines:\n 20 Gauge - 01:30 AM\n Prophylaxis:\n DVT: Pneumobots\n Stress ulcer: Lansoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU for now\n"
},
{
"category": "Echo",
"chartdate": "2113-02-15 00:00:00.000",
"description": "Report",
"row_id": 96813,
"text": "PATIENT/TEST INFORMATION:\nIndication: LV/RV FXN, Pre-op\nHeight: (in) 65\nWeight (lb): 157\nBSA (m2): 1.79 m2\nBP (mm Hg): 124/99\nHR (bpm): 94\nStatus: Outpatient\nDate/Time: at 15:27\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: Normal RA size. Dynamic interatrial septum.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Hyperdynamic LVEF\n>75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Focal calcifications in aortic\narch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Mild PA systolic hypertension.\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 mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Left ventricular\nsystolic function is hyperdynamic (EF 70-80%). There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. There\nare focal calcifications in the aortic arch. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened; there is trivial\nmitral regurgitation. There is no mitral valve prolapse. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: hyperdynamic, mildly hypertrophic left ventricle\n\n\n"
},
{
"category": "ECG",
"chartdate": "2113-02-12 00:00:00.000",
"description": "Report",
"row_id": 270970,
"text": "Sinus tachycardia. Low precordial lead voltage. Compared to the previous\ntracing of the rate has increased. Otherwise, no diagnostic interim\nchange.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-02-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1114280,
"text": " 8:53 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for interval change in bleed.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with new finding of intraparenchymal and subdural hemorrhages\n after fall.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change in bleed.\n CONTRAINDICATIONS for IV CONTRAST:\n head bleed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with new finding of intraparenchymal and\n subdural hemorrhages after fall, please evaluate for interval change and\n bleed.\n\n COMPARISONS: CT of the head without contrast from .\n\n TECHNIQUE: MDCT images were acquired from the vertex down to the first\n cervical vertebrae without contrast. Multiplanar reconstructions were\n obtained and reviewed.\n\n FINDINGS:\n\n There is unchanged appearance of the anterior falcine, more to the left\n side, and bilateral frontal acute subdural hemorrhages with blood seen\n tracking down the falx posteriorly. The right posterior parieto-occipital\n subdural hematoma is unchanged as well. The largest focus of hemorrhage in\n the left frontal region, subdural in location measures 15 x 19 mm (2:26, prior\n measuring 19 x 17 mm). The right frontal area of acute subdural hemorrhage\n (2:26, measures 10 mm today versus a 9-mm yesterday) is unchanged when\n accounting for differences in technique. Bilateral prominent subdural fluid\n containing spaces are noted representing hygromas or chronic subdural fluid\n collections. The subdural location of the foci of hemorrhage at the vertex is\n better appreciated on sag and coronal reformations. Again seen is\n hypoattenuation of the periventricular white matter consistent with\n small-vessel ischemic disease. There is diffuse osteopenia. Scalp hematoma in\n the vertex is unchanged.\n\n IMPRESSION:\n Multiple areas of acute subdural hemorrhage, as described above, without\n significant change.\n Follow up as clinically indicated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-02-15 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1114378,
"text": " 4:48 PM\n CT ABD W&W/O C Clip # \n Reason: CT with PO and IV contrast. PLEASE DO arterial, venous and\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 39.6 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CBD stricture and FNA concerning for cholangiocarcinoma\n REASON FOR THIS EXAMINATION:\n CT with PO and IV contrast. PLEASE DO arterial, venous and portal vein phases.\n To be done when patient has been transferred to \n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb WED 10:47 PM\n 1. Large infiltrative mass at the porta hepatis encasing the celiac axis, SMA,\n and common bile duct with associated clot in the right portal vein, pancreatic\n ductal dilation and mild intrahepatic ductal dilation, highly suspicious for\n cholangiocarcinoma. Other differential considerations would include\n pancreatic adenocarcinoma. There are multiple enlarged lymph nodes with a\n large conglomerate mass of lymph nodes in the left paraaortic station\n measuring up to 3.5 cm.\n\n 2. Splenic infarct.\n\n 3. Renal cyst.\n\n 4. Partially visualized colonic wall thickening and pericolonic fluid, may\n reflect an infectious, ischemic, and inflammatory colitis. If further\n clinical concern, a dedicated CT abdomen and pelvis should be considered.\n\n 5. Ascites.\n\n 6. Hiatal hernia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CBD stricture, FNA concerning for cholangiocarcinoma, evaluate\n for cholangiocarcinoma.\n\n COMPARISON: ERCP .\n\n TECHNIQUE: Helical CT acquisition through the abdomen with and without\n intravenous contrast. Imaging was performed in multiple phases including\n arterial, portal venous, and delayed phases. Multiplanar reformations were\n generated.\n\n CT ABDOMEN WITH AND WITHOUT IV CONTRAST: The lung bases demonstrate mild\n atelectasis. Mitral annulus calcifications are noted. There is a small axial\n hiatal hernia. There are 2-mm right lower lobe and middle lobe pulmonary\n nodules (2:2), and given underlying malignancy, close interval followup is\n recommended.\n\n There is an ill-defined infiltrative porta hepatis mass encasing the CBD,\n common hepatic artery, and portal vein. Given infiltrative nature, accurate\n (Over)\n\n 4:48 PM\n CT ABD W&W/O C Clip # \n Reason: CT with PO and IV contrast. PLEASE DO arterial, venous and\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 39.6 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n measurement of this mass is limited; however, grossly it measures 4.7 x 4.8 cm\n (3B:142). The CBD is narrowed with a stent in situ. There is near-occlusive\n narrowing of the main portal vein with filling defect consistent with\n thrombus(3B:137) and smaller foci of thrombus in the intrahepatic portal\n venous branches (3b:126; 102). There is mild intrahepatic biliary ductal\n dilation. The pancreatic duct is markedly dilated and irregular, measuring\n 6.2 mm, with an abrupt cutoff at the interface with the mass in the pancreatic\n head (3b:147).\n\n Abnormal soft tissue density extends around the celiac axis, and a large soft\n tissue mass is located adjacent to the SMA, measuring 3.5 x 3.1 cm. This mass\n narrows the SMA in its most proximal course without occluding, invading it and\n likely reflects a conglomerate adenopathy in the setting of malignancy.\n In addition, there is enhancing aortocaval node measuring 1.1 x 1 cm (3B:142).\n Similar enhancing retrocrural node measuring 1.4 x 1.4 cm (3B:132) is noted.\n Multiple mesenteric nodes are noted which measure up to 1 cm in short axis.\n\n\n Area of hypoattenuation adjacent to the falciform ligament is in a location\n typical of focal fatty change (3B:130). There is a hypoattenuating lesion in\n the right hepatic lobe (3B:125), measuring 6 mm, too small to characterize.\n Ascites is noted. The gallbladder is distended without significant wall edema.\n Splenomegaly and the spleen demonstrates a hypoattenuating band in the\n superior pole which could represent infarct, but is otherwise unremarkable.\n\n There is colonic wall thickening, partially visualized with associated\n pericolonic stranding involving the hepatic flexure and to some extent also\n the splenic flexure, and these findings suggest an underlying colitis which\n could be infectious, ischemic, or inflammatory in etiology. This may be\n further evaluated with a dedicated CT abdomen and pelvis as clinically\n indicated.\n\n Partly visualized colonic diverticulosis is noted. Mild duodenal inflammation\n and periduodenal fat stranding is noted. Both adrenals appear normal. Kidneys\n demonstrate multiple low-attenuation lesions, subcentimeter on the left, too\n small to characterize and measuring up to 2.4 cm on the right in the\n interpolar region, consistent with a simple cyst.\n\n Evaluation of vascular structures demonstrates tumor encasement of the celiac\n axis, common hepatic artery, gastroduodenal artery and to some extent the left\n gastric artery. Hepatic arterial anatomy is conventional.\n\n OSSEOUS STRUCTURES: There are no suspicious osteolytic or osteosclerotic\n lesions. Heterogeneous appearance of the vertebrae suggests changes of\n osteoporosis.\n (Over)\n\n 4:48 PM\n CT ABD W&W/O C Clip # \n Reason: CT with PO and IV contrast. PLEASE DO arterial, venous and\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 39.6 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Large infiltrative mass at the porta hepatis with encasement of multiple\n arterial and venous structures including near occlusive narrowing and\n thrombosis of the portal vein; pancreatic and biliary ductal dilation.\n Findings are highly suspicious for cholangiocarcinoma. Other differential\n considerations would include pancreatic adenocarcinoma.\n\n 2. Multiple metastatic lymph nodes with a large conglomerate mass of lymph\n nodes in the left paraaortic station narrowing the SMA.\n\n 3. Partially visualized colonic wall thickening and pericolonic fluid, may\n reflect an infectious, ischemic, and inflammatory colitis. Clinical\n correlation recommended. Pelvis not imaged on this examination.\n\n 4. Splenic infarct, Renal cysts, Ascites and Hiatal hernia.\n\n 5. 2 mm pulmonary nodules for which attention at next follow up imaging is\n recommended.\n\n These findings were verbally discussed with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-02-15 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1114379,
"text": ", S. MED 4:48 PM\n CT ABD W&W/O C Clip # \n Reason: CT with PO and IV contrast. PLEASE DO arterial, venous and\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 39.6 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CBD stricture and FNA concerning for cholangiocarcinoma\n REASON FOR THIS EXAMINATION:\n CT with PO and IV contrast. PLEASE DO arterial, venous and portal vein phases.\n To be done when patient has been transferred to \n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Large infiltrative mass at the porta hepatis encasing the celiac axis, SMA,\n and common bile duct with associated clot in the right portal vein, pancreatic\n ductal dilation and mild intrahepatic ductal dilation, highly suspicious for\n cholangiocarcinoma. Other differential considerations would include\n pancreatic adenocarcinoma. There are multiple enlarged lymph nodes with a\n large conglomerate mass of lymph nodes in the left paraaortic station\n measuring up to 3.5 cm.\n\n 2. Splenic infarct.\n\n 3. Renal cyst.\n\n 4. Partially visualized colonic wall thickening and pericolonic fluid, may\n reflect an infectious, ischemic, and inflammatory colitis. If further\n clinical concern, a dedicated CT abdomen and pelvis should be considered.\n\n 5. Ascites.\n\n 6. Hiatal hernia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-02-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1114216,
"text": " 6:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: R/O SDH/ICH\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with fall in the hospital\n REASON FOR THIS EXAMINATION:\n R/O SDH/ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a small left parafalcine acute subdural hematoma, which\n measures up to 6 mm. There are three hyperattenuating foci in the vertex, the\n largest in the left frontal region measures 1.9 x 1.7 cm. There are two other\n hemorrhagic foci, measuring 9.3 and 5-mm respectively noted in the right\n frontal and left posterior frontal region (2:27), subdural in location, better\n seen on reformations on subsequent CT. There is associated left posterior\n scalp hematoma at the vertex. There is no underlying fracture.\n\n There is no mass effect, or shift of normally midline structures. There is\n bilateral periventricular white matter hypoattenuation, predominantly in the\n frontal lobes consistent with chronic small vessel ischemic disease.\n\n There is diffuse osteopenia.\n\n IMPRESSION:\n 1. Acute subdural hemorrhages, see details on subsequent report. Diffuse\n osteopenia; no acute fracture.\n\n Prelim. report findings were communicated to Dr. at 7:10 p.m.\n\n"
}
] |
81,630 | 147,738 | Admitted and underwent surgery with Dr. . For surgical details, please see operative note. Following surgery, he was transferred to the CVICU in stable condition on titrated propofol and phenylephrine drips. Extubated later that day and transferred to the floor on POD #1 to begin increasing his activity level. Beta blockade slowly initiated and Warfarin started on POD #2 for mechanical aortic valve. He was bridged with IV heparin until therapeutic. INR was monitored daily and Warfarin was dosed for a goal INR between 2.0 - 2.5. Chest tubes and pacing wires removed per protocol. Over several days, he continued to make clinical improvements with diuresis and was cleared for discharge to home on postoperative day six when his INR rose over 2.0. Prior to discharge, arrangements were made with Dr. and the Coumadin Clinc to monitor Warfarin as an outpatient. At discharge, he was in a normal sinus rhythm with 1+ pedal edema and oxygen saturations of 97% on room air. All wounds were clean, dry and intact. | Right-sided apical pleural thickening is unchanged from preop chest film. Normal aortic arch diameter. Normal sinus rhythm with non-specific ST-T wave abnormalities. Focal calcifications in aortic arch.Normal descending aorta diameter. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Small right apical pneumothorax is noted after interval removal of right chest tube. Linear opacities in the right lower lung are consistent with atelectasis, unchanged. Trivial mitral regurgitationis seen.There is no pericardial effusion.Dr. Current study demonstrates interval decrease in currently minimal right apical pneumothorax. Residual mean gradient is 12 mm of Hg.Intact thoracic aorta. Unchanged cardiomegaly is noted. A right IJ catheter terminates with its tip in the mid SVC. Mildly dilated ascending aorta. IMPRESSION: Right Swan-Ganz catheter terminates in the right pulmonary artery. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. The cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. Right subclavian line has been inserted with its tip at the level of mid low SVC. No atrial septal defect is seen by 2D or color Doppler.There is mild symmetric left ventricular hypertrophy with normal cavity sizeand regional/global systolic function (LVEF>55%).Right ventricular chamber size and free wall motion are normal.The ascending aorta is mildly dilated. The cardiac silhouette is top normal. Stable mild cardiomegaly. FINDINGS: Poor lung expansion without focal radiopacities on the left side and with linear radiopacities in the right lower lung field, indicating plate-like atelectasis. There is interval improvement of pulmonary edema, currently with no evidence of fluid overload/edema noted. PATIENT/TEST INFORMATION:Indication: AVRHeight: (in) 69Weight (lb): 237BSA (m2): 2.22 m2Status: InpatientDate/Time: at 10:43Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or theRA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Tiny R apical PTX. The mediastinal silhouette and hilar contours are normal. Bibasal linear opacities are unchanged consistent with atelectasis. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There is severeaortic valve stenosis (valve area 0.8-1.0cm2).Mild to moderate (+) aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Sternotomy wires are intact. Pulmonary artery is of normal size.PostBypass:Preserved biventricular systolic function.LVEF 55%.There is a bimetallic prosthesis seen at the native aortic position, stableand f unctioning well. Mild to moderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. ONE VIEW OF THE CHEST: The lungs are low in volume and show bilateral lower lobe opacities. Compared to theprevious tracing of no diagnostic interim change. Right basal opacity most likely representing a combination of atelectasis and post-chest tube removal changes. R basilar opacity, combination of atelectasis and post- procedural (chest tube) changes. Cardiomediastinal silhouette is stable. Otherwise, stable compared with prior exam. Left atrialabnormality. Post-sternotomy wires are unremarkable. IMPRESSION: Small left effusion. Evaluate for pleural effusions. IMPRESSION: Interval improvement of lung aeration and right lower lobe atelectasis. Improved aeration of the left lung base is noted. Thepatient appears to be in sinus rhythm. COMPARISON: Chest radiograph from . COMPARISON: Chest radiograph from . Non-diagnostic Q waves in the inferior leads. A Swan-Ganz catheter in the right pulmonary artery and mediastinal drains and a right chest tube are noted. Sternal wires are intact. Portable AP chest radiograph was reviewed in comparison to . A left-sided line ends at the level of the cavoatrial junction. No appreciable pleural effusion is seen. Rule out pneumothorax and infiltrate. There may be a small left pleural effusion. Results were personally reviewed withthe MD caring for the patient.Conclusions:PRE-BYPASS:No spontaneous echo contrast or thrombus is seen in the body of the leftatrium/left atrial appendage or the body of the right atrium/right atrialappendage. ptx WET READ: ENYa SAT 11:05 AM Interval removal of R chest tube, Swan-Ganz, ETT and NGT. The patient was undergeneral anesthesia throughout the procedure. Cardiomediastinal and hilar contours are unremarkable. Portable AP radiograph of the chest was reviewed in comparison to . Portable AP radiograph of the chest was reviewed in comparison to . No TEE related complications. No acute intrathoracic process. Bilateral lower lobe atelectasis. Old left rib fractures are redemonstrated. Focal calcifications in descending aorta.AORTIC VALVE: Bicuspid aortic valve. Early extubation after cardiac surgery. COMPARISON: Preop chest radiograph from and portable chest films from . There is no pleural effusion or pneumothorax. Severely thickened/deformed aortic valveleaflets. The aortic valve is bicuspid.The aortic valve leaflets are severely thickened/deformed. No left pneumothorax is seen. No appreciable pneumothorax is noted, neither on the right or on the left side. Focal calcifications inaortic root. No pneumothorax is present. There may be a small left effusion. There is no pneumothorax. No mediastinal shift. 1:06 PM CHEST PORT. Focal calcifications in ascendingaorta. There are focal calcifications in theaortic arch. There is no mediastinal shift. An ET tube terminating 3 cm above the , NG tube passing out of view below the diaphragm. I certifyI was present in compliance with HCFA regulations. Severe AS (area 0.8-1.0cm2). FINAL REPORT REASON FOR EXAMINATION: Followup of the patient after aortic valve replacement. TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. 10:23 AM CHEST (PORTABLE AP) Clip # Reason: ? 7:30 AM CHEST (PORTABLE AP) Clip # Reason: PTX Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT /SDA MEDICAL CONDITION: 64 year old man POD #1 s/p AVR, please evaluate right apical PTX. | 8 | [
{
"category": "Radiology",
"chartdate": "2105-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199754,
"text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man POD #1 s/p AVR, please evaluate right apical PTX.\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient first day after aortic\n valve replacement.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Current study demonstrates interval decrease in currently minimal right apical\n pneumothorax. Bibasal linear opacities are unchanged consistent with\n atelectasis. Improved aeration of the left lung base is noted. There is no\n pleural effusion or pneumothorax. Old left rib fractures are redemonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-09-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1199791,
"text": " 2:56 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line placemnet\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval line placemnet\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after aortic valve\n replacement.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n Right subclavian line has been inserted with its tip at the level of mid low\n SVC. Linear opacities in the right lower lung are consistent with\n atelectasis, unchanged. No appreciable pneumothorax is noted, neither on the\n right or on the left side. Cardiomediastinal silhouette is stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-09-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1199521,
"text": " 1:06 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with AVR\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 64-year-old man with aortic valve replacement. Early\n extubation after cardiac surgery.\n\n COMPARISON: Chest radiograph from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show bilateral lower lobe opacities. The\n cardiac silhouette is top normal. The mediastinal silhouette and hilar\n contours are normal. There may be a small left effusion. An ET tube\n terminating 3 cm above the , NG tube passing out of view below the\n diaphragm. A Swan-Ganz catheter in the right pulmonary artery and mediastinal\n drains and a right chest tube are noted. No pneumothorax is present.\n\n IMPRESSION:\n\n Right Swan-Ganz catheter terminates in the right pulmonary artery. Bilateral\n lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199658,
"text": " 10:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? ptx\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with AVR.CT out\n REASON FOR THIS EXAMINATION:\n ? ptx\n ______________________________________________________________________________\n WET READ: ENYa SAT 11:05 AM\n Interval removal of R chest tube, Swan-Ganz, ETT and NGT. Tiny R apical PTX.\n No mediastinal shift. R basilar opacity, combination of atelectasis and post-\n procedural (chest tube) changes. Stable mild cardiomegaly.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after aortic valve\n replacement.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Small right apical pneumothorax is noted after interval removal of right chest\n tube. There is no mediastinal shift. Right basal opacity most likely\n representing a combination of atelectasis and post-chest tube removal changes.\n Unchanged cardiomegaly is noted. Post-sternotomy wires are unremarkable. No\n left pneumothorax is seen.\n\n There is interval improvement of pulmonary edema, currently with no evidence\n of fluid overload/edema noted. No appreciable pleural effusion is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-09-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1199916,
"text": " 3:13 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o ptx, inf\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with avr\n REASON FOR THIS EXAMINATION:\n r/o ptx, inf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient status post aortic valve replacement. Rule out\n pneumothorax and infiltrate.\n\n COMPARISON: Preop chest radiograph from and portable chest films\n from .\n\n FINDINGS: Poor lung expansion without focal radiopacities on the left side\n and with linear radiopacities in the right lower lung field, indicating\n plate-like atelectasis. There is no pneumothorax. Right-sided apical pleural\n thickening is unchanged from preop chest film. Cardiomediastinal and hilar\n contours are unremarkable. A left-sided line ends at the level of the\n cavoatrial junction. Sternotomy wires are intact.\n\n IMPRESSION: Interval improvement of lung aeration and right lower lobe\n atelectasis. Otherwise, stable compared with prior exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-09-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1200330,
"text": " 9:33 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p AVR\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old man status post AVR. Evaluate for pleural effusions.\n\n COMPARISON: Chest radiograph from .\n\n TWO VIEWS OF THE CHEST:\n\n The lungs are well expanded and clear. The cardiomediastinal silhouette,\n hilar contours, and pleural surfaces are normal. There may be a small left\n pleural effusion. A right IJ catheter terminates with its tip in the mid SVC.\n Sternal wires are intact.\n\n IMPRESSION:\n\n Small left effusion. No acute intrathoracic process.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2105-09-04 00:00:00.000",
"description": "Report",
"row_id": 91879,
"text": "PATIENT/TEST INFORMATION:\nIndication: AVR\nHeight: (in) 69\nWeight (lb): 237\nBSA (m2): 2.22 m2\nStatus: Inpatient\nDate/Time: at 10:43\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta. Normal aortic arch diameter. Focal calcifications in aortic arch.\nNormal descending aorta diameter. Focal calcifications in descending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve\nleaflets. Severe AS (area 0.8-1.0cm2). 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\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler.\n\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\n\nThe ascending aorta is mildly dilated. There are focal calcifications in the\naortic arch. The aortic valve is bicuspid.\n\nThe aortic valve leaflets are severely thickened/deformed. There is severe\naortic valve stenosis (valve area 0.8-1.0cm2).\nMild to moderate (+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\nThere is no pericardial effusion.\nDr. was notified in person of the results before surgical incision.\nAll four pulmonary veins identified. Pulmonary artery is of normal size.\n\nPost_Bypass:\nPreserved biventricular systolic function.\nLVEF 55%.\nThere is a bimetallic prosthesis seen at the native aortic position, stable\nand f unctioning well. Residual mean gradient is 12 mm of Hg.\nIntact thoracic aorta.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2105-09-04 00:00:00.000",
"description": "Report",
"row_id": 258485,
"text": "Normal sinus rhythm with non-specific ST-T wave abnormalities. Left atrial\nabnormality. Non-diagnostic Q waves in the inferior leads. Compared to the\nprevious tracing of no diagnostic interim change.\n\n"
}
] |
68,807 | 136,015 | She was admitted to the Acute Care Surgery team with left sided rib fractures and left pneumothorax. She was transferred to the Trauma ICU with a chest tube in place and for close monitoring of her respiratory status. The Acute Pain service was consult for thoracic epidural placement. Once hemodynamically stable she was transferred to the floor where her care was continued. Once she arrived to the floor her pain was noted to not be controlled despite the epidural. Her dose was increased along with adding standing Tylenol, Dilaudid and Ultram to her regimen. This combination was reported as not being effective and the epidural was removed. Her pain regimen was then again adjusted to include prn Oxycodone instead of the Dilaudid with addition of Lidoderm patch. This regimen proved to be more effective. Her home medications were restarted and she was able to tolerate a regular diet. She was evaluated by Physical therapy and is being recommended for rehab after her acute hospital stay. | A small left apical pneumothorax is unchanged over four hours, and a small left pleural effusion, presumably hemorrhagic to some degree, has accumulated, despite the small bore apical pleural drain. FINDINGS: In comparison with the study of , there has been reduction in the degree of left pneumothorax with the chest tube in place. Left lower lobe opacity, a combination of small left pleural and atelectasis, is grossly unchanged. Progressive opacification of the left lung base relative to chest radiographs performed 6 hours earlier, is likely a combination of subpleural hemorrhage, atelectasis and pleural fluid. 3:25 AM CHEST (PORTABLE AP) Clip # Reason: please assess chest tube MEDICAL CONDITION: History: 87F with PTX at OSH and chest tube placement REASON FOR THIS EXAMINATION: please assess chest tube No contraindications for IV contrast FINAL REPORT INDICATION: 870year-old female with pneumothorax and outside hospital chest tube placement, assess chest tube. FINDINGS: In comparison with the earlier study of this date, with the chest tube on waterseal, there is no evidence of pneumothorax. Cardiomediastinal contours are unchanged with mild cardiomegaly. 5:26 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval changes Admitting Diagnosis: S/P FALL MEDICAL CONDITION: 87 year old woman with rib fractures, PTX REASON FOR THIS EXAMINATION: eval for interval changes FINAL REPORT HISTORY: Rib fractures and pneumothorax, to assess for change. Mild scoliosis is probably positional or otherwise unrelated to trauma, but if there are clinical findings related to spinal injury dedicated neurospinal imaging should be obtained. Multiple left rib fractures are again noted. 10:20 AM CHEST (PORTABLE AP) Clip # Reason: Post chest tube pull film Admitting Diagnosis: S/P FALL MEDICAL CONDITION: 87 year old woman s/p fall with L PTX REASON FOR THIS EXAMINATION: Post chest tube pull film FINAL REPORT SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Status post fall, assess for pneumothorax. 12:05 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: assess for interval change Admitting Diagnosis: S/P FALL MEDICAL CONDITION: 87 year old woman with L PTX now with Chest tube on water seal REASON FOR THIS EXAMINATION: assess for interval change FINAL REPORT HISTORY: Pneumothorax with chest tube on waterseal. PORTABLE AP CHEST RADIOGRAPH: Contiguous left rib fractures involve at least the fifth through ninth ribs, several in two places, raising the possiblity of flail chest. COMPARISON: Outside hospital portable AP chest radiograph, . Cardiomediastinal silhouette is normal. Multiple rib fractures are again seen. Left perihilar opacities are likely atelectases. Opacification at the left base persists. Otherwise, little change. There is no evident pneumothorax. There may be a tiny residual. Dr discussed these findings and associated thoracic findings on outside hospital CT timed at 22:37 on , by telephone with Dr , in the ED, at 8:30AM. | 4 | [
{
"category": "Radiology",
"chartdate": "2146-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1251902,
"text": " 5:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval changes\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with rib fractures, PTX\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rib fractures and pneumothorax, to assess for change.\n\n FINDINGS: In comparison with the study of , there has been reduction in\n the degree of left pneumothorax with the chest tube in place. There may be a\n tiny residual. Multiple rib fractures are again seen. Opacification at the\n left base persists.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1251999,
"text": " 10:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Post chest tube pull film\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman s/p fall with L PTX\n REASON FOR THIS EXAMINATION:\n Post chest tube pull film\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post fall, assess for pneumothorax.\n\n Comparison is made with prior study, .\n\n There is no evident pneumothorax. Cardiomediastinal contours are unchanged\n with mild cardiomegaly. Left lower lobe opacity, a combination of small left\n pleural and atelectasis, is grossly unchanged. Left perihilar opacities are\n likely atelectases. Multiple left rib fractures are again noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1251771,
"text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess chest tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 87F with PTX at OSH and chest tube placement\n REASON FOR THIS EXAMINATION:\n please assess chest tube\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 870year-old female with pneumothorax and outside hospital chest\n tube placement, assess chest tube.\n\n COMPARISON: Outside hospital portable AP chest radiograph, .\n\n PORTABLE AP CHEST RADIOGRAPH: Contiguous left rib fractures involve at least\n the fifth through ninth ribs, several in two places, raising the possiblity of\n flail chest. A small left apical pneumothorax is unchanged over four hours,\n and a small left pleural effusion, presumably hemorrhagic to some degree, has\n accumulated, despite the small bore apical pleural drain. Progressive\n opacification of the left lung base relative to chest radiographs performed 6\n hours earlier, is likely a combination of subpleural hemorrhage, atelectasis\n and pleural fluid.\n\n Cardiomediastinal silhouette is normal. Mild scoliosis is probably positional\n or otherwise unrelated to trauma, but if there are clinical findings related\n to spinal injury dedicated neurospinal imaging should be obtained.\n\n Dr discussed these findings and associated thoracic findings on outside\n hospital CT timed at 22:37 on , by telephone with Dr , in the\n ED, at 8:30AM.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1251938,
"text": " 12:05 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess for interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with L PTX now with Chest tube on water seal\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumothorax with chest tube on waterseal.\n\n FINDINGS: In comparison with the earlier study of this date, with the chest\n tube on waterseal, there is no evidence of pneumothorax. Otherwise, little\n change.\n\n\n"
}
] |
30,610 | 180,378 | 1. Cardiovascular: The patient was felt to be hypotensive, likely either to septic shock, anaphylaxis, or reaction to sedating drugs used for intubation. Notably, the patient received seven liters of normal saline at , as well as two units of packed red blood cells. Her continuing tachycardia was felt to be compensatory for fluid depletion. Continuous arterial blood pressure monitoring was obtained through the right radial artery. The patient received a 500 cc normal fluid saline bolus and was started on high volume sodium bicarbonate drip at 200 cc per hour. It was possible to rapidly wean the patient off of pressors and her blood pressure remained stable from that time. All anti-hypertensives were initially held, but as the patient recovered, Lopressor was resumed, followed by other cardiac medicines. Troponin I returned at 2.2. The patient did have continuous mild substernal chest pain radiating to both arms, which increased with chest wall palpation. This was believed to be secondary to lupus pericarditis and as electrocardiogram had no changes. However, to be safe, the patient was started on aspirin and pharmacologic cardiac stress evaluation should be considered when the patient is fully recovered. 2. Pulmonary: The patient was hyperventilated with positive pressure and dilation on the morning of admission. Her responsiveness rapidly improved with therapy and she was given a trial of pressure support ventilation on the afternoon of . She tolerated this quite well and was extubated in the evening of . Post extubation gas was pH 7.43, pCO2 29, pO2 76, on 40% oxygen. Oxygen was rapidly weaned until the patient had peripheral oxygen saturations of 92% to 96% on nasal cannula. Lungs remained clear and the patient had no further acute pulmonary issues on this admission. 3. Infectious Disease: Due to her immunocompromise status and concern for periorbital cellulitis with sepsis, the patient was started on Meropenem 500 mg q 24 hours as well as continued vancomycin dosing for levels. In retrospect, it is felt that hypotension was likely secondary to drug reaction, rather than sepsis and as broad coverage as Meropenem probably was not required. However, as the patient is improving on vancomycin and Meropenem, it is felt not to be safe to narrow therapy until the patient's symptoms have fully resolved. The patient's fevers rapidly resolved and she became afebrile. Ophthalmology was consulted on the morning of and concurred that there was no orbital involvement. Infectious Disease was consulted and recommended continuation of vancomycin and Meropenem with reasoning described above. CT scan sinuses was repeated at their recommendation and showed preseptal soft tissue swelling and inflammatory soft tissue changes in the perinasal sinuses with a question of sinusitis. No air fluid levels were noted. Ear, Nose, and Throat service was consulted and felt that there was no fluid collection that could be drained. Conservative therapy with antibiotics was recommended. The patient was initially started on acyclovir due to concern that the lesions on her face could be herpetic in nature. Direct fluorescent antibody staining was sent and was negative; at this point acyclovir was halted. Bacterial cultures of the vesicles, blood and urine, were unrevealing and we were unable to narrow antibiotic coverage due to lack of a specific bacterial organism to treat. The patient received symptomatic management including Afrin for a question of sinusitis. 4. Gastrointestinal: The patient rapidly resumed a renal diet after extubation. Liver panel was normal. There were no other gastrointestinal issues. 5. Hematologic: The patient received 0.5 mg of IV vitamin K secondary to an INR of 8.0. Her INR decreased to 1.6 with this therapy and no further vitamin K was administered. The patient resumed Coumadin 3.0 mg q HS, although close INR monitoring is indicated, due to concern for overdose at that dose. The patient was also started on heparin for a history of lupus anticoagulant and elevated PTT even with anticoagulation reversed. The patient remains on a heparin drip, currently at 1,050 units per hour and it is recommended that this be continued until INR is therapeutic due to history of pulmonary embolism off Coumadin. DIC panel was negative. The patient received a third and final unit of packed red blood cells at - with appropriate response with hematocrit. 6. Endocrine: The patient received regular insulin sliding scale due to elevated blood sugars, probably secondary to stress dose steroids. The patient's rheumatology and renal outpatient attendings were consulted. It was felt that the patient's lupus nephritis had been stable on prednisone and CellCept had been started in the hopes of getting the patient off prednisone. However, due to acute immunocompromise, CellCept was discontinued and the patient was eventually returned to her outpatient dose of prednisone 10 mg q day. The patient's primary care physician and renal attending have been informed and this will be managed further at . 7. Neurologic: The patient's outpatient symptomatic neuropsychiatric therapy was resumed, including Zanaflex, Ativan, Percocet, Paxil, Neurontin, Benadryl. 8. Renal: The patient was felt to be in acute on chronic renal failure on admission due to rapid rise in creatinine. Urine electrolytes were sent with a calculated fractional excretion of sodium of 3.33% and this was felt to confirm the diagnosis of acute tubular necrosis. The patient initially received aggressive bicarbonate drip due to profound metabolic acidosis, receiving approximately 400 mEq of bicarbonate over the course of twelve hours. CellCept was discontinued as above. Stress dose steroids were initially continued at hydrocortisone 100 mg q eight hours, but this was rapidly weaned to her outpatient dose of prednisone. Renal service was consulted on the morning of . Their recommendation was supportive management, including fluid restriction. Complement was measured and found to be low with a C3 of 65 and a C4 of 9.0. Outpatient rheumatologist was Dr. , was contact and felt that this was consistent with outpatient and that there was no increase in the activity of her lupus. The patient received Tums 1.0 gm tid with meals for hyperphosphatemia which stabilized at a level of 6.0 mg/Dl. The patient's creatinine stabilized between 3.5 and 4.0 and she began to diurese on her own on the morning of . At the request of Dr. , outpatient nephrologist, Renal service as asked whether Cytoxan would be more appropriate than CellCept. Their feeling was that full resolution of acute tubular necrosis as well as a renal biopsy would be required before this therapy could be started. 9. Fluids, electrolytes, and nutrition: As above, the patient received approximately 2.5 liters of dextrose 5% in water with 100 mEq of sodium bicarbonate. Her blood pressure rapidly resolved and fluid restriction was initiated. She received gentle potassium and calcium repletion and oral calcium carbonate was given for hyperphosphatemia as above. The patient was started on a renal diet with supplements on . 10. Prophylaxis: The patient received Prilosec and IV heparin during her admission. | Compared to theprevious tracing of sinus tachycardiais no longer present. RULE OUT SINUS OR ORBITAL INFECTION. The anterior clinoid processes are not pneumatized. Small bilateral pleural effusions. IMPRESSION; Small bilateral pleural effusions. IMPRESSION: Preseptal soft tissue swelling without evidence of post-septal orbital infection. Borderline low voltage in the precordial leads. Compared to the previous tracingof previously seen mild ST segment elevations are no longer present.Precordial lead voltage is lower. Thisis not a septal Q wave. Deep narrow Q waves in lead III of uncertain significance. Small Q waves in leads II and aVF. Sinus tachycardia. Diffusenon-specific ST-T wave flattening. The intra and extraconal fat as well as the extraocular muscles and optic nerves are within normal limits bilaterally. The ventricles and sulci are normal in appearance. The cribriform plates are symmetric. There is normal -white matter differentiation. The ostiomeatal units are patent. Heart size is borderline. Sinus rhythm. Mucosal thickening is seen in the sphenoid sinus with a small air fluid level on the left. No pneumothorax. The lamina papyracea are intact. There is bilateral preseptal soft tissue swelling, right greater than left. No mass lesions are seen. No pulmonary consolidations. CT HEAD AND PARANASAL SINUSES WITHOUT CONTRAST: There is no intracranial hemorrhage or shift of normally midline structures. TECHNIQUE: Axial noncontrast images were obtained from the skull base to the vertex, as well as through the paranasal sinuses without the use of intravenous contrast. There is mucosal thickening in both maxillary sinuses, right greater than left. The ethmoid air cells and frontal sinuses are clear. CV line is in mid SVC. In reviewingthe tracings, th the Q wave appears to be more pronounced when the axis isapproximately plus 30 degrees and less pronounced when the axis isapproximately plus 60 degrees. Subsequent coronal reconstructions were then obtained. No evidence for pneumonia or CHF. HISTORY: Recent sepsis with crackles. There are no prior studies for comparison. There is no evidence of major or minor vascular territorial infarct. Inflammatory mucosal changes are noted in the paranasal sinuses. Clinical correlation is suggested. Note: The preseptal soft tissue swelling could be inflammatory or post- traumatic in origin- clinical correlation is required to provide further differentiation of this abnormality. REASON FOR THIS EXAMINATION: evaluate for infiltrate and CHF FINAL REPORT CHEST, TWO VIEWS, PA AND LATERAL. 8:12 AM CT HEAD W/O CONTRAST; CT ORBIT, SELLA & IAC W/O CONTRAST Clip # CT,CORONAL,SAGITAL,OBL RECONSTRUCTION Reason: PERIORBITAL CELLULITIS MEDICAL CONDITION: 43 year old woman with SLE, periorbital cellulitis REASON FOR THIS EXAMINATION: r/o sinus/orbit infection FINAL REPORT INDICATION: 43 YEAR OLD WOMAN WITH PERIORBITAL CELLULITIS. | 4 | [
{
"category": "ECG",
"chartdate": "2165-05-08 00:00:00.000",
"description": "Report",
"row_id": 145841,
"text": "Sinus tachycardia. Borderline low voltage in the precordial leads. Diffuse\nnon-specific ST-T wave flattening. Compared to the previous tracing\nof previously seen mild ST segment elevations are no longer present.\nPrecordial lead voltage is lower. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2165-05-11 00:00:00.000",
"description": "Report",
"row_id": 145801,
"text": "Sinus rhythm. Deep narrow Q waves in lead III of uncertain significance. This\nis not a septal Q wave. Small Q waves in leads II and aVF. Compared to the\nprevious tracing of sinus tachycardiais no longer present. In reviewing\nthe tracings, th the Q wave appears to be more pronounced when the axis is\napproximately plus 30 degrees and less pronounced when the axis is\napproximately plus 60 degrees.\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-05-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 739520,
"text": " 9:29 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for infiltrate and CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with crackles on exam and recent sepsis.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate and CHF\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, TWO VIEWS, PA AND LATERAL.\n\n HISTORY: Recent sepsis with crackles.\n\n CV line is in mid SVC. Heart size is borderline. Small bilateral pleural\n effusions. No pneumothorax. No pulmonary consolidations.\n\n IMPRESSION; Small bilateral pleural effusions. No evidence for pneumonia or\n CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-05-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 739484,
"text": " 8:12 AM\n CT HEAD W/O CONTRAST; CT ORBIT, SELLA & IAC W/O CONTRAST Clip # \n CT,CORONAL,SAGITAL,OBL RECONSTRUCTION\n Reason: PERIORBITAL CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with SLE, periorbital cellulitis\n REASON FOR THIS EXAMINATION:\n r/o sinus/orbit infection\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43 YEAR OLD WOMAN WITH PERIORBITAL CELLULITIS. RULE OUT SINUS OR\n ORBITAL INFECTION.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Axial noncontrast images were obtained from the skull base to the\n vertex, as well as through the paranasal sinuses without the use of\n intravenous contrast. Subsequent coronal reconstructions were then obtained.\n\n CT HEAD AND PARANASAL SINUSES WITHOUT CONTRAST:\n\n There is no intracranial hemorrhage or shift of normally midline structures.\n The ventricles and sulci are normal in appearance. No mass lesions are seen.\n There is normal -white matter differentiation. There is no evidence of\n major or minor vascular territorial infarct.\n\n There is bilateral preseptal soft tissue swelling, right greater than left.\n The intra and extraconal fat as well as the extraocular muscles and optic\n nerves are within normal limits bilaterally. There is mucosal thickening in\n both maxillary sinuses, right greater than left. The ostiomeatal units are\n patent. The ethmoid air cells and frontal sinuses are clear. Mucosal\n thickening is seen in the sphenoid sinus with a small air fluid level on the\n left. The cribriform plates are symmetric. The anterior clinoid processes\n are not pneumatized. The lamina papyracea are intact.\n\n IMPRESSION:\n\n Preseptal soft tissue swelling without evidence of post-septal orbital\n infection. Inflammatory mucosal changes are noted in the paranasal sinuses.\n\n Note: The preseptal soft tissue swelling could be inflammatory or post-\n traumatic in origin- clinical correlation is required to provide further\n differentiation of this abnormality.\n\n\n"
}
] |
7,648 | 118,565 | The patient was admitted to general floor for treatment of her hypokalemia, however, she continued to refuse medications, blood transfusions and several blood draws. She continued to have nonbloody diarrhea as she was having the week before admission. Urinalysis demonstrated bacteruria on , which was treated with Flagyl and Ceftriaxone. The patient eventually agreed to transfusion of two units of packed red blood cells for hematocrit of 23.6 on , and her hematocrit subsequently increased to 32.0. The patient decided to make her son her held care proxy but stood firm in her decision to remain a full code. The patient continued to be treated for hypokalemia. During her admission, we were unable to place a central line for her intravenous antibiotics and surgery attempted and was unsuccessful. The patient continued to refuse medications. The patient continued to develop erythema on the right side of her abdominal wall which ruptured on , with discharge of yellow material which was cultured as pansensitive pseudomonas. The patient's antibiotics were changed to Levofloxacin and Flagyl for full coverage of the flora of the abscess. On , the patient began to seize and underwent ventricular fibrillation arrest for which she received CPR two shocks and was intubated and sent to the Medical Intensive Care Unit. In the Medical Intensive Care Unit, the patient ruled out for myocardial infarction, had a negative echocardiogram, no events on telemetry and was quickly extubated, loaded with Depakote and transferred back to the floor. On the floor, the patient was then maintained on Valproate which was adjusted by levels for therapeutic levels. The patient continued to have discharge from her abscess wound but maintained her blood pressure, did not have elevated white blood cell count, and was afebrile during her hospitalization. On , a family meeting was held with the patient, her son , her sister , and various members of her health care team. The patient decided that she wanted to remain full code. The patient had had a femoral line placed during her code which was used to adjust her intravenous medications. The patient developed anasarca with weeping of her skin from her intravenous sites, and her wounds over the next few days. The patient's pain was well controlled with Morphine and then Dilaudid. On , it was decided to discontinue her antibiotics as she had received a full course of Levofloxacin, Flagyl and Vancomycin (Vancomycin had been started secondary to a positive sputum culture for Methicillin resistant Staphylococcus aureus during the hospitalization. The patient had discussion with her primary care physician, , Dr. , and her son , on , and it was decided to change her code status to DNR/DNI. | MONITOR SR TO SINUS TACH WITH STIMULATION-NO ECTOPY NOTED. PATIENT/TEST INFORMATION:Indication: ?Pericardial effusion.Height: (in) 60Weight (lb): 120BSA (m2): 1.50 m2BP (mm Hg): 104/64Status: InpatientDate/Time: at 14:27Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. Right ventricular systolic function isnormal. Physiologicmitral regurgitation is seen (within normal limits).TRICUSPID VALVE: Physiologic tricuspid regurgitation is seen. There is a small anteriorclear space which is consistent with either a loculated anterior pericardialeffusion or a pericardial fat pad. CHEST, SINGLE VIEW: There is an endotracheal tube whose tip is located at the thoracic inlet approximately 4.7 cm superior to the carina. PT IS HAVING IMAGINARY TACTILE SENSATIONS,FEELS WET ON SKIN WHEN ARM IS DRY.ALT IN RESP STATUS: LUNG SOUNDS COARSE AND DIMINISHED AT BASES, SATS= 98-100% ON NASAL CANNULA O2.ALT IN SKIN INTEGRITY: LOT OF EDEMA ESPECIALLY RT LEG,LEFT ARM, DEPENDENT AREAS. The spleen is diminuative. Right ventricular systolic function isnormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion.MITRAL VALVE: The mitral valve leaflets are mildly thickened. NO SEIZURE ACTIVITY-HEAD CT SCAN DONE.-, AFEBRILE. Right hydronephrosis is again seen, though further evaluation of the ureter is limited by abscence of IV contrast. Left ventricular wall thicknesses arenormal. Rule out pneumothorax. There isborderline pulmonary artery systolic hypertension.PERICARDIUM: There is a small pericardial effusion. TECHNIQUE: Unenhanced CT was performed from the lung bases to the pubic symphysis. There is linear atelectasis versus scarring at the left lateral lung base. PT ADM TO ON WITH HYPOKALEMIA. SKIN IS MOSTLY DRY,EXCEPT GROIN AREA WHICH DRAINS LARGE AMTS CLEAR FLUID FROM OLD IV SITES. 2) Linear atelectasis versus scarring at the left lateral lung base. There is relative lucency at the left apex adjacent to an interface, though no visceral pleural line is identified. There are multiple retroperitoneal lymph nodes, with low attenuation centers, consistent with metastatic disease. Sinus tachycardia, rate 105Borderline low voltage in frontal leadsNonspecific anterolateral T abnormalitiesBorderline ECG This is nonspecific in appearance and could reflect effusion, atelectasis or pneumonia. The inner dilator was removed, and a .035 glidewire was used in an attempt to access the subclavian vein or superior vena cava. ; abd wound dehiscence now c stoo FINAL REPORT (Cont) 3) Right abdominal subcutaneous air containing mass, concerning for gas forming infection or feces. The rounded low attenuation lesion in the medial segment of the left hepatic lobe is not significantly changed, measuring 4.3 x 4.6cm, and suspicious for a metastatic lesion. Evaluation of the bowel loops deep to this is limited due to abscence of IV contrast or enteric contrast at this level. Through this needle, a .018 guidewire was passed. There is a small uterine fibroid. The adrenals are unremarkable. The 4.5cm liver lesion is unchanged in the interval. PORTABLE AP CHEST: The right IJ line terminates within the left internal jugular vein at the level of the right clavicle. Further evaluation of the liver is limited due to absence of IV contrast. FIB IN PLACE-SM AMT LIQUID STOOL. There isborderline pulmonary artery systolic hypertension. Evaluation of the bowel is severely limited. There has been interval developement of a small amount of ascites, predominantly in a perisplenic distribution. CT ABDOMEN WITHOUT CONTRAST: Compared to , there has been significant interval development of large bilateral pleural effusions with compressive atelectasis/collapse of the dependent lower lobes. IMPRESSION: 1) An endotracheal tube with its tip at the thoracic inlet as described above. The previously noted mid abdominal mass measures 5.4 x 6.1cm, unchanged. Using son guidance (son was used as no superficial veins were visible), the left brachial vein was identified, and no basilic vein was seen. The gallbladder is full but not frankly distended. PT HAS OPEN AREA ON ABD-COVERED BY OSTOMY APPLIANCE DRAINING BROWNISH DRAINAGE.PT ADM TO SICU ON S/P SEIZURE, VFIB-DEFIB X1. There are no echocardiographic signsof tamponade.Conclusions:The left atrium is normal in size. Standard sterile dressing was applied. HR=76-98 NSR NO ECTOPY NOTED. (PT DEPAKOTE LEVEL LOW). There is an anterior spacewhich most likely represents a fat pad, though a loculated anteriorpericardial effusion cannot be excluded. The left ventricular cavity size is normal. HAS POOR IV ACCESS AND NO VISIBLE VEINS WERE APPARENT AT BEDSIDE BY WHICH TO PLACE PICC LINE. , PT REMAINS IN SINUS RHYTHM NO ECTOPY NOTED. The pancreas is unremarkable, though the head is poorly evaluated due to surrounding unenhanced bowel loops and previously noted abdominal mass. R FEMORAL CVL DC'D IN AFTERNOON-CONT OOZING CLEAR SEROUS FLUID FROM PUNCTURE SITE. However, there appear to be several foci of gas which are not definitely within bowel lumen, raising the concern for bowel perforation. CT PELVIS WITHOUT CONTRAST: There is interval increase in the moderate amount of free pelvic fluid. Sinus tachycardia, rate 111Low voltage in frontal leadsNonspecific anterolateral T abnormalitiesAbnormal ECG There is hazy increased desnity at the right lung base medially. This could represent infusion posteriorly, though the costophrenic angles are clear. This may represent a skin fold rather than a pneumothorax, as there is no visceral pleural line as would be expected with a pneumothorax. The left kidney is unremarkable. Although this may represent air within fecal material within the bowel lumen, an extra luminal collection cannot be excluded. The heart and mediastinal silhouettes are within normal limits. This is worrisome for a subcutaneous gas forming infection, or subcutaneous fecal material from the dehiscence. The leftventricular cavity size is normal. 4) Severe right hydronephrosis appears worse in the interval. Evaluate for position and presence of pneumothorax. K+/MG/CA REPLACED AS ORDERED. | 16 | [
{
"category": "Nursing/other",
"chartdate": "2130-10-06 00:00:00.000",
"description": "Report",
"row_id": 1364764,
"text": "FOCUS-ADM NOTE\nDATA-PT ADM FROM 3 S/P SEIZURE/V FIB. PT INTUBATED, AWAKE,\n FOLLOWS SIMPLE COMMANDS. BILAT FEM CVL IN PLACE FROM CODE.\n MONITOR SR TO SINUS TACH WITH STIMULATION-NO ECTOPY NOTED.\n ABD DISTENDED WITH OSTOMY APPLIANCE ON OPEN AREA ON ABD-DRAINING\n BROWN LIQUID DRAINAGE. PT WITH GENERALIZED EDEMA.\nACTION-IV OF D5NS INFUSING AT 125CC/HR. K+/MG/CA REPLACED AS\n ORDERED. FOLEY CATHETER INSERTED. URINE FOR U/A AND CULT\n SENT. BLOOD CULT SENT FROM FEMORAL LINES. PT WEANED TO CPAP WITH 5 PT HAVING OF APNEA-PLACED ON SIMV RATE OF 4.\n PT TRANSPORTED TO CT SCAN FOR CT SCAN OF HEAD.\n ECHO DONE AT BEDSIDE.\nDATA-AFTER RETURN FROM CT SCAN PT PLACED BACK ON CPAP WITH 5 IPS.\n PT SUCTIONED FOR SCANT YELLOW SECRETIONS. PT SM AMT LIQUID\n DARK BROWN STOOL-QUIAC POS.\nRESPONSE-RESP RATE 8-10, SPON TV 400CC.\nACTION-PT EXTUBATED AT 14:45-PLACED ON 50% FACE MASK.\nRESPONSE-O2 SATS 96-98%, RESP RATE 8-10. PT DENIES ANY RESP DISTRESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-10-07 00:00:00.000",
"description": "Report",
"row_id": 1364765,
"text": "Hemodynamics\nD: pt is alert and oriented. no seizure aactivity noted. pt continues to remain in nsr with a rate of 88-94. pt c/o back pain\nA: pt medicated with morphine for pain 2mg\nR: pain improved but bp down to 86/40. pt mentating and urine output down to 22.\nA: Dr. aware and ns bolus of 250cc given. Morphine and Ativan on hold.\nR: sbp up to 90-1-4/40's. urine output remains greater than 30cc/hr. pt c/o rt hip pain\nA: pt repositioned and treated with warm pack.\nR: pain diminshed with warm pack.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-10-07 00:00:00.000",
"description": "Report",
"row_id": 1364766,
"text": "FOCUS-TRANSFER NOTE\nDATA-SEE CHART FOR PMH. PT ADM TO ON WITH HYPOKALEMIA.\n PT VERY DIFFICULT IV ACCESS. PT HAD PICC LINE -WAS CLOTTED ON .\n INTERVENTIONAL RADIOLOGY WITHOUT SUCCESS FOR ACCESS. PT HAD CT SCAN\n ON -BILAT PLEURAL EFFUSION, LIVER METS, R UMBILICUS SUBCU MASS.\n PT HAS OPEN AREA ON ABD-COVERED BY OSTOMY APPLIANCE DRAINING\n BROWNISH DRAINAGE.\nPT ADM TO SICU ON S/P SEIZURE, VFIB-DEFIB X1. (PT DEPAKOTE\n LEVEL LOW). PT INTUBATED AT CODE FOR AIRWAY PROTECTION. 2 FEMORAL\n CVL INSERTED AT CODE. R FEMORAL CVL DC'D IN AFTERNOON-CONT OOZING\n CLEAR SEROUS FLUID FROM PUNCTURE SITE.\n PT WAS WEANED AND EXTUBATED YESTERDAY WELL, PT ON\n 4L NP AT PRESENT WITH 02 SATS 98-100%.\n , PT REMAINS IN SINUS RHYTHM NO ECTOPY NOTED.\n BLOOD CULT SENT VIA FEMORAL LINES, URINE CULT SENT.\n NO SEIZURE ACTIVITY-HEAD CT SCAN DONE.\n-, AFEBRILE. LUNGS CLEAR, O2 SATS 98%. U/O ADEQUATE.\n CONTINUES TO OOZE SEROUS FLUID FROM R FEM CVL SITE.\n FIB IN PLACE-SM AMT LIQUID STOOL. IV FLUIDS AT 125CC/HR D5NS VIA\n LEFT FEMORAL CVL. MEDICATED WITH OXYCODONE FOR ABD DISCOMFORT\n WITH EFFECT. PT LIKES PILLS CRUSHED-PLACED IN JELLO.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2130-10-08 00:00:00.000",
"description": "Report",
"row_id": 1364767,
"text": "ALT IN CO: AFEBRILE. HR=76-98 NSR NO ECTOPY NOTED. SBP=84-97. SKIN IS MOSTLY DRY,EXCEPT GROIN AREA WHICH DRAINS LARGE AMTS CLEAR FLUID FROM OLD IV SITES. PT IS HAVING IMAGINARY TACTILE SENSATIONS,FEELS WET ON SKIN WHEN ARM IS DRY.\nALT IN RESP STATUS: LUNG SOUNDS COARSE AND DIMINISHED AT BASES, SATS= 98-100% ON NASAL CANNULA O2.\nALT IN SKIN INTEGRITY: LOT OF EDEMA ESPECIALLY RT LEG,LEFT ARM, DEPENDENT AREAS. TWO TINY SKIN TEARS ON COCCYX-COVERED WITH DUODERM. NO OTHER OPEN AREAS NOTED. AIR MATTRESS ON.\nALT IN ELIMINATION: U/O=30-40CC/H. LOOSE BROWN STOOL IN FIB,SMALL AMT. ALSO LIGHTER BROWN FECAL DRAINAGE IN ABDOMENAL OSTOMY BAG-SMALL AMT.\nALT IN NUTRITION: NO NUTRITION AT PRESENT,TAKES WATER AND SMALL AMT JELLO WITH A PILL.\nPLAN TO TRANSFER TO TELE BED WHEN AVAILABLE. HOSPICE TO MEET WITH PT AND FAMILY IN NEAR FUTURE.\n"
},
{
"category": "Echo",
"chartdate": "2130-10-06 00:00:00.000",
"description": "Report",
"row_id": 97557,
"text": "PATIENT/TEST INFORMATION:\nIndication: ?Pericardial effusion.\nHeight: (in) 60\nWeight (lb): 120\nBSA (m2): 1.50 m2\nBP (mm Hg): 104/64\nStatus: Inpatient\nDate/Time: at 14:27\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function is\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\nmitral regurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: Physiologic tricuspid regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is a small pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded. There are no echocardiographic signs\nof tamponade.\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%). Right ventricular systolic function is\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion. The mitral valve leaflets are mildly thickened. There is\nborderline pulmonary artery systolic hypertension. There is a small anterior\nclear space which is consistent with either a loculated anterior pericardial\neffusion or a pericardial fat pad. There are no echocardiographic signs of\ntamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2130-10-08 00:00:00.000",
"description": "Report",
"row_id": 269416,
"text": "Sinus rhythm, rate 86\nEarly transition\nLow voltage in frontal leads\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2130-10-07 00:00:00.000",
"description": "Report",
"row_id": 269417,
"text": "Sinus tachycardia, rate 111\nLow voltage in frontal leads\nNonspecific anterolateral T abnormalities\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2130-10-06 00:00:00.000",
"description": "Report",
"row_id": 269418,
"text": "Sinus tachycardia, rate 105\nBorderline low voltage in frontal leads\nNonspecific anterolateral T abnormalities\nBorderline ECG\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-10-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 742921,
"text": " 10:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p attempted L IJ CVL placement\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Attempted placement of left IJ line. Evaluate for\n position and presence of pneumothorax.\n\n No IJ line is seen. There is no evidence of pneumothorax. There is increased\n density overlying the right lower lobe, which was present on the previous\n film. This could represent infusion posteriorly, though the costophrenic\n angles are clear. Alternatively, it could represent overlying soft tissue\n shadow. A lateral film might resolve this.\n\n IMPRESSION: No IJ line seen. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-28 00:00:00.000",
"description": "CVL/PICC",
"row_id": 742675,
"text": " 3:14 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: END STAGE COLON CA\n Contrast: CONRAY Amt: 0\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 56 YEAR OLD FEMALE WITH METASTATIC COLON CANCER. HAS POOR IV\n ACCESS AND NO VISIBLE VEINS WERE APPARENT AT BEDSIDE BY WHICH TO PLACE PICC\n LINE. PATIENT NEEDS PICC LINE ACCESS FOR IV MEDICATIONS AND FLUID.\n\n RADIOLOGISTS: Dr. , interventional radiology fellow: Dr. \n .\n\n TECHNIQUE: Informed consent was obtained from the patient and signed prior to\n the procedure and documentation placed within the chart. Dr. was\n present for the entirety of the procedure.\n\n The patient was brought to the angiography was suite, placed in the supine\n position with the left upper extremity sterilely prepped and draped. Using\n son guidance (son was used as no superficial veins were\n visible), the left brachial vein was identified, and no basilic vein was seen.\n After cutaneous anesthesia using 1% Lidocaine, a 21 gauge needle was used to\n access the left basilic vein under son guidance. Through this needle,\n a .018 guidewire was passed. The guidewire met resistance at the level of the\n axilla and a 4 FR transitional dilator sheath were inserted over the wire. The\n inner dilator was removed, and a .035 glidewire was used in an attempt to\n access the subclavian vein or superior vena cava. These measures failed,\n likely secondary to blockage. A venogram could not be performed to evaluate\n the venous structures due to this patient's allergy to iodinated contrast\n material. A PICC line was then cut to a length of 20 cm, and placed with its\n tip in the left axillary vein. Standard sterile dressing was applied.\n\n MEDICATIONS: Local anesthesia was achieved using 1% Lidocaine delivered via\n 25 gauge syringe. There was no intravenous conscious sedation.\n\n COMPLICATIONS: No complications were evident.\n\n IMPRESSION:\n\n 1. Placement of a left upper extremity 5 FR single lumen PICC with its tip in\n the left axillary vein as discussed above. The catheter could not be passed\n into the central veins most likely due to venous occlusion. A venogram could\n not be performed due to the patient's contrast allergy.\n\n\n\n\n\n\n (Over)\n\n 3:14 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: END STAGE COLON CA\n Contrast: CONRAY Amt: 0\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-10-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 742918,
"text": " 9:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ATTLINE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p attempted L IJ CVL placement\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left IJ line placed. Rule out pneumothorax.\n\n No IJ line is present. There is no pneumothorax. Increased densities are seen\n over both lower zones. There is no air bronchograms and this probably\n represents posterior fluid. It is possible it could however represent\n underlying soft tissue. This was not seen on previous chests .\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 743127,
"text": " 9:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with above\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, :\n\n HISTORY: Intubation, query pneumothorax.\n\n Comparison to prior study from .\n\n PORTABLE CHEST: The ETT is in satisfactory position, approximately 4 cm above\n the carina. There is relative lucency at the left apex adjacent to an\n interface, though no visceral pleural line is identified. Minimal linear\n atelectasis is seen at the left base. Otherwise the lungs are clear and there\n are no effusions. The heart size and mediastinal and hilar contours are\n stable.\n\n IMPRESSION:\n 1) Satisfactory position of ETT.\n 2) Unusual interface with peripheral relative lucency at the left apex. This\n may represent a skin fold rather than a pneumothorax, as there is no visceral\n pleural line as would be expected with a pneumothorax. However, given\n clinical concern for pneumothorax, a repeat study is warranted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 742640,
"text": " 10:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 65 yo F with CA - s/p Right IJ IV placement - no triple lume\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with above\n REASON FOR THIS EXAMINATION:\n 65 yo F with CA - s/p Right IJ IV placement - no triple lumen - single lumen\n angiocath placed. Please check for line tip and r/o PTX.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56 year old female status post right IJ line placement.\n\n The prior study is not available for immediate comparison, the report only is\n reviewed.\n\n PORTABLE AP CHEST: The right IJ line terminates within the left internal\n jugular vein at the level of the right clavicle. There is no pneumothorax.\n The cardiomediastinal silhouette is normal. There is hazy increased desnity\n at the right lung base medially. This is nonspecific in appearance and could\n reflect effusion, atelectasis or pneumonia. There are prominent loops of bowel\n in the left abdomen. Clinical correlation and follow up studies are\n recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-10-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 743145,
"text": " 12:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with end stage colon ca, h/o sz, no known brain mets, now s/p\n sz, VF arrest, on lovenox. r/o bleed.\n REASON FOR THIS EXAMINATION:\n r/o intracranial bleed\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY:\n\n 56 y/o woman with end stage colon cancer, history of seizures with known\n metastases. To r/o bleed.\n\n The study is compared with the previous examination performed on .\n\n FINDINGS:\n\n There is no evidence of hemorrhage, edema, midline shift, mass effect,\n hydrocephalus or extra-axial collections. The skull is unremarkable.\n\n No significant interval change since the prior examination. Please note that\n MRI is a more sensitive examination to rule out subtle parenchymal\n abnormalities.\n\n IMPRESSION:\n\n No significant interval change in the CT of the head since the prior\n examination performed on . No intracranial hemorrhage is noted.\n\n 2) Please note that MRI is the more sensitive examination to rule out subtle\n parenchymal abnormalities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-10-03 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 742942,
"text": " 11:38 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: 56 yF c end-stage colon ca.; abd wound dehiscence now c stoo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with stage IIIb colon CA s/p colectomy now w/ increasing abd\n pain, increasing white cell count and new dehiscence of abdominal wall\n REASON FOR THIS EXAMINATION:\n 56 yF c end-stage colon ca.; abd wound dehiscence now c stool being extruded;\n CT to evaluate abdomen\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Colon cancer with increasing abdominal pain and WBC, with wound\n dehisance.\n\n TECHNIQUE: Unenhanced CT was performed from the lung bases to the pubic\n symphysis.\n\n CT ABDOMEN WITHOUT CONTRAST: Compared to , there has been significant\n interval development of large bilateral pleural effusions with compressive\n atelectasis/collapse of the dependent lower lobes. The liver is diffusely\n fatty, with a small focus of sparing in the left hepatic lobe. The rounded low\n attenuation lesion in the medial segment of the left hepatic lobe is not\n significantly changed, measuring 4.3 x 4.6cm, and suspicious for a metastatic\n lesion. The gallbladder is full but not frankly distended. Further evaluation\n of the liver is limited due to absence of IV contrast. There has been interval\n developement of a small amount of ascites, predominantly in a perisplenic\n distribution. The spleen is diminuative. The pancreas is unremarkable, though\n the head is poorly evaluated due to surrounding unenhanced bowel loops and\n previously noted abdominal mass. The adrenals are unremarkable. Right\n hydronephrosis is again seen, though further evaluation of the ureter is\n limited by abscence of IV contrast. The left kidney is unremarkable.\n Evaluation of the bowel is severely limited. However, in the right upper\n quadrant, there are several foci of air which are not definitively within\n bowel. Although this may represent air within fecal material within the bowel\n lumen, an extra luminal collection cannot be excluded. To the right of the\n umbilicus, there is a subcutaneous mass measuring 2.2 x 6.3cm, which contains\n gas. This is worrisome for a subcutaneous gas forming infection, or\n subcutaneous fecal material from the dehiscence. The previously noted mid\n abdominal mass measures 5.4 x 6.1cm, unchanged.\n\n CT PELVIS WITHOUT CONTRAST: There is interval increase in the moderate amount\n of free pelvic fluid. There is a small uterine fibroid. The bladder is filled\n with urine. There are multiple retroperitoneal lymph nodes, with low\n attenuation centers, consistent with metastatic disease.\n\n There are no suspicious osseous lesions.\n\n IMPRESSION: 1) Interval developement of large bilateral pleural effusions,\n with compressive atelectasis.\n\n 2) Interval enlargement of abdominal and pelvic ascites\n\n (Over)\n\n 11:38 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: 56 yF c end-stage colon ca.; abd wound dehiscence now c stoo\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3) Right abdominal subcutaneous air containing mass, concerning for gas\n forming infection or feces. Evaluation of the bowel loops deep to this is\n limited due to abscence of IV contrast or enteric contrast at this level.\n However, there appear to be several foci of gas which are not definitely\n within bowel lumen, raising the concern for bowel perforation. No significant\n pneumoperitoneum is noted.\n\n 4) Severe right hydronephrosis appears worse in the interval. The left kidney\n is not obstructed.\n\n 5) Multiple intra-abdominal masses, some of which represent retroperitioneal\n lymph nodes. The 4.5cm liver lesion is unchanged in the interval.\n\n"
},
{
"category": "Radiology",
"chartdate": "2130-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 743125,
"text": " 8:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endotracheal tube placement.\n\n CHEST, SINGLE VIEW: There is an endotracheal tube whose tip is located at the\n thoracic inlet approximately 4.7 cm superior to the carina. There is linear\n atelectasis versus scarring at the left lateral lung base. The heart and\n mediastinal silhouettes are within normal limits. There are no pleural\n effusions. No areas of consolidation. No osseous abnormalities are\n identified.\n\n IMPRESSION: 1) An endotracheal tube with its tip at the thoracic inlet as\n described above.\n\n 2) Linear atelectasis versus scarring at the left lateral lung base.\n\n"
}
] |
7,965 | 124,460 | The patient is an 82 year old male with CAD s/p CABG and multiple MIs, HTN, CHF EF 35%, afib, and sustained VT with ICD and subsequent catheter ablation treatment who presents with an episode of ICD firing, found to be in slow VT. # CAD - The patient has a history of CAD with multiple MIs, but had no signs of active ACS while hospitalized (cardiac enzymes negative x 3, EKGs without changes). Pt was maintained on his medical regimen, with switch of hydralazine to ace inhibitor. Pt maintained his baseline normal renal function after initiating ACE inhibitor and was monitored carefully given his prior history of ARF on ACEi. # - Pt remained euvolemic, with a known baseline LVEF of 35%. # Rhythm - Pt presented after ICD firing and was found to be in slow VT in the ED. He was able to be paced out of VT, received a bolus of amiodarone, was started on a gtt, and eventually transitioned to an oral amiodarone regimen. Pt underwent ablation, with success in 1 of 2 foci. Pt's pacer setting was changed to Anti-Tachycardia Pacing at 122bpm, and his beta-blocker was titrated up. Pt was monitored on telemetry with no additional arrhythmias. # Groin bleed - Pt's ablation was complicated by a bleed after removal of the venous and arterial sheaths. Pt developed a new bruit which was evaluated by a femoral ultrasound. This showed an AV fistula, in the setting of INR 2 and PTT 78. Vascular surgery was consulted and did not feel surgical intervention was necessary unless pt developed uncontrollable bleeding, hypoperfusion to the extremity or high output heart failure. Pt did not develop any of these complications, maintained a stable Hct for several days and on reevaluation by ultrasound had resolution of the AV fistula. # Hypertension - Continue home meds. No active issues. # History of Atrial fibrillation - Pt remained in sinus rhythm thoughout admission. His coumadin was held given the ablation, and not restarted in the setting of groin bleed/ AV fistula. Upon resolution of these issues, pt was restarted on anticoagulation with Lovenox bridge to be administered by VNA, and INR follow up. # h/o DVT - Pt was prophylaxed with pneumoboots while anticoagulation was held. | # Pump - Currently euvolemic. # Pump - Currently euvolemic. # Pump - Currently euvolemic. # Pump - Currently euvolemic. Response: Vascular cxd & evaluated pt. Response: Vascular cxd & evaluated pt. # h/o DVT - heparin gtt, hold coumadin for now . # h/o DVT - heparin gtt, hold coumadin for now . # h/o DVT - heparin gtt, hold coumadin for now . # Dispo - CCU 1. # Dispo - CCU 1. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. He received a bolus of amiodarone and started on a gtt. He received a bolus of amiodarone and started on a gtt. He received a bolus of amiodarone and started on a gtt. S/p ventricular ablation w/ AICD interrogation/ adjustment. S/p ventricular ablation w/ AICD interrogation/ adjustment. Plan: Cont Amio & Heparin gtts until cardiology/ EP evals. - Hold anticoagulation for now. IV amiodarone off at start of case. IV amiodarone off at start of case. IV amiodarone off at start of case. IV amiodarone off at start of case. To start heparin gtt in AM after AM INR comes back per EP fellow. # h/o atrial fibrillation - Currently in sinus rhythm. # h/o atrial fibrillation - Currently in sinus rhythm. # h/o atrial fibrillation - Currently in sinus rhythm. # h/o atrial fibrillation - Currently in sinus rhythm. Recd HCTZ once back to CCU. Recd HCTZ once back to CCU. Recd HCTZ once back to CCU. CCU team notified of difference. CCU team notified of difference. CCU team notified of difference. Ventricular tachycardia, sustained Assessment: Action: Response: Plan: Will restart home coumadin when stable. Ventricular tachycardia, sustained Assessment: S/p overdrive pacing out of slow VT. Tnsf to CCU on amio/ heparin gtts, CE x3 flat. Tnsf to CCU on amio/ heparin gtts, CE x3 flat. Tnsf to CCU on amio/ heparin gtts, CE x3 flat. Tnsf to CCU on amio/ heparin gtts, CE x3 flat. Tnsf to CCU on amio/ heparin gtts, CE x3 flat. Tnsf to CCU on amio/ heparin gtts, CE x3 flat. Slurred R waveacross the precordial leads, probable ventricular tacycardia. There is borderline pulmonary artery systolic hypertension.There is a trivial/physiologic pericardial effusion.Compared with the prior study (images reviewed) of , findings aresimilar. There isno pericardial effusion.Compared with the prior study (images reviewed) of , the severity ofmitral regurgitation is similar. Response: Vascular cxd & evaluated pt. PATIENT/TEST INFORMATION:Indication: S/p VT ablation; Thermacool Protocol required f/u. Moderate regionalLV systolic dysfunction. # Pump - Currently euvolemic. # h/o atrial fibrillation - Currently in sinus rhythm. Ventricular tachycardia, sustained Assessment: S/p overdrive pacing out of slow VT. Mild (1+) mitral regurgitation isseen. CONCLUSION: Previously demonstrated AV fistula appears to have resolved. Mild-moderate regional LV systolicdysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- dyskinetic; mid inferior - akinetic; basal inferolateral - akinetic; midinferolateral - akinetic;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Since the previous tracing no significant change.Probable ventricular tachycardia. Since the previous tracingthere is now sinus rhythm with a narrow QRS complex. S/p ventricular ablation done on w/ adjustments made to ICD. Underwent VT ablation. Underwent VT ablation. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is dilated. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Called EMS & brought to EW. Tissue Doppler imaging suggests anincreased left ventricular filling pressure (PCWP>18mmHg). VTHeight: (in) 74Weight (lb): 167BSA (m2): 2.01 m2BP (mm Hg): 134/56HR (bpm): 65Status: InpatientDate/Time: at 10:17Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV cavity size. There is moderate regional leftventricular systolic dysfunction with thinning/akinesis of the basal half ofthe inferior and inferolateral walls. # Hypertension Variable. Evaluate for AV fistula or pseudoaneurysm. - Continue ASA, BB, Statin - serial EKGs . Plan: Cont Amio & Heparin gtts until cardiology/ EP evals. Mild (1+) MR.TRICUSPID VALVE: Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views.Conclusions:The left atrium is elongated. Action: HO made aware, pressure held until hemostasis obtained. - Hold anticoagulation for now. No AS.MITRAL VALVE: Normal mitral valve leaflets. R DP dopplerable, R PT palpable. to Height: (in) 74Weight (lb): 167BSA (m2): 2.01 m2BP (mm Hg): 117/54HR (bpm): 70Status: InpatientDate/Time: at 11:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. He was found to be in slow VT in the ED. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- akinetic; mid inferior - hypo; basal inferolateral - akinetic; midinferolateral - hypo; basal anterolateral - hypo; lateral apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Focal calcifications in aortic root. | 39 | [
{
"category": "Nursing",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352862,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, made NPO p mn for prob EP study\n tomorrow. CE x3 flat. S/p ventricular ablation w/ AICD\n interrogation/ adjustment. Procedure c/b R groin hematoma/ bleed.\n Arteriovenous fistula (AVF) , Procedure-related\n Assessment:\n S/p ventricular ablation via R groin approach using 6 & 8fr sheaths.\n 6fr sheath removed in CCU, fellow noted hematoma formation, site\n outlined. Later site assessed for lg blood loss.\n Action:\n HO made aware, pressure held until hemostasis obtained. Bruit\n appreciated on auscultation, US showed AV fistula formation, no further\n bleeding.\n Response:\n Vascular cx\nd & evaluated pt.\n Plan:\n Keep flat lying overnoc until AM rounds, monitor BP/Hr, serial Hcts. ?\n surgical intervention vs monitoring for self resolution.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352958,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n anti-tachycardial pacing. Was Amio loaded & started on a gtt. Also\n plavix loaded, got 80 lipitor & started on heparin gtt for concerns of\n ACS. Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n EPS complete . Successful ablation of one source of VT,\n unsuccessful ablation attempts at second source. ICD interrogated and\n adjustments made to ATP rate. Pt w/ chest pain/ nausea/ vomiting at\n end of case- tx\nd with 50mcg fentanyl w/ complete relief of chest pain\n and some residual nausea. Hematoma at end of sheath pull noted and\n marked by EP fellow Dr. . Later that evening, pt w/ new groin\n bleed and +AV fistula per US. Manual pressure held and Vascular surgery\n consulted- no need for intervention at this time, but continuing to\n follow.\n Arteriovenous fistula (AVF) , Procedure-related\n Assessment:\n R femoral AV fistula per US . +R fem bruit. Soft\n hematoma/ecchymosis at site- within marked borders. R DP dopplerable,\n R PT palpable. BLE equally warm to touch with baseline coloring. Pt\n denied pain/ numbness/ or any other abnormal feelings in R leg. Dsg\n this AM with very small amt new bright red blood (approx 1-2 drops).\n HCT stable 28.9 this am.\n Action:\n Vascular following. Repeat US today. Team notified of new blood on\n dsg. Dsg removed- no visible bleeding from sites. Pressure dsg applied.\n Frequent assessment of pedal pulses, distal circulation.\n Response:\n Stable. R groin without further bleeding. Await results of US.\n Plan:\n Continue to closely monitor R groin for expanding/worsening hematoma/\n fistula or s/s RLE ischemia. Recheck HCT at 17:00.\n Ventricular tachycardia, sustained\n Assessment:\n HR AV/V paced @ 70BPM with PVCs. No further runs V-tach.\n Action:\n Continues on PO lopressor and Amiodarone. Awaiting restart of IV\n heparin gtt bridge back to coumadin for hx A-fib. ICD interrogated\n yesterday as noted above.\n Response:\n Stable on current regimen.\n Plan:\n Continue to closely monitor HR/rhythm.\n Knowledge Deficit\n Assessment:\n Still intermittently refusing dosing of PO hydralazine. Concern for\n medication compliance at home- please see yesterday\ns nursing note.\n Action:\n Reinforced teaching from .\n Response:\n Still appears skeptical re: teaching.\n Plan:\n Evaluate need for home VNA at time of DC for med compliance issues and\n BP/R groin checks. Reinforce initial teaching.\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 352745,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n No events\n Allergies:\n Morphine\n Rash;\n Asacol (Oral) (Mesalamine)\n Fever/Chills;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 900 units/hour\n Amiodarone - 0.5 mg/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 04:09 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: 62 (60 - 79) bpm\n BP: 137/54(74) {137/51(73) - 154/64(87)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Total In:\n 118 mL\n 89 mL\n PO:\n TF:\n IVF:\n 118 mL\n 89 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 118 mL\n -411 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n Gen: WD/WN elderly male in NAD. Oriented x 3. Mood, affect\n appropriate.\n HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were\n pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple without JVD or lymphadenopathy.\n CV: PMI located in 5th intercostal space, midclavicular line.\n RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no wheezes or rhonchi.\n Abd: Soft, NT/ND. No HSM or tenderness. Normoactive BS.\n Ext: No c/c/e.\n Rectal: Guaiac negative in the ED.\n Labs / Radiology\n 135\n [image002.gif]\n 101\n [image002.gif]\n 24\n [image004.gif]\n 90\n AGap=12\n [image005.gif]\n 5.0\n [image002.gif]\n 27\n [image002.gif]\n 1.1\n [image007.gif]\n Comments:\n K: Hemolysis Falsely Elevates K\n K: Hemolyzed, Moderately\n CK: 125\n MB: 3\n Trop-T: 0.01\n Comments:\n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n Ca: 8.5 Mg: 1.8 P: 3.1\n 82\n 6.2\n [image007.gif]\n 10.5\n [image004.gif]\n 192\n [image008.gif]\n [image004.gif]\n 31.2\n [image007.gif]\n PT: 21.5\n PTT: 78.1\n INR: 2.0\n 12:23 AM\n TropT\n 0.01\n Other labs: CK / CKMB / Troponin-T:102/3/0.01\n Assessment and Plan\n The patient is an 82 year old male with CAD s/p CABG and multiple MIs,\n HTN, CHF EF 35%, afib, and sustained VT with ICD and subsequent\n catheter ablation treatment who presents with an episode of ICD firing,\n found to be in slow VT.\n .\n # CAD - The patient has a history of CAD with multiple MIs and is\n medically managed on atorvastatin, metoprolol, and isosorbide\n mononitrate. Will continue home meds for now. Ischemia unlikely as a\n cause for his ICD firing and slow VT however will complete a rule out\n for ACS. No evidence for infection or volume overload on exam.\n - cycle CEs\n - monitor on telemetry\n - serial EKGs\n .\n # Pump - Currently euvolemic. He has chronic systolic heart failure\n with an LVEF of 35%. No active issues.\n - continue home meds\n .\n # Rhythm - The pt is now s/p ICD firing. He was found to be in slow VT\n in the ED. He was able to be paced out of VT. He received a bolus of\n amiodarone and started on a gtt.\n - continue amiodarone gtt\n - monitor on telemetry\n - NPO after MN for possible ablation/EP study in AM, he has had several\n ablation procedures in the past but unclear how successful it may be\n given past unsuccessful attempts, will d/w EP\n - will d/w EP in AM about alternative antiarrhythmic for recurrent VT\n such as flecanide/mexilitine for long term, will d/w outpatient\n cardiologist\n .\n # Hypertension - Continue home meds. No active issues.\n .\n # h/o atrial fibrillation - Currently in sinus rhythm. Will continue\n home meds for now. Heparin gtt, hold Coumadin for now given possibility\n of study, follow INR.\n .\n # h/o DVT - heparin gtt, hold coumadin for now\n .\n # FEN - cardiac healthy diet, NPO after MN for possible EP\n study/ablation\n .\n # Access - PIV\n .\n # Code - full code\n .\n # Dispo - CCU\n 1. IV access: Peripheral line Order date: @ 2049\n 9. Heparin IV per Weight-Based Dosing Guidelines\n Order date: @ 2049\n 2. Acetaminophen 325-650 mg PO Q6H:PRN Pain, fever Order date: @\n 2304\n 10. HydrALAzine 50 mg PO Q8H\n Please hold for SBP < 100. Order date: @ 2125\n 3. Amiodarone 1 mg/min IV INFUSION\n For a total of six hours Order date: @ 2053\n 11. Hydrochlorothiazide 25 mg PO DAILY Start: In am\n Please hold for SBP < 100. Order date: @ 2125\n 4. Amiodarone 0.5 mg/min IV INFUSION\n To be started after six hours of 1 mg/min Order date: @ 2053\n 12. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY Start: In\n am\n Please hold for SBP < 100. Order date: @ 2125\n 5. Atorvastatin 40 mg PO DAILY Start: In am Order date: @ 2058\n 13. Metoprolol Tartrate 37.5 mg PO BID\n Please hold for SBP < 100 and HR < 60. Order date: @ 2125\n 6. Calcium Carbonate 500 mg PO DAILY:PRN Order date: @ 2125\n 14. Sertraline 25 mg PO DAILY Order date: @ 2125\n 7. Digoxin 0.0625 mg PO EVERY OTHER DAY Order date: @ 2125\n 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2049\n 8. Docusate Sodium 100 mg PO DAILY Order date: @ 2125\n 16. Spironolactone 25 mg PO DAILY Start: In am\n Please hold for SBP < 100. Order date: @ 2125\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352758,
"text": "Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min . Other VSS. Denied pain.\n Action:\n To EPS at 10:30.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352759,
"text": "Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min . Other VSS. Denied pain.\n Action:\n To EPS at 10:30.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352760,
"text": "Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min . Other VSS. Denied pain.\n Action:\n To EPS at 10:30.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352761,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n - EPS today.\n Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min . Other VSS. Denied pain.\n Action:\n To EPS at 10:30.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352842,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n - EPS today. IV amiodarone off at start of case. Successful\n ablation of one source of VT, unsuccessful ablation attempts at second\n source. ICD interrogated and adjustments made to ATP rate. Pt w/ chest\n pain/ nausea/ vomiting at end of case- tx\nd with 50mcg fentanyl w/\n complete relief of chest pain and some residual nausea. Rec\nd 1700ml\n IVF during case- given 20mg IV lasix. R groin venous and arterial\n sheaths in place. ACT @ 1745= 180. Of note R femoral artery SBP 30-40\n points higher than NIBP- ABP in the 180s upon arrival back to CCU.\n Given afternoon dose of hydralazine and daily dose of HCTZ with no\n change. NIBP 140s at that time. CCU team notified of difference. To\n start increased dose of lopressor tonight.\n Dr. in to pull R groin sheaths at 18:30.\n Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min. Other VSS. Denied pain.\n Action:\n To EPS at 10:30- able to ablate one source of VT, unable to ablate\n another source.\n Response:\n Without further runs of V-tach. Hypertensive since EPS.\n Plan:\n Continue to monitor s/p EPS w/ ablation. Follow HTN- to increase\n lopressor to TID dosing. Follow R groin, pedal pulses. Monitor HR,\n rhythm, e-lytes. To restart PO Amiodarone tomorrow. IV heparin\n currently off. Anticipate restart 6 hours after sheath pull for hx\n Afib.\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n LS rales\n up bilat,\n up after EPS (IVF) load 1700ml. SPO2 >95% 2l NC.\n No edema noted.\n Action:\n Rec\nd 20mg IV lasix in EP lab. Rec\nd HCTZ once back to CCU. ECHO today.\n Response:\n Good urine output after diuretics.\n Plan:\n Continue to monitor lung exam, SPO2. Assess resp status.\n Knowledge Deficit\n Assessment:\n Concern for medication compliance at home. Pt stating that he does not\n always take certain cardiac meds at home, especially if he is feeling\n dizzy for fear that his ICD will fire. Stating that he checks his BP\n everyday and if its too low (<130) he won\nt take certain pills.\nThey\n all do the same thing anyway.\n Action:\n CCU team notified of above. Medications and rationales reviewed with\n pt. Explained to pt the importance of taking all pills everyday. If\n concerned about BP pt encouraged to call PCP before changing home\n regime. Explained that all cardiac pills work differently and that he\n needs each of them.\n Response:\n Unclear if pt fully understood rationale and explanation of why he\n should not abruptly stop cardiac meds. Needs reinforcement.\n Plan:\n Verbally reinforce with pt and wife the importance of taking medication\n (especially cardiac) as prescribed.\n ------ Protected Section ------\n R femoral artery/venous sheath pull 18:30- 19:30. Small marked\n hematoma/ecchymosis directly under puncture sites at time of hemostasis\n 19:30. Bedrest x 6 hours. To start heparin gtt in AM after AM INR comes\n back per EP fellow. give coumadin tonight. Closely monitor site.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:41 ------\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352855,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, made NPO p mn for prob EP study\n tomorrow. CE x3 flat. S/p ventricular ablation w/ AICD\n interrogation/ adjustment. C/b R groin hematoma/ bleed, pressure held &\n hemostasis obtained. Auscultated +bruit, US showed AV fistula\n formation, vascular cx\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 352915,
"text": "TITLE:\n Chief Complaint:\n s/p ICD\n Firing\n 24 Hour Events:\n Ablation - unable to get 2nd focus, changed pacer settings to kick in\n to ATP pace at 122, start on home amio dose and uptitrated BB.\n Bleeding from groin site after venous and arterial sheaths removed.\n New bruit -> US with AV fistula. Evaluated by vascular surgery - no\n plan for surgery unless uncontrollable bleeding, hypoperfusion to\n distal extremity or develops high output CHF. Otherwise usually heals\n on its own. NPO after MN just in case.\n Allergies:\n Morphine\n Rash;\n Asacol (Oral) (Mesalamine)\n Fever/Chills;\n Other medications:\n Lipitor 40mg\n Isosorbide 90mg daily\n Colace 100mg \n Hydralazine 50mg q8hrs\n HCTZ 25mg daily\n Spironolactone 25mg daily\n Sertraline 25mg daily\n Dig 0.0625 QOD\n Lopressor 37.5mg TID\n Amiodarone 200mg daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 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: 36.8\nC (98.2\n HR: 70 (60 - 72) bpm\n BP: 128/55(73) {111/50(64) - 170/75(98)} mmHg\n RR: 22 (12 - 27) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Total In:\n 2,160 mL\n 188 mL\n PO:\n 120 mL\n 120 mL\n TF:\n IVF:\n 2,040 mL\n 68 mL\n Blood products:\n Total out:\n 3,000 mL\n 350 mL\n Urine:\n 3,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -840 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///29/\n Physical Examination\n Neck: Supple without JVD.\n CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: CTAB, no wheezes or rhonchi.\n Abd: Soft, NT/ND. Normoactive BS.\n Ext: No c/c/e. Pedal/PT pulses bilaterally. R Femoral Bruit\n Labs / Radiology\n 210 K/uL\n 10.3 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 21 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.9 %\n 7.0 K/uL\n [image002.jpg]\n 12:23 AM\n 04:20 AM\n 08:03 PM\n 02:17 AM\n 05:10 AM\n WBC\n 6.2\n 6.7\n 7.2\n 7.0\n Hct\n 31.2\n 32.4\n 27.9\n 28.9\n Plt\n 192\n 207\n 181\n 210\n Cr\n 1.1\n 1.1\n TropT\n 0.01\n 0.01\n Glucose\n 90\n 95\n Other labs: PT / PTT / INR:17.8/27.7/1.6, Ca++:8.5 mg/dL, Mg++:1.5\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n The patient is an 82 year old male with CAD s/p CABG and multiple MIs,\n HTN, CHF EF 35%, afib, and sustained VT with ICD and subsequent\n catheter ablation treatment who presents with an episode of ICD firing,\n found to be in slow VT.\n .\n # CAD - The patient has a history of CAD with multiple MIs and is\n medically managed on atorvastatin, metoprolol, and isosorbide\n mononitrate. Will continue home meds for now. Ischemia unlikely as a\n cause for his ICD firing and slow VT however will complete a rule out\n for ACS. No evidence for infection or volume overload on exam.\n - cycle CEs\n - monitor on telemetry\n - serial EKGs\n .\n # Pump - Currently euvolemic. He has chronic systolic heart failure\n with an LVEF of 35%. No active issues.\n - continue home meds\n .\n # Rhythm - The pt is now s/p ICD firing. He was found to be in slow VT\n in the ED. He was able to be paced out of VT. He received a bolus of\n amiodarone and started on a gtt.\n - continue amiodarone gtt\n - monitor on telemetry\n - NPO after MN for possible ablation/EP study in AM, he has had several\n ablation procedures in the past but unclear how successful it may be\n given past unsuccessful attempts, will d/w EP\n - will d/w EP in AM about alternative antiarrhythmic for recurrent VT\n such as flecanide/mexilitine for long term, will d/w outpatient\n cardiologist\n .\n # Hypertension - Continue home meds. No active issues.\n .\n # h/o atrial fibrillation - Currently in sinus rhythm. Will continue\n home meds for now. Heparin gtt, hold Coumadin for now given possibility\n of study, follow INR.\n .\n # h/o DVT - heparin gtt, hold coumadin for now\n .\n # FEN - cardiac healthy diet, NPO after MN for possible EP\n study/ablation\n .\n # Access - PIV\n .\n # Code - full code\n .\n # Dispo - CCU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352811,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n - EPS today. IV amiodarone off at start of case. Pt w/ chest\n pain/ nausea/ vomiting at end of case- tx\nd with 50mcg fentanyl w/\n complete relief of chest pain and some residual nausea. R groin venous\n and arterial sheaths in place. ACT @ 1630= .\n Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min . Other VSS. Denied pain.\n Action:\n To EPS at 10:30.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 353008,
"text": "TITLE:\n Chief Complaint:\n s/p ICD\n Firing\n 24 Hour Events:\n Ablation - unable to get 2nd focus, changed pacer settings to kick in\n to ATP pace at 122, start on home amio dose and uptitrated BB.\n Bleeding from groin site after venous and arterial sheaths removed.\n New bruit -> US with AV fistula. Evaluated by vascular surgery - no\n plan for surgery unless uncontrollable bleeding, hypoperfusion to\n distal extremity or develops high output CHF. Otherwise usually heals\n on its own. NPO after MN just in case.\n Allergies:\n Morphine\n Rash;\n Asacol (Oral) (Mesalamine)\n Fever/Chills;\n Other medications:\n Lipitor 40mg\n Isosorbide 90mg daily\n Colace 100mg \n Hydralazine 50mg q8hrs\n HCTZ 25mg daily\n Spironolactone 25mg daily\n Sertraline 25mg daily\n Dig 0.0625 QOD\n Lopressor 37.5mg TID\n Amiodarone 200mg daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 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: 36.8\nC (98.2\n HR: 70 (60 - 72) bpm\n BP: 128/55(73) {111/50(64) - 170/75(98)} mmHg\n RR: 22 (12 - 27) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Total In:\n 2,160 mL\n 188 mL\n PO:\n 120 mL\n 120 mL\n TF:\n IVF:\n 2,040 mL\n 68 mL\n Blood products:\n Total out:\n 3,000 mL\n 350 mL\n Urine:\n 3,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -840 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///29/\n Physical Examination\n Neck: Supple without JVD.\n CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: CTAB, no wheezes or rhonchi.\n Abd: Soft, NT/ND. Normoactive BS.\n Ext: No c/c/e. Pedal/PT pulses bilaterally. R Femoral Bruit\n Labs / Radiology\n 210 K/uL\n 10.3 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 21 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.9 %\n 7.0 K/uL\n [image002.jpg]\n 12:23 AM\n 04:20 AM\n 08:03 PM\n 02:17 AM\n 05:10 AM\n WBC\n 6.2\n 6.7\n 7.2\n 7.0\n Hct\n 31.2\n 32.4\n 27.9\n 28.9\n Plt\n 192\n 207\n 181\n 210\n Cr\n 1.1\n 1.1\n TropT\n 0.01\n 0.01\n Glucose\n 90\n 95\n Other labs: PT / PTT / INR:17.8/27.7/1.6, Ca++:8.5 mg/dL, Mg++:1.5\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n The patient is an 82 year old male with CAD s/p CABG and multiple MIs,\n HTN, CHF EF 35%, afib, and sustained VT with ICD and subsequent\n catheter ablation treatment who presents with an episode of ICD firing,\n found to be in slow VT.\n .\n # Rhythm - The pt is now s/p ICD firing. He was found to be in slow VT\n in the ED. Patient taken to EP lab and had RFA to one culprit foci. A\n second foci was not amenable to ablation. ICD was reset for ATP at\n 122.\n - continue amiodarone 200mg daily\n - Continue Metoprolol 37.5mg TID\n - monitor on telemetry\n - NPO after MN for possible ablation/EP study in AM, he has had several\n ablation procedures in the past but unclear how successful it may be\n given past unsuccessful attempts, will d/w EP\n - will d/w EP in AM about alternative antiarrhythmic for recurrent VT\n such as flecanide/mexilitine for long term, will d/w outpatient\n cardiologist\n # CAD - The patient has a history of CAD with multiple MIs and is\n medically managed on atorvastatin, metoprolol, and isosorbide\n mononitrate. Patient has r/o for MI, Ischemia unlikely as a cause for\n his ICD firing and slow VT however will complete a rule out for ACS.\n No evidence for infection or volume overload on exam.\n - cycle CEs\n - monitor on telemetry\n - serial EKGs\n .\n # Pump - Currently euvolemic. He has chronic systolic heart failure\n with an LVEF of 35%. No active issues.\n - continue home meds\n .\n .\n # Hypertension - Continue home meds. No active issues.\n .\n # h/o atrial fibrillation - Currently in sinus rhythm. Will continue\n home meds for now.\n - Hold anticoagulation for now. Will restart home coumadin when\n stable.\n .\n # h/o DVT\n In light of femoral fistula bleed, hold anticoagulation for\n now\n - Pneumoboots\n .\n # FEN - cardiac healthy diet, NPO after MN for possible EP\n study/ablation\n .\n # Access - PIV\n .\n # Code - full code\n .\n # Dispo\n To Floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352680,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching tv @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also\n plavix loaded, got 80 lipitor & started on heparin gtt for concerns of\n ACS. Tnsf to CCU on amio/ heparin gtts, made NPO p mn for prob EP study\n tomorrow. CE x2 flat.\n Ventricular tachycardia, sustained\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352993,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n anti-tachycardial pacing. Was Amio loaded & started on a gtt. Also\n plavix loaded, got 80 lipitor & started on heparin gtt for concerns of\n ACS. Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n EPS complete . Successful ablation of one source of VT,\n unsuccessful ablation attempts at second source. ICD interrogated and\n adjustments made to ATP rate. Pt w/ chest pain/ nausea/ vomiting at\n end of case- tx\nd with 50mcg fentanyl w/ complete relief of chest pain\n and some residual nausea. Hematoma at end of sheath pull noted and\n marked by EP fellow Dr. . Later that evening, pt w/ new groin\n bleed and +AV fistula per US. Manual pressure held and Vascular surgery\n consulted- no need for intervention at this time, but continuing to\n follow.\n Arteriovenous fistula (AVF) , Procedure-related\n Assessment:\n R femoral AV fistula per US . +R fem bruit. Soft\n hematoma/ecchymosis at site- within marked borders. R DP dopplerable,\n R PT palpable. BLE equally warm to touch with baseline coloring. Pt\n denied pain/ numbness/ or any other abnormal feelings in R leg. Dsg\n this AM with very small amt new bright red blood (approx 1-2 drops).\n HCT stable 28.9 this am.\n Action:\n Vascular following. Team notified of new blood on dsg. Dsg\n removed- no visible bleeding from sites. Pressure dsg applied. Frequent\n assessment of pedal pulses, distal circulation.\n Response:\n Stable. R groin without further bleeding..\n Plan:\n Continue to closely monitor R groin for expanding/worsening hematoma/\n fistula or s/s RLE ischemia. Recheck HCT at 17:00. Follow-up US on\n Friday . Restart anticoagulation for A-fib (coumadin/\n heparin gtt).\n Ventricular tachycardia, sustained\n Assessment:\n HR AV/V paced @ 70BPM with PVCs. No further runs V-tach.\n Action:\n Continues on PO lopressor and Amiodarone. Awaiting restart of IV\n heparin gtt bridge back to coumadin for hx A-fib. ICD interrogated\n yesterday as noted above.\n Response:\n Stable on current regimen.\n Plan:\n Continue to closely monitor HR/rhythm.\n Knowledge Deficit\n Assessment:\n Still intermittently refusing dosing of PO hydralazine. Concern for\n medication compliance at home- please see yesterday\ns nursing note.\n Action:\n Reinforced teaching from .\n Response:\n Still appears skeptical re: teaching.\n Plan:\n Evaluate need for home VNA at time of DC for med compliance issues and\n BP/R groin checks. Reinforce initial teaching.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 352994,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n anti-tachycardial pacing. Was Amio loaded & started on a gtt. Also\n plavix loaded, got 80 lipitor & started on heparin gtt for concerns of\n ACS. Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n EPS complete . Successful ablation of one source of VT,\n unsuccessful ablation attempts at second source. ICD interrogated and\n adjustments made to ATP rate. Pt w/ chest pain/ nausea/ vomiting at\n end of case- tx\nd with 50mcg fentanyl w/ complete relief of chest pain\n and some residual nausea. Hematoma at end of sheath pull noted and\n marked by EP fellow Dr. . Later that evening, pt w/ new groin\n bleed and +AV fistula per US. Manual pressure held and Vascular surgery\n consulted- no need for intervention at this time, but continuing to\n follow.\n Arteriovenous fistula (AVF) , Procedure-related\n Assessment:\n R femoral AV fistula per US . +R fem bruit. Soft\n hematoma/ecchymosis at site- within marked borders. R DP dopplerable,\n R PT palpable. BLE equally warm to touch with baseline coloring. Pt\n denied pain/ numbness/ or any other abnormal feelings in R leg. Dsg\n this AM with very small amt new bright red blood (approx 1-2 drops).\n HCT stable 28.9 this am.\n Action:\n Vascular following. Team notified of new blood on dsg. Dsg\n removed- no visible bleeding from sites. Pressure dsg applied. Frequent\n assessment of pedal pulses, distal circulation.\n Response:\n Stable. R groin without further bleeding..\n Plan:\n Continue to closely monitor R groin for expanding/worsening hematoma/\n fistula or s/s RLE ischemia. Recheck HCT at 17:00. Follow-up US on\n Friday . Restart anticoagulation for A-fib (coumadin/\n heparin gtt).\n Ventricular tachycardia, sustained\n Assessment:\n HR AV/V paced @ 70BPM with PVCs. No further runs V-tach.\n Action:\n Continues on PO lopressor and Amiodarone. Awaiting restart of IV\n heparin gtt bridge back to coumadin for hx A-fib. ICD interrogated\n yesterday as noted above.\n Response:\n Stable on current regimen.\n Plan:\n Continue to closely monitor HR/rhythm.\n Knowledge Deficit\n Assessment:\n Still intermittently refusing dosing of PO hydralazine. Concern for\n medication compliance at home- please see yesterday\ns nursing note.\n Action:\n Reinforced teaching from .\n Response:\n Still appears skeptical re: teaching.\n Plan:\n Evaluate need for home VNA at time of DC for med compliance issues and\n BP/R groin checks. Reinforce initial teaching.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352709,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, made NPO p mn for prob EP study\n tomorrow. CE x3 flat.\n Ventricular tachycardia, sustained\n Assessment:\n S/p overdrive pacing out of slow VT. Received V-paced @ 60 w/ freq\n PVCs, runs of NSVT in. Amio gtt @ 1mg/min, Heparin gtt @ 900u, no c/o\n cp.\n Action:\n Amio reduced to .5mg & made NPO p MN.\n Response:\n No further runs of NSVT, only rare PVCs.\n Plan:\n Cont Amio & Heparin gtts until cardiology/ EP evals. ? Ablation.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352832,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n - EPS today. IV amiodarone off at start of case. Pt w/ chest\n pain/ nausea/ vomiting at end of case- tx\nd with 50mcg fentanyl w/\n complete relief of chest pain and some residual nausea. Rec\nd 1700ml\n IVF during case- given 20mg IV lasix. R groin venous and arterial\n sheaths in place. ACT @ 1630= = 180. Of note R\n femoral artery SBP 30-40 points higher than NIBP- ABP in the 180s upon\n arrival back to CCU. Given afternoon dose of hydralazine and daily dose\n of HCTZ with no change. NIBP 140s at that time. CCU team notified of\n difference.\n Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min. Other VSS. Denied pain.\n Action:\n To EPS at 10:30- able to ablate one source of VT, unable to ablate\n another source.\n Response:\n Without further runs of V-tach. Hypertensive since EPS.\n Plan:\n Continue to monitor s/p EPS w/ ablation. Follow HTN- to increase\n lopressor to TID dosing. Follow R groin, pedal pulses. Monitor HR,\n rhythm, e-lytes. To start PO Amiodarone tomorrow. IV heparin currently\n off. Anticipate restart 6 hours after sheath pull for hx Afib.\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n LS rales\n up bilat,\n up after EPS (IVF) load 1700ml. SPO2 >95% 2l NC.\n No edema noted.\n Action:\n Rec\nd 20mg IV lasix in EP lab. Rec\nd HCTZ once back to CCU. ECHO today.\n Response:\n Good urine output after diuretics.\n Plan:\n Continue to monitor lung exam, SPO2. Assess resp status.\n Knowledge Deficit\n Assessment:\n Concern for medication compliance at home. Pt stating that he does not\n always take certain cardiac meds at home, especially if he is feeling\n dizzy for fear that his ICD will fire. Stating that he checks his BP\n everyday and if its too low (<130) he won\nt take certain pills.\nThey\n all do the same thing anyway.\n Action:\n CCU team notified of above. Medications and rationales reviewed with\n pt. Explained to pt the importance of taking all pills everyday. If\n concerned about BP pt encouraged to call PCP before changing home\n regime. Explained that all cardiac pills work differently and that he\n needs each of them.\n Response:\n Unclear if pt fully understood rationale and explanation of why he\n should not abruptly stop cardiac meds. Needs reinforcement.\n Plan:\n Verbally reinforce with pt and wife the importance of taking medication\n (especially cardiac) as prescribed.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352835,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n - EPS today. IV amiodarone off at start of case. Successful\n ablation of one source of VT, unsuccessful ablation attempts at second\n source. ICD interrogated and adjustments made to ATP rate. Pt w/ chest\n pain/ nausea/ vomiting at end of case- tx\nd with 50mcg fentanyl w/\n complete relief of chest pain and some residual nausea. Rec\nd 1700ml\n IVF during case- given 20mg IV lasix. R groin venous and arterial\n sheaths in place. ACT @ 1745= 180. Of note R femoral artery SBP 30-40\n points higher than NIBP- ABP in the 180s upon arrival back to CCU.\n Given afternoon dose of hydralazine and daily dose of HCTZ with no\n change. NIBP 140s at that time. CCU team notified of difference. To\n start increased dose of lopressor tonight.\n Dr. in to pull R groin sheaths at 18:30.\n Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min. Other VSS. Denied pain.\n Action:\n To EPS at 10:30- able to ablate one source of VT, unable to ablate\n another source.\n Response:\n Without further runs of V-tach. Hypertensive since EPS.\n Plan:\n Continue to monitor s/p EPS w/ ablation. Follow HTN- to increase\n lopressor to TID dosing. Follow R groin, pedal pulses. Monitor HR,\n rhythm, e-lytes. To restart PO Amiodarone tomorrow. IV heparin\n currently off. Anticipate restart 6 hours after sheath pull for hx\n Afib.\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n LS rales\n up bilat,\n up after EPS (IVF) load 1700ml. SPO2 >95% 2l NC.\n No edema noted.\n Action:\n Rec\nd 20mg IV lasix in EP lab. Rec\nd HCTZ once back to CCU. ECHO today.\n Response:\n Good urine output after diuretics.\n Plan:\n Continue to monitor lung exam, SPO2. Assess resp status.\n Knowledge Deficit\n Assessment:\n Concern for medication compliance at home. Pt stating that he does not\n always take certain cardiac meds at home, especially if he is feeling\n dizzy for fear that his ICD will fire. Stating that he checks his BP\n everyday and if its too low (<130) he won\nt take certain pills.\nThey\n all do the same thing anyway.\n Action:\n CCU team notified of above. Medications and rationales reviewed with\n pt. Explained to pt the importance of taking all pills everyday. If\n concerned about BP pt encouraged to call PCP before changing home\n regime. Explained that all cardiac pills work differently and that he\n needs each of them.\n Response:\n Unclear if pt fully understood rationale and explanation of why he\n should not abruptly stop cardiac meds. Needs reinforcement.\n Plan:\n Verbally reinforce with pt and wife the importance of taking medication\n (especially cardiac) as prescribed.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352910,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, made NPO p mn for prob EP study\n tomorrow. CE x3 flat. S/p ventricular ablation done on also\n adjustments made to ICD (VT threshold reduced, rate ^70) returned to\n CCU. Procedure c/b R groin hematoma/ bleeding.\n Arteriovenous fistula (AVF) , Procedure-related\n Assessment:\n S/p ventricular ablation via R groin approach using 6 & 8fr sheaths.\n 6fr sheath removed in CCU, EP fellow noted hematoma formation, site\n outlined. Later site was assessed for lg blood loss.\n Action:\n HO made aware, pressure held until hemostasis obtained. Bruit\n appreciated on auscultation, US showed AV fistula formation, no further\n bleeding.\n Response:\n Vascular cx\nd & evaluated pt.\n Plan:\n Keep flat lying overnoc until AM rounds, no heparin products, monitor\n BP/Hr, serial Hcts. ? surgical intervention vs monitoring for self\n resolution.\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 352690,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n No events\n Allergies:\n Morphine\n Rash;\n Asacol (Oral) (Mesalamine)\n Fever/Chills;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 900 units/hour\n Amiodarone - 0.5 mg/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 04:09 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: 62 (60 - 79) bpm\n BP: 137/54(74) {137/51(73) - 154/64(87)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Total In:\n 118 mL\n 89 mL\n PO:\n TF:\n IVF:\n 118 mL\n 89 mL\n Blood products:\n Total out:\n 0 mL\n 500 mL\n Urine:\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 118 mL\n -411 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n Gen: WD/WN elderly male in NAD. Oriented x 3. Mood, affect\n appropriate.\n HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were\n pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple without JVD or lymphadenopathy.\n CV: PMI located in 5th intercostal space, midclavicular line.\n RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp\n were unlabored, no accessory muscle use. CTAB, no wheezes or rhonchi.\n Abd: Soft, NT/ND. No HSM or tenderness. Normoactive BS.\n Ext: No c/c/e.\n Rectal: Guaiac negative in the ED.\n Labs / Radiology\n [image002.jpg]\n 12:23 AM\n TropT\n 0.01\n Other labs: CK / CKMB / Troponin-T:102/3/0.01\n Assessment and Plan\n The patient is an 82 year old male with CAD s/p CABG and multiple MIs,\n HTN, CHF EF 35%, afib, and sustained VT with ICD and subsequent\n catheter ablation treatment who presents with an episode of ICD firing,\n found to be in slow VT.\n .\n # CAD - The patient has a history of CAD with multiple MIs and\n is medically managed on atorvastatin, metoprolol, and isosorbide\n mononitrate. Will continue home meds for now. Ischemia unlikely as a\n cause for his ICD firing and slow VT however will complete a rule out\n for ACS.\n - cycle CEs\n - monitor on telemetry\n - serial EKGs\n .\n # Pump - Currently euvolemic. He has chronic systolic heart failure\n with an LVEF of 35%. No active issues.\n - continue home meds\n .\n # Rhythm - The pt is now s/p ICD firing. He was found to be in slow VT\n in the ED. He was able to be paced out of VT. He received a bolus of\n amiodarone and started on a gtt.\n - continue amiodarone gtt\n - monitor on telemetry\n - NPO after MN for possible ablation/EP study in AM, he has had several\n ablation procedures in the past but unclear how successful it may be\n given past unsuccessful attempts, will d/w EP\n - will d/w EP in AM about alternative antiarrhythmic for recurrent VT\n such as flecanide/mexilitine for long term, will d/w outpatient\n cardiologist\n .\n # Hypertension - Continue home meds. No active issues.\n .\n # h/o atrial fibrillation - Currently in sinus rhythm. Will continue\n home meds for now. Heparin gtt, hold Coumadin for now given possibility\n of study, follow INR.\n .\n # h/o DVT - heparin gtt, hold coumadin for now\n .\n # FEN - cardiac healthy diet, NPO after MN for possible EP\n study/ablation\n .\n # Access - PIV\n .\n # Code - full code\n .\n # Dispo - CCU\n 1. IV access: Peripheral line Order date: @ 2049\n 9. Heparin IV per Weight-Based Dosing Guidelines\n Order date: @ 2049\n 2. Acetaminophen 325-650 mg PO Q6H:PRN Pain, fever Order date: @\n 2304\n 10. HydrALAzine 50 mg PO Q8H\n Please hold for SBP < 100. Order date: @ 2125\n 3. Amiodarone 1 mg/min IV INFUSION\n For a total of six hours Order date: @ 2053\n 11. Hydrochlorothiazide 25 mg PO DAILY Start: In am\n Please hold for SBP < 100. Order date: @ 2125\n 4. Amiodarone 0.5 mg/min IV INFUSION\n To be started after six hours of 1 mg/min Order date: @ 2053\n 12. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY Start: In\n am\n Please hold for SBP < 100. Order date: @ 2125\n 5. Atorvastatin 40 mg PO DAILY Start: In am Order date: @ 2058\n 13. Metoprolol Tartrate 37.5 mg PO BID\n Please hold for SBP < 100 and HR < 60. Order date: @ 2125\n 6. Calcium Carbonate 500 mg PO DAILY:PRN Order date: @ 2125\n 14. Sertraline 25 mg PO DAILY Order date: @ 2125\n 7. Digoxin 0.0625 mg PO EVERY OTHER DAY Order date: @ 2125\n 15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 2049\n 8. Docusate Sodium 100 mg PO DAILY Order date: @ 2125\n 16. Spironolactone 25 mg PO DAILY Start: In am\n Please hold for SBP < 100. Order date: @ 2125\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352710,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, made NPO p mn for prob EP study\n tomorrow. CE x3 flat.\n Ventricular tachycardia, sustained\n Assessment:\n S/p overdrive pacing out of slow VT. Received V-paced @ 60 w/ freq\n PVCs, runs of NSVT in. Amio gtt @ 1mg/min, Heparin gtt @ 900u, no c/o\n cp.\n Action:\n Amio reduced to .5mg & made NPO p MN.\n Response:\n No further runs of NSVT, only rare PVCs.\n Plan:\n Cont Amio & Heparin gtts until cardiology/ EP evals. ? Ablation.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352907,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, made NPO p mn for prob EP study\n tomorrow. CE x3 flat. S/p ventricular ablation done on w/\n adjustments made to ICD. Returned to CCU post procedure c/b R groin\n hematoma/ bleed.\n Arteriovenous fistula (AVF) , Procedure-related\n Assessment:\n S/p ventricular ablation via R groin approach using 6 & 8fr sheaths.\n 6fr sheath removed in CCU, fellow noted hematoma formation, site\n outlined. Later site assessed for lg blood loss.\n Action:\n HO made aware, pressure held until hemostasis obtained. Bruit\n appreciated on auscultation, US showed AV fistula formation, no further\n bleeding.\n Response:\n Vascular cx\nd & evaluated pt.\n Plan:\n Keep flat lying overnoc until AM rounds, monitor BP/Hr, serial Hcts. ?\n surgical intervention vs monitoring for self resolution.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 352816,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n antitachycardia pacing. Was Amio loaded & started on a gtt. Also plavix\n loaded, got 80 lipitor & started on heparin gtt for concerns of ACS.\n Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n - EPS today. IV amiodarone off at start of case. Pt w/ chest\n pain/ nausea/ vomiting at end of case- tx\nd with 50mcg fentanyl w/\n complete relief of chest pain and some residual nausea. R groin venous\n and arterial sheaths in place. ACT @ 1630= .\n Ventricular tachycardia, sustained\n Assessment:\n HR 60s AV/V paced with rare-occasional PVCs on IV amiodarone @\n 0.5mg/min. Other VSS. Denied pain.\n Action:\n To EPS at 10:30-\n Response:\n Plan:\n Heart failure (CHF), Systolic, Chronic\n Assessment:\n LS rales\n up bilat.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 353038,
"text": "TITLE:\n Chief Complaint:\n s/p ICD\n Firing\n 24 Hour Events:\n Ablation - unable to get 2nd focus, changed pacer settings to kick in\n to ATP pace at 122, start on home amio dose and uptitrated BB.\n Bleeding from groin site after venous and arterial sheaths removed.\n New bruit -> US with AV fistula. Evaluated by vascular surgery - no\n plan for surgery unless uncontrollable bleeding, hypoperfusion to\n distal extremity or develops high output CHF. Otherwise usually heals\n on its own. NPO after MN just in case.\n Allergies:\n Morphine\n Rash;\n Asacol (Oral) (Mesalamine)\n Fever/Chills;\n Other medications:\n Lipitor 40mg\n Isosorbide 90mg daily\n Colace 100mg \n Hydralazine 50mg q8hrs\n HCTZ 25mg daily\n Spironolactone 25mg daily\n Sertraline 25mg daily\n Dig 0.0625 QOD\n Lopressor 37.5mg TID\n Amiodarone 200mg daily\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:48 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: 36.8\nC (98.2\n HR: 70 (60 - 72) bpm\n BP: 128/55(73) {111/50(64) - 170/75(98)} mmHg\n RR: 22 (12 - 27) insp/min\n SpO2: 92%\n Heart rhythm: V Paced\n Total In:\n 2,160 mL\n 188 mL\n PO:\n 120 mL\n 120 mL\n TF:\n IVF:\n 2,040 mL\n 68 mL\n Blood products:\n Total out:\n 3,000 mL\n 350 mL\n Urine:\n 3,000 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -840 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 92%\n ABG: ///29/\n Physical Examination\n Neck: Supple without JVD.\n CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n Chest: CTAB, no wheezes or rhonchi.\n Abd: Soft, NT/ND. Normoactive BS.\n Ext: No c/c/e. Pedal/PT pulses bilaterally. R Femoral Bruit\n Labs / Radiology\n 210 K/uL\n 10.3 g/dL\n 95 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 3.4 mEq/L\n 21 mg/dL\n 101 mEq/L\n 138 mEq/L\n 28.9 %\n 7.0 K/uL\n [image002.jpg]\n 12:23 AM\n 04:20 AM\n 08:03 PM\n 02:17 AM\n 05:10 AM\n WBC\n 6.2\n 6.7\n 7.2\n 7.0\n Hct\n 31.2\n 32.4\n 27.9\n 28.9\n Plt\n 192\n 207\n 181\n 210\n Cr\n 1.1\n 1.1\n TropT\n 0.01\n 0.01\n Glucose\n 90\n 95\n Other labs: PT / PTT / INR:17.8/27.7/1.6, Ca++:8.5 mg/dL, Mg++:1.5\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n The patient is an 82 year old male with CAD s/p CABG and multiple MIs,\n HTN, CHF EF 35%, afib, and sustained VT with ICD and subsequent\n catheter ablation treatment who presents with an episode of ICD firing,\n found to be in slow VT.\n .\n # Rhythm - The pt is now s/p ICD firing. He was found to be in slow VT\n in the ED. Patient taken to EP lab and had RFA to one culprit foci. A\n second foci was not amenable to ablation. ICD was reset for ATP at\n 122.\n - continue amiodarone 200mg daily\n - Continue Metoprolol 37.5mg TID\n - monitor on telemetry\n # Femoral AV Fistula: Patient had episode of bleeding from femoral\n site yesterday PM. HCT has been stable. Bruit is present, fistula\n confirmed by ultrasound. Vascular consulted, recommended no\n intervention and f/u u/s on Friday.\n - f/u u/s on Friday\n - Monitor HCT\n # CAD - The patient has a history of CAD with multiple MIs and is\n medically managed on atorvastatin, metoprolol, and isosorbide\n mononitrate. Patient has r/o for MI, Ischemia unlikely as a cause for\n his ICD firing and slow VT. No evidence for infection or volume\n overload on exam.\n - Continue ASA, BB, Statin\n - serial EKGs\n .\n # Pump - Currently euvolemic. He has chronic systolic heart failure\n with an LVEF of 35%. No active issues.\n - continue HCTZ\n .\n # Hypertension\n Variable. Patient intermittently refusing doses of\n hydralazine. Given patient\ns CHF, it is warranted to add an ACE to his\n regimen. It appears that ACE had been d/c in in light of his\n transient renal failure. Patient\ns renal function is at baseline\n currently\n - Will d/c hydral, switch to Captopril 25mg TID and titrate as\n needed\n - Continue HCTZ, Imdur, BB\n .\n # h/o atrial fibrillation - Currently in sinus rhythm. Will continue\n home meds for now.\n - Hold anticoagulation for now. Will restart home coumadin when\n stable.\n .\n # h/o DVT\n In light of femoral fistula bleed, hold anticoagulation for\n now\n - Pneumoboots\n .\n # FEN - cardiac healthy diet, NPO after MN for possible EP\n study/ablation\n .\n # Access - PIV\n .\n # Code - full code\n .\n # Dispo\n To Floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 353019,
"text": "Pt is an 82yo male w/ hx of CAD s/p CABG, HTN, CHF w/ EF 35%, AF,\n sustained VT w/ ablation & AICD. Was watching TV @ home when suddenly\n felt lightheaded/ diaphoretic, followed by his AICD firing x1. Called\n EMS & brought to EW. Was found to be in a slow VT rate 120s. EP planned\n for cardioversion (received etomidate) but was able to brake VT by\n anti-tachycardial pacing. Was Amio loaded & started on a gtt. Also\n plavix loaded, got 80 lipitor & started on heparin gtt for concerns of\n ACS. Tnsf to CCU on amio/ heparin gtts, CE x3 flat.\n EPS complete . Successful ablation of one source of VT,\n unsuccessful ablation attempts at second source. ICD interrogated and\n adjustments made to ATP rate. Pt w/ chest pain/ nausea/ vomiting at\n end of case- tx\nd with 50mcg fentanyl w/ complete relief of chest pain\n and some residual nausea. Hematoma at end of sheath pull noted and\n marked by EP fellow Dr. . Later that evening, pt w/ new groin\n bleed and +AV fistula per US. Manual pressure held and Vascular surgery\n consulted- no need for intervention at this time, but continuing to\n follow.\n Arteriovenous fistula (AVF) , Procedure-related\n Assessment:\n R femoral AV fistula per US . +R fem bruit. Soft\n hematoma/ecchymosis at site- within marked borders. R DP dopplerable,\n R PT palpable. BLE equally warm to touch with baseline coloring. Pt\n denied pain/ numbness/ or any other abnormal feelings in R leg. Dsg\n this AM with very small amt new bright red blood (approx 1-2 drops).\n HCT stable 28.9 this am.\n Action:\n Vascular following. Team notified of new blood on dsg. Dsg\n removed- no visible bleeding from sites. Pressure dsg applied. Frequent\n assessment of pedal pulses, distal circulation.\n Response:\n Stable. R groin without further bleeding..\n Plan:\n Continue to closely monitor R groin for expanding/worsening hematoma/\n fistula or s/s RLE ischemia. Recheck HCT at 17:00. Follow-up US on\n Friday . Restart anticoagulation for A-fib (coumadin/\n heparin gtt).\n Ventricular tachycardia, sustained\n Assessment:\n HR AV/V paced @ 70BPM with PVCs. No further runs V-tach.\n Action:\n Continues on PO lopressor and Amiodarone. Awaiting restart of IV\n heparin gtt bridge back to coumadin for hx A-fib. ICD interrogated\n yesterday as noted above.\n Response:\n Stable on current regimen.\n Plan:\n Continue to closely monitor HR/rhythm.\n Knowledge Deficit\n Assessment:\n Still intermittently refusing dosing of PO hydralazine. Concern for\n medication compliance at home- please see yesterday\ns nursing note.\n Action:\n Reinforced teaching from .\n Response:\n Still appears skeptical re: teaching.\n Plan:\n Evaluate need for home VNA at time of DC for med compliance issues and\n BP/R groin checks. Reinforce initial teaching.\n ------ Protected Section ------\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n VENTRICULAR TACHYCARDIA;TELEMETRY\n Code status:\n Full code\n Height:\n 74 Inch\n Admission weight:\n 75.9 kg\n Daily weight:\n Allergies/Reactions:\n Morphine\n Rash;\n Asacol (Oral) (Mesalamine)\n Fever/Chills;\n Precautions: No Additional Precautions\n PMH: Renal Failure\n CV-PMH: Angina, Arrhythmias, CAD, CHF, Hypertension, MI, Pacemaker,\n PVD\n Additional history: s/p CABG, EF 35%, AFIB, ICD/PCM, GERD, HTN, MI, PVD\n Surgery / Procedure and date: Hip fx repair ; EPS w/ ablation \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:140\n D:53\n Temperature:\n 97.7\n Arterial BP:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,360 mL\n 24h total out:\n 650 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:10 AM\n Potassium:\n 3.4 mEq/L\n 05:10 AM\n Chloride:\n 101 mEq/L\n 05:10 AM\n CO2:\n 29 mEq/L\n 05:10 AM\n BUN:\n 21 mg/dL\n 05:10 AM\n Creatinine:\n 1.1 mg/dL\n 05:10 AM\n Glucose:\n 95 mg/dL\n 05:10 AM\n Hematocrit:\n 28.9 %\n 04:23 PM\n Valuables / Signature\n Patient valuables: Glasses and underwear\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry: none\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: 17:10\n ------ Protected Section Addendum Entered By: , RN\n on: 17:05 ------\n"
},
{
"category": "Echo",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Report",
"row_id": 64323,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/p VT ablation; Thermacool Protocol required f/u. to \nHeight: (in) 74\nWeight (lb): 167\nBSA (m2): 2.01 m2\nBP (mm Hg): 117/54\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:00\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: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate regional\nLV systolic dysfunction. No LV mass/thrombus. TDI E/e' >15, suggesting\nPCWP>18mmHg. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - hypo; basal inferolateral - akinetic; mid\ninferolateral - hypo; basal anterolateral - hypo; lateral apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in aortic root. Moderately dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is moderate regional left\nventricular systolic dysfunction with thinning/akinesis of the basal half of\nthe inferior and inferolateral walls. The distal lateral wall is also\nhypokinetic. The remaining segments contract normally (LVEF = 35 %). No masses\nor thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg). Right ventricular\nchamber size and free wall motion are normal. The ascending aorta is\nmoderately dilated. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. The mitral valve leaflets are structurally\nnormal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is\nseen. The pulmonary artery systolic pressure could not be determined. There is\nno pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the severity of\nmitral regurgitation is similar. The distal lateral wall appears hypokinetic\non the current study.\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": "Echo",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Report",
"row_id": 64324,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. VT\nHeight: (in) 74\nWeight (lb): 167\nBSA (m2): 2.01 m2\nBP (mm Hg): 134/56\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 10:17\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV cavity size. Mild-moderate regional LV systolic\ndysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- dyskinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic;\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 AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild to moderate (+) MR. to the eccentric MR jet, its\nseverity may be underestimated (Coanda effect).\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. The left ventricular cavity size is normal. There\nis mild to moderate regional left ventricular systolic dysfunction with\ninferior akinesis/dyskinesis and inferolateral akinesis. Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nare mildly thickened. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Mild to moderate (+) mitral regurgitation is\nseen. Due to the eccentric nature of the regurgitant jet, its severity may be\nsignificantly underestimated (Coanda effect). The tricuspid valve leaflets are\nmildly thickened. There is borderline pulmonary artery systolic hypertension.\nThere is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar. Left ventricular systolic function appears similar.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1047784,
"text": " 4:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with aicd firing\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old with AICD firing, to assess for cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with radiograph of .\n\n FINDINGS: The right costophrenic angle and the right lower rib cage has not\n been included at this examination. Within these limitations, an AICD device\n projects over the left upper chest with lines properly positioned. There is\n evidence of prior CABG. The cardiac silhouette is moderately enlarged, though\n stable. There is blunting of the left costophrenic angle, unchanged since the\n prior examination. There is no focal pulmonary consolidation. There is a\n stable granuloma in the left mid zone. There are degenerative changes present\n in the spine.\n\n CONCLUSION: Stable cardiomegaly with no acute pulmonary process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-28 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 1047991,
"text": " 10:12 PM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: Eval for pseudoaneurysm\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man admitted for VT. Underwent VT ablation. Hematoma and bruit on R\n side with bleeding.\n REASON FOR THIS EXAMINATION:\n Eval for pseudoaneurysm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr WED 1:40 AM\n AV fistula of right groin.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old man with hematoma, bruit under right groin after\n catheterization. Please evaluate for pseudoaneurysm.\n\n Comparison is made to the prior study of .\n\n TECHNIQUE AND FINDINGS: Grayscale color flow and Doppler images of the right\n groin area were obtained. Proximal to the puncture site, the common femoral\n artery and common femoral vein demonstrate normal arterial and venous flow\n pattern. However, at the puncture site, there is diffuse turbulence at the\n expected location of the artery and vein and the interrogation of the common\n femoral vein and artery at the puncture site demonstrates to and fro waveform\n with mixed arterial and venous flow pattern. There is 1.8 x 1.2x 0.6 cm\n hematoma at area of bruising in the proximal thigh.\n\n IMPRESSION: Findings are compatible with the arteriovenous fistula at the\n puncture site.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-30 00:00:00.000",
"description": "RP FEMORAL VASCULAR US RIGHT PORT",
"row_id": 1048237,
"text": " 9:35 AM\n FEMORAL VASCULAR US RIGHT PORT Clip # \n Reason: repeat US to f/u on AV fistula vs. pseudoaneurysm\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with CAD s/p CABG and multiple MIs, HTN, CHF EF 35%, afib, and\n sustained VT with ICD and subsequent catheter ablation treatment who presents\n with an episode of ICD firing\n REASON FOR THIS EXAMINATION:\n repeat US to f/u on AV fistula vs. pseudoaneurysm\n ______________________________________________________________________________\n WET READ: 9:56 AM\n no fistula, pseudoaneurysm. 1.4 cm collection superficial to the cfa/v which\n likely represents a smal hematoma.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old male with CAD, status post CABG. Evaluate for AV\n fistula or pseudoaneurysm.\n\n FINDINGS: Targeted ultrasound of the right groin with grayscale and color\n ultrasound show normal common femoral vein and artery. No AV fistula or\n pseudoaneurysm is identified. Note is made of a 1.4 cm collection in the soft\n tissues of the right groin, which likely represents hematoma.\n\n The previously identified region of color thrill in the soft tissues of the\n right groin is no longer identified, most compatible with resolution of the AV\n fistula.\n\n\n IMPRESSION:\n 1. No AV fistula or psueudoaneurysm.\n 2. Small right groin hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-12-01 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 1048379,
"text": " 9:18 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: please evaluate for presence of continued fisutula\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man s/p VT ablation, with AV fistula seen on u/s and continued\n bruit\n REASON FOR THIS EXAMINATION:\n please evaluate for presence of continued fisutula\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FRI 11:42 AM\n Normal study with resolution of previously identified AV fistula.\n ______________________________________________________________________________\n FINAL REPORT\n FEMORAL VASCULAR ULTRASOUND AND DUPLEX ULTRASOUND\n\n CLINICAL INDICATION: 82-year-old male status post VT ablation with small AV\n fistula seen on with continued bruit. Please re-evaluate for\n presence of continued fistula.\n\n Color flow and pulse Doppler assessment of the right groin, above, at and\n below the puncture site shows normal flow dynamics throughout. The previously\n identified color thrill and abnormal pulse Doppler waveforms consistent with\n an AV fistula are now no longer present.\n\n CONCLUSION: Previously demonstrated AV fistula appears to have resolved.\n There is now no evidence of fistula or pseudoaneurysm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-12-01 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 1048380,
"text": ", H. 9:18 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: please evaluate for presence of continued fisutula\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man s/p VT ablation, with AV fistula seen on u/s and continued\n bruit\n REASON FOR THIS EXAMINATION:\n please evaluate for presence of continued fisutula\n ______________________________________________________________________________\n PFI REPORT\n Normal study with resolution of previously identified AV fistula.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-28 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 1047992,
"text": ", H. 10:12 PM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: Eval for pseudoaneurysm\n Admitting Diagnosis: VENTRICULAR TACHYCARDIA;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man admitted for VT. Underwent VT ablation. Hematoma and bruit on R\n side with bleeding.\n REASON FOR THIS EXAMINATION:\n Eval for pseudoaneurysm\n ______________________________________________________________________________\n PFI REPORT\n AV fistula of right groin.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-30 00:00:00.000",
"description": "Report",
"row_id": 131925,
"text": "Sinus rhythm. Short P-R interval. Vertical axis. Probable inferior\nmyocardial infarction, age indeterminate. Since the previous tracing\nthere is now sinus rhythm with a narrow QRS complex.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-29 00:00:00.000",
"description": "Report",
"row_id": 131926,
"text": "A-V paced rhythm. ST-T wave abnormalities. Since the previous tracing\nof the QRS morphology has changed and may represent biventricular\npacing. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-28 00:00:00.000",
"description": "Report",
"row_id": 131927,
"text": "A-V paced rhythm. Since the previous tracing of no significant\nchange.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-27 00:00:00.000",
"description": "Report",
"row_id": 131928,
"text": "A-V sequential pacing. Since the previous tracing of the wide\ncomplex tachycardia has resolved.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-27 00:00:00.000",
"description": "Report",
"row_id": 131929,
"text": "Wide complex tachycardia with marked left axis deviation. Slurred R wave\nacross the precordial leads, probable ventricular tacycardia. Compared to the\nprevious tracing of the wide complex tachycardia is new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-27 00:00:00.000",
"description": "Report",
"row_id": 131930,
"text": "Wide complex tachycardia. Since the previous tracing no significant change.\nProbable ventricular tachycardia. Clinical correlation is suggested.\nTRACING #2\n\n"
}
] |
27,237 | 156,521 | 54 y/o F with paroxysmal afib (recently with RVR), diastolic dysfunctoin, and hypertension who presents with ventricular escape bradycardia with relative hypotension from the floor to the CCU. . # Bradycardia: The patient has been on escalating doses of antihypertensives/nodal agents over the past few days believed related to poor medication compliance at home. On day of transfer to CCU, she received verapamil, disopyramide, and lopressor. Her presentation could represent tachy-brady syndrome but likely exaggerated AV block due to increasing doses of verapamil, beta-blocker. Initially, temporary pacing wire placed via the right groin. All nodal blockers (disopyramide, verapamil, beta blocker)were held. Patient was discussed with EP felt there was no current need for a permanent pacer. Cardiac enzymes were cycled to rule out myocardial infarction and thyroid function was normal. She was monitored on telemetry with return of NSR which progressed to Afib. QT-prolonging agents(ciprofloxacin/reglan)were discontinued. There were no further episodes of bradycardia and patient was transferred to the floor. . # AFib w/ RVR: Patient with long-standing history of AFib likely a result of her underlying OSA. After episode of bradycardia and slow restart of nodal agents, she returned to AFib w/ RVR after brief stay on the floor. She was transferred back to the unit and started on Esmolol drip, but the Afib remained refractory. Metoprolol dose was increased, amiodarone TID began on , and diltiazem drip required for rate control as the esmolol was titrated down. Patient was converted to po medications with successful rate control of Afib and regimen simplified to once daily dosing as possible to increase likelihood of compliance. She was started on a stable coumadin dosing and she will need INR monitoring in the coumadin clinic. She will also need monitoring for amiodarone (PFTs, LFTs, eye exam, thyroid funciton tests yearly). Coumadin will be held again on the evening of discharge (due to INR 3.6) and should be restarted on at dose 2.5 mg daily. . #Diastolic Dysfunction: Patient with evidence of volume overload with increasing O2 requirements after home lasix dose held for low BP. Patient diuresed with IV lasix and metolazone and is placed on a standing regimen of 80mg po lasix daily with potassium repletion. . # Acute renal failure: Likely related to poor perfusion in the setting of relative hypotension and bradycardia. Baseline of 1.0. Creatine improved with improved BP and HR control. She is discharged on an ACE inhibiotr. . # Hypoxia/hypercarbia: Due to low O2 sats, and persistent respiratory vs. metabolic acidosis, the patient was intubated on the day of transfer to CCU. Her O2 sats on the ventilator remained high, and the following morning tolerated a trial of pressure support. During this time, her pH normalized and revealed a likely chronic CO2 retaining pattern. Patient was quickly extubated the following day once rate control was acheived. Hypercarbia likely related to hypoventilation in combination with obstructive physiology due to body habitus & question of tracheomalacia seen on CXR. Reason for hypoxia related to fluid overload of 4L. Patient found to have episodes of hypoxia/hypercarbia associated with observed apnea overnight. Patient started on BIPAP 8/5 with improvement in mental status and desaturations overnight. Sleep study as outpatient planned. . # Hypertension: Likely a result of obesity, OSA, and diabetes. As patient's antihypertensives were held, she did experience a steady increase in BP. Nifedipine was initially tried for BP control, but converted to metoprolol, diltiazem, and amiodarone regimen for both HR and BP control. . # Hyperkalemia: Found on transfer to the CCU and treated with insulin gtt, bicarb IVF, albuterol nebs, kayexalate, and lasix. Already received calcium gluconate on the floor. Likely acute renal failure. Resolved on the morning following transfer to CCU. . # Leukocytosis: Question of aspiration in setting of depressed mental status on transfer to CCU. S/P 7 days of levofloxacin (discontinued on ) for treatment of pneumonia when patient became febrile and showed new RLL consolidation on CXR. Antibiotics changed to ceftriaxone/flagyl, seven day course completed. . # Anemia: Chronic issue with iron studies suggesting deficiency of chronic disease. Hemolysis labs were negative. Hct has remained stable with one drop below 25, s/p 1 unit PRBCs with adequate response. Stools remained guiac negative throughout stay. | COMPARISON: 07/23.. AP PORTABLE UPRIGHT VIEW OF THE CHEST: The right subclavian line terminates at the cavoatrial junction. FINAL REPORT INDICATION: History of CHF and shortness of breath. IMPRESSION: Limited single bedside AP examination labeled "upright" with markedly lordotic positioning is compared with frontal and lateral views dated . IMPRESSION: Interval placement of a left subclavian PICC line with tip projecting over the right atrium; recommend withdrawal by 7-8 cm. Nasogastric tube has been retracted in the interval, with side port near the GE junction. nasal BIPAP as tolerated overnite. CHEST, ONE VIEW: There has been interval placement of a left subclavian PICC line with its tip projecting over the right atrium; recommend withdrawal by 7-8 cm. RESP CARE NOTEATROVENT MDI GIVEN QID. Cardiac size is enlarged and mediastinal and hilar contours are unchanged. COMPARISON: Non-contrast head CT from . 3:18 PM CHEST (PA & LAT) Clip # Reason: R/O acute process. PICC L brachial intact. Rule out intracranial bleed. no abx.RESP: LS clear, dim. Marked decrease in tracheal caliber with expiration suggestive of tracheomalacia. FINDINGS: This study is slightly limited secondary to patient motion. The left subclavian line was inserted in the meantime interval with its tip terminating at the level of distal SVC. WORSE AFTER EVENING AMBIEN AND ATIVAN OR BASELINE BREATHING PATTERN.TEAM CALLED- CHECKED AM CXR EARLY AND ABG- 3:30A- 7.38-60-69 WITH O2 SAT AT TIME 93-94%. ccu nursing progress notes: I am moving around bettero: pls see carevue flowsheet for complete vs/data/eventsid: afeb.cv: remains in afib rate 70-80s, rare pvc. Patient is ordered for nebulizers Albuterol Q6PRN and atrovent Q6; Order to be changed to MDI's.CXR shown (R) lower lobe opacity.Now on PSV with plan to extubate in Am.ABG shown metabolic compensation, negative 334. - ISSUES WITH DESATURATION/POSSIBLE D/T APNEA -PT WITH ALTERED MS/AGITATION/?CONFUSION R/T ?CONTINUE TO KEEP DILT GTT, PO LOPRESSOR/PO AMIO AS ORDERED.INCREASE AM LOPRESSOR DOSE TO 100 MG AS WEAN OFF ESMOLOL SOON.CHECK AM LABS- CREAT/LYTES/PTT. Monitor her VS, O2 sats while new medications being started.GOAL HR <80 with sats <92% CCU NPN 0700-1900S: Pt continues orally intubated and mechanically ventilated.O: Please see careview for VS and additional data.CV: Pt HR 67-89 NSR, rare PVC's noted. CONTINUE TO ATTEMPT TO DIURESE OFF VOLUME.ASK FAMILY RE: PT'S ALTERED MS- AGITATION AT NITE, CALLING OUT- IF THIS IS CLOSE TO BASELINE. Cont to monitor resp status, ABGs-wean vent as tol, anticipate extubation at am. HOLD OFF ON MORE AMBIEN/ATIVAN TONITE TO SEE IF MENTAL STATUS IMPROVES/IS LESS AGITATED TONITE!CONTINUE TO COVER BS WITH GLARGINE QHS/QID REGULAR. Afternoon K 3.8, repleted with 20 MeQ KCL.Resp: Please see careview for vent settings and ABGs. Sheath pulled and after 2 1/2 hrs, pt sat upright, sedation decreased and placed on PSV 5 peep 5. v-theshold @ 8, ma 12. intrinsic rate overnoc 46-49 junctional, but w stable bp 130-160. slow return of p-waves and @ 0430 pt w consistent p-waves now in sb-nsr w hr's 60-66.. a-line inserted via r radial site. Hypotension.Height: (in) 62Weight (lb): 267BSA (m2): 2.16 m2BP (mm Hg): 109/52HR (bpm): 124Status: InpatientDate/Time: at 11:12Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Moderate symmetric LVH. Compared totracing #1 patient is now back in sinus rhythm. lactic acid on adm 5.4, now down to 1.7. team notifed this am of rising bp's sbp now 160-170.resp; received alb/atr nebs. Compared to tracing #3patient is now back in sinus rhythm. Tissue Doppler imaging suggests anincreased left ventricular filling pressure (PCWP>18mmHg). Abgs wnl, borderline hypoxemia. wean pt further, did not respond well to decreased peep this AM.continue monitor CV and resp status, check with EP regarding pacer,monitor lytes, I/o, Urine output. Left ventricular hypertrophy with secondary ST-T waveabnormalities. HR 84, afib rate controlled, bp 124/67, heparin 300units/hr diltiazem 15mg/hr.Resp: pt has diminished lung sounds. hr 46-48 junctional rhythm, but w stable bp 140/ aed @ bedside and placed on pt. head ct neg for hemmorrahge or fracture. Pt A&Ox3, asking appropriate questions regarding care.GI/GU/ENDO: Pt abd soft obese, +BS x4, 1 lg soft formed stool this eve, guiac negative. Compared to tracing #4patient is now again in atrial fibrillation. Left ventricularhypertrophy with secondary repolarization changes.TRACING #1 Left ventricular hypertrophy with secondary repolarizationchanges.TRACING #2 Left ventricularhypertrophy with associated ST-T wave changes. Compared to tracing #2 sinus rhythm has beenreplaced by atrial fibrillation.TRACING #2 There is leftventricular hypertrophy with associated ST-T wave changes. Diffuse repolarizationabnormalities consistent with left ventricular strain pattern. Probable left ventricular hypertrophy with secondaryST-T wave abnormalities. Probable junctional rhythm with borderline voltage criteria for leftventricular hypertrophy with secondary ST-T wave abnormalities. Sinus rhythmLVH with secondary repolarization abnormalityExtensive ST-T changes are probably due to ventricular hypertrophySince previous tracing of the same date, atrial fibrillation resolved Leftventricular hypertrophy with associated ST-T wave changes. Compared to the prior tracingof atrial fibrillation has been replaced by junctional rhythm.Clinical correlation is suggested.TRACING #1 Left ventricular hypertrophy. Normal sinus rhythm with voltage criteria for left ventricular hypertrophy andsecondary ST-T wave abnormalities. Technically difficult studySinus rhythmLVH with secondary ST-T changesSince previous tracing of , sinus rhythm restored Probable atrial fibrillation with rapid ventricular rate. Paroxysmal atrial fibrillation. A single probablysinus P wave with prolonged A-V conduction with resumption of atrialfibrillation. Occasional prematureventricular contraction. Atrial fibrillation with rapid ventricular response with multifocal PVCs or aberrant ventricular conduction.Extensive ST-T changes are probably due to ventricular hypertrophySince previous tracing of the same date, atrial fibrillation recurred The lungs lucencies are different with the opacity projecting over the right lung which might represent pleural effusion. Atrial fibrillation with rapid ventricular response. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Cannot excludeanterolateral ischemia with T wave inversions in leads I, aVL and V3-V6.There is also marked Q-T interval prolongation. | 62 | [
{
"category": "Radiology",
"chartdate": "2176-06-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 969337,
"text": " 5:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chf, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with sob, doe\n REASON FOR THIS EXAMINATION:\n chf, pna\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST\n\n HISTORY: 54-year-old woman with shortness of breath and dyspnea on exertion;?\n CHF or pneumonia.\n\n IMPRESSION: Limited single bedside AP examination labeled \"upright\" with\n markedly lordotic positioning is compared with frontal and lateral views dated\n . Again demonstrated is globular cardiomegaly with no definite\n pulmonary vascular congestion or significant pleural effusion. Vague opacity\n projected over both hemithoraces is likely technical and related to overlying\n soft tissues. Allowing for this, no focal consolidation is seen.\n\n IMPRESSION: Quite limited study, with marked cardiomegaly but no definite CHF\n or focal consolidation. Recommend PA/lateral study in the Department, when\n feasible.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 971048,
"text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 yo with CHF/obstructive sleep apnea with hypoxia\n\n REASON FOR THIS EXAMINATION:\n CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF, obstructive sleep apnea with hypoxia.\n\n COMPARISON: .\n\n AP PORTABLE UPRIGHT VIEW OF THE CHEST: There is stable\n cardiomegaly/enlargement of the cardiac silhouette. Lungs are grossly clear.\n Penetration is limited due to body habitus. Costophrenic angles are sharp.\n There is no pneumothorax.\n\n IMPRESSION: Stable cardiac enlargement with no evidence of CHF or pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 970489,
"text": " 3:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial bleed.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with hyperglycemia, afib, s/p fall.\n REASON FOR THIS EXAMINATION:\n r/o intracranial bleed.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST AXIAL HEAD CT\n\n HISTORY: 54-year-old woman with hyperglycemia, atrial fibrillation, status\n post fall. Rule out intracranial bleed.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: Non-contrast head CT from .\n\n FINDINGS: This study is slightly limited secondary to patient motion. There\n is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The\n ventricles and sulci are normal in caliber and configuration. No fractures\n are identified. Visualized paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION: Normal study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 970493,
"text": " 3:18 PM\n CHEST (PA & LAT) Clip # \n Reason: R/O acute process.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with CHF and SOB, hypertensive, febrile.\n\n REASON FOR THIS EXAMINATION:\n R/O aspiration. Patient found down in vomit.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of CHF and shortness of breath. Patient was found down\n in vomit. Febrile. Rule out aspiration.\n\n COMPARISON: and .\n\n FIVE PA AND LATERAL VIEWS OF THE CHEST: The study is limited by body habitus.\n There is stable cardiomegaly. A prominent skinfold overlies the cardiac\n silhouette on the frontal view. There are low lung volumes. Apparent patchy\n opacity is demonstrated on the lateral view affecting the posterobasal\n segments of the lower lobe(s) that is not well localized on the frontal views.\n Notably, on the lateral view, decrease in the AP diameter of the trachea from\n 15 mm in inspiration to 6 mm in expiration is noted.\n\n IMPRESSION:\n 1. Apparent posterobasal lower lobe lung opacity concerning for aspiration or\n pneumonia.\n 2. Marked decrease in tracheal caliber with expiration suggestive of\n tracheomalacia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 970966,
"text": " 2:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for failure\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 yo with CHF/obstructive sleep apnea with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF with obstructive sleep apnea with hypoxia.\n\n COMPARISON: 07/23..\n\n AP PORTABLE UPRIGHT VIEW OF THE CHEST: The right subclavian line terminates\n at the cavoatrial junction. Nasogastric tube has been retracted in the\n interval, with side port near the GE junction. Lungs remain clear. Cardiac\n and mediastinal contours are stable. There is no evidence of pneumothorax.\n\n IMPRESSION: Nasogastric side port near the GE junction, recommend advancement\n to ensure complete placement within stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 971093,
"text": " 12:08 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: picc placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 yo with CHF/obstructive sleep apnea with hypoxia s/p picc placement\n\n REASON FOR THIS EXAMINATION:\n picc placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF, obstructive sleep apnea with hypoxia status post PICC\n placement. Query PICC placement.\n\n COMPARISON: , at 8:30 a.m.\n\n CHEST, ONE VIEW: There has been interval placement of a left subclavian PICC\n line with its tip projecting over the right atrium; recommend withdrawal by\n 7-8 cm. There is no pneumothorax. Cardiac size is enlarged and mediastinal\n and hilar contours are unchanged. Lungs are grossly clear, although the study\n is limited by body habitus. The costophrenic angles appear grossly blunt.\n\n IMPRESSION: Interval placement of a left subclavian PICC line with tip\n projecting over the right atrium; recommend withdrawal by 7-8 cm. These\n results were communicated with the intravenous access team at 2:30 p.m. on\n , by Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 971566,
"text": " 8:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: volume status\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 yo with CHF/obstructive sleep apnea with hypoxia and agitation.\n\n REASON FOR THIS EXAMINATION:\n volume status\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: CHF, sleep apnea, hypoxia.\n\n One view. Comparison with the previous study done on . There is\n interval improvement in bilateral pulmonary infiltrates thought to represent\n edema. The lungs are somewhat difficult to assess due to overlying soft\n tissue. The heart appears enlarged, as before. Mediastinal structures are\n unchanged. A left subclavian line has been withdrawn. The tip of a left PICC\n line is not identified but it appears to be in central position.\n\n IMPRESSION: Limited study demonstrating interval improvement in bilateral\n pulmonary infiltrates thought to represent edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 970640,
"text": " 8:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check line placement and ET tube\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with sob, doe s/p intubation\n\n REASON FOR THIS EXAMINATION:\n check line placement and ET tube\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: SOB status post intubation.\n\n CHEST\n\n The tip of the endotracheal tube lies 3.6 cm from the carinal angle. The tip\n of the nasogastric tube lies within the stomach in a satisfactory position.\n\n Cardiomegaly persists, failure and effusion particularly on the right side\n difficult to exclude. The pacer wire has been repositioned. Probably lies in\n the right atrium.\n\n IMPRESSION: Endotracheal tube, satisfactory repositioning of pacemaker wire.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 970519,
"text": " 8:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: temp wire placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with sob, doe\n\n REASON FOR THIS EXAMINATION:\n temp wire placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: SOB and DOE.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n Comparison is made with prior study performed five hours before.\n\n There is a new wire with the tip projecting in the right ventricle. There is\n a stable mild cardiomegaly. There is no pneumothorax or sizable pleural\n effusion. There is\n engorgement of the vasculature due to vascular congestion. There is mild\n increase in right lower lobe opacity that could represent pneumonia or\n aspiration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-28 00:00:00.000",
"description": "P CHEST FLUORO PORT",
"row_id": 970516,
"text": " 8:21 PM\n CHEST FLUORO PORT Clip # \n Reason: will need c-arm temporary wire placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with sob, doe\n\n REASON FOR THIS EXAMINATION:\n will need c-arm temporary wire placement\n ______________________________________________________________________________\n FINAL REPORT\n Chest fluoroscopy was performed without the presence of a radiologist. There\n were 30 seconds of fluoro time used. There are no films submitted. Fluoro\n was for placement of a temporary pacer wire in the ICU.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 970535,
"text": " 2:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: endotracheal tube position\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with sob, doe s/p intubation\n\n REASON FOR THIS EXAMINATION:\n endotracheal tube position\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: Post-intubation. Check endotracheal tube.\n\n Comparison is made with prior study performed six hours before.\n\n ET tube tip projects 4 cm above the carina. No other acute changes are seen.\n Note is made of the right lower lobe opacity as more conspicuous in this\n examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 971207,
"text": " 2:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 yo with CHF/obstructive sleep apnea with hypoxia and agitation\n\n REASON FOR THIS EXAMINATION:\n CHF\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of a patient after obstructive sleep\n apnea.\n\n Portable AP chest radiograph compared to obtained at 12:17 p.m.\n\n The heart size is markedly enlarged but unchanged. There is new bilateral\n perihilar and lower lobe consolidations involving the entire lungs. Given\n their appearance and rapid progression most likely representing pulmonary\n edema. No sizeable pleural effusion is demonstrated.\n\n The left subclavian line was inserted in the meantime interval with its tip\n terminating at the level of distal SVC. The left PICC line tip is barely\n visible beyond the level of left subclavian vein thus its tip location cannot\n be determined.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-06 00:00:00.000",
"description": "Report",
"row_id": 1618822,
"text": "CCU NPN 2300-0700\nS; Yes, I know I am in the hospital, I am doing fine tonight.\"\nO: Please see carevue for VS and objective data\nCVS; Hemodynamically stable with HR 80-90's Afib, no vea noted, K+3.6 with diuresis, repleted with 20meq po KCL per orders. BP ranges 105-130/40-60's.\nResp; Pt. placed on nasal bipap at change of shift by RT for sleep. Pt. tolerated for approx. 2 hours then awoke and removed it, attempted it again but Pt. requesting to remove it. Placed on N/C by RT, initially at 6L, weaned to 2L n/c with sats 99-94%. Lungs with fine bibasilar rales, diuresed well to previous shift IV Lasix, without further diuresis this shift.\nGI:GU: Taking po's and pills without incident. Foley to drainage with clear, yellow urine, u/o 60-500cc/hour, I/O neg. 889cc at MN.\nAbdomen obese with active bowel sounds, no further stool this shift.\nHeme: repeat Hct stable at 26.2\nNeuro: Pt. A/A/0x3, initially unable to state time, but reoriented easily. Pleasant and cooperative. Requesting to go to sleep. No sleep aid needed, slept well most of night.\nA: stable, tolerated nasal bibpap for only 2 hours of night sleep, sats stable\nP: Cont to monitor hemodynamics, med. adjustments, assess resp. status, cont to increase activity and ADLs, plan for rehab. Comfort an emotional support to Pt. and family\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-06 00:00:00.000",
"description": "Report",
"row_id": 1618823,
"text": "CCU progress note 7a-7p\n\nUneventful day. VSS. OOB to chair. ambulating under supervision to bathroom on portable monitor. steady gait. no c/o dizziness or weakness. \"I'm doing so much better than yesterday!\"\n\nNEURO: A+Ox3. family in visiting all afternoon. no c/o pain or discomfort.\n\nID: afebrile. no abx.\n\nRESP: LS clear, dim. occ wheezes. taking inhalers w/ spacer. O2 decreased to 3L n/c. - was 5L at change of shift. sats 100% - on room air after walking to bathroom without O2 pt's sats were 78% after she settled back in chair, so make sure patient had O2 on when walking!\n\nCARDIAC: remains in AFIB 70-120 today. Amiodarone 400mg TID, ToprolXL 200mg daily and DiltiazemXR 360mg daily. SBP 98-120s. PICC L brachial intact. KCL repleated x 2 today. recheck lytes this evening.\n\nGI/GU: foley patent. clear yellow. zaroxyln 5mg po + Lasix 120mg IVP given this morning - goal 1-1.5L negative today. currently -2.3L for day at 6pm. abd obese. +BS. on reglan qid. stooling loose stool x 5 times today - able to get to bathroom each time w/ minimal assist. hold stool softeners tonite. eating well. good appetite.\n\nENDO: FS QID - am BS not requiring insulin. Afternoon/evenign BS ~280 - increased SS humalog given. Glargine dose remains same at 20units at dinner time. Reassess blood sugars tommorrow to ?increase glargine if BS aren't <200 by the afternoon. cont' sliding humalog scale.\n\nPLAN: monitor FS this evening, cover w/ sliding scale. no further need for diuresis overnite. recheck lytes this evening. pt seems to be tolerating daily extended release doses of lopressor and diltiazem. PICC line for access. OOB to chair w/ minimal assistance and to bathroom, amublating well. ?call out to step down unit in am. nasal BIPAP as tolerated overnite.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-05 00:00:00.000",
"description": "Report",
"row_id": 1618816,
"text": "RESP CARE NOTE\nATROVENT MDI GIVEN QID. CPAP ORDERED PER RESP FOR SETTINGS. TRIED PT ON NASAL CPAP OF +10CMH20 AND 6LPM O2 WITH SATS IN THE 70'S WHEN PT WAS ASLEEP. CHANGED TO BIPAP INCREASING SETTINGS SLOWLY TO GET SATS >90%. KEPT PT ON 14/8 WITH 6LPM O2 INLINE TO GET SAT OF 91-92%. WHEN PT WOKE PULLED MASK OFF AND COULDN'T TOLERATE THE SETTINGS. ATTEMPTED ONCE MORE AND AGAIN PT COULDN'T TOLERATE. THEN PLACED ON A NASAL CANNULA FOR THE DURATION OF SHIFT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-05 00:00:00.000",
"description": "Report",
"row_id": 1618817,
"text": "Nursing Progress Note\nnote entered in error on this patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-05 00:00:00.000",
"description": "Report",
"row_id": 1618818,
"text": "Nursing Progress Note\n\nS:\" I hope I go soon.\"\n\nO: Please see flow sheet for objective data. Tele sinus rhythm. Remains on IV Heparin and Nitro till OR. PTT 55. Pt denies chest pain.\nAnesthesia here to place R radial aline.\n\nResp: Lungs clear diminshed in bases. O2 sats >96% on RA.\n\nNeuro: Pt is alert and oriented x's 3. Anxious at baseline. More anxious about surgery. Given ativan 2mg po with good effect.\n\nGI/GU: Pt is NPO for CABG/AVR. Pt underwent hemodialysis yesterday and the day before. Pt has L AV fistula. Pt voids in sm amts.\n\nSocial: Pt has spoken with multiple family members by phone this am. Brother in to visit prior to surgery. He will take all belongings home with him including cell phone.\n\nA&P: Pt to OR for CABG/AVR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-05 00:00:00.000",
"description": "Report",
"row_id": 1618819,
"text": "CCU Nursing Progress Note\nS-\"I don't remember not taking my pills last night.\" \"I wish I could have this catheter out.\"\nO-Neuro alert and oriented x3 most of the day. Pleasant and cooperative most of the day, does require bed alarms on with 3 rails up and chair alarm when up. Noticed patient was closing her eyes while in the chair and offered pt to return back to bed for a nap. Sleepy and confused agreed to wear CPAP for 80 minutes and awoke alert and refreshed and ready to get OOB and have lunch. Mental status is certainly dependant on her O2 sat level and CPAP time. Also becomes alittle lonely and frightened without anyone to talk to. Is a very social person, saying hello to people walking by her room.\nCV-VSS able to tolerated metoprolol XL 150mg, started diltiazem 90mg TID and weaned dilt gtt off by 2nd dose. HR 64-100 AF, SBP 92-150. Heparin gtt d/c'd-on coumadin with INR 1.9\nResp-RA sat 69%, 2l np 94-98% increased to 5lnp when sats dropping while active. Physical therapy assess pt, walked pushing wheel chair and O2 sat dropped to 84%. LS clear with few exp wheezes in afternoon,\ndiminished at bases.\nID afebrile with WBC 12.8\nGI-Appetite good. LBM c/o constipation started on colace with ducolax po given last evening and this am. OOB commode small brown hard stool +impacted large amount of hard stool. Pt recieved SSE with very good effect with some digital assist. OB- with some blood streaking from hemmorrhoids. HCT remains borderline at 24.\nEndo-Elevated blood sugars for past 5 days, following. BS 0600 received 15 unnits humalog SC and Glargine increased to 20 units at dinner.\nActivity-OOB chair, commode most of the day. Improving transfer with only supervision. Very deconditioned to any further activity. Easily fatigues with minimal activity. No c/o pain or SOB.\nSkin-intact\nAccess-double lumen PICC\nCode Status-Full\nSocial-children and siblings, no calls today as of yet. Pt alittle lonely calling her children to come and visit her.\nDispo-case manager is aware of pt and is planning on a \nstay before d/c home. Family will need to be instructed to draw up and give insulin, VNA teaching for insulin, FS and diet, weight control, and ensure she takes her medications (preferably in the am)\nA/P-54yof with NIDDM, CHF and AF now requiring insulin for BS control.\nAF rate control improved on po medications off dilt gtt. Mental status is improved with short periods of CPAP.\nCPAP for short periods while in bed, Does need alittle encouragement and support while awake on CPAP. Encourage pt to do more of her ADL's. Monitor her VS, O2 sats while new medications being started.\nGOAL HR <80 with sats <92%\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-05 00:00:00.000",
"description": "Report",
"row_id": 1618820,
"text": "ccu nursing progress note\ns: I am moving around better\no: pls see carevue flowsheet for complete vs/data/events\nid: afeb.\ncv: remains in afib rate 70-80s, rare pvc. bp 120-140/60-70. diltiazem, toprol amd amiodarone doses unchanged.\nresp: no sob. on nc 5l, sats 95-100%. basilar cxs.\ngi: good intake. several loose stools. green, brn ob-.\nbs 230-270, covered per ss. rec'd eve dose glargine 20units.\ngu: foley to . rec'd iv lasix. fair response.\nms: alert early on shift and oob w min assist. requesting sleeping pill at 8:30pm. but asked pt to hold off, pt then fell off to sleep and has remained asleep.\nsocial: dtr visited, updated.\na: rhythm, rate stable.\np: follow response to diuretics. needs cpap w sleeping. monitor rhythm, hemodynamics, volume status. support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-06 00:00:00.000",
"description": "Report",
"row_id": 1618821,
"text": "Resp: Pt rec'd on 6 lpm n/c then placed on bipap 14/8 with 6 lpm 02 bleed. 02 sats @ 97-100%. Pt remained on bipap for approximately 2 hrs then took off mask. Placed pt back on n/c @ 6 lpm for remainder of night. No distress noted with 02 sats @ 100%. Bipap remains @ bedside and will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-07 00:00:00.000",
"description": "Report",
"row_id": 1618824,
"text": "ccu npn 1900-0700\nS;\"I am doing so much better today.\"\nO:Please see carevue for VS and objective data\nCVS; Hemodynamically stable with HR 70-90's Afib, rare vea noted. BP ranges 119-140/40-60's. Conts on po regime as ordered.\nResp; Sats 92-94% on 1-2L n/c, Pt. placed on nasal bipap for sleep, tolerated for approx. 3 hours then awoke and requested it off, stating she couldn't get back to sleep with it on. Lungs clear with diminished breathe sounds in bases. No further diuresis this shift.\nGI:GU: Taking po's, no N/V. Abdomen obese with active bowel sounds, one loose golden stool in bathroom (not saved by Pt. for guaic). Pt. refused bowel meds this shift. Foley to drainage with clear, yellow urine, u/o 80-100cc/hour. Total I/O neg. 2500cc at MN.\nEndo; glucose 246 at bedtime, covered with 9units Humalog. Will need daily dose of Glargine increased.\nID: Tmax 98.7 po\nNeuro: Pt. A/A/0x3, pleasant and cooperative, appreciative of care. Ambulating to bathroom with supervision of RN, gait steady. Spent eve. in chair watching Red Sox game with family members present. Slept at intervals without sleep med given.\nA: stable\nP: Cont to monitor hemodynamics and resp. status, probable call out to floor with plan for rehab. Cont to increase activity.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-07 00:00:00.000",
"description": "Report",
"row_id": 1618825,
"text": "Resp: Pt on 2 lpm n/c with 02 sats @ 100%. Pt placed on bipap with settings of and 4lpm 02 bleed. Remained on bipap for approximately 3 hrs then began pulling off mask. Placed back on nc 2 lpm with no distress noted. Possibly called out to floor today. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-03 00:00:00.000",
"description": "Report",
"row_id": 1618811,
"text": "CCU NPN: please see flowsheet for objective data\n\nCardiac:HR 106-130's afib BP 91-111/47-65 esmolol increased to 200mcg/kg/min from 50 with no change in rate. amiodorone 400mg TID at 4pm. lopressor increased to 75mg TID dose given at 2pm.\n\nResp: able to wean O2 to 2l NP with good sats,lungs clear diminished at bases,at 5pm needed to increase to 4l NP due to sats 85-87. receiving MDI's as ordered\n\nGI: after one bite of breakfast vomitted large amount including fruit she had eaten overnight,had received meds 15 minutes prior. given 4mg IV zofran,then reglan 10mg IV as nausea persisted and a couple of hrs later as nausea continued given 10mg IV compazine and finally felt better. does receive reglan 5mg po prior to meals\n\nGU: creat increased to 1.6 this am from 1.3. urine output 50-120cc/hr. received 40mg lasix at 8am urine output only increased to 260 over next two hrs.esmolol gtt 100-149/hr now positive 1800cc\n\nEndocrine: FS remains in 200's insulin order changed and to start glargine 12 units this evening and sliding scale changed to regular from humalog\n\nHeme: PTT 99.3 within range heparin at 1075 units/hr\n\nAccess: dble lumen PICC placed in rt brachial\n\nNeuro: alert and oriented x3,at times very lethargic. OOB to chair x 2. teary eyed and at one pt attempted to get OOB on her own...wanted to go home. now placed on hogh risk for falls and bed alarm on.asked for percocet,when ? about pain denied pain wanted to be\"knocked out\". anxiously awaiting families arrival.\n\nA:rapid afib uncontrolled on esmolol drip, increased O2 requirement\n\nP: team to discuss possible change to diltiazem from esmolol\n increase lopressor as ordered\n cont to follow HR,BP and labs as ordered\n monitor I&O's\n offer antiemetics as needed,reglan 1/2hr before meals\n cont to follow FS and cover w/ SSI and start glargine this evening\n high risk for falls,keep bed alarm on ,bed in low position,signage in and out of room\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-04 00:00:00.000",
"description": "Report",
"row_id": 1618812,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P AFIB/CHF\n\nS- \" I NEED TO SLEEP - WHERE IS MY MEDICINE, I NEED TO SLEEP..\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS IN AFIB- BURSTS TO 120-130'S BUT INITIALLY RATE IN THE 110'S RANGE ON ESMOLOL 200 MCG, LOPRESSOR 75 MG TID AND AMIODORONE 400 TID LOAD. PT PUT ON PACER PADS AS BACKUP AND STARTED DILT GTT 5 MG AFTER 5 MG GTT. OVER COURSE OF EVENING INCREASED GTT TO 15 MG . RATE SLIGHTLY BETTER- 90-110'S OVERALL. CURRENTLY WEANING DOWN ESMOLOL GTT- AT 100 MCG AT 4AM. AM LYTES/CBC/PTT PENDING.\n\nRESP- ISSUES OVERNITE WITH DESATURATION- TO MID 70'S, LOW 80'S- TRANSIENTLY THEN INCREASING OVER TIME BACK UP TO 93-96%. WHEN OBSERVED, PT NOTED TO BE APNEIC, BELLY BREATHING- ? WORSE AFTER EVENING AMBIEN AND ATIVAN OR BASELINE BREATHING PATTERN.\nTEAM CALLED- CHECKED AM CXR EARLY AND ABG- 3:30A- 7.38-60-69 WITH O2 SAT AT TIME 93-94%. INCREASE NC TO 6L CURRENTLY AND O2 SATS 96-99%.\nDIM LUNG SOUNDS, CXR RELATIVELY UNCHANGED BY REPORT.\n? TO OBTAIN SLEEP STUDY PRIOR TO D/C HOME THIS ADMIT.\n\nID- AFEBRILE- REMAINS ON ANTIBX FOR ? PNA\n\nGU- FOLEY CATH IN PLACE- DRAINING CLEAR YELLOW TO AMBER URINE. GIVEN 100 MG LASIX IVP 8P- 600CC OUT OVER NEXT 6 HOURS. I/O REMAINS (+)- (+) 2800CC AS OF MN. ORDERED FOR REPEAT 100 MG LASIX 4AM. AWAIT RESULTS, AWAIT EARLY MORNING CHEM 7 CHECK.\n\nGI- NO FOOD THIS SHIFT, NO C/O NAUSEA AS PREVIOUS SHIFT.\n\n\nLINES- REMAINS WITH 2 PIV RT ARM, LEFT PICC- ALL FLUSHED AND PATENT.\n\n PT VERY AGITATED OVER NITE, AT FIRST ASKING REPEATEDLY FOR \"SLEEPER PILL\"- GIVEN AMBIEN 9:45P- NOT MUCH PT EITHER AGITATED OR ASLEEP NOT ANSWERING QUESTIONS AT ALL. GIVEN ATIVAN 0.5 MG IVP AT 11PM- PT CONTINUES TO BE VERY AGITATED THROUGHOUT THE NITE- CALLED HO BY 2-3AM TO ASSESS. PT CALLING WHEN GO IN TO ASSESS, PT ASLEEP(?) NOT ANSWERING AT ALL OR ANSWERING NONSENSICAL.VERY LABILE MENTAL STATUS ALL NITE.\nC/O BACK PAIN 4:30 AM- GIVEN PERCOCET 2.\nCONSTANT SETTLING, REPOSITIONING, REATTACHING OF LEADS, O2 SATS MONITOR, O2, UNTANGLING OF LINES AND CATHETER ETC.\nPT REQUIRING MUCH SUPERVISION ALL NITE. VERY CLOSE TO REQUIRING A SITTER 1:1.\n\nSOCIAL- FAMLILY PRESENT AT CHANGE OF SHIFT. 2 DAUGHTERS HERE- NUMBERS HERE TO CALL ON BOARD.\nINFORMED RN TO CALL FOR ANYTHING OR HAVE PT CALL IF SHE NEEDED TO.\nBOTH APPEAR TO BE AWARE OF PLAN OF CARE.\n\nA/ PT WITH REFRACTORY AFIB, VOLUME OVERLOAD CURRENTLY RECEIVING\nDILT AND AMIODORONE IN ATTEMPTS TO CDV CHEMIMCALLY AND WEAN OFF ESMOLOL.\n - ISSUES WITH DESATURATION/POSSIBLE D/T APNEA\n\n -PT WITH ALTERED MS/AGITATION/?CONFUSION R/T ?\n\n\nCONTINUE TO KEEP DILT GTT, PO LOPRESSOR/PO AMIO AS ORDERED.\nINCREASE AM LOPRESSOR DOSE TO 100 MG AS WEAN OFF ESMOLOL SOON.\nCHECK AM LABS- CREAT/LYTES/PTT. KEEP HEPARIN AT THERAPEUTIC DOSE- CONTINUE COUMADIN LOAD.\nPLAN FOR ? TEE/CDV ATTEMPT TODAY.\n\nCONTINUE TO ASSESS FOR RESP DESATURATION- ? PULM CONSULT/SLEEP STUDY PRIOR TO D/C HOME. CONTINUE TO ATTEMPT TO DIURESE OFF VOLUME.\n\nASK FAMILY RE: PT'S ALTERED MS- AGITATION AT NITE, CALLING OUT- IF THIS IS CLOSE TO BASELINE. CONTIN\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-04 00:00:00.000",
"description": "Report",
"row_id": 1618813,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P AFIB/CHF\n(Continued)\nUE TO KEEP PT UNDER CLOSE OBSERVATION, OBSERVE FOR PAIN- MEDICATE AS NEEDED.\nSITTER IF NEEDED TODAY UNTIL FAMILY COMES TO VISIT. CONTINUE TO CLOSELY OBSERVE MENTAL STATUS AND GET INFO RE: PT BASELINE FROM FAMILY. HOLD OFF ON MORE AMBIEN/ATIVAN TONITE TO SEE IF MENTAL STATUS IMPROVES/IS LESS AGITATED TONITE!\n\nCONTINUE TO COVER BS WITH GLARGINE QHS/QID REGULAR. NUTRITION, SAFETY, DECREASE ANXIETY.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE, CURRENT PROGRESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-02 00:00:00.000",
"description": "Report",
"row_id": 1618809,
"text": "CCU Progress Note:\n\nThis is a 54 yr old female with Hx PAF, non-obstructive hypertrophic cardiomyopathy, CHF & HTN who was admitted to CC7 on with increasing SOB- On , Pt was transferred to CCU with syncope ? secondary to increased dose of antihypertensive and beta blocker- required intubation for Co2 retention- insulin gtt for glucoses 400's-\ndeveloped ventricular escape bradycardia requiring temp pacer- Pt extubated on & temp pacing wire Transferred to 6 - This am, went back into RAF- lopressor given with little effect- Transferred back to CCU for rate control.\n\nO- see flowsheet for all objective data.\n\nCV- Upon arrival to CCU, Pt converted to SR- Tele: SR all shift- no VEA- HR 69-81- NIBP 126-160/47-68 MAPs 67-89- no cardiac c/o- Hct 25.9- K 4.2- Mg 2.3- Heparin gtt increased to 1075units from 950units for PTT 53.3- repeat PTT due @ 2100.\n\nResp- In O2 2L via NC- Initially, lung sounds coarse, diminished @ bases- At 1430, developed SOB & dropped Sat 80's- CXR showed CHF- lasix 40mg IV given- no further resp distress noted- SpO2 now 96-99%\n\nNeuro- A&O X3- acts childlike @ times- anxious- moving all extremities\ncooperative- follows command.\n\nGI- abd obese- (+) bowel sounds- taking Po well- no BM- glucose high initially 290-369- insulin given as per sliding scale- glucose @ 1730 140.\n\nGU- diuresed well from lasix- (-) 1L - BUN 20 Crea 1.3\n\nA- stable in SR\n\nP- monitor vs, lung sounds, I&O & labs- Ptt due @ 2100- increase activity- ? transfer back to 6 tomorrow.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-03 00:00:00.000",
"description": "Report",
"row_id": 1618810,
"text": "S:\"Am I dying.\"\n\nCV:Pt in rapid afib, bp 92/40-130/107. pt received total of 20mg IVP of Lopressor and 50mg po lopressor with a slight decrease in rate. Pt was then started on Esmolol titrated up to 200mcg/kg/min. Pts HR now 120-98 bp 91/52(61). Pt continues on heparin gtt 1075units/hr. PTT 62.7 AT 2200 UNABLE TO DRAW A.M. LABS k 4.0.\n\nResp:pts o2 sats decreased to 80% while sleeping while on 2liters of o2 via nc. increased o2 to 5L via nc maintaining o2 sats of 90-99%. LS clear diminished at bases bilat. Pt denies SOB.\n\nNeuro:alert and oriented x3. Pt very anxious at the beginning of the night crying wanting to call her daughter. pt spoke to daughter and received .5mg ativan ivp with good effect. Pt more relaxed. Pt c/o back pain and received oxycodone for pain. Pt awoke x3 during night confused calling out for pt was easily reoriented to place and time.\n\nGU: urin output has decreased now -100cc since midnight since admit 5700cc. yellow clear and yellow\n\nGI:BS +, - BM. pt has good appetite. BS 240's on ss insulin.\n\nAccess:pt has two good working peripheral IV's in place. Unabel to get a.m. labs. phlebotomy tried and was unable to get blood. MD aware of difficulty with blood draws and will assess the need for central IV access.\n\nA:RAPID AFIB UNABLE TO CONVERT NOW HEART RATE CONTROLLED BELOW 130.\n\nP: CONTINUE TO MONITOR HEART RATE AND RHYTHM. MONIOTR BP FOR HYPOTENSION. ASSESS URIN OUTPUT. ASSESS MENTAL STATUS\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-29 00:00:00.000",
"description": "Report",
"row_id": 1618800,
"text": "(Continued)\n00meq nahco3 @ 75cc/hr x1 liter.\n\nlabs: liver enzymes/bun/creat rising likly d/t bradycardia/hypotension.\n hct 27.0 has chronic anemia\n inr 1.5\n am labs pending\nsocial: pt lives in w daughter and grand-daughter. family members names and numbers on contact board. daughter is contact and hcp.\n\na/p; 54 yr old adm w vent escape rhythm and bradycardia/hypotension. may be seen by ep ? pacer although event may be related to bb adm. follow abg's con't to update family on poc, support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-29 00:00:00.000",
"description": "Report",
"row_id": 1618801,
"text": "Patient is ordered for nebulizers Albuterol Q6PRN and atrovent Q6; Order to be changed to MDI's.CXR shown (R) lower lobe opacity.Now on PSV with plan to extubate in Am.ABG shown metabolic compensation, negative 334. Patient alert will continue to follow.\u0013\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-29 00:00:00.000",
"description": "Report",
"row_id": 1618802,
"text": "CCU NPN 0700-1900\ncorrection: incorrectly documented that pt has restricitve lung disease, error\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-29 00:00:00.000",
"description": "Report",
"row_id": 1618803,
"text": "CCU NPN 0700-1900\nS: Pt continues orally intubated and mechanically ventilated.\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 67-89 NSR, rare PVC's noted. R femoral pacing wire intact, no pacing throughout shift, pacer checked by EP MD, see flowsheet. ABP 139-197/42-73. Pt started on nifedipine this am, pt tol, to have increased dose tonight MD's. Bilat pedal pulses palp. Afternoon K 3.8, repleted with 20 MeQ KCL.\n\nResp: Please see careview for vent settings and ABGs. Pt weaned to CPAP 50% 16 PS 10 peep, RR 18-27, O2 sats 93-98%. Most recent ABG 7.44/51/89/36/8. Pt sxn'd for small amt thick white sputum, sputum cx sent. LS coarse throughout.\n\nNeuro: Pt sedated on propofol 45 mcg/kg/min. Pt MAE, PERLA 3mm, follows commands, opens eyes to voice and squeezes hands/ wiggles toes. At times pt shifting weight/repositioniong self in bed (when stimulated by RN or family memebers), pt mouthing appropriately to RN and family members at times.\n\nGI/GU/ENDO: Pt abd soft obese, +BS x4, no stool this shift. OGT with minimal bilious aspirates, pt cont NPO in anticipation of extubation tomorrow am. Foley cath draining clr light yellow u/o 130-240 cc/hr, pt -580 @ 1600, goal -1L at midnoc. FS 50-138, 2 amps D50 given as ordered, CCU intern and resident aware, will cont to monitor, no tube feeding or additional D50 gtt's at this time MD's.\n\nID: T max 100.8 rectal, pt started on flagyl and ceftriaxone, sputum cx sent as yesterday's cx discarded. Bld cx's from last noc pending, tylenol 650 mg given x2.\n\nSocial: Pt daughters, and multiple family members in to see pt this afternoon. Pt dtr and updated by RN on pt condition and POC.\n\nA/P: 54 y/o female with hx cardiomyopathy, diastolic dysfunction, afib, diabetes and restrictive pulmonary disease transferred to CCU last eve for junctional rhythm/bradycardia. Temp wire placed overnoc, no pacing noted since placement-pt in NSR this am, resumed nifedipine and tolerating vent wean. As discussed per interdisciplinary rounds, cont to monitor pt hemodynamics, titrate cardiac meds as ordered and pt tol, obtain evening K and lytes as ordered. Cont to monitor resp status, ABGs-wean vent as tol, anticipate extubation at am. F/u with cx results, temps, cont to monitor u/o-lasix as ordered, goal pt -1L at midnoc. Cont to monitor FS, f/ with MD's regarding FS. Cont to provide emotional support to pt and family, awaiting further POC per CCU Team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-30 00:00:00.000",
"description": "Report",
"row_id": 1618807,
"text": "Resp. Care Note\nPt received intubated and vented on PSV settings as charted on resp flowsheet. Plan today to wean as tolerated with goal of extubation in afternoon. Beta blockers started in AM for rate control, pt tolerated well with no resp compromise. Weaned to PSV 10 peep 8, good ABG. Sheath pulled and after 2 1/2 hrs, pt sat upright, sedation decreased and placed on PSV 5 peep 5. RSBI rechecked and was 78. Good ABG on , cuff leak noted and pt extubated per team. Placed on 70% face tent, good sats and weaned to 50%. BS slight coarse at times, white secretions, MDI's as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-30 00:00:00.000",
"description": "Report",
"row_id": 1618804,
"text": "NPN 7 AM--7 PM\n\nS: pt intubated and sedated but does open eyes follows commands nods to questions\n\no: Please see care view for vitals and other objective data\n\nPT here after having syncope and fall on floor, Bradycardic, juctional rhythm after having high dose ca channel blockers and lopressor.\nTemp wire was placed and pt did not require pacing as her own SR came back.\n\nEvents overnight: Pt was in SR, pacer was set to demand mode at ventricular rate of 40. During repositioning noted pacer not sensing,\nbut no pacer spikes either, turned pt towards left side and interogated pacer. Increased M/A to 8, turned sensitivity to 0.8 most sensitive, and pacer did pace capture and sense appropriately. Later around 0100 Am, pt went into rapid AF and inappropriate pacer spikes were noted ( failure to sense), Shut off pacer, MDs at bedside, diltiazem 10 mg IV x 3 doses and diltiazem drip started.\nPt also had another episode of hypoglycemia, FS-56, gave dextrose 50 ml of 50 percent dextrose, changed all IV to D5W, spoke with team. Continue frequent checks. One hr later FS 136.\n\nOtherwise pt has been tolerating her Afib, On dilt drip 15MG/HR, HR 97-110 BP 124/58--147/70, tolerating verapamil which was restarted\nlast night as well as nifedipine. CPK coming down, 653 with MB 3,\nK -4.3 this Am. Neuro wise she is arousable, moves all extrem to command, tries to assist with turning, we did have to increase sedation while we were attempting IV placement. She c/o back pain, tylenol and repositioned, denied CP. Respiratory wise- pt is suctioned Q2 hours for moderate to large amount thick white secreations, T max 100.2 oral. ABG this AM - 7.44 54 and 92- attempted to decrease peep at 0500 and pt became restless BP up to 170 systolic sat down to 93\npercent, placed back on 10 peep, and 15 of PS.\nGu- renal wise- pt continues to diurese without any lasix, 120-250 cc per hr overnight, creatinine has come down to 1.5 this am.\n\nA: pt with medication induced bradycardai, now in rapid Afib. Temp\npacer off as it is not sensing currently. remains intubated with increased secreations overnight.\n\nP: ? wean pt further, did not respond well to decreased peep this AM.\ncontinue monitor CV and resp status, check with EP regarding pacer,\nmonitor lytes, I/o, Urine output. keep pt and family updated on POC as discussed in CCU rounds\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-30 00:00:00.000",
"description": "Report",
"row_id": 1618805,
"text": "Resp Care\nPt remains on vent. Abgs wnl, borderline hypoxemia. peep decreased. Rsbi 106. Mdis given. Will conitnue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-30 00:00:00.000",
"description": "Report",
"row_id": 1618806,
"text": "CCU NPN 0700-1900\nS: \"Can I have some water.\"\n\nO: Please see careview for VS and additional data.\n\nCV: pt with HR 90-117 afib, pacing box off, on diltiazem gtt 15 mg/hr. Per Dr. , pt started on esmolol gtt, esmolol up to 150 mcg/kg/min, at approx 1210 pt given 50 mg PO metoprolol and at 1230 pt HR noted to be in NSR 60-72, EKG done, CCU intern and resident aware, esmolol gtt off d/t MAPs dropping to 60. ABP 97-183/48-69. Temp pacing wire dc'd this afternoon by CCU fellow. R groin soft, CDI, bilat pedal pulses palp. Pt to start Heparin gtt this eve.\n\nResp: Please see careview for vent settings and ABGS. Pt extubated at 1615, + gag/cough, +cuff leak, tolerating 12L 50% face tent, expectorating small amts white-yellow sputum. LS coarse throughout.\n\nNeuro: Pt MAE, PERLA 4 mm brisk, pt able to assist with turning/repositioning in bed. Pt A&Ox3, asking appropriate questions regarding care.\n\nGI/GU/ENDO: Pt abd soft obese, +BS x4, 1 lg soft formed stool this eve, guiac negative. Pt NPO throughout day d/t extubation, pt tol swabs in water. FS 90's throughout shift, no ss insulin, pt continues on D51/2NS @ 75 cc/hr.\n\nID: pt T max 100.3, tylenol 650 mg given x2. Pt cont on IV flagyl and ceftriaxone.\n\nSkin/access: Pt skin intact. L wrist PIV infiltrated (IVF infusing), PIV removed and L arm elevated. @ PIV's and R radial aline intact.\n\nSocial: Pt dtr's in at bedside this afternoon briefly and this eve post extubation, spoke with RN regarding pt condition and POC.\n\nA/P: 54 y/o female now in NSR post-esmolol/metoprolol dose, pt extubated without incident this afternoon. As discussed per rounds, cont to monitor pt hemodynamics, titrate cardiac meds as ordered, start heparin gtt when ordered. Cont to monitor resp status, wean O2 as tol. Cont to follow cx results, temps, abx. Advance diet and activity as tolerated. Cont to provide emotional support to pt and family, awaiting further POC per CCU team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-01 00:00:00.000",
"description": "Report",
"row_id": 1618808,
"text": "NPN 7 PM--7 AM\n\nS: \" My bUttocks is sore\"\n\nO: please see careview for vitals and other objective data.\n\nPt was extubated yesterday at 1600 and did quite well overnight. Pt went into Afib with Rapid ventricular response at 1900 last night, has hx of a fib and has been in out of it over last 2 days. Pt was given lopressor PO and 5 mg IV and she did convert back to SR at midnight.\nCurrently SR in the 70's. pt had alot of PAC and some atrial bigeminy,\nteam aware, morning labs drawn early, Lytes WNL. Less ectopy as morning progressed now just occasional PAC and PVC's. Pt has been chest pain free, denies SOB, did C/O of palpitatatons when she was in Afib. Heparin decreased to 700 units per hour for PTT 106.9-- next PTT at 0800. Pt did C/O of buttocks pain and requested pain med q 2-3 hours, spoke with team they will increase percocet dose. She was able to sleep after ambien in long naps. coughing at times, expectorating thick white sputum, afebrile overnight continues on antibiotics for posible aspiration pna.\n\nA: Pt admitted with CHF exaserbation thought to be from med noncompliance, C/B syncope and temp wire for junctional rhythm, now extubated, taking PO pills and soft food.\n\nP: continue to monitor resp and CV status, follow rhythm, labs, get pt OOB today, med teaching, keep pt and family updated on POC as discussed in CCU rounds\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-29 00:00:00.000",
"description": "Report",
"row_id": 1618798,
"text": "Resp Care\nPt requiring Niv to remove high Pco2. No changes in Pco2 after many changes. Pt intubated with 75 ett @ 20. Suctioned for mod amt of thick white secretions. Abgs improving, setings titrated accordingly. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-06-29 00:00:00.000",
"description": "Report",
"row_id": 1618799,
"text": "ccu npn\n\n54 yr old w pmh: a-fib ( coumadin @ home),diastolic dysfunction,htn. initially adm to floor w ^ sob. on the floor cv meds adjusted and pt started on beta blocker.. on , noon, pt became nauseous and vomited, became bradycardic w hr 50's. pt had syncopal episode, fell forward and hit her head. head ct neg for hemmorrahge or fracture. ekg showed hr 50, but no further changes. @ 1700 pt's hr dropped to 30. ekg showed vent escape rhythm, prolong qt. sbp 100 ( usual sbp 160) also had ms changes. abg 7.26/60/63, k+ 7.0. transfered to ccu for temp wirer. on adm received 2 amps ca chloride, 10 u reg insulin and started on insulin gtt for bs 435. pt drapped and prepared for travenous pacer wirer.\n\ncv: introducer and wirer inserted via r groin. subclavian attempted initally. hr 46-48 junctional rhythm, but w stable bp 140/ aed @ bedside and placed on pt. transvenous pacer rate set to 40, by md's. v-theshold @ 8, ma 12. intrinsic rate overnoc 46-49 junctional, but w stable bp 130-160. slow return of p-waves and @ 0430 pt w consistent p-waves now in sb-nsr w hr's 60-66.. a-line inserted via r radial site. ck 285, mb 4 trop 0.03 am enzymes pending.k+ on adm 7.0. received iv insulin 10u and started on gtt. also received k-ex. 30gm po and k+ now 5.4 ( am pending). denied cp. lactic acid on adm 5.4, now down to 1.7. team notifed this am of rising bp's sbp now 160-170.\n\nresp; received alb/atr nebs. acidotic w ^pco2. 7.27-7.28, pc02,65-66. several attempts w bipap, cpap/ps several changes made (please see flow) ,but no improvments in pco2. also mild changes noted in ms, more difficult to arouse. pt intubated w #7.5 20 @ l. cxr completed post intubation. suctioned for small amt's thick white secretions. initailly placed on ac 50%,500x24,10 abg 7.47,40,95,30,4,97%. additional changes made and rate now decreased to 20. will plan to follow abg's w rate chnages. bs course w exp wheezes, crackles @ the bases. lasix given 40 mg iv.\n\ngu; foley placed. poor u/o 10-15cc/hr creat 2.8 (was 1.3) lasix 40 mg iv given with good responce in u/o. am bun/creat pending. arf in the setting of bradyc/hypotension\n\ngi: abd obese,but soft. hypoactive bs. no stool noted. ngt placed post intubation. cxr comfirmed placment. interm suctioned for small bilious output.\n\nskin: intact, could benefit from big boy bed.\n\nid: low grade temp 99.0 wbc ^ 14.4 bld cult x2 sent. ua and sputum also sent. no abx @ this time.\n\nneuro; prior to intubation/sedation opens eyes to voice alert @ times, but falls back to sleep easily. oriented to person,and time. answers appropriately. knows and recognizes family members. post intubation. now on propofol @ 40-50mcg. opens eyes to pain and @ times voice. follows commands inconsistently. mae on bed.\n\nendo; insulin gtt titrated per carevue flow. insulin now off and team aware. bs 109-120.\n\niv access: #22 via l hand. additional iv's attempted but unable. iv therapy also evaluated but unable to access. has introducer in groin. receiving d5w w 1\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-04 00:00:00.000",
"description": "Report",
"row_id": 1618814,
"text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 78-96 afib w/occ PAC's,BP 104-134/57-38 esmolol off and remains on diltiazem drip at 15mg/hr. received one dose 30mg po dilt.\ncont w/ lopressor 100mg TID,amiodorone 400mg TID\n\nResp: able to wean O2 to 2l NP diminished at bases. receiving atrovent MDI's.\n\nGU: urine output 30-140cc/hr last BUN/Creat 32/1.7 received 100mg lasix prior to transfusion\n\nEndocrine: FS 334-355 consult,increased sliding scale insulin and glargine increased to 14 units tonight\n\nGI: c/o nausea this am after receiving reglan,given ondansetron 8mg IV x1,no more nausea. ate small amount for breakfast and lunch. has not had BM for at least days,given colace,senna and then 10mg duculax po.\n\nID: afebrile,WBC 12.8 last dose of cefpodoxine proxef due at 8pm\n\nHeme:HCT this am 23 transfused one unit packed cells,repeat HCT 25.4. PTT at 4pm >150 heparin off for one hour then repeat PTT sent awaiting results,to receive coumadin 5mg this evening INR 1.6\n\nNeuro: improved mental status today,alert and interactive. very cooperative. OOB three times today,two person light assist.still using bed and chair alarms for safety\n\nSocial: daughter visiting early am and again this evening. Many visitors this evening\n\nA: Afib rate controlled on IV dilt,lopressor and amiodorone.improved neuro status.transfusion for HCT 23.\n\nP: cont w/ dilt drip team to order another dose of po dilt this evening.\n follow FS closely and cover w/ SSI,increase dose glargine tonight\n keep pt OOB as long as possible this evening to promote better sleep tonight\n cont with bowel meds and reglan\n emotional support pt and family\n check results of PTT and adjust heparin drip\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-05 00:00:00.000",
"description": "Report",
"row_id": 1618815,
"text": "S:\"I dont know who you are where am I. I'm not in the hospital.\"\n\nNeuro:pt very confused after she awoke after sleepin for about 2hrs. Pt had no idea where she was, she did not recognize her daughters name and she was acting very suspicious of rn pt refused to take her pills. Pt thought rn was trying to hurt her. pt needed to have a sitter sit with her for the rest of the night after pt tried to fit threw side rail on the bed. pt had bed alarm on and continues to have bed alarm on for safety. Pt is a high fall risk.\n\nCV:Pt refused lopressor all night lopressor was offered to her when ever she would wake up. HR 84, afib rate controlled, bp 124/67, heparin 300units/hr diltiazem 15mg/hr.\n\nResp: pt has diminished lung sounds. o2 sats on 5L NC FOR SLEEPING IS 95%. PT WAS ON CPAP FOR SLEEP APNEA AND IT WAS NOT TOLERATED FOR ORE THAN A HOUR. PT KEPT REMOVING HER MASK SHE THEN REFUSED IT ALL TOGTHER.\n\nGI: NO BM PT IS ON A AGGRSSIVE BOWEL REGIMEN. BS +.\n\nGU: -2093CC SINCE ADMISSION SINCE MIDNIGHT -73CC..\n\nENDO: BS 200'S-300'S. SS INSULIN AND FIXED DOSE INSULIN.\n\nA:CHF EXACERBATION:\n\nP:CONTINUE TO DIURESE AT TOLERATED. CONTINUE TO HELP PT AMBULATE TO CHAIR AS NEEED FOR COMFORT, KEEP FAMILY INFORMED. CLOSELY I/O'S AND MENTAL STATUS\n"
},
{
"category": "Echo",
"chartdate": "2176-07-02 00:00:00.000",
"description": "Report",
"row_id": 94550,
"text": "PATIENT/TEST INFORMATION:\nIndication: Assess structure/function. Atrial fibrillation. Diastolic dysfunction. Hypotension.\nHeight: (in) 62\nWeight (lb): 267\nBSA (m2): 2.16 m2\nBP (mm Hg): 109/52\nHR (bpm): 124\nStatus: Inpatient\nDate/Time: at 11:12\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: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Small LV cavity. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nHyperdynamic LVEF >75%. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. Cannot exclude AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Normal PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Resting\ntachycardia (HR>100bpm). The rhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is moderate symmetric left ventricular hypertrophy. The left ventricular\ncavity is unusually small. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an\nincreased left ventricular filling pressure (PCWP>18mmHg). The number of\naortic valve leaflets cannot be determined. The increased transaortic gradient\nis likely related to high cardiac output but cannot exclude mild aortic\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. No mitral regurgitation is seen. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Extremely limited study given poor acoustic windows and rapid\natrial fibrillation. Moderate biatrial enlargement. Moderate symmetric left\nventricular hypertrophy with hyperdynamic left ventricular function. Elevated\nleft ventricular filling pressures. Increased gradient across the aortic valve\nconsistent with high output state; however, aortic valve not well visualized\nso mild aortic stenosis cannot be excluded.\n\nCompared with the prior study (images reviewed) of , the rhythm is\nnow atrial fibrillation with a rapid ventricular response. Other findings are\nsimilar.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-08 00:00:00.000",
"description": "Report",
"row_id": 270049,
"text": "Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy with secondary ST-T wave abnormalities. Compared to the previous\ntracing of no significant diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-04 00:00:00.000",
"description": "Report",
"row_id": 270050,
"text": "Atrial fibrillation. Left ventricular hypertrophy with QRS splintering\nin the anterior leads and repolarization changes which likely represent\nleft ventricular hypertrophy but could also be secondary to myocardial\nischemia. Compared to tracing of no significant change except for\nrate. Ventricular response to atrial fibrillation is now controlled.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-03 00:00:00.000",
"description": "Report",
"row_id": 270051,
"text": "Atrial fibrillation with rapid ventricular response. Compared to tracing #4\npatient is now again in atrial fibrillation. Clinical correlation is\nsuggested.\nTRACING #5\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-03 00:00:00.000",
"description": "Report",
"row_id": 270052,
"text": "Sinus rhythm. Occasional ventricular premature beat. Compared to tracing #3\npatient is now back in sinus rhythm. Other multiple abnormalities described\npreviously persist. Clinical correlation is suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-02 00:00:00.000",
"description": "Report",
"row_id": 270053,
"text": "Atrial fibrillation with rapid ventricular response. Occasional ventricular\npremature beats. Compared to tracing #2 patient is now in atrial fibrillation\nwith rapid ventricular response. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-02 00:00:00.000",
"description": "Report",
"row_id": 270054,
"text": "Sinus rhythm. Occasional ventricular premature beats. Compared to\ntracing #1 patient is now back in sinus rhythm. Other multiple abnormalities\npersist. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-02 00:00:00.000",
"description": "Report",
"row_id": 270055,
"text": "Atrial fibrillation with rapid ventricular response. Occasional ventricular\npremature beats. Left ventricular hypertrophy with secondary ST-T wave\nabnormalities. Extensive ST-T wave abnormalities are most likely related to\nleft ventriciular hypertrophy but cannot rule out myocardial ischemia.\nCompared to tracing of atrial fibrillation is new. Clinical\ncorrelation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-02 00:00:00.000",
"description": "Report",
"row_id": 270056,
"text": "Sinus rhythm. Left ventricular hypertrophy. Diffuse repolarization\nabnormalities consistent with left ventricular strain pattern. Compared to\nprevious tracing of multiple abnormalities as noted persist without\nmajor change.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-07-01 00:00:00.000",
"description": "Report",
"row_id": 270057,
"text": "Technically difficult study\nSinus rhythm\nLVH with secondary ST-T changes\nSince previous tracing of , sinus rhythm restored\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-30 00:00:00.000",
"description": "Report",
"row_id": 270058,
"text": "Atrial fibrillation with rapid ventricular response with multifocal PVCs or abe\nrrant ventricular conduction.\nExtensive ST-T changes are probably due to ventricular hypertrophy\nSince previous tracing of the same date, atrial fibrillation recurred\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-24 00:00:00.000",
"description": "Report",
"row_id": 270299,
"text": "Paroxysmal atrial fibrillation. Spontaneous termination. A single probably\nsinus P wave with prolonged A-V conduction with resumption of atrial\nfibrillation. Left ventricular hypertrophy with secondary repolarization\nchanges.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-23 00:00:00.000",
"description": "Report",
"row_id": 270300,
"text": "Probable atrial fibrillation with rapid ventricular rate. Left ventricular\nhypertrophy with secondary repolarization changes.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-21 00:00:00.000",
"description": "Report",
"row_id": 270301,
"text": "Sinus rhythm. Atrial ectopy. The QRS duration is 100 milliweconds. Left\nventricular hypertrophy with associated ST-T wave changes. Compared to the\nprevious tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-20 00:00:00.000",
"description": "Report",
"row_id": 270302,
"text": "Sinus rhythm. Atrial ectopy. The Q-T interval is prolonged. There is left\nventricular hypertrophy with associated ST-T wave changes. Compared to the\nprevious tracing no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-20 00:00:00.000",
"description": "Report",
"row_id": 270303,
"text": "Sinus rhythm. Atrial ectopy. The Q-T interval is prolonged. Left ventricular\nhypertrophy with associated ST-T wave changes. Compared to the previous tracing\nno significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-30 00:00:00.000",
"description": "Report",
"row_id": 270295,
"text": "Sinus rhythm\nLVH with secondary repolarization abnormality\nExtensive ST-T changes are probably due to ventricular hypertrophy\nSince previous tracing of the same date, atrial fibrillation resolved\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-30 00:00:00.000",
"description": "Report",
"row_id": 270296,
"text": "Atrial fibrillation with rapid ventricular response. Occasional premature\nventricular contraction. Probable left ventricular hypertrophy with secondary\nST-T wave abnormalities. Compared to tracing #2 sinus rhythm has been\nreplaced by atrial fibrillation.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-29 00:00:00.000",
"description": "Report",
"row_id": 270297,
"text": "Normal sinus rhythm with voltage criteria for left ventricular hypertrophy and\nsecondary ST-T wave abnormalities. Compared to the prior tracing #1 the\njunctional rhythm has been replaced by normal sinus rhythm.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-28 00:00:00.000",
"description": "Report",
"row_id": 270298,
"text": "Probable junctional rhythm with borderline voltage criteria for left\nventricular hypertrophy with secondary ST-T wave abnormalities. Cannot exclude\nanterolateral ischemia with T wave inversions in leads I, aVL and V3-V6.\nThere is also marked Q-T interval prolongation. Compared to the prior tracing\nof atrial fibrillation has been replaced by junctional rhythm.\nClinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 969366,
"text": " 10:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Assess for PNA vs. CHF vs. PE\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with CHF and SOB, hypertensive, febrile.\n REASON FOR THIS EXAMINATION:\n Assess for PNA vs. CHF vs. PE\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever.\n\n Portable AP chest radiograph compared to .\n\n The marked cardiomegaly is again demonstrated grossly unchanged. The\n bilateral perihilar vascular prominence is noted, with some upward vascular\n redistribution, which might represent a mild degree of pulmonary edema. The\n lungs lucencies are different with the _____opacity projecting over the right\n lung which might represent pleural effusion.\n\n Evaluation with upright standard PA and lateral chest radiograph would be\n highly recommended for precise description of the findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 969442,
"text": " 12:04 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate vs. pulm edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with CHF and SOB, hypertensive, febrile.\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate vs. pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: and radiographs.\n\n INDICATION: CHF. Fever.\n\n Cardiac silhouette is enlarged but stable in size since . Upper\n zone vascular redistribution is present. Asymmetric hazy opacities involving\n the right lung to a greater degree than the left show interval improvement\n since the recent exam, although technical differences probably account for\n part of this apparent change. No definite pleural effusions are identified.\n\n IMPRESSION: Improving asymmetrical opacities in the right lung, which may be\n due to resolving asymmetrical pulmonary edema. Continued radiographic\n followup is recommended to exclude underlying pneumonia considering clinical\n suspicion for this entity.\n\n"
}
] |
52,363 | 123,420 | MEDICAL COURSE: Mr. is a 61 year-old man without ongoing medical care presents with 2 month failure to thrive with dyspnea and lower extremity edema and hypoxia, found to have severe endocarditis with destruction of multiple valve leaflets. Patient was initially in MICU for ongoing work-up and treatment of his endocarditis and was transferred to CT surgery for valve repair. | No PS.Physiologic PR.PERICARDIUM: Very small pericardial effusion.Conclusions:PREBYPASS: The left atrium is moderately dilated. Moderate tricuspidregurgitation directed towards the interatrial septum is seen. There is mild symmetric leftventricular hypertrophy. Left pleural effusion.Conclusions:The left atrium is mildly dilated. The right atrium is moderately dilated.There is mild symmetric left ventricular hypertrophy. Normal interatrial septum.LEFT VENTRICLE: Mild symmetric LVH. Physiologic (normal) PR.PERICARDIUM: Very small pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm). There is moderate pulmonary artery systolichypertension. Moderate-sizedvegetation on aortic valve. Normal regionalLV systolic function. Normal regionalLV systolic function. Endotracheal and nasogastric tubes in standard position. A probable vegetation or mass is seen on the pulmonic valve.There is a very small pericardial effusion.IMPRESSION: Endocarditis on the mitral and aortic valve and possibly also onthe tricuspid valve. Pericardial effusion.Height: (in) 69Weight (lb): 145BSA (m2): 1.80 m2BP (mm Hg): 118/47HR (bpm): 111Status: InpatientDate/Time: at 12:48Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. Dilated left ventricle with preserved ejectionfraction. There are bilateral simple pleural effusions, moderate on the right and small to moderate on the left. Moderate cardiomegaly and central venous congestion persist. There remains a mild-to-moderate pulmonary edema and small bilateral pleural effusions. Moderate PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Probable vegetation or mass on pulmonicvalve. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is some patchy enhancement of the sacrum identified which is likely due to pulsation artifacts from the adjacent iliac arteries. The left ventricularcavity is mildly dilated. The coronary sinus appears normal.POSTBYPASS: Normally functioning AV, MV bioprosthesis. Mediastinal and bilateral chest tubes are in place. Endocarditis.Status: InpatientDate/Time: at 11:18Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Moderate left and small right layering pleural effusions are unchanged. FINDINGS: There is a right-sided pneumothorax which is stable to slightly larger than on the prior study. This finding indicates a small area of acute infarct. Small area of acute infarct in the left parietal lobe. FINDINGS: CHEST: Diffuse geographic ground-glass opacities are present throughout the lungs, with a perihilar predominance, and largely sparing the pleural surfaces. Noresting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Neighboring opacities most likely reflect atelectasis or mild edema. FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. There is a very small pericardial effusion. The left ventricular cavity is mildly dilated.Regional left ventricular wall motion is normal. There is persistent small bilateral pleural effusions. Trace bilateral pleural effusions are unchanged. Moderate to severe aortic regurgitation islikely present. Severe (4+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. The ascending,transverse and descending thoracic aorta are normal in diameter and free ofatherosclerotic plaque. Mildly dilated LV cavity. Mildly dilated LV cavity. The patient has received a right-sided PICC line. On the right side, there is a small apical pneumothorax. Moderate alveolar edema. Small right apical pneumothorax, stable since . Non-specific J pointdepression in the left precordial leads. IMPRESSION: Unchanged appearance of moderate bibasilar effusions, atelectasis and tiny right apical pneumothorax. Compared to the previoustracing of ventricular ectopic beats are no longer present. A right upper extremity PICC terminates at the level of the upper SVC. An endotracheal tube remains at the clavicular heads. Right-sided chest tube is unchanged in position terminating in the right basal pleural space. PORTABLE AP CHEST RADIOGRAPH: Small right apical pneumothorax and a small right pleural effusion, are stable since . FINDINGS: A right-sided internal jugular line has been inserted with the tip in the low SVC. Lateral ST segmentdepression is consistent with myocardial ischemia. Small bilateral pleural effusions are noted. A right apical pneumothorax is tiny and unchanged. There is mild pulmonary edema with perihilar haziness, vascular indistinctness, and Kerley B lines. Right axis deviationconsistent with possible left posterior fascicular block. Right PICC line tip can be seen at the level of mid SVC. There is minimal prominence of the pulmonary interstitial markings and small bilateral pleural effusions. Cannot exclude prior anteroseptalwall myocardial infarction. Small left pleural effusion and moderate left basal atelectasis are unchanged. Sinus rhythm with ventricular premature beats. There is a trace pulmonary edema. There is again seen a chest tube at the right base. Atrial fibrillation with a mean ventricular rate of 121. IMPRESSION: Right IJ tip in the low SVC. Ventricular ectopy is less frequent. Heterogeneous areas of consolidation in both lungs, predominantly seen in the lower lobes, have not significantly changed and likely represent asymmetric pulmonary edema, less likely infection. Sinus tachycardia with ventricular premature beats. ST-T waveabnormalities. The right apical pneumothorax is small, grossly unchanged since the prior study. Delayed anterior R wave progression of native beatssuggests prior anteroseptal myocardial infarction. Bilateral pulmonary consolidations, predominant in the lower lobes, likely represent asymmetric pulmonary edema, less likely infection. Evaluate for pneumothoraces. Small bilateral pleural effusions are new or newly apparent. The cardiomediastinal and hilar contours are stable. There are bilateral chest tubes. There are bilateral chest tubes. Bilateral layering effusions are unchanged. There is alate transition with small R waves in the anterior leads and associatedanterior and anterolateral ST-T wave changes consistent with possibleinfarction. Bilateral pleural effusions are again present and stable in size. Sinus rhythm. The cuff is mildly overinflated. A tiny apical pneumothorax in the left side is also identified. The right-sided PICC line tip is at the level of the proximal right atrium. Moderate cardiomegaly has improved slightly. Heart size and mediastinum are unchanged. Left atrialabnormality. The cardiac size is enlarged but stable. Additional non-specific ST-T wave changes. Delayed R wave progression. Mild cardiomegaly is unchanged. Since the previous tracing of probably no significantchange. Conducted complexes have lowlimb lead voltage. The mediastinal contours are within normal limits. Hyperinflation of endotrachial tube cuff. | 28 | [
{
"category": "Radiology",
"chartdate": "2174-05-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1240372,
"text": " 2:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change after diuresis\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with dyspnea and orthopnea\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:27 A.M. ON \n\n HISTORY: 61-year-old man with dyspnea and orthopnea. Evaluate for interval\n change after diuresis.\n\n IMPRESSION: AP chest compared to :\n\n What was previously moderately severe interstitial pulmonary edema has\n progressed to severe pulmonary edema with a perihilar distribution. Moderate\n cardiomegaly may be slightly larger and small bilateral pleural effusions are\n larger as well. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1240573,
"text": " 8:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with endocarditis, pulm edema\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST \n\n HISTORY: 61-year-old man with endocarditis, evaluate pulmonary edema.\n\n IMPRESSION: AP chest compared to through .\n\n Severe pulmonary edema has worsened again since , more pronounced than\n it was at its maximum, , accompanied by small bilateral pleural\n effusion, left greater than right.\n\n Dr. was paged at 10:03 a.m., one minute after the findings were\n recognized, and we discussed them by telephone one minute after that.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-11 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 1240676,
"text": " 1:34 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: Please eval for abscess, osteomyelitis, diskitis. PLEASE DO\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with back pain, GPC bacteremia, endocarditis, back pain. Please\n eval for abscess, osteomyelitis, diskitis.\n REASON FOR THIS EXAMINATION:\n Please eval for abscess, osteomyelitis, diskitis. PLEASE DO THORACIC AND\n LUMBAR FIRST and remainder of MRI after.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg TUE 5:36 AM\n Enhancing foci within vertebral bodies of T4, L4, L5 consistent with bacterial\n osteomyelitis, though unusual in that discs are spared. Ddx includes\n hypervascular metastatic disease (e.g. renal, melanoma, lung ca). No epidural\n or intradural component is seen.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI OF THE CERVICAL, THORACIC, AND LUMBAR SPINE\n\n CLINICAL INFORMATION: Patient with endocarditis, rule out osteomyelitis or\n epidural abscess.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of\n cervical, thoracic, and lumbar spine obtained before gadolinium. T1 sagittal\n and axial images were obtained following gadolinium.\n\n FINDINGS: There is diffuse low signal in the visualized bony structures which\n could be secondary to marrow hyperplasia or infiltration. There is also\n diffuse hyperintense signal seen in the soft tissue surrounding the spine\n which could be due to soft tissue edema and mild diffuse enhancement is also\n identified. However, there is no evidence of enhancement seen within the\n discs or vertebral endplate abnormalities identified to indicate discitis.\n There are foci of hyperintense signal within the T4 and L4 vertebral bodies\n which are hyperintense on T2 and inversion recovery images and demonstrates\n some enhancement. However, the appearance, although somewhat unusual is\n likely due to hemangiomas in correlation with the prior torso CT of \n which demonstrated some trabecular abnormalities in the region. In addition,\n the enhancement pattern is more in favor of hemangioma than metastatic foci or\n foci of osteomyelitis, which would be unusual with this appearance.\n\n There are mild multilevel degenerative changes in the cervical, thoracic, and\n lumbar region without spinal stenosis. There is no spinal cord compression or\n intrinsic spinal cord signal abnormalities.\n\n There is fluid seen within the nasopharynx secondary to intubation.\n\n There is some patchy enhancement of the sacrum identified which is likely due\n to pulsation artifacts from the adjacent iliac arteries.\n\n (Over)\n\n 1:34 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR W & W/O CONTRAST\n Reason: Please eval for abscess, osteomyelitis, diskitis. PLEASE DO\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is no evidence of paraspinal abscess identified. A visualized thorax,\n pleural effusion and pleural parenchymal changes are seen which are better\n evaluated with the prior chest CT.\n\n IMPRESSION:\n 1. No evidence of discitis or definite evidence of osteomyelitis seen.\n 2. Foci of signal abnormality within the T4 and L4 vertebral bodies are\n likely due to hemangiomas which have atypical appearance secondary to diffuse\n bony abnormality secondary to marrow hyperplasia or infiltration. This foci\n are less likely secondary to metastasis or foci of osteomyelitis given the\n appearances on the post-gadolinium images. However, a followup study can\n confirm this suspicion.\n 3. Diffuse low signal in the bony structures due to marrow hyperplasia or\n infiltration.\n 4. No evidence of epidural abscess or spinal cord compression.\n 5. Diffuse high signal on T2 images within the soft tissues likely secondary\n to soft tissue edema. Other findings as above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-11 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1240677,
"text": " 1:34 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please eval for septic emboli to brain. PLEASE DO THORACIC\n Admitting Diagnosis: CHF VS PNA\n Contrast: PROHANCE Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with endocarditis, bacteremia. Please eval for septic emboli to\n brain.\n REASON FOR THIS EXAMINATION:\n Please eval for septic emboli to brain. PLEASE DO THORACIC AND LUMBAR FIRST\n and remainder of MRI after.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg TUE 5:36 AM\n scattered foci of diffusion abnormality (se9;21,17,15) and an enhanceing focus\n (se14;12) c/w embolic disease.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with endocarditis. Rule out septic emboli in\n the brain.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal\n images acquired following the administration of gadolinium. There are no\n prior similar examinations for comparison.\n\n FINDINGS: On the diffusion images, there is a focus of restricted diffusion\n in the left parietal lobe visualized on series 9, image 17. This finding\n indicates a small area of acute infarct. In addition, there are small foci of\n T2 hyperintensity as well as some hyperintensity on diffusion images in the\n right temporal region with associated blood products. One of this focus in\n the right temporal region was best visualized on series 14, image 12,\n demonstrate enhancement. There are no territorial areas of infarction seen or\n other areas of abnormal enhancement identified. Foci of enhancement in both\n temporal lobes appear to be due to pulsation artifacts.\n\n There is no hydrocephalus or midline shift seen.\n\n There is diffuse decreased signal in the visualized bony structures which\n could be due to marrow hyperplasia or infiltration and clinical correlation is\n recommended.\n\n IMPRESSION:\n 1. Small area of acute infarct in the left parietal lobe. Additional small\n areas of T2 shine-through in the right temporal region with associated blood\n products and a subtle area of enhancement. These findings indicate a\n combination of acute infarcts and subacute infarcts with blood products.\n There is no abscess identified or abnormal meningeal enhancement seen.\n 2. Diffuse decreased signal in the visualized bony structures could be due to\n marrow hyperplasia or infiltration and clinical correlation is recommended.\n (Over)\n\n 1:34 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please eval for septic emboli to brain. PLEASE DO THORACIC\n Admitting Diagnosis: CHF VS PNA\n Contrast: PROHANCE Amt: 14\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. No evidence of mass effect or hydrocephalus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1240610,
"text": " 12:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval new ETT position\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with endoacrditis\n REASON FOR THIS EXAMINATION:\n eval new ETT position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male with endocarditis, endotracheal tube placement.\n\n COMPARISON: .\n\n CHEST, AP UPRIGHT: A new endotracheal tube terminates 6 cm above the carina.\n A nasogastric tube courses through the stomach and inferiorly beyond the film.\n Moderate left and small right layering pleural effusions are unchanged.\n Moderate cardiomegaly and central venous congestion persist. There has been\n slight improvement in moderate interstitial and airspace pulmonary opacities.\n Persistent retrocardiac opacity could represent atelectasis or consolidation.\n\n IMPRESSION:\n 1. Endotracheal and nasogastric tubes in standard position.\n 2. Slight improvement in moderate pulmonary edema.\n 3. Left lower lobe atelectasis or consolidation.\n\n"
},
{
"category": "Echo",
"chartdate": "2174-05-10 00:00:00.000",
"description": "Report",
"row_id": 104474,
"text": "PATIENT/TEST INFORMATION:\nIndication: Valvular heart disease. Endocarditis.\nStatus: Inpatient\nDate/Time: at 11:18\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Normal regional\nLV systolic function. Overall normal LVEF (>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Large vegetation on aortic valve. Severe (4+) AR.\n\nMITRAL VALVE: Large vegetation on mitral valve. Severe (4+) MR.\n\nTRICUSPID VALVE: Large vegetation on tricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Very small pericardial effusion.\n\nConclusions:\nPREBYPASS: The left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is mildly dilated.\nRegional left ventricular wall motion is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%) with mild LV dilation. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque. There is a large vegetation on the aortic valve.\nSevere (4+) aortic regurgitation is seen. There is a large vegetation on the\nmitral valve. Severe (4+) mitral regurgitation is seen. There is a large\nvegetation on the tricuspid valve attached to the TV subvalvular apparatus.\nThere is no significant pulmonic regurg and NO veg on the PV. Normal PV\nleaflets. There is a very small pericardial effusion. There is a large right\npleural effusion. The interatrial septum is intact. There is no clot in the\nLAA. The coronary sinus appears normal.\n\nPOSTBYPASS: Normally functioning AV, MV bioprosthesis. Mild TR. No sig\nvalvular stenosis or regurgitation. Mildly decreased LV systolic function with\nLVEF = 40-45%. Otherwise unchanged.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2174-05-07 00:00:00.000",
"description": "Report",
"row_id": 104475,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Left ventricular function. Pericardial effusion.\nHeight: (in) 69\nWeight (lb): 145\nBSA (m2): 1.80 m2\nBP (mm Hg): 118/47\nHR (bpm): 111\nStatus: Inpatient\nDate/Time: at 12:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Normal regional\nLV systolic function. Overall normal LVEF (>55%). [Intrinsic LV systolic\nfunction likely depressed given the severity of valvular regurgitation.] No\nresting 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: Mildly thickened aortic valve leaflets (3). Moderate-sized\nvegetation on aortic valve. No aortic valve abscess. Moderate to severe (3+)\nAR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Small vegetation on\nmitral valve. Eccentric MR jet. Severe (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Probable vegetation on\ntricuspid valve. Mild to moderate [+] TR. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Probable vegetation or mass on pulmonic\nvalve. Physiologic (normal) PR.\n\nPERICARDIUM: Very small pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is mildly dilated. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%). [Intrinsic\nleft ventricular systolic function is likely more depressed given the severity\nof valvular regurgitation.] Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened. There\nis a moderate-sized vegetation on the aortic valve. No aortic valve abscess is\nseen. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is small vegetation on the mitral valve.\nTwo jets of severe (4+) mitral regurgitation is seen. There is a probable\nvegetation on the tricuspid valve. There is moderate pulmonary artery systolic\nhypertension. A probable vegetation or mass is seen on the pulmonic valve.\nThere is a very small pericardial effusion.\n\nIMPRESSION: Endocarditis on the mitral and aortic valve and possibly also on\nthe tricuspid valve. There is a vegetation seen on the anterior leaflet of the\nmitral valve with a perforation in the mid part of the anterior leaflet. There\nis severe mitral regurgitation with jets between the valve leaflets and\nthrough the perforation. There is a vegetation on the aortic valve (right\ncoronary cusp). There may be vegetations on the other cusps also. The other\ncusps are thickened and damaged. Moderate to severe aortic regurgitation is\nlikely present. There is an echodensity seen at the base of the septal leaflet\nof the tricuspid valve, which is probably a vegetation. Moderate tricuspid\nregurgitation directed towards the interatrial septum is seen. The pulmonic\nvalve domes in diastole - a frank vegetation is however not seen. Dilated and\nhypokinetic right ventricle. Dilated left ventricle with preserved ejection\nfraction. Moderate to severe pulmonary hypertension. Small circumferential\npericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-07 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1240411,
"text": " 10:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: please evaluate for underlying malignancy (high suspects are\n Admitting Diagnosis: CHF VS PNA\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man has not seen MD in 20 years, with dyspnea, pulmonary edema,\n night sweats, fever and weight loss\n REASON FOR THIS EXAMINATION:\n please evaluate for underlying malignancy (high suspects are prostate,\n colorectal, hepatobiliary) and please complete CT-A for r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MLHh SAT 12:36 PM\n Pulm edema, bilateral effusions, and volume overload. Possible superimposed\n PNA. No PE.\n No CT evidence of malignancy in the torso.\n WET READ VERSION #1 MLHh SAT 11:49 AM\n Multifocal PNA, reactive LN, pulm edema, bilateral effusions, and volume\n overload. No PE.\n No CT evidence of malignancy in the torso.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male with pulmonary edema and dyspnea, high fever,\n night sweats, and weight loss. Evaluate for pulmonary embolus and underlying\n malignancy.\n\n COMPARISON: Chest radiographs from and at 3:27.\n\n TECHNIQUE: Helical MDCT images were acquired through the chest before and\n after the uneventful administration of 130 cc of intravenous , the\n chest CTA protocol. Subsequently, 5-mm coronal and sagittal and 3-mm\n bilateral oblique multiplanar reformats were generated. Subsequently,\n scanning was carried through the abdomen and pelvis. 5-mm axial, coronal, and\n sagittal multiplanar reformats were generated. Patient received oral contrast\n prior to the examination.\n\n FINDINGS:\n\n CHEST: Diffuse geographic ground-glass opacities are present throughout the\n lungs, with a perihilar predominance, and largely sparing the pleural\n surfaces. Smooth interlobular septal thickening is present. There are\n bilateral simple pleural effusions, moderate on the right and small to\n moderate on the left. Superimposed peripheral and peribronchovascular foci of\n consolidation are present. The central airways are patent to the subsegmental\n levels.\n\n There is no main, branch, lobar, or segmental pulmonary embolus. Mild\n cardiomegaly is present, without evidence of right heart strain or pericardial\n effusion. The thoracic aorta is normal in caliber throughout.\n\n Several reactive intrathoracic lymph nodes are present, measuring up to 18 mm\n (Over)\n\n 10:43 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABD & PELVIS WITH CONTRASTClip # \n Reason: please evaluate for underlying malignancy (high suspects are\n Admitting Diagnosis: CHF VS PNA\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n in the right hilum, 15 mm in the subcarinal region, 12 mm in the paraaortic\n region, and 16 mm in the left hilum.\n\n Note is made of a 2-cm exophytic lesion along the left lateral chest wall,\n likely a sebaceous cyst (502B:22, 3B:126).\n\n ABDOMEN: There is a 6-mm hypodensity in hepatic segment II (3B:131), too\n small to characterize. Gallbladder is partially collapsed, with\n circumferential wall edema that likely reflects third spacing. 5-mm cystic\n hypodensity in the pancreatic head (3b:143). There is no intra- or\n extra-hepatic biliary ductal dilation. The spleen is normal in size, with\n accessory splenule anterior to the inter pole.\n\n The adrenals are normal. Kidneys enhance and excrete contrast promptly and\n symmetrically, without masses or hydronephrosis. Tiny hypodensity in the left\n upper renal pole, too small to characterize.\n\n The stomach and small bowel are normal.\n\n PELVIS: Colon and rectum are unremarkable. There is a Foley catheter present\n in the bladder, with a large amount of non-dependent air. Prostate and\n seminal vesicles are unremarkable.\n\n Retroperitoneal and mesenteric lymph nodes are not pathologically enlarged.\n There is no free intraperitoneal air.\n\n There are mild multilevel degenerative changes in the spine.\n\n IMPRESSION:\n 1. Pulmonary edema. Please note that superimposed infection cannot be\n excluded. Follow-up after diuresis is recommended. No evidence of pulmonary\n embolism.\n 2. No CT evidence of malignancy in the torso.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1240803,
"text": " 10:50 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p bronch evaluate LUL collapse\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p bronch evaluate LUL collapse\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate collapse after bronchoscopy.\n\n Comparison is made with prior study .\n\n Left upper lobe aeration has markedly improved. There has been interval\n worsening of consolidation in the left lower lobe, consistent with increasing\n atelectasis . Mild cardiomegaly is stable. Severe pulmonary edema is\n unchanged. ET tube is in standard position. Mediastinal and bilateral\n chest tubes are in place. The Swan-Ganz catheter tip is in the right outflow\n tract. NG tube tip is in the . There is no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241416,
"text": " 12:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for bilateral PTX\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with removal of left CT.\n REASON FOR THIS EXAMINATION:\n eval for bilateral PTX\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 61-year-old man with removal of left-sided chest tube.\n Evaluate for pneumothorax.\n\n FINDINGS: There is a right-sided pneumothorax which is stable to slightly\n larger than on the prior study. The left apical pneumothorax is no longer\n seen. There is a right-sided PICC line whose distal lead tip is in the\n proximal SVC. Cardiac silhouette is enlarged. There is persistent small\n bilateral pleural effusions. There is consolidation in the lower lungs\n bilaterally which are stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1241119,
"text": " 12:06 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt had a right sided picc line placed,44cm and needs tip con\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man 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 with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated, the nasogastric tube and the Swan-Ganz catheter have been removed.\n The mediastinal and pericardial drains have also been removed, but the\n bilateral chest tubes remain in place.\n\n There is less pulmonary edema than on the previous exam, but the size of the\n cardiac silhouette is slightly bigger.\n\n The patient has received a right-sided PICC line. The tip of the line\n projects over the mid SVC. There is no evidence of complications, notably no\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1240756,
"text": " 1:20 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p AVR/MVR. Please at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 61-year-old male patient status post aortic valve and mitral\n valve replacement, fast track extubation cardiac protocol, phone is\n abnormal.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-upright position. The patient remains intubated, the ETT terminating in\n the trachea some 5 cm above the level of the carina. A right internal jugular\n sheath carries a Swan-Ganz catheter, the tip of which reaches the central\n portion of the pulmonary artery. An NG tube reaches well below the diaphragm.\n There are bilateral chest tubes advanced from below. An additional two\n mediastinal drainage tubes are seen. No pneumothorax exists in the apical\n area. The previously described pulmonary congestive pattern with central\n edema persists, but may have improved slightly. Clearly, one can identify\n that the basal densities are less prominent, indicating the effective drainage\n by the chest tubes. Noteworthy is that no sternotomy wires can be identified\n in this recently operated patient. Page was placed to .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1240799,
"text": " 9:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p AVR/MVR TV repair w/acute hypoxia r/o PTX\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p AVR/MVR TV repair w/acute hypoxia r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Patient status post AVR, MVR with acute hypoxia.\n\n Comparison is made with prior study performed 8 hours earlier.\n\n Acute worsening in left upper lobe opacity and elevation of the left\n hemidiaphragm is consistent with new left upper collapse. There are no other\n acute interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241281,
"text": " 4:12 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate for ptx ***please perform after 4:00pm***\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cardiac surgery- air leak in pleurevacs, placed to\n waterseal\n REASON FOR THIS EXAMINATION:\n evaluate for ptx ***please perform after 4:00pm***\n ______________________________________________________________________________\n WET READ: LLTc SAT 7:55 PM\n Bilateral thoracostomy tubes unchanged in position. Neighboring opacities most\n likely reflect atelectasis or mild edema. Stable cardiomegaly. No pneumothorax\n detected. Trace bilateral pleural effusions are unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 61-year-old man status post cardiac surgery with air leaks.\n\n FINDINGS: Cardiac silhouette is enlarged. There are again seen bilateral\n chest tubes which are stable in position. No pneumothoraces are seen. There\n is a right-sided PICC line whose distal lead tip is in the proximal SVC.\n Overall, these findings are unchanged. There remains a mild-to-moderate\n pulmonary edema and small bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241243,
"text": " 11:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumothorax\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cardiac surgery, air leaks in bilateral pleurevacs\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n CLINICAL HISTORY: 61-year-old male status post cardiac surgery with air leaks\n and bilateral Pleur-evac. Evaluate for pneumothorax.\n\n FINDINGS: Comparison is made to the prior study from .\n\n The right-sided PICC line tip is at the level of the proximal right atrium.\n There are bilateral chest tubes. These are unchanged in position. No\n pneumothoraces are seen on either side. The cardiac size is enlarged but\n stable. There is a trace pulmonary edema. Bilateral pleural effusions are\n again present and stable in size.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241331,
"text": " 7:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ptx with CTs to waterseal\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cardiac surgery, air leaks in bilateral pleurevacs\n REASON FOR THIS EXAMINATION:\n evaluate for ptx with CTs to waterseal\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: Evaluate for pneumothorax following chest tube to water\n seal.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is again seen a chest tube at the right base. There is no significant\n pneumothorax on either side. There is again seen increased density at the\n right base at the site of the chest tube. There is minimal prominence of the\n pulmonary interstitial markings and small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241391,
"text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ptx\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with persistent air leaks, chest tubes clamped at midnight\n REASON FOR THIS EXAMINATION:\n evaluate for ptx\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n CLINICAL HISTORY: 61-year-old man with persistent air leaks. Chest tubes\n have been clamped. Evaluate for pneumothoraces.\n\n FINDINGS: Comparison is made to prior study from .\n\n There are bilateral chest tubes. The chest tube on the left side has migrated\n more proximally and is now projecting over GE junction. On the right side,\n there is a small apical pneumothorax. A tiny apical pneumothorax in the left\n side is also identified. The heart size is enlarged but stable. There are\n some areas of consolidation at lung bases with the consolidation on the right\n side having improved.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1240627,
"text": " 2:17 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for CVL placement, PTX\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with new R IJ CVL\n REASON FOR THIS EXAMINATION:\n eval for CVL placement, PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New right IJ CVL.\n\n COMPARISONS: to .\n\n FINDINGS: A right-sided internal jugular line has been inserted with the tip\n in the low SVC. Moderate alveolar edema is unchanged since the preceding\n study one hour ago but improved since 9 a.m. this morning. An endotracheal\n tube remains at the clavicular heads. The cuff is mildly overinflated. An\n orogastric tube extends inferiorly below the edge of the film. Bilateral\n layering effusions are unchanged. Mild cardiomegaly is unchanged.\n\n IMPRESSION: Right IJ tip in the low SVC. Moderate alveolar edema.\n Hyperinflation of endotrachial tube cuff. Discussed with Dr via\n phone at .\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1240331,
"text": " 5:04 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for infiltrate, mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 61M with shortness of breath\n REASON FOR THIS EXAMINATION:\n please evaluate for infiltrate, mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: None.\n\n PA AND LATERAL VIEWS OF THE CHEST: The cardiac silhouette size is moderately\n enlarged. The mediastinal contours are within normal limits. There is mild\n pulmonary edema with perihilar haziness, vascular indistinctness, and Kerley B\n lines. Small bilateral pleural effusions are noted. There is no focal\n consolidation or pneumothorax. No acute osseous abnormality is present.\n\n IMPRESSION: Mild congestive heart failure with mild pulmonary edema and small\n bilateral pleural effusions.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1240491,
"text": " 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for inrtercval change\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with pul;m edema and endocarditis\n REASON FOR THIS EXAMINATION:\n eval for inrtercval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:56 A.M., \n\n HISTORY: Endocarditis. Any change in pulmonary edema.\n\n IMPRESSION: AP chest compared to and 19:\n\n Moderately severe pulmonary edema, which worsened from to , has\n redistributed, now more dependent, but also improved slightly over the past\n day. Small bilateral pleural effusions are new or newly apparent. Moderate\n cardiomegaly has improved slightly. Given the distribution of edema,\n concurrent pneumonia cannot be excluded, but does not need to be invoked to\n explain the sequence of changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241488,
"text": " 8:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval chnange in right ptx\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with Right PTX\n REASON FOR THIS EXAMINATION:\n interval chnange in right ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with right-sided pneumothorax, to assess interval\n change.\n\n COMPARISON: Chest radiograph, .\n\n PORTABLE AP CHEST RADIOGRAPH: Small right apical pneumothorax and a small\n right pleural effusion, are stable since . Right-sided chest tube is\n unchanged in position terminating in the right basal pleural space.\n Heterogeneous areas of consolidation in both lungs, predominantly seen in the\n lower lobes, have not significantly changed and likely represent asymmetric\n pulmonary edema, less likely infection. The cardiomediastinal and hilar\n contours are stable. Small left pleural effusion and moderate left basal\n atelectasis are unchanged. A right upper extremity PICC terminates at the\n level of the upper SVC.\n\n IMPRESSION:\n 1. Small right apical pneumothorax, stable since .\n 2. Bilateral pulmonary consolidations, predominant in the lower lobes, likely\n represent asymmetric pulmonary edema, less likely infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1241641,
"text": " 11:12 AM\n CHEST (PA & LAT) Clip # \n Reason: (R)PTX\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cardiac surgery-(R)PTX\n REASON FOR THIS EXAMINATION:\n (R)PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man status post cardiac surgery.\n\n COMPARISON: to .\n\n FINDINGS: Bibasilar effusions and atelectasis are similar to yesterday's\n exam. No new consolidation, effusion, pneumothorax is present. A right\n apical pneumothorax is tiny and unchanged.\n\n IMPRESSION: Unchanged appearance of moderate bibasilar effusions, atelectasis\n and tiny right apical pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241532,
"text": " 12:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: (R)PTX\n Admitting Diagnosis: CHF VS PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p cardiac surgery/(R)PTX post pull\n REASON FOR THIS EXAMINATION:\n (R)PTX\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after cardiac surgery with\n pneumothorax.\n\n AP radiograph of the chest was reviewed in comparison to at 0837\n a.m.\n\n The right apical pneumothorax is small, grossly unchanged since the prior\n study. Right PICC line tip can be seen at the level of mid SVC. No change in\n bibasal atelectasis and bilateral pleural effusions, right more than left is\n noted. Heart size and mediastinum are unchanged.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2174-05-14 00:00:00.000",
"description": "Report",
"row_id": 304289,
"text": "Atrial fibrillation with a mean ventricular rate of 121. Lateral ST segment\ndepression is consistent with myocardial ischemia. Compared to the previous\ntracing of the rhythm is now rapid atrial fibrillation and\nrepolarization abnormalities are more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-05-09 00:00:00.000",
"description": "Report",
"row_id": 304290,
"text": "Sinus rhythm with ventricular premature beats. Conducted complexes have low\nlimb lead voltage. Inferior axis. Late R wave progression. ST-T wave\nabnormalities. Since the previous tracing of probably no significant\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-05-13 00:00:00.000",
"description": "Report",
"row_id": 304425,
"text": "Sinus rhythm. The P-R interval is prolonged at 350 milliseconds. There is a\nlate transition with small R waves in the anterior leads and associated\nanterior and anterolateral ST-T wave changes consistent with possible\ninfarction. Additional non-specific ST-T wave changes. Compared to the previous\ntracing of ventricular ectopic beats are no longer present. \nP-R interval is longer and ST-T wave changes are more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-05-08 00:00:00.000",
"description": "Report",
"row_id": 304426,
"text": "Sinus tachycardia with ventricular premature beats. Right axis deviation\nconsistent with possible left posterior fascicular block. Left atrial\nabnormality. Delayed R wave progression. Cannot exclude prior anteroseptal\nwall myocardial infarction. Compared to the previous tracing of the\nheart rate is slightly slower. Ventricular ectopy is less frequent.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-05-06 00:00:00.000",
"description": "Report",
"row_id": 304427,
"text": "Sinus tachycardia with frequent unifocal ventricular premature beats. Left\natrial abnormality. Delayed anterior R wave progression of native beats\nsuggests prior anteroseptal myocardial infarction. Non-specific J point\ndepression in the left precordial leads. No previous tracing available for\ncomparison.\n\n"
}
] |
793 | 100,777 | In short, this is a 78-year-old female with a history of severe Parkinson's, multiple falls, who presents status post choking. Patient most likely had temporary-complete airway obstruction and possible pulseless electrical activity. The patient was emergently intubated and required no defibrillation. 1. Pulmonary: The patient has no known lung disease. Because of her episode and fear of any residual foreign objects, the patient was bronched. This revealed no evidence of upper airway obstruction. Patient's vent was changed from SIMV to CPAP with pressure support. She was taking good ventilations with very little sedation. The patient was noted to have very thigh secretions on suctioning. There was a question of aspiration pneumonia especially given elevated white count. Discussion took place with the daughter, who is the proxy. Decision was made to extubate the patient despite the large volume of secretions. The daughter was well aware of the risks, benefits. If the patient remained intubated, she would be much more likely to develop vent-acquired pneumonia. If she was extubated, there was a significant risk of drowning in secretions. The patient's daughter chose the latter choice, according to her what she thought her mother would want. There was no plan to reintubate once extubated. Patient was extubated on . Following extubation, the patient became tachypneic and uncomfortable. Patient's comfort was maximized with Morphine drip. Because of the revised goals, the patient was transferred to the floor. The following day, she was transferred to hospice care. 2. Heme: The patient was noted to have a hematocrit drop from 38.2 to 30.3. She was also having coffee-grounds suctioned. Her hematocrit further decreased to 25. The patient was treated with 2 units of packed red blood cells. Her hematocrit came up to 32. The patient had no further coffee-grounds, and he hematocrit stabilized. No nasogastric lavage was performed. Hematocrit came up to 32 and remains stable. 3. Infectious Disease: The patient developed a fever, although her white count came down. Fever was up to 101.3. Blood cultures and urine cultures were negative. Chest x-ray showed no sign of infiltrate. No antibiotics were initiated. 4. Neurologic: Patient has known severe Parkinson's on Sinemet. Although despite the lateral gaze deviation, the patient's head CT scan was negative. | Resp Care,Pt. Pt placed on propophol gtt and plan for extubation in am.GI: Abd soft and nontender. Gag intact.CV: Monitor shows NSR with multifocal pvc's noted. Hypotension felt to be related to sedation and pt now on propophol gtt.RESP: LS coarse throughout. T+R q2hr.HEME: Mg repleted as ordered.I-D: Afebrile. Patient cont's to be NPO. Bronchoscopy performed. NoteRemains intubated. PALPABLE PULSES TO BILATERAL RADIALS AND DORSALIS PEDIS.GI: ABDOMEN IS SOFT, NON-DISTENDED. +BS noted. PLEASE SEE CAREVUE AS NEEDED.GI: ABD IS SOFT, ND. PALPABLE PUSLES TO BILATERAL RADIAL AND DORSALIS PEDIS. ADEQUATE UOP NOTE > OR TO 30CC/HR.INTEG: PT HAS REDNESS NOTED TO COCCYX. There has been interval placement of an NG tube which courses well below the hemidiaphragm and beyond the limits of the image. +PERRLA noted. OGT IN PROPER PLACEMENT AS VERIFIED WITH AUSCULTATION OF 30CC/ AIR BOLUS. NPN 07:00-19:00 MICU*Please refer to Careview for additional patient information*Code Status: DNR/DNINeuro: Propofol titrated down this am. BILE NOTED UPON ASPIRATION.GU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. WShaky baseline. Note is made of an unusual irregular lucency in the right retrocardiac area. Rhythm strip lead II revealssinus tachycardia. OGT IS IN PROPER PLACEMENT AS VERIFIED WITH AUSCULTATION OF 30CC/AIR BOLUS. AWARE OF PT'S CONDITION. PROPER POSITION AS VERIFIED WITH AUSCULTATION OF 30CC/AIR. PASSING FLATUS.GU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. PASSING FLATUS.GU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. IMPRESSION: 1) ET tube in good position. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS PEDIS. (would be okay to use pressors short term overnoc if pt becomes hypotensive secondary to sedation). Resp. BS equal. **Plan is to 1. obtain sputum cx; 2. NS bolus X3 given. Started on PPI. BBS = ESSENTIALLY COARSE TO BILATERAL UPPER AND LOWER LOBES. SP02 HAVE REMAINED > OR = TO 98%. NO SEIZURE NOTED.CV: NSR WITH FREQUENT PVC'S, PAC'S AND PAUSES. U/O wnl >30cc/hr.Access: Lt hand 20g; Rt hand 18gx2, all wnl.Skin: Small abrasion on R side of face. There is a new NG tube with its tip in the stomach. WILL CONTINUE TO WEAN PROPOFOL AND VENT AS PT TOLERATES. NO SEIZURE ACTIVITY NOTED.RR: PT IS CURRENTLY INTUBATED. 3) Unusual lucency in the right retrocardiac area. #20 PIV TO LEFT HAND SECURE AND PATENT. DISCUSSED WITH , MD. IN THE PROCESS OF WEANING VENT AS PT CAN TOLERATE WITH HOPES FOR EXTUBATION SOMETIME TODAY. 3) Possible hiatal hernia. Pt place on 100% NRB and MSO4 2mg IV x2 with improvement in resp status. BRONCH SPECIMEN SENT FOR CULTURE AND SMEAR.CV: PT ST WITH OCCASSIONAL PVC'S NOTED. Currently weaning on SBT protocol. AFEBRILE. AFEBRILE. COCCYX IS REDDENED BUT NO SINGS OF BREAKDOWN. NURSING PROGRESS AND ADMISSION NOTE 2215-0700(Continued)EAN OFF OF VENTILATOR WITH HOPES FOR EXTUBATION. BBS =, ESSENTIALLY CLEAR. Pt deferred bipap and requesting that pt "be kept comfortable". Non-specific ST segment depression withlow amplitude T waves in leads I and V5-V6 and inverted T waves in lead aVL.Compared to the previous tracing of sinus tachycardia has appearedalong with anterolateral ST segment abnormalities. AS PER PT CURRENTLY TAKING CIPRO DUE TO UTI. S1 AND S2 AS PER AUSCULATION. Pt with brief episode of hypotension in afternoon which responded to FB. LAST ABG'S ARE WNL. The ventricles, cisterns, and sulci are unchanged in appearance, showing age related atrophy. RR 18-25 AND REGULAR. **Plan is to cont' to try and wean down sedation o/n (early am.) Pt extubated and placed on 100 % cool neb mask. SUCTIONING FOR SCANT, THICK, TAN SECRETIONS. PT'S ENVIRONMENT SECURED FOR SAFETY.NEURO: PT REMAINS SEDATED ON 30MCG/KG/MIN IV PROPOFOL WITH THERAPEUTIC RESULTS. POSITIVE FLATUS. 3.2 K REPLETED WITH 60MEQ OF K AS PER OGT. Supraventricular tachycardia. IMPRESSION: 1) Satisfactory placement of NG tube. IMPRESSION: 1) NG tube tip in stomach. Pulses palpable in distal extremities. Rare ventricular premature beats. 2) Retrocardiac density compatible with atelectasis or pneumonia. TECHNIQUE: Noncontrast head CT. Study is limited by patient motion. CONTRACTED EXTREMETIES. LS cont' to be coarse throughout. Bolused w/ a total of Propofol 10mcg/kg/min w/ little effect. Plan is to keep patient lightly sedated but comfortable.CV: HR~70's, NSR, rare PVC's. TX TO MICU-B 771 WITH NO UNTOWARD EVENT. BILATERAL CHEST EXPANSION NOTED.CV: PT IN NSR HR 70-90'S WITH RARE PVC'S NOTED. CONTINUE TO MONITOR CRIT, SEDATIONS AND RESP STATUS. Plan to extubate, see vent flowsheet. ABRASION NOTED TO RIGHT CHEEK AND TO LEFT EAR. BILATERAL CHEST EXPANSION NOTED. BILATERAL CHEST EXPANSION NOTED. UO remains ~ 10cc/hr and team aware.SKIN: Coccyx pink and intact. APPROPRIATELY CONCERNED, ALL QUESTIONS ANSWERED.PLAN: CONTINUE TO W Comparison is made to the head CT from . The cardiac and mediastinal contours are stable. BRONCH DONE UPON ARRIVAL TO MICU- NO SIGNS OF OBSTRUCTION. NURSING PROGRESS AND ADMISSION NOTE 2215-0700REPORT RECEIVED FROM EW. BBS= COARSE THROUGHOUT. MANAGE ANXIETY, CONSTANT REORIENTATION, CONTINUE CIPRO FOR UTI AND OBSERVE FOR SEPSIS. *Oral secretions cont' to be small-moderate in amounts. SBP > OR = TO 90 WITH NO HYPO OR HYPERTENSIVE CRISIS NOTED. MICU TEAM IS AWARE- EKG OBTAINED WITH NO SIGNIFICANT CHANGES NOTED. NEURO: Pt alert and agitated in am. There is a retrocardiac density, compatible with collapse or consolidation of the left lower lobe. S1 AND S2 AS PER AUSCULTATION. S1 AND S2 AS PER AUSCULTATION. PT NOTED TO HAVE CONTRACTED BILATERAL LOWER EXTREMETIES AND ALL EXTREMITIES ARE NOTED TO BE RIGID UPON MANIPULATION.ACCESS: PT HAS 18G PIV TO RIGHT HAND, 20G TO LEFT HAND.DIAGNOSTIC: BLOOD CULTURES X2, URINE AND BRONCH SPECIMEN ARE PENDING.HEAD CT RESULTS PENDING.SOCIAL: DAUGHTER IS AN ANESTHESIOLOGIST. 3.3 K LEVEL THIS AM REPLETED WITH 60MEQ PER OGT. ABRASION TO LEFT EAR AND RIGHT CHEEK- OTA. OGT LAVAGED WITH 1000CC/NS HEME NEGATIVE. Team notified and repeat hct sent @ 1730. ? Further evaluation with PA/lateral view is recommended when possible. | 15 | [
{
"category": "Radiology",
"chartdate": "2109-02-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 784664,
"text": " 7:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation s/p choking\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p intubation s/p choking\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post choking.\n\n AP SUPINE CHEST: There are no prior films for comparison.\n\n There is an ET tube in good position, its tip 3.6 cm above the carina.\n Evaluation of cardiac and mediastinal contours is limited by supine technique\n and rotation, although the heart does not appear frankly enlarged.\n\n Note is made of an unusual irregular lucency in the right retrocardiac area.\n\n There is no definite acute change within the lung parenchyma. The right lower\n costophrenic angle is excluded from the film; there is no evidence of left\n pleural effusion.\n\n IMPRESSION: 1) ET tube in good position.\n 2) Clear lungs.\n 3) Unusual lucency in the right retrocardiac area. Further evaluation with\n PA/lateral view is recommended when possible.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-02-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 784671,
"text": " 9:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with parkinson's, s/p respiratory arrest, choking on chicken.\n Not intubated, HD stable\n REASON FOR THIS EXAMINATION:\n r/o bleed\n CONTRAINDICATIONS for IV CONTRAST:\n n/a\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Choking on chicken, not intubated evaluate for bleed.\n\n Comparison is made to the head CT from .\n\n TECHNIQUE: Noncontrast head CT.\n\n Study is limited by patient motion. Allowing for these limitations, there are\n no areas of intra or extraaxial hemorrhage. There is no mass effect or shift\n of normally midline structures. The ventricles, cisterns, and sulci are\n unchanged in appearance, showing age related atrophy.\n\n There is preservation of white differentation.\n\n No fractures or soft tissue swelling is present. Visualized paranasal sinuses\n are clear.\n\n IMPRESSION: No acute hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 784700,
"text": " 9:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with recent aspiration, rising wbc\n REASON FOR THIS EXAMINATION:\n assess for PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Elevated white count with history of aspiration.\n\n PORTABLE CHEST: Comparison is made with film from 1 day earlier. The ETT is in\n satisfactory position. There is a new NG tube with its tip in the stomach.\n\n The current study is quite limited by significant patient rotation and\n kyphosis. Midline structures are not satisfactorily evaluated. There appears\n to be a large rounded lucency behind the heart, suggesting there may be a\n large hiatal hernia. No focal air space infiltrate is seen in visualized\n portions of the lungs. Interstitial markings appear somewhat indistinct, but\n this may be technical. There is no definite pleural effusion.\n\n IMPRESSION: 1) NG tube tip in stomach.\n 2) Quite limited study detailed above. No focal infiltrate seen in visualized\n portions of the lung parenchyma.\n 3) Possible hiatal hernia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 784866,
"text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman s/p choking episode, now with fever.\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78 y/o female with fever following choking event.\n\n TECHNIQUE: Portable AP chest.\n\n COMPARISON: .\n\n FINDINGS: The ETT remains in stable, satisfactory position. There has been\n interval placement of an NG tube which courses well below the hemidiaphragm\n and beyond the limits of the image. The cardiac and mediastinal contours are\n stable. There is a retrocardiac density, compatible with collapse or\n consolidation of the left lower lobe. The lungs otherwise appear clear. There\n is no pulmonary vascular engorgement and there are no pleural effusions.\n\n IMPRESSION: 1) Satisfactory placement of NG tube. 2) Retrocardiac density\n compatible with atelectasis or pneumonia.\n\n"
},
{
"category": "ECG",
"chartdate": "2109-02-16 00:00:00.000",
"description": "Report",
"row_id": 126591,
"text": "Supraventricular tachycardia. WShaky baseline. Rhythm strip lead II reveals\nsinus tachycardia. Rare ventricular premature beats. Tall R wavse, deep S waves\nin leads VI-V2. Axis slightly leftward. Non-specific ST segment depression with\nlow amplitude T waves in leads I and V5-V6 and inverted T waves in lead aVL.\nCompared to the previous tracing of sinus tachycardia has appeared\nalong with anterolateral ST segment abnormalities.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-17 00:00:00.000",
"description": "Report",
"row_id": 1271750,
"text": "NEURO: Pt alert and agitated in am. Pt started on fentanyl gtt which was changed to Propophol in afternoon for probable extubation in am. Extremities x4 rigid wtih tremors secondary to Parkinson's. +PERRLA noted. Gag intact.\nCV: Monitor shows NSR with multifocal pvc's noted. Pt with brief episode of hypotension in afternoon which responded to FB. Hypotension felt to be related to sedation and pt now on propophol gtt.\nRESP: LS coarse throughout. Lg amts thick tan/blood tinged oral secretions and sm amts tan secretions via ett. Pt on PS 5 throughout day and tol well, however pt placed on SIMV in afternoon secondary to decreased rr with sedation. Pt placed on propophol gtt and plan for extubation in am.\nGI: Abd soft and nontender. +BS noted. No stools this shift. OGT with coffee ground secretions heme+. Team notified and repeat hct sent @ 1730. ? ogt to be lavaged by team this eve.\nGU: Foley intact and patent draining scant amts cloudy yellow urine with sedimentation. NS bolus X3 given. UO remains ~ 10cc/hr and team aware.\nSKIN: Coccyx pink and intact. T+R q2hr.\nHEME: Mg repleted as ordered.\nI-D: Afebrile. Pt finished 7 day course of cipro for +uti.\nPSY-SOC: Pt has lg supportive family (6 children). Dr. met with family (dtr, son, and husband) in afternoon and in agreement that pt would wish to be DNR. (would be okay to use pressors short term overnoc if pt becomes hypotensive secondary to sedation). Family stating that pt would not want feeding tube or long term ventilatory support. Plan to extubate in am after PCP and neurologist are updated on recent admission and are in agreement with plan of care per family request.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-18 00:00:00.000",
"description": "Report",
"row_id": 1271751,
"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 30MCG/KG/MIN IV PROPOFOL WITH THERAPEUTIC RESULTS. PT IS STILL WITH VERBAL AND PAINFUL STIMULI. GET'S ANXIOUS AND AGITATED AT TIMES REQUIRING 1CC BOLUSES. PT HAS BASELINE OF NEUROLOGICAL DEFICIT DUE TO END STAGE PARKINSONS AND SENILE DEMENTIA. PT DOES NOT MOVE EXTREMETIES X 4 WHICH ARE CONTRACTED AND NOTED TO HAVE TREMORS. AFEBRILE. NO SEIZURE NOTED.\n\nCV: NSR WITH FREQUENT PVC'S, PAC'S AND PAUSES. HR 50-80'S. MICU TEAM IS AWARE- EKG OBTAINED WITH NO SIGNIFICANT CHANGES NOTED. 3.2 K REPLETED WITH 60MEQ OF K AS PER OGT. AM LABS ARE WNL. S1 AND S2 AS PER AUSCULTATION. SBP > OR = TO 90 WITH NO HYPO OR HYPERTENSIVE CRISIS NOTED. PALPABLE PUSLES TO BILATERAL RADIAL AND DORSALIS PEDIS. PT TX WITH 2 UNITS OF PRBCS FOR CRIT OF 25, POST TX AM LAB CRIT IS 32. PT TOLERATED TX WITH NO REACTION.\n\nRR: PT REMAINS INTUBATED. OETT IS SECURE AND PATENT. CURRENT VENT SETTINGS ARE IMV/10/500/40%/5. SUCTIONING Q 2-4 FOR SMALL TAN, THICK SECRETIONS. BBS= COARSE THROUGHOUT. BILATERAL CHEST EXPANSION NOTED. SP02 > OR = TO 95%. LAST ABG'S ARE WNL. PLEASE SEE CAREVUE AS NEEDED.\n\nGI: ABD IS SOFT, ND. BS X 4 QUADRANTS. OGT IS IN PROPER PLACEMENT AS VERIFIED WITH AUSCULTATION OF 30CC/AIR BOLUS. OGT LAVAGED WITH 1000CC/NS HEME NEGATIVE. LAVAGE DONE DUE TO EPISODE OF COFFEE GROUND DRAINAGE VIA OGT. NO BM THIS SHIFT. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. UUP HAS IMPROVED- NO LONGER TURBID BUT YELLOW AND CLEAR- IMPROVED AMOUNTS FROM 15CC/HR TO 40-100CC/HR.\n\nINTEG: PT HAS BRUISES NOTED TO BILATERAL UPPER AND LOWER EXTREMETIES. ABRASION TO LEFT EAR AND RIGHT CHEEK- OTA. COCCYX IS REDDENED BUT NO SINGS OF BREAKDOWN. PT HAS BEEN AGGRESSIVELY TURNED AND REPOSITIONED Q 2 HOURS DUE TO RAPID TENDENCY TO DEVELOP PRESSURE SORES AS PER PT'S FAMILY.\n\nACCESS. #18 PIV TO RIGHT FOREARM IS SECURE AND INTACT. #20 PIV TO LEFT HAND SECURE AND PATENT. ANOTHER #18 PIV STARTED TO RIGHT HAND- SECURE AND PATENT- AVALIABLE FOR ADDITIONAL BLOOD TX IF NEEDED.\n\nPLAN: POSSIBLE EXTUBATION AFTER PT'S PCP AND NEUROLOGIST HAVE BEEN CONSULTED. PT IS DNR AND AS PER FAMILY WOULD NOT HAVE WANTED AGGRESSIVE TREATMENT ASIDE FROM POSSIBLE PRESSERS NOC AS NEEDED. WILL NEED TO CHECK WITH FAMILY AS TO ANY ADDITIONAL WISHES OR PLANS OF ACTION. CONTINUE TO MONITOR CRIT, SEDATIONS AND RESP STATUS. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-19 00:00:00.000",
"description": "Report",
"row_id": 1271756,
"text": "Pt extubated and placed on 100 % cool neb mask. Post extubation pt tacypnic with RR 40-50's with decrease in sats into mid 80,s. Pt place on 100% NRB and MSO4 2mg IV x2 with improvement in resp status. Dr. spoke with family at great length re: poor prognosis,a dn ? bipap trial. Pt deferred bipap and requesting that pt \"be kept comfortable\". Pt started on MSO4 gtt and scapolamine patch for increased secretions. Pt requiring additional boluses for increased resp distress with improvement. Fr. in and Sacraments of the Sick administered. Husband and son present for SOS. Pt has very supportive family and emotional support given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-18 00:00:00.000",
"description": "Report",
"row_id": 1271752,
"text": "NPN 07:00-19:00 MICU\n*Please refer to Careview for additional patient information\n*Code Status: DNR/DNI\n\nNeuro: Propofol titrated down this am. from 30mcg/kg/min to 15mcg/kg/min. Patient tolerating decrease in sedation up until this afternoon (16:00) when patient began to show moderate discomfort, assessed by facial expressions as well as increase in RR->~30. Bolused w/ a total of Propofol 10mcg/kg/min w/ little effect. Increased sedation to 25mcg/kg/min. Resting comfortably now. **Plan is to cont' to try and wean down sedation o/n (early am.) in hopes of potential extubation tomorrow. Overall neuro: responding to stimuli/sternal rub and at times voice, however cont's to be contracted throughout all extremities.\n\nResp: Cont's on CPAP+PS 7/Peep 5/FiO2 40%, RR 20-30(when agitated), TV350-380, Minute Volumes7-8L, O2 sat's ~98%. Patient needed to be suctioned q2hrs up until about 12pm today; secretions via ETT were moderate in amounts, tan and thick. This afternoon there have been less secretions noted. *Oral secretions cont' to be small-moderate in amounts. LS cont' to be coarse throughout. **Plan is to 1. obtain sputum cx; 2. Trial on PS 5/5 tomorrow to assess for potential extubation.\n\nCV: HR~70-low80's, NSR, no ectopy noted. SBP 129-150/62-72 (per family patient's baseline SBP is 90-100). Pulses palpable throughout all distal extremities. Tmax, 100.8.\n\nGI/GU: +bs, no bm today. Patient cont's to be NPO. OGT in place per auscultation, no coffee grounds noted. Started on PPI. U/O wnl >30cc/hr.\n\nAccess: Lt hand 20g; Rt hand 18gx2, all wnl.\n\nSkin: Small abrasion on R side of face. Slight bruising around IV sites, and on R lower/radial portion of arm. R heel is red, pillow under to reduce pressure.\n\nSocial: Family in this am. and this afternoon, updated on patient's status, and understand patients condition, and plan of care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-18 00:00:00.000",
"description": "Report",
"row_id": 1271753,
"text": "Resp. Note\nRemains intubated. Switched to CPAP/PSV 7/5/40%. TVs 300-500cc with RR<25. Planning possible extubation late this evening or tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-19 00:00:00.000",
"description": "Report",
"row_id": 1271754,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON VENTILATOR AND MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT BEING WEANED OFF OF PROPOFOL GTT STARTING AT 3 THIS AM DUE TO POSSIBLE IMPENDING EXTUBATION LATER THIS AFTERNOON. PT HAS BEEN MORE ALERT AND HAS BEEN OPENING EYES SPONTANEOUSLY. DIFFICULT TO ASSESS MENTAL STATUS DUE TO DECREASED BASELINE. DOES NOT OBEY COMMANDS. RESPONDS TO VERBAL STIMULUS. CONTRACTED EXTREMETIES. RIGIDNESS DUE TO END STAGE PARKINSONS. TMAX OF 100.5. SPUTUM, URINE AND BC X 2 SENT TO LAB. FEVER RESPONDED WELL TO TYLENOL.\n\nRR: PT TO BE EXTUBATED TODAY WITH FAMILY PRESENT. OETT IS SECURE AND PATENT. CURRENT VENT WEAN PROTOCOL IN PLACE- AT PRESENT VENT SETTINGS ARE CPAP 5/5, 40% PT HAS HAD TIDAL VOLUMES 300-400'S. RR 18-25 AND REGULAR. SP02 95% OR GREATER. BBS = ESSENTIALLY COARSE TO BILATERAL UPPER AND LOWER LOBES. SUCTIONING FOR SCANT, THICK, TAN SECRETIONS. BILATERAL CHEST EXPANSION NOTED.\n\nCV: PT IN NSR HR 70-90'S WITH RARE PVC'S NOTED. 3.3 K LEVEL THIS AM REPLETED WITH 60MEQ PER OGT. S1 AND S2 AS PER AUSCULTATION. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED ALTHOUGH FAMILY DOES STATE THAT SHE NORMALLY HAS A LOW SBP AS BASELINE. PALPABLE PULSES NOTED TO BILATERAL RADIALS AND DORSALIS PEDIS. NO GENERALIZED EDEMA NOTED.\n\nGI: ABDOMEN IS SOFT, NON-DISTENDED. BS X 4 QUADRANTS. OGT IN PROPER PLACEMENT AS VERIFIED WITH AUSCULTATION OF 30CC/ AIR BOLUS. NO BM THIS SHIFT. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. YELLOW AND CLEAR URINE NOTED. ADEQUATE UOP NOTE > OR TO 30CC/HR.\n\nINTEG: PT HAS REDNESS NOTED TO COCCYX. NO SIGNS OF BREAKDOWN. ABRASION TO LEFT EAR AND RIGHT CHEEK OTA. REDNESS NOTED TO LEFT SHIN NOTED. AGRRESSIVE TURNING AND REPOSITIONING Q 2 HOURS.\n\nPLAN: PT'S FAMILY AND HEALTH PROXY- HAVE REQUESTED THAT PT IS NOT TO BE EXTUBATED UNTIL THEY ARE IN THE HOSPITAL. DISCUSSED WITH , MD. WILL CONTINUE TO WEAN PROPOFOL AND VENT AS PT TOLERATES. POSSIBLE EXTUBATION IN THE AFTERNOON. PLEASE SEE CAREVUE AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-19 00:00:00.000",
"description": "Report",
"row_id": 1271755,
"text": "NPN 07:00-15:00 MICU\n*Please refer to Careview for additional patient information\n*DNR/DNI\n\nNeuro: Received patient on Propofol 5mcg/kg/min; patient very agitated, reaching for throat, and grimacing. Given multiple boluses of Propofol (5mcg) w/ little effect. Plan is to keep patient lightly sedated but comfortable.\n\nCV: HR~70's, NSR, rare PVC's. SBP's 130's, no episodes of HTN or Hypotension. Pulses palpable in distal extremities. Temp this afternoon, down to 98.9, will re-check and give Tylenol if needed.\n\nResp: CPAP+PS 5/Peep 5/FiO2 40%, RR 20's, TV's 300-400, Min Vol ~7L, O2 sat's high 90's. Sxn lavaged x2 for small amounts of thick tan secretions. Small amounts of oral secretions. Plan is to extubate patient this afternoon-> start on BiPAP if needed. If patient cannot tolerate, family plan is not to reintubate.\n\nGI/GU: +bs, bm=smear. OGT in place per ausculatation, no coffee grounds noted. U/O wnl.\n\nSkin: please refer to careview.\n\nPlan: Extubate this afternoon; BiPAP if needed.\n\nSocial: Family is to be called and Present at time of extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-17 00:00:00.000",
"description": "Report",
"row_id": 1271747,
"text": "NURSING PROGRESS AND ADMISSION NOTE 2215-0700\nREPORT RECEIVED FROM EW. PT ARRIVED VIA STRETCHER ACCOMPANIED BY MD . TX TO MICU-B 771 WITH NO UNTOWARD EVENT. PT PLACED ON CARDIAC MONITOR AND VENTILATOR. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 78 YEAR OLD PATIENT THAT LIVES AT HOME WITH HER DAUGHTER. FAMILY STATES THAT SHE IS BEDRIDDEN AND THAT SHE IS UNABLE TO PERFORM ANY ADLS ASIDE FROM FEEDING HERSELF. LAST EVENING SHE WAS WITNESSED TO HAVE CHOKED ON A PIECE OF CHICKEN. FINGER SWEEP AND HEIMLICH MANEUVER WERE PRODUCTIVE FOR PIECES OF FOOD. COMPLETE AIRWAY OBSTRUCTION PRIOR TO REMOVAL OF FOOD PARTICLES. QUESTIONABLE EPISODE OF ASYSTOLE- CPR WAS INITIATED AND EMS INTUBATED ON THE FIELD. PT TX TO EW AND ADMITTED TO MICU FOR OBSERVATION.\n\nNEURO: AS PER PT HAS A BASELINE OF DEMENTIA AND ANXIETY AND HAS A DECREASED LEVEL OF ALERTNESS AS WELL AS UNABLE TO SPEAK. QUESTIONABLE EPISODE OF TIA 2 WEEKS AGO. HEAD CT DONE IN ER- RESULTS ARE PENDING. PT WILL OPEN EYES AND BITE DOWN ON OETT. WILL MOVE HER BILATERAL UPPER EXTREMEITES WHICH HAVE BEEN RESTRAINED AS A PRECAUTION DUE TO MEDICAL DEVICE INTERFERENCE. OPENS EYES SPONTANEOUSLY. DOES NOT OBEY COMMANDS. AFEBRILE. NO SEIZURE ACTIVITY NOTED.\n\nRR: PT IS CURRENTLY INTUBATED. OETT IS SECURE AND PATENT. IN THE PROCESS OF WEANING VENT AS PT CAN TOLERATE WITH HOPES FOR EXTUBATION SOMETIME TODAY. CURRENT VENT SETTINGS ARE CPAP/10PS/40%/5. SP02 HAVE REMAINED > OR = TO 98%. BBS =, ESSENTIALLY CLEAR. BILATERAL CHEST EXPANSION NOTED. RR 11-15 AND REGULAR. BRONCH DONE UPON ARRIVAL TO MICU- NO SIGNS OF OBSTRUCTION. BRONCH SPECIMEN SENT FOR CULTURE AND SMEAR.\n\nCV: PT ST WITH OCCASSIONAL PVC'S NOTED. SBP > OR = TO 100 WITH NO HYPERTENSIVE OR HYPOTENSIVE CRISIS. S1 AND S2 AS PER AUSCULATION. NO PERIPHERAL EDEMA NOTED. PALPABLE PULSES TO BILATERAL RADIALS AND DORSALIS PEDIS.\n\nGI: ABDOMEN IS SOFT, NON-DISTENDED. BS X 4 QUADRANTS. NO BM THIS SHIFT. POSITIVE FLATUS. OGT INSERTED WITH NO UNTOWARD INCIDENCE. PROPER POSITION AS VERIFIED WITH AUSCULTATION OF 30CC/AIR. BILE NOTED UPON ASPIRATION.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. AS PER PT CURRENTLY TAKING CIPRO DUE TO UTI. YELLOW, CLOUDY URINE NOTED.\n\nSKIN: PT HAS NOTED BRUISES TO BILATERAL UPPER AND LOWER EXTREMETIES- SKIN IS FRAGILE AND THIN. ABRASION NOTED TO RIGHT CHEEK AND TO LEFT EAR. PT HAS BEEN AGGRESSIVELY REPOSITIONED Q 2 HOURS DUE TO HAVING A HISTORY OF FREQUENT BEDSORES AND POOR SKIN QUALITY AND INTEGRITY. PT NOTED TO HAVE CONTRACTED BILATERAL LOWER EXTREMETIES AND ALL EXTREMITIES ARE NOTED TO BE RIGID UPON MANIPULATION.\n\nACCESS: PT HAS 18G PIV TO RIGHT HAND, 20G TO LEFT HAND.\n\nDIAGNOSTIC: BLOOD CULTURES X2, URINE AND BRONCH SPECIMEN ARE PENDING.\nHEAD CT RESULTS PENDING.\n\nSOCIAL: DAUGHTER IS AN ANESTHESIOLOGIST. AWARE OF PT'S CONDITION. 2 SONS AND 2 DAUGHTERS IN TO VISIT. APPROPRIATELY CONCERNED, ALL QUESTIONS ANSWERED.\n\nPLAN: CONTINUE TO W\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-17 00:00:00.000",
"description": "Report",
"row_id": 1271748,
"text": "NURSING PROGRESS AND ADMISSION NOTE 2215-0700\n(Continued)\nEAN OFF OF VENTILATOR WITH HOPES FOR EXTUBATION. MANAGE ANXIETY, CONSTANT REORIENTATION, CONTINUE CIPRO FOR UTI AND OBSERVE FOR SEPSIS. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-02-17 00:00:00.000",
"description": "Report",
"row_id": 1271749,
"text": "Resp Care,\nPt. admitted from ER intubated #7 ET taped at 21@lip. BS equal. Bronchoscopy performed. Currently weaning on SBT protocol. RSBI 50. Plan to extubate, see vent flowsheet.\n"
}
] |
29,848 | 128,921 | Respiratory: Infant admitted to the Neonatal Intensive Care Unit requiring nasal cannula oxygen for a brief period of time. Chest X-ray at that time showed infiltrates consistent with fluid, pneumonia or atelectasis. Infant progressed, requiring nasal CPAP and remained on CPAP for a total of 24 hours, then transitioned back to nasal cannula oxygen and has been in room air since . Follow up Chest X-ray showed clearing of infiltrates therefore initial X-ray likely atelectasis or fluid, especially in light of no set up for infection. Infant has had mild apnea and bradycardia of prematurity. Last documented episode was on . She has now completed a five day countdown. | Remains in R air, BBS clear, equal, mild subcostal/intercostal retractions present, spellx2 thus far this shift, occassional sat drifts noted with po feeds.Chest Xraydone this am.A; spellx2. Resp: Remains in RA, 3 A's and B's this shift, one withspit. Wakes forfeeds. Abd exambenign, vdg and stooling well.4. Tf=, IVF D/c'd. Very sm area of breakdown.#4 Dev- + active w/cares. Pediatrician is Dr. in ().A: Stable. Updated.Plans to be in for AMD/C. Momcalled x1 and was updated by RN on . Wakingappropriately for bottle. P: Monitor spells andresp status.3. Given reassurances yesterday.A: Stable. Neonatal NP- discharge examAFOF. Read and agrees with above PCA note. Fontanels soft and flat.P: Continue to monitor and promote normal infantdevelopment. P: Continueto monitor.#3. LS clear and equal, RR 30's-60's.3. A: No resp distress, occasional spellscontinue with apnea and color change. Currently with stable sats on NCO2.CV: Stable BPs. Abd benign.Voiding and stooing heme negative. Countdown complete. and well perfused. RESP Received infant in RA. Infant remains in RA. Continue toeducate and support . DEV-Infant has stable temperatures swaddled in OAC. Lusty cry.Hips stable. Seeflowsheet.#3 F/N- Abd soft,+bs, no loops.Bottles well ad lib demand.Waking q 4-5 hrs. 2spells this shift-apneic with desat to 70's, HR 70's. Continue to monitor.FEN: NPO until respiratory status stabilizes. +RROU.Breath sounds clear and equal. updatedby Dr. as to current plan. Mom independent with care and handling.A; Loving P;cont update and support. DEV remains in OAC with stable temp. Updated by this RN. P: Cont with current feedingplan.#4DEV: Temps stable, swaddled in OAC. A/bradycardic spell noted thisshift. Wakes forfeeds. Resp. Concent for PKU and Hep done. A: Tol feed well. Noretractions noted. Hep B given. Desitan applied. P/cont. P/cont. P: Cont toencourage po feeding.DEV O/A: is swaddled in an OAC; temps stable. P: Continue tosupport, teach and update.#6 O: Bili this am 9.2/0.3 down from 10.6/0.3. Independent withfeeding and cares. Waking for fdgs. in G/D.P/Cont. Independent with temp, diaperchange and feeds. MAE, , AGA. CBC nland Bld cx neg to date. O/Remains in RA. to monitorskin integrity. Abd benign. Now in RA. Sucks onpacifier. A: AGA. Updated.Took temp, changedand fed baby. Respiratory Care NotePt. BBS =/clear. P: Continue to supportnutritional needs.#4 O: is swaddled in OAC, and temp is stable. Voiding in adeq amts. Noother s/s of infection at this time. LS clear and equal withno increased WOB noted. NPN I have examined this infant and am in agreement w/abovenote and assessment by PCA . and infant is voidingwell. Feeding ad lib. NPwith family. O/Mother called. CBG today of 7.31/47/47/25/-2. P: Continue to monitorresp. P: Cont to supportand update .REVISIONS TO PATHWAY: 6 Hyperbilirubinemia; resolved Nospits. DS 63-74. A: Infant improving withresp. A: Infant stable in RA. Cont. Edema has gone down. Small spit noted on blankets this am.4. Question occ grunting orsounds with cares. Wakesfor cares, and active throughout. Abdsoft and round, no loops, +BS. BP=64/32 (45). Fontanels soft and flat.P: Continue to monitor and promote normal infantdevelopment. Bili level down to 9.2/0.3. CXR done. P: Cont to supp andupdate. BC pnding. A CXR was obtained. Plan CXR in am. Newly off CPAP. DS111, 78. A: Remainsjaundice in color. P: Cont tomonitor.#3 FEN: Infant cont npo. CBG this shift7.31/47/47/25/-2. Approp w/cares and ques. Hct 57.1 andplt 362. A: AGA. A: AGA. Lungsounds cl/= and SCR. D10W, dstx=111active bowel sounds. APPEARSEDEMATOUS. Bottles well. (LASTVOID 40+ CC.) Stooling (heme neg). SOMEGRUNTING NOTED WHEN OFF CPAP.3. Resp rate20s-70s w/occasional tachypnea to 80s-100s. Took 170 ml/kg yest. PKU sent.Mother in. BBS CLEAR,RR 70-80, NOW AFTER 0200 60'S. A: Coordinated bottler. A: DS stable. A:Stable in RA. D2 of countdown. Noretractions. BP 70/21 mean 48Feeding ad lib on Good Start. 133/6.7 (grossly hemolyzed)/98/19 DS 64. NURSING PROGRESS NOTE1. Initially in RA but placed on nasal cannula for O2 sat drifts. A PIV was placed and infant was started on D10W at 60cc/k/d and gent and ampi.P: As per NICU protocol and as per infant need. P: Continue to monitor respiratory status.FEN:O: CW2.980kg (-30g). I uh good aeration, no murmur, benign abd, active and alertPapdated her.rents in. I uh good aeration, no murmur, benign abd, active and alertPapdated her.rents in. Last hemoccult was negative.A. Fonts are S/F. DS-76. , . Bili this am 10.6/0.3 down from 14.6/0.3. NPO. On D10W at 60 ml/kg/d. VSS. Baby is and activeduring cares. Feeding ad lib. Rests well betweencares with boundaries. BiliLast bili was 10.6 0.3 which was down from 14.6 0.3.Phototheraphy was D/C and bili will be rechecked in themorning. Temp now stable inair isolette. HOB elevated per reflux precautions. Wakes forfeedings and remains A/A throughout cares. Both updated by RN and . P: Continue tosupport nutritional needs.#4 O: Temp stable and swaddled in OAC. Stooling- hemenegative. Wakes forfeeds. Ad lib. HOB elevated.Abd soft, +, no loops. Infant ad libdemand, Nestle Goodstart. Fontanels soft and flat.P: Continue to monitor and support normal infantdevelopment. Abd benign. Hep B given. Infant voiding, stoolingwell. RR stable. Did have 2brady spells today, QSR-mild stim required. Resp is stable in RA.P. exam benign. to support nutritional needs.#4 DEVELOPMENT: Swaddled in oac, temps stable.Active/alert, wakes for feeds Q4hrs. Well-perfused. Nursing Progress Note:#2 Resp: O: Infant remains in RA. Mild SCretractions noted. Lungsounds clear/=, no spells thus far this shift. Wakes for feeds andsleeps well in between. BBS cl/=. P: Continue to monitor infant's resp. A: Infantstable in RA. A: Infantstable in RA. +BS, voidingand stooling heme -. Feeding adlib. A:AGA. A: AGA. Continue to monitor resp status.3. 73cc q4. LS cl/=. Mom with cares andfeedings. Comparison film is from . Voidingand stooling qs. A: AGAP:Cont to support dev needs.#5: in earlier today. visited, updated at bedside. Wakes on her own forfeeds. NPN 7a-7p#2: remains in RA, breathing comfortably withintermittent mild SC retractions. Notedto have occassional sat drifts to low 90- QSR. Prepare for discharge. Active bowel sounds. P: Continue to supportG&D.#5 O: Mom called x1 thus far and updated by RN. Infant'sabdomen is soft, +BS, no loops. AGA. Independent with cares. | 72 | [
{
"category": "Nursing/other",
"chartdate": "2191-08-15 00:00:00.000",
"description": "Report",
"row_id": 2057670,
"text": "Neonatal NP- discharge exam\n\nAFOF. Palate intact. +RROU.\n\nBreath sounds clear and equal. Nl S1S2, no audible murmur. and well perfused. Abd benign, no HSM. Active bowel sounds. Buttocks with breakdown and bleeding in areas (pinpoint). Being treated with Criticaid ointment. Infant active and with exam. Lusty cry.\n\nHips stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-15 00:00:00.000",
"description": "Report",
"row_id": 2057671,
"text": "NPN\n\n\n#2 Resp- Remains in RA w/o2 sats 95-100%.BS clear.RR=\n40-60.No A's or B's or desats yet tonight.Day . See\nflowsheet.\n#3 F/N- Abd soft,+bs, no loops.Bottles well ad lib demand.\nWaking q 4-5 hrs. Taking 130cc of Goodstart.Wt up\n65gms.Voiding+ stooling in adeq amts.Criticaide to diaper\narea w/every change. Very sm area of breakdown.\n#4 Dev- + active w/cares. Temp stable swaddled in open\ncrib.\n#5 Mom called x1. Updated.Plans to be in for AM\nD/C.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-15 00:00:00.000",
"description": "Report",
"row_id": 2057672,
"text": "Neonatology Attending\n\nDOL 12 PMA 39 2/7 weeks\n\nExam AF soft, flat, normal RR OU, clear bs, soft intermittent murmur, benign abd, no hip click, active, normal tone, sleeping, good perfusion\n\nStable in RA. No A/B.\n\nNo h/o murmur. Murmur today sounds benign. BP 78/40 mean 54\n\nFeeding ad lib demand on Good Start. Took 213 ml/kg yesterday. Voiding. Stooling. Wt 3275 grams (up 65). HC 36.5 cm Lt 50 cm\n\nHearing screen passed.\n\nCar seat test passed.\n\n in and up to date. Pediatrician is Dr. in ().\n\nA: Stable. Countdown complete. Likely flow murmur. Ready for discharge.\n\nP: Home with \n f/u Dr. on \n decline VNA\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-15 00:00:00.000",
"description": "Report",
"row_id": 2057673,
"text": "Nursing Progress and Discharge Note\n\n\n2. RESP Received infant in RA. Infant remains in RA. LS\nCL=. No retractions noted, no incr WOB noted.\n\n3. FEN Infant is ad lib feeding Goodstart 20. tol well.\nNo spits. Belly soft, no loops. Voiding, stooling.\n\n4. DEV remains in OAC with stable temp. A/A with\ncares, waking for feeds. discharge PKU done and sent.\n\n5. Mom and Dad in for infant's discharge. All D/C\nteaching complete. All parental questions answered at this\ntime. Family very excited infant is going home.\n\nSee flowsheet for further details.\n\nDischarge infant to home with as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-03 00:00:00.000",
"description": "Report",
"row_id": 2057605,
"text": "Admission Note\nOB: \nPED: (Centre Peds, )\n\nBG is the 3245 gm product of a 37 wk gestation, born to a 24 yo G2 P1-2 mother. history notable for gallstones and hip dysplasia.\nPNS: MBT O+, Ab-, HepBsAg-, RPRNR, RI, GBS -. No other sepsis risk factors.\nROS otherwise negative.\n\nThe infant wsa delivered by SVD. Apgars , .\nThe infant was initially in the Newborn Nursery, but developed mild respiratory distress with grunting within a few hours of life. Transferred to the NICU for admission.\n\nPE: Wt 3245 gm Ln 19 in Hc 36.5 cm\nAfebrile P 130s RR 30s BP 60/28 (39) pOx in RA 84%\nAFOF\nPalate, clavicles intact\nMostly clear BS with fair aeration, moderate grunting and retractions\nRRR no murmur, good fem pulses\nAbd soft, ND with no HSM\nPink and well-perfused\nMAE with good tone\nNl female\nPatent anus\n\nCXR obtained: LLL and RML infiltrates\n\nA/P:\nNewborn infant with respiratory distress, with CXR c/w pneumonia.\nRESP: Started on NC. Monitor respiratory status closely to determine potential need for CPAP or intubation. Currently with stable sats on NCO2.\nCV: Stable BPs. Continue to monitor.\nFEN: NPO until respiratory status stabilizes. Start on IVF. Monitor D-sticks and lytes.\nID: Obtain CBC and blood culture and start empiric Amp and Gent.\nSOC: We will update the parents and Pedaitrician about the plan.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-13 00:00:00.000",
"description": "Report",
"row_id": 2057659,
"text": "Nursing Progress Note\n\n\n#2. O: Infant remains in RA with O2 sats > 94%. RR\n30's-50's. Breath sounds are clear and equal. No GFR. No\nspells thus far. A: Day for spell countdown. P: Continue\nto monitor.\n\n#3. O: Infant remains po adlib on Good Start 20cal formula.\nWaking to feed Q4-5hrs. No spits. Abd soft and full with\nactive bowel sounds. Voiding qs. Lrg yellow stool, neg heme.\nReceived 211cc/k/d yesterday. Wgt is up 15gms tonight to\n3145gms. A: Tolerating po feeds. P: Continue to monitor.\n\n#4. O: Infant remains in open crib with stable temp. She is\n and active with cares. MAEW. Po feeding well. A: AGA.\nP: Continue to assess and support developmental needs. Will\nneed hearing screen and carseat test prior to d/c.\n\n#5. O: Mom called x1 for update. Asking appropriate\nquestions. Stated they will be in for visit today. A:\nInvolved family. P: Continue to inform and support.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-13 00:00:00.000",
"description": "Report",
"row_id": 2057660,
"text": "Neonatology- Progress Note\nPE: Baby girl remains in her big girl crib, in room air, bbs cl=, rrr s1s 2no murmur, abd soft, nontender, well perfused,appropriate for ga\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-06 00:00:00.000",
"description": "Report",
"row_id": 2057626,
"text": "NPN (1500-2300)\n\n\n2. Resp: Remains in RA, 3 A's and B's this shift, one with\nspit. HOB elevated. LS clear and equal, RR 30's-60's.\n\n3. f/N: Weight down 20gm to 3010. Ad lib demand feeds of\nCarnation good Start, taking 55-65cc po well. Abd exam\nbenign, vdg and stooling well.\n\n4. Dev: Alert and active with cares, sleeping well in\nbetween, temp stable.\n\nBili : Remains jaundiced, to have bili in am.\n\n5. Soc: Mom and Dad in visiting throughout evening.\n staying in parent room overnight. updated\nby Dr. as to current plan.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-13 00:00:00.000",
"description": "Report",
"row_id": 2057661,
"text": "Neonatology Attending Progress Note:\nDOL #10\nPMA 39 weeks\nremains in RA, sats over 94%, RR=30-50's, no retx, clear/equal\nday # spell free\nno murmur, , HR=140-170's, 68/32 (mean=43)\nwt=3145g (inc 15g), min of 140cc/kg/d took 211cc/kg/d, 20 cal good start\nvoiding, stooling\n\nImp/Plan: premie infant with spell countdown\n--monitor weight\n--monitor for spells\n--d/c planning\n--cont rest of present management\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-13 00:00:00.000",
"description": "Report",
"row_id": 2057662,
"text": "PCA Progress Note 0700-1900\n\n\nRESP O/A: Infant remains on room air with sats 96-100%. Lung\nsounds clear and equal. No retractions. No spells this\nshift. P: Continue to monitor.\n\nFEN O/A: Total fluids minimum 140 cc/k/day GoodStart.\nFeeding ad lib, wakes every 4-5 hours. Took 125 cc, 115 cc\npo. Abdomen soft and round. Active bowel sounds. No loops.\nSmall spit x2. Voiding qs. Large heme neg stool. Criticaid\napplied to rash. P: Continue to encourage po feeds.\n\nG&D O/A: Temps stable swaddled in open air crib. Wakes for\nfeeds. and active with cares. Fontanels soft and flat.\nP: Continue to monitor and promote normal infant\ndevelopment. Hearing screen needed before discharge.\n\n O/A: Mom and dad both in with sister and grandma.\nIndependent with cares. Asking appropriate questions. P:\nContinue to update and educate about .\n\n\nsee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-13 00:00:00.000",
"description": "Report",
"row_id": 2057663,
"text": "NICU nursing note 7a-7p\nThis RN has examined infant. Read and agrees with above PCA note. Cont to monitor infant for spells. Prepare for discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-05 00:00:00.000",
"description": "Report",
"row_id": 2057620,
"text": "NPNOte\n\n\n#1. Amp+ gent d/c'd, blood culture negative at 48hrs.\nA;asymptomatic P; problem solved.\n\n#2. Remains in R air, BBS clear, equal, mild subcostal/\nintercostal retractions present, spellx2 thus far this s\nhift, occassional sat drifts noted with po feeds.Chest Xray\ndone this am.A; spellx2. P; cont to monitor for spells, need\n5day count down as advised.\n\n#3. Tf=, IVF D/c'd. on Goodstart po fed adlib,\ntolerated, small spit x1.voided, stooled, A; feeds\ntolerated. P; cont current feeding plan.\n\n#4.Alert,active with care, temp stable in a open crib,\nswaddled with blanket, mae. A; AGa P; cont dev support.\n\n#5. Parents visited with grand parents, asking app\nquestions,was updated by NNp Rivers, and Dr at\nbedside. Mom independent with care and handling.A; Loving P;\ncont update and support.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-05 00:00:00.000",
"description": "Report",
"row_id": 2057621,
"text": "1 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; d/c'd\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-06 00:00:00.000",
"description": "Report",
"row_id": 2057622,
"text": "NICU NPN\n\n2. O: Infant remains on RA, BS cl= to bases. RR is 30-50. 2\nspells this shift-apneic with desat to 70's, HR 70's. Mild\nstim needed x2. A: No resp distress, occasional spells\ncontinue with apnea and color change. P: Monitor spells and\nresp status.\n\n3. O: PO feeding ad lib amts of Nestle Good Start- took 60cc\nx1. Weight is 3030g, down 55g. No spits. Slow to start\nbottler, guzzles and gulps with drifting HR and\ndesat-recovers quickly with removal of bottle. Coordination\nimproved fairly quickly. TF in =95cc/k/d for yesterday. A:\nSlow to start Po feeder, but did improve with time. P: Pace\nfeeding, monitor weight and intake.\n\n4. O: Swaddled in open crib, awake and vigorous with cares,\nsleeps well between feeds. PO feeds fair. A: Now 38weeks,\nhaving apnea and desats.P: Monitor and support developmental\nneeds.\n\n5. O: No contact from . A/P: Support and keep\ninformed with contact.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-12 00:00:00.000",
"description": "Report",
"row_id": 2057654,
"text": "PCA note 1900-0700\n\n\n2. RESP-Infant remains in room air breathing comfortably\nwith RR 30-50's. LS are clear and equal, no retractions\nseen. O2 sats are 97-100%. No spells, last spell was at 5pm\non the 12th. Continue to monitor respiratory status.\n\n3. FEN-Todays new weight is 3130 (up 80 grams). Infant\nremains on adlib feedings with min 140cc/kg of Good start 20\n or 76cc's q4hrs. Infant bottling 100cc x2 so far this shift\nusing regular yellow nipple. Eager and coordinated bottler\nthis shift. Yesterdays 24hr intake was 224cc/kg. Abd benign.\nVoiding and stooing heme negative. One small spit. Criticaid\nbeing applied to areas of broken down skin with diaper\nchanges. Exceeding minimum. Continue to encourage po feeds.\n\n4. DEV-Infant has stable temperatures swaddled in OAC. \nand active during cares, resting well in between. Waking\nappropriately for bottle. Infant continues to have clear\nbilateral eye drainage. Continue to support developmental\nneeds.\n\n5. -No contact so far this shift with this PCA. Mom\ncalled x1 and was updated by RN on . Continue to\neducate and support .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-12 00:00:00.000",
"description": "Report",
"row_id": 2057655,
"text": "NPN 1900-0700\nI have examined this infant and agree with the above note\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-12 00:00:00.000",
"description": "Report",
"row_id": 2057656,
"text": " On-Call\nPhysical Exam\n, well-perfused infant in open crib, room air; breath sounds clear/=; no murmur; abdomen soft, no masses; + bowel sounds; cord on; moving all extremities; with appropriate tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-12 00:00:00.000",
"description": "Report",
"row_id": 2057657,
"text": "Neonatology Attending\n\nDOL 9 PMA 38 6/7 weeks\n\nStable in RA. No A/B. Last .\n\nNo murmur. BP 67/27 mean 42\n\nFeeding ad lib Good Start. Took 204 ml/kg yesterday. Voiding. Stooling. Excoriations on buttocks being treated with criticaid. Wt 3130 grams (up 80).\n\n in. Mother distressed re spells. Given reassurances yesterday.\n\nA: Stable. D2 of countdown.\n\nP: Monitor\n Home when 5 days spell free\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-12 00:00:00.000",
"description": "Report",
"row_id": 2057658,
"text": "NPN (0700-1900)\n\n\n2. Resp: Remains in RA, no A's or B's, breathing\ncomfortably in the 30's-50's range. LS clear and equal.\nDay 2 of 5-day countdown for bradys.\n\n3. F/N: Continues to po ad lib amounts q4-5 hours on\ndemand. Has already taken in 130cc/kg for today. Abd exam\nbenign, vdg and stooling well...yellow stools. Diaper area\ncontinues to be slightly excoriated and is responding well\nto criticaid oitment. Small spit noted on blankets this am.\n\n\n4. Dev: and active with cares, temp stable, swaddled\nin open crib. Mom gave sponge bath today.\n\n5. Soc: Mom and Grandmother in this afternoon. Mom is\nready and anxious to take baby home. Infant is slated to be\nD/C'd on if no more bradys. Needs hearing and car seat\ntest prior to D/C. Other D/C teaching has been done.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-06 00:00:00.000",
"description": "Report",
"row_id": 2057623,
"text": "NNP ON-Call\nPhysical Exam\nGeneral; infant in open crib, room air\nSkin; warm and dry; color pink/jaundiced\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=; easy respirations\nCV: RRR< no murmur; normal S1 S2; pulses +2\nAbd: soft; non-tender; no masses; + bowel sounds\nExt: moves all\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-10 00:00:00.000",
"description": "Report",
"row_id": 2057646,
"text": "Neonatology note\nPE:\n\nNEURO: infant swaddled in open crib, active on exam, AFOS, sutures approximated, aga tone.\n\nRESP: infant in r/a, breath sounds = clear with no retractions.\n\nCARDIAC: color /sl jaundice well perfused, no audible murmur on exam, pulses palpable =x4, cap refill < 3secs, mucous membranes and moist.\n\nSKIN: intact, no lesions, rashes or bruises on exam.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam.\n\nGU: normal female genitalia\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-10 00:00:00.000",
"description": "Report",
"row_id": 2057647,
"text": "NPN 0700-1900\n\n6 Hyperbilirubinemia\n\n#2RESP: Pt stable in RA, sats 95-100%. RR 30's-50's. Lung\nsounds clear and equal bilaterally. No increased WOB. No\nspells thus far. Pt is currently day day spell\ncountdown. P: Cont to monitor.\n\n#3FEN: Pt adlib demand on a min of 140cc/kg/day of Nestle\nGoodstart 20cal. Waking Q 4-5 hrs and bottling 110-120cc per\nfeeding thus far. Tolerating feedings well, no spits. Abd\nsoft and round, no loops, +BS. Voiding & stooling, heme neg.\nDesitin applied to diaper area. P: Cont with current feeding\nplan.\n\n#4DEV: Temps stable, swaddled in OAC. Wakes for feedings.\n and active with cares. Settles and sleeps well in\nbetween. MAE. . Likes pacifier. Hep B given. PKU done.\nPt needs hearing screen prior to d/c. P: Cont to support dev\nneeds.\n\n#5PAR: Mom visited for afternoon care time. Loving and\ninvolved mother, asking questions. Independent with\nfeeding and cares. Updated by this RN. P: Cont to support\nand update .\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-11 00:00:00.000",
"description": "Report",
"row_id": 2057649,
"text": "NPN:\n\nRESP: Sats 95-100% in RA. RR=40-60. BBS =/clear. No desats or A&Bs thus far tonight; A&B x 1 (HR=73) over past 24 h -> QSR. Day 0/7 of spell count prior to discharge. .\n\nCV: No mumrur. HR=130-140s. BP=64/32 (45). Color with jaundice. Perfusion good.\n\nFEN: Wt=3050g (+ 10g). BW=3245g. Ad Lib fdgs of Good Start-20 ~ q 4 h. Intake yesterday 162cc/kg/d. Bottled well for 115cc w/good coordination. No spits. Abd benign. Voiding qs; small yellow stool.\n\nSKIN: Excoriation of diaper area; Criticaid applied w/each diaper change.\n\nG&D: CGA=38-5/7 wk. Temp stable in crib. Waking for fdgs. Active and w/good tone. Small amt yellow eye drainage. Hearing screen to be done prior to discharge. Swaddled and resting well.\n\nSOCIAL: No contact w/.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-11 00:00:00.000",
"description": "Report",
"row_id": 2057650,
"text": "Neonatology Attending\n\nDOL 8 PMA 38 5/7 weeks\n\nStable in RA. 1 A/B.\n\nNo murmur. BP 64/32 mean 45\n\nFeeding ad lib on Good Start. Took 162 ml/kg yesterday. Voiding. Stooling. Wt 3050 grams (up 10).\n\nStable temp in crib.\n\nHep B vaccine given\n\nMother in and up to date.\n\nA: Stable. Still immature. Countdown restarted.\n\nP: Monitor\n Home when spell free x 5 days\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-11 00:00:00.000",
"description": "Report",
"row_id": 2057651,
"text": "PCA Progress Note 0700-1900\n\n\nRESP O/A: Infant remains on room air with sats 96-100%. Lung\nsounds clear and equal. No retractions. No spells this\nshift. P: Continue to monitor.\n\nFEN O/A: Total fluid 140 cc/k/day GoodStart20 = 76 cc q 4\nhours. Infant feeding ad lib; took 85 cc, 105 cc, 90 cc po.\nAbdomen soft and round. No loops. Active bowel sounds. No\nspits. Voiding qs. Heme neg stools. Criticaid applied with\ndiaper changes. P: Continue to encourage po feeds. P:\nContinue to encourage po feeds.\n\nG&D O/A: Temps stable sawddled in open air crib. Wakes for\nfeeds. and active with cares. Fontanels soft and flat.\nP: Continue to monitor and promote normal infant\ndevelopment.\n\n O/A: Mom and dad in this afternoon. Mom upset that\n has to stay longer due to spell last night. NP\nwith family. Asking appropriate questions. Very loving\ntoward infant. P: Continue to update and educate \nabout .\n\n\nsee flowsheet for further details\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-11 00:00:00.000",
"description": "Report",
"row_id": 2057652,
"text": "NPN \n\n\n\n I have examined this infant and am in agreement w/above\nnote and assessment by PCA .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-11 00:00:00.000",
"description": "Report",
"row_id": 2057653,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\nPhysical Exam\nGeneral: infant in open crib, room air\nSkin; warm and dry; color , mildly jaundiced\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +\nAbd: soft; no masses; active bowel sounds; cord on/drying\nExt: moves all\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-04 00:00:00.000",
"description": "Report",
"row_id": 2057617,
"text": "NPN 7am-7pm\n\n\nID: Infant remains on amp and gent for min of 48hrs. CBC nl\nand Bld cx neg to date. Infant is improving with resp. No\nother s/s of infection at this time. A: Doing well in RA. P:\nWill check CxR in am to r/o pneumonia and DC abx. Will cont\nto monitor.\n\nRESP: Received infant on CPAP of 6cm's in 24%. Was able to\nwean to 21% and off CPAP at 0830 with sats > 94%. At 10 am\ninfant was sating 88-90%. Placed on NC 200cc's in 100%.\nWeaned throughout day to RA at 5pm. LS clear and equal with\nno increased WOB noted. RR 30-50's. Question occ grunting or\nsounds with cares. A: Comfortable in RA. P: Will cont to\nmonitor and keep sats > 94%. Repeat cxr in am.\n\nFEN: Infant was NPO with IVF running at 60cc/kg/day through\nPIV. Started ent feeds ad lib with Good start 20cals at 4pm\nand took 20cc's. Weaned IVF to 40cc/kg/day. Abd soft, +bs,\nno loops. Voiding and stooling mec. No spits. Will check DS\nwith next feeding. A: Tol feed well. P: Will cont to monitor\nweight and exam.\n\nG/D: Received infant on off warmer swaddled. Temp stable.\nMoved to open crib. Alert and active with cares. Sucks on\npacifier. MAE. Edema has gone down. and infant is voiding\nwell. Concent for PKU and Hep done. A: Infant improving with\nresp. P: will cont to support dev needs.\n\nPARENTS: Parents were in throughout shift with visitors.\nFamily meeting held at 4pm with questions answered. Mom took\ntemp and changed diaper. Gave infant first bottle. Very\nnervous about infant needing help with breathing. They are\nhappy with her progress. A: very loving and supportive\nfamily. P: Will cont to support and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-05 00:00:00.000",
"description": "Report",
"row_id": 2057618,
"text": "NPN\n\n\n#1 Sepsis-Remains on 48 hr r/o of Amp+ Gent.Plan for chest\nX- ray in AM.\n#2 Resp- Remains in RA w/o2 sats 94-100%. BS clear. No F or\nR.Occ grunting QSR.RR= 40-70.\n#3 F/N- Abd soft,+bs, no loops. Voiding in adeq amts. Lg mec\nstools.Patent PIV LH decreased to 20cc/kg/ day.Bottles well\nad lib amts q 4 hrs taking 30-40cc w/sm spits.Wt down\n95gms.D/S=74 +67.\n#4 Dev-Alert+ active w/ cares.Temp stable swaddled in off\niso.\n#5 Parents-Mom here to visit x1. Updated.Took temp, changed\nand fed baby.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-10 00:00:00.000",
"description": "Report",
"row_id": 2057648,
"text": "Nursing NICU Note\n\n\n2. Resp. O/Remains in RA. Please refer to spell noted and\ndocumented on flowsheet. A/bradycardic spell noted this\nshift. P/cont. to monitor.\n\n3. F/N. O/TF remain at a min of 140ml/k/d of Nestle Good\nStart infant formula. Please refer to flowsheet for\nexaminations of pt from this shift. Voiding. Passing stool.\nButtocks excoriated. Desitan applied. A/Alt. in F/N. P/Cont.\nto monitor for s/s of feeding intolerance. Cont. to monitor\nskin integrity. notify of excoriated buttocks and\nsee if Criticaid can be applied.\n\n4. Dev. O/Temp remains stable swaddled in a crib. Wakes on\nown eager to feed every 4-5 hours. Demonstrates a\ncoordinated suck/swallow/breathing reflex. A/Alt. in G/D.\nP/Cont. to support growth and development.\n\n5. . O/Mother called. Mother updated on pt's status\nand plan of care. Mother started to cry during conversation.\nThis nurse support. A/Mother is actively\ninvolved in pt's care. P/cont. to support and educate\n.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-05 00:00:00.000",
"description": "Report",
"row_id": 2057619,
"text": "Neonatology Attending\n\nDOL 2 PMA 37 6/7 weeks\n\nStable in RA since 5 pm. R 40s-60s. Baseline O2 sats 94-95%. Sat drifts at end of feed. Occ grunt at end of feed. 1 A/B (sat 83%, HR 73) at 9 am today. CXR clear.\n\nNo murmur.\n\nFeeding po ad lib. Took 30-40 ml Good Start q feed. IV at 20 ml/kg/d. DS 63-74. Voiding. Stooling. Wt 3085 grams (down 95).\n\nOn A/G. BC NGSF.\n\nParents in and up to date. I updated them at bedside yesterday. Had family meeting yesterday.\n\nA: Stable. Now in RA. No evidence of pneumonia. ? immature breathing pattern. Feeding ad lib. Sepsis ruled out.\n\nP: Monitor\n Likely 5 day countdown\n D/C IV\n Feed ad lib\n D/C A/G\n Check bili\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-03 00:00:00.000",
"description": "Report",
"row_id": 2057610,
"text": "Respiratory Care\nBaby Girl was placed on +6 nasal prong CPAP at 0900 this morning for grunting and WOB. Fio2 today ranging from 21-39%, RR 30s-80s. Breath sounds clear, no spells. CBG today of 7.31/47/47/25/-2. Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-04 00:00:00.000",
"description": "Report",
"row_id": 2057611,
"text": "Respiratory Care Note\nPt. continues on 6cmH2O of nasal prong CPAP and FIO2 29-40%. FIO2 decreased after prongs changed to 15fr and pt. placed prone. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-09 00:00:00.000",
"description": "Report",
"row_id": 2057642,
"text": "Nursing PCA Progress Note\n\n\n#2 O: Infant remains in RA. RR 30-40's, sats >96%. No\nretractions noted. Lung sounds clear/=, no spells thus far\nthis shift. A: Infant stable in RA. P: Continue to monitor\nresp. status.\n\n#3 O: Infant feeding ad lib demand of Nestle Good Start\nformula q3-4 hours this shift. Bottling 35-90cc with each\nfeed. A: Tolerating feeds well, with 1 small spit. Abdomen\nis benign, voiding and stooling well. P: Continue to support\nnutritional needs.\n\n#4 O: is swaddled in OAC, and temp is stable. Wakes\nfor cares, and active throughout. A: AGA. Sleeps well\nbetween cares. Sucks on pacifier and brings hands to face\nfor comfort. P: Continue to support G&D.\n\n#5 O: Mom in for 1200 cares. Independent with temp, diaper\nchange and feeds. A: Loving towards daughter. P: Continue to\nsupport, teach and update.\n\n#6 O: Bili this am 9.2/0.3 down from 10.6/0.3. A/P: Recheck\nbili levels in the morning as ordered. Continue to monitor.\n\n\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-09 00:00:00.000",
"description": "Report",
"row_id": 2057643,
"text": "NPNOte\nI have examined the baby,I agree with above note by PCA.Mom in to visit, stayed at bedside for most of the , updated mom at bedside, independent with care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-10 00:00:00.000",
"description": "Report",
"row_id": 2057644,
"text": "Nursing Progress Note 1900-0700\n\n\nRESP O/A: Infant remains stable in RA; maintaining O2 sats\n>93%. RR 20-50s, LS clear/=, normal WOB. No apena,\nbradycardia or desats noted overnight. Infant continues on\nday 3 of 5 day countdown. P: Cont to monitor.\n\nFEN O/A: BW: 3.245Kg, Current Wt: 3.040 Kg. Ad lib; Good\nStart 20 cal/oz. Infant has bottled 80-115cc q4h with the\nyellow nipple thus far tonight. 24h intake= 214cc/k/d.\nAbdomen benign, active BS. Voiding/stooling (heme neg).\nDesitin applied to red bottom prn. No spits. P: Cont to\nencourage po feeding.\n\nDEV O/A: is swaddled in an OAC; temps stable. Sleeps\nwell b/t cares, wakes for feeds. MAE, , AGA. P: Cont to\nsupport developmental needs.\n\nPAR O/A: Mother & grandparents in for the cares and\nfeeding. Mother is independent with all aspects of care.\nAsking appropriate questions. P: Cont to educate & support\nNICU family.\n\nBILI O/A: Infant appears jaundice. P: Monitor clinically.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-10 00:00:00.000",
"description": "Report",
"row_id": 2057645,
"text": "Neonatology Attending\n\nDOL 7 PMA 38 4/7 weeks\n\nStable in RA. No A/B. Last at 3 pm.\n\nNo murmur. BP 77/50 mean 59\n\nFeeding ad lib on Good Start. Took 214 ml/kg yesterday (!). Voiding. Stooling. Wt 3040 grams (up 50).\n\nHep B vaccine given . Hearing screen to be done. PKU sent.\n\nMother in. I updated her at bedside yesterday.\n\nA: Stable. Immature breathing pattern. D3/5 of countdown. Feeding well and gaining wt.\n\nP: Monitor\n Hearing screen\n Home if no further A/B\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-04 00:00:00.000",
"description": "Report",
"row_id": 2057612,
"text": "NURSING PROGRESS NOTE\n\n\n1. SEPSIS\nON ANTIBIOTICS, AMPICILLIN GIVEN AS ORDERED. LENGTH OF\nTREATMENT TO BE DETERMINED.\n2. RESPIRATORY\nCONTINUES ON PRONG CPAP AT 6CM. LARGER PRONGS NOW IN PLACE.\nO2 REQUIREMENT 25-40%, 25-30% AFTER PRONG CHANGE. BBS CLEAR,\nRR 70-80, NOW AFTER 0200 60'S. NO SPONTANEOUS DESATS. SOME\nGRUNTING NOTED WHEN OFF CPAP.\n3. F/N\nTONIGHT'S WEIGHT DOWN 65 GRAMS TO 3.18KG. APPEARS\nEDEMATOUS. TOTAL FLUIDS OF D10W AT 60CC/KH VIA PIV.\nGLUCOSE 64. NPO. VOIDING .8CC/KG/HOUR FOR 24 HOURS. (LAST\nVOID 40+ CC.) 24 HOUR ELECTROLYTES PENDING.\n4. G&D\nIRRITABLE WHEN DISTURBED. SUCROSE OFFERED WITH CARE. LOVES\nPACIFIER. COMFORTABLE ON ABDOMEN.\n5. PARENTS\nMOM AND DAD IN AT , APPROPRIATELY CONCERNED.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-04 00:00:00.000",
"description": "Report",
"row_id": 2057613,
"text": "Neonatology Attending\n\nDOL 1 PMA 37 5/7 weeks\n\nOn CPAP 6 RA then transitioned to RA this morning. R 40s. No A/B.\n\nNo murmur. BP 59/30 mean 41.\n\nNPO. On D10W at 60 ml/kg/d. 133/6.7 (grossly hemolyzed)/98/19 DS 64. Voiding (0.8 ml/kg/hr yesterday but improved today). Stooling. Wt 3180 grams (down 65).\n\nOn A/G. BC NGSF.\n\nTemp stable in off isolette.\n\nParents in and up to date.\n\nA: Improving. Newly off CPAP. ? TTN vs pneumonia. Will need to f/u CXR, if normal pneumonia not likely. If pneumonia, will need 1 week course of antibiotics and LP.\n\nP: Monitor\n Repeat CXR in am to determine length of antibiotic course\n Start feeds if resp status remain stable off CPAP\n Continue A/G with course dependent on labs\n Family meeting today\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-04 00:00:00.000",
"description": "Report",
"row_id": 2057614,
"text": "Neonatology Attending\nDISREGARD ABOVE WRONG PT\n\nExam for this baby:\nAF sExam AF soft, flat, prong CPAP in place, shallow respirationoft, flat, NCO2 in place, pink and comfortable, clear bs wits, clear bs, soft murmur, normal pulses, benign abd, active and responsive, normal tone, good perfusion\n\nMother in. I uh good aeration, no murmur, benign abd, active and alert\n\nPapdated her.rents in. I updated them at bedside. Answered questions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-04 00:00:00.000",
"description": "Report",
"row_id": 2057615,
"text": "Neonatology Attending\nDISREGARD ABOVE WRONG PT\n\nExam for this baby:\nAF sExam AF soft, flat, prong CPAP in place, shallow respirationoft, flat, NCO2 in place, pink and comfortable, clear bs wits, clear bs, soft murmur, normal pulses, benign abd, active and responsive, normal tone, good perfusion\n\nMother in. I uh good aeration, no murmur, benign abd, active and alert\n\nPapdated her.rents in. I updated them at bedside. Answered questions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-04 00:00:00.000",
"description": "Report",
"row_id": 2057616,
"text": "Respiratory Care Note\nBaby Girl was taken off CPAP in am. Initially in RA but placed on nasal cannula for O2 sat drifts. BS clear. No grunting noted. RR 30's-50's. Plan CXR in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-03 00:00:00.000",
"description": "Report",
"row_id": 2057606,
"text": "NPN admit to the NICU\n\nBaby girl was admitted from the NBN in resp distress, grunting. (See Note above for details.) She was placed on a warmer on servo. VSS. O2 sat was 86 in RA. She was placed in a nc and is on 100% FiO2 and 500cc flow. She is still grunting. A CBC and blood cx was sent. D/s was 87. A CXR was obtained. A PIV was placed and infant was started on D10W at 60cc/k/d and gent and ampi.\n\nP: As per NICU protocol and as per infant need.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-03 00:00:00.000",
"description": "Report",
"row_id": 2057607,
"text": "Neonatology Attending Progress Note:\nfew hours of age\nnow in 500cc 100% NC, RR=30-50's, sats 94-96%, mostly clear/equal but still with significant grunting and retx\nsoft murmur, HR=120-140's, BP mean=43\ncrit=57, plt=362\namp and gent, blood culture pending\nWBC=20.6 (59N6B31L, toxic granulations)\nnpo, TF=60cc/kg/d. D10W, dstx=111\nactive bowel sounds. voided and passed stool\nservowarmer, stable temps\nCXR (read by radiology this am): probable pneumonia\nImp/Plan: FT infant with probable pneumonia with respiratory distress.\n--will place on CPAP, repeat CXR and obtain gas\n--monitor murmur, if persists will do evaluation\n--will obtain 24 hour lytes\n--length of antibiotics most likely 7 days if radiographic evidence of pneumonia persists\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-03 00:00:00.000",
"description": "Report",
"row_id": 2057608,
"text": "NPN 0700-1900\n\n\n#1 Sepsis: Infant cont 48 hr r/o amp/gent-potential 7 day\ncourse for CXR on admission c/w pneumonia. BC pnding. CBC\nfrom admission: WBC 20.6, 59 neuts, 6 bands. Hct 57.1 and\nplt 362. A: No signs/symp sepsis. P: Cont antibiotics as\nordered.\n\n#2 Resp: Received infant in nasal cannula 500 cc, FiO2 100%.\nInfant placed in CPAP 6 cm @ 0900 for persistent GFR and\ndrifts in sat to low 90s. CXR done. CBG this shift\n7.31/47/47/25/-2. FiO2 on CPAP has been 32-39%. Resp rate\n20s-70s w/occasional tachypnea to 80s-100s. Sat 94-97%. Lung\nsounds cl/= and SCR. A: Infant appears more comfortable\nbreathing on CPAP 6 cm w/intermittent tachypnea. P: Cont to\nmonitor.\n\n#3 FEN: Infant cont npo. TF 60 cc/kg of D10W via PIV. DS\n111, 78. Abdomen round/pink/soft w/active bowel sounds and\nno loops. AG stable, 28-29 cm. Voiding 0.9 cc/kg/hr x 8 hr\nand mec stool x 2 so far this shift. A: DS stable. P: Cont\nw/current plan and plan to check 24 hr lytes.\n\n#4 Dev: Infant nested in servo warmer-warmer weaned x 1.\nTemp stable. Alert/drowsy w/cares and occasionally\nirritable. Settles well and sleeps well inbtwn. A: AGA. P:\nCont to supp dev needs.\n\n#5 Parents: Parents in freq w/visitors and were updated by\nthis RN and team. Mom took temp and changed diaper. A:\nLoving parents. Approp w/cares and ques. P: Cont to supp and\nupdate. Plan for fam meeting or Fri.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-03 00:00:00.000",
"description": "Report",
"row_id": 2057609,
"text": "1 Infant with Potential Sepsis\n2 Term Respiratory Distress\n3 FEN\n4 Dev\n5 Parents\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Term Respiratory Distress; added\n Etiologies:\n Transient Tachypnea of the Newborn\n Meconium Aspiration\n Start date: \n 3 FEN; added\n Start date: \n 4 Dev; added\n Start date: \n 5 Parents; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-08 00:00:00.000",
"description": "Report",
"row_id": 2057637,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\nPhysical Exam\nGeneral: infant in open crib, room air\nSkin; warm and dry; color pink/jaundiced\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur appreciated; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds; cord on/drying\nExt: moves all\nNeuro: + suck; + grasps; symmetric moro\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-09 00:00:00.000",
"description": "Report",
"row_id": 2057638,
"text": "2. Resp\nIn RA with sats above 98%. Lungs sound clear and equal. No\nretractions. No spells so far this shift.\nA. Resp is stable in RA.\nP. Continue to monitor resp status.\n3. FEN\nBaby's wt is 2.990 up 10g. Baby is ad lib on nestle\ngoodstart formula. All po's. One sm spit so far this shift.\nBaby wakes every 4-5 hours for feeds. Bottles well. Voiding\nand stooling. Last hemoccult was negative.\nA. Baby is tolerating feeds and gaining weight.\nP. Continue to monitor FEN status.\n4. G&D\nTemps stable in an open crib. Fonts are S/F. Baby is \nbut slightly jaundiced. Using desitin on baby's bottom to\nprevent further skin breakdown. Baby is and active\nduring cares. Rests well in between cares. Hep B consent has\nbeen signed but orders have yet to be written. Baby had a\nbath today on the day shift.\n5. \nNo contact with so far this shift.\n6. Bili\nLast bili was 10.6 0.3 which was down from 14.6 0.3.\nPhototheraphy was D/C and bili will be rechecked in the\nmorning.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-09 00:00:00.000",
"description": "Report",
"row_id": 2057639,
"text": "NPN\nI have examined infant and sgree with PCA assessment and care of infant. Bili level down to 9.2/0.3.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-09 00:00:00.000",
"description": "Report",
"row_id": 2057640,
"text": " On-Call\nPhysical Exam\nGeneral: infant in room air crib\nSkin; warm and dry; color , less jaundiced\nHEENT: anterior fontanel open, level; sutures opposed; eyes clear\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; femoral pulses +2\nAbd: soft; no masses; active bowel sounds; cord on/drying\nGU: normal female\nExt: moves all symmetrically\nNeuro: ; + suck; + grasps; + moro\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-09 00:00:00.000",
"description": "Report",
"row_id": 2057641,
"text": "Neonatology Attending\n\nDOL 6 PMA 38 3/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 70/21 mean 48\n\nFeeding ad lib on Good Start. Took 144 ml/kg yesterday. Voiding. Stooling. Wt 2990 grams (up 10).\n\nBili 9.2/0.3 (rebound)\n\nMother visiting and up to date.\n\nA: Stable. No spells. D2 of countdown. Feeding well. Hyperbili resolved.\n\nP: Monitor\n Hep B vaccine after consent\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-08 00:00:00.000",
"description": "Report",
"row_id": 2057632,
"text": "1900-0730 PCA Progress Note\n\n\nRESP:\nO: Infant remains in RA, RR 30-40s, maintaining O2SATs >94%.\nBS are clear and equal, no retractions noted. No episodes of\napnea, bradycardia or desaturation as of this writing. A:\nStable in RA. P: Continue to monitor respiratory status.\n\nFEN:\nO: CW2.980kg (-30g). Infant continues to demand feeds of\nNestle Goodstart Q4 hours this shift, taking 85-90cc at each\nfeed. Abdomenal exam is unremarkable. 1 small spit. Voiding,\npassing heme negative stools. DS-76. Total intake for 24\nhours =170cc/kg. A: Coordinated bottler. P: Continue to\nsupport nutritional needs.\n\nDEV:\nO: Infant remains nested in air mode isolette (r/t\nphototherapy) maintaining stable temps. , . Wakes for\nall cares, alert and active throughout. Rests well between\ncares with boundaries. Enjoys pacifier, brings hands to\nface. A: AGA. P: Continue to support developmental needs.\n\n:\nO/A: Mom called x1. Updated by RN over the phone. P:\nContinue to support, update and teach.\n\nBILI:\nO: Infant remains under neoblue bank with eye shields in\nplace. Bili this am 10.6/0.3 down from 14.6/0.3. A: Remains\njaundice in color. P: Continue to monitor bili levels per\nteam.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-08 00:00:00.000",
"description": "Report",
"row_id": 2057633,
"text": "I have examined the above patient and agree w/ the above note by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-08 00:00:00.000",
"description": "Report",
"row_id": 2057634,
"text": "Neonatology Attending\n\nDOL 5 PMA 38 2/7 weeks\n\nStable in RA. 2 A/B.\n\nNo murmur. BP 71/42 mean 52\n\nAd lib demand Good Start. Took 170 ml/kg yest. Voiding. Stooling (heme neg). DS 76 Wt 2980 grams (down 30).\n\nBili 10.6/0.3. On phototherapy.\n\n in and up to date. Mother restarting nursing school today.\n\nA: Stable. Immature breathing control. Feeding ad lib. Hyperbili responding to phototherapy.\n\nP: Monitor\n D/C phototherapy and check rebound in am\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-08 00:00:00.000",
"description": "Report",
"row_id": 2057635,
"text": "Nursing PCA Progress Note\n\n\n#2 O: Infant in RA, breathing 40-60's, sats >94%. Lung\nsounds clear/=, no spells thus far this shift. A: Infant\nstable in RA. P: Continue to monitor respiratory status.\n\n#3 O: Infant feeding ad lib demand of Nestle Good Start\nformula q4 hours. Bottling 89cc both feeds thus far. A:\nTolerating feeds well with wet burps, coordinated with\nbottle. Abdomen is soft and round, no loops. +BS, voiding\nand stooling heme -. 2 spits after feeds. P: Continue to\nsupport nutritional needs.\n\n#4 O: Temp stable and swaddled in OAC. Wakes for feeds and\nsleeps well in between. Settles with pacifier and brings\nhands to face for comfort. A: AGA. P: Continue to support\nG&D.\n\n#5 O: Mom called x1 thus far and updated by RN. A/P:\nContinue to support, teach and update regularly.\n\n#6 O: Phototherapy was turned off as ordered and infant\ntransfered into open air crib. Recheck bili in the morning.\n\n\nSee flowsheet for further details.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-08 00:00:00.000",
"description": "Report",
"row_id": 2057636,
"text": "Nursing PCA Progress Note\nI have examined this infant. I agree with note and assessment by PCA .\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-14 00:00:00.000",
"description": "Report",
"row_id": 2057664,
"text": "2 Resp\nIn RA with sats above 97%. Lungs sound clear and equal. No\nretractions. No spells so far this shift. Today will be day\n of the spell countdown.\nA. Resp is stable in RA.\nP. Continue to monitor resp status.\n3. FEN\nBaby's wt is 3210 up 65g. TF= min140cc/k/d of Nestle\nGoodstart 20 formula. 73cc q4. Ad lib. Wakes for feeds every\n4-5 hours. Abd is benign. One sm spit so far this shift.\nVoiding and stooling. Last hemoccult was negative.\nA. Baby is tolerating feeds and gaining weight.\nP. Continue to monitor FEN status.\n4. G&D\nTemps stable in an open crib. Fonts are S/F. Baby is .\nApplied Critic Aid to baby bottom to prevent further skin\nbreakdown. Baby's bottom is very red. Mineral oil is at the\nbedside. Hep B given. Consent can be found in baby's chart.\nBaby still needs hearing and carseat test.\nA. Alt in G&D.\nP.Continue to monitor and encourage further G&D.\n5. \nNo contact with so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-14 00:00:00.000",
"description": "Report",
"row_id": 2057665,
"text": " On-Call\nPhsyical Exam\n, well-perfused infant in open crib, room air; breath sounds clear/=; RRR without murmur, normal pulses; abdomen soft with active bowel sounds; cord on/drying; normal tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-14 00:00:00.000",
"description": "Report",
"row_id": 2057666,
"text": "NPN 1900-0700\nI have examined this infant and agree with the note above by A. , PCA.\n\nMom called and was given update. Mom will bring in carseat for screen today. Infant will need hearing screen today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-14 00:00:00.000",
"description": "Report",
"row_id": 2057667,
"text": "PCA Progress Note 0700-1900\n\n\nRESP O/A: Infant remains on room air with sats 96-100%. Lung\nsounds clear and equal. No retractions. No spells this\nshift. Day of spell countdown. P: Continue to monitor.\n\nFEN O/A: Total fluids minimum 140 cc/k/day GoodStart20 = 73\ncc q 4 hours. Feeding adlib. Took 135 cc po x2. Abdomen soft\nand round. Active bowel sounds. No spits. No loops. Voiding\nand stooling qs. Criticaid applied due to rash/fissure. P:\nContinue to encourage po feeds.\n\nG&D O/A: Temps stable swaddled in open air crib. Wakes for\nfeeds. and active with cares. Fontanels soft and flat.\nP: Continue to monitor and support normal infant\ndevelopment. Planned discharge home tomorrow.\n\n O/A: Mom called this am and was updated by RN. Mom\nand dad both in at 1330. Independent with cares. Asking\nappropriate questions. P: Continue to support as well as\nupdate and educate about .\n\n\nsee flowsheet for further information.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-14 00:00:00.000",
"description": "Report",
"row_id": 2057668,
"text": "Neonatology Attending\nDOL 11 / PMA 39-1/7 weeks\n\nIn room air with no distress and no cardiorespiratory events in 4 days.\n\nNo murmur. Well-perfused. BP 62/32 (42).\n\nWt 3210 (+65) on TFI 140 ml/kg/day min goodstart 20 with intake 208 ml/kg/day yesterday. Abd benign. Voiding and stooling normally (guiac negative).\n\nA&P\n37-4/7 week GA infant with resolving respiratory immaturity\n-Continue to monitor until free of significant apnea/bradycardia for at least 5 days prior to discharge home\n-Discharge planning in progress\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-14 00:00:00.000",
"description": "Report",
"row_id": 2057669,
"text": "NICU nursing note 7a-7p\nThis RN has examined infant, read and agrees with above PCA note.\n\nHearing screen passed. Please do carseat screen this evening. visited, updated at bedside. Loving and involved, anxious to take infant home. Prepare for discharge.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-07 00:00:00.000",
"description": "Report",
"row_id": 2057627,
"text": "Nursing Progress Note:\n\n\n#2 Resp: O: Infant remains in RA. LS cl/=. Mild SC\nretractions noted. No spells thus far this shift. A: Infant\nstable in RA. P: Continue to monitor infant's resp. status.\n\n#3 FEN: O: Tonight's weight = 3.010kg (-20g). Infant ad lib\ndemand, Nestle Goodstart. Waking for feedings q 3-4hrs. PO\nintake = 65-70cc/feeding. Med. spit x1. Infant showing signs\nof reflux. HOB elevated per reflux precautions. Infant's\nabdomen is soft, +BS, no loops. Infant voiding, stooling\nwell. A: Infant tolerating feedings well. P: Continue to\nsupport infant's nutritional needs.\n\n#4 DEV: O: Infant remains swaddled in an OAC. Maintaining\nstable temps. Infant sleeps well between cares. Wakes for\nfeedings and remains A/A throughout cares. MAE. AFSF. A:\nAGA. P: Continue to support infant's developmental needs.\n\n#5 : O: No contact from thus far this shift.\nP: Continue to update, support and teach .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-07 00:00:00.000",
"description": "Report",
"row_id": 2057628,
"text": "NNP Physical Exam\nPE: pink, jaundiced, AFOF, under phototherapy with eyes covered, breath sounds clear/equal, easy WOB, no murmur, abd soft, + bowel sounds, active, normal tone and reflexes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-07 00:00:00.000",
"description": "Report",
"row_id": 2057629,
"text": "Neonatology Attending Progress Note:\nDOl #4\nPMA 38 1/7 weeks\nremains in RA, RR=30-50's, mild sc retx, 7 spells in 24 hours (most self-resolving), no spells overnight and this am.\nno murmur, HR=110-150's,\nBP 80/43 (mean=54)\nneoblue last night for bili of 14.6/0.3\nwt=3010g ( 20g), ad lib feeding, took 100cc/kg/d\nvoiding, stooling\n\nImp/Plan: FT infant with resolved respiratory distress, immature respiratory pattern, indirect hyperbilirubinemia, stable.\n--head of bed elevate\n--monitor for spells\n--cont phototherapy, monitor bili\n--cont rest of present management\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-07 00:00:00.000",
"description": "Report",
"row_id": 2057630,
"text": "Respiratory Care\nPt remains on nasal prong CPAP +7cm's with the fio2 30 to 40%. Pt's resp rates 40's to 60's. Pt bulb sx'ed for a small amt of thick tan secretions. Duoderm replaced on nose and upper lip. MDI with albuterol given Q8 at noon x 2puffs. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-07 00:00:00.000",
"description": "Report",
"row_id": 2057631,
"text": "NPN 7a-7p\n\n\n#2: remains in RA, breathing comfortably with\nintermittent mild SC retractions. BBS cl/=. RR stable. Noted\nto have occassional sat drifts to low 90- QSR. Did have 2\nbrady spells today, QSR-mild stim required. See flowsheet\nfor details. A: stable in Ra with occ mild apnea/brady\nspells P:Cont to monitor and provide support as needed.\n\n#3: Infant conts on ad lib demand feeding schedule. She woke\n~q3.5-4.5hrs for feeds. Bottling 70-90cc of Nestle Good\nStart formula. Few wet burps and sm-med spits. HOB elevated.\nAbd soft, +, no loops. Voiding qs. Stooling- heme\nnegative. A: tol'ing PO feeds P:Cont with current feeding\nplan. Follow wt and exam.\n\n#4: Weaned isolette several times today. Temp now stable in\nair isolette. Infant does sleep in btw cares, but can be\nfiesty at times. Likes her boundaries. Wakes on her own for\nfeeds. Fonts soft/flat. Brings hands to face. A: AGA\nP:Cont to support dev needs.\n\n#5: in earlier today. Both updated by RN and \n. Mom r/t infant spells, 5 day countdown and\nher leaving hospital today. Mom with cares and\nfeedings. A: Loving family P:Cont to support and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-06 00:00:00.000",
"description": "Report",
"row_id": 2057624,
"text": "NICU Attending Note\n\nDOL # 3 = 38 weeks PMA with overall improving resp sxs, now in RA but with some residual A/B, no other concerns.\n\nI agree with above NNP Buck, well appearing.\n\nCVR/RESP (and ID): RRR without murmur, no G/F/R, BS clear/=. Remains in RA but A/B x 8 in last 24 hours, HR to 60's with apnea, + stim for some, facial CPAP x 1. Well between episodes, alert and active, pink and well perfused. Repeat CXR from this am with diffuse bilaterall haziness at bases, R>L, unchanged over 2 days. Pleural spaces clear. Resp sxs likely secondary to findings of lfuid by CXR. Given no perinatal risk factors for sepsis (GBS -, no fever, ROM x 8 hours, no intrapartum antibiotic prophylaxis, initially CBC/diff benign and non pre-treated blood cx NGSF), most likely diagnosis is resolving atypical TTN. Will continue to monitor closely, if A/B continues, progresses or if any s/s sepsis (hypotension, ill appearance), will send repeat CBC/diff, blood cx, LP and start A/G for treatment of presumed pneumonia.\n\nFEN: Abd benign, weight today 3030 gm, down 55 gm, on ad lib PO feeds, Carnation good start, took 95 mL/kg in last 24 hours. Voiding/stooling\nWill continue current diet.\n\nBILI: Bili 13.0/0.3 ( up slightly from yesterday). Not under phototox at this point. Will repeat bili tomorrow am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-08-06 00:00:00.000",
"description": "Report",
"row_id": 2057625,
"text": "NPN/0700-1500\n\n\n#2 RESP: Infant breathing room air with sats >94%. RR\n40-50's. LSC/=, no retractions or ^ in WOB. Cont. to have\nspells, has had 3 thus far with HR to the 60's and sats down\nto 80%'s at times (see nsg flowsheet). Team aware, plan to\nclosely monitor.\n#3 FEN: Ad lib demand bottle feeding, taking goodstart\nformula. Bottling well Q4hrs, took 70cc at first feed.\nSmall spit x1. Abd. exam benign. Voiding, no stools thus\nfar. Cont. to support nutritional needs.\n#4 DEVELOPMENT: Swaddled in oac, temps stable.\nActive/alert, wakes for feeds Q4hrs. Sucks on pacifier when\noffered. AFOF. AGA. Support developmental needs.\n#5 : Mom called this morning and updated. \nwill be in this afternoon to visit.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-03 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 977014,
"text": " 6:06 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: EVALAUTE LUNG FIELDS\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RESPIRATORY DISTRESS\n REASON FOR THIS EXAMINATION:\n EVALAUTE LUNG FIELDS\n ______________________________________________________________________________\n FINAL REPORT\n AP view of the chest in a neonate with respiratory distress.\n\n No tubes nor catheters are apparent. Bony skeleton looks normal.\n\n There is hazy opacity involving both lung bases, left more so than right. No\n overt pleural effusions present. Cardiac size is borderline.\n\n Differential diagnosis is between asymmetric clearing of fetal lung fluid and\n infection. If this film was taken soon after birth, fetal fluid is the likely\n explanation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-03 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 977062,
"text": " 10:41 AM\n BABYGRAM (CHEST ONLY) PORT; -76 BY SAME PHYSICIAN # \n Reason: premie infant with HMD, now on CPAP for worsening respirator\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above.\n REASON FOR THIS EXAMINATION:\n premie infant with HMD, now on CPAP for worsening respiratory distress\n ______________________________________________________________________________\n FINAL REPORT\n FILM OF THE CHEST, :\n\n Comparison film is from 3-1/2 hours before. Allowing for the better expansion\n of the lungs on the current film, probably related to CPAP, there is no\n appreciable change with persisting airspace disease at the bases and now, more\n obvious opacity involving upper lobes. No pleural fluid is evident. Heart\n size is upper normal allowing for the degree of expansion of the lungs.\n\n IMPRESSION: Little appreciable change allowing for increasing expansion in\n the lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-05 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 977367,
"text": " 8:09 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress, initial CXR suggestive of pneumonia\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST .\n\n Comparison film is from . Lung bases continue to show diffuse\n bilateral haziness, more so on the right than the left. This really has not\n changed over the last two days. Typically, retained fetal fluid clears within\n two days. However, there has been no progression of findings and the pleural\n spaces remain clear. The heart size remains normal.\n\n IMPRESSION: Continued basilar pulmonary density, right more so than the left.\n No new abnormality.\n\n"
}
] |
7,599 | 186,433 | 1. NSTEMI: Patient presented with chest pain that was worse than his usual chest wall pain and was refractory to percocet. EKG and cardiac enzymes were consistent with a NSTEMI. He presented on heparin and ASA/Plavix; integrillin was added and he was taken to the cath lab. Cardiac cath showed the SVG-Diagonal graft with a thrombotic occlusion in the proximal segment - this was stented using a 3.5 mm Cypher stent and post dilation with a 4.0 mm balloon. Final angiogram showed TIMI III flow with no residual stenosis, no residual thrombus, no dissection and no embolization. Of note the patient became very combative prior to the intervention and asked to terminate the case. Consent to intubate was obtained from the daughter and the patient was sedated and intubated. Post-cath, the patient was monitored in the CCU and remained intubated overnight. His pressures were in the 80s systolic and he was given IVF boluses; he did not require pressors. He was extubated the morning after admission without incident Echo showed an EF of 35% with antero-septal and apical wall motion abnormalities. The integrillin was continues for 18 hours. ASA and Plavix (initially daily, increased to on HD#2) were also continued. Metoprolol and captopril were written, but note dosed early on, given his low blood pressures. He did not present on a statin; high dose atorvastatin was added. Given the patient's depressed EF and CAD, outpatient referral for possible ICD was recommended. 2. Pneumonia: At the OSH, the patient had a CXR which showed a possible pneumonia. On presentaiton, his WBC was elevated and he had low grade fevers. The CXR showed a possible RLL infilitrate. Given this, he was continued on antibiotics for community acquired pneumonia (azithromycin and ceftriaxone with plan for seven day course. Cultures (sputum and blood) did not show any growth. 3. Hypertension: Antihypertensives were used, as above. 4. GERD: Continued PPI. 5. COPD: Nebs were given PRN. 6. Bipolar disorder: Monitored; did not required any medications. 7. Chronic pain: Morphine, the percocet were used PRN. 8. Constipation: Bowel regimen | "Resp/ID-LS clear to diminished. Mild (1+) mitral regurgitation is seen. Moderate regionalLV systolic dysfunction. IVF d/c'd s/p fluid boluses. There is a trivial/physiologicpericardial effusion.IMPRESSION: Regional left ventricular dysfunction consistent with coronarydisease. Mild (1+) MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets. Trazadone @ HS c minimal effect. Mild mitralannular calcification. The aortic valve leaflets (?#) are moderatelythickened. There is mild aortic valve stenosis (area 1.2-1.9cm2) and trivialaortic regurgitation. bowel med dosed previous shift.gu-voiding w/o difficulty.Dispo/social-full code. There is moderate regional left ventricular systolicdysfunction with hypokinesis of the septum, and anterior wall. Mild [1+] TR. SQ Heprin. Left ventricular function.Height: (in) 71Weight (lb): 168BSA (m2): 1.96 m2BP (mm Hg): 91/54HR (bpm): 74Status: InpatientDate/Time: at 12:05Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Marked LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Respiratory Care:Pt. S/P extubation . ASA/plavix/statin as ordered. Mild AS (AoVA1.2-1.9cm2). Noresting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; anterior apex -hypo; septal apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Currently NPO.GU-foley. update pt on POC. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is markedly dilated. Hct stable. Sinus rhythmConsider left atrial abnormalityProbable left ventricular hypertrophy and consider also biventricularhypertrophyNonspecific intraventricular conduction delayNonspecific ST-T abnormalities - cannot exclude in part ischemiaSince previous tracing of the same date, sinus bradycardia absent and Q-Tcinterval appears shorter Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral regurgitation.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). afebrile. Update pt per interdisiplanary rounds. +BS, -BM. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). Mild thickening of mitral valve chordae. Sinus rhythm. CCU Nursing noteS-intubated.O-see flowsheet for additional details.N-Propofol decreased to 18mcg/kg/min. Continue abxs. Mild aortic stenosis. LS bronchial to diminished. F/U cxray, cultures. K, mag wnl. Percocet x1 for back discomfort. The leftventricular inflow pattern suggests impaired relaxation. IS c encouragement. Focal calcifications inaortic root. The ascendingaorta is mildly dilated. Captopril held this shift. Tmax 100.1. right groin site wnl. Normal interatrial septum.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mildly dilated ascending aorta.AORTIC VALVE: Moderately thickened aortic valve leaflets. SBP 80s-120s. Tissue Dopplerimaging suggests a normal left ventricular filling pressure (PCWP<12mmHg).Right ventricular chamber size and free wall motion are normal. Sinus bradycardiaConsider left atrial abnormalityProbable left ventricular hypertrophy and consider also biventricularhypertrophyNonspecific intraventricular conduction delayST-T wave abnormalities with probable QT interval prolonged although isdifficult to measure - cannot exclude in part ischemiadrug/metabolic/electrolyte effectSince previous tracing of the same date, QRs voltages more prominent and ST-Twave changes decreased Calcified tipsof papillary muscles. Sinus rhythmConsider left atrial abnormalityConsider left ventricular hypertrophy and possible biventricular hypertrophyNonspecific intraventricular conduction delayST-T wave abnormalities with probable QT interval prolonged although isdifficult to measure - cannot exclude in part ischemia ordrug/metabolic/electrolyte effectSince previous tracing of , inferior myocardial infarction less evident D/C integrillin @ 1000.Resp/ID-RISBI 30, pt currently on CPAP+PS 5/5 tolerating well. ?C/o to floor. "O-see flowsheet for additional details.N-a/ox3, no focal deficits, OOB c steady gait to commode x1 assist. ?infiltrate on cxray-abxs as ordered. The estimatedpulmonary artery systolic pressure is normal. ?extubate today. Sinus rhythmConsider left atrial abnormalityProbable left ventricular hypertrophy and consider also biventricularhypertrophyNonspecific intraventricular conduction delayNonspecific ST-T abnormalities - cannot exclude in part ischemiaSince previous tracing of the same date, no significant change R fem c transparent dsg, no hemotoma, wnl, pulses palable +2. B/S essentially clear, CXR showed OET in good position with ? Bilateral wrist restraints for ETT/piv integrity. ?infiltrates on cxray @ OSH. basilar atelectasis (report to follow). Sinus rhythmConsider left atrial abnormalityProbable left ventricular hypertrophy and consider also biventricularhypertrophyNonspecific intraventricular conduction delayNonspecific ST-T abnormalities - cannot exclude in part ischemiaSince previous tracing of , further ST-T wave changes present on low level PSV. Nicotine patch on left arm.Gi-abd soft, non-tender. 2 pivs. 2 pivs. and cooperative.CV-NSR 70s-80s. Spoke to team>>left Pt. Currently 1.2L positive after boluses.Social/Dispo-supportive children c calls x2. Left ventricular wall thicknesses andcavity size are normal. WBC 17.3. Lopressor decreased to 12.5mg. ? FB x1 500cc for MAP<60 c desired effect. Get OOB to chair, encourage PO intake. Smoking cessation education. RSBI this a.m. was 31. palpable pulses. Team to evaluate today re: extubation. Disscuss plan on interdisiplanary rounds-c/o to floor? -358 @ mdnight. The mitral valve leaflets are mildly thickened. There isno mitral valve prolapse. received, and orders obtained for initial A/C settings from cath lab intubation. Full code.A/P-72y.o male c CAD s/p CABG ' who p/w CP to OSH. No significant change compared to the previous tracingof . tolerating diet. IV morphine 1mg x2 for complaints of throat discomfort.CV-NSR70s-90s c non-sustained VT x1 13 beats. No A-line, but aterial blood gas was hyperoxemic with normal acid-base on 60%, and A/C settings per flowsheet. CCU Nursing noteS-"I'm glad I got transferred to ! cultures from pending. case management involved for possible VNA services as pt lives alone.A/P-72y.o male c CAD s/p CABG ', HTN who presented to OSH c CP and r/i for NSTEMI. SBP 80s-100 requiring 500cc fluid bolus x2 for MAP <60 c low UO. Ruled in for NSTEMI, now s/p cath c thrombectomy to SVG to D2 and placement of cypher stent to 80% occlusion of previous, distal SVG to D2 graft stent. 2L NC while asleep for sat<90% (COPD). CKs trending down 737,694. Responded to IVF bolus with increase in UO. 72 YR OLD RI NSTEMI HX CABG STENTED SVG TO DIAG .INTUBATED IN CATH LAB FOR COMBATIVE BEHAVIOR .NEEDED FLUID BOLLUSES FOR BP DURING NIGHT .SMOKER,COPD,HTN,BIPOLAR ,HAS CHRONIC CHEST WALL PAIN SINCE CABG RX C PERCOCETTE.SR NO ECT .BP TO 80S P 12 NOON CAPTORIL .NO CO DIZZINESS .CAPTOPRIL DOSE DECREASED.500 CC FLUID BOLLUS GIVEN .BP NOW 90/50.HCT 38.DSD R FEM C/D.DP PALP.EXTUBATED 8AM.SAT 90 TO 93 RM AIR ,BS COARSE .C/R THICK YELLOW.SPEC SENT.LOW GRADE TEMP.POSSIBLE PNA ,ON ANTIBX .GOOD APPETITE .POS BS ,ABD SOFT .FOLEY DC 12NOON.DTV 8PMALERT,ORIENTED COOPERATIVE.ANXOIUS ABOUT CONDITION..PERCOCETTE GIVEN FOR CHRONIC PAIN .LOW BP POST CARDIAC MEDSFOLLOW BP ,LOPRESSER DOSE NEED TO BE HELD .REASSURE PTADVANCE ACTIVITY WHEN BP ALLOWS | 13 | [
{
"category": "Echo",
"chartdate": "2193-04-16 00:00:00.000",
"description": "Report",
"row_id": 70336,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 71\nWeight (lb): 168\nBSA (m2): 1.96 m2\nBP (mm Hg): 91/54\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 12:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Moderate regional\nLV systolic dysfunction. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No\nresting 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; anterior apex -\nhypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (AoVA\n1.2-1.9cm2). Trace 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. Mild (1+) MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is moderate regional left ventricular systolic\ndysfunction with hypokinesis of the septum, and anterior wall. Tissue Doppler\nimaging suggests a normal left ventricular filling pressure (PCWP<12mmHg).\nRight ventricular chamber size and free wall motion are normal. The ascending\naorta is mildly dilated. The aortic valve leaflets (?#) are moderately\nthickened. There is mild aortic valve stenosis (area 1.2-1.9cm2) and trivial\naortic regurgitation. The mitral valve leaflets are mildly thickened. There is\nno mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left\nventricular inflow pattern suggests impaired relaxation. The estimated\npulmonary artery systolic pressure is normal. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Regional left ventricular dysfunction consistent with coronary\ndisease. Mild aortic stenosis. Mild mitral regurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-17 00:00:00.000",
"description": "Report",
"row_id": 1363953,
"text": "CCU Nursing note\nS-\"I'm glad I got transferred to !\"\nO-see flowsheet for additional details.\n\nN-a/ox3, no focal deficits, OOB c steady gait to commode x1 assist. Percocet x1 for back discomfort. Trazadone @ HS c minimal effect. and cooperative.\n\nCV-NSR 70s-80s. SBP 80s-120s. FB x1 500cc for MAP<60 c desired effect. Captopril held this shift. Lopressor decreased to 12.5mg. ASA/plavix/statin as ordered. right groin site wnl. 2 pivs. palpable pulses. EKG x1 c no changes for chest discomfort \"it's the same pain I've had for ten years, but if I just lay real still it goes away.\"\n\nResp/ID-LS clear to diminished. IS c encouragement. 2L NC while asleep for sat<90% (COPD). ?infiltrate on cxray-abxs as ordered. cultures from pending. afebrile. Nicotine patch on left arm.\n\nGi-abd soft, non-tender. tolerating diet. small bmx1. bowel med dosed previous shift.\ngu-voiding w/o difficulty.\n\nDispo/social-full code. 3 supportive, adult children. ?C/o to floor. case management involved for possible VNA services as pt lives alone.\n\nA/P-72y.o male c CAD s/p CABG ', HTN who presented to OSH c CP and r/i for NSTEMI. s/p cath c thrombectomy to SVG to D2 and placement of stent to 80% occlusion of previous SVG to D2 graft stent. S/P extubation . Get OOB to chair, encourage PO intake. Smoking cessation education. Disscuss plan on interdisiplanary rounds-c/o to floor? update pt on POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-16 00:00:00.000",
"description": "Report",
"row_id": 1363950,
"text": "CCU Nursing note\nS-intubated.\nO-see flowsheet for additional details.\n\nN-Propofol decreased to 18mcg/kg/min. PERRL, opens eyes to voice, follows commands consistently, cooperative c care, writting coherently on clipboard, MAE. Bilateral wrist restraints for ETT/piv integrity. IV morphine 1mg x2 for complaints of throat discomfort.\n\nCV-NSR70s-90s c non-sustained VT x1 13 beats. SBP 80s-100 requiring 500cc fluid bolus x2 for MAP <60 c low UO. All BP meds held this shift. R fem c transparent dsg, no hemotoma, wnl, pulses palable +2. 2 pivs. IVF d/c'd s/p fluid boluses. SQ Heprin. Hct stable. K, mag wnl. CKs trending down 737,694. D/C integrillin @ 1000.\n\nResp/ID-RISBI 30, pt currently on CPAP+PS 5/5 tolerating well. ?infiltrates on cxray @ OSH. WBC 17.3. Tmax 100.1. Blood and urine cultures sent. No secreations via ETT. LS bronchial to diminished. Abxs include PO azithromycin, IV ceftriaxone.\n\nGi-no NGT placed per resident as all PO meds held over night. +BS, -BM. Currently NPO.\n\nGU-foley. Responded to IVF bolus with increase in UO. -358 @ mdnight. Currently 1.2L positive after boluses.\n\nSocial/Dispo-supportive children c calls x2. No designated HCP. Full code.\n\nA/P-72y.o male c CAD s/p CABG ' who p/w CP to OSH. Ruled in for NSTEMI, now s/p cath c thrombectomy to SVG to D2 and placement of cypher stent to 80% occlusion of previous, distal SVG to D2 graft stent. ??extubate today. Continue abxs. F/U cxray, cultures. Update pt per interdisiplanary rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-16 00:00:00.000",
"description": "Report",
"row_id": 1363951,
"text": "Respiratory Care:\nPt. received, and orders obtained for initial A/C settings from cath lab intubation. No A-line, but aterial blood gas was hyperoxemic with normal acid-base on 60%, and A/C settings per flowsheet. Weaned to 40% with SPO2 99-100% this shift. B/S essentially clear, CXR showed OET in good position with ? basilar atelectasis (report to follow). RSBI this a.m. was 31. Spoke to team>>left Pt. on low level PSV. Team to evaluate today re: extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-16 00:00:00.000",
"description": "Report",
"row_id": 1363952,
"text": "72 YR OLD RI NSTEMI HX CABG STENTED SVG TO DIAG .INTUBATED IN CATH LAB FOR COMBATIVE BEHAVIOR .NEEDED FLUID BOLLUSES FOR BP DURING NIGHT .SMOKER,COPD,HTN,BIPOLAR ,HAS CHRONIC CHEST WALL PAIN SINCE CABG RX C PERCOCETTE.\n\nSR NO ECT .BP TO 80S P 12 NOON CAPTORIL .NO CO DIZZINESS .CAPTOPRIL DOSE DECREASED.500 CC FLUID BOLLUS GIVEN .BP NOW 90/50.HCT 38.DSD R FEM C/D.DP PALP.\n\nEXTUBATED 8AM.SAT 90 TO 93 RM AIR ,BS COARSE .C/R THICK YELLOW.SPEC SENT.LOW GRADE TEMP.POSSIBLE PNA ,ON ANTIBX .\n\nGOOD APPETITE .POS BS ,ABD SOFT .\n\nFOLEY DC 12NOON.DTV 8PM\n\nALERT,ORIENTED COOPERATIVE.ANXOIUS ABOUT CONDITION..PERCOCETTE GIVEN FOR CHRONIC PAIN .\n\nLOW BP POST CARDIAC MEDS\n\nFOLLOW BP ,LOPRESSER DOSE NEED TO BE HELD .\nREASSURE PT\nADVANCE ACTIVITY WHEN BP ALLOWS\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-15 00:00:00.000",
"description": "Report",
"row_id": 1363948,
"text": "72 yr old admitted to hospital c cp 230 am ,troponin of 20.to cath lab.confused and combative p sedation in ambulance.intubated for procedure.svg to to diag stented.plavix load,asa given at .other hx cabg ,chronic chest wall pain presently rx c percocette .copd,bipolar dz,pna ,carotid endarterrectomy ,stomach sx .\n\narrived in ccu intubated sedated on propofol .fio2 decreased to 60% .bs cl ,sx min. cmv 600tv/14/5 peep\n\nsr no ect .bp by aline 90 to 120 ,propofol decreased .integrillin at 2 .no bleeding from r fem site.pulses weakly palp .sheath to be pulled ,act 157\n\nabd soft ,pos bs.foley drained 600cc cyu .\n\npt minimally responsive ,on propofol 20 mic .pupils pinpoint ,grimaces to pain .son and daughter at bedside.\n\nkeep sedated till sheath dc wean sedation,vent early am\nmonitor for bleeding\nfollow enzymes\nkeep family updated\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-15 00:00:00.000",
"description": "Report",
"row_id": 1363949,
"text": "72 yr old male admitted fro Cath lab post false alarm of cardiac arrest.PMHX: CABG,stent, Chronic chest pain.Patient electively intubated transfered to CCU.Sedated,on mechanical ventilation,#7.0 ETT @ 24 cm lips,please look @ CXR for ETT placement.\n"
},
{
"category": "ECG",
"chartdate": "2193-04-16 00:00:00.000",
"description": "Report",
"row_id": 151276,
"text": "Sinus rhythm\nConsider left atrial abnormality\nProbable left ventricular hypertrophy and consider also biventricular\nhypertrophy\nNonspecific intraventricular conduction delay\nNonspecific ST-T abnormalities - cannot exclude in part ischemia\nSince previous tracing of , further ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2193-04-15 00:00:00.000",
"description": "Report",
"row_id": 151277,
"text": "Sinus rhythm\nConsider left atrial abnormality\nProbable left ventricular hypertrophy and consider also biventricular\nhypertrophy\nNonspecific intraventricular conduction delay\nNonspecific ST-T abnormalities - cannot exclude in part ischemia\nSince previous tracing of the same date, sinus bradycardia absent and Q-Tc\ninterval appears shorter\n\n"
},
{
"category": "ECG",
"chartdate": "2193-04-18 00:00:00.000",
"description": "Report",
"row_id": 151274,
"text": "Sinus rhythm. No significant change compared to the previous tracing\nof .\n\n"
},
{
"category": "ECG",
"chartdate": "2193-04-16 00:00:00.000",
"description": "Report",
"row_id": 151275,
"text": "Sinus rhythm\nConsider left atrial abnormality\nProbable left ventricular hypertrophy and consider also biventricular\nhypertrophy\nNonspecific intraventricular conduction delay\nNonspecific ST-T abnormalities - cannot exclude in part ischemia\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2193-04-15 00:00:00.000",
"description": "Report",
"row_id": 151508,
"text": "Sinus bradycardia\nConsider left atrial abnormality\nProbable left ventricular hypertrophy and consider also biventricular\nhypertrophy\nNonspecific intraventricular conduction delay\nST-T wave abnormalities with probable QT interval prolonged although is\ndifficult to measure - cannot exclude in part ischemia\ndrug/metabolic/electrolyte effect\nSince previous tracing of the same date, QRs voltages more prominent and ST-T\nwave changes decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2193-04-15 00:00:00.000",
"description": "Report",
"row_id": 151509,
"text": "Sinus rhythm\nConsider left atrial abnormality\nConsider left ventricular hypertrophy and possible biventricular hypertrophy\nNonspecific intraventricular conduction delay\nST-T wave abnormalities with probable QT interval prolonged although is\ndifficult to measure - cannot exclude in part ischemia or\ndrug/metabolic/electrolyte effect\nSince previous tracing of , inferior myocardial infarction less evident\n\n"
}
] |
12,892 | 156,142 | Pt was admitted to the labor and delivery for ruptured membranes and in active labor. Pt was initially managed per expectant managment, but was started on oxytocin per protocol as her contractions started to space out and was making only minimal cervical change. Upon active management of labor, pt delivered by normal vaginal delivery a live viable male infant. Following spontaneous vaginal delivery, patient continued to have vaginal bleeding. Pt was noted to have postpartum hemorrhage of approximately 1 liter in the delivery room. Pt received multiple uterotonics serially, including methergine 0.2mg IM x2, hemabate x2, cytotec 1000mcg x1 PR. Patient was then brought back to the OR for exam under anesthesia. Steady bleeding was noted. U/S guided sharp and suction endometrial curettage were performed with small fragments of possible tissue and large amounts of clot retrieved. Labs were sent on arrival to the OR, including coagulation studies. Hct returned at 23; transfusion was begun. No vaginal nor cervical laceration noted. Pt remained hemodynamically stable throughout but had lost approximately 2500cc. OB hemorrhage protocol was initiated. Decision was made to proceed with laparotomy with likely hysterectomy, given lower uterine segment with considerable atony despite efforts thus far. The details of the procedure are available elsewhere in a separate operative report. Briefly, total abdominal hysterectomy was performed under GETA for significantly atonic lower uterine segment and postpartum hemorrhage without complications. Total blood loss was approximately 4500cc. Pt received 4units of PRBC, 4bags of FFP and 10units cryoprecipitate. The uterus/cervix were sent as specimens. Pt was transferred to the ICU for close hemodynamic observation. While in ICU, there was no longer any evidence of bleeding. Pt remained with 2 large borse IVs and q4h cbc, coags, and fibrinogen were checked and noted to all be stable. Pt was transferred to regular postpartum floor on POD#1. The rest of her postpartum/postoperative course remained uncomplicated. Pt was discharged on POD#4 in good condition: afebrile, stable vitals, tolerating po, ambulant and with pain controlled. Pt was advised to follow up later in the week at her primary OB's office. | Perineal swelling unchanged.A/P: Draw serial Hct/PT/PTT/fibrinogen q 4 hrs (9a,1p& perhaps 5p) Am labs drawn 90 min after transfusion (PC's) finished.Resp: Lungs: clear to auscultation w/ diminished BS @ R base.Using IS X3 overnight.GI: hypoactive + bowel sounds. Was subsequently medicated w/tylenol 650mg PR & benadryl 25mg IV pre transfusion X2 (pre PC's & pre cryoprecipitate).Gyn: Had medialateral episiotomy w/hematoma. Required hysterectomy .Came to MICU for low BP down to 80/40 &low Hct (27 earlier down to low of 14). Also 1-2mg IV dilaudid q1-2 hrs prn relieved abd pain.Coping: Very anxious. C/o itching & developed raised not red rash from IV site up L arm to axilla & neck (urticaria). Received 2 units FFP & 2 units PC's for Hct 17.1. Relieved w/benadryl 25mg IV. Addendum 0730CV: Patient had transfusion reaction after 2nd unit FFP. Received 10 units cryoprecipitate for low fibrinogen level. Did not want to see baby overnight although does want to breastfeed.Gyn: Small amt old blood to moderate amt serosanguinous drainage vaginally.Skin: Small midline abdominal drsg & intact. Hct after 3rd unit PC's was 18. Received 6L crystalloid & transfused w/4 units FFP & 4 units PC's. A-line BP: 85-110's/systolic. Pneumo boots on.A/P: Await am Hct results, follow Hcts seriallyTransfuse as needed--premedicate w/ tylenol & benadryl.Try to get baby down to spend time w/mother. Vulvar hematoma ubchanged. NPN -0700Thus 29 yr old G3P2 woman delivered her 2nd child vaginally , & then bled 2L despite pitoccin, meds & D&C. Kept NPO overnight.GU: Foley draining copious amounts of clear yellow urine: 220-600cc/hrPain: C/o burning incisional abdominal pain & some perineal pain from episiotomy. son is healthy & in nursery.Neuro: A&O X3; Moves all extremities equally: lifts & holds.CV: HR: 70's -90's SR no ectopy. Relieved w/ice to perineum. Received LR @ 150cc/hr. Used Cantonese translator forL&D. He provided some translating for patient. Cuff BP about 8 points higher than A-line BP in same arm. Asked to have nurse w/her all the time. Has 3.5 yr old son @ home. Speaks Cantonese as primary language, also some English. Felt relieved when husband visited. Husband slept in room overnight. No PMH. | 2 | [
{
"category": "Nursing/other",
"chartdate": "2154-05-10 00:00:00.000",
"description": "Report",
"row_id": 1431426,
"text": "Addendum 0730\nCV: Patient had transfusion reaction after 2nd unit FFP. C/o itching & developed raised not red rash from IV site up L arm to axilla & neck (urticaria). Relieved w/benadryl 25mg IV. Was subsequently medicated w/tylenol 650mg PR & benadryl 25mg IV pre transfusion X2 (pre PC's & pre cryoprecipitate).\n\nGyn: Had medialateral episiotomy w/hematoma. Vulvar hematoma ubchanged. Perineal swelling unchanged.\n\nA/P: Draw serial Hct/PT/PTT/fibrinogen q 4 hrs (9a,1p& perhaps 5p)\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-05-10 00:00:00.000",
"description": "Report",
"row_id": 1431425,
"text": "NPN -0700\nThus 29 yr old G3P2 woman delivered her 2nd child vaginally , & then bled 2L despite pitoccin, meds & D&C. Required hysterectomy .\nCame to MICU for low BP down to 80/40 &low Hct (27 earlier down to low of 14). Received 6L crystalloid & transfused w/4 units FFP & 4 units PC's. Hct after 3rd unit PC's was 18. No PMH. Speaks Cantonese as primary language, also some English. Has 3.5 yr old son @ home. son is healthy & in nursery.\n\nNeuro: A&O X3; Moves all extremities equally: lifts & holds.\n\nCV: HR: 70's -90's SR no ectopy. A-line BP: 85-110's/systolic. Cuff BP about 8 points higher than A-line BP in same arm. Received LR @ 150cc/hr. Received 2 units FFP & 2 units PC's for Hct 17.1. Received 10 units cryoprecipitate for low fibrinogen level. Am labs drawn 90 min after transfusion (PC's) finished.\n\nResp: Lungs: clear to auscultation w/ diminished BS @ R base.Using IS X3 overnight.\n\nGI: hypoactive + bowel sounds. No flatus. Kept NPO overnight.\n\nGU: Foley draining copious amounts of clear yellow urine: 220-600cc/hr\n\nPain: C/o burning incisional abdominal pain & some perineal pain from episiotomy. Relieved w/ice to perineum. Also 1-2mg IV dilaudid q1-2 hrs prn relieved abd pain.\n\nCoping: Very anxious. Asked to have nurse w/her all the time. Felt relieved when husband visited. Husband slept in room overnight. He provided some translating for patient. Used Cantonese translator for\nL&D. Did not want to see baby overnight although does want to breastfeed.\n\nGyn: Small amt old blood to moderate amt serosanguinous drainage vaginally.\n\nSkin: Small midline abdominal drsg & intact. Pneumo boots on.\nA/P: Await am Hct results, follow Hcts serially\nTransfuse as needed--premedicate w/ tylenol & benadryl.\nTry to get baby down to spend time w/mother.\n"
}
] |
45,542 | 140,428 | The patient was admitted to the General Surgical Service in the TSICU on for evaluation and treatment of epigastric pain and elevated pancreatic enzymes, initially consistent with gallstone pancreatitis. Admission abdominal ultra-sound showed no fluid seen in right upper quadrant and no findings of acute cholecystitis. A tiny 1.5-mm nonmobile echogenic focus probably represents a tiny adherent stone was appreciated. Abdominal CT revealed inflammatory change and fluid surrounding the pancreas, consistent with acute pancreatitis. There was no evidence of necrotizing pancreatitis, pancreatic pseudocyst, vascular involvement, or biliary obstruction or biliary stones. Findings now consistent with recurrent pancreatitis. He was made NPO, given IV fluid rescusitation, a foley catheter was placed, and Dilaudid IV PRN for pain with good effect. He was hemodynamically stable. Transferred to floor on . | Pancreatitis, acute Assessment: Remains npo this am. Pancreatitis, acute Assessment: Remains npo this am. Pancreatitis, acute Assessment: Remains npo. Pancreatitis, acute Assessment: Remains npo. Pancreatitis, acute Assessment: Remains npo. Pancreatitis, acute Assessment: Remains npo. Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Admitted to the ed at 0400 with chief c/o of right sided abd pain. Admitted to the ed at 0400 with chief c/o of right sided abd pain. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. He had an abd and pelvic ct and abd u/s done in the ed. Admitted to the ed today at 0400 with chief c/o of right sided abd pain. Admitted to the ed today at 0400 with chief c/o of right sided abd pain. Admitted to the ed today at 0400 with chief c/o of right sided abd pain. Admitted to the ed today at 0400 with chief c/o of right sided abd pain. Admitted to the ed today at 0400 with chief c/o of right sided abd pain. Admitted to the ed today at 0400 with chief c/o of right sided abd pain. Admitted to the ed today at 0400 with chief c/o of right sided abd pain. Admitted to the ed today at 0400 with chief c/o of right sided abd pain. Pancreatitis, acute Assessment: Remains npo. Pancreatitis, acute Assessment: Remains npo this am. Pancreatitis, acute Assessment: Remains npo this am. CT ABDOMEN WITHOUT AND WITH IV CONTRAST: At the lung bases, there is mild dependent atelectasis bilaterally. Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? Hx of GERD, pericarditis of ? divisum Admitting Diagnosis: PANCREATITIS FINAL REPORT (Cont) ascites and no pathologic lymphadenopathy. Findings consistent with acute uncomplicated pancreatitis, without evidence of peripancreatic fluid collection. No fever currently.. Plan: Cont wth iv fluids. Chief complaint: pancreatitis PMHx: PMH: GERD - Pt had EGD done at in early after which his PCP started PPI, no Ulcer disease per pt. Chief complaint: pancreatitis PMHx: PMH: GERD - Pt had EGD done at in early after which his PCP started PPI, no Ulcer disease per pt. PULM: no issues GI: NPO for now RENAL: Good u/o. The main portal vein is patent, with normal hepatopetal flow. (Over) 9:34 AM CT ABD W&W/O C Clip # Reason: eval for source of pancreatitis and tachycardia Admitting Diagnosis: PANCREATITIS FINAL REPORT (Cont) OSSEOUS STRUCTURES: There is no fracture or worrisome bony lesion. NEURO: AAOx3, nonfocal, pain well controlled on dilaudid PCA, ativan PRN. In the abdomen, the liver and gallbladder are within normal limits. The patient was diffusely tender over the epigastric region; sign was not present. Hx of pericarditis of ? HEME: no issues, f/u Hct . The gallbladder appears normal except to note tiny 2-mm nonmobile echogenic focus along the superior wall of the gallbladder, likely representing an adherent non-shadowing stone. Pericarditis in of unknown etiology treated with Indocin. Pericarditis in of unknown etiology treated with Indocin. A left retrocardiac consolidation is noted, non-specific, possibly atelectasis or a focus of aspiration or infection. This is a single left and single right patent renal arteries. Compared to the previous tracing of there is nochange. | 26 | [
{
"category": "Nursing",
"chartdate": "2165-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720682,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Arrived in the micu in no acute distress. C/o of pain in ruq. His\n sats were in the mid to upper 90\ns on ra. Resp mid 20\ns. hr 140\ns on\n admission to the unit. Sbp 120\ns. `\n Action:\n Med with .5mg iv dilaudid. Iv fluids going at 200cc/hr of ns.\n Response:\n Fell asleep after the dilaudid given. Hr down to the 120\n Plan:\n Social- girlfiriend here visiting the patient. This nurse called\n patient\ns mother and updated her on plan of care.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720904,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo. Only c/o of pain with movement. Has much better pain\n control with pca pump. Urine output >100cc/hr. D5 LR w/ 40pottassium\n running @ 100ml/hr.\n Action:\n Cont to use pca. Will remain npo for now.\n Response:\n Pain remains much improved from yesterday. Temp max 100.\n Plan:\n Cont wth iv fluids. Pain control. ? to start po\ns if stable tomorrow.\n ?C/O.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 720987,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed at 0400 with chief c/o of right sided\n abd pain. In the ed his hr was 130-170 sbp 130\ns. He received a total\n of 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo.\n Only c/o of pain with movement. Has much better pain control with\n dilaudid pca pump.\n Urine output >100cc/hr. LR running @ 100ml/hr.\n Action:\n Cont to use pca. Will remain npo for now.\n Response:\n Pain remains much improved from yesterday per pt currently at rest\n and about 5 transiently at max with movement.\n No fever currently..\n Plan:\n Cont wth iv fluids.\n Pain control. With pca\n Remains npo\n For surgery sometime in future.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n PANCREATITIS\n Code status:\n Height:\n 65 Inch\n Admission weight:\n 65.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: GERD on omeprazole at home. Hx of pancreatitis in\n . Hx of pericarditis of ? etiology tx with indocin.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:73\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,750 mL\n 24h total out:\n 2,160 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 05:07 AM\n Potassium:\n 4.8 mEq/L\n 05:07 AM\n Chloride:\n 99 mEq/L\n 05:07 AM\n CO2:\n 28 mEq/L\n 05:07 AM\n BUN:\n 3 mg/dL\n 05:07 AM\n Creatinine:\n 0.7 mg/dL\n 05:07 AM\n Glucose:\n 99 mg/dL\n 05:07 AM\n Hematocrit:\n 40.6 %\n 05:07 AM\n Finger Stick Glucose:\n 105\n 06:00 AM\n Valuables / Signature\n Patient valuables: cell phone and charger transferred with pt\n valuables:\n Clothes: Sent home with: clothes transferred with pt.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 7\n Transferred to: 919 \n"
},
{
"category": "Nursing",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720775,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Cont to have pain , HR 120\ns NST.\n Action:\n Med with a total of 3.5mg iv dilaudid in divided doses and 1mg ativan.\n . Iv fluids going at 200cc/hr of ns.\n Response:\n Pain down to 4/10 and acceptable to patient . hr up to 130-140. Dr.\n made aware and iv fluids increased to 250cc/hr and 1l lr bolus\n ordered and given. Repeat lipase and an amylase were sent. Results\n pending.\n Plan:\n Tx for pain. Iv fluids\n Social- girlfiriend here visiting the patient. This nurse called\n patient\ns mother and updated her on plan of care.\n Iv changed to LR at 250cc/hr. Famotidine dc\nd and pantoprazole to be\n started. To start on pca pump once pump available.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720776,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Cont to have pain , HR 120\ns NST. Amylase 530 and lipase 1654.\n Action:\n Dilaudid PCA started Iv fluids cont LR 250cc/hr.\n Response:\n Pain is well controlled on PCA, Slept through night.\n Plan:\n Tx pain. Iv fluids, Follow AM labs\n"
},
{
"category": "Physician ",
"chartdate": "2165-03-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 721026,
"text": "TSICU\n HD# 3\n HPI:\n 29 year old male admitted last night with sudden onset of epigastric\n pain and nausea. Patient states had some wine last night. No fever or\n chills. States he had a similar episode and was hospitalized for\n pancreatitis where he was admitted with 1 day h/o abdominal\n pain, initial elevation of lipase and amylase consistent with gallstone\n pancreatitis. The CT scan obtained during that admission revealed a\n peripancreatic fluid without evidence of pancreatic ductal dilatation\n or pancreatic necrosis. No gallstones were identified on CT scan.\n During the same admission within three days, his hyperamylasemia and\n hyperlipasemia returned to . Ultrasound examination at that time\n revealed a 3-mm common duct. No peripancreatic or pericholecystic\n fluid.\n Chief complaint:\n Abd pain\n PMHx:\n GERD\n Previous episode of pancreatitis\n 24 Hour Events:\n Pt stayed in the MICU for slight tachycardia. Passed flatus yesterday\n morning. No abx given. Pt remains NPO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 10:13 AM\n Pantoprazole (Protonix) - 12:17 PM\n Heparin Sodium (Prophylaxis) - 09:51 PM\n Other medications:\n Flowsheet Data as of 01:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.8\nC (100\n HR: 115 (102 - 126) bpm\n BP: 128/84(94) {118/70(84) - 141/91(102)} mmHg\n RR: 18 (16 - 25) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 3,902 mL\n 133 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,902 mL\n 133 mL\n Blood products:\n Total out:\n 5,360 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,458 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy, HR 105\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender: epigastrum\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 244 K/uL\n 13.5 g/dL\n 98 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 101 mEq/L\n 137 mEq/L\n 39.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:52 AM\n WBC\n 9.8\n Hct\n 39.0\n Plt\n 244\n Creatinine\n 0.7\n Glucose\n 98\n Other labs: ALT / AST:23/20, Alk-Phos / T bili:78/0.8, Amylase /\n Lipase:398/905, Ca:8.5 mg/dL, Mg:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n Assessment and Plan: 29-year-old male with recurrent pancreatitis of\n unknown etiology, possibly gallstone.\n NEURO: AAOx3, nonfocal, pain well controlled on dilaudid PCA, ativan\n PRN.\n Neuro checks Q4:\n Pain: Dilaudid PCA\n .\n CVS: stable HD. ST. Tachycardia increases with anxiety (pt reports\n anyone being in his room provokes his anxiety). Continue monitoring, no\n interventions at this time.\n .\n PULM: no issues\n .\n GI: NPO for now. Amylase and lipase trending down.\n .\n RENAL: Good u/o. Decreased LR to 100cc/hr yesterday as pt's UOP had\n been high at 200-400cc/hr. well hydrated\n .\n HEME: no issues, f/u Hct\n .\n ENDO: RISS. Keep BG < 150\n .\n ID: Tmax 100.4\n .\n TLD: PIV\n .\n IVF: 100cc/hr of D5LR w/ 40mEq K\n .\n CONSULTS: Gold (West 2) \n .\n BILLING DIAGNOSIS:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:39 AM\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720851,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo this am. Only c/o of pain with movement. Has much better\n pain control with pca pump today. Uo this am >200cc/hr. k 3.6.\n Amylase down to 398 this am form 530 yesterday. Lipase 905 from 1654.\n Action:\n Team in iv fluids decreased to 100cc/hr. if fluids d5lr with 40meq kcl\n at 100cc/hr. Cont to use pca. Will remain npo for now. Oob to chair.\n Response:\n Pain remains much improved from yesterday. Temp max 100. using is.\n Plan:\n Cont wth iv fluids. Pain control. ? to start po\ns if stable tomorrow.\n sister and girlfriend in to visit. Updated patient\ns mother via\n phone.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 720950,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed at 0400 with chief c/o of right sided\n abd pain. In the ed his hr was 130-170 sbp 130\ns. He received a total\n of 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo.\n Only c/o of pain with movement. Has much better pain control with\n dilaudid pca pump.\n Urine output >100cc/hr. LR running @ 100ml/hr.\n Action:\n Cont to use pca. Will remain npo for now.\n Response:\n Pain remains much improved from yesterday per pt currently at rest\n and about 5 transiently at max with movement.\n No fever currently..\n Plan:\n Cont wth iv fluids.\n Pain control. With pca\n Remains npo\n For surgery sometime in future.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720923,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo. Only c/o of pain with movement. Has much better pain\n control with pca pump. Urine output >100cc/hr. D5 LR w/ 40pottassium\n running @ 100ml/hr.\n Action:\n Cont to use pca. Will remain npo for now.\n Response:\n Pain remains much improved from yesterday. Temp max 100.\n Plan:\n Cont wth iv fluids. Pain control. ? to start po\ns if stable tomorrow.\n ?C/O.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720673,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720824,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo this am. Only c/o of pain with movement. Has much better\n pain control with pca pump today. Uo this am >200cc/hr. k 3.6.\n Amylase down to 398 this am form 530 yesterday. Lipase 905 from 1654.\n Action:\n Team in iv fluids decreased to 100cc/hr. if fluids d5lr with 40meq kcl\n at 100cc/hr. Cont to use pca. Will remain npo for now. Oob to chair.\n Response:\n Pain remains much improved from yesterday. Temp max 100. using is.\n Plan:\n Cont wth iv fluids. Pain control. ? to start po\ns if stable tomorrow.\n sister and girlfriend in to visit. Updated patient\ns mother via\n phone.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720735,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Arrived in the micu in no acute distress. C/o of pain in ruq. His\n sats were in the mid to upper 90\ns on ra. Resp mid 20\ns. hr 140\ns on\n admission to the unit. Sbp 120\ns. `lipase 4605.\n Action:\n Med with a total of 3.5mg iv dilaudid in divided doses and 1mg ativan.\n . Iv fluids going at 200cc/hr of ns.\n Response:\n Pain down to 4/10 and acceptable to patient . hr up to 130-140. Dr.\n made aware and iv fluids increased to 250cc/hr and 1l lr bolus\n ordered and given. Repeat lipase and an amylase were sent. Results\n pending.\n Plan:\n Tx for pain. Iv fluids\n Social- girlfiriend here visiting the patient. This nurse called\n patient\ns mother and updated her on plan of care.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720737,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Arrived in the micu in no acute distress. C/o of pain in ruq. His\n sats were in the mid to upper 90\ns on ra. Resp mid 20\ns. hr 140\ns on\n admission to the unit. Sbp 120\ns. `lipase 4605.\n Action:\n Med with a total of 3.5mg iv dilaudid in divided doses and 1mg ativan.\n . Iv fluids going at 200cc/hr of ns.\n Response:\n Pain down to 4/10 and acceptable to patient . hr up to 130-140. Dr.\n made aware and iv fluids increased to 250cc/hr and 1l lr bolus\n ordered and given. Repeat lipase and an amylase were sent. Results\n pending.\n Plan:\n Tx for pain. Iv fluids\n Social- girlfiriend here visiting the patient. This nurse called\n patient\ns mother and updated her on plan of care.\n ------ Protected Section ------\n Iv changed to LR at 250cc/hr. Famotidine dc\nd and pantoprazole to be\n started. To start on pca pump once pump available.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:14 ------\n"
},
{
"category": "Physician ",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 720809,
"text": "TSICU\n HPI:\n 29 year old male admitted last night with sudden onset of\n epigastric pain and nausea. Patient states had some wine last\n night. No fever or chills. States he had a similar episode and\n was hospitalized for pancreatitis where he was admitted\n with 1 day h/o abdominal pain, initial elevation of lipase and\n amylase consistent with gallstone pancreatitis. The CT scan\n obtained during that admission revealed a peripancreatic fluid\n without evidence of pancreatic ductal dilatation or pancreatic\n necrosis. No gallstones were identified on CT scan. During the\n same admission within three days, his hyperamylasemia and\n hyperlipasemia returned to . Ultrasound examination at\n that time revealed a 3-mm common duct. No peripancreatic or\n pericholecystic fluid.\n Chief complaint:\n pancreatitis\n PMHx:\n PMH: GERD - Pt had EGD done at in early \n after which his PCP started PPI, no Ulcer disease per pt.\n Pericarditis in of unknown etiology treated with Indocin.\n Current medications:\n HYDROmorphone (Dilaudid) 4. HYDROmorphone (Dilaudid) 5. HYDROmorphone\n (Dilaudid)\n 6. HYDROmorphone (Dilaudid) 7. HYDROmorphone (Dilaudid) 8. Heparin 9.\n Lorazepam 10. Ondansetron\n 11. Pantoprazole\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:05 AM\n Famotidine (Pepcid) - 11:06 AM\n Hydromorphone (Dilaudid) - 06:00 PM\n Lorazepam (Ativan) - 06:41 PM\n Other medications:\n Flowsheet Data as of 06:56 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: 37.1\nC (98.7\n HR: 113 (104 - 144) bpm\n BP: 134/83(95) {124/77(89) - 150/98(109)} mmHg\n RR: 22 (17 - 25) insp/min\n SPO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 4,093 mL\n 1,199 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,093 mL\n 1,199 mL\n Blood products:\n Total out:\n 6,130 mL\n 1,770 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -2,037 mL\n -571 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 244 K/uL\n 13.5 g/dL\n 98 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 101 mEq/L\n 137 mEq/L\n 39.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:52 AM\n WBC\n 9.8\n Hct\n 39.0\n Plt\n 244\n Creatinine\n 0.7\n Glucose\n 98\n Other labs: ALT / AST:23/20, Alk-Phos / T bili:78/0.8, Amylase /\n Lipase:398/905, Ca:8.5 mg/dL, Mg:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n Assessment and Plan: 29-year-old male with recurrent pancreatitis\n NEURO: AAOx3, nonfocal, pain well controlled on dilaudid PCA, ativan\n PRN\n Neuro checks Q4:\n Pain: Dilaudid PCA\n CVS: stable HD. ST. Just monitor for now, no need to intervene.\n PULM: no issues\n GI: NPO for now\n RENAL: Good u/o. Please decrease LR rate as UOP is very high (200-400\n cc/h). well hydrated\n HEME: no issues, f/u Hct\n ENDO: RISS. Keep BG < 150\n ID: Afebrile. No evidence of infection\n TLD: PIV\n IVF: LR @ 250\n CONSULTS:\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT - SQH, SCDs\n STRESS ULCER - PPI\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: P\n CODE STATUS: FUll\n DISPOSITION: TICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:39 AM\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 min\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720811,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo this am. Only c/o of pain with movement. Has much better\n pain control with pca pump today. Uo this am >200cc/hr.\n Action:\n Team in iv fluids decreased to 100cc/hr. Cont to use pca. Will remain\n npo for now.\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2165-03-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 720873,
"text": "TSICU\n HD# 3\n HPI:\n 29 year old male admitted last night with sudden onset of epigastric\n pain and nausea. Patient states had some wine last night. No fever or\n chills. States he had a similar episode and was hospitalized for\n pancreatitis where he was admitted with 1 day h/o abdominal\n pain, initial elevation of lipase and amylase consistent with gallstone\n pancreatitis. The CT scan obtained during that admission revealed a\n peripancreatic fluid without evidence of pancreatic ductal dilatation\n or pancreatic necrosis. No gallstones were identified on CT scan.\n During the same admission within three days, his hyperamylasemia and\n hyperlipasemia returned to . Ultrasound examination at that time\n revealed a 3-mm common duct. No peripancreatic or pericholecystic\n fluid.\n Chief complaint:\n Abd pain\n PMHx:\n GERD\n Previous episode of pancreatitis\n 24 Hour Events:\n Pt stayed in the MICU for slight tachycardia. Passed flatus yesterday\n morning. No abx given. Pt remains NPO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 10:13 AM\n Pantoprazole (Protonix) - 12:17 PM\n Heparin Sodium (Prophylaxis) - 09:51 PM\n Other medications:\n Flowsheet Data as of 01:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38\nC (100.4\n T current: 37.8\nC (100\n HR: 115 (102 - 126) bpm\n BP: 128/84(94) {118/70(84) - 141/91(102)} mmHg\n RR: 18 (16 - 25) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 3,902 mL\n 133 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,902 mL\n 133 mL\n Blood products:\n Total out:\n 5,360 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,458 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy, HR 105\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender: epigastrum\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 244 K/uL\n 13.5 g/dL\n 98 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 101 mEq/L\n 137 mEq/L\n 39.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:52 AM\n WBC\n 9.8\n Hct\n 39.0\n Plt\n 244\n Creatinine\n 0.7\n Glucose\n 98\n Other labs: ALT / AST:23/20, Alk-Phos / T bili:78/0.8, Amylase /\n Lipase:398/905, Ca:8.5 mg/dL, Mg:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n Assessment and Plan: 29-year-old male with recurrent pancreatitis of\n unknown etiology, possibly gallstone.\n NEURO: AAOx3, nonfocal, pain well controlled on dilaudid PCA, ativan\n PRN.\n Neuro checks Q4:\n Pain: Dilaudid PCA\n .\n CVS: stable HD. ST. Tachycardia increases with anxiety (pt reports\n anyone being in his room provokes his anxiety). Continue monitoring, no\n interventions at this time.\n .\n PULM: no issues\n .\n GI: NPO for now. Amylase and lipase trending down.\n .\n RENAL: Good u/o. Decreased LR to 100cc/hr yesterday as pt's UOP had\n been high at 200-400cc/hr. well hydrated\n .\n HEME: no issues, f/u Hct\n .\n ENDO: RISS. Keep BG < 150\n .\n ID: Tmax 100.4\n .\n TLD: PIV\n .\n IVF: 100cc/hr of D5LR w/ 40mEq K\n .\n CONSULTS: Gold (West 2) \n .\n BILLING DIAGNOSIS:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:39 AM\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 720790,
"text": "TSICU\n HPI:\n 29 year old male admitted last night with sudden onset of\n epigastric pain and nausea. Patient states had some wine last\n night. No fever or chills. States he had a similar episode and\n was hospitalized for pancreatitis where he was admitted\n with 1 day h/o abdominal pain, initial elevation of lipase and\n amylase consistent with gallstone pancreatitis. The CT scan\n obtained during that admission revealed a peripancreatic fluid\n without evidence of pancreatic ductal dilatation or pancreatic\n necrosis. No gallstones were identified on CT scan. During the\n same admission within three days, his hyperamylasemia and\n hyperlipasemia returned to . Ultrasound examination at\n that time revealed a 3-mm common duct. No peripancreatic or\n pericholecystic fluid.\n Chief complaint:\n pancreatitis\n PMHx:\n PMH: GERD - Pt had EGD done at in early \n after which his PCP started PPI, no Ulcer disease per pt.\n Pericarditis in of unknown etiology treated with Indocin.\n Current medications:\n HYDROmorphone (Dilaudid) 4. HYDROmorphone (Dilaudid) 5. HYDROmorphone\n (Dilaudid)\n 6. HYDROmorphone (Dilaudid) 7. HYDROmorphone (Dilaudid) 8. Heparin 9.\n Lorazepam 10. Ondansetron\n 11. Pantoprazole\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:05 AM\n Famotidine (Pepcid) - 11:06 AM\n Hydromorphone (Dilaudid) - 06:00 PM\n Lorazepam (Ativan) - 06:41 PM\n Other medications:\n Flowsheet Data as of 06:56 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: 37.1\nC (98.7\n HR: 113 (104 - 144) bpm\n BP: 134/83(95) {124/77(89) - 150/98(109)} mmHg\n RR: 22 (17 - 25) insp/min\n SPO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n Total In:\n 4,093 mL\n 1,199 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,093 mL\n 1,199 mL\n Blood products:\n Total out:\n 6,130 mL\n 1,770 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -2,037 mL\n -571 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 93%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 244 K/uL\n 13.5 g/dL\n 98 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 4 mg/dL\n 101 mEq/L\n 137 mEq/L\n 39.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:52 AM\n WBC\n 9.8\n Hct\n 39.0\n Plt\n 244\n Creatinine\n 0.7\n Glucose\n 98\n Other labs: ALT / AST:23/20, Alk-Phos / T bili:78/0.8, Amylase /\n Lipase:398/905, Ca:8.5 mg/dL, Mg:1.7 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n Assessment and Plan: 29-year-old male with recurrent pancreatitis\n NEURO: AAOx3, nonfocal, pain wellcontrolled on dilaudid PCA, ativan\n PRN\n Neuro checks Q: shift\n Pain: Dilaudid PCA\n CVS: stable\n PULM: no issues\n GI: NPO\n RENAL: f/u UOP\n HEME: no issues, f/u Hct\n ENDO: RISS\n ID: Afebrile\n TLD: PIV\n IVF: LR @ 250\n CONSULTS:\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL:\n PROPHYLAXIS:\n DVT - SQH, SCDs\n STRESS ULCER - PPI\n VAP BUNDLE -\n COMMUNICATIONS:\n ICU Consent: P\n CODE STATUS: FUll\n DISPOSITION: TICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:39 AM\n 18 Gauge - 10:40 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720822,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo this am. Only c/o of pain with movement. Has much better\n pain control with pca pump today. Uo this am >200cc/hr. k 3.6.\n Action:\n Team in iv fluids decreased to 100cc/hr. if fluids d5lr with 40meq kcl\n at 100cc/hr. Cont to use pca. Will remain npo for now. Oob to chair.\n Response:\n Pain remains much improved from yesterday. Temp max 100. using is.\n Plan:\n Cont wth iv fluids. Pain control. ? to start po\ns if stable tomorrow.\n sister and girlfriend in to visit. Updated patient\ns mother via\n phone.\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 720783,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed today at 0400 with chief c/o of right sided abd\n pain. In the ed his hr was 130-170 sbp 130\ns. He received a total of\n 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Cont to have pain , HR 120\ns NST. Amylase 530 and lipase 1654.\n Action:\n Dilaudid PCA started Iv fluids cont LR 250cc/hr.\n Response:\n Pain is well controlled on PCA, Slept through night.\n Plan:\n Tx pain. Iv fluids, Follow AM labs\n"
},
{
"category": "Nursing",
"chartdate": "2165-03-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 720974,
"text": "29 year old with NKA. Hx of GERD, pericarditis of ? etiology in tx\n with indocin, and hx of acute pancreatitis in .\n Admitted to the ed at 0400 with chief c/o of right sided\n abd pain. In the ed his hr was 130-170 sbp 130\ns. He received a total\n of 5mg dilaudid in divided doses and 1mg iv ativan. He had an abd and\n pelvic ct and abd u/s done in the ed. He received 8l ivf and had 2000cc\n in urine. Transferred to micu as a sicu border for futher care.\n Pancreatitis, acute\n Assessment:\n Remains npo.\n Only c/o of pain with movement. Has much better pain control with\n dilaudid pca pump.\n Urine output >100cc/hr. LR running @ 100ml/hr.\n Action:\n Cont to use pca. Will remain npo for now.\n Response:\n Pain remains much improved from yesterday per pt currently at rest\n and about 5 transiently at max with movement.\n No fever currently..\n Plan:\n Cont wth iv fluids.\n Pain control. With pca\n Remains npo\n For surgery sometime in future.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n PANCREATITIS\n Code status:\n Height:\n 65 Inch\n Admission weight:\n 65.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: GERD on omeprazole at home. Hx of pancreatitis in\n . Hx of pericarditis of ? etiology tx with indocin.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:73\n Temperature:\n 98.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,750 mL\n 24h total out:\n 2,160 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 05:07 AM\n Potassium:\n 4.8 mEq/L\n 05:07 AM\n Chloride:\n 99 mEq/L\n 05:07 AM\n CO2:\n 28 mEq/L\n 05:07 AM\n BUN:\n 3 mg/dL\n 05:07 AM\n Creatinine:\n 0.7 mg/dL\n 05:07 AM\n Glucose:\n 99 mg/dL\n 05:07 AM\n Hematocrit:\n 40.6 %\n 05:07 AM\n Finger Stick Glucose:\n 105\n 06:00 AM\n Valuables / Signature\n Patient valuables: cell phone and charger transferred with pt\n valuables:\n Clothes: Sent home with: clothes transferred with pt.\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu 7\n Transferred to: 919 \n"
},
{
"category": "ECG",
"chartdate": "2165-03-02 00:00:00.000",
"description": "Report",
"row_id": 235718,
"text": "Sinus tachycardia. Compared to the previous tracing of there is no\nchange.\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-03-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1118874,
"text": " 8:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for free air, acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with tachycardia, pancreatitis\n REASON FOR THIS EXAMINATION:\n eval for free air, acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachycardia and pancreatitis.\n\n COMPARISON: .\n\n Bedside AP radiograph of the chest shows normal cardiac, mediastinal and hilar\n contours. A left retrocardiac consolidation is noted, non-specific, possibly\n atelectasis or a focus of aspiration or infection. There is no pleural\n effusion or pneumothorax. There is no evidence of pneumoperitoneum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-03-02 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1118861,
"text": " 5:07 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: eval for cholecystitis, stones,pancreatic abnormalities\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with RUQ pain, history of pancreatitis\n REASON FOR THIS EXAMINATION:\n eval for cholecystitis, stones,pancreatic abnormalities\n ______________________________________________________________________________\n WET READ: AGLc SAT 7:16 AM\n\n no findings of acute cholecystitis. tiny 1.5 mm echogenic focus nonmobile\n could represent a tiny stone adherent to GB wall. no biliary dilatation. panc\n not well visualized. no fluid in RUQ.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 29-year-old male with history of pancreatitis, now with right upper\n quadrant pain concerning for cholecystitis, stones or pancreatic abnormality.\n WBC 20.5, lipase 4605.\n\n COMPARISON: CT abdomen/pelvis of and right upper quadrant ultrasound\n of .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates no focal,\n echotextural or architectural abnormality. The main portal vein is patent,\n with normal hepatopetal flow. No intra- or extra-hepatic biliary ductal\n dilatation is noted, with the common duct measuring 4 mm. The gallbladder\n appears normal except to note tiny 2-mm nonmobile echogenic focus along the\n superior wall of the gallbladder, likely representing an adherent\n non-shadowing stone. No other gallstone is noted. No findings specific for\n acute cholecystitis are noted. The patient was diffusely tender over the\n epigastric region; sign was not present. No free fluid is seen\n within the right upper quadrant. There is very limited visualization of the\n pancreatic; no focal abnormality is seen where visualized. Views of the right\n kidney appear unremarkable.\n\n IMPRESSIONS:\n 1. Limited visualization of pancreas. No fluid seen in right upper quadrant.\n 2. No findings of acute cholecystitis. Tiny 1.5-mm nonmobile echogenic focus\n probably represents a tiny adherent stone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-03-02 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1118878,
"text": " 9:34 AM\n CT ABD W&W/O C Clip # \n Reason: eval for source of pancreatitis and tachycardia\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with epigastric tenderness, tachycardia and elevated lipase\n REASON FOR THIS EXAMINATION:\n eval for source of pancreatitis and tachycardia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CXWc SAT 10:22 AM\n Inflammatory change and fluid surrounding the pancreas and tracking through\n the lesser sac and paracolic gutters c/w acute pancreatitis. No organized\n fluid collection. No necrotizing pancreatitis or vascular involvement. No\n other acute abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 29-year-old man with epigastric tenderness, tachycardia, and\n elevated lipase.\n\n COMPARISON: CT. Right upper quadrant ultrasound obtained\n approximately five hours earlier.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen\n before and after administration of intravenous contrast material. Oral\n contrast was also administered. Multiplanar reformatted images were\n generated.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: At the lung bases, there is mild\n dependent atelectasis bilaterally. There is no consolidation or pleural\n effusion. There is no pericardial effusion.\n\n In the abdomen, the liver and gallbladder are within normal limits. There is\n no biliary ductal dilatation. No gallstones are identified.\n\n The pancreas demonstrates a moderate degree of peripancreatic inflammatory\n change and fluid tracking throughout the lesser sac, and into both pericolic\n gutters, extending to the pelvis. There is no organized fluid collection at\n this time. The pancreatic parenchyma enhances uniformly, without evidence of\n necrotizing pancreatitis. Arteries and veins adjacent to the pancreas are\n normal, without pseudoaneurysm or thrombus. Small peripancreatic lymph nodes\n are present, but not enlarged by size criteria.\n\n The spleen, adrenal glands, stomach, and duodenum are unremarkable. The\n kidneys enhance and excrete contrast symmetrically without hydronephrosis,\n stones, or renal masses. The abdominal aorta and its major branches are\n normal. There is no free air in the abdomen.\n\n Visualized loops of large and small bowel demonstrate mild bowel wall\n thickening in the jejunum, which could be reactive related to the adjacent\n pancreatitis, or could be related to underdistension.\n\n (Over)\n\n 9:34 AM\n CT ABD W&W/O C Clip # \n Reason: eval for source of pancreatitis and tachycardia\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n OSSEOUS STRUCTURES: There is no fracture or worrisome bony lesion.\n\n IMPRESSION:\n 1. Inflammatory change and fluid surrounding the pancreas, consistent with\n acute pancreatitis. No evidence of necrotizing pancreatitis, pancreatic\n pseudocyst, or vascular involvement.\n 2. No biliary obstruction or biliary stones.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-03-07 00:00:00.000",
"description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS",
"row_id": 1119875,
"text": " 9:54 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess biliary anatomy, pancreatic ducts, ? divisum\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with pancreatitis unclear etiology\n REASON FOR THIS EXAMINATION:\n assess biliary anatomy, pancreatic ducts, ? divisum\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf FRI 9:55 AM\n Findings consistent with acute pancreatitis, no evidence of complications,\n such as no necrosis or peripancreatic fluid collection. No cholelithiasis or\n choledocholithiasis.\n ______________________________________________________________________________\n FINAL REPORT\n MRCP\n\n INDICATION: 29-year-old male with recurrent pancreatitis.\n\n COMPARISON: Not available at the . Note is made of CT abdomen dated\n and right upper quadrant son dated .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 3T\n magnet, including dynamic 3D imaging obtained prior to, during, and after the\n uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA (14 mL\n of Magnevist).\n\n Multiplanar 2D and 3D reformations and subtraction images were created on a\n different workstation.\n\n FINDINGS: There is a slightly boggy appearance of the pancreas, which\n however, maintains normal signal intensity, and enhancing briskly on the\n arterial phase on the post-contrast images, without evidence of necrosis.\n There is a mild amount of fat stranding surrounding the gland, without a\n discrete fluid collection. There is trace fluid in the left anterior\n perirenal space. The pancreatic duct is not dilated, and there are no dilated\n side branches. The duct is difficult to delineate likely due to gland edema -\n consider follow-up after the episode resolves, perhpas with secretin to\n asssess for divisum.\n\n There is no intra- or extra-hepatic biliary ductal dilatation or\n choledocholithiasis. The liver is normal in size and signal intensity,\n without evidence of underlying cirrhosis. The gallbladder is normal.\n\n There is no evidence of venous thrombosis, the portal and splenic and superior\n mesenteric veins are widely patent.\n\n This is a single left and single right patent renal arteries. The hepatic\n artery anatomy is conventional.\n\n The spleen, adrenal glands, kidneys are unremarkable. There is no abdominal\n (Over)\n\n 9:54 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess biliary anatomy, pancreatic ducts, ? divisum\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ascites and no pathologic lymphadenopathy. The visualized loops of bowel are\n normal in appearance.\n\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\n dynamic series and were essential in delineating the above findings.\n\n IMPRESSION:\n 1. Findings consistent with acute uncomplicated pancreatitis, without\n evidence of peripancreatic fluid collection. Pancreatic duct not well seen\n and therefore a divisum can not be ruled out.\n 2. No cholelithiasis or choledocholithiasis.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-03-07 00:00:00.000",
"description": "MRCP (MR ABD W&W/OC)",
"row_id": 1119876,
"text": ", M. FA9A 9:54 PM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: assess biliary anatomy, pancreatic ducts, ? divisum\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with pancreatitis unclear etiology\n REASON FOR THIS EXAMINATION:\n assess biliary anatomy, pancreatic ducts, ? divisum\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Findings consistent with acute pancreatitis, no evidence of complications,\n such as no necrosis or peripancreatic fluid collection. No cholelithiasis or\n choledocholithiasis.\n\n"
}
] |
23,471 | 182,978 | Phototherapy was initiated and the bilirubin continued to decrease to 16.7 after approximately 9 hours of phototherapy. Repeat level 6 hours later was 13.1 and at noon on . Fed formula ad lib. Discharge weight 2765 grams. Repeat hearing screen during this admission (due to hyperbilirubinemia): referred in both ears. Had passed during birth hospitalization. Of note, paternal grandfather reportedly "deaf/mute" since childhood. | Neonatology AttendingInfant readmitted with hyperbilirubinemiaDetails of prior course are in old chart (pending)Neonatal course - At home, infant has been feeding well, voiding, stooling and asymptomatic. Baby arrived to the NICU for for bilirubin check (17.5). DDx also includes ABO incompatibility, and other less common pathologiesPLAN-CBC, blood type and DAT, and repeat bilirubin have been drawn.-We will start double phototherapy and repeat bilirubin in 6 hours-Check state screen in am-Continue with enteral feeds-Current status, diagnostic considerations and our management plan discussed with parentsPCP: CBC with diff, and type and coombs sent. MD spoke with parents, examined by MD, and is stable for transfer to nbn for phototherapy. Baby placed under single photo while here in the NICU. NICU NPNPlease see MD note for history and details. Hyperbilirubinemia. Given absence of symptoms, maternal blood type and Asian ethnicity, this is likely simply exaggerated physiologic hyperbilirubinemia. Bilirubin today at 20.6 and referred to for managementPEvery well-appearing infant in no distressHEENT AFSF; non-dytsmorphic; palate intact; neck/mouth normal; no nasal flaringCHEST no retractions; good bs bilat; no adventitious soundsCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmurABD soft, non-distended; no organomegaly; no masses; bs active; anus patentGU normal female genitaliaCNS active, alert, resp to stim; tone normal and symm; MAE symm; normal suck/root/gag intact; grasp symm; spont eye openingINTEG jaundiced to trunk and extremitiesMSK normal insp/palp/ROM all extIMPRESSIONTerm infant with1. | 2 | [
{
"category": "Nursing/other",
"chartdate": "2175-11-06 00:00:00.000",
"description": "Report",
"row_id": 1995733,
"text": "Neonatology Attending\nInfant readmitted with hyperbilirubinemia\n\nDetails of prior course are in old chart (pending)\n\nNeonatal course - At home, infant has been feeding well, voiding, stooling and asymptomatic. Bilirubin today at 20.6 and referred to for management\n\nPE\nvery well-appearing infant in no distress\nHEENT AFSF; non-dytsmorphic; palate intact; neck/mouth normal; no nasal flaring\nCHEST no retractions; good bs bilat; no adventitious sounds\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent\nGU normal female genitalia\nCNS active, alert, resp to stim; tone normal and symm; MAE symm; normal suck/root/gag intact; grasp symm; spont eye opening\nINTEG jaundiced to trunk and extremities\nMSK normal insp/palp/ROM all ext\n\nIMPRESSION\nTerm infant with\n1. Hyperbilirubinemia. Given absence of symptoms, maternal blood type and Asian ethnicity, this is likely simply exaggerated physiologic hyperbilirubinemia. DDx also includes ABO incompatibility, and other less common pathologies\n\nPLAN\n-CBC, blood type and DAT, and repeat bilirubin have been drawn.\n-We will start double phototherapy and repeat bilirubin in 6 hours\n-Check state screen in am\n-Continue with enteral feeds\n-Current status, diagnostic considerations and our management plan discussed with parents\n\nPCP: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-11-06 00:00:00.000",
"description": "Report",
"row_id": 1995734,
"text": "NICU NPN\nPlease see MD note for history and details. Baby arrived to the NICU for for bilirubin check (17.5). CBC with diff, and type and coombs sent. Baby placed under single photo while here in the NICU. VSS. MD spoke with parents, examined by MD, and is stable for transfer to nbn for phototherapy.\n"
}
] |
26,392 | 126,101 | 83 year old female with anoxic brain injury s/p VT arrest in , chronically vent / trach / PEG, with history of CHF, DM presented with acute hypoxia and sepsis. . # Respiratory Failure: The patient was empirically started on vancomycin and zosyn given her history of MRSA, VRE, and pseudomonas infections. She completed a 7 day course of these in addition to a 4 day course of flagyl, and then she was switched to meropenem on when her sputum grew out pseudomonas (meropenem sensitive), proteus, and an unidentified gram neagive rod. On she had a right thoracentesis which showed exudative fluid. Plan to continue meropenem for 6 weeks (see below). She was also started on a steroid taper while in the hospital due to her respiratory distress. . # ?Endocarditis - The patient had a TTE which showed a questionable vegetation on the mitral valve. When the daughter was asked to consent for a TEE she refused, and so the decision to empirically treat the patient for endocarditis was made. The patient did not have a murmur while in hospital and did not have any positive blood cultures. Plan to treat with meropenem for 6 weeks. . # Renal failure: Patient was admitted with a creatinine of 1.2 which rose to 2.7 by hospital day 7. She also developed low urine output which did not respond well to either IVFs or lasix. The renal service was consulted and felt that the acute renal failure was likely multifactorial ATN due to sepsis, hypotension, CHF, and IV contrast dye. They recommended not diuresing her and to minimize fluid intake, in the hope that her renal function would improve over time. Epogen was started on . . # Hypotension: The patient initially required levophed but weaned off rapidly. During most of her hospitalization she had high CVPs, positive ins/outs, appeared hypervolemic, and was normotensive (but with low urine output). An echo on showed an EF of 65%, and ? vegetation on MV. Her initial hypotension was presumed to be caused by sepsis. . # Anemia: Chronic anemia but now with an acute decrease. Possibly a slow GI bleed as she has had guaiac positive stools during this hospitalization. She received 1 unit of pRBC on and another unit on . Her hct did not remain stable while in the hospital. . # Endo: The patient has a history of diabetes and hypothyroidism. While in hospital she was maintained on NPH, regular insulin sliding scalem and levothyroxine. . . **The hospital course was explained to the daughter (health care proxy) by Dr. on and by Dr. on . Daughter feels comfortable assuming the risk and sending the patient back to rehab. Medications on Admission: rehab: nepro 35, senna, MOM, MVI, , vit d, colace, protonix, peridex, nystatin, levothyroxin, lasix 40, NPH, RISS, tylnenol, alubtero, synthroid? | MAG 2.4.GI- ABD FIRM DISTENDED WITH POS BS. BS RHONCHOROUS. BS course with expiratory wheezes present at times. Albuterol/atrovent given. Albuterol/atrovent given. Suctioned for moderate amts. firm, distended, +BS, protruding hiatal hernia noted. ADMITTED FROM REHAB DESATING ON VENT AND HYPOTENSIVE REQUIRING LEVO THAT WAS DC'D /REVEIW OF SYSTEMS-NEURO- REMAINS . Freq trach & oral care provided today. VRE/MRSA+ Contact precautions in place. Pt c fairly clear LS today (diminished @ bases) c rare coarseness that clears c sxn'ing. CONT ANTIBIODICS AS ORDERED. CONT TO SUCTION PRN. RESULTS PENDING.ID- TEMP MAX 98.6. resp. Pt withdraws to noxious stimuli. REPEAT HCT DRAWN POST TRANSFUSION. OCCASIONAL WHEEZES ON MDI'S PER RESP.CARDIAC- HR 70-80'S NSR WITH RARE PVC. remains on IV Hydralazine, Lopressor via Peg.GI/GU: Abd. ON THIS ABG 7.37/46/75/28. Cont to receive Albuterol and Atrovent MDI's Q vent check. Hourly urinary output now trending down and will discuss c team whether pt should receive additional diuretics. LUNG SOUNDS COARSE.CV: HR NSR WITH RATES 70-80'S WITH OCC PVC'S NOTED. stool Guiac +. ADMITTED WITH DESATURATION ON VENT AND HYPOTENSION.REVEIW OF SYSTEMS-NEURO- OPENS EYES SPONTANEOUSLY. Abd is obese, distended c +BS appreciated. DR NOTIFIED. Afebrile. PERRL. BILAT WITH SCAT WHEEZES. Alb/Atr inhalers given x3 with good aeration noted. CVL d/c'd upon return to floor. movement noted, pupils minimally reactive, impaired gag/cough.Resp: Remains vented via trach, no changes made overnight, A/C 16, Vt 400, FiO 2 60%, PEEP 10, rr 18-20s. Sats mid to high 90s.CV: HR 60s-70s, NSR with BBB, no ectopy noted. TENDS TO RUN ON THE HIGHER SIDE AFTER SHE IS STIMULATED.GI- ABD OBESE. Foley with min. K 4.0. SX FOR MOD AMTS. NSR c occ PVC's. Mushroom cath with sm. OPENS EYES SPONTANEIOUSLY. MEDS GIVEN. WILL RE EVALUATE. tinged secretions. CALLED TO BE UPDATED. NO INCREASE SINCE THIS AM. BECOMES VERY HYPERTENSIVE WITH STIMULATION, COMES BACK DOWN TO BASELINE WITH VERSED.GI: TUBE FEEDS ON HOLD. SBP 130-160'S. Breathsounds remain coarse.Trach cuff pressure 24 no cuff leak noted this shift. Pt c coarse BS and occ exp wheezes, both clearing c sxn'ing and nebs per RT respectively. withdraws to nailbed pressure x4 extremites noted. Pt withdraws to noxious stimuli.CV: Pt arrived from EW on Levo gtt infusing @ 0.03mcg/kg/min c hyperdynamic ABP values in the 160-190 range. trach care done.gi: abd obese, firm and distended with +hernia noted. withdraws to nailbed pressure x4 extremities noted. Pt probably septic c bandemia & elevated WBCC noted above. pt w/intermittant positinal cuff leak, resealed x1 w/one cc air.gi/gu- abd obese firm. AM lytes essentially WNL. BS course bilaterally with exp wheezes present when stimulated post sxing. NSR c bundle branch noted, afebrile oral temp of 97.4. remains on asa, lopressor and hydralazine. MIN RESIDUALS ON ATC REGLAN. remains on asa, lopressor, and hydralazine. NSR c BBB noted and occ PVC's. settles down to 1teens-130/sys. Lacrilube eye ointment applied, pt noted to have poor blink reflex.SOC: Dtr called this AM and kept up-to-date c POC/pt status. remains on tube feeds, tolerating well on reglan. WHILE HERE HYPOTENSIVE REQUIRING LEVO. Pt currently c min vol of liters and breathing @ set MV rate. RENAL FOLLOWING.HEME- HCT STABLE AT 29.9.ID- WBC UP TO 17.1. peg tube exit site retention sutures c/d/i. BREATHS WITH AND OVER THE VENT.RESP: PT IS VENT DEPENDENT AT BASELINE. PT IS .GI: PT IS NPO, PT HAS PEG BUT CURRENTLY CLAMPED. ADMITTED WITH DESATING EPISODES ON VENT AT JMH. natrecor gtt d/c'd this shift. +cough/impaired gag noted. started on reglan atc. VRE/MRSA+ Contact isolation precautions in place. CONT ON MEROPENUM. MG 2.4.GI- ABD OBESE DISTENDED WITH POS BS. Resp carePt remians on unchanged vent settings. Foley patent with clear yello urine out.Skin: Coccyx duoderm c/d/i. Abd remains firm, distended c erythema & warm of lower quadrants noted. hiatal hernia noted above umbilicus, +BS, mushroom cath with min. no vent changes this shift.gi: abd obese, firm and distended with +hernia noted. NOW WITH ARF AND TTE THAT SHOWED ? It measures 1.1 most likely represents asymmetric edema. ADMITTED WITH PNA AND HYPOTENSION. There has been interval right thoracentesis with associated decrease in size of right pleural effusion with residual moderate pleural effusion remaining. Status post thoracentesis, right lung. Focal calcifications in aortic root.Mildly dilated aortic arch. ventral hernia, active bowel tones, one loose drk brwn stool, spec sent for Cdiff. Ambu/syringe @ hob. INDICATION: Hypoxia. Suboptimal image quality - ventilator.Conclusions:The left atrium is moderately dilated. There is a minimally increased gradientconsistent with minimal aortic valve stenosis. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. lungs coarse to clear after suction, diminished bil. There is mild symmetric leftventricular hypertrophy. IONIZED CA 1.07 THIS AM TX WITH 2GMS OF IV CAGLUCONATE.GI- ABD OBESE DISTENDED AND FIRM. DR MADE AWARE ON ROUNDS. The aorticarch is mildly dilated. Moderate PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. MDI's administered Q4 Alb/Atr. BS auscultated reveal bilateral coarse sounds. Moderately thickened aortic valveleaflets. Minimally increased gradient c/w minimal AS. There is moderate pulmonary artery systolichypertension. pulm care. Mild to moderate (+)mitral regurgitation is seen. IMPRESSION: Improved right pleural effusion following thoracentesis with no evidence of pneumothorax. Assess for CHF. ALSO CARDIAC ECHO ORDERED FOR AM. This demonstrated a stenosis of the axillary vein at the level of the proximal humerus. Moderate mitral annular calcification.Mild thickening of mitral valve chordae. SUPINE ABDOMINAL X-RAY: Limited evaluation for G-tube position. drsg . ANTIBIODICS AS ORDERED. There are focal calcifications in the aortic arch. REMAINS ON SS AND DOSING OF NPH.ID- TEMP MAX 99.9. There is a globulat thickening at the base of the posterior mitralleaflet; this most likely represents mitral annular calcification, but a massor vegetation on the mitral valve cannot be excluded. 3) Hypodense areas in the spleen most likely represent old infacts. bronchospastic with turns s/s and suction. Calcified tips of papillary muscles.No MS. The basilic and brachial veins were patent and compressible. The degree of perihilar haziness is slightly improved. | 48 | [
{
"category": "Nursing/other",
"chartdate": "2129-04-18 00:00:00.000",
"description": "Report",
"row_id": 1606994,
"text": "Neuro: Pt. opens eyes spontaneously and to stimulation, does not track or follow commands. No spont. movement noted, pupils minimally reactive, impaired gag/cough.\nResp: Remains vented via trach, no changes made overnight, A/C 16, Vt 400, FiO 2 60%, PEEP 10, rr 18-20s. LS coarse. Suctioned for moderate amts. of blood tinged thick secretions, copious amt of oral secretions, suctioned with yankauer. Sats mid to high 90s.\nCV: HR 60s-70s, NSR with BBB, no ectopy noted. BP 90s-120s/40s-50s, pt. remains on IV Hydralazine, Lopressor via Peg.\nGI/GU: Abd. firm, distended, +BS, protruding hiatal hernia noted. Mushroom cath with sm. brown liq. stool Guiac +. Foley with min. yellow clear urine out. Tolerating Nepro with Promode at goal of 35 cc/hr via Peg.\nSkin: Abd echymosis with improvement, coccyx duoderm intact.\nContinues on tapering Prednisone.\nPLan PICC placement today, possible discharge to . Awaiting for pending blood culutres due to increase in WBC to 23.5 .\nSocial: Daughter called, updated on status and plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-18 00:00:00.000",
"description": "Report",
"row_id": 1606995,
"text": "Pt down to IR for single lumen PICC placement and tolerated procedure well. CVL d/c'd upon return to floor. Sxn ~q4hr for mod amt thick tan- /blood tinged secretions. No vent changes. Plan for d/c to hospital @1600 via acls. dtr aware of d/c and updated on status and plan of care by dr. . please care carevue for all other data.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-12 00:00:00.000",
"description": "Report",
"row_id": 1606968,
"text": "resp care\nPt remained on a/c 400x16 50% 7peep with peak/plat 29/26.BS coarse bil. Suct for thick creamy sput. Alb/atr mdi given with no change in BS. RSBI not done due to no spont resp. Will cont to assess.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-12 00:00:00.000",
"description": "Report",
"row_id": 1606969,
"text": "\nPT MAINTAINED ON A/C VENTILATION AT 50%. VITALS STABLE. B.S. BILAT WITH SCAT WHEEZES. MEDS GIVEN. SX FOR MOD AMTS. MENTALLY PT IS AND NEEDING SEDATION FOR AGITATION. LAST ABG SHOWED A MILD ACIDOSIS WITH MARGINAL OXYGENATION--PEEP INCREASED TO 10CM. NO OTHER CHANGES OR WEANING TODAY. PLAN IS TO CONT ON A/C VENTILATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-12 00:00:00.000",
"description": "Report",
"row_id": 1606970,
"text": "FOCUS; NURSING PROGRESS NOTE\nPATIENT IS AN 83 YEAR OLD S/P VFIB ARREST WITH ANOXIC BRAIN INJURY, S/P TRACH AND PEG, HX OF CRF WITH HX OF C DIFF, VRE, MRSA DN PSEUDOMONAS CONILIZATION. ADMITTED FROM REHAB DESATING ON VENT AND HYPOTENSIVE REQUIRING LEVO THAT WAS DC'D /\nREVEIW OF SYSTEMS-\nNEURO- REMAINS . DOES NOT TRACT. PUPILS EQUAL AND UNREACTIVE. DOES NOT BLINK TO THREAT. OPENS EYES SPONTANEIOUSLY. WITHDRAWS TO PAINFUL STIMULI. MED X 2 THIS SHIFT WITH 1MG VERSED AS SHE LOOKED UNCOMFORTABLE. THIS HAD A GOOD EFFECT.\nRESP- TRACHED AND VENTED. ON 50% FIO2/ TV 400/ A/C RATE OF 16 OVERBREATHING BY UP TO 10 BREATHS WHEN STIMULATED. PEEP 8. ON THIS ABG 7.37/46/75/28. PEEP INCREASED TO 10 PER DR S/P THIS ABG. SATS 93% IR GREATER. SUCTIONED FOR OLD BLOOD TINGED THICK SPUTUM. BS COARSE. OCCASIONAL WHEEZES ON MDI'S PER RESP.\nCARDIAC- HR 70-80'S NSR WITH RARE PVC. K THIS AM 3.3. TX WITH 40MEQ KCL VIA PEG AND UP TO 4.2. SBP 130-160'S. TENDS TO RUN ON THE HIGHER SIDE AFTER SHE IS STIMULATED.\nGI- ABD OBESE. NO INCREASED DISCOLORATION ON ABD NOTED. NONE INCREASING OVER LINE SURGEONS DREW. LEFT THICH ALSO DISCOLORED. NO INCREASE SINCE THIS AM. SC HEPARIN DC'D AS THIS FELT TO BE THE CAUSE OF THE DISCOLORATION. CONT ON TF NEPRO WITH PROMOD AT GOAL RATE OF 35ML/HR WITH MIN RESIDUALS. NO STOOL TODAY.\nGU- FOLEY WITH MIN URINE TODAY. 2 500CC FLUID BOLUSES GIVEN THIS SHIFT. WHEN CVP UP TO 17-20 LASIX 40MG IV X2 ATTEMPTED. BLADDER PRESSURE 17. DR NOTIFIED. FOLEY CHANGED AS BLADDER SCANNER SAID THAT > 125CC URINE WAS IN BLADDER. SHE HASD A # 14 FRENCH THAT WAS CHANGED TO A # 16. NO INCREASE IN URINE OUTPUT AND WITH NEW CATHETER IN BLADDER SCANNER SAID THERE WAS NO URINE IN BLADDER. DR AWARE. CREAT 1.5 THIS AM. UP TO 1.8 THIS PM.\nHEME- HCT DOWN TO 23.8 FROM 26.2. 1 U PRBC TRANSFUSED AS ORDERED WITHOUT SIGNS OR SYMPTOMS OF REACTION. REPEAT HCT DRAWN POST TRANSFUSION. RESULTS PENDING.\nID- TEMP MAX 98.6. WBC TRENDING DOWN 13.6. FLAGYL DC'D AND SHE CONTINUES ON VANCO AND ZOSYN.\nSOCIAL- DAUGHTER CALLED AND WAS UPDATED X2.\nDISPO- REMINS IN THE MICU A FULL CODE.\nPLAN- CONT TO MONITOR UO.\n CONT TO SUCTION PRN.\n CONT ANTIBIODICS AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-12 00:00:00.000",
"description": "Report",
"row_id": 1606971,
"text": "FOCUS; ADDENDUM\nHEME- REPEAT HCT UP TO 28.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-12 00:00:00.000",
"description": "Report",
"row_id": 1606972,
"text": "focus; addendum\nENDO- NPH DOSES OF INSULIN DECREASED THIS AM. BS AT NOON 102\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-17 00:00:00.000",
"description": "Report",
"row_id": 1606990,
"text": "Respiratory care:\nPatient remains trached and mechanically vented. Vent checked and alarms functioning. Fio2 increased over night from 50% to 60% secondary to decreased sats. Suctioned several times for bld. tinged secretions. Albuterol/atrovent given. Breathsounds remain coarse.\nTrach cuff pressure 24 no cuff leak noted this shift. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-17 00:00:00.000",
"description": "Report",
"row_id": 1606991,
"text": "FOCUS; NURSING PROGRESS NOTE\n83 YEAR OLD WITH ANOXIC BRAIN INJURY S/P VFIB ARREST IN . ADMITTED WITH DESATURATION ON VENT AND HYPOTENSION.\nREVEIW OF SYSTEMS-\nNEURO- OPENS EYES SPONTANEOUSLY. DOES NOT TRACK. DOES NOT FOLLOW COMMANDS. PUPILS EQUAL AND MINIMALLY REACTIVE. DOES WITHDRAW TO PAINFUL STIMULI.\nRESP- TRACHA DN VENTED ON 60% FIO2/ TV 400/ A/C RATE OF 16 OVERBREATHING BY UP TO 5 BREATHS AND 10 PEEP. ON THIS SATS 96% OR GREATER. SUCTIONED FOR THICK BLOOD TINGED SECRETIONS. AT TIMES REQUIRING LAVAGING. BS RHONCHOROUS. DIMINISHED AT THE BASES. PREDINISONE DOSE DECREASED TO 10MG QD TODAY.\nCARDIAC- HR 60'S NSR WITHOUT ECTOPI. ALINE FELL OUT TODAY. NBP SBP 109-142. K 4.0. MAG 2.4.\nGI- ABD FIRM DISTENDED WITH POS BS. HAS PEG TUBE THROUGH WHICH SHE IS RECEIVING NEPRO WITH PROMOD AT 35CC/HR WHICH IS HER GOAL RATE. PASSING SMALL AMOUNTS BROWN GUIAC POS LIQUID STOOL VIA MUSHROOM CATHETER.\nGU/RENAL- UO 5-22CC/HR. CREATININE DOWN TO 2.5 FROM 2.7 YESTERDAY.\nID- TEMP MAX 98.7 TODAY. WBC UP TO 23.5. BC X 2 DONE INCLUDING FUNGAL CULT.\nSKIN- SKIN ON ABD WITH LESS ECCHYMOSIS. ALSO LEFT THIGH ECCHYMOSIS IMPROVING. DUODERM INTACT ON COCCYX.\nSOCIAL- DAUGHTER IN TO VISIT AND WAS UPDATED BY THIS NURSE.\nDISPO- REMAINS IN MICU A FULL CODE.\nPLAN- FOR PICC PLACEMENT TOMMORROW AND THEN TO REHAB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-17 00:00:00.000",
"description": "Report",
"row_id": 1606992,
"text": "resp. Care Note\nPt remains trached and vented on settings as charted on resp flowsheet. No vent changes made this shift. Cont to receive Albuterol and Atrovent MDI's Q vent check. Sxn for blood tinged secretions. O2 sats high 90's, no ABG's. cont current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-18 00:00:00.000",
"description": "Report",
"row_id": 1606993,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. No vent changes made this shift. Breathsounds are coarse. Albuterol/atrovent given. Continues on A/C 400*16 60% with 10 Peep. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-10 00:00:00.000",
"description": "Report",
"row_id": 1606960,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes throughout the night. Morning abg results reveal a fully compensated respiratory acidemia with good oxygenation (see CareVue)\n\nNo RSBI measured due to the level of PEEP currently required by the patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-10 00:00:00.000",
"description": "Report",
"row_id": 1606961,
"text": "Nursing Progress Note.\n\nRESP: Pt received on AC-16-60-450-10 c pt breathing @ set rate of 16 c nl sats. Pt noted to have abd accessory muscle recruitment to assist c resp fxn. Pt c fairly clear LS today (diminished @ bases) c rare coarseness that clears c sxn'ing. Small quantities of sputum is thick yellow and slightly blood tinged. Freq trach & oral care provided today. FiO2 successfully decreased to baseline FiO2 of 50% today c no change evident in RR/sats. PEEP dropped from 10 to 7 @ 15:00, currently assessing pt tol and will send an ABG to eval tol shortly. Pt c small cuff leak despite adequately inflated cuff balloon. Pt positioned upright 30-45 degrees to assist resp fxn.\n\nCV: Hemodynamically stable off IV pressors. Afebrile. NSR c occ PVC's. AM labs WNL. CVP values remain elevated in the 15-23 range. Hourly urinary output dropped off this AM to approx 20ml/hr, team notified and pt subsequently med c 40mg IV Lasix c approx 250ml output over the next three hours. Hourly urinary output now trending down and will discuss c team whether pt should receive additional diuretics. Pt is net input 500ml today. Venodyne boots applied today.\n\nGI: FS Nepro c Pro-Mod TF's started today and currently infusing @ 25ml/hr via PEG c minimal residuals and target goal of 35ml/hr per Nutrition recs. Abd is obese, distended c +BS appreciated. No BM thus far today. Will send a stool spec to r/o c.diff as requested by team when a suitable spec becomes available.\n\nMS: Pt is does not appear purposeful and does not follow commands. Pt spontaneously opens eyes/blinks, moves LE in responce to tactile stimuli. Pt withdraws to noxious stimuli. Pt appears to grimace uncomfortably @ times (turns, sxn'ing), pt med c 1.0mg IV Verced @ 11:00 c questionable efficacy and 2mg IV Morphine Sulfate @ 15:45 c some improvement noted. Pt appears to favor lying on left side. The pt is not restrained. PERRL. Very weak gag reflex, fair cough reflex.\n\nDERM: Duoderm dsg remains affixed to stage III coccyx pressure ulcer wound site. Size med waffle boot applied to LE in alt pattern.\n\nSOC: Dtr called twice today, kept up-to-date c POC/pt status. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. VRE/MRSA+ Contact precautions in place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-10 00:00:00.000",
"description": "Report",
"row_id": 1606962,
"text": "Resp Care\nPt Remains trached on A/C 400X16 50% peep 7 with ABG pending on these settings. BS course with expiratory wheezes present at times. Alb/Atr inhalers given x3 with good aeration noted. Pt sxed for small to mod amts of thick tan secretions. Spo2 in the mid 90s on 50% and peep 7. Will continue with vent support and continue to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-11 00:00:00.000",
"description": "Report",
"row_id": 1606963,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT'S CONDITION UNCHANGED. OPENS EYES SPONTANEOUSLY AND TO STIMULATION BUT NOT TO COMMAND. TONGUE CONSTANTLY STICKING OUT, CHIN QUIVERING. EXTREMTIES VERY RIGID.\n\nRESP: REMAINS VENT DEPENDENT NO WEANING. SX FOR MOD AMT'S OF THICK TAN SECRETIONS. O2 SAT'S IN HIGH 90'S. DOES NOT TOLERATE TURNING, SAT'S DROP TO THE 80'S. MED WITH PRN VERSED WHEN TACHYPNEIC AND SAT'S DOWN IN THE 80'S. LUNG SOUNDS COARSE.\n\nCV: HR NSR WITH RATES 70-80'S WITH OCC PVC'S NOTED. BECOMES VERY HYPERTENSIVE WITH STIMULATION, COMES BACK DOWN TO BASELINE WITH VERSED.\n\nGI: TUBE FEEDS ON HOLD. ABD CAT SCAN DONE TO VISUALIZE WHY PT IS SO DISTENDED. SKIN VERY PURPLE LOWER ABDOMEN. CT SCAN SHOWED HEMATOMA MOST LIKELY DUE TO HEPARIN SC.\n\nGU: FOLEY CATH PATENT DRAINING SM AMT'S OF CLEAR YELLOW URINE.\n\nSKIN: PT HAS NEW SKIN BREAK ON LEFT ARM. APPEARS TO HAVE A MOLE OR A COMPROMISED AREA THAT BROKE OPEN AND IS NOW BLEEDING. DSG APPLIED SEVERAL TIMES WITHOUT ABLE TO CONTROL BLEEDING. GEL FOAM DSG APPLIED, INTERN IN TO SEE AND FEELS THAT IT'S SLOWING DONE AND TO KEEP DRESSING ON IT. WILL RE EVALUATE. PT ALSO HAS INTACT DUODERM ON COCCYX.\n\nENDO: PT RECEIVED NPH EARLIER IN THE EVENING, TUBE FEEDS HELD, BLOOD SUGAR DOWN TO 75 AT MIDNIGHT AND BACK UP TO 110 BY 1AM WITHOUT TREATMENT.\n\nSOCIAL: DAUGHTER STILL VERY UNREALISTIC ABOUT MOTHER'S SITUATION. CALLED TO BE UPDATED. PLEASED THAT SHE IS NO WORSE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-11 00:00:00.000",
"description": "Report",
"row_id": 1606964,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Patient to CT for abdominal scan. No morning abg results at this time.\n\nNo RSBI measured due to lack of spontaneous respiration.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-11 00:00:00.000",
"description": "Report",
"row_id": 1606965,
"text": "Nursing Progress Note.\n\nRESP: Pt received on AC-16-50-400-7.0 c pt breathing @ set MV rate and nl sats. Pt c coarse BS and occ exp wheezes, both clearing c sxn'ing and nebs per RT respectively. Pt c small amounts of thick off white/blood tinged sputum per trach, freq trach care provided. No RSBI performed this AM 2nd apnea. 10:00 ABG values; 7.42-48-81, no MV setting changes made thus far today. Thoracentesis performed @ BS today c 1400mls of clear serous drained s diff, specs sent to lab for analysis. CXR performed s/p thoracentesis confirm no negative sequelae s/p procedure. Freq oral care performed, small bleeding lesions of tongue noted. Pt has a very weak gag reflex and a fair cough reflex.\n\nCV: Hemodynamically stable and afebrile. NSR c BBB noted and occ PVC's. Venodyne & waffle boots in place. AM lytes essentially WNL. CVP values in the 14-22 range today.\n\nGU: Poor hourly urinary output this AM (20ml/hr), pt subsequently med c 40mg IV Lasix @ 11:00 c approx 300ml output over the next three hours. The pt is currently net output 1.3 liters for today and she is net output 1.0 liter since admit.\n\nGI: PEG tube came out of stoma site and found to have a broken balloon. PEG tube replaced and primed c gastrographin f/b abd x-ray which confirmed good placement. FS tube feeding of Nepro c Pro-mod restarted and currently infusing @ 30ml/hr (target rate of 35ml/hr) c low residuals thus far. Pt med c 3# Dulcolax supp today, no BM output thus far today. Abd remains firm, distended c erythema & warm of lower quadrants noted. Surgery team visited pt to eval abdomen, no surgical proc applicable for this abnormality. Will send a stool spec to r/o c.diff c next suitable spec.\n\nMS: Pt does not follow commands or appear purposeful in any way today. Pt withdraws to noxious stimuli. PERRL. Pt becomes hyperdynamic (increase HR, WOB, RR) c turns, trach care, mouth care and procedures (thoracentesis) -- med c 2mg IVP Morphine Sulfate today c + affects. The pt is not restrained. Lacrilube eye ointment applied, pt noted to have poor blink reflex.\n\nSOC: Dtr called this AM and kept up-to-date c POC/pt status. The pt is a Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. VRE/MRSA+ Contact isolation precautions in place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-11 00:00:00.000",
"description": "Report",
"row_id": 1606966,
"text": "Patient remains on mechanical ventilation suctioned for moderate amount of thick yellow secretion. Pleural fluid taped 1.5 liter.BS wheezy,not responding to commands but to stimulation (ie) suctioning.ABG metabolic compensation from mild resp acidosis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-14 00:00:00.000",
"description": "Report",
"row_id": 1606978,
"text": "1900-0700 npn\nNEURO: status unchanged from prev. exam\n\nCV: HR sinus 60-80 with occasional ectopy. cvp 10-13 with good trace. maps stable above 60. natrecor started with bolus preceeding. some transient decrease in sbp, gtt cont. 0.01 mcq/kgk/min. no increase in hrly urine output seen. pp intact Tmax 98.4 oral\n\nRESP: vent sets unchanged. sats 92-94% , coarse all lobes with intermittant exp. wheeze. no rales, cont to suction large amt. blood tinged sputum thick yellow requiring saline lavage to clear. oral secretions tan mod. amt. no bleeding noted in mouth this pm. trach drainage green mod.\n\nGU/GI: foley drains amber urine 0-15 cc hr. natrecor gtt cont. , lasix total 80 mgm IV given with little response. active BT, ventral hernia, mushroom cath in place for mod brwn stool. tf at goal 35 cc hr through peg., peg site wnl.\n\nSKIN: duoderm on coccyx intact. abrasion left forearm with tegaderm healing.\n\nENDO: BS 129, no coverage needed.\n\nSOCIAL: dtr called to inquire regarding status. update given SW consult requested to assist dtr in process and coping.\n\nACCESS: triple lumen all lumens patent, art line wnl, sharp.\n\nPlan: cont supportive care, pulm toilet, skin care, SW referral to assist dtr with and coping. Plan ECHO .\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-15 00:00:00.000",
"description": "Report",
"row_id": 1606982,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT REMAINS TO HER SURROUNDINGS. OPENS EYES SPONTANEOUSLY AND WITH STIMULATION. DOES NOT FOLLOW COMMANDS. PEARL.\n\nRESP: REMAINS ON CMV 50% 400 X 12 10PEEP. NO VENT CHG'S MADE. WITH O2 SATS IN THE MID TO HIGH 90'S. WILL DESAT WHEN TURNING OR SX'ING. SX FOR MOD TO LRG AMT'S OF THICK TAN BLOOD STREAKED SECRETIONS. TRACH SITE WELL HEALED. DRAINING SOME TAN SECRETIONS AROUND SITE. TRACH CARE DONE. LUNG SOUNDS COARSE WITH INS/EXP WHEEZES. IN LINE NEBS GIVEN BY RT. OVERBREATHING VENT INTO THE TWENTIES.\n\nCV: NSR WITH RATES IN THE 60'S TO 80'S. AFEBRILE. HYPERTENSIVE AT TIMES OTHERWISE BP WITHIN ACCEPTABLE LIMITS. TOLERATING HYDRALAZINE.\n\nGI: ABDOMEN GREATLY OBESE. CONT ON TUBE FEEDS AT GOAL RATE. SKIN ON ABD CONT TO BE PURPLISH IN COLOR. PASSING LIQ BROWN STOOL VIA MUSHROOM CATH.\n\nGU: FOLEY CATH PATENT DRAINING EXTREMELY SMALL AMT'S OF AMBER URINE.\n\nSKIN: DUODERM ON COCCYX INTACT. OTHER AREAS ARE HEALING.\n\nENDO: FINGERSTICKS Q 6/HR'S. SSRI. SEE FLOWSHEET AND .\n\nSOCIAL: DAUGHTER IN VISITING AT CHANGE OF SHIFT AND CALLED TO BE UPDATED OVERNIGHT. PT CONT TO BE FULL CODE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-15 00:00:00.000",
"description": "Report",
"row_id": 1606983,
"text": "83 y.o. with anoxic brain injury vf arrest , vent dependent, chf, dm, mrsa, vre, pseudomonas pna, sepsis, ...hosp course c/b pleural effusions, arf and ? vegetation on valve from recent echo.\n\nneuro: pt remains ...opens eyes spontaneously but does not track or follow commands. withdraws to nailbed pressure x4 extremites noted. cough impaired/gag absent.\ncv: monitor shows nsr with no ectoy noted. remains on asa, lopressor and hydralazine. cvp remains ^. cardiology consulted for tee for ? of vegetation on valve from echo ...dtr explained risks and by md and refused procedure.\nresp: ls coarse througout with diffuse wheezes noted. mdi's given by rt. sxn for mod amts thick yellow/blood-tinged secretions via trach and copious amts tan colored oral secretions. no vent changes this shift.\ngi: abd obese, firm and distended with +hernia noted. bs present. tf's off in am residuals >200. started on reglan atc. tf's resumed this afternoon @ 15 cc/hr and to be advanced as tolerated to goal of 35 cc/hr. mushroom catheter intact draining loose brown stool.\ngu: foley intact and patent draining sm amts amber colored urine with no sedimentation noted. renal consult in place and ? need for hd in near future.\nskin: l breast and L inner abd fold with superficial open areas noted and barrier products applied. duoderm to coccyx c/d/i. discoloration to abd and L upper leg unchanged from previous. sm skintear to l forearm and tegaderm intact. peg tube exit site retention sutures c/d/i. sm superficial rash noted on back...? etiology...dr. aware and assessed. remains on kinair bed.\nendo: remains on fingersticks q6rh with nph and humalog insulin q6hr per s/s. scale titrated for tighter blood sugar control.\ni-d: afebrile. remains on meropenum. contact maintained.\nheme: plan for 1 uprbc to be given this eve per renal's recomendations. awaiting availability from bb. will need lab work sent this eve ~2200.\naccess: l radial aline, r scv. iv rn up to eval for bedside picc...unable to place and to be done under ir.\npsy-soc: dtr called x4 and updated on status and plan of care by this rn and dr. . dtr expressing that she wishes mother to be transferred back to memorail asap. Dr. spoke with accepting md @ jmh and discussed acute issues of ?endocarditis, resp status, arf and possibility of need for return. dr. (jmh) felt comfortable accepting pt and these ongoing issues given dtr's desire to have her return. plan for d/c on monday. screener in to eval and case mgmt aware. remains full code on micu service.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-15 00:00:00.000",
"description": "Report",
"row_id": 1606984,
"text": "Respiratory Care:\nPt continues to be mechanically ventilated via trach on A/C settings. No changes made to settings today; MDI's given as ordered. Plan to continue ventilating as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-09 00:00:00.000",
"description": "Report",
"row_id": 1606958,
"text": "Nursing Progress/Admission Note.\n\nBriefly, this is a 83 yr old female from c hypoxic resp failure. Pt has a long PMH including; cardiac arrest c hypoxic brain injury, trach(03)/vent dependent, PNA, CHF, MRSA/VRE+, Pseudomonal inf, COPD, OSA, HTN, CHF, s/p thyroidectomy, PUD, Anemia. Pt c recent desats @ requiring freq sxn'ing for small amounts of white clear sec. However, today pt desat to 80's, given IV Lasix s affect, EMS subsequently activated and pt brought to /EW. In EW pt was found to have an elevated WBCC of 24.4 c 6% bands and PNA on CXR. Pt subsequently placed on 100% AC mode and loaded c IV Vanco, Zosyn, Ceftriaxone. Pt med c 2mg IV Morphine Sulfate & 1.5mg IV Lorazepam to help pt settle and brought to MICU-B for continuation of care. The pt is a Full Code per dtr who is visiting @ BS.\n\nRESP: Pt currently on AC-16-60-450-5.0 c pt breathing c vent c a sat of 100%, will draw/send repeat ABG shortly. Pt currently c min vol of liters and breathing @ set MV rate. Trach site appearance is benign, trach ties changed. Last ABG values @ 17:00; 7.36-52-170 on 80% FiO2.\n\nMS: Pt does not appear purposeful and does not follow commands. PERRL weakly. No restraints required @ this time. Significant muscle atrophy noted. Pt withdraws to noxious stimuli.\n\nCV: Pt arrived from EW on Levo gtt infusing @ 0.03mcg/kg/min c hyperdynamic ABP values in the 160-190 range. Levo gtt subsequently weaned off s diff and pt cont to maintain MAP's in the 70-80 range since gtt d/c. CVP values of 15-18 obtained @ BS, team notified of results. Pt has a 20# gauge PIV in LUE AC. NSR c bundle branch noted, afebrile oral temp of 97.4. Pt probably septic c bandemia & elevated WBCC noted above. Pt pan cultured in EW, still needs a urine C&S sent for analysis.\n\nDERM: Stage III pressure ulcer noted on coccyx, site was cleaned followed by application of barrier cream and pt positioned off ulcer on L side. Pt needs Venodyne boots.\n\nSOC: Dtr currently visiting @ BS, kept up-to-date c POC/pt status. Pt is a long standing Full Code.\n\nOTHER: Please see CareVue for additional pt care data/comments. Contact isolation precautions in place.\n\nGI: PEG in place, site appearance is benign (recently placed per dtr report). Expect to re-start TF's to meet the pts nutritional needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-10 00:00:00.000",
"description": "Report",
"row_id": 1606959,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT IS . WILL OPEN EYES BUT WILL NOT TRACK, EXTREMETIES VERY RIGID. DOES NOT MOVE THEM ON HER OWN. BREATHS WITH AND OVER THE VENT.\n\nRESP: PT IS VENT DEPENDENT AT BASELINE. PT ALSO . SEE FLOWSHEET FOR VENT SETTINGS/AND ABG'S . TRACH SITE CLEAN AND DRY. PT SX FOR SMALL AMT'S OF BLOOD TINGED SPUTUM. O2 SAT'S IN HIGH 90'S TO 100% BUT WILL DESAT BRIEFLY WHEN HEAD IS DOWN AND WHILE TURNING. LUNG SOUNDS WHEEZY AND IS RECEIVING IN LINE NEBS WITH GOOD EFFECT. PT BREATHING WITH VENT BUT ALSO BECOMES TACHYPNEIC WITH RATES IN THE 30'S.\n\nCV: PT IN NSR WITH OCC PVC'S, LEVOPHED ON AND OFF TO KEEP MAPS 65 OR BETTER. CURRENTLY LEVO IS ON SMALL DOSE. SEE FLOWSHEET FOR DATA. PT IS .\n\nGI: PT IS NPO, PT HAS PEG BUT CURRENTLY CLAMPED. ABD GREATLY OBESE AND DISTENDED WITH VENTRAL HERNIA. WHEN HEAD TOO LOW PT UNABLE TO GET ENOUGH AIR. NO STOOL.\n\nGU: PT HAS FOLEY CATH DRAINING SMALL AMT'S OF CLEAR YELLOW URINE. U/A SENT FOR C/S. PT HAS CHRONIC RENAL FAILURE.\n\nSKIN: PT HAS STAGE 3 DECUBITUS ON COCCYX, DUODERM APPLIED.\n\nENDO: ON SSRI. FINGERSTICKS q 6/hrs.\n\nLABS: HCT 22 RECEIVED ONE UNIT PACKED CELLS. CORTISOL LEVELS DONE DURING THE NIGHT.\n\nACCESS: PT HAS LEFT RAD ALINE AND LEFT SUBCLAV TRIPPLE.\n\nSOCIAL: PT HAS VERY INVOLVED DAUGHTER WHO WAS HERE TO VISIT AND CALLED DURING THE NIGHT TO BE UPDATED. PT IS FULL CODE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-14 00:00:00.000",
"description": "Report",
"row_id": 1606979,
"text": "Resp: Pt remains on a/c ventilation. 02 sats 93-97% noc. Bs reveal bilateral wheezes.Improvement noted following MDI.Suctioned for moderate amounts of thick bloody secretions. MDI's given Q4 hrs. AM ABG's 7.37/43/81/26. Plans are to return to critical care facility. No vent changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-14 00:00:00.000",
"description": "Report",
"row_id": 1606980,
"text": "Resp care\nPt remians on unchanged vent settings. No recent ABG's. BS coarse, sx mod thick blood tinged secretions. MDI's given as noted. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-14 00:00:00.000",
"description": "Report",
"row_id": 1606981,
"text": "83 y.o. with anoxic brain injury vf arrest , vent dependent, CHF, DM, MRSA, VRE, pseuodomonas pna, sepsis ...hosp course c/b pleural effusions and ARF.\n\nneuro: pt ...eyes open spontaneously but does not track or follow commands. withdraws to nailbed pressure x4 extremities noted. cough impaired/gag absent.\ncv: monitor shows nsr with rare pvc noted. remains on asa, lopressor, and hydralazine. cvp 14-20. pt had cardiac echo done at bedside and results pending.\nresp: ls coarse throughout with occ wheezes noted. nebs via rt. no vent changes this shift. sxn for mod amts thick blood tinged secrtions and copious amts oral secretions. trach care done.\ngi: abd obese, firm and distended with +hernia noted. mushroom catheter intact draining loose brown stool heme-. tf's infusing at goal with minimal residuals noted.\ngu: foley intact and patent draining scant amts amber colored urine with no sedimentation noted. natrecor gtt d/c'd this shift. renal consult in place.\nskin: peg tube exit site with sm amt old brown drainiage noted...wash with ns and ota. abd with purplish discoloration. bilat legs reddended. tegaderm to l forearm intact. duoderm to coccyx intact. remains on kinair bed.\ni-d: afebrile. contact precautions for pseudomonas in sputum. remains on meropenum.\nendo: remains on fingersticks q6hr with humalog insulin in addition to nph.\nheme: cbc sent this afternoon and hct stable.\npsy-soc: dtr called x2...updated on status and plan fo care by this rn and dr. . remains full code on micu service. dtr in to visit this evening.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-16 00:00:00.000",
"description": "Report",
"row_id": 1606985,
"text": "micu npn 1900-0700\nplease see carevue flowsheet for all objective data\n\nros-\n\nneuro- ms. remains essentially . opens eyes spontaneously. w/d extremeties to pain. +cough/impaired gag noted. no neurological changes\ncv/resp- vss. hypertensive w/movement/turning, am care, etc. settles down to 1teens-130/sys. hr 60's. tolerating metoprolol and hydralizine. remains vented on cmv 50% fio2 400x16, peep10. suctioned q3-4 hrs for thick bloody pluggy secretions. of note mouth secretions also bloody. pt w/intermittant positinal cuff leak, resealed x1 w/one cc air.\ngi/gu- abd obese firm. +bs. passing sm amts of loose bvrown stool via intact mushroom catheter. remains on tube feeds, tolerating well on reglan. increased back to goal of 35cc/hr overnight. uop remains marginal at best 6-20cc/hr. bun/cr slightly elevated from yest am, last eve 104/2.7.\nheme- recevived 1 unit of prbc's w/o incident.\nsocial- heard from dtr x2 overngiht.\nplan for picc in IR on monday am and probable transfer back to rehab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-16 00:00:00.000",
"description": "Report",
"row_id": 1606986,
"text": "Respiratory Therapy\nPt remains trached via #7.0 Shiley trach tube, on full mechanical support. No vent changes made this shift. BLBS scattered rhonchi/coarse, suctioned for small amounts of thick tan sputum. MDIs given as ordered to good effect. PIP/Pplat = 30/27. SpO2 remained 90s t/o shift. See resp flowsheet for specific vent data.\n\nPlan: maintain support, ?d/c to rehab monday\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-16 00:00:00.000",
"description": "Report",
"row_id": 1606987,
"text": "FOCUS; NURSING PROGRESS NOTE\n83 YEAR OLD FEMALE WITH ANOXIC BRAIN INJURY S/P V FIB ARREST . ADMITTED WITH DESATING EPISODES ON VENT AT JMH. WHILE HERE HYPOTENSIVE REQUIRING LEVO. OFF LEVO SINCE . NOW WITH ARF AND TTE THAT SHOWED ? VEGETATION ON MITRAL VALVE. DAUGHTER REFUSING .\nREVIEW OF SYSTEMS-\nNEURO- OPENS EYES SPONTANEOUSLY. WITHDRAWS TO PAINFUL STIMULI. POS COUGH AND GAG. DOES NOT TRACT. DOES NOT FOLLOW COMMANDS.\nRESP- TRACHED AND VENTED ON 50% FIO2/ TV 400/ A/C RATE OF 16 OVERBREATHING BY UP TO 6 BREATHS. PEEP 10. ON THIS SATS 93% OR GREATER. BS RHOUNCHOROUS DIMINISHED AT BASES. PREDISONE DOSES BEING TAPERED.\nCARDIAC- HR 60-70'S NSR WITHOUT ECTOPI. SBP 120-160 DEPENDING ON HOW STIMULATED THE PATIENT IS. SHE CONT ON LOPRESSOR AND HYDRALAZINE.\nK 4.0 TODAY. MG 2.4.\nGI- ABD OBESE DISTENDED WITH POS BS. HAS PEG WITH TF OF NEPRO WITH PROMOD AT GOAL RATE OF 35ML/HR. MIN RESIDUALS ON ATC REGLAN. PASSING BROWN LOOSE STOOL VIA MUSHROOM CATHETER THAT IS GUIAC POS.\nGU/RNEAL- UO VIA FOLEY 13-23CC/HR OF CLEAR YELLOW URINE. CREAT STABE AT 2.7. RENAL FOLLOWING.\nHEME- HCT STABLE AT 29.9.\nID- WBC UP TO 17.1. TEMP MAX 98.4. CONT ON MEROPENUM. WILL NEED ANTIBIODIC COVERAGE FOR 6 WEEKS DUE TO ? VEG ON MITRAL VALVE.\nSKIN- ECCHYMOSIS DECREASING ON ABD AND LEFT THIGH FROM SC HEPARIN INJECTIONS. SC HEPARIN DC'D A COUPLE DAYS AGO. HAS SKIN TEARS IN UNDER LEFT BREAST AND LEFT GROIN. BARRIER CREAM APPLIED. DUODERM REMAINS ON COCCYX.\nSOCIAL- DAUGHTER CALLED AND WAS UPDATED BY THIS NURSE.\nDISPO- REMAINS IN THE MICU A FULL CODE.\nPLAN- TRANSFER BACK TO JMH AT DAUGHTERS REQUEST AFTER A PICC IS PLACED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-16 00:00:00.000",
"description": "Report",
"row_id": 1606988,
"text": "Resp Care\nPt remains on full venilatory support with no changes made to parameter settings this shift. BS course bilaterally with exp wheezes present when stimulated post sxing. Alb/atr given x3 with good increased aeration noted post tx. Sxed occasionally t.o shift for small to mod amts of thick tan/blood tinged secretions. WIll cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-17 00:00:00.000",
"description": "Report",
"row_id": 1606989,
"text": "Neuro: Pt. opens eyes to stimuli, does not track or follow commands, withdraws to nail bed pressure, pupils minimally reactive 3mm bilat, no extremities movement noted.\nResp: Vented via trach on AC 16, FiO2 60%, Vt 400, PEEP 10, sats 91-97, suctioned for copious amt of blood tinged thick sputum, occasionally expectorates yellow or blood tinged secretions, requiring frequent oral suctioning as well. LS rhonchi, diminishe at bases.\nCV: HR 60s-70s, NSR, with BBB, no ectopy. SBP 130s-150s. Pedal pulses palpable bilat. Minimal UO 10-30 cc/hr.\nGI/GU: Abd. obese, lrg. hiatal hernia noted above umbilicus, +BS, mushroom cath with min. brown liquid stool. Tolerating Nepro with Promode at goal rate of 35 cc/hr via Peg, no residuals. Foley patent with clear yello urine out.\nSkin: Coccyx duoderm c/d/i. Abd. ant lt. thigh bruising due to Hep injections persist.\nEndo: BS checked QID, covered with sliding scale.\nSocial: Daughter called twice, updated on status.\nPlan: Awaiting PICC placement in IR on Monday, d/c to Memorila after procedure, paperwork initiated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-13 00:00:00.000",
"description": "Report",
"row_id": 1606973,
"text": "1900-0700 NPN\nNEURO: unchanged neuro exam, responds to tactile stim by opening eyes, does not track with eyes, no blink, no gag reflex.\n\nCV: hr 60-80 sr, sys 130-160 with stim., urine out light yellow in color but min. 10-15 cc hr. bolus x1 500cc with initial increase in urine out to 33 hr x1 hr. cvp 11, pp intact x4, extremities warm Tmax 98.9 oral.\n\nRESP: large amt thick yellow blood tinged sputum, requires saline lavage, copious thick oral blood tinged mucous, some old blood on tongue. lungs coarse to clear with suction, sats 92%-95%, sats slightly improved with right side down. peep at 10 50%. no vent changes this pm. trach site with green thick drainage. mod amt.\n\nGU/GI: urine yellow clear, foley patent, urine lytes unremarkable. ventral hernia, active bowel tones, one loose drk brwn stool, spec sent for Cdiff. tf at goal nepro with promod at 35 cc hr per peg tube. peg tube site wnl.\n\nSKIN: duoderm intact on coccyx. left forearm abrasion no active bleed. drsg . discoloration on lower abdomen and left thigh resolving.\n\nPAIN: appears in no discomfort based on vs/grimace scale.\n\nACCESS: multilumen cath in left shoulder without drainage, all lumens patent, cvp trace sharp. art line in left radial with good trace. site wnl.\n\nENDO: bs 136 with reduced fixed dose and sliding scale.\n\nID: sputum c/s shows psuedomonas, blood and urine cultures pending.\n\nSOCIAL: dtr. called x 2 to inquire re: pt. status. Update provided. Note to social work to assess dtr. understanding of pt. prognosis and long term care plan/assistance with coping.\n\nPLAN: cont. to provide supportive care, pulm toilet, refer dtr to social work to assist dtr in coping and planning for LTC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-13 00:00:00.000",
"description": "Report",
"row_id": 1606974,
"text": "Resp: pt on a/c 16/400/50%/+10. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds. Suctioned for moderate amounts of thick bloody secretions, as welll as oral cavity for same. MDI's administered Q4 Alb/Atr. No RSBI due to ^ peep. AM ABG's 7.38/43/76/26. No vent changes noc. Will continue to wean appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-13 00:00:00.000",
"description": "Report",
"row_id": 1606975,
"text": "\nPT MAINTAINED ON A/C VENTILATION AT 50%. VITALS STABLE WITH GOOD SATS. B.S. BILAT WITH EXP. WHEEZES TO ALL. MENTALLY PT . NO NEW ABGS. NO WEANING OR CHANGES TODAY. PT BEING ASSESSED FOR TRANS. BACK TO CHRONIC CARE FACILITY. PLAN IS TO CONT. ON A/C VENTILATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-13 00:00:00.000",
"description": "Report",
"row_id": 1606976,
"text": "FOCUS; NURSING PROGRESS NOTE\n83 YEAR OLD WITH ANOXIC BRAIN INJURY TRACH, VENTED AND PEGGED. ADMITTED WITH PNA AND HYPOTENSION. HAS BEEN OFF LEVO SINCE .\nREVEIW OF SYSTEMS-\nNEURO- NONRESPONSIVE. PUPILS EQUAL AND NONREACTIVE. DOES NOT BLINK TO THREAT. WITHDRAWS TO PAINFUL STIMULI.\nRESP- TRACH AND VENTED ON 50% FIO2/ TV 400/ A/C RATE OF 16 OVERBREATHING BY UP TO 3 BREATHS AND 10 PEEP. SATS ON THIS 93-98%. SUCTIONED FOR THICK BLOOD TINGED SPUTUM. DOES REQUIRE LAVAGING AT TIMES. BS RHONCHOROUS.\nCARDIAC- HR 70-80'S NSR WITHOUT ECOTPI. SBP UP TO 160'S THIS AM. STARTED ON LOPRESSOR AND HYDRALAZINE TODAY. SBP 120-150. IONIZED CA 1.07 THIS AM TX WITH 2GMS OF IV CAGLUCONATE.\nGI- ABD OBESE DISTENDED AND FIRM. WITH HYPERACTIVE BS TODAY. PASSING LARGE AMOUNTS OF BROWN GUIAC POS STOOL TODAY. SPEC HAD BEEN SENT ON NIGHTS FOR C DIFF. HAS RECTAL MUSHROOM CATHETER IN PLACE. HAS PEG WITH TF OF NEPRO WITH PROMOD AT GOAL RATE OF 35CC/HR. MIN RESIDUALS. HAD ONE EPISODE OF EMESIS OF APPROXIMATLEY 50CC THIS AM. ? IF ASPIRATION WITH THIS. MICU TEAM MAD AWARE ON ROUNDS.\nGU/RENAL - FOLEY PATENT DRAINING SMALL AMOUNTS OF YELLOW URINE. UO 10CC/HR THIS AM. DR MADE AWARE ON ROUNDS. 80MG IV LASIX ORDERED AND GIVEN. URINE FOR ESINOPHILS AND UREA NITROGEN, CREAT DONE. BY RESLULTS PATIENT LOOKS DR DR . DR MADE AWARE THAT UO SINCE LASIX 15-20CC/HR. NO TX ORDERED FOR THIS AT THIS TIME. CREAT UP TO 1.9 TODAY. REPEAT LYTES TO BE DONE AT 1800.\nENDO- BS AT NOON 126. REMAINS ON SS AND DOSING OF NPH.\nID- TEMP MAX 99.9. WBC UP TODAY TO 16.5. TROUGH VANCO LEVEL DONE TODAY\n42.8. DR INFORMED AND VANCO DC'D AS WELL AS ZOSYN AND PATIENT STARTED ON MEROPNUM FOR PSEUDOMONAS IN SPUTUM.\nHEME- HCT STABLE AT 27.2 . WILL TRANSFUSE FOR HCT < 25. REPEAT HCT TO BE DRAWN AT 1800.\nSOCIAL- DAUGHTER CALLED AND WAS UPDATED BY THIS NURSE X 2 TODAY. SHE IS TO BE IN THIS EVENING TO VISIT.\nDISPO- REMAINS IN THE MICU A FULL CODE.\nPLAN- CONT TO MONITOR UO.\n CONT PULM TOILET.\n ANTIBIODICS AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-13 00:00:00.000",
"description": "Report",
"row_id": 1606977,
"text": "focus; adendum\nGU- PATIENT TO START ON NATRECOR. TO BE BOLUSED THEN START ON A DRIP. IF THIS DOES NOT WORK TO INCREASE PATIENT'S UO DR WOULD LIKE TO BE NOTIFIED AND LASIX WILL BE OREDERED. ALSO CARDIAC ECHO ORDERED FOR AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2129-04-12 00:00:00.000",
"description": "Report",
"row_id": 1606967,
"text": "1900-0700 NPN\nNEURO: unchanged neuro check, eyes deviated up and left, when on left, dolls eyes, no blink, gag absent, cough present.\n\nCV: sinus rate 70-80 with occ ectopy, urine out min 20-40 cc hr., pp weak but intact x4, sys bp 110-140 dependant on stimulation. afebrile\n\nRESP: secretions thick yellow blood tinged, mod to large amt. using saline lavage to clear. lungs coarse to clear after suction, diminished bil. oral secretions tan, mod. tongue protrudes consistantly. bronchospastic with turns s/s and suction. sats 96%, trach site wnl\n\nGU/GI: abd distended firm, tf at goal 35 cc hr, peg site intact, ventral hernia, marked area on bil. lower quad abd non progressive, firm right vs left, progressing to drk red color, . saw pt to reeval x2. no planned. BT absent. no stool, urine min. via cath. irrigated foley to ensure patency, patent,\n\nSKIN: coccyx stage one decub, cleansed duoderm on, skin tear on left forearm bleeding, redressed.\n\nENDO: pt. fingersticks wnl\n\nID: started on metrodiazanole q 8 hr. cont. pipercillin, vanco\n\nACCESS: art line patent, good waveform, triple lumen wnl.\n\nSOCIAL: dtr at bedside, numerous questions regarding current meds, anxious, focused on moms care.\n\nPLAN: cont. supportive care, antibiotics, min. needlesticks due to bleeding easily, cont. pulm care. no plan to . for changes in abd at this time.\n"
},
{
"category": "Echo",
"chartdate": "2129-04-14 00:00:00.000",
"description": "Report",
"row_id": 79100,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 66\nWeight (lb): 220\nBSA (m2): 2.08 m2\nBP (mm Hg): 137/54\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:08\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: 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%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nMildly dilated aortic arch. Focal calcifications in aortic arch.\n\nAORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve\nleaflets. Minimally increased gradient c/w minimal AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Cannot exclude\nmass or vegetation on mitral valve. Moderate mitral annular calcification.\nMild thickening of mitral valve chordae. Calcified tips of papillary muscles.\nNo MS. Mild to moderate (+) MR. [Due to acoustic shadowing, the severity of\nMR may be significantly UNDERestimated.] Prolonged (>250ms) transmitral E-wave\ndecel time.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. Mild to moderate [+] TR. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor apical\nviews. Suboptimal image quality - ventilator.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is normal (LVEF 60%).\nRight ventricular chamber size and free wall motion are normal. The aortic\narch is mildly dilated. There are focal calcifications in the aortic arch. The\nnumber of aortic valve leaflets cannot be determined. The aortic valve\nleaflets are moderately thickened. There is a minimally increased gradient\nconsistent with minimal aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. There is a globulat thickening at the base of the posterior mitral\nleaflet; this most likely represents mitral annular calcification, but a mass\nor vegetation on the mitral valve cannot be excluded. Mild to moderate (+)\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-10 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 858062,
"text": " 5:53 PM\n PORTABLE ABDOMEN Clip # \n Reason: assess for bowel obstruction\n Admitting Diagnosis: HYPOXIA RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with increasing abdominal girth and tense\n REASON FOR THIS EXAMINATION:\n assess for bowel obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for intestinal obstruction.\n\n COMPARISON: None.\n\n SUPINE PORTABLE ABDOMINAL X-RAY: Study is markedly limited secondary to\n technique and patient body habitus. No bowel dilatation. Degenerative\n changes are seen within the spine.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858496,
"text": " 10:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for CHF\n Admitting Diagnosis: HYPOXIA RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with anoxic brain injury vent-dependent who presents w/\n hypoxia now s/p thoracentesis on right\n REASON FOR THIS EXAMINATION:\n assess for CHF\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON .\n\n INDICATION: Anoxic brain injury with ventilator dependence. Assess for CHF.\n\n FINDINGS: Compared with , no obvious significant interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-18 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 858935,
"text": " 7:24 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc placement\n Admitting Diagnosis: HYPOXIA RESPIRATORY FAILURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1750 CATH,HEMO/PERTI DIALYSIS LONG *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with anoxic injury & sepsis\n REASON FOR THIS EXAMINATION:\n picc placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83 year-old with anoxic injury and seposis requiring PICC line\n for IV antibiotics.\n\n RADIOLOGISTS: Drs. and . Dr. , the attending\n radiologist, was present for and supervised the procedure.\n\n The right upper arm was prepped and draped in the usual sterile fashion. Since\n no suitable superficial vein was visible, ultrasound was used for localization\n of a suitable vein. The basilic and brachial veins were patent and\n compressible. After local anesthesia, the basilic vein was entered under\n ultrasonographic guidance with a 21-gauge needle. However, an 0.18 guidewire\n was not able to pass easily through the basilic vein.\n\n Subsequently, the brachial vein was entered with the 21-gauge needle under\n ultrasonographic guidance. Hardcopy ultrasound images were obtained\n documenting patent vein before and after establishing an access. An .018\n guidewire was advanced under fluoroscopy in the brachial vein, but did not\n pass beyond the axillary vein. A 4-French introducer sheath was inserted into\n the brachial vein. The guidewire was removed and approximately 5 cc of\n nonionic contrast were injected. This demonstrated a stenosis of the axillary\n vein at the level of the proximal humerus. Collaterals were seen between the\n axillary and right brachiocephalic vein. An .018 glidewire was then advanced\n through the sheath under fluoroscopic guidance beyond the stenotic area and\n into the right brachiocephalic vein and superior vena cava. The PICC line was\n then trimmed to length and advanced over the glidewire into the SVC. A length\n of 36 cm was deemed to be appropriate. The catheter was flushed, and a final\n chest x-ray was obtained documenting the tip positioned in the mid to distal\n SVC.\n\n A statlock was applied and the line was heplocked. The line is ready for use.\n\n IMPRESSION: Successful placement of a single lumen 36 cm PICC with its tip in\n the mid to distal SVC. The line is ready for use. There is also noted to be\n stenosis of the right axillary vein with several collaterals to the right\n brachiocephalic.\n (Over)\n\n 7:24 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: picc placement\n Admitting Diagnosis: HYPOXIA RESPIRATORY FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857957,
"text": " 12:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with hx hypoxia at nursing home requiring frequent\n suctioning.\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia and frequent suctioning required.\n\n CHEST, ONE VIEW: There are no comparisons. A tracheostomy tube appears in\n satisfactory position. There appears to be cardiomegaly, bilateral pleural\n effusions, right greater than left, and pulmonary edema. There is an\n increased opacity at both lung bases, right greater than left, which could\n represent atelectasis or pneumonia. Surgical clips are seen in the right\n lateral chest.\n\n IMPRESSION: Findings consistent with CHF and bibasilar consolidations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 858191,
"text": " 3:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for lung re-expansion, pneumothorax\n Admitting Diagnosis: HYPOXIA RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with anoxic brain injury vent-dependent who presents w/\n hypoxia now s/p thoracentesis on right\n REASON FOR THIS EXAMINATION:\n assess for lung re-expansion, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Hypoxia. Status post thoracentesis, right lung.\n\n There has been interval right thoracentesis with associated decrease in size\n of right pleural effusion with residual moderate pleural effusion remaining.\n No pneumothorax is evident on this supine radiograph. Tracheostomy tube and\n central venous catheter remain in place. There is stable cardiac enlargement\n and persistent vascular engorgement. The degree of perihilar haziness is\n slightly improved. Small left pleural effusion is unchanged.\n\n IMPRESSION: Improved right pleural effusion following thoracentesis with no\n evidence of pneumothorax. Slight improvement in degree of congestive heart\n failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-11 00:00:00.000",
"description": "P G/GJ TUBE CHECK PORT",
"row_id": 858129,
"text": " 9:48 AM\n G/GJ TUBE CHECK PORT Clip # \n Reason: please evaluate tube placement\n Admitting Diagnosis: HYPOXIA RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with chronic G-tube which was dislodged this am\n REASON FOR THIS EXAMINATION:\n please evaluate tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of G/J tube.\n\n COMPARISON: CT scan from .\n\n SUPINE ABDOMINAL X-RAY: Limited evaluation for G-tube position. The tube is\n seen with the tip positioned in the stomach. Gastrografin contrast has been\n injected, which is seen within the stomach lumen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 857970,
"text": " 3:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with anoxic brain injury vent-dependent who presents w/\n hypoxia.\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Anoxic brain injury, central line placement.\n\n AP SUPINE CHEST: Compared with 3 hours prior, a left central venous catheter\n has been inserted and terminated in the region of the mid SVC. No\n pneumothorax is visualized on the single view. The cardiac and mediastinal\n contours are otherwise stable. Tracheostomy tube is in place. There is\n persistent cardiomegaly, bilateral opacities, likely representing\n atelectasis/consolidation and bilateral pleural effusions. There is also\n pulmonary edema.\n\n IMPRESSION: Bibasilar opacities, as well as progressive CHF. Satisfactory\n line placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2129-04-11 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 858087,
"text": " 1:26 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: concern of abd wall hematoma\n Admitting Diagnosis: HYPOXIA RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with anoxic brain injury, s/p trach + PEG, p/w resp failure\n REASON FOR THIS EXAMINATION:\n concern of abd wall hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83 year old woman with anoxic brain injury status post\n tracheostomy and PEG tube, presents with respiratory failure. There is\n concern about abdominal wall hematoma.\n\n COMPARISON: No comparisons are available.\n\n TECHNIQUE: A-MDCT axial images of the abdomen and pelvis were obtained with IV\n contrast only.\n\n 150 cc of Optiray 350 were administered.\n\n CT ABDOMEN WITH IV CONTRAST: There is a large right pleural effusion with\n associated atelectasis. There is a small left pleural effusion also with\n associated atelectasis. There is a patchy opacity in the left lower lobe that\n could represent atelectasis or pneumonia. There is no pericardial effusion.\n\n There is a large amount of abdominal wall edema. In the lower abdominal wall\n there is no evidence of hematoma. In the upper abdominal wall on the right\n side just at the level of the ribs, there is an increased density that is\n asymmetric when compared to the left side. It measures 1.1 most\n likely represents asymmetric edema. There is a large gallstone in the neck of\n the gallbladder measuring 1.5 cm.\n\n There is a well defined hypodense geographic area in the spleen upper pole\n that measures 11 x 9 cm and could represent an old infarct. There are 2 other\n hypodense areas in the spleen. The pancreas is unremarkable. There is no free\n air in the abdomen. There is a large anterior abdominal wall hernia containing\n nonobstructed small bowel. There is a small amount of free fluid around the\n liver.\n\n CT PELVIS WITH IV CONTRAST: There are multiple calcified fibroids. The rectum\n and intrapelvic bowel loops are unremarkable. There are at least 2 large\n anterior abdominal wall hernia which contain nonobstructed small bowel and\n colon. There is no free fluid in the pelvis.\n\n BONE WINDOWS: There are severe degenerative changes of the lumbar spine.\n Multiple lytic areas in T12 could be due to degenerative changes. However\n correlate with patient's history of pain.\n\n (Over)\n\n 1:26 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: concern of abd wall hematoma\n Admitting Diagnosis: HYPOXIA RESPIRATORY FAILURE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1) Severe abdominal wall edema. No abdominal wall hematoma.\n 2. Small amount of free fluid in the abdomen.\n 3) Hypodense areas in the spleen most likely represent old infacts.\n 4) Large anterior abdominal wall hernias.\n 5) Large gallstone.\n\n\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2129-04-09 00:00:00.000",
"description": "Report",
"row_id": 191861,
"text": "Sinus rhythm. P-R interval approximately 0.18. Left bundle-branch block. No\nprevious tracing available for comparison.\n\n"
}
] |
8,465 | 168,869 | The patient was admitted to , evaluated for surgery. On evaluation, review of the cardiac catheterization films revealed that the patient's inferior ejection fraction was approximately 20 percent. Patient was taken to the operating room on with Dr. where a coronary artery bypass graft times three with a LIMA to LAD and saphenous vein graft to diagonal and saphenous vein graft to OM. Please see operative note for full details. Total cardiopulmonary bypass time was 36 minutes, crossclamp time 51 minutes. Patient was transferred to the Intensive Care Unit on dobutamine infusion with good hemodynamics. In the operating room by transesophageal echocardiogram the patient's ejection fraction was estimated to be approximately 25 percent which improved to 40 percent post cardiopulmonary bypass plus the addition of inotropic support. Patient was weaned and extubated from the mechanical ventilation on his first postoperative evening. The dobutamine was weaned off on postoperative day number one with continued good hemodynamics. Patient was started on low dose Lopressor which he tolerated well. On the night of postoperative day number one patient went into rapid atrial fibrillation with subsequent hypotension. Patient was given Lopresor and amiodarone due to hypotension. The patient was started on Neo-Synephrine. During this patient did not have pulmonary artery catheter but signs of cardiac output were good. Postoperative day number two electrophysiology service was consulted and the patient would undergo attempted EP cardioversion and anesthesia administered adequate sedation and cardioversion was attempted times three. On the second and third attempts at 360 joules patient had two beats of sinus rhythm and subsequently returned to atrial fibrillation. At that time it was decided to continue the patient on amiodarone and to attempt cardioversion at a later date. In addition, the electrophysiology team had been consulted for placement of an AICD due to patient's preoperative cardiac arrest. Also on postoperative day number two patient was found by laboratory data to have a sodium of 127. The day previously, postoperative day number one the patient's sodium was 130. Patient had a moderate to large amount of urine output without any administration of Lasix. A renal consult was obtained for management of the hyponatremia with the laboratory data of the plasma osmolarity of 264 and a urine osmolarity of 352 it was felt that the patient was having SIADH versus heart failure related ADH really. He recommended fluid restriction and Lasix administration as needed. Patient's sodium slowly began to rise after declining on postoperative day three to 126 and ultimately rose to 134. Postoperative day number three patient continued in atrial fibrillation requiring Ancef and continued on amiodarone infusion. Preliminary coagulation studies were checked. Prior to starting patient on heparin for anticoagulation it was noted that the patient had an elevated PTT and examination of prior laboratory data showed that the patient had consistently had PTTs in the mid 50s. Hematology consult was obtained and on laboratory examination it was determined that patient had a lupus anticoagulant and elevated anticardiolipin antibody titer. In light of this it was recommended that patient be started on heparin for anticoagulation as this patient made patient hypercoagulable and recommended as patient's PTTs were elevated factor 10A level should be followed. Also on postoperative day number three patient was taken by the electrophysiology service for implantation of automatic implantable cardiac defibrillator. Patient had a AICD with DDD pacing facilities, model number 7289 implanted on . Patient tolerated this procedure well. During the implantation of the AICD patient was converted into sinus rhythm. On postoperative day number seven it was found that patient's platelet count was decreasing, had been 113 on postoperative day number five, had dropped to 79 on postoperative day number six and was 70 on postoperative day number seven. Patient had previously had a heparin antibody sent which was negative. However, repeat heparin antibody sent at the time was subsequently positive and the heparin infusion was discontinued. Per the recommendation of hematology patient was started on lepirudin as well as Coumadin. On postoperative day number eight patient went back into atrial fibrillation, continued to require low dose Neo- Synephrine which was eventually weaned off on postoperative day number nine. Patient had been started on beta blocker, continued on amiodarone and by postoperative day number nine patient was transferred from the Intensive Care Unit to the regular side of the hospital. Patient had converted from atrial fibrillation to AV paced and after less than 24 hours of patient being on the lepirudin infusion and two doses of Coumadin patient was found to have a PPD greater than 150 and an INR of 2.2. The lepirudin infusion was stopped and consultation with the hematology service recommended if patient's INR remains greater than 2 to not restart the lepirudin infusion. Physical therapy was working with the patient. It was recommended patient would benefit from acute rehabilitation and by postoperative day 11 patient was taken to the electrophysiology laboratory for testing of the AICD. It was found to be functioning properly. By postoperative day number 11 patient was cleared for discharge to rehabilitation. | DP's palpable and pt's by doppler. USING IS UP TO .CV: AFIB 100-130'S. SOME GENERALIZED EDAM NOTE. CI by fick > 2.0. as appropriate, PP+, afebrile.RESP: Lungs clear with some crackles at bases, on RA with sats. Comfort: Pacemaker insertion site achiness releived with 1 percocet po. dobutamine gtt weaned to off this am (per NP). (NA 128, CONTINUE TO CHECK TID)ENDO: ELEVATED BG'S TREATED PER SSRI.GI/GU: BS+. hct stable.resp: LS clear with dim bases bil. MOD AMOUNTS OF C/Y/U.PLAN: NPO. CONTINUE AMIO GTT. CSRU addendum:CV: Pt. svt vs vt. Sbp stable throughout.skin and dryresp status: rm air sats 94-96% bbs clear ^ lobes few crackles lt>rt. pt using IS. Taking in cl liqs po. CARDIOVERTED THIS PM 200J X3. mixed in nacl, serum coritsol and urine lytes sent.RESP: Lungs clear, diminished at bases, on RA with sats. TOLERATING PO'S. 20meq KCL given po for K level 4.1. 99%, using IS well.GI: Abd. COAGS ELEVATED THIS AM, ? Hr comes back to baseline with rest. 7A-3PCONTINUE AMIO GTT AS ORDERED. BP stable. + FLATUS.PLAN: NEO TO MAINTAIN SBP>90. MONITOR RYTHYM. Repleted Ca++ and Mg.RESP: Lungs are clear w/ dim bases. NEO TITRATED FOR SBP>90. LOPRESSOR 2.5MG IV GIVEN X2 AS WELL AS AMIO BOLUS THIS AM FOR HR 130'S. updated. CONTINUES ON AMIO GTT AND NEO GTT TITRATED FOR SBP>90. Started on Neo. Pt. TITRATE NEO FOR SBP>90. CT's dc'd this afternoon.gi/gu: pt with + bs. ?ABLATION. FREQUENT PVC'S NOTED. abg wnl. soft, BS+, no BM this shift.GU: Foley cath. pt ambualted with 2 assist. gtt. gtt. svo2 66-72. Continues to have freq. to maintain SBP>90, Mg+ 2gm bolus given as well. CONTINUES ON FLUID RESTRICTION. Afebrile. FREQUENT PVC'S. Wean FIO2. HR decreased to 110's-120's and continues to have frequent PVC's, amio.gtt. 7p-7aCV: Pt had permanent pacer/AICD placed today. The rightatrium is moderately dilated. Pt recieved one unit prbc for hct 26. MAE and able to follow commands.CV; pt remains NSR/ST, occasionally pvc's noted. Neuro: Pt a&o x3. GI: NPO for procedure, had small bm on bsc. CV: Asensing/vpaced. HR 80-100's. ?NEED FOR ABLATION. 150mg IV bolus. SBP up > 100. started. Pulm: RA sat 97%, lungs clear with fine rales at bases, pcxr taken this am. Uses IS with encouragement.NEURO: Oriented. Neo gtt weaned slowly to .15mcg/kg/min keeping sbp equal to or >90. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 69Weight (lb): 185BSA (m2): 2.00 m2BP (mm Hg): 124/82HR (bpm): 80Status: InpatientDate/Time: at 16:57Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated. AMBULATED AROUND UNIT WITH MINIMAL ASSIST.RESP: LS CLEAR WITH DIM BASES. if BP tolerates, replete electrolytes, monitor Na+, fluid restriction. CAUSE. Neuro: A&O x 3. Pts friend "". to maintain SBP>90, able to wean to .50mcg/kg/min, continues on amio.gtt. PAPABLE PEDAL PULSES. PAPABLE PEDAL PULSES. CSRU NOTE:NEURO: A/O X 3, MAE, very pleasant and cooperative.CV: Continues in AFIB with rates 100-120's with frequent PVC's and occassional PAC's, continues on neo. GI: Abd soft, bs+, lg bm x 1 this shift. Adendum: Pt returned from cathlab s/p placement of DDD permanent pacemaker. Neo gtt in place to keep sbp >90 Heparin gtt currently at 1100u/hr. BS 178 AND GTT STARTED-CONT TO BE TITRATED. NOW SOMEWHAT HYPERTENSIVE WITH VERY SIMILAR PA NUMBERS TO HYPOTENSIVE EPISODES-CVP7 AND PAD 15. CONT TO TITRATE LEVO-NTG PRN. GI: OGT-LCWS-SCANT DRG. -> clear ^ lobes dimins lower lobes after diuresing 1liter urine in 2hrs.neuro status: aaoriented, follows simple commands. RESP: PT NOW ON CPAP WITH SATS 100 AND RR 16-20. FICK CHECKED AND 2.87. ^ audible exp wheeze by 0300 crackles noted to apices. Amiod bolus150mg/ gtt@ 1mg/m x6 then 0.5mg x 18hrs. Titrate heparin to keep factor 10 between 0.3 and 0.7. to maintain SBP>90, amio.gtt. Neuro: A&O x3 CV: In afib this am with rate 120 up to 157 with activity. UpdateO: cv status: vpaced(perm pacer)-> rafib to 130's. GU: PT WHEN FIRST ARRIVED-HAS SLOWED DOWN TO 100/HR. LAB: ION CA AND MG REPLETED. Endo: Per ssc. PT UPDATE PT ARRIVED FROM OR AT 1230 S/P CABG X3. INITIALLY PT HYPOTENSIVE AND HYPOVOLEMIC. R: Neo currently at 0.17mcg/kg/min, factor 10 pending. Heparin gtt. @ 0.5 dc'd at 0400, heparin gtt. Converted to Asensing/Vpacing in late morning after 2.5mg IV lopressor. abd distended, soft, +bowel snds-> hyperactive. BP now low 100/60's sys. WITH INITIAL CI 2.8-DOWN TO 1.8. Passing lg amts flatus & sm liq stool. sbp bdline w rapid hr& transiently in response to iv lopressor.Repleted k+ w lasix 10mg iv dosing for crackles throughout bilat.resp status: O2 added @ 2lpm prophylac w rapid hr. DOSE AT THIS TIME. increased to 900U/hr, goal of Factor Xa of .3-.7, will continue to monitor, DDD, PP+, afebrile.RESP: Lungs clear with crackles at bases, 02 @ 2L via NC with sats>97%, using IS, productive cough.GI: Abd. PT WAS GRADE 3 VIEW INTUB. BS clear in upper airway, rales in bases and rising, bilaterally.GI: Pt has poor appetite. Pt started on Neo currently at .3 mcg/k/min perpherially, please monitor closely. Lytes repleated.Resp: Pt on RA O2 sat 96-98%. BP stable in low 100-110 sys. colace held.gu status: uop as noted above. B:Neuro: a and o x 3, mae, following commands correctly, mso4 for pain.Cardiac: nsr in the 90's with frequent pvc's, continues dobuta gtt, going by cardiac fics for indexes which have all been good, svo2's running in the 60 range, palpible pedial pulses, skin warm dry and intact, a-febrile, +2 edema inextremities, did get 1 liter of lr for low cvp's this shift.Resp: dim inbases, did vagal hr down with sxning pre extubation and did come back up on own shortly after, on 2 liters nc satting at 99% post extubation gas is good, no leak in ct system which is draining scant sero-sang.Skin: chest with dsd with old moderate serosang drainage from or, ct dsds are cdi, right leg ace is cdi.Gi/gu: tolerating ice chips, abd soft round and nontender with hypoactive bowel sounds,continues riss gtt, making good u/o.Plan: increase activity, monitor blood sugars, monitor ci's, monitor u/o, monitor for increase ectopy, encourage to cough and deep breath. | 28 | [
{
"category": "Echo",
"chartdate": "2122-03-27 00:00:00.000",
"description": "Report",
"row_id": 103123,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 69\nWeight (lb): 185\nBSA (m2): 2.00 m2\nBP (mm Hg): 124/82\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 16:57\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated. The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. There is severe global left ventricular\nhypokinesis. Overall left ventricular systolic function is severely depressed.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function is\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: There is mild mitral annular calcification. Mild (1+) mitral\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The left atrium is elongated. The right\natrium is moderately dilated. Left ventricular wall thicknesses are normal.\nThe left ventricular cavity size is normal. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed. Right ventricular chamber size is normal. Right\nventricular systolic function is normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nAt least mild (1+) mitral regurgitation is seen. There is no pericardial\neffusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , no change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-04 00:00:00.000",
"description": "Report",
"row_id": 1374234,
"text": "7p-7a\nCV: Pt had permanent pacer/AICD placed today. Rhythm is a-sense and v-pace with a rate in the 70-80s. Epicardial wires protected and secured to chest. No ectopy. Afebrile. BP stable. Aline began to dampen, blood could not be drawn back, and oozing-aline d/c'd.\n\nPULM: 1L/NC with sats 97%. Attempted room air, sats dropped to 91-92%. Lungs clear. Uses IS with encouragement.\n\nNEURO: Oriented. Benadryl given for sleep, worked very well. Bedrest as until a.m. Sling on left arm.\n\nGU: Voiding on own.\n\nGI: Active bowel sounds. Ate dinner after cath lab. No BM.\n\nPLAN: Bed rest and sling. Wean FIO2. Change amio to po? No heparin per cath lab due to heme consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-04 00:00:00.000",
"description": "Report",
"row_id": 1374235,
"text": "Neuro: A&O x 3. CV: Asensing/vpaced. See cardiology note for adjustments made this morning. 20meq KCL given po for K level 4.1. Pt recieved one unit prbc for hct 26. Pulm: Room air sats 93-96%. Lungs with fine scattered rales that improve somewhat after coughing. Pt using IS independently with good technique. GU: Pt voids 200-300cc clear yellow urine q 2-3hrs. Seen by renal this am who are following hyponatremia. Am Na 131, 129 this pm. Pt has had some restriction of fluid and is using salt in small quantity with meals. GI: Taking meals with good appetite, bs+, abd soft. Activity: Sling in place on left arm until 1700,pt oob in chair most of day, back in bed this evening for removal of temporary pacer wires. Comfort: Pacemaker insertion site achiness releived with 1 percocet po. P: Transfer to telemtry floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-05 00:00:00.000",
"description": "Report",
"row_id": 1374236,
"text": "Update\nO: cv status: perm ddd pacer pacing rate 80.Isolated burst rapid hr ? svt vs vt. Sbp stable throughout.\nskin and dry\n\nresp status: rm air sats 94-96% bbs clear ^ lobes few crackles lt>rt. Cough w/o raising sputum.\n\nneuro status: sleeping in long naps. Med w perc 1tab x 1 for discomfort lt shoulder pacer insertion site-> w gd effect.aaoriented\n\ngi status: glucose managed w riss protocol. Taking in cl liqs po. Leaking liq stool w passing flatus-> oob to commode sm formed soft brwn stool + liq stool guiac neg.Abd soft distend nontender + bowel snds.\n\ngu status: vding sm amts amber urine.\n\nheme/id: still receiving vanco post proced. Per hematology lab Factor 10 to be drawn/run after 7am-> call before lab draw.\n\nA/P: Stable.? transfer to 2. Labs to be drawn w factor 10.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-02 00:00:00.000",
"description": "Report",
"row_id": 1374228,
"text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative.\n\nCV: Continues in AFIB with rates 100-120's with frequent PVC's and occassional PAC's, continues on neo. gtt. to maintain SBP>90, able to wean to .50mcg/kg/min, continues on amio.gtt. @ 0.5mg, V wires tested, not sensing and capturing appropriately 100%, pacer turned off because of inappropriate pacing spikes, PP+, afebrile. Continues to be hyponatremic, serum Na+ levels drawn Q6 hours, on fluid restriction, all gtts. mixed in nacl, serum coritsol and urine lytes sent.\n\nRESP: Lungs clear, diminished at bases, on RA with sats. 97%, using IS up to 1000ml, productive cough.\n\nGI: Abd.soft, BS+\n\nGU: Foley intact, draining clear yellow urine, adequate HUO.\n\nPAIN: no c.o pain.\n\nPLAN: ?ablation for AF, continue to monitor and treat ectopy, wean neo. if BP tolerates, replete electrolytes, monitor Na+, fluid restriction.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-02 00:00:00.000",
"description": "Report",
"row_id": 1374229,
"text": "7A-3P\n\nNEURO: ALERT AND ORIENTED. MAE AND FOLLOWS COMMANDS. NO C/O PAIN THIS SHIFT. AMBULATED AROUND UNIT WITH MINIMAL ASSIST.\n\nRESP: LS CLEAR WITH DIM BASES. O2 SATS 96-99% ON RA. USING IS UP TO .\n\nCV: AFIB 100-130'S. FREQUENT PVC'S. LOPRESSOR 2.5MG IV GIVEN X2 AS WELL AS AMIO BOLUS THIS AM FOR HR 130'S. CONTINUES ON AMIO GTT AND NEO GTT TITRATED FOR SBP>90. PAPABLE PEDAL PULSES. COAGS ELEVATED THIS AM, ? CAUSE. ?NEED FOR HEPARIN GTT FOR A FIB. WIRES ATTACHED TO PACER AND PACER TURNED OFF. SEE FLOW SHEET FOR LABS. (NA 128, CONTINUE TO CHECK TID)\n\nENDO: ELEVATED BG'S TREATED PER SSRI.\n\nGI/GU: BS+. ABD SOFT. TOLERATING PO'S. CONTINUES ON FLUID RESTRICTION. C/Y/U. FOLEY DC'D @ 1430. NO BM THIS SHIFT. + FLATUS.\n\nPLAN: NEO TO MAINTAIN SBP>90. CONTINUE AMIO GTT. MONITOR LABS (COAGS/NA). MONITOR RYTHYM. INCREASE DIET AND ACTIVITY AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-02 00:00:00.000",
"description": "Report",
"row_id": 1374230,
"text": "7A-3P\nCONTINUE AMIO GTT AS ORDERED. (18 HOURS EXPIRED->REORDERED TO CONTINUE) SCHELDULED FOR AICD PLACEMENT TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-03 00:00:00.000",
"description": "Report",
"row_id": 1374231,
"text": "NEURO: A+ox3, MAE, Follows commands.\n\nCV: RAF 100-130's. Given 5mg iv lopressor once. Afterwards, required neo gtt because sbp in 80's from lopressor. Neo gtt started @ .25mcg/k/min. SBP up > 100. Continues to have freq. pvc's. Repleted Ca++ and Mg.\n\nRESP: Lungs are clear w/ dim bases. Spo2 > 95% RA.\n\nGU: Urinating adequate amts cyu.\n\nGI: NPO.\n\nPLAN: Monitor lytes, Coags, Npo, AICD placement today. Maintain fluid restriction.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-03 00:00:00.000",
"description": "Report",
"row_id": 1374232,
"text": "D: See data, MD notes/orders. Neuro: Pt a&o x3. CV: Afib with hr 1teens to 160's with increase in activity. Hr comes back to baseline with rest. Neo gtt weaned slowly to .15mcg/kg/min keeping sbp equal to or >90. Amiodorone gtt continues at .5mg/min. Pulm: RA sat 97%, lungs clear with fine rales at bases, pcxr taken this am. GU: Pt voids in urinal 100-200cc q1-2hr. GI: NPO for procedure, had small bm on bsc. Skin: Surfaces intact, pulses palpable, 2+ pedal/leg edema noted. Pt transported to cath lab for aicd placement in early afternoon, return to room pending and will be another hour +/- per cath lab nurse. Pts friend \"\". updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-03-31 00:00:00.000",
"description": "Report",
"row_id": 1374224,
"text": "7am-7pm update\nNeuro: pt alert and oreianted x3. MAE and able to follow commands.\n\nCV; pt remains NSR/ST, occasionally pvc's noted. HR 80-100's. BP 90-140's/50-60's. MAP 60-90's. pt becomes slightly hypertensive and tachycardic with activity. dobutamine gtt weaned to off this am (per NP). svo2 66-72. CI by fick > 2.0. PA line dc'd this afternoon and introducer left intact. pt started on lopressor this afternoon. DP's palpable and pt's by doppler. hct stable.\n\nresp: LS clear with dim bases bil. pt on 2 L nc, o2 sats 96-98%. pt using IS. pt with strong nonproductive cough. abg wnl. CT's dc'd this afternoon.\n\ngi/gu: pt with + bs. tolerting cardiac diet. foley draining clear yellow urine. UO adequate.\n\nendo: BS in the 140's -> treated with ss reg insulin per protocol\n\nactivity/comfort: percocets for pain ~ q4h. pt oob to chair x2. pt ambualted with 2 assist. steady gait\n\nplan: pain control, pulm toliet, monitor lytes/hct/bs, advance diet and activity as tolerated, ?? 2 in am\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-01 00:00:00.000",
"description": "Report",
"row_id": 1374225,
"text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative.\n\nCV: NSR-ST 90's-115's, with occasional to frequent PVC's, short run of SVT->lopressor 5mg IV and Mg+2gm given with good effect, lytes repleted, PP+, afebrile, pacer on backup Ademand 60.\n\nRESP: Lung clear, diminished at bases, 02 @ 2L via NC with sats.>97%, using IS, productive cough.\n\nGI: Abd. soft, BS+, no BM this shift.\n\nGU: Foley cath. intact, draining clear yellow urine, .\n\nPAIN: no c/o pain.\n\nENDO: RISS per unit protocol.\n\nPLAN: Continue to monitor CV status, replete electrolytes as needed, increase activity, transfer to floor in a.m.?\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-01 00:00:00.000",
"description": "Report",
"row_id": 1374226,
"text": "CSRU addendum:\n\nCV: Pt. went into RAF with rates of 140's with frequent multifocal PVC' , NP made aware, Lopressor 5mg IV given in addition to Amio. 150mg IV bolus. Started on Neo. gtt. to maintain SBP>90, Mg+ 2gm bolus given as well. HR decreased to 110's-120's and continues to have frequent PVC's, amio.gtt. started. Pt. remained talkative and asymtomatic throughout this time. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-01 00:00:00.000",
"description": "Report",
"row_id": 1374227,
"text": "7a-7p\n\nNEURO: ALERT AND ORIENTED. MAE AND FOLLOWS COMMANDS. OOB TO CHAIR WITH MINIMAL ASSIST. PROPOFOL GIVEN BY ANASTHESIA FOR PROCEDURE, PT SEDATED FOR APPROX 10MIN. PLEASANT AND COOPERATIVE.\n\nRESP: LS CLEAR WITH DIM BASES. ABLE TO WEAN O2 TO RA, SATS>96%. USING IS TO 1000, NO ENCOURAGEMENT NEEDED. EXPECTORING MIN AMOUNTS OF THICK YELLOW SPUTUMN.\n\nCV: AFIB 100-120'S. FREQUENT PVC'S NOTED. CARDIOVERTED THIS PM 200J X3. NO CONVERSION. ?NEED FOR ABLATION. NEO TITRATED FOR SBP>90. PAPABLE PEDAL PULSES. SOME GENERALIZED EDAM NOTE. TEMP PACING WIRES ATTACHED AND PACEMAKER OFF. SEE FLOW SHHET FOR LABS, NA 126.\n\nENDO: BG'S NOT TREATED PT NPO.\n\nGI/GU: BS+. PT NPO FOR CARDIOVERSION AND ?ABLATION. NO BM THIS SHIFT. MOD AMOUNTS OF C/Y/U.\n\nPLAN: NPO. ?ABLATION. MONIOTR LABS AND NA, ALL IV MEDS INFUSED WITH NS. TITRATE NEO FOR SBP>90. PULM TOILETING. INCREASE DIET AND ACTIVITY AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-08 00:00:00.000",
"description": "Report",
"row_id": 1374243,
"text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative.\n\nCV: DDD a-sensing,v-pacing @ 80, with no ectopy noted, BP stable, neo. weaned to off at start of shift, continues on heparin gtt. @ 1100U/hr, last Factor Xa @ 1700=.47 (therapeutic), stil awaiting results of 2200 lab draw, continue to follow and adjust heparin gtt. as appropriate, PP+, afebrile.\n\nRESP: Lungs clear with some crackles at bases, on RA with sats. 99%, using IS well.\n\nGI: Abd. soft, BS+\n\nGU: Voiding via urinal clear yellow urine.\n\nENDO: RISS per unit protocol.\n\nPLAN: Continue to monitor CV status, monitor Factor Xa to adjust for heparin dosage Q6 hours, possible transfer to 2?\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-08 00:00:00.000",
"description": "Report",
"row_id": 1374244,
"text": "CSRU Addendum:\n\nLAB RESULTS:\n\nFactor Xa drawn @ 2300->1.0\nDr. made aware. Heparin gtt. stopped for one hour and then resumed @ 950U/hr. Next lab draw will be at 1030. Oncoming nurse made aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-03-30 00:00:00.000",
"description": "Report",
"row_id": 1374222,
"text": "PT UPDATE\n PT ARRIVED FROM OR AT 1230 S/P CABG X3.\n\n NEURO: PT REVERSED AND OFF PROPOFOL SINCE 1500-REMAINS SLEEPY; BUT EASILY AROUSABLE TO VOICE-OPENS EYES ONLY TO VOICE. FOLLOWS ALL COMMANDS AND MAE TO COMMAND.\n\n RESP: PT NOW ON CPAP WITH SATS 100 AND RR 16-20. BS CLEAR, DECREASED IN BASES. PT WAS GRADE 3 VIEW INTUB.; SO HAS TO BE PERFECTLY READY FOR EXTUB.\n\n CV: HR 80-90 WITH OCCAS-FREQUENT PVC'S-LYTES REPLETED WITH NO CHANGE IN PVC'S. INITIALLY PT HYPOTENSIVE AND HYPOVOLEMIC. LEVO TITRATED AND RX WITH FLUID AND PC'S. LAST HOUR OR SO PT AT TIMES HYPERTENSIVE-LEVO ON AND OFF. PT ON 5 DOBUT. WITH INITIAL CI 2.8-DOWN TO 1.8. FICK CHECKED AND 2.87. NO CHANGE IN DOBUT. DOSE AT THIS TIME.\n\n GU: PT WHEN FIRST ARRIVED-HAS SLOWED DOWN TO 100/HR.\n\n GI: OGT-LCWS-SCANT DRG.\n\n LAB: ION CA AND MG REPLETED. K LOW OF 4.2; DESPITE LG DIURESIS-HAS RECEIVED 20MEQ KCL ONLY. HCT 24.8-GIVEN 2 PC AND UP TO 31. BS 178 AND GTT STARTED-CONT TO BE TITRATED.\n\n OTHER: CT DRG MINIMAL. SM AMT DRG ON STERNAL DSG-HAS NOT INCREASED. PT MED WITH IV MSO4 X1 FOR DISCOMFORT-WITH GOOD RELIEF AND COMF SINCE. FRIEND- WHO IS SPOKESPERSON-IN TO VISIT X2.\n\n\n A/P: PT STILL SOMEWHAT SLEEPY-DOES NOT SEEM READY TO EXTUB. REMAINS CALM AND APPROPRIATE. NOW SOMEWHAT HYPERTENSIVE WITH VERY SIMILAR PA NUMBERS TO HYPOTENSIVE EPISODES-CVP7 AND PAD 15. CONT TO TITRATE LEVO-NTG PRN. EXTUB. WHEN MORE AWAKE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-03-31 00:00:00.000",
"description": "Report",
"row_id": 1374223,
"text": " B:\n\nNeuro: a and o x 3, mae, following commands correctly, mso4 for pain.\n\nCardiac: nsr in the 90's with frequent pvc's, continues dobuta gtt, going by cardiac fics for indexes which have all been good, svo2's running in the 60 range, palpible pedial pulses, skin warm dry and intact, a-febrile, +2 edema inextremities, did get 1 liter of lr for low cvp's this shift.\n\nResp: dim inbases, did vagal hr down with sxning pre extubation and did come back up on own shortly after, on 2 liters nc satting at 99% post extubation gas is good, no leak in ct system which is draining scant sero-sang.\n\nSkin: chest with dsd with old moderate serosang drainage from or, ct dsds are cdi, right leg ace is cdi.\n\nGi/gu: tolerating ice chips, abd soft round and nontender with hypoactive bowel sounds,continues riss gtt, making good u/o.\n\nPlan: increase activity, monitor blood sugars, monitor ci's, monitor u/o, monitor for increase ectopy, encourage to cough and deep breath.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-06 00:00:00.000",
"description": "Report",
"row_id": 1374239,
"text": "CSRU Nursing Progress Note\nNeuro: Pt A&O x3. Pt OOB in am then became hypotensive and placed back into bed. Pt to get OOB once more for meals.\n\nCardiac: Pt in AF/V-paced at times however poorly controlled HR 93-114, no ectopy. pt given 2.5mg IV lopressor for HR, BP then became very low, 78/47, no MS changes. Pt placed back to bed. Pt started on Neo currently at .3 mcg/k/min perpherially, please monitor closely. BP now low 100/60's sys. Pts heparin increased to 750u/hr, factor XA pending, goal .3-.7. Please con't to monitor platelets, they con't to drop. Pt decreased to .5mg/min amio gtt, minimal effect.\n\nResp: Pt on 2L via NC. O2 sat 97%. BS clear in upper airway, rales in bases and rising, bilaterally.\n\nGI: Pt has poor appetite. +BS, -BM.\n\nGU: Pt voids via urinal.\n\nID: Afebrile.\n\nEndo: Requiring coverage via RISS.\n\nMonitor for signs of increased fluid overload, monitor platelets, HR, BP closely. Please follow factor X A in lue of PTT q6 hours. Test will be run overnight. HIT sent off.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-06 00:00:00.000",
"description": "Report",
"row_id": 1374240,
"text": "CSRU Nursing Progress Note\nPt given additional 1mg IV lopressor for HR in 120-130. HR increases and BP drops when sitting in chair. Pt con't on perph neo, when spoke to NP , hand evaluated, slightly purple, NP said it was okay.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-07 00:00:00.000",
"description": "Report",
"row_id": 1374241,
"text": "CSRU NOTE:\n\nNEURO: A/O X 3, MAE, very pleasant and cooperative.\n\nCV: Continues in AFIB with rates of 95-110 with occassional PVC's noted, on neo. gtt. to maintain SBP>90, amio.gtt. @ 0.5 dc'd at 0400, heparin gtt. increased to 900U/hr, goal of Factor Xa of .3-.7, will continue to monitor, DDD, PP+, afebrile.\n\nRESP: Lungs clear with crackles at bases, 02 @ 2L via NC with sats>97%, using IS, productive cough.\n\nGI: Abd. soft, BS+\n\nGU: Voiding via urinal, clear yellow urine.\n\nENDO: RISS per unit protocol.\n\nPLAN: Continue to monitor Factor Xa level to adjust heparin gtt., wean neo. gtt. as BP tolerates, monitor CV and RESP system, pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-07 00:00:00.000",
"description": "Report",
"row_id": 1374242,
"text": "D: Please see data, MD notes/orders. Neuro: A&O x3 CV: In afib this am with rate 120 up to 157 with activity. Converted to Asensing/Vpacing in late morning after 2.5mg IV lopressor. Po carvediol and amiodorone also given at that time. Neo gtt in place to keep sbp >90 Heparin gtt currently at 1100u/hr. Pulm: RA sats 98% at rest and with activity. Lungs clear with fine scattered rales at bases. GU: Using urinal to void 100-300cc urine q2-3hrs. GI: Abd soft, bs+, lg bm x 1 this shift. Endo: Per ssc. Activity: Amublated length of unit this afternoon tolerating activity well. P: Continue to wean neo gtt as tolerated keeping sbp >90. Monitor for recurring afib. Titrate heparin to keep factor 10 between 0.3 and 0.7. ?Transfer to telemetry tomorrow. R: Neo currently at 0.17mcg/kg/min, factor 10 pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-05 00:00:00.000",
"description": "Report",
"row_id": 1374237,
"text": "CSRU Nursing Progress Note\nNeuro: Pt A&O x3 OOB all day and ambulated x1. Pt doing very well, denies pain.\n\nCardiac: Pt HR in the 80's. BP stable in low 100-110 sys. Pt started on Heparin at 500 u/hr, not following PTT, following factor X A. Goal is .3-.7. Please draw q6 hours. Results of 1600 draw still pending, has to be sent to and please notify lab at 30min prior to draw to start machine. Lytes repleated.\n\nResp: Pt on RA O2 sat 96-98%. BS clear in upper airway rales in the bases.\n\nGI: Small BM x2. Good appetite, +BS. OOB to commode.\n\nGU: Pt voiding via urinal.\n\nAccess: Very poor only 1 IV.\n\nPt needs txr note written for floor tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-06 00:00:00.000",
"description": "Report",
"row_id": 1374238,
"text": "Update\nO: cv status: vpaced(perm pacer)-> rafib to 130's. additional lopr 25mg po & lopr 15mg total iv. Mgso4 2gms ivpb. Poor rate control w same. Amiod bolus150mg/ gtt@ 1mg/m x6 then 0.5mg x 18hrs. Now w improved rate control. sbp bdline w rapid hr& transiently in response to iv lopressor.Repleted k+ w lasix 10mg iv dosing for crackles throughout bilat.\n\nresp status: O2 added @ 2lpm prophylac w rapid hr. ^ audible exp wheeze by 0300 crackles noted to apices. Dr updated lasix 10 iv ordered w excellent response. -> clear ^ lobes dimins lower lobes after diuresing 1liter urine in 2hrs.\n\nneuro status: aaoriented, follows simple commands. slept in brief naps overnight.denies pain or discomf.\n\ngi status: up to commode x 1 overnight w liq lt brwn stool. abd distended, soft, +bowel snds-> hyperactive. Passing lg amts flatus & sm liq stool. colace held.\n\ngu status: uop as noted above. Vdg small amts cl yellow urine-> lasix w excellent response.\n\nheme/id: tmax 98.6. wbc flat. hct 29. hematology following pt. See pt chart for recommendations. Factor X sent to w Factor X labs to be run after 0700.? check hit antibody in view of plt ct.\n\nA/P: rapid afib rate controlled w amiod. Decr amiod gtt to 0.5mg/min at 1000. Replete lytes as necessary.Titrate heparin per heme recommendations.pcxr this am. 2 transfer on hold for now.\n"
},
{
"category": "Nursing/other",
"chartdate": "2122-04-03 00:00:00.000",
"description": "Report",
"row_id": 1374233,
"text": "Adendum: Pt returned from cathlab s/p placement of DDD permanent pacemaker. Please see procedure notes and pacer literature for data and for vs. Pt hemodynamically stable, monitor show 100% vpacing. SBP 120-140. Left arm in sling, dressing at pacemaker insertion site d&i. Pt denies pain or other distress. Pt placed in high fowlers and evening meal offered. Full report given to oncoming shift, pt with call light in hand.\n"
},
{
"category": "ECG",
"chartdate": "2122-04-06 00:00:00.000",
"description": "Report",
"row_id": 313244,
"text": "Ventricular paced rhythm with single premature beat\nAtrial rhythm unclear\nSince previous tracing, atrial paced artifact not seen\n\n"
},
{
"category": "ECG",
"chartdate": "2122-04-08 00:00:00.000",
"description": "Report",
"row_id": 313245,
"text": "A-V paced rhythm\nSince previous tracing, atrial pacing now seen\n\n"
},
{
"category": "ECG",
"chartdate": "2122-04-04 00:00:00.000",
"description": "Report",
"row_id": 313246,
"text": "Atrio-ventricular paced rhythm. Paced beats show Left bundle-branch block with\nsuperior axis. Compared to the previous tracing of pacemaker rhythm is\nnow present.\n\n"
},
{
"category": "ECG",
"chartdate": "2122-03-31 00:00:00.000",
"description": "Report",
"row_id": 313247,
"text": "Sinus rhythm\nLeft bunch branch block\nSince previous tracing, sinus bradycardia absent\n\n"
}
] |
4,115 | 188,447 | 71M w/ CAD, DM, HTN, hypercholesterolemia, PVD p/w stuttering CP, sent for cath and found to have left main disease. Carotid u/s showed < 40% , 50-60% . He underwent celiac and L subclavian stenting on . On he went to the operating room where he underwent a CABG x 3. He was transferred to the SICU in critical but stable condition. He awoke and was extubated by POD #1. He was weaned from his nitroglycerine and tansferred to the floor on POD #2. He did well post operatively. He was seen by physical therapy. He was started on heparin and coumadin for paroxysmal afib. He continued to have a sternal click with no fevers, white count, drainage or erythema. He was seen in consultation by cardiology for his continued bursts of afib, they recommended continuing with lopressor, anticoagulation, and increasing his ACE-I. He was ready for discharge on . | Simpleatheroma in ascending aorta. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. Top normal/borderline dilated LV cavitysize. The ascending aorta is mildlydilated. Dopplerable pedal pulses.Resp: LS clear diminished bases. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild (1+) mitralregurgitation is seen. There is moderateregional left ventricular systolic dysfunction. The left ventricularcavity size is top normal/borderline dilated. Normal ascending aorta diameter. Sinus rhythmIncomplete right bundle branch blockDiffuse ST-T wave changes - may be in part primary and are nonspecificSince previous tracing of , intraventricular conduction delay and ST-Twave changes decreased +palpable pulses.Resp: LS coarse. protamine,platelets & prbc given with some slowing. Mild mitralannular calcification. There is apical hypokinesis of theright ventricle. Moderate global LVhypokinesis. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Left ventricular hypertrophy with ST-T waveabnormalities. There is moderate pulmonaryartery systolic hypertension. Moderatelydepressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- akinetic; mid anterior - akinetic; basal inferoseptal - hypo; midinferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basalanterolateral - akinetic; mid anterolateral - akinetic; anterior apex - hypo;RIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.AORTA: Simple atheroma in aortic root. There is mild symmetric left ventricularhypertrophy with normal cavity size. There is moderate pulmonary artery systolichypertension. There are simple atheroma in the aortic root. The mitral valve leaflets are mildlythickened. Mildly dilated descending aorta. The aortic root ismildly dilated. Preoperative assessment.Height: (in) 70Weight (lb): 192BSA (m2): 2.05 m2BP (mm Hg): 129/65HR (bpm): 63Status: InpatientDate/Time: at 14:15Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Mild symmetric LVH. Probable left atrial abnormality. Possible right ventricularhypertrophy with secondary repolarization abnormalities. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Mild [1+] TR. Physiologic(normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. The aortic valve leaflets (3) are mildlythickened. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; basal inferior - akinetic; mid inferior - hypo; basalinferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo;mid anterolateral - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic root. The ascending aorta is mildly dilated. The right atrium is moderately dilated.There is mild symmetric left ventricular hypertrophy. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is moderately dilated. Left ventricularhypertrophy with secondary repolarization abnormalities. Left ventricularhypertrophy with secondary repolarization abnormalities. variable ci & svo2 with low filling pressures,hr 60's(post reversals),marginal huo treated with volume,a pacing for hemodynamic support & resumption of low dose epi.glucoses managed per protocol. Mildly dilated ascending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). The patient appears to be in sinusrhythm.Conclusions:Suboptimal study. Overall rightventricular systolic is improved, though apical hypokinesis remains. Monitor resp. Right ventricularsystolic function is borderline normal. Left ventricular function.Height: (in) 70Weight (lb): 192BSA (m2): 2.05 m2BP (mm Hg): 166/84HR (bpm): 77Status: InpatientDate/Time: at 14:00Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Modest non-specificintraventricular conduction delay. ).Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a low risk (prophylaxis not recommended). NTG weaned back. changing over to serosang.GI) ogt to lcws: bilious drng. Clinical correlation issuggested.TRACING #1 Lytes repleted prn. Epicardial wires intact, a side sense appropriately, do not capture appropriately. Probable sinus rhythm. Drng. Mild (1+) MR. (<140ms) transmitral E-wavedecel time. Left ventricular function. Mildly dilated ascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3).MITRAL VALVE: Mildly thickened mitral valve leaflets. Sinus arrhythmia. There is no pericardial effusion.Compared with the prior study (images reviewed) of ,regional leftventricular systolic dysfunction is similar, but moderate global hypokinesisof the remaining segment and mild right ventricular free wall hypokinesis arenow seen c/w diffuse process (toxin, metabolic, etc. Intraventricular conduction delay, Left ventricular hypertrophywith secondary repolarization abnormalities. Mild global RV free wall hypokinesis.AORTA: Normal aortic root diameter. Left ventricular hypertrophywith secondary repolarization abnormalities. Possible left atrial abnormality. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.Prominent Eustachian valve (normal variant).LEFT VENTRICLE: Moderate regional LV systolic dysfunction. QRS voltage has decreased.Clinical correlation is suggested. Resting regional wall motionabnormalities include basal inferior akinesis and lateral hypokinesis. Sinus rhythm. Sinus rhythm. Sinus rhythm. Pulmonary hygeine. The ST-T wave changes are diffuse - cannot exclude ischemia.Clinical correlation is suggested. ST-T wave abnormalities. Intraventricular conduction delay. Intraventricular conduction delay. Intraventricular conduction delay. Since the previous tracing of ST-T wave changes appear less prominent. FS 100-170s.Plan: Monitor hemodynamcis. Mild to moderate [+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a low risk (prophylaxis not recommended). Suboptimal image quality. The superior mesenteric artery and celiac axis are patent and also demonstrate normal waveforms. No AR.MITRAL VALVE: Normal mitral valve leaflets. Institute po antihypertensives and SSRI. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for CABGHeight: (in) 70Weight (lb): 194BSA (m2): 2.06 m2BP (mm Hg): 112/67HR (bpm): 74Status: InpatientDate/Time: at 09:05Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: No mass/thrombus in the LAA. Respiratory TherapyPt received from OR s/p CABG x3. Holding off on Nicardipine for now unless hypertension is sustained. Sinus bradycardia. There is moderate global left ventricularhypokinesis with focal mild aneurysm/akinesis of the basal inferior wall.Tissue velocity imaging E/e' is elevated (>15) suggesting increased leftventricular filling pressure (PCWP>18mmHg)/ Right ventricular chamber size isnormal with mild global free wall hypokinesis. 7a-7pNeuro: Pt alert and oriented, forgetful at times. notified,hydralazine added with improved control. There aresimple atheroma in the ascending aorta. Remains orally intubated, weaned to PSV. Inhalers given as ordered. | 20 | [
{
"category": "Nursing/other",
"chartdate": "2105-10-30 00:00:00.000",
"description": "Report",
"row_id": 1316206,
"text": "RESPIRATORY CARE;\n\nPt remained intubated overnight. Not extubated, secondary to pt 'sleepy', not awake enough. RSBI 30 this am, planning to wean and extubate. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-10-30 00:00:00.000",
"description": "Report",
"row_id": 1316207,
"text": "7a-7p\nNeuro: Pt alert and orientedx3. MAE equally. Perrla. Intermittent twitching of left arm noted, PA aware, no new orders. Right eye droopy pt states \"has been like that for years\". Perrla,smile symmetrical, mae equally. Morphine and percocets po for incisional pain, percocets po work better per pt. Pt states is anxious at times,team aware.\n\nCV: HR 70-110s. 110s at start of shift, lopressor started, received total of 10mgx2 IVP during shift. Lopressor 50mg po started. SBP 110-140s. Goal SBP<140 per PA . NTG as high as 3mcg, PA aware, captopril and hydralazine started, see med orders, captopril increased during day as per PA . Pt received 1 unit of PRBCs no adverse reactions, repeat hct 27.2, PA and MD aware, no new orders. CI>2. SVO2 57 when received pt PA aware, recal'd, SVO2 improved >60, see carevue. PA dc'd w/o incident. Cordis flushes well though unable to draw blood from, PA aware, ok to use per PA . Plavix started today 300mg loading dose today as ordered. Epicardial wires intact, a side sense appropriately, do not capture appropriately. On VDemand 50, v wires sense and capture appropriately. Lytes repleted prn. Dopplerable pedal pulses.\n\nResp: LS clear diminished bases. Sats decreased on 6lnc to 91-93%, PA aware, inhalers ordered. Face tent and nc applied, see carevue for settings and sats. Present sat 95% on face tent 50%, 4Lnc. Pt using IS appropriately, 750cc. Encouraged coughing and deep breathing. CT no air leak, draining 10-40cc/hr serosang drainage.\n\nGI/GU: Abd soft hypoactive BS. No BM. Tolerating sips of clears. Foley draining clear yellow urine, lasix 20mg IVP given this am, w/ minimal (1st hour only 140cc after lasix then tapered to 30cc/hr) results, PA aware, additional lasix 40mg ivp given at approx. 1400 as ordered w/ improved results. See carevue for I+O's.\n\nEndo: Insulin gtt as per protocol. FS 100-170s.\n\nPlan: Monitor hemodynamcis. Monitor resp. status. Pulmonary hygeine. Follow labs and treat as appropriate. Wean ntg to keep SBP<140. Pain control. Increase diet and activity as pt tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-10-31 00:00:00.000",
"description": "Report",
"row_id": 1316208,
"text": "S. I can't take deep breathes I am in too much pain. I cut back on my smoking to 1pack for 3 days just before my \nO. Neuro a/o x3 mae, fc, pupils equal and reactive. Lies in bed stiff afraid to move. Given 2 percocets at 1900 then 2mg morphine IV then 2 percocets q 4hr he still needed encouragement to take deep breathes\nResp pt splinting not taking deep breathes o2 sats dropped to 78% on 50% fm, once pain under control pt able to use IS CDB bringing up thick yellow secretions abg on 70% during desats 7.46/32/54/23/0 repeat at 0400 7.47/35/82/25/1 lungs cont to be coarse with I/E wheezes inhaler given\nCVS HTN NTG on 3mcg most of the night, nicardipine gtt started at 2mcg now off bp 109/60- Hct 26.1 Sternum wound c+d mediat c+d CT output 150cc serosang pp +3 except lt DP, ace on left leg wounds c+d\nGI tol po abd obese BS hypo no stool\ngu u/o 30cc-100cc mn to 0500 -44 cr 1.1\nendo on insulin gtt high sugars on 8u reg q hr\naccess rua 20g, lla 18g, aline lt r\na. HTN\nresp distress not taking deep breathes +smoker +pain\nDM2\np. antihypertensive as ordered keep sbp <120/, pulm toliet IS q hr wean o2 as tol, teaching stop smoking cdb, pain med q 4, q hr bs titrate insulin\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-10-31 00:00:00.000",
"description": "Report",
"row_id": 1316209,
"text": "7a-7p\nNeuro: Pt alert and oriented, forgetful at times. At 1600, when asked where pt was noted to mumble words at first. Answering questions appropriately, HOH. MD aware, no new orders. Pt answering questions appropriately, mae ,smile symmetrical. Perrla. Family into visit at 1700, noted pt being confused, not knowing where he is, MD aware. Last percocet given at 1430 for incisional pain.\n\nCV: HR 50-70s SR rare PVC noted. Lopressor dose increased this am to 100mg po BID. After getting back to bed after ambulating to nurses' station HR 50s SB, SBP 110s. MD aware, no new orders. Aline dc'd w/o incident, going by left cuff pressure significant difference btw right and left side, MD aware. SBP 100-130s. +palpable pulses.\n\nResp: LS coarse. Inhalers given as ordered. Sats 92-96% on 6Lnc. Using IS to 750cc, encouraged coughing deep breathing. MD aware of sats 92-96% on 6Lnc. After ambulation CT dumped serosang 120cc, MD aware, no new orders.\n\nGI/GU: Abd soft distended, +BS. Poor po intake eating only bites of meals. Foley draining clear yellow urine, at 1600 u/ decreasing MD aware, NS 500cc fluid bolus MD . U/o did not improve u/o 10-20cc/hr after bolus, additional lasix 20mg ivp given as ordered.\n\nEndo: Insulin gtt weaned off. Poor po intake. FS 68-122. RISS. MD aware of pt's pre meds antihyperglycemics, no new orders at this time since poor po intake and low fs.\n\nActivity: Pt ambulated to nurses' station, when back to bed HR 50s SB, MD .\n\nPlan: Monitor hemodynamics. Monitor neuro status. Aggressive pulmonary toilet. Follow FS and treat as appropriate. Follow i+o's. Increase activity and po intake as pt tolerates. ? transfer later in evening or in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-10-29 00:00:00.000",
"description": "Report",
"row_id": 1316202,
"text": "increased ct dng post turning with elevated act. protamine,platelets & prbc given with some slowing. dr. aware,plan to repeat cxr to r/o collection. variable ci & svo2 with low filling pressures,hr 60's(post reversals),marginal huo treated with volume,a pacing for hemodynamic support & resumption of low dose epi.glucoses managed per protocol. children in,questions answered. they report pt. to be high anxiety/emotional at baseline & feel it is in pt's best interest not to be present until extubation as they increase his agitation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-10-29 00:00:00.000",
"description": "Report",
"row_id": 1316203,
"text": "Respiratory Therapy\n\nPt received from OR s/p CABG x3. Remains orally intubated, weaned to PSV. See resp flowsheet for specifics.\n\nPlan: maintain support; wean per fast track protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-10-29 00:00:00.000",
"description": "Report",
"row_id": 1316204,
"text": "much improved svo2/hemodynamics after above volume,transient a pacing for hr < 70. requiring increased ntg for bp control,climbs into the 160's-190's with procedures,i.e.mouth care & turning. notified,hydralazine added with improved control. epi weaned to off with continued hemodynamic stability,bp control.awoke,mae x 4 to command but remains lethargic & asleep unless stimulated. weaned to cpap w 10 ips,maintaining adequate tv's,mv but unable to lift & hold any extremity off the bed at present.extubation delayed until able to adequately protect airway.glucoses managed as indicated,see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-10-30 00:00:00.000",
"description": "Report",
"row_id": 1316205,
"text": "Neuro) Awakens easily but falls back to sleep when left alone.Pt. is now able to lift head off pillow. Will keep on cpap and plan for early morning extubation. Moves all extr.\n\nCV) NSR 90-105. BP up to 160's with position changes but settles back to 100-130's at rest. NTG weaned back. Holding off on Nicardipine for now unless hypertension is sustained. CI >2 and SVO2 >65%.\n\nResp) Cpap for now until more awake for extubation. Secretions thick white and tenacious. Chest tubes to 20cm sx without air leak. Drng. changing over to serosang.\n\nGI) ogt to lcws: bilious drng. no s/s n/v.\n\nGU) adequate huo per foley.\n\nSkin) intact with no breakdown. Chest dsg reinforced and left leg rewrapped with ace bandage.\n\nEndo) insulin drip infusing but unable to follow insulin guidelines due to dropping BS with high insulin dose.\n\nID) Vanco for post-op prophylaxis.\n\nPlan) wean to extubate. wean off NTG and insulin. Institute po antihypertensives and SSRI. ADvance DAT when extubated and ADL's as tol.\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\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\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\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": "Echo",
"chartdate": "2105-11-02 00:00:00.000",
"description": "Report",
"row_id": 103915,
"text": "PATIENT/TEST INFORMATION:\nIndication: H/O recent cardiac surgery. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 192\nBSA (m2): 2.05 m2\nBP (mm Hg): 166/84\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 14:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate global LV\nhypokinesis. TVI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data. Echocardiographic results were reviewed by telephone\nwith the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is moderate global left ventricular\nhypokinesis with focal mild aneurysm/akinesis of the basal inferior wall.\nTissue velocity imaging E/e' is elevated (>15) suggesting increased left\nventricular filling pressure (PCWP>18mmHg)/ Right ventricular chamber size is\nnormal with mild global free wall hypokinesis. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of ,regional left\nventricular systolic dysfunction is similar, but moderate global hypokinesis\nof the remaining segment and mild right ventricular free wall hypokinesis are\nnow seen c/w diffuse process (toxin, metabolic, etc.).\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": "2105-10-29 00:00:00.000",
"description": "Report",
"row_id": 103916,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG\nHeight: (in) 70\nWeight (lb): 194\nBSA (m2): 2.06 m2\nBP (mm Hg): 112/67\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 09:05\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No mass/thrombus in the LAA. Good (>20 cm/s) LAA ejection\nvelocity. All four pulmonary veins not identified.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of\nthe RA or RAA. A catheter or pacing wire is seen in the RA and extending into\nthe RV. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.\nProminent Eustachian valve (normal variant).\n\nLEFT VENTRICLE: Moderate regional LV systolic dysfunction. Moderately\ndepressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- akinetic; mid anterior - akinetic; basal inferoseptal - hypo; mid\ninferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal\nanterolateral - akinetic; mid anterolateral - akinetic; anterior apex - hypo;\n\nRIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.\n\nAORTA: Simple atheroma in aortic root. Normal ascending aorta diameter. Simple\natheroma in ascending aorta. Mildly dilated descending aorta. There are\ncomplex (>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. No MS. Mild (1+) MR. (<140ms) transmitral E-wave\ndecel time. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. Suboptimal image quality. The patient appears to be in sinus\nrhythm.\n\nConclusions:\nSuboptimal study. Trans-gastric images not obtained as patient has history of\ngastric surgery.\n\nPRE-CPB No mass/thrombus is seen in the left atrium or left atrial appendage.\nNo spontaneous echo contrast is seen in the body of the right atrium or right\natrial appendage. No atrial septal defect or patent foramen ovale is seen by\n2D, color Doppler or saline contrast with maneuvers. There is moderate\nregional left ventricular systolic dysfunction. Resting regional wall motion\nabnormalities include akinesis/severe hypokinesis of the anterior and\nanteriolateral walls and hypokinesis of the inferior wall. Right ventricular\nsystolic function is borderline normal. There is apical hypokinesis of the\nright ventricle. There are simple atheroma in the aortic root. There are\nsimple atheroma in the ascending aorta. There are complex (>4mm) atheroma in\nthe descending thoracic aorta. The aortic valve leaflets (3) are mildly\nthickened. There is no aortic valve stenosis. Trace aortic regurgitation can\nnot be completely ruled out. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\nleft ventricular inflow pattern suggests impaired relaxation.\n\nPOST-CPB The patient is receiving epinephrine by infusion. Overall right\nventricular systolic is improved, though apical hypokinesis remains. Overall\nleft ventricular function is also improved, with EF now about 35-40%. The\nfocal wall motion abnormalities noted above remain, but tthere is improvement\nin each segment. There is no change in valvular function. The thoracic aorta\nappears intact.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2105-10-23 00:00:00.000",
"description": "Report",
"row_id": 103917,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Preoperative assessment.\nHeight: (in) 70\nWeight (lb): 192\nBSA (m2): 2.05 m2\nBP (mm Hg): 129/65\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 14:15\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - akinetic; mid inferior - hypo; basal\ninferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo;\nmid anterolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\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 top normal/borderline dilated. Resting regional wall motion\nabnormalities include basal inferior akinesis and lateral hypokinesis. Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated. The ascending aorta is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2105-11-04 00:00:00.000",
"description": "Report",
"row_id": 298889,
"text": "Sinus rhythm\nIncomplete right bundle branch block\nDiffuse ST-T wave changes - may be in part primary and are nonspecific\nSince previous tracing of , intraventricular conduction delay and ST-T\nwave changes decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2105-10-31 00:00:00.000",
"description": "Report",
"row_id": 298890,
"text": "Baseline artifact. Probable sinus rhythm. Since the previous tracing of \nthe rate has decreased. ST-T wave pattern is somewhat different. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2105-10-29 00:00:00.000",
"description": "Report",
"row_id": 298891,
"text": "Sinus tachycardia. Possible left atrial abnormality. Inferior axis. Right\nbundle-branch block. ST-T wave abnormalities. Since the previous tracing\nof the rate has increased and the QRS complexes have widened and now\nhave right bundle-branch block configuration. QRS voltage has decreased.\nClinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2105-10-27 00:00:00.000",
"description": "Report",
"row_id": 298892,
"text": "Sinus rhythm. Probable left atrial abnormality. Modest non-specific\nintraventricular conduction delay. Left ventricular hypertrophy with ST-T wave\nabnormalities. The ST-T wave changes are diffuse - cannot exclude ischemia.\nClinical correlation is suggested. Since the previous tracing of \nST-T wave changes appear less prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2105-10-24 00:00:00.000",
"description": "Report",
"row_id": 298893,
"text": "Sinus bradycardia. Intraventricular conduction delay. Left ventricular\nhypertrophy with secondary repolarization abnormalities. Extensive ST-T wave\nchanges are probably due to ventricular hypertrophy. Compared to the previous\ntracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2105-10-23 00:00:00.000",
"description": "Report",
"row_id": 298894,
"text": "Sinus rhythm. Intraventricular conduction delay. Left ventricular hypertrophy\nwith secondary repolarization abnormalities. Possible right ventricular\nhypertrophy with secondary repolarization abnormalities. Extensive ST-T wave\nchanges may be due to left ventriciular hypertrophy and/or ischemia. Compared\nto the previous tracing of no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2105-10-22 00:00:00.000",
"description": "Report",
"row_id": 298895,
"text": "Sinus rhythm. Intraventricular conduction delay, Left ventricular hypertrophy\nwith secondary repolarization abnormalities. Extensive ST-T wave changes may\nbe due to left ventricular hypertrophy and/or ischemia. Compared to the\nprevious tracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2105-10-22 00:00:00.000",
"description": "Report",
"row_id": 298896,
"text": "Sinus arrhythmia. Intraventricular conduction delay. Left ventricular\nhypertrophy with secondary repolarization abnormalities. Extensive ST-T wave\nchanges may be due to left ventricular hypertrophy and/or ischemia. Compared to\nthe previous tracing of there is mild increase in voltage and changes\nin St-T wave are significantly more pronounced. Clinical correlation is\nsuggested.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-10-23 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 933306,
"text": " 9:17 AM\n DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: doppler needed to evaluate mesenteric vasculature\n Admitting Diagnosis: CONGETIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with DM, HTN, hyperlipidemia presents with CP has left main\n disease. Going for CABG.\n REASON FOR THIS EXAMINATION:\n doppler needed to evaluate mesenteric vasculature\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for CABG, please assess mesenteric vasculature.\n\n DUPLEX ULTRASOUND OF THE ABDOMEN: Ultrasound evaluation of the portal and\n hepatic vein using -scale, color, and pulsed wave Doppler demonstrates the\n IVC, portal vein, hepatic veins, and left hepatic artery to be patent with\n normal waveforms. The superior mesenteric artery and celiac axis are patent\n and also demonstrate normal waveforms. The celiac access has a slightly\n elevated systolic peak, > 300 cm per second, which could suggest celiac\n stenosis.\n\n The liver is normal in echogenicity with no focal lesions. The gallbladder\n has been removed. The common bile but measures up to 0.75 cm, however tapers\n proximally and distally and is within normal limits for age. A pleural\n effusion is seen.\n\n IMPRESSION:\n 1. Patent celiac and SMA arteries with slightly increased systolic peak in the\n celiac axis. If there is clinical suspicion for celiac axis stenosis, this\n could be better evaluated by MRA or CTA.\n 2. Left-sided pleural effusion.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n (Over)\n\n 9:17 AM\n DUPLEX DOPP ABD/PEL; LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: doppler needed to evaluate mesenteric vasculature\n Admitting Diagnosis: CONGETIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n\n"
}
] |
1,697 | 100,545 | 1.) Respiratory: The patient was initially intubated on settings of 20/5 at a rate of 25. He received three doses of Surfactant. On day of life #3, he was weaned to C-pap of 6 cm on room air. He was also started on caffeine on day of life three. He weaned from C-pap to room air on day of life #20. He remained on caffeine with mild apnea of prematurity. The caffeine was discontinued on day of life 45. He has remained apnea free and, at the time of discharge, he is breathing comfortably on room air with good saturations, with no evidence of apnea of prematurity for over two weeks. 2.) Cardiovascular: He initially required two normal saline boluses and was started on Dopamine. He was weaned off Dopamine on day of life number two. He continued to have stable blood pressures. He never had a patent ductus arteriosus. At the time of discharge, he has stable blood pressures with good perfusion. 3.) Fluids, electrolytes and nutrition: The infant was initially made n.p.o. and was started on intravenous nutrition. Feeds were started on day of life 6 and gradually advanced. He reached full feeds on day of life 13 and calories were gradually increased to a maximum of 30 calories per ounce. His growth continued to be good and he started orally feeding. At the time of discharge, he was tolerating full feeds of breast milk for Enfamil supplement at 24 calories per ounce. His discharge weight is 3.525 kg. 4.) Gastrointestinal: The infant developed unconjugated hyperbilirubinemia of prematurity and was treated with phototherapy from day of life #1 through day of life #8. His maximum total bilirubin level was 4.9 over 0.3 on day of life number one. 5.) Hematology: The infant did receive one blood transfusion on day of life #12 for a low hematocrit. 6.) Infectious disease: Initial complete blood count showed neutropenia as subsequent CBC on day of life one had an impressive left shift. He was started on Ampicillin and Gentamycin on day of life one and completed a 7 day course. All cultures remained negative. A lumbar puncture was performed on day of life number four which revealed zero red blood cells and three white blood cells. Cultures in the spinal fluid were also negative. At the time of discharge, the patient has remained off antibiotics with negative cultures. 7.) Neurology: Head ultrasounds were performed on day of life number 3, day of life number 10 and day of life number 31. All head ultrasounds remained within normal limits. 8.) Ophthalmology: Ophthalmology examination was performed on and Mid- and revealed immaturity bilaterally in zone three. Follow-up ophthalmology is required. | G&DWEANING ISOLETTE TEMP. Tolerating well.BLS c/=, RRR, Suctioned x2 this shift. invested and , independent withcares. TOlerating with +bs,occassional soft loops. On caffine, One spell this AM. Gradually weaning isolette temp aspt tolerates. Resp. Now recieving 69ccq4hrs. P/Cont. P/Cont. P/Cont. P/Cont. Hemangioma on LLQ. to monitor resp. Settles well inbetween cares. Conintue toencourage and support , and update. Taking temps and changingdiapers. Breathsounds, resp rate, and WOB are at baseline. Swaddled w/i boundaries. Continue tosupport G+D. Resp. P/Cont. P/Cont. P/Cont. Abd exam benign. Abd is benignw/active BS. Suctioned for moderate secretions. P: Cont. Toleratingwell. Resp. P/Cont. P/Cont. P/Cont. to support andupdate . MildSC rtx. Independent withdiapering and taking temp. On vit E and Fe.G&D: Temps stable, swaddled in 'off' isolette. ASSISITNG WITHCARES. Tolerating well. : Both in for cares. P:Cont. P:Cont. P: Cont. P: Cont. P: Cont. Min benignasps. Stable temp in off isolette. Settles well inbetween cares. RR 30-70's stable on CPAP cont to follow. Infant continues on Vit E and ferinsol. A/G stable. Abd exam benign.Voiding. BP stable.3. RR stable. Breath sounds,resp rate, and WOB are at baseline. Suctioned for sm amount clear secretions. Remainder gavaged. Tolerating feeds o9f bm/pe26with pm well. GIRTHSTABLE. TF CONT. MildSCR noted. MildSCR noted. P:Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Update given. G/D: Temps stable swaddled in OAC. Remains oncaffeine. Abd benign. to monitor resp. to monitor resp. Min benignasps. On vit E and Fe.G&D: Temps stable, swaddled in 'off' isolette. OnFe and Vit E.DEV: Temps stable off isolette. Toleratingwell. MildSC rtx. Recovered QSR. Caffiene given asordered. Contswith mild IC/SC retractions. LS clear/=. 0700- NPNRESP: RA. No ^'ed WOB noted. Bottling partial/full volumes. Cont withcurrent plan.G&D: Temp stable in servo isolette. Bld cx neg to date. remainderwith sm. A: Tolfeeds. OnCaffeine. Isolette temp27.4. Updated atbedside. Cont to support andupdate.Sepsis: D5/7 of amp and gent. Rn updated . Independant withcares. Remains npo conts on tf140cc/kg. Mild I/S retractions. Rests well inbewteen cares. A: Stable in RA P: Continue to monitor.#3 FEN S/O: TF 150cc/k/d. Mild sc rtxns. Infant remains on caffeine with nospells thus far this shift. BS cl and =. Abd soft, +BS. Remains on NP CPAP of 6cm, Fio2 21%, BS clear, equal,mild subcostal/intercostal retractions present, no spellsthus far this shift. Settles well inbetween cares. P/cont. P/cont. P/Cont. Oncaffeine. Resp. to support andeducate . gavage well. Updates given. Infant continues on Vit E and ferinsol. P:Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Tolerating well. Sm. Inf PO/PGfeeding this shift. Offered bottle again atnoon care. A/A withcares. Settles well inbetween cares. Well perfuse. Bld cx neg to date. Independent withcares. A-AGA. A-AGA. Temp stable. Updated atbedside. P: Cont. P: Cont. Alert and acitve withcares. A: AGA. A: AGA. Abd benign. +. AGA. STill req gavage. , involved .P: Cont. Updated. Hypoactive bs. Cont with current plan.G&D; Temp stable in servo isolette. Nospits, min aspirates. Settles well inbetween cares. Min aspirates. Stable on CPAP cont to follow. Uptaded regardinginfant's plan of cares and weight by RN . Updatedat bedside. A-AGA. P:Cont. P: Cont. P: Cont. P: Cont. P: Cont. updated by this rn. updated by this rn. Infant continues on Vit E and ferinsol. NPN 0700-3. tosupport and update . HUS planned fortomorrow. G/D: Temps stable in servo-isolette. to monitor resp. IC/SCRnoted. ABG 7.32/41/53/22. +ic/sc rtxns. BP 42/24, 30. 142/3.5/117/19. UAC and UVC in place. Toleratingwell. to moitor resp. P: Check abili in am. P/Cont. P/Cont. P/Cont. P/Cont. Resp. BCneg to date. LSclear and equal. Pulseswnl. Independent withcares. : Both in for cares. PN/IL infusing via DLUVC. HUS planned fortomorrow. P:Cont. P: Cont. P: Cont. P: Cont. P: Cont. adequate pre gent level. Wean Dopa as able.#3FENWt 905g. Updatesgiven. Settings weaned with minimal O2 requirement.P. TEmp stable. , SNNP Abd benign. Stable temp in heated isolette. Gent pre level 1.0. Conts on Ampi and Genta as ordered. mild subcostal retractions. Appropr. appropriateP. Brisk capillary refill. A/ Stable on CPAP. Temps stable inservo isolette. BSCEbilat. A: Stable P: cont to follow.GDO: temp stable in servo controlled isolette, active andalert with cares, MAE. Resp. Calmswith containment and pacifier. BSCE bilat. Update given. Transitional stool. Abd benign. Cl and = BS. Infant remains oncaffeine. G/D: TEmp. A: stable P: COnt. temp. Abd benign. Abd benign. Abd full, soft.Bowel snds present. TOLERATING WELL. Ic/sc ret. A: AGA P: contto support dev. Agree with above written by A. , PCA TF CONT. BS+. BS+. PAR: in to do cares at . MildSCR noted. Infant continues on Vit E andferinsol. O: in for care. Infantcontinues on Vit E and ferinsol. Rate ecchymoses. Remains on Vit E and Fe. Nml pulses and brisk cap.refill noted. Lytesin bili in am. P: Cont. P: Cont. P: Cont. P: Cont. Waking for care times.Temps stable cobedding in OAC. Willcheck d/stick with next set of cares.Growth and Dev: Temp stable in servo isolette. HUStoday normal. INDEPENDENT WITH TEMP/DIAPERCHANGING. Tolerating feedingswell; abd exam benign, no spits, AG stable, and min asp. G/D: Temps stable in servo-isolette. Intubated by . Stable temp in servo isolette. Team aware(?hemanginoma). Infusingwell. Temps stable cobeddingw/twin in OAC. Temps stable in servoisolette. TEMPS STABLE AT 98.2. REMAINS IN SERVO ISOLLETTE. Rebound bili to be drawn in AM. tosupport and update . to monitor resp. TOMONITOR RESP. IC/SCRnoted. G/D: Temps stable in servo-isolette. Abd benign as charted, seeflowsheet. Abdomen benign.Starting po. Stable temp in servo isolette. Infant remainsNPO. Settles well inbetween cares. Ampi was givenas ordered. Infant continues on Vit E and ferinsol. Infant continues on Vit Eand ferinsol. tosupport and update . to monitor resp. to monitor resp. Independent withdiapering and taking temp. TOlerating well wwithno spits, abd unremarkable, stable girth, v/s heme neg. Temp stable in cirvo iso. G/D: Temps stable in servo-isolette. to support andupdate . Infant continues on Vit E and ferinsol. very andinvested.A/P:Cont. Tolerating well. RR 30-60's stable on CPAP cont to follow. Compared to a prior normal ultrasound study dated . UVC tip terminates in the right atrium. IMPRESSION: Normal head ultrasound. IMPRESSION: Normal cranial ultrasound. Tip now terminates in the expected location of the right innominate vein. UVC tip projects over the expected location of the right atrium. | 425 | [
{
"category": "Nursing/other",
"chartdate": "2148-12-05 00:00:00.000",
"description": "Report",
"row_id": 1702291,
"text": "Newborn meed Attending\n\n DOL#60. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2765 up 40, on 150 cc/kg/d PE24 Po/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-25 00:00:00.000",
"description": "Report",
"row_id": 1702373,
"text": "Clinical Nutrition\nO:\n~38 wk CGA BB on DOL 80.\nWT: 3345g(+5)(75-90 %ile); Birth WT: 936g. Average wt gain over past wk ~21g/kg/d.\nHC: 35cm(~90 %ile); last wk: 34cm\nLN: 48cm(~50 %ile); last wk: 46.5cm\nMeds include Fe & Vit.E\n not needed.\nNutrition: 140cc/kg/d as BM 24 w/ 4cal/oz of Enf powder or E24, po/pg. Average of past 3d intake ~141cc/kg/d, providing ~113kcals/kg/d and ~2.6-4.0g pro/kg/d.\nGI: Abdomen benign\n\nA/Goals:\nTolerating feeds w/o GI problems, po/pg. not needed. Current feeds & supps meeting recs for kcals/pro/vits/mins. Growth is slightly exceeding recs for WT/LN gains of ~15-20g/kg/d for WT & of ~1.0cm/wk for LN. Will monitor trends. Growth is meeting recs for HC gain. Will continue to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-25 00:00:00.000",
"description": "Report",
"row_id": 1702374,
"text": "Clinical Nutrition\nAddendum:\nCurrent intake provides ~1.9-2.5g protein/kg/d which meet weaned recommendations.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-25 00:00:00.000",
"description": "Report",
"row_id": 1702375,
"text": "NPN 0700-\n\n\n3. TF minimal 140cc/kg/day, BM/E 24. Bottling with every\nfeeding. Bottled 35cc, 67cc and 45cc respectively, with\nremainder gavaged in. Belly soft, + BS, no loops. One\nsmall spit, max aspirate 2.4cc. Voiding, no stool thus far\nthis shift. Continue to monitor tolerance to feedings,\nbottle with every feed.\n\n4. Temp stable in open crib, cobedding with brother. \nand active with cares, yet not waking for feeds.\nErythromycin ointment to right eye applied at noon. No\ndrainage from eyes this shift. Continue to promote growth\nand development.\n\n5. here for 4pm feeding, updated on progress and\nplan of care. invested and , independent with\ncares. Continue to update, educate and support .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-26 00:00:00.000",
"description": "Report",
"row_id": 1702376,
"text": "3. F/N: O: Infant is on 140cc/k/d of 24cal E/BM, q 4 hour\nfeeds. Abd is benign. He is voiding--no stools so far this\nshift. No spits, min asps. He is bottled q 4 hours and has\nbeen taking @ of his volume. He is gavaged the rest. He\ngained 50g. A: feeds, still learning to bottle. P:\nContinue w/ plan.\n\n4. G/d: Temp is stable in the open crib. He is co-bedding w/\nhis brother. is and active w/ cares. A/P: Continue\nto support infant needs.\n\n5. : O: Mom called for an update. A: , involved\n. P: Continue to support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-26 00:00:00.000",
"description": "Report",
"row_id": 1702377,
"text": "Nebworn Med Attending\n\nDOL#81. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=3395 up 50, on min 140 cc/kg/d E24 PO/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-22 00:00:00.000",
"description": "Report",
"row_id": 1702090,
"text": "NPN Nights\n\n\n#1 O: Infant remains on NPCPAP of 5 cms of pressure and has\nremained in 21% FIO2. Sxn mod secretions NP tube and\nlarge per nares. Lung sounds are clear and equal with\ncontinued mild retractions. Resp rates 40s-50s. Remains on\nq day dose of caffine - has had 2 episodes of bradys thus\nfar this shift, both with apnea and both QSR. A: stable in\nroomair CPAP, having occasional spells. P: Continue to\nmoniter.\n#3 O: Wgt 985g, ^10g. Remains on TF of 150cc/k/d of BM/Pe\n26 cals. Tolerating gave feeds well with no spits, min\naspirates. Abd remains softly round, +bs, soft loops X 1 ,\nAg stable. Voiding adeq amts, stool heme neg. A:\ntolerating 26 cal formula tonight. P: Continue to moniter.\n#4 O: Infant alert and active with cares. Temp stable on\nservo control. Sucking occasionally on pacifier. A: AGA.\nP: Continue to moniter for milestones.\n#5 No contact with thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-22 00:00:00.000",
"description": "Report",
"row_id": 1702091,
"text": "Neonatal NP-Exam\n\nsee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures overriding. Breath sounds clear and equal with good CPAP transmission. Nl S1S2, no murmur. Pink, mottled with exam. Abd benign, no HSM. Hemangioma on LLQ. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-22 00:00:00.000",
"description": "Report",
"row_id": 1702092,
"text": "Neonatology Attending\n\nDay 16\n\nRemains on CPAP at 5cm with fio2 0.21. On caffeine with five bradycardia episodes over last 24 hours. No murmur. HR 140-160s. Pink. BP mean 41. Weight 985 gms (+10). TF at 150 cc/kg/d- PE/BM 26. Occasional palpable loops and aspirates. Passing heme negative stool. Stable temperature in servo-controlled incubator.\n\nBreathing control immaturity persists. Adequately controlled in current regimen. Will maintain current caloric regimen while assuring feeding tolerance. Family up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-22 00:00:00.000",
"description": "Report",
"row_id": 1702093,
"text": "Respiratory Care Note\nPt remains on NPCPAP +5,.21FiO2. BBS ess clear. RR 35-60s w/SCR/ICR. NP tube sx'd for blood tinged secretions. Continues on caffeine. One spell early in shift requiring mild stim. Otherwise w/occ sat drifts. NARD. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-22 00:00:00.000",
"description": "Report",
"row_id": 1702094,
"text": "Nursing Note\n\n\n1. Recieved pt on NPCPAP 5 with 21% FiO2. Tolerating well.\nBLS c/=, RRR, Suctioned x2 this shift. See flowsheet for\ndetails. On caffine, One spell this AM. See flowsheet for\ndetails. Otherwise, stable, no ^WOB. Will continue to\nmonitor.\n3. TF requirements met with NG feeds. TOlerating with +bs,\noccassional soft loops. Pink abd, well perfused. Non\ndistended, nontender. v/s heme neg stools. One large asp of\n9.2cc of partially digested formula this AM.Team aware. Will\nhold on increasing cals today and reevaluate tomorrow.\nOtherwise, min asp. ABd girth stable. WIll continue to\nmonitor.\n4. Temps stable in cirvo iso, a/a with cares, sleeps well\nbetween. Likes paci, afosf, , . COntinue to support\ngd.\n5. Mom in this AM/PM. Kangarood for apprx 1h. Infant\ntolerated well. Mom asking quest. Will continue\nto update and educate at bedside.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-18 00:00:00.000",
"description": "Report",
"row_id": 1702345,
"text": "Clinical Nutrition\nO:\n~37 wk CGA BB on DOL 73.\nWt: 3195 g (+45)(~75th to 90th %ile); birth wt: 936 g. Average wt gain over past wk ~26 g/d.\nHC: 34 cm (~75th to 90th %ile); last: 33.25 cm\nLN: 46.5 cm (~25th to 50th %ile); last: 46.5 cm\nMeds include Fe\n not needed\nNutrition: Ad lib po, minimum 130 cc/kg/d, E 24/BM 24 w/ 4 kcal/oz Enfamil powder, po/pg. Infant takes ~ to full volume po; po feeds w/ q feed. Limited supply of BM; infant receives mostly formula. Feeds just changed today to ad lib min. of 130 cc/kg/d from 150 cc/kg/d. Average of past 3 d intake ~145 cc/kg/d, providing ~116 kcal/kg/d and ~1.9 to 2.1 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. Taking good po volumes now; will try po ad lib w/ minimum 130 cc/kg/d now. not needed. Current feeds + supps meeting weaned recs for kcals/vits and mins. Not quite meeting protein recs of ~2.2 g/kg/d, but anticipate infant to start taking increased po volumes soon, which will increase intake. Also, growth has been adequate on current feeds. Meeting recs for wt gain and HC gain. LN shows no change over past wk; will follow long term trends. Will continue to follow w/team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-18 00:00:00.000",
"description": "Report",
"row_id": 1702346,
"text": "NPN 7a-7p\n\n\n#3: TF: decreased to min 130cc/k/d. Now recieving 69cc\nq4hrs. Conts on E24/BM24. Bottle offered at each feed\ntoday. Took 31-40cc, with good coordination. Slow bottler,\ntiring half way through. Med spit x1. Min benign asps.\nAbd soft, +, no loops. Sm soft umbi hernia noted.\nConts with mild gen edema, particularly in groin. Voiding\nqs. Trace smear of green stoolx1. A: 'ing feeds,\nworking on PO skills P:Cont with current feeding plan.\nFollow wt and exam. Monitor to feeds.\n\n#4: conts to maintain stable temps while swaddled in an\nopen crib. He is co-bedding with his brother. /active\nwith cares. Stirring-waking on own for feeds. Fonts\nsoft/flat. Mod amt yellow crusty eye drainage noted from\nright eye. Cleansed with warm water and gentle massage\napplied to tear duct. A: AGA P:Cont to support dev needs.\n\n#5: No contact with thus far in shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-19 00:00:00.000",
"description": "Report",
"row_id": 1702347,
"text": "PCA Note\nI have examined this infant and agree with above note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-06 00:00:00.000",
"description": "Report",
"row_id": 1702166,
"text": "Nursing NICU Note\n\n\n1. Resp. O/PT remains in RA. NO A/B noted. One brief\ndesaturation to the high 80s noted- QSR. A/Resp status\nremains stable in RA. P/Cont. to monitor.\n\n3. F/N. O/TF remain at 150cc/k/d of PE30PM/BM30PM PNGT.\nPlease refer to flowsheet for examinations of pt from this\nshift. Voiding. Passed lg stool. A/Appears to be tolerating\npresent feeding regimen. P/Cont. to monitor for s/s of\nfeeding intolerance.\n\n4. G/D. O/Temp slightly elevated nested in sheepskin in an\nair controled isolette. Gradually weaning isolette temp as\npt tolerates. Pt is quietly awake and alert with cares and\nis sleeping well in between. Good muscle tone noted\nthroughout shift thus far. A/Alt. in G/D. P/Cont. to support\npt's growth and dev. needs.\n\n5. . O/ in at afternoon care times. \nupdated on pt's status and plan of care at bedside and at\nfamily team meeting with this nurse also present.\n participated in cares by taking pt's temp and\nchanging pt's diaper. A/ are actively involved in\npt's care. P/Cont. to support and educate .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-07 00:00:00.000",
"description": "Report",
"row_id": 1702167,
"text": "NURSING PROGRESS NOTE\n\n\n1. RESPIRATORY\nCONTINUES IN ROOM AIR. NO EPISODES OF DESATURATION. BBS\nCLEAR.\n3. F/N\nTONIGHT'S WEIGHT UP 20 GRAMS TO 1.49KG. TOLERATING 150CC/KG\nOF PE30 WITH PROMOD. ABD FULL, SOFT. STOOL X1.\n4. G&D\nWEANING ISOLETTE TEMP. LOVES BEING SWADDLED.\nQUIET UNLESS DISTURBED.\n5. \nMOM CALLED AND UPDATED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-07 00:00:00.000",
"description": "Report",
"row_id": 1702168,
"text": "Neonatology Attending Note\nDay 32\n\nRA. RR30-70s. Cl and =. Mild rtxns. No A&Bs. On caffeine. No murmur. Pale/pink. HR 150-180s.\n\nWt 1490, up 20 gms. TF 150 cc/k/day BM/PE30 w promod. well. Nl voiding and stooling. On Vit E and Fe.\n\nIn air control isolette.\n\nD30 HUS wnl.\n\nA/P:\n-- Monitor AOP\n-- Good growth, will reduce cals to 28\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-07 00:00:00.000",
"description": "Report",
"row_id": 1702169,
"text": "Neonatology- Physical Exam\n\nInfant remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equla with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, strawberry hemangioma on left abdomen, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-07 00:00:00.000",
"description": "Report",
"row_id": 1702170,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining her O2 sat above\n95%. Lung sounds clear/=. RR 30-70's. IC/SCR noted. No\nspells noted thus far this shift. Infant remains on\ncaffeine. P: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 150 cc/kg/day of BM/PE28 with promod.\nTolerating NGT feedings well; abd exam benign, no spits, AG\nstable, and min asp. Voiding qs and no stool thus far.\nInfant continues on Vit E and ferinsol. P: Cont. to support\nnutritional needs.\n\n3. G/D: Temps stable swaddled in air-controlled isolette.\nAlert and active with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. : Mom in for 1200 cares. Independent with\ndiapering, taking temp, and handling infants. Updated on\ninfant's condition and plan of care. Asking appropriate\nquestions. Mom held for 90 minutes - \ninteraction.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-14 00:00:00.000",
"description": "Report",
"row_id": 1702036,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on NP CPAP 5 FIO2 21%. Suctioned NP tube for sm-mod amt of white/yellow secretions and lg amt of yellow oral secretions. Breath sounds are clear. RR 30-50's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-14 00:00:00.000",
"description": "Report",
"row_id": 1702037,
"text": "Neonatology- Physical Exam\n\nInfant remains on CPAP. Active, alert in an isolette, AFOF, sutures overriding, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pale/pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-14 00:00:00.000",
"description": "Report",
"row_id": 1702038,
"text": "Neonatology Attending\n\nDay 8\n\nRemains on CPAP with fio2 0.21. RR 30-50s. Suctioned for moderate secretions. Clear breath sounds. Had one bradycardia episode over last 24 hours. HR 150s. Pale, pink. BP 60/38, 46. Bilirubin 1.2 on phototherapy. Weight 860 gms (+40). TF at 150 cc/kg/d. On BM/PE 20 at 50 cc/kg/d by gavage. Supplemented with PN and lipids via PICC. Benign abdomen. No spits, aspirates. Passing meconium. Blood glucose 78. Stable temperature on servo-control.\n\nAcceptable breathing control on current regimen. Will continue to monitor closely. Gaining weight. Will continue to advance feeds by 10 cc/kg twice daily. Discontinuing phototherapy. Will check rebound in days. Family up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-26 00:00:00.000",
"description": "Report",
"row_id": 1702255,
"text": "NPN 1615\n\n\n#3 F/N: remains on 150cc/kg/d PE24/BM24, 60cc q 4 hrs.\nInfant put to breast at 12pm and latched successfully\nX10-15mins. At that time the infant was given 45cc br. milk\n24. Tolerates gavage w/o spitting. Abd soft, bowel snds\npresent. Voiding well, no stool today.\nA: Tolerating present feeding plan.\nP: Cont to encourage br. feeding, bottle X1 during the\nnight.\n#4 G/D: Infant remains in an open crib w/ temps\n97.6ax-97.9ax. Hat placed on baby today. Awake and w/\ncares. Swaddled w/i boundaries. Interested in nursing and\nlatched well.\nA: AGA\nP: Cont dev. supports.\n#5 : Mother in at 12pm. Taking temps and changing\ndiapers. Handles babies confidently. Asking appropriate\nquestions. Parvo titre still pending, takes up to 7 days.\nA: Invested, mother.\nP: Cont parent support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-27 00:00:00.000",
"description": "Report",
"row_id": 1702256,
"text": "PCA Progress Note, 7p-7a\n\n\nFEN:\n TF:150cc/kg/D of BM/PE24. Infant is POing x1 /shift. BF\nwell for 10 mins, suck was eager. Gavaged feedings are given\nover 50mins-1hr. Tolerating all feeds well w/minimal\naspirates and no spits so far this shift. Abd is benign\nw/active BS. vosing and stooling w/ each diaper chg. Remains\non vit E and Fe. Please refer to Pt's chart for additional\nFEN data. Continue to encourage and support PO feeds and\ncurrent plan of care.\n\n\n\nDEV:\n Infant's temp remains stable while swaddled in OAC. Infant\nis and active w/ cares, wakes for most feeds and\nsleeps well in between cares. Continues to root and suck on\npacifier for comfort. COntinue to encourage and support\ndevelopmental milestones.\n\nPAR:\n Mom was in for last care this shift. SHe is very\nindependent w/ cares and feedings, and acts very appropriate\ntoward her son. BF and held the infant. Conintue to\nencourage and support , and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-27 00:00:00.000",
"description": "Report",
"row_id": 1702257,
"text": "NPN 1900-0700\nI have examined infant and agree with above note bye PCA, . Mother was updated at bedside on infant's condition and plan of care by this RN. Asking appropriate questions. Will be in to visit this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-27 00:00:00.000",
"description": "Report",
"row_id": 1702258,
"text": "Neonatology\nDoing well. RA. No spells. Comfortable apeparing. No murmur.\nHad two bradys yesterday.\n\nWT 2420 up 30. Tolerating feeds at 150 cc/k/d of 24 cal. Abdomen benign.\n\nTemps table in open crib.\n\nStill requiring some gavage.\n\nActivity normal. Moving all 4 well. Neuro non-focal\n\nCOntinue to await maturation of resp control and feeds.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-27 00:00:00.000",
"description": "Report",
"row_id": 1702259,
"text": "Clinical Nutrition\nO:\n~34 wk CGA BB on DOL 52.\nWT: 2420g(+30)(~75th %ile); birth wt: 936g. Average wt gain over past week ~17g/kg/d.\nHC: N/A\nLN: N/A\nMeds include Fe & Vit.E\n not needed.\nNutrition: 150cc/kg/d as BM/PE 24, po/pg over 1 hr. Average of past 3d intake ~149cc/kg/d, providing ~119kcals/kg/d and ~3.2-3.6g/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds w/o GI problems over extended feeding time. Attempting po's & breastfeeding. not needed. Current feeds & supps meeting recommendations for pro/vits/mins. Kcals not quite meeting recommendations of ~120-150kcals/kg/d, but gaining well; will monitor intake & growth. Growth is meeting recs for wt gain. HC/LN N/A for comparison; will follow trends. Will continue to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-13 00:00:00.000",
"description": "Report",
"row_id": 1702032,
"text": "Neonatology Attending Progress Note:\nCGA 27 3/7 weeks, DOL #7\ncontinues on NPCPAP 5 RA\noccasional spells overnight-2 requiring stim\ns/p 1 course indomethacin\nHR=150-160, BP mean=39\nwt=820g (inc 50g), TF=150cc/kg/d, feeds at 30cc/kg/d\nvoiding.\nD #7 amp and gent (negative LP)\nbili=4.3 on phototherapy\nPICL\n\nPE: well appearing, AFOF, normal S1S2, no murmur, breath sounds slightly coarse bilaterally, mild ic/sc retx. abdomen soft, nontender, nondistended, ext warm, well perfused. tone aga.\n\nImp/Plan: x-27 week infant with residual RDS, indirect hyperbilirubinemia, possible sepsis with mild apnea\n--continue caffeine, monitor for apnea\n--d/c amp and gent\n--increase feeds to 40cc/kg/d, monitor weight\n--repeat HUS on Wednesday\n--continue phototherapy, check bili in am\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-13 00:00:00.000",
"description": "Report",
"row_id": 1702033,
"text": "Respiratory Care Note\nPt remains on +5 NP CPAP, 21% O2 t/o shift. BS clear. RR 40-60. Will remain on CPAP until further wt. gain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-14 00:00:00.000",
"description": "Report",
"row_id": 1702039,
"text": "Clinical Nutrition\nO:\n~27 wk CGA BB on DOL 8.\nWt: 860 g (+40)(~25th %ile); birth wt: 936 g. Wt currently down ~8% from birth wt\nHC: 24.5 cm (~25th %ile); last: 24.5 cm\nLN: 35.75 cm (~25th to 75th %ile); last: 35.5 cm\nLabs noted\nNutrition: 150 cc/kg/d TF. EN currently @ 50 cc/kg/d BM/PE 20, increasing 10 cc/kg/. Remainder of fluids as PN via non central PICC line; projected intake for next 24 hrs from PN ~54 kcal/kg/d, ~2.5 g pro/kg/d, and ~1.5 g fat/kg/d. From EN: ~40 kcal/kg/d, ~0.6 to 1.2 g pro/kg/d, and ~2.0 t 2.3 g fat/kg/d. Glucose infusion rate from PN ~5.9 mg/kg/min.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems so far; advancing slowly and monitoring closely for tolerance. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Current feeds + PN meeting recs for kcals/pro/fat/vits. Full mineral recs will not be met until feeds are advanced to initial goal. Growth should improve as feedings are advanced to initial goal. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-27 00:00:00.000",
"description": "Report",
"row_id": 1702119,
"text": "Neonatology Attending Note\nDay 21\nCGA 29 \n\nRA. +Sat drifts w/ feeding. On caffeine. No murmur. HR 140-170s. BP 55/33, 41.\n\nWt up 5 to 1075. TF 150 cc/k/day BM/PE30. well. Nl voiding and stooling. On Fe and Vit E.\n\nIn isolette.\n\nA/P: Growing preterm infant.\n - Continue to monitor O2 need, and AOP on caffeine.\n - No change to nutritional plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-27 00:00:00.000",
"description": "Report",
"row_id": 1702120,
"text": "Nursing NICU Note.\n\n\n1. Resp. O/pt remains in RA at this time. Please refer to\nflowsheet for desaturation noted and for A/B spells noted\nthis shift. Remains on caffeine. A/Occasional spells noted.\nOtherwise appears stable in RA. P/Cont. to monitor for A/B\nand intervene as pt needs. Cont. to monitor for s/s of resp\ndistress.\n\n3. F/N. O/Tf remain at 150cc/k/d of BM30PM/PE30PM pngt.\n refer to flowsheet for examinations of pt from this\nshift. Voiding. No stool passed this shift as of yet.\nA/Appears to be tolerating present feeding regimen at this\ntime. P/Cont. to monitor for s/s of feeding intoleranc.\n\n4. G/D. O/Temp stable thus far on servo control in a covered\nisolette, nested in sheepskin. Awake and alert with care\nthis am and sleeping well thus far in between. A/Alt. in\nG/D. P/Cont. to support pt's growth and dev. needs.\n\n5. . O/No contact from thus far this shift.\nA/ are known to be actively involved in pt's care.\nP/Cont. to support pt's growth and dev needs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-27 00:00:00.000",
"description": "Report",
"row_id": 1702121,
"text": " ON-Call\nPhysical Exam\nGeneral: infant in room air, isolette\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures open/opposed\nChest: breath sounds equal, well-aerated\nCV: RRR without murmur; normal S1 S2; femoral pulses +2\nAbd: soft; no masses; non-tender; + bowel sounds\nGU: pre-term male\nExt: moves all\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-16 00:00:00.000",
"description": "Report",
"row_id": 1702338,
"text": "NPN 0700-1900\n\n\n1. FEN: TF remain at 150 cc/kg/day of E24/BM24. Infant is\nbottling q care. Infant has bottled 60 cc and 50 cc thus\nfar respectively. The remainder of the feedings have been\ngiven via NGT. Tolerating feedings well; abd exam benign,\nno spits, and min asp. Voiding qs and stooling heme neg.\nInfant continues on ferinsol. P: Cont. to support\nnutritional needs.\n\n2. G/D: Temps stable swaddled cobedding in open crib with\nsibling. and active with cares. Settles well in\nbetween cares. Appropriately brings hands to face and sucks\non pacifier to comfort self. AFSF. AGA. P: Cont. to\nsupport developmental needs.\n\n3. : Mom called x 1. She was updated on infant's\ncondition and plan of care. Asking appropriate questions.\nWill be in for 1600 or cares. , involved\n. P: Cont. to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-17 00:00:00.000",
"description": "Report",
"row_id": 1702339,
"text": "NPN 1900-0730\n\n\n3. Wt 3150gm- no change. TF 150cc/kg/day, BM 24 with\nEnfamil/E 24. Bottling with every feed- needs 79cc Q4\nhours. Bottled 45cc, 62cc, and 55cc consecutively. Belly\nsoft, + BS, no loops. Min aspirates, no spits. Voiding,\ntrace stool. Continue to monitor tolerance to feeds.\n\n4. Temp stable in open crib, cobedding with brother. \nand active with cares, rests well between cares. MAE,\nbrings hands to face. Continue to promote growth and\ndevelopment.\n\n5. Mom called this evening, updated on progress. \nwill return for 20:00 care tomorrow. Continue to update,\neducate and support . Discharge teaching ongoing.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-17 00:00:00.000",
"description": "Report",
"row_id": 1702340,
"text": "Neonatology Attending\n\nDay 72\n\nRemains in RA. RR 40-60s. Clear breath sounds. Mild retractions. No murmur. HR 140-160s. Pink, well-perfused. Weight 3150 gms (unchanged). Taking E24. Took about half volume po. STable temperature in open crib.\n\nMature breathing control evident. Immature feeding still experienced. Will continue to encourage po feeding. Gaining weight well overall.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-17 00:00:00.000",
"description": "Report",
"row_id": 1702341,
"text": "0700- NPN\n\n\nFEN: TF= 150cc/kg/d of E24/BM24 (with enfamil powder).\nAttempting PO qfeed. Infant bottled 32cc at 0800 care and\n25cc at 1200 care, remainder gavaged. Abdomen pink, soft,\nround, +BS, no loops. Minimal aspirates, small spits.\nVoiding and stooling (guiac negative). Continues on iron.\nContinue to monitor FEN status.\n\nG+D: Temps stable, swaddled in OAC. Infant cobedding with\nsibling. Active and with cares, sleeps between. Brings\nhands to face, sucks on pacifier for comfort. Continue to\nsupport G+D.\n\n: No contact with thus far. Continue to\nsupport/answer questions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-18 00:00:00.000",
"description": "Report",
"row_id": 1702342,
"text": "#3 PT PO FED FULL FEED X2. FED FULL FEED AT . ABD\nBENIGN. VOIDING NO STOOL AT THIS TIME IN SHIFT. WEIGHT\nINCREASE 45GM.\n#4 TEMPS ARE STABLE COBEDDING IN OPEN CRIB. AND\nACTIVE. PO FEEDING WELL.\n#5 MOM AND IN FOR EVENING CARES. \nWITH CARES.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-18 00:00:00.000",
"description": "Report",
"row_id": 1702343,
"text": "Newborn Med Attending\n\nCont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=3195 up 45, on 150 cc/kg/d e24, PO/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-13 00:00:00.000",
"description": "Report",
"row_id": 1702034,
"text": "NICU Nursing Progress Note\n\nRESP/APNEA AND BRADYCARDIA\nO: Remains on NPCPAP 5 cms in room air with O2 sats 98-100.\n1 spell noted so far this shift. Remains on caffeine. Breath\nsounds, resp rate, and WOB are at baseline. Suctioned every\n4 hrs for mod amount white secretions.\nA: Occasional spells. Otherwise, no evidence of compromise.\nP: Monitor and assess.\n\nHYPERBILI\nO: Remains under single spotlight phototherapy with eyes\ncovered. Slightly jaundiced. Has not developed regular\nstooling pattern yet.\nA: Hyperbili of prematurity.\nP: Check serum bili in a.m.\n\nSEPSIS\nO: Completed 7 days of ampicillin and gentamycin IV. Active\nand alert with good tone, stable VS and brisk cap refill.\nA: No evidence of compromise.\nP: D/C problem and continue to monitor.\n\nNUTRITION\nO: Advanced enteral feeds to 40cc/kg/day. PIC line infusing\nwithout difficulty (PN and IL.) TF=150cc/kg/day. Dextrostix\n96. Abd exam benign. Voiding and passing sm amt green stool\nafter rectal stim.\nA: No evidence of intolerance to increased feeds.\nP: Assess and avvance enteral feeds by 10cc/kg every 12 hrs\nif tol.\n\nDEVELOPMENT\nO: Temp stable in servo isolette (except for interference\nfrom phototherapy lights. Infant is active, sucking on\npacifier and fingers.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom called for update and progress report given. She\nstates pumping is going slowly and she will make appt with\nL.C. Mom plans to visit today sometime.\nA: Involved parent.\nP: Support and keep involved.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-14 00:00:00.000",
"description": "Report",
"row_id": 1702035,
"text": "NPN NOCS\n\n\n1. Remains on NPT CPAP of 5. FiO2 21%. LS clear. Suctioned\nfor thick secretions. On caffeine, no spells. RR 30-50's.\n\n3. Wt 860gms, up 40. TF remains at 150cc/kg. Advancing feeds\nas ordered. IVF PN and lipids infusing at 100cc/kg via PICC.\nDS stable. Feedings currently at 50cc/kg of BM/PE20. Gavaged\nover 30min. No spits. No residuals. Abdomen benign. Voiding\nand stooling.\n\n4. Temp stable in servo isolette. Nested with boundaries in\nplace. Alert and active with cares.\n\n5. Parents in last eve. Updated, asking appropriate\nquestions. Participating in cares. Will be in this eve for\ncares and to kangaroo.\n\n7. Sl. jaundice in color. Remains under single phototherapy\nlight. Bili sent and pending\n\nSkin: Continues with a red mark noted on scapula area and\nleft quad of belly. Areas both red, non\nblanchable.?hemangioma vs bruise. Will continue to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-28 00:00:00.000",
"description": "Report",
"row_id": 1702122,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\nbetween 94-99%. Lung sounds clear/=. RR 40-70's. IC/SCR\nnoted. One spell noted thus far - please see flowsheet for\nfurther details. Infant continues on caffeine. P: Cont. to\nmonitor resp. status.\n\n2. FEN: Weight is 1090 gms up 15 gms. TF remain at 150\ncc/kg/day of BM/PE30 with promod. Tolerating NGT feedings\nwell; abd exam benign, no spits, AG stable, and min asp.\nVoiding qs and no stool noted thus far. Infant continues on\nVit E and ferinsol. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. AFSF. AGA. P:\nCont. to support developmental needs.\n\n4. : Mom in for cares. Independent with\ndiapering, taking temp, and handling infants. Updated at\nbedside on infant's condition and plan of care. Asking\nappropriate questions. , involved . P: Cont.\nto support and update .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-15 00:00:00.000",
"description": "Report",
"row_id": 1702200,
"text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 94-100%. RR 40-70's.\nOccasional mild SC rtx. LS clear and equal. No spells thus\nfar. On caffeine.\n\nFEN: wt=1840g (up 35g). TF=150cc/kg/d of BM/PE 26 with\npromod. Equals 46cc q4hrs, gavaged over 60min. Tolerating\nwell. Abdomen soft, +BS, AG stable, no loops, no spits,\nvoiding and stooling. On vit E and Fe.\n\nG&D: Temps stable, swaddled with hat in open crib. HOB up.\nAlert and active with cares. Sleeps well between. Hands to\nface.\n\n: No contact thus far.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-15 00:00:00.000",
"description": "Report",
"row_id": 1702201,
"text": "Neonatology Attending Note\nDay 40\n\nRA. RR40-70s. Mild rtxns. No spells. On caffeine. No murmur. HR 140-170s. BP 57/30, 42.\n\nWt 1840, up 35. TF 150 cc/k/day PE/BM26 w promod. All pg. well. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nMonitor AOP on caffeine\nNo change to nutritional plan\nEye exam due next week\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-15 00:00:00.000",
"description": "Report",
"row_id": 1702202,
"text": "0700- NPN\nResp: Infants remains in RA. O2 sats 95-100%. RR 50-70's. Mild subcostal retractions noted. Breath sounds clear and equal. No spells or desats. Infant on caffeine.\n\nFEN: TF=150cc/kg/d. Infant receiving BM 26 or PE 26 with promod, 46 cc q4h pg over 1 hour. BF x 1, latched and sucked <5 min. Abdomen soft, no loops,+BS, abdominal girth =26.5 cm. Infant tolerating feeds. Minimal aspirates, no spits. Continues on Vit E and Iron.\n\nG+D: Temps stable. Infant swaddled with hat in open crib. Infant alert and active with cares. Sleeps between cares. AGA.\n\nParenting: Mom and Dad in today. Mom breastfed at 12:00 pm care, football, less than 5 min. involved, .\n\nContinue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-16 00:00:00.000",
"description": "Report",
"row_id": 1702203,
"text": "NICU NPN 1900-0700\n\n\nRESP O: O2 sats 94-100%, lungs are clear, no bradys or\ndesats noted to time this shift, rr 30-60' remains on\ncaffeine, hr 130-160's, color pink, no murmur.\n\nFEN O: Gaining weight, tolerating gavage feeds of pe26 with\npm well. Voiding and stooling, abdominal exam benign. No\nspits, minimal ngt aspirates.\n\nDEV O: temps are stable, swaddled in crib. baby is and\nactive with cares, sleeps well in between cares, fontanells\nare soft and flat.\n\nParenting O: No contact overnight.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-26 00:00:00.000",
"description": "Report",
"row_id": 1702114,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in NC O2 100%, requiring between\n13-25 cc flow to maintain his O2 sats greater than 97%.\nLung sounds clear/=. RR 40-70's. Infant was sxn x 1 thus\nfar for mod amts of white secretions from nares. No spells\nthus far. Infant continues on caffeine. P: Cont. to\nmonitor resp. status.\n\n2. FEN: Weight is 1070 gms up 50 gms. TF remain at 150\ncc/kg/day of BM/PE30 with promod. Tolerating NGT feedings\nwell; abd exam benign, no spits, min asp and AG stable.\nVoiding qs and no stool noted thus far. Infant continues on\nvit E and ferinsol. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. Kangarooing QOD.\nAFSF. AGA. P: Cont. to support developmental needs.\n\n4. : Mom and Dad in for cares. Independent with\ndiapering and taking temp. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nMom remains inpatient on . , involved\n. P: Cont. to support and update .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-26 00:00:00.000",
"description": "Report",
"row_id": 1702115,
"text": "Nursing NICU NOte.\n\n\n1. Resp. O/Pt placed in RA. 2 A/B spells noted this shift.\nRemains on caffeine. Occasional brief sat drifts noted as\nlow as 88%. A/Resp status appears stable in RA. P/Cont. to\nmonitor.\n\n2. F/N. O/TF=150cc/k/d BM30PM/PE30PM PNGT. PLease refer to\nflowsheet for examinations of pt from this shift. Voiding.\nPassed heme neg stool. A/appears to be tolerating present\nfeeding regimen. P/Cont. to monitor for s/s of feeding\nintolerance.\n\n4. G/D. O/Kangaroo'd with NC FiO2 100%, 50cc flow; tolerated\nwell. Temp remains stable on servo control. Awake and alert\nwith cares and sleeping well in between. A/Alt. in G/D.\nP/Cont. to monitor and cont. to support pt's growth and dev.\nneeds.\n\n5. . O/Mother in; updated. Kangarood. A/Mother is\nactively involved. P/Cont. to support and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-26 00:00:00.000",
"description": "Report",
"row_id": 1702116,
"text": "Neonatology- PRogress Note\n\nPE: is currently in room air, bbs cl=, rrr s1s2no murmur,abd soft,nontender, V&S, afs, sutures split, pale pink, hemangioma on back and chest unchanged\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-26 00:00:00.000",
"description": "Report",
"row_id": 1702117,
"text": "Neonatology Attending Progress Note\n\nNow 20 days of life for this 26 week gestation twin A.\nNow in RA with RR 40-70s.\n2 episodes of apnea and bradycardia in the past 24 hours - on caffeine.\nHR 140-170s\nBP 50/37 41\n\nWt. up 50 to 1070gm on 150cc/kg/d of MM or PE30 with Promod\nFeedings are well tolerated by gavage.\nNormal urine and stool output - stool heme neg.\n\nAssessment/plan:\nVery nice progress continues.\nWill continue with current management.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-27 00:00:00.000",
"description": "Report",
"row_id": 1702118,
"text": "#1 PT CONT ON RA. LS ARE CLEAR AND EQUAL. RR 30-70. 25CC OF\n100% FIO2 FOR 1HR OVERNIGHT SECONDARY TO DRIFTING WITH A\nFEEDING. SAT DROP X1, ? REFLUXING.\n#3 TF 150CC/KG BM/PE30C/PRO. FEEDS TOLERATED WELL OVER\n50MIN. NO SPITS, MIN ASP, ABD BENIGN. VOIDING AND STOOLING.\nWEIGHT INCREASE 5GM.\n#4 TEMPS ARE STABLE IN SERVO WARMER. ALERT AND ACTIVE WITH\nCARES. CONT WITH LIGHT YELLOW EYE DRAINAGE IN RIGHT EYE.\n#5 MOM AND DAD IN FOR EVENING CARES. ASSISITNG WITH\nCARES.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-16 00:00:00.000",
"description": "Report",
"row_id": 1702204,
"text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. BS clear and equal with mild subcostal retractions, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes. Noncirced male, testes down bilaterally. Good tone, AFSF, PFSF, +suck, +, +plantar relfexes. Please see attending neonatologist note for detailed plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-16 00:00:00.000",
"description": "Report",
"row_id": 1702205,
"text": "Neonatology\nDOL #41\nremains in RA\nBS clear, RR=50's\non caffeine, no spells\nHR=130-160's, no murmur\nwt=1905g (inc 65g), TF=150cc/kg/d, BM/PE 26 with Promod\nno spits, minimal aspirates\nvoiding, stooling (heme negative)\nVItamin E and Fe\nopen crib\nImp/Plan: premie with AOP, F and G\n--continue monitor for spells\n--monitor weight\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-04 00:00:00.000",
"description": "Report",
"row_id": 1702287,
"text": "NPN\n\n\n#3FEN:\nO: Wt 2.725(+40) On 150cc/k/d PE24/BM24. Abd. exam benign.\nVoiding qs, no stools. no asp or spits. Bottled 50cc/68 X1.\nA: adequate nutritional support for wt gain\nP: Cont to offer po QOF\n\n#4G@D:\no: Temps stable in open crib. and active with cares,\nMAE. Bath done.waking for feeds\nA/P: Cont to support G@D. 60 day . due tomorrow.\n\n#5Parenting:\nO: Mom and grandmother in to visit. Mom independent with\ncares. Gave bath.CPR class scheduled.Mom stated that EI\ncontact her.\nA: Mom preparing for D/C\nP: Cont to support and inform.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-04 00:00:00.000",
"description": "Report",
"row_id": 1702288,
"text": "Newborn Med Atttending\n\nDOL#59. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2725 up 45, on 150 cc/kg/d P24 PO/PG.\nA/P: Growing inafnt working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-04 00:00:00.000",
"description": "Report",
"row_id": 1702289,
"text": "NPN 7a-7p\n\n\n3) TF 150cc/kg/day. tolerating feeds of PE 24 gavaged over\n50 min. Alt po/pg. Bottled only 15cc this am out of 68. will\ngavage infant this evening b/c to be in for the 8pm.\nAbdomen soft and benign. No spits or asp. Trace stool.\nVoiding well. continue to encourage pos.\n4) infant and active with cares. Stirring for feeds.\nSleeping well between swaddled and cobedding with brother.\nTemps stable. Yellow drainage from right eye today. cleaned\nwith sterile water. Continue to support dev.needs.\n5)Father called and update given. with be in to\nvisit this evening.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-05 00:00:00.000",
"description": "Report",
"row_id": 1702290,
"text": "NPN 1900-0700\n\n\n1. FEN: Weight is 2765 gms up 40 gms. TF remain at 150\ncc/kg/day of PE24/BM24. Infant is alt PO/PG. Infant has\nbottled 30 cc thus far with good coordination. Tolerating\nNGT feedings well; abd exam benign, no spits, and min asp.\nVoiding qs and stooling heme neg. Infant continues on Vit E\nand ferinsol. P: Cont. to support nutritional needs.\n\n2. G/D: Temps stable swaddled cobedding in open air crib.\n and active with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n3. : Mom and were in for cares at . Updated\nat bedside on infant's condition and plan of care. Asking\nappropriate questions. Independent with diapering, taking\ntemp, and handling infants. , involved . P:\nCont. to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-13 00:00:00.000",
"description": "Report",
"row_id": 1702195,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 97%. Lung sounds clear/=. RR 50-70's. Mild\nSCR noted. No spells noted thus far. Infant continues on\ncaffeine. P: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 150 cc/kg/day of BM/PE26 with promod.\nTolerating NGT feedings well; abd exam benign, no spits, AG\nstable, and min asp. Voiding qs and stooling heme neg.\nInfant continues on Vit E and ferinsol. P: Cont. to support\nnutritional needs.\n\n3. G/D: Temps stable swaddled in off-isolette. Alert and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. : Mom in for 1200 cares. Independent with\ndiapering, taking temp, and handling infants. Updated at\nbedside on infant's condition and plan of care. Asking\nappropriate questions. , involved . Both Mom\nand Dad will be in for cares. P: Cont. to support and\nupdate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-14 00:00:00.000",
"description": "Report",
"row_id": 1702196,
"text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 97-100%. RR 40-70's. Mild\nSC rtx. LS clear and equal. 1 A/B thus far, QSR. On\ncaffeine.\n\nFEN: wt=1805g. TF=150cc/kg/d of BM/PE 26 with promod. Equals\n45cc q4hrs, gavaged over 60min. Tolerating well. Abdomen\nsoft, +BS, AG stable, no loops, no spits, voiding and\nstooling, heme neg. On vit E and Fe.\n\nG&D: Temps stable, swaddled in 'off' isolette. Alert and\nactive with cares. Sleeps well between. Hands to face.\nOccasionally takes paci. Some clear/yellow eye drainage\nnoted, cleaned with sterile water.\n\n: Both in for cares. Dad providing cares\nindependently. Held infant. updated at bedside.\n and invested.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-14 00:00:00.000",
"description": "Report",
"row_id": 1702197,
"text": "Neonatology\nDOing well. RA. No spells. Comfortable appearing.\n\nWT 1805 up 40. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen benign. Tolerating gavage\n\nTEmp stable in isollette.\n\nCOntinue to awiat maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-14 00:00:00.000",
"description": "Report",
"row_id": 1702198,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. 1 spell noted over last 24 hours. He is tolerating full volume pg feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in off isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-14 00:00:00.000",
"description": "Report",
"row_id": 1702199,
"text": "NPN 0700-1900\n\n\n#1 RESP S/O: Infant in RA. Lungs are clear with subcostal\nretractions. RR 30-60's. No spells. A: Stable in RA. P:\nContinue to monitor.\n\n#3 FEN S/O: TF 150cc/k/d. Infant to get bm or pe 26 with\npromod, 45cc q4h pg. Infants abdomen is benign, voiding no\nstools today. No spits or aspirates. On Vit and iron supps.\nA: Tolerating feeds. P: Continue to monitor.\n\n#4 DEV S/O: Infant changed from isolette to OAC. Temps\nstable. Awake with cares. Sleeping in between. Bringing\nhands to face. A: AGA P: Continue to support.\n\n#5 Parenting S/O: Mom in today for cares. Mom changed\ndiapers and took temps. Attempted to breast feed . A:\nInvolved, . P: Continue to support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-14 00:00:00.000",
"description": "Report",
"row_id": 1702040,
"text": "NPN 0700-\n\n7 Hyperbili\n\n1. NP CPAP at 5, FiO2 21%, O2 sats 97-100%, no increased\noxygen requirement with cares. RR 40-60. LSC and equal\nwith subcostal/intercostal retractions. Suctioned with each\ncare for small amount clear secretions NP, and moderate\namount of clear secretions orally. No spells, no desats\nthis shift. Continues on caffeine. Continue to monitor\nresp status and for A's and B's.\n\n3. TF 150cc/kg/day. IVF at 90cc/kg; D10 PN and\nintralipids. Enteral feeds increased to 60cc/kg at noon- PE\n20/BM. Increasing by 10cc/kg . Belly soft, + BS, no\nloops. No spits, minimal aspirates, girth stable at\n17-17.5cm. 8 hour u/o is 2.9cc/kg/hr, no stool thus far\nthis shift. Continue to monitor tolerance to feeds and\nincrease 10cc/kg . Monitor D sticks while working up on\nfeeds.\n\n4. Temp stable in servo isolette. Alert and awake with\ncares, rests well in between cares. Repeat head u/s to be\ndone on Wednesday, initial head u/s negative. Reddened area\nleft upper back, non blanching- ? hemangioma. Small red\nareas to left upper quadrant and shin, + blanching.\nContinue to promote growth and development.\n\n5. No contact with thus far this shift. Expecting\n to be in this afternoon to kangaroo. Continue to\nupdate, educate and support .\n\n7. Phototherapy dc'd today for bili of 1.2/0.4. Rebound\nbili to be checked on Wednesday. Continue to monitor for\ns/s of hyperbilirubenemia.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbili; d/c'd\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-12 00:00:00.000",
"description": "Report",
"row_id": 1702027,
"text": "NICU Nursing Progress Note\n\nRESP\nO: NPCPAP reduced to 5 cms. No apnea, bradycardia, or\nspontaneous desat noted. Remains on caffeine. Breath sounds,\nresp rate, and WOB are at baseline. Secretions minimal.\nA: No evidence of compromise.\nP: Monitor and assess.\n\nHEMODYNAMICS\nO: Pale pink with brisk cap refill. VSS. No murmur\nappreciated.\nA: No evidence of compromise.\nP: Monitor and assess.\n\nHYPERBILI\nO: Rebound bili 4.3/0.4. Single spotlight phototherapy\nstarted at 1100.\nA: Rebonded bili of prematurity.\nP: Recheck bili on Monday a.m.\n\nSEPSIS\nO: Day Ampi and Genta. Infant is active and alert with\ngood tone and cap refill.\nA: No evidence of compromise.\nP: Continue 7 day course.\n\nNUTRITION\nO: Advancing enteral feeds to 30cc/kg/day. Abd exam benign.\nVoiding. PIC line infusing without difficulty. Total fluids\n150cc/kg/day.\nA: No evidence of intolerance to increased feeds.\nP: Check dextrostix prior to next feed.\n\nDEVELOPMENT\nO: Infant nested in sheepskin. Sucking on pacifier and\nfingers.\nA: Appropriate behavior.\nP: Support development.\n\nPARENTING\nO: Mom called and came to visit. Asking pertinent questions.\nPumping has been going well and she plans to breastfeed\ninfants. Mom plans to visit later tonight with FOB and hopes\nto Kangaroo.\nA: Involved parent.\nP: Support and keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-12 00:00:00.000",
"description": "Report",
"row_id": 1702028,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal with good CPaP transmission. Nl S1S2, no audible murmur. Pink and slightly jaundiced. Red mark vs bruise across scapula. Abd benign, no HSM. active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-12 00:00:00.000",
"description": "Report",
"row_id": 1702029,
"text": "Respiratory Care Note\nPt. decreased to +5 NP CPAP from +6. FiO2 .21 t/o shift. No spells. BS clear. RR 40-50. Suctioned for sm amount clear secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-13 00:00:00.000",
"description": "Report",
"row_id": 1702030,
"text": "NPN 1900-0700\n\n\n1. RESP: Pt remains on NP CPAP 5, requiring 21% FiO2. RR\n30-70's. Lung sounds are clear. Mild IC/SC retractions.\nSxn for small secretions via NP tube and large oral\nsecretions. No spells noted. Pt is on caffeine.\n\n2. C/V: No murmur heard. HR 150-170's. Pt is pale pink\nand well-perfused. BP stable.\n\n3. F&N: TF remain at 150cc/k/d. Feeds are at 30cc/k/d of\nBM20. IVF of PND12 with IL infusing well via PICC. Abd\nbenign. BS+. A/G stable. no spits and minimal aspirates\nnoted. U/O 2.6cc/k/h. No stool noted. Weight gain 50\ngrams.\n\n4. DEV: is active and alert during his cares. Temp\nstable nested on sheepskin in servo-controlled isolette.\nTol kangaroo care well for 1 hour.\n\n5. PAR: Parents in to do cares. Mom gave kangaroo care\nand stated that she was very pleased.\n\n6. : Pt remains on Ampi and Gent.\n\n7. HYPERBIL: Pt remains under single phototherapy.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-13 00:00:00.000",
"description": "Report",
"row_id": 1702031,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on NP CPAP 5 FiO2 21%. Suctioned NP tube for sm amt of cloudy secretions and lg amt of oral secretions. Breath sounds are clear. RR 30-70's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-03 00:00:00.000",
"description": "Report",
"row_id": 1702282,
"text": "NPN 1900-0700\n\n\n1. FEN: Weight is 2685 gms up 70 gms. TF remain at 150\ncc/kg/day of BM/PE24. Infant is attempting to PO once q\nshift. Infant bottled 45 cc this shift with good\ncoordination. Tolerating NGT feedings well; abd exam\nbenign, no spits, and min asp. Voiding qs and no stool\nnoted. Infant continues on Vit E and ferinsol. P: Cont. to\nsupport nutritional needs.\n\n2. G/D; Temps stable swaddled cobedding in an open crib with\nhis sibling. and active with cares. Settles well in\nbetween cares. Appropriately brings hands to face and sucks\non pacifier to comfort self. AFSF. AGA. P: Cont. to\nsupport developmental needs.\n\n3. : Mom and were in for cares. Independent\nwith diapering, taking temp, and handling infants. Updated\nat bedside on infant's condition and plan of care. Asking\nappropriate questions. , involved . P: Cont.\nto support and update .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-03 00:00:00.000",
"description": "Report",
"row_id": 1702283,
"text": "Neonatology Attending\n\nDay 58- 34 5/7 weeks\n\nRemains in RA. SaO2 > 98%. RR 30-60s. No bradycardia. No murmur. HR 140-160s. BP mean 58. weight 2685 gms (+70). TF at 150 cc/kg/d. PE/BM 24. Offered bottles once per shift. No spits. Minimal aspirates. On vitamin E and iron. Stable temperature. Eye exam- immature zone 2. Consents for 60-day immunizations signed. Fifth Disease titers negative.\n\nDoing well overall. Still with immature feeding. Will continue to encourage. Gaining weight well. Follow up eye exam in two weeks. Continuing to monitor cardio-respiratory status. Will discontinue oximetry.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-03 00:00:00.000",
"description": "Report",
"row_id": 1702284,
"text": "Neonatology- PRogress Note\n\nPE; remains in his big boy crib, in room air, bbs cl=, rrr s1s2 no murmur, abd soft,nontneder, V&S< afso, gavage tube in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-03 00:00:00.000",
"description": "Report",
"row_id": 1702285,
"text": "PCA Progress Note, 7a-7p\n\n\nFEN:\n TF:150cc/kg/D of PE24. Total volumes are being gavaged\nover 50-60 mins. Infant bottled at last care, taking close\nto full volume, while the remainder was gavaged. Tolerating\nfeeds well w/ minimal asp and no spits so far this shift.\nAbd is benign w/ active BS. Infant is voiding w/ each diaper\nchg, no stool this shift. Please refer to Pt's chart for\nadditional FEN data. Continue to encourage and support Po\nfeeds and current plan.\n\nDEV:\n Infant's temp remains stable while swaddled in OAC,\nco-bedded w/sibling. Infant is and active w/ cares,\nwakes for some feeds and sleeps well in between cares.\nContinue to encourage and support developmental milestones.\n\nPAR:\n No contact with by this PCA so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-03 00:00:00.000",
"description": "Report",
"row_id": 1702286,
"text": "NPN 0700-\nI have examined the infant and agree with the above note by , PCA. Mom called this afternoon, will be here for 8pm care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-14 00:00:00.000",
"description": "Report",
"row_id": 1702041,
"text": "Respiratory Care\nPt recieved on NP-CPAP +5cm's with the fio2 21%. Pt suctioned for a mod amt of thickish white secretions. Pt's respiratory rates 30's to 50's with clear B/S. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-15 00:00:00.000",
"description": "Report",
"row_id": 1702042,
"text": "NPN\n\n\nNPN#1 O= remains on NPCPAP of 5cm in 21%FIO2 all night with\nsats 99-100%, no desats or bradys, cont on caffeine qd as\nordered, RR 40's-60's, LS clear & equal with mild IC/SCR,\nsxn'inf for sm amts via NP tube..Lg via OP, A= stable on\nCPAP in RA, no spells P= cont to monitor for spells, cont\nplan of care\n\nNPN#3 O= WT down10gms to 850gms, TF at 150cc/kg/d..adv on\nenteral feeds by 10cc/kg ..prsently on Feeds of\n70cc/kg/d..tol well, no spits, scant asp, AG 17-17.5cm, exam\nsoft flat/ sl rounded, no loops, +BS, voiding well, trace\nmec stool only, IVF of PN/Lipids infusing at 80cc/kg/d via\nPIC, A=tol adv of feeds P= cont to assess for any S &S of\nfeeding intolerence/ monitor abd exams/ follow daily wts\nclosely\n\nNPN#4 O= remains on servo in heated isolette..weaned x1 for\nTmax of 99.0, active & alert with cares, sleeps well between\nfeeds, nested in sheepskin bed with boundaries in place,\ngood tone, AF soft & flat with sl overriding sutures A=\nbehaviors appropriate for GA P= cont to assess & support dev\nneeds\n\nNPN#5 O= left at begining of shift after visit..no\ncontact from thus far this shift..plan is for Dad to\nvisit with 1200 cares today to kangaroo A/P=cont to\nteach/ update & support\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-15 00:00:00.000",
"description": "Report",
"row_id": 1702043,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on NP CPAP 5 FiO2 21%. Suctioned NP tube for sm amt of white secretions and lg amt of yellow from baby's mouth. Breath sounds are clear. Baby is on caffeine. RR 40-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-28 00:00:00.000",
"description": "Report",
"row_id": 1702123,
"text": "Neonatology Attending\n\nDay 22\n\nRemains in RA. Sats 94-100%. Mild retractions. RR 40-70s. Has had four bradycardia episodes over last 24 hours. HR 140-160s. BP mean 40. Weight 1090 gms (+15). TF at 150 cc/kg/d- BM 30 with Promod. Minimal aspirates. Stable girth. Passing stool. Stable temperature in servo-controlled incubator.\n\nImproving respiratory status. Increasing caffeine dosing. Monitoring. Mother having CT scan today to rule out abscess. Remains hospitalized for antibiotic therapy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-28 00:00:00.000",
"description": "Report",
"row_id": 1702124,
"text": "Clinical Nutrition\nO:\n~29 wk CGA BB on DOL 22.\nWt: 1090 g (+15)(~25th %ile); birth wt: 936 g. AVerage wt gain over past wk ~15 g/kg/d.\nHC: 26 cm (~10th to 25th %ile); last: 25 cm\nLN: 37.5 cm (~25th to 50th %ile); last: 36.5 cm\nMeds include Fe and Vit E\n not due yet\nNutrition: 150 cc/kg/d BM/PE 30 w/ promod, pg over 50 min due to hx of spits. Feeds just recently increased; projected intake for next 24 hrs ~150 kcal/kg/d, ~4.1 to 4.4 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for all parameters. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-28 00:00:00.000",
"description": "Report",
"row_id": 1702125,
"text": "NPN 7a-7p\n\n\n#1: remains in RA, sating >/= 94%. RR stable. BBS cl/=\nBreathing with mild IC/SC retractions. Rare drift to 80's\nnoted- QSR. Did have 1 brady thus far. Occurred while\nsleeping during gavage feed. Mild stim needed to recover.\nCaffiene dose ^'ed- given. A: stable in RA P:Cont to\nmonitor and provide support as needed.\n\n#3: TF: 150cc/k/d. Conts on Bm30/PE30 with Promod. 'ing\n27cc q4hrs gavaged over 50mins. No spits noted. Min benign\nasps. Abd soft, +, no loops. AG stable. Voiding qs.\nStooled x1, guiac negative. A: 'ing feeds P:Cont with\ncurrent feeding plan. Monitor to feeds. Follow wt and\nexam.\n\n#4: conts to maintain stable temps while nested in\nservo isolette. He sleeps comfortably nested on sheepskin\nwithin boundaries. MAE. Fonts soft/flat. Loves to suck on\npacifier. Sm amt pale yellow eye drainage noted. Cleansing\neyes with warm water and applying gentle massage to tear\nducts. Team aware. Will kangaroo at 16care with Mom. A:\nAGA P:Cont to support dev needs.\n\n#5: in for afternoon care. Dad with temp and\ndiaper. Both updated. Mom will be in for 16care.\nGrandmother also visited briefly. A: Involved, \nfamily P:Cont to support and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-28 00:00:00.000",
"description": "Report",
"row_id": 1702126,
"text": "Neonatology- Progress Note\nPE: remains in his isolette, in room air, bbs cl=, rrr s1s2 no murmur, abd soft,nontender, V&S, afso, active with care, hemangioma on back and chest unchanged, gavage tube in place\n\n\nSee attending note for plan\n\nUpdated at bedisde\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-16 00:00:00.000",
"description": "Report",
"row_id": 1702206,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 95%. Lung sounds clear/=. RR 40-70's. Mild\nSCR noted. Infant continues on caffeine. No desats or\napnea noted. P: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 150 cc/kg/day of BM/PE26 with promod.\nTolerating NGT feedings well; abd exam benign, no spits, AG\nstable, and min asp. Voiding qs and no stool thus far.\nInfant continues on Vit E and ferinsol. P: Cont. to support\nnutritional needs.\n\n3. G/D: Temps stable swaddled in OAC. Infant is and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. : Mom called x 1. She was updated on infant's\ncondition and plan of care. Asking appropriate questions.\nWill be in for 1600 cares. , involved . P:\nCont. to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-17 00:00:00.000",
"description": "Report",
"row_id": 1702207,
"text": "NICU NPN 1900-0700\n\n\nRESP O: baby remains in room air, rr 40-60's, lings are\nclear, no bradys or desats to time this shift. HR 140-160's,\ncolor pink, mottles slightly with cares. No murmur.\n\nFEN O: Weight 1940g, up 35g. Tolerating feeds o9f bm/pe26\nwith pm well. Voiaing and stooling, abdominal exam benign,\nno spits, min ngt aspirates.\n\nDEV O: Temps are stable, swaddled in crib. is and\nactive with cares, sleeps well in between cares. Fontanells\nare soft and flat.\n\nParenting O: Mom and dad in for 8pm cares, independent, very\n towards babies.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-17 00:00:00.000",
"description": "Report",
"row_id": 1702208,
"text": "Day of life 42\nstable in room air RR 40-60\nno spell in past few day on caffiene\nHR 140- 160\nweigth up 35 on 150 cc/kg/day of PE 26\nor BM 26 with promod\nvoiding and stooling\non vit E and iron\n\neye exam schededuled for this week.\nPlan doing well will continue to\nencourage po feeds\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-17 00:00:00.000",
"description": "Report",
"row_id": 1702209,
"text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. BS clear and equal with mild subcostal retractions, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Noncirced male. Without rashes. Good tone, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-17 00:00:00.000",
"description": "Report",
"row_id": 1702210,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 93%. Lung sounds clear/=. RR 40-60's. Mild\nSCR noted. No spells noted. Infant remains on caffeine.\nP: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 150 cc/kg/day of BM/PE26 with promod.\nTolerating NGT feedings well; abd exam benign, no spits, AG\nstable, and min asp. Voiding qs and no stool noted thus\nfar. Infant continues on Vit E and ferinsol. P: Cont. to\nsupport nutritional needs.\n\n3. G/D: Temps stable swaddled in open crib. and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. : Mom called x 1. She was updated on infant's\ncondition and plan of care. Asking appropriate questions.\n, involved . Will be in for 1600 cares and to\ngive the boys baths. P: Cont. to support and update\n.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-05 00:00:00.000",
"description": "Report",
"row_id": 1702292,
"text": "Clinical Nutrition\nO:\n~35 wk CGA BB on DOL 60.\nWT: 2765g(+40)(75th-90th %ile); birth wt: 936g. Average wt gain over past wk ~49g/d.\nHC: 32.5cm(50th-75th %ile); last: 29.5cm()\nLN: 46.5cm(50th-75th %ile); last: 42.5cm()\nMeds include Fe & Vit.E\n not needed.\nNutrition: 150cc/kg/d as PE/BM 24, po/pg. Average of past 3d intake ~147cc/kg/d, providing ~118kcals/kg/d and ~3.1-3.5g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds w/o GI probs; po/pg. not needed. Current feeds & supps meeting weaned recs for kcals/pro/vits/mins. Growth is exceeding recs for wt gain of ~20-35g/d; will keep current feeds & monitor trends. Average of 2-week Growth is exceeding recs for HC/LN gain of ~0.5-1cm/wk for HC & ~1cm/wk for LN; will monitor trends. Will continue to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-05 00:00:00.000",
"description": "Report",
"row_id": 1702293,
"text": "NPN 7a-7p\n\n\n3) TF 150cc/kg/day. tolerating feeds of Pe24 gavaged every 4\nhours over 50 min. offered bottle x 2 and took 25 and 30cc\nout of 69. Will gavaged last feed. Abdomen soft and benign.\nVoiding well. no stool. No spits or asp. continue to asess.\n4) infant and active with cares. sleeping well between\nswaddled in crib. Cobedding with sibling. Temps stable.\ncontinues with yellow drainage of right eye. Cleaned with\nsterile water. Hib and DTAP given today. All 60 day\nimmunizations now given. continue to support dev.needs\n5) Mom called . Update given. To be in to visit this\nevening.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-25 00:00:00.000",
"description": "Report",
"row_id": 1702110,
"text": "NPN 1900-0700\n\n\n1. RESP: Pt received in RA. Frequent sat drifts and 2\nspells occurred and pt was placed in low flow nasal cannula,\n100% FiO2 at 13cc flow. Sat drifts have resolved and no\nspells noted since. RR 30-60's. Lung sounds are clear.\nMild baseline retractions noted.\n\n3. F&N: TF remain at 150cc/k/d of BM/PE28 with promod.\nFeeds gavaged in over 40 minutes. Abd benign. BS+. A/G\nstable. No spits and max asp was 2.6cc of nonbilious,\npartially digested breast milk. Voiding and passing guiac\nnegative stool. Weight gain 5 grams.\n\n4. DEV: is active and alert during his cares. Temp\nstable nested on sheepskin in servo-controlled isolette.\n\n5. PAR: No contact from so far this shift.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-25 00:00:00.000",
"description": "Report",
"row_id": 1702111,
"text": "Neonatology Attending\n\nDay 19- CGA 29 2/7 weeks\n\nRemains on nasal cannula at 13-25 cc/min. Has occasional drifts and 5 bradycardia episodes over last 24 hours. On caffeine. RR 40-60s. Clear breath sounds. Mild retractions. Suctioned for small secretions. No murmur. Pale, pink. BP mean 41. Weight 1020 gms (+5). TF at 150 cc/kg/d- BM/PE 28 with Promod. Benign abdomen. Minimal aspirates. Stable temperature in incubator. Family in daily.\n\nMild respiratory insufficiency. Monitoring closely. Inconsistent weight gain. Will increase Polycose for caloric concentration 30 cals/oz. Tolerating feeds well.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-25 00:00:00.000",
"description": "Report",
"row_id": 1702112,
"text": "Neonatology- Progress Note\nPE: Remains in his isolette, in nasal cannual O2, bbs cl=, rrr s1s 2no murmur,abd soft, nontender, V&S, afso, active with care, hemangioma n back, unchanged\n\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-25 00:00:00.000",
"description": "Report",
"row_id": 1702113,
"text": "NPN 0700-\n\n\n1. RECEIVED INFANT ON NC 100% AT FLOW OF 13CC. UP TO 25CC AT\nTIMES WITH CARES AND FEEDING. SAO2 B/T 94-99%. LS CL/=.\nINCREASE IN BRADY'S IF INFANT FEQUIRED SX. WITH FIRST CARES\nINFANT HAD 2 SPELLS NASAL SX DONE FOR SMALL CLOUDY SX. NO\nSPELLS UNTILL 1600 CARES AND REQUIRING SX FOR MOD. CLOUDY\nSPUTUM. ALL SPELLS REQUIRING MILD STIM AND BBO2. RR 40'S\n-60'S. ATTEMPTED OFF O2 FOR 1/2 HR. INCREASING DESATS,\nTHEREFORE REPLACED BACK ON. PLAN; CONT. TO MONITOR RESP.\nSTATUS ON CURENT SUPPORT OF NC. SX AS NEEDED.\n\n3. TF CONT. AT 150CC/K/D OF BREASTMILK 30. INCREASED TO 30\nCALS FROM 28 CALS AT 1200 FEEDING. TOLERATING FEEDS. NO\nSPITS OR ASP. NOTED. ABD SOFT, FULL. + BS ALL QUADS. GIRTH\nSTABLE. VOIDING WELL, NO STOOL. NO ASP. OR SPITS NOTED.\nPLAN; CONT. TO MONITOR WT. GAIN ON INCREASED CALS. MONITOR\nTOLERANCE TO INCREASE IN FLUIDS. .\n\n4. CONT. IN SERVO ISOLLETTE. A/A WITH CARES. MOVING ALL\nEXTREMETIES WELL. CONT. WITH ALL PG FEEDS. PLAN; CONT. TO\nSUPPORT G/D.\n\n5. MOM REMAINS . CAME FOR ALL THREE CARES.\nINDEPENDANT WITH TEMP TAKING AND DIAPER CHANGING. APPEARS\nVERY AND CARING. ASKING MANY APPROPRIATE QUESTONS.\nPLAN; CONT. TO SUPPORT AND EDUCATE .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-12 00:00:00.000",
"description": "Report",
"row_id": 1702189,
"text": "Neonatology\nDOing well. RA. No spells. Comfortable apeparing.\nNo murmur\n\nWt 1695 up 50. feeds well. Abdomen benign. Still req gavage.\nGood weight gain over time on 28 cal.\n\nSKin w/o leisions. Eye drainage continue int. No sx infection. Being rxed with local measures.\n\nCOntnue to awit maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-23 00:00:00.000",
"description": "Report",
"row_id": 1702366,
"text": "nursing note\n\n\n1)f/n: weight 3085, up 20 grams. continues on minimum of\n140cc/kg/day of enfamil 24. nipples ok, approximately half\nto of feeds. no stool noted since yesterday, abdomen\nremains soft and round with no loops and active bowel\nsounds. continues to void. plan to continue to encourage\nbottle feeds every feed and to monitor gi status closely.\n2)g/d: cobedding with twin. is swaddled in open crib, sucks\non pacifier when stimulated. plan to continue to encourge\ndevelopmentally appropriate care as tolerated.\n3)par: mom called today, updated on babe's progress. plan\nto continue to encourage parental involvement when\navailable.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-24 00:00:00.000",
"description": "Report",
"row_id": 1702367,
"text": "NPN NOCS\n\n\n3. Wt up 55 gms. TF at min 140cc/kg of BM24/E24. PO/PG\nfeeds. Using Dr. bottles, bottling about of\nfeeding. Remainder gavaged. No spits. Abd . Voiding\nand stooling.\n\n4. and active with cares. Temp stable in open crib\nCobedding with sibling. Waking on own for feedings. Pink sl.\nraised rash noted to infants facial area. No drainage noted.\n in to evaluate. Will monitor rash. Continues on emycin\nas ordered to eyes with no drainage noted.\n\n5. in for eve cares. Updated. Asking appropriate\nquestions. Also spoke with regarding facial rash.\nIndependent with cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-24 00:00:00.000",
"description": "Report",
"row_id": 1702368,
"text": "Newborn Med Attending\n\n Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=3340 up 55, on 140 cc/kg/d Bm24 Po>PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-24 00:00:00.000",
"description": "Report",
"row_id": 1702369,
"text": "Nursing Progress Notes.\n\n\n#3 O: Total fluids 140cc/kg/day of BM/E24. Feeds offered\nevery 4 hours and completed by gavage. 1 x spit, no large\naspirates. Abdomen benign, voiding well, last stool\nyesterday. A: Learning to PO feed. P: Continue encourage\nPO feeding.\n#4 O: Temp stable in open crib while cobedding with\nsibbling. Baby wakes for most feedings and sleeps well\nbetween feedings. A: Appropriate for age. P: Continue to\nsupport development.\n#5 O: Mother called for an update and plans to visits later\nthis evening.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-24 00:00:00.000",
"description": "Report",
"row_id": 1702370,
"text": "NPN 1500-2300\n\n\n#3 FEN O: Infant remains on TF 140cc/k/day of BM24/E24.\nINfant bottled fair today, slow with much encouragement.\nBottles about of feeding and requires gavage feed for\nrest of feed, tolerates well, no spits or aspirates. Voiding\nand stooling. A: Stable FEN P: Cont to encourage po feedings\n, wt q day.\n#5 SOCIAL O: Mom in to visit, asking appropriate questions\nand update infant's progress. A: Involved and concerned\nfamily P: cont to inform and support family as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-25 00:00:00.000",
"description": "Report",
"row_id": 1702371,
"text": "NPN NOCS\n\n\n3. Wt up 5gms. Po/Pg feeds. Using Dr. bottles. Abd\nbenign. No spits. Voiding, no stool. Continue to encourage\npo feeds.\n\n4. amd active with cares. Temp stable in open crib.\nCobedding with sibling. Waking on own for feedings.\nContinues to have mild sl pink, sl raised rash to facial\narea-to monitor. Erytho as ordered to eyes-no drainage.\n\n5. No contact from thus far.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-25 00:00:00.000",
"description": "Report",
"row_id": 1702372,
"text": "Newborn Med Attending\n\nCont in RA, no spells. AF flat, clear BS, no murmur,abd soft, MAE. WT=3345 up 5, on 140 cc/kg/d E24 Po/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702023,
"text": "Nursing Progress Note:\n#1 - RESP: Remains on NP CPAP of 6. FIO2 (21%). RR (40-70).\nIntercostal/subcostal retractions. Minimal secretions from\ntube. Large copious cloudy secretions from mouth. Remains on\ncaffeine. No spells thus far today. Gas in am with other\nlabs.\n\n#2 - CV: Pale pink. Mottles easily. HR (130-160). BP -55/32\n41. Normal pulses. No murmur heard s/p 1 coarse of Indo.\n\n#3 - F&N: TF increased to 150cc/kilo/day. IVF - TPN (D12)\nand lipids as ordered. PIC line placed today. DLUVC d/c'd\nthis evening. Started Enteral feeds today at 20cc/kilo =\n3cc's Q 4 hours of BM/PE20. Tolerating well thus far.\nAbdomin soft and flat. +BS. Girth 15-15.5cm. No aspirates.\nTaped at 14cm. Voiding 3.4cc/kilo/hour for last 12 hours. No\nstool this shift. Dstick 118. Lytes/Bili in am.\n\n#4 - G&D: Temps stable in servo controlled isolette. Alert\nand active with cares. Irritable at times. Loves boundaries.\nNested in sheeps skin. Bringing hands to face. First Head US\n- normal. Follow up - next wed - DOL 10. Bruising on back\nlooks like it could be a hemangioma. Will follow. Aquaphor\nto skin as needed.\n\n#5 - PARENTS: Mom and Dad in at different times today. Mom\ndischarged this afternoon. Updated at the bedside. Signed\nPIC line consents.\n\n#6 - SEPSIS: Day of Amp and Gent. Received as ordered.\nLast Blood cultre on Wed - neg. LP last night - neg.\n\n#7 - BILI: Lights shut off at midnight last night. Last bili\n(2.4/0.5). Rebound bili in am with lytes and gas.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702024,
"text": "NEONATOLOGY- PROCEDRUE NOTE\n\nDLUVC removed using sterile technique without incident\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-12 00:00:00.000",
"description": "Report",
"row_id": 1702025,
"text": "NPN\nHAND WRITTEN NOTE PLACED IN INFANT'S CHART WHILE CAREVUE WAS OFF LINE..REFER TO THAT FOR NPN...\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-12 00:00:00.000",
"description": "Report",
"row_id": 1702026,
"text": "Neonatology Attending\n\nDay 6\n\nRemains on CPAP with fio2 0.21. CBG 7.31/37. No bradycardia on caffeine. Small secretions. Pale, pink. No murmur. HR 140-150. BP mean 44. Bilirubin rebound 4.3/0.4. Day ampicillin and gentamicin. Blood culture negative. Weight 770 gms (+16). Lytes 134/4.9/105/17. PICC in place. TF at 150 cc/kg/d. Enteral feeds at 20 cc/kg/d. Central PN and lipids. Stable temperature.\n\nAcceptable breathing control on caffeine/CPAP. Will wean CPAP pressure. Monitoring closely. Tolerating feeds well so far. Will increase to 30 cc/kg enterally today. Following exam. Metabolically well.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-24 00:00:00.000",
"description": "Report",
"row_id": 1702108,
"text": "Respiratory Care Note\nPt. off CPAP today. Placed on 25cc nasal cannula for O2 drifts. No bradys thus far this shift. Suctioned nares for lge amount old bloody/green secretions. BS clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-12 00:00:00.000",
"description": "Report",
"row_id": 1702190,
"text": "0700- NPN\n\n\nRESP: RA. RR 30's-60's. LS clear/=. Mild SC retractions.\nNo A/B spells or desats. On Caffeine.\n\nFEN: TF=150cc/kg/d of PE28 with PM all PG. No spits.\nMinimal aspirates. Abdomen benign. Voiding, stooling. On\nFe and Vit E.\n\nDEV: Temps stable off isolette. Alert/active with cares.\nSleeps between cares. Sucks pacifier. Fontanels soft/flat.\n\nPARENTING: Mom in to visit, held infant, participated in\ncare.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-13 00:00:00.000",
"description": "Report",
"row_id": 1702191,
"text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 96-100%. RR 30-80's. Mild\nSC rtx. LS clear and equal. No spells, no desats. On\ncaffeine.\n\nFEN: wt=1745g (up 50g). TF=150cc/kg/d of BM/PE28 with\npromod. Equals 44cc q4hrs, gavaged over 60min. Tolerating\nwell. Abdomen soft, +BS, AG stable, no loops, no spits,\nvoiding, trace stool. On vit E and Fe.\n\nG&D: Temps stable, swaddled in 'off' isolette. Alert and\nactive with cares. Sleeps well between. Hands to face. Clear\nbilateral eye drainage, cleaned with sterile water.\n\n: No contact thus far.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-13 00:00:00.000",
"description": "Report",
"row_id": 1702192,
"text": "Neonatology\nRemains in RA. SIngle spell overnight on caffeine.\n\nWt 1745 up 50. Abdomen benign. Toleratin gfeeds via gavage. Good weight gain on 150 cc/k/d of 28 cal.\n\nCOntinue as at present awaiting maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-13 00:00:00.000",
"description": "Report",
"row_id": 1702193,
"text": "Clinical Nutrition\nO:\n~32 wk CGA BB on DOL 38\nWt: 1745 g (+50)(~50th to 75th %ile); birth wt: 936 g. Average wt gain over past wk ~23 g/kg/d.\nHC: 28.5 cm (~25th to 50th %ile); last: 26.5 cm\nLN: 40 cm (~25th to 50th %ile); last: 38.5 cm\nMeds include Fe and Vit E\n noted\nNutrition: 150 cc/kg/d PE/BM 26 w/ promod, pg over 60 min. due to hx of spits. Feeds just decreased today for good wt gain. Projected intake for next 24 hrs ~130 kcal/kg/d, ~4.1 to 4.4 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. noted and within acceptable range. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is exceeding recs for all parameters; kcals decreased in response. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-13 00:00:00.000",
"description": "Report",
"row_id": 1702194,
"text": "Neonatology- Physical Exam\n\n remains in RA. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, small strawberry hemangioma on L abdomen, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-01 00:00:00.000",
"description": "Report",
"row_id": 1702278,
"text": "Student Nursing Note\n\n\n3-O: 150cc/k of breast milk and/or PE24, maximum aspirate of\n.8, voiding, no stools,\nA: Tolerating feeds well, learning to breast and botttle\nfeed\nP: Continue encouraging breast and bottle feeding\n4-O: Temps stable, open crib, sleeps well between feeds in a\nflat crib, right eye drainage of clear fluid, warm soak\napplied, due for follow up eye exam on monday\nA: Development approprite for gestational age\nP: Continue supporting development\n5-O: Mom and in to visit at 12pm accompanied by patients\nolder sister and grandmother, with\ncares, child held by both mommy and daddy, have\nsigned up for CPR course\nA: Supportive and family\nP:Continue to keep aware of plan of care\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-24 00:00:00.000",
"description": "Report",
"row_id": 1702109,
"text": "NPN 7a-7p\n\n\n#1: weaned off CPAP this am. Since then has fluccuated\nbtw RA and min NC O2 req.(25ccflow/100%). Currently, out\nkangarooing with Mom and needed 100%, 25cc flow NC. Sx'ed x2\nfor thick copious yellow secretions, especially just after\nNP tube was pulled. RR stable. No ^'ed WOB noted. Conts\nwith mild IC/SC retractions. BBS cl/=. Sats >/= 90%. Occ\ndrifts to 80's with QSR. Did have on brady spell during\nkangarooing/gavage feed. Recovered QSR. Caffiene given as\nordered. A: 'ing trial off CPAP. P:Cont to monitor and\nprovide support as needed.\n\n#3: TF: 150cc/k/d. ^'ed to Bm28/PE28 with Promod. 'ing\n25cc q4hrs gavaged over 40mins. No spits noted. Min benign\nasps. Abd soft, +. Ag stable 19.5-20cm. Did have soft\nloops this am prior to stooling. Since has had 2 lg heme\nnegative stools, and loops have resolved. Voiding qs. A:\n'ing feeds, ^'ing cals. P:Cont with current feeding\nplan. Monitor to feeds. Follow wt and exam.\n\n#4: conts to maintain stable temps in servo isolette.\nHe sleeps comfortably in btw cares, nested on sheepskin and\ncontained within boundaries. MAE. Very fiesty with cares.\nFonts soft/flat. Sm amt pale yellow drainage noted from\nleft eye. Cleansed with water sterile water and gentle\nmassage applied to tear duct. Kangarooed with Mom for ~1hr,\n'ed well. A: AGA P:Cont to support dev needs.\n\n#5: Mom in x2 today. States that she is feeling better, but\ndoes tire easily. Mom too tired to do care today, but did\nkangaroo infant. Both 'ed well. Mom excited to see\ninfant off CPAP. A: Involved parent P:Cont to\nsupport and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-10 00:00:00.000",
"description": "Report",
"row_id": 1702182,
"text": "Neonatology- Progress Note\n\nPE: remains in his isoletet, in room air, bbs cl=, rrr s1s2no murmur,abd soft, nontender, V&S, hemangioma on back/side afso,active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-11 00:00:00.000",
"description": "Report",
"row_id": 1702183,
"text": "NPN 1900-700\n\n\n#1 RESP S/O: infant in RA. RR 50's to 60's. Lungs clear with\nsubc retractions. O2 sats >95%, No drifts or spells. A:\nStable in RA P: Continue to support.\n\n#3 FEN S/O: TF 150cc/k/d. To get bm or pe28 with promod,\n41cc q4h pg. Infants abdomen is benign, voiding. No stools\nthis shift. No spits, min aspirates. A: Tolerating feeds. P:\nContinue to monitor.\n\n#4 DEV S/O: Infant in air isolette, maintaining temps. Sucks\non pacifier occasionally. Good tone. Active with cares. A:\nAGA P: Continue to support dev.\n]\n#5 Parenting S/O: No contact from yet this shift. A:\nUnable to assess. P: Continue to support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-11 00:00:00.000",
"description": "Report",
"row_id": 1702184,
"text": "Neonatology Attending Note\nDay 36\nCGA 31 4\n\nRA. On caffeine, No A&Bs. No murmur. HR 170s. Mean BP 50.\n\nWt 1645, up 65 gms. TF 150 cc/k/day BM/PE28 with promod. Nl voiding and stooling.\n\nIn air isolette.\n\nA/P:\n- monitor AOP\n- no change to nutritional plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-11 00:00:00.000",
"description": "Report",
"row_id": 1702185,
"text": "Neonatololgy- PRogress Note\n\nPE: in his isolette, in room air, bbs cl=, rrr s1s2no murmur,abd soft, nontender, V&S, small hemangioma on back/chest unchanged, afso, active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-02 00:00:00.000",
"description": "Report",
"row_id": 1702279,
"text": "NPN\n\n\nF/N O- Infant remains on feeds of PE24cal at 150cc/kg.\nWt2615 up 15gms. Bottle offered x1 and he took 15cc's. No\nspits. minimal aspirates. Voiding well. No stool passed\nduring night. A- . feeds P- Follow wts.\n#4Dev. No change. Due for eye exam in am.\n#5Family No contact during night.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-02 00:00:00.000",
"description": "Report",
"row_id": 1702280,
"text": "Neonatology Attending\n\nDay 57\n\nRemains in RA. RR 40-70s. Mild retractions. Clear breath sounds. No bradycardia. No murmur. HR 140-160s. BP mean 67. Pink. Weight 2615 gms (+15). On PE/BM 24- bottling once per shift. TF at 150 cc/kg/d. No spits, aspirates. Eye exam showed immature zone 2. Mild right eye drainage receiving warm soaks. Stable temperature in open crib.\n\nDoing well overall with mature breathing control. Encouraging po feeding. Gaining weight well. Eye exam to be repeated in two weeks. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-02 00:00:00.000",
"description": "Report",
"row_id": 1702281,
"text": "NPN 0700-\n\n\n3. TF 150cc/kg/day, PE/BM 24. Feeds gavaged at 8am and\n12pm, will bottle/breastfeed with mom at 4pm care. Belly\nsoft, + BS, no loops. Min aspirates, no spits. Voiding, no\nstool this shift. Continue to monitor tolerance to feeds;\noffer bottle/breast once a shift, increase frequency as\ntolerated.\n\n4. Temp stable in open crib, swaddled. and active\nwith cares, resting well between cares. Eye exam this AM-\nimmature zone 2, will have f/u in 2 weeks. Right eye\ncontinue with thick yellow drainage, warm soaks with cares.\nLeft eye with clear drainage. Strawberry hemangioma to left\nabdomen. Continue to promote growth and development.\n\n5. Mom called twice this AM, updated on plan of care. Mom\nplans to be here for 8pm care, hoping to make it for 4pm.\nContinue to update, educate and support ; continue\nd/c teaching.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-21 00:00:00.000",
"description": "Report",
"row_id": 1702359,
"text": "Nursing Progress Notes.\n\n\n#3 O: Total fluids increased to 140cc/kg/day of BM/E24.\nFeeds offered every 4 hours, 60 to 65cc taken today.\nRemainder of feeding completed by gavage. Abdomen benign,\nno spits, voiding well, no stool for 48 hours now.\nUmbilical hernia, increasing in size, soft and reduces\neasily. Strawberry hemangioma larger than last week. A:\nLearning to PO feed. P: Continue to encourage Po feeding.\n#4 O: Temp stable in open crib while cobedding with\nsibbling. Baby does not wake for feedings on his own but is\n once awake and feeds eagerly until he tires out and\ngoes to sleep. Baby sleeps well between feedings. A:\nAppropriate for age. P: Continue to support development.\n#5 O: called for an update and plan to visit this\nevening.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-22 00:00:00.000",
"description": "Report",
"row_id": 1702360,
"text": "NPN 1900-0700\n\n\nFEN: wt=3260g (up 40g). TF=150cc/kg/d of BM/E24. Equals 76cc\nq4hrs, PO/PG. Bottling partial/full volumes. Abdomen soft,\n+BS, no loops, no spits, voiding and stooling.\n\nG&D: Temps stable, swaddled in open crib. Cobedding with\ntwin. and active with cares. Wakes for feeds. Takes\npaci.\n\n: and grandmother in to visit. providing\ncares independently. Updated at bedside.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-22 00:00:00.000",
"description": "Report",
"row_id": 1702361,
"text": "Neonatology NP Note\nPE\ncobedding with twin\n, sutures opposed\nrespirations unlabored in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, umbilical hernia, hemangioma on abdomen\ngood .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702017,
"text": "NPN 7p-7a\n\n\nResp: Infant remains on np cpap 6cm. fio2 21%. RR 30-60's.\nNo spells or desats so far this shift. Sxn for lg cloudy\nsecretions orally. Sm white via et tube. Conts caffiene.\nCont to monitor.\n\nCV: Infant conts with soft murmur. Hr 120-140's. Pale pink.\nWell pefused. UAC line dc'd this evening by . Bp 57/32\n(41). Total bld out 4.7cc. Cont to monitor.\n\nFen: Wt tonoc .754kg (-51gsm). Remains npo conts on tf\n140cc/kg. REc pn d9 with IL infusing via dluvc. Abd soft.\nhypoactive bs. No loops noted. Ag stable 15.5-16cm. No stool\nthus far. U.O 4.3cc/kg for 12hrs. Dstick 80. Cont with\ncurrent plan.\n\nG&D: Temp stable in servo isolette. Nested in sheepskin with\nboundries in place. Alert with cares. Irritable at times.\nLikes pacifier. Settles well in prone position. Cont to\nsupport developmental milestones.\n\nParenting: Mom and Dad in for cares. Updated at\nbedside. Asking appropriate questions. Dad changed diaper\nfor first time. Mom to be dc'd today. Cont to support and\nupdate.\n\nSepsis: D5/7 of amp and gent. Bld cx neg to date. Lp done\nsee carevue for results. No new signs of sepsis noted.\n\nBili: Single Phototx dc'd at 2400 . Await plan to\nrecheck.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702018,
"text": "Neonatology- PRogress Note\n\nPE; remains in his isolette, on CPAP 6 .21, bbs cl=, rrr s1s2 o murmur, abd soft,nontender, DLUVC in place, v&s, pale, pink, mottles with care, brusing, red on upper back (? beginning hemangioma), active with care\n\nSee attending note plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702019,
"text": "Neonatology Attending\n\nDay 5\n\nRemains on CPAP at 6cm with fio2 0.21. RR 50-60s. Minimal secretions. On caffeine. Has had one bradycardia episode over last 24 hours. UA discontinued. BP mean 41. Hct 34. HR 130-160s. Blood out 5.9 cc. NPO. Weight 754 gms (-51). TF at 140 cc/kg/d. Double lumen UVC with PN 9 and lipids. Benign abdomen. Girth stable. Urine output 4 cc/kg/hr. Blood glucose 80. Bilirubin 2.4 yesterday. Phototherapy discontinued. Day antibiotics. Blood culture negative. CSF clear. Pre-gent 0.3. Stable temperature in incubator.\n\nAcceptable breathing control on current regimen. Will continue to monitor closely. No evidence of PDA. Will start feeds and advance as tolerated. Will increase fluids to 150 cc/kg/d. Completing antibiotic course. No evidence of meningitis. Family up to date. Mothe to be discharged today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702020,
"text": "Respiratory Care Note\nPt remains on NP CPAP +6, .21FiO2. BBS ess clear. NP tube for minimal clear secretions; lg white oral secretions. Comfortable respirations 50-60s with IC/SC retractions. 1 spell early this shift that was QSR. Continues on caffeine. NARD. Gas w/lytes to be drawn tomorrow a.m. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702021,
"text": "Neonatal NP-Procedure\n\nprocedure: PICC line placement\nIndication: Long-term IV nutritional needs\n\nInformed consent in chart. Under sterile procedure # 24 guage introducer utilized to cannulate right antecubital with postive blood flash. Premeasured PICC (cut at 12 cm) advanced to 11cm mark without difficulty and secured. Awaiting Xray confirmation.\n\n\nInfant tolerated procedure well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702022,
"text": "PICC line pulled back 2.5 cm following Xray. Will obtain repeat to assess position.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-11 00:00:00.000",
"description": "Report",
"row_id": 1702186,
"text": "NPN 0700-1900\n\n\n#1: O: Infant in room air, maintaining saturations 96-100%.\nRespiratory rate 40's-70's, lung sounds clear and equal with\nmild subcostal retractions. Infant remains on caffeine, no\nspells. A: Infant stable in room air. P: Continue to monitor\ninfant for spells.\n\n#3: O: Total fluid minimum of 150ml/kg/d. of Breastmilk or\nPE28 with promod, 41cc gavaged over 50 minutes, Q4 hours.\nAbdomen benign, voiding, no stools on day shift. No spits.\nA: Infant tolerating feeds. P: Continue to monitor feeding\nand support weight gain.\n\n#4: O: Temperature stable in covered isolette. Isolette temp\n27.4. Alert and active with cares, brings hands to face for\ncomfort, remains swaddled in isolette. A: AGA. P: Continue\nto support growth and development.\n\n#5: O: Mom in to visit this morning. Independant with\ncares. A: parent. P: Continue to support in\nthe care of their infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-11 00:00:00.000",
"description": "Report",
"row_id": 1702187,
"text": "NPN\nI agree with above note written per co-worker . Infant did have one episode of bradycardia to 80 with desat to 84.Episode self-resolved.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-12 00:00:00.000",
"description": "Report",
"row_id": 1702188,
"text": "NPN\n\n\n#1Resp:\nO: remains in Ra . rr 40's, lungs cl=, mild ic/sc\nretractions. no spells on caffeine.\nA/P: Cont to monitor\n\n#3FEN:\nO; Wt 1.695(+50 gms) On 150cc/k/d PE 28 with prom. Abd. exam\nbenign. Bottled X1 well, full volume.\n gavages well.\nA/p: Cont to offer po if appears eager X1/day. gavage prn\n\n#4G@D:\nO: temps stable in low heated isolette with infant swaddled.\nAlert and active with cares, waking for feeds. Bath given\nA/P: Cont to support dev.\n\n#5Parenting:\nO: Mom and dad and grandmother in to visit. Bath given.\nhandling infant's well. Mom stated she had MRI with contrast\nto observe for uterine abscess. Mom still on abx with PIc\nline in place. Mom told to \"pump and dump BM \" for 48 hours\nA/P: Cont to support and inform.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-30 00:00:00.000",
"description": "Report",
"row_id": 1702271,
"text": "Neonaotlogy Attending\nDOL 55\n\n remains in room air with no distress and no apneas/bradycardias.\n\nNo murmur.\n\nWt 2560 (+50) on TFI 150 cc/kg/day BM24/PE24, tolerating by gavage over 50 minutes. Bottling to full volume. Voiding and stooling normally.\n\nA&P\n26-3/7 week GA infant with feeding immaturity\n-No changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-30 00:00:00.000",
"description": "Report",
"row_id": 1702272,
"text": "Neonaotlogy Attending\nAddendum - Physical Examination\nwell-appearing infant\nHEENT AFSF\nCHEST no retractions; good bs bialt; no crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; bs active\nCNS active, , resp to stim; axial and appendicular normal; gag/suck/root normal; grasp symm\nINTEG normal\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-22 00:00:00.000",
"description": "Report",
"row_id": 1702362,
"text": "Neonatology Attending\n\nDay 77\n\nRemains in RA. RR 50-70s. No bradycardia. HR 140-150s. BP mean 67. Weight 3260 gms (+40). TF at 140 cc/kg/d- E24. Took one full bottle. Receiving erythromycin ophthalmic ointment. , active. Stable temperature in open crib.\n\nAdequate breathing control. Will continue to monitor. Gaining weight well. Will continue to encourage po feeding.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-22 00:00:00.000",
"description": "Report",
"row_id": 1702363,
"text": "Nursing Progress Notes.\n\n\n#3 o: Total fluids 140cc/kg/day of BM/E24. Feeds offered by\nbottle every 4 hours. 41 to 52cc taken and remainder given\nby gavage. No spits or large aspirates. Abdomen benign,\nvoiding well, no stool to time or report. Umbilical hernia\nsoft. A: Learning to PO feed. P: Continue to encourage PO\nfeeds.\n#4 O: Temp stable in open crib. Baby is and active\nwith cares and sleeps well between cares. A: Appropriate\nfor age. P: Continue to support development.\n#5 O: called and expect to visit later this evening.\n A: Involved family. P: Continue to keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-23 00:00:00.000",
"description": "Report",
"row_id": 1702364,
"text": "Nursing\n\n\n#3O: Wt. up 25 g on 24 fal Enfamil, q 4 hrs. Bottle\nattempted at each feed, taking 30 - 40 cc, gav. remainder\nwith sm. spits. Belly soft, voids qs, no stool.\n#4O: Co-bedding with brother, stable temp. Active with\ncares. Eye ointment to both eyes, green drainage conts. in\nright eye.\n#5O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-23 00:00:00.000",
"description": "Report",
"row_id": 1702365,
"text": "Neonatology Attending\n\nDay 78\n\nRemains in RA. RR 40-70. HR 130-150. BP mean 48. No murmur, bradycardia. Continues on E/BM 24. Taking about half of feeding goal of 140 cc/kg/d. Remains on erythromycin ophthalmic ointment. Stable temperature in open crib.\n\nDoing well overall. Adequate breathing control. Still with immature feeding. Will continue to encourage po feeds.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-10 00:00:00.000",
"description": "Report",
"row_id": 1702011,
"text": "Neonatology- Progress Note\n\nPE: in his isolette, on CPAP6 .21, mild retractions, rrr soft systolyc murmur, no palmar pulsed, abd soft, nontender, V, nonstool, ua, dluvc lineds in place, afs,approximated, active with care, under single pt\n\nSee attending note for plan\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-23 00:00:00.000",
"description": "Report",
"row_id": 1702101,
"text": "SOCIAL WORK\nMet with mother at bedside today. States she is feeling increasingly better as she recovers from her c/s infection, altho has been tired and seeking sleep. Mother kangarooing and enjoys this closeness with her boys. Father, , is managing family business and visiting whenever possible. Extended family continue to be available to help this very and invested couple. Will cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-23 00:00:00.000",
"description": "Report",
"row_id": 1702102,
"text": "Respiratory Care\nPt recieved on NP-CPAP +5cm's with the fio2 21%. Pt's resp rate 30's to 50's with clear B/S. Suctioned for a mod amt of cloudy secretions. Plan is to trial off CPAP at the end of the week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-24 00:00:00.000",
"description": "Report",
"row_id": 1702103,
"text": "NPN Nights\n\n\n1. O: Received pt on NP CPAP of 5 RA. O2 sats 91-100%. Ls\nclera. RR 30-50's. Mild I/S retractions. No spells. On\nCaffeine. Sxn'd sm-mod thick yellow. A/P: Cont to monitor\nresp status.\n\n3. O: Wt 1015gms, up15. TF 150cc/kg of BM/PE 26+pm via ngt.\nMin asp. No spits. Voiding and stooling G-. AG 19cm. A: Tol\nfeeds. P: Cont to monitor wt, abd, and tol of feeds.\n\n4. O: Temp stable nested in servo isolette. Alert and active\nwith cares. Rests well inbewteen cares. A/P: Cont to monitor\ntemp. Cont to cluster cares.\n\n5. O: Mom and Dad in in between cares. asking\nappropriate questions. Rn updated . A/P: Cont to\neducate and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-24 00:00:00.000",
"description": "Report",
"row_id": 1702104,
"text": "Respiratory Care\nBaby remains on cpap 5 21%.RR 30-60.BS clear throughout.Sx nptube for mod thick yellow secs.No spells documented this shift.On caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-24 00:00:00.000",
"description": "Report",
"row_id": 1702105,
"text": "Neonatology Attending\n\nDay 18\n\nRemains on CPAP at 5cm with fio2 0.21. Moderate secretions. On caffeine. No bradycardia. RR 30-50s. HR 140-150s. BP mean 49. Pink. Weight 1015 gms (+15). TF at 150 cc/kg/d. On BM/PE 26 with Promod. No spits. Minimal aspirates. Stable temperature in incubator.\n\nAcceptable breathing control on CPAP. Will trial off today and monitor closely. Gaining weight well. Family up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-24 00:00:00.000",
"description": "Report",
"row_id": 1702106,
"text": "Neonatal NP-Exam\n\nsee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, no audible murmur. pink, mottled with exam. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-24 00:00:00.000",
"description": "Report",
"row_id": 1702107,
"text": "Clinical Nutrition\nO:\n~29 wk CGA BB on DOL 18.\nWt: 1015 g (+15)(~25th %ile); birth wt: 936 g. Average wt gain over past wk ~17 g/kg/d.\nHC: 25 cm (~10th to 25th %ile); last: 24.5 cm\nLN: 36.5 cm (~25th to 50th %ile); last: 35.75 cm\nMeds include Fe and Vit E\nLabs not due yet\nNutrition: 150 cc/kg/d BM/PE 28 w/ promod, all pg. Feeds just increased today; projected intake for next 24 hrs ~140 kcal/kg/d, ~4.1 to 4.4 g pro/kg/d.\nGI: Abdomen benign except few soft loops.\n\nA/Goals:\nTolerating feeds without GI problems except loops as noted above; however, abdomen generally benign appearing, so decision made to continue to feed and monitor closely for tolerance. Labs not due. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for wt gain and HC gain. LN gain is slightly below recommended ~1 cm/wk; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-30 00:00:00.000",
"description": "Report",
"row_id": 1702273,
"text": "Nursing Progress Notes.\n\n\n#3 O: Total fluids 150cc/kg/day of BM/pe24. Feeds given\nevery 4 hours over 50 min. No spits, 1x 5.5cc aspirate.\nAbdomen benign, voiding and stooling guiac negative stools.\nA: Tolerating feeds well, learning to PO feed. P: Continue\nwith current feeds and offer breast or bottle feedings at\nalternate feedings.\n#4 O: Temp stable in open crib. Baby wakes quietly and is\n and active. Baby slept well between cares in a flat\ncrib. A: Appropriate for age. P: Continue to support\ndevelopment.\n#5 O: Mother in to visit and feed baby this afternoon.\nMother is with cares and breatfeeding.\nInformation given on immunizations, CPR classes and\nstrawberry heamangiomas were discussed. A: Involved family.\nP: Continue to keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-01 00:00:00.000",
"description": "Report",
"row_id": 1702274,
"text": "NPN\n\n\n#3FEN:\nO: Wt 2.6 (+40) On 150cc/k/d. BM24/PE24. Abd. exam benign.\nNo asp. small spit X1. Po full feed X1 well. Gavages .\nwell.Voiding qs, no stool\nA/P: Cont to offer po q shift.\n\n#4 G@D:\nO: Temps stable in open crib. and active with feeds.\nMAE. AFSOF.\nA: AGA\nP: Cont to support G@D\n\n#5Parenting:\nO: Mom and in to visit. Handling infant well. \nplan to take CPR. inquiring about results of Fifth's\ndisease titre. wearing masks when visiting.\nA: Involved family with appropriate concerns\nP: Cont to support and inform. Unable to locate in\nCCC for blood results.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-01 00:00:00.000",
"description": "Report",
"row_id": 1702275,
"text": "Neonatology attending Note\nDay 56\n\nRA. RR40-50s. BS cl and =. Mild sc rtxns. No A&Bs. HR 140-160s. No murmur. BP 78/32, 48.\n\nWt 2600,up 40 gms. TF 150 cc/k/day PE/BM24 po/pg. well. Nl voiding and stooling.\n\nIn open crib.\n\nA/P:\nawaiting maturation of feeding/po skills\nno changes to nutritional plan\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-01 00:00:00.000",
"description": "Report",
"row_id": 1702276,
"text": "Neonatology attending Note\nOn exam:\n\nResting comfortably in open crib. AFSF. +NG. Lungs CTA, =. CV RRR, no murmur, 2+FP. Abd soft, +BS. Ext warm, pink, and well perfused.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-01 00:00:00.000",
"description": "Report",
"row_id": 1702277,
"text": "Student Nursing Note\nI have read and agree with the above note written by \n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-20 00:00:00.000",
"description": "Report",
"row_id": 1702353,
"text": "Newborn Med Attending\n\nCont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=3205 up 5, on 130 cc/kg/d BM Po/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-10 00:00:00.000",
"description": "Report",
"row_id": 1702012,
"text": "NPNote;\n\n\n#1. Remains on NP CPAP of 6cm, Fio2 21%, BS clear, equal,\nmild subcostal/intercostal retractions present, no spells\nthus far this shift. small white et secretions, oral cloudy\nsecretions in small amount suctioned.ABG at 2.30pm, 7.31/32\n/71/17/-9, On Caffine given as ordered.A; No spells thus far\nthis shift, on CPAP support. P; cont resp support as needed.\n\n#2.Pale pink well perfused, HCt off above gas 32,soft murmur\nheard, BP means 37-44. Cuff BP 50/33(40).Precordium quiet.\nIndomethacin last dose given.A; soft murmur persist. P; cont\nto monitor.\n\n#3. TF=140cc/kg/day, NPO, UA line 0.45% saline with heparin\nhalf unit/cc infusing, UA patent, On D8.5, PN with lipids at\ndouble lumen UVC infusing well.Abd soft, flat, hypoactive\nBS, no loops, pink abd, voided, no stool thus far this\nshift. D'stix 68. Lytes, nutritional labs sent, pending\nresults.P; cont current nutritional plan.\n\n#4. Alert,a ctive with acre, temp stable in a servo control\nisolette, nested in sheepskin, MAE, bruised skin on the\nback, heels, and extremities, aquphor applied.A;AGA p; cont\ndev support.\n\n#5. Mom visited, asking app questions, was updated by \nZ at bedside.A; mom P; cont update and teaching.\n\n#6. CBC with def sent today, pending results,on AMP + gent\ngiven as ordered.A; asymptomatic. P; cont antibiotics as\nordered, LP when mom signs consent.\n\n#7. Mildly jaundiced, under single bili lights. eye patches\non A; mildly jaundiced. P; cont bili lights as ordered.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-10 00:00:00.000",
"description": "Report",
"row_id": 1702013,
"text": "Respiratory Care\nPt recieved on +6cm of NP-CPAP with the fio2 21%. Pt's respiratory rates 30's to 60's. Blood gas obtain with good results. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-10 00:00:00.000",
"description": "Report",
"row_id": 1702014,
"text": "npnote;\naddendum; aware of lytes,hct lab results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702015,
"text": "Procedure Note: Lumbar Puncture\nIndication: to complete sepsis evaluation.\n\nSigned parental consent in chart.\n\nInfant positioned left lateral decubitus/recumbent, prepped and draped in sterile fashion. #22 g spinal needle introduced into L3-4 interspace with clear fluid return. CSF sent for culture, gram stain, cell count, diff, glucose, protein. Infant tolerated procedure well, no complications.\n\nAdditional note;\n\nUmbilical arterial catheter removed without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-11 00:00:00.000",
"description": "Report",
"row_id": 1702016,
"text": "Respiratory Care\nBaby continues on NPCPAP 6, 21%. BS clear. NPT and naris sxn for scant secretions. RR 30's-60's with IC/SCR. On caffiene. No spells recorded as of this writing. Plan cont CPAP @ present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-22 00:00:00.000",
"description": "Report",
"row_id": 1702095,
"text": "Rehab/OT\n\n observed today for care plan. Plan posted at the bedside, please refer to for infant strengths, stress signals, and recommendations on how to maximize infant comfort. present, educated re: the role of OT and developmental care. OT to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-09 00:00:00.000",
"description": "Report",
"row_id": 1702178,
"text": "NPN 0700-1900\n\n\n1.Resp: Infant remains in room air with RR 50s-60s and 02\nsats 95-100%. Lung sounds are clear and equal with mild\nSC/IC retractions. Infant remains on caffeine with no\nspells thus far this shift. Continue to monitor respiratory\nstatus.\n\n3.FEN: Infant remains on TF 150cc/kg/day of BM/PE 28 with\npromod. Mom breastfed infant today for less than 5 minutes\nwith poor latch on. Infant is tolerating feeds well with no\nspits, minimal aspirates. Abdomen is round and soft, no\nloops and consistent abdominal girths. He is voiding and\nstooling. Feeding plan also includes vitamin E and Fe+\nsupplements. Continue to monitor FEN status.\n\n4.DEV: Infant is swaddled in an air isolette with stable\ntemps. He is alert and active with cares, sleeps well\nbetween care times. He sucks vigorously on pacifier and\nbrings hands to face. Continue to support growth and\ndevelopment.\n\n5.Parenting: Mom in today to visit and held both infants.\nMom is independent in cares and appropriate with infant.\nContinue to support and keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-10 00:00:00.000",
"description": "Report",
"row_id": 1702179,
"text": "NPN 1900-700\n\n\n#1 RESP S/O: Infant in RA, rr 50-60's. Lungs are clear with\nsubcostal retractions. O2 sats > 95%. No spells. On\ncaffeine. A: Stable in RA P: Continue to monitor.\n\n#3 FEN S/O: TF 150cc/k/d. Infant to get 39cc q4h, pe28 with\npromod. Infants abdomen is benign, voiding, no stools on\nthis shift. AG stable, no spits, minimal aspirates. A:\nTolerating feeds. P: Continue to monitor.\n\n#4 DEV S/O: Infant in air isolette. Temps stable. Alert and\nactive with cares, sleeping in between. A: AGA P: Continue\nto support dev.\n\n#5 Parenting S/O: No contact with yet on this shift.\nA: Unable to assess. P: Continue to support.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-10 00:00:00.000",
"description": "Report",
"row_id": 1702180,
"text": "Neonatology Attending\n\nDOL 35 CGA 31 3/7 weeks\n\nStable in RA. 1 A/B. On caffeine.\n\nBP 72/32 mean 43\n\nOn 150 cc/kg/d BM/PE 28 with promod. Tolerating feeds well. Voiding. Stooling. Wt 1580 grams (up 20).\n\nWeaning isolette.\n\n visiting and up to date.\n\nA: Stable. Spells controlled on caffeine. Tolerating feeds.\n\nP: Monitor\n Continue current management\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-10 00:00:00.000",
"description": "Report",
"row_id": 1702181,
"text": "NPN\n\n\n1.Resp: Infant remains in room air with RR 40s-60s and 02\nsats 95-100%. Lung sounds are clear and equal with mild\nSC/IC retractions. He remains on caffeine, no spells thus\nfar this shift. Continue to monitor respiratory status.\n\n3.FEN: Infant remains on TF 150cc/kg/day of BM/PE 28 with\npromod. He is tolerating feeds well, no spits and max.\naspirate 3.0 cc. Abdomen is soft and round, no loops and\nconsistent abdominal girths. He is voiding, no stool thus\nfar this shift. His feeding plan includes vitamin E and Fe+\nsupplements. Plan to allow infant to go to breast once per\nshift. Continue to monitor.\n\n4.DEV: Infant is swaddled with hat on sheepskin in a 27.0\ndegree isolette with stable temps. He is alert and active\nwith cares, sleeps soundly in between. He brings hands to\nface and sucks vigorously on pacifier. He is now holding q\nday. Continue to support growth and development.\n\n5.Parenting: Mom called this morning to check on infants.\nShe plans to visit at 1600 cares. Continue to support\n and keep informed.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-20 00:00:00.000",
"description": "Report",
"row_id": 1702354,
"text": "NPN 7a- 7p\n\n\n#3: TF: min130cc/k/d. Conts on E24. Still not able to meet\nmin req. Bottled 51cc this am, slowly over 40mins. Needed\nmuch encouragemnt to take last 10cc. Team aware. NG tube\nreplaced as discussed with Team. Offered bottle again at\nnoon care. Infant was sleepy, took 5cc and then had .\nGavaged remainder to allow infant to rest. Sm spit x1. Abd\nsoft, +, no loops. Sm. soft umbi hernia noted.\nVoiding. No stool thus far in shift. A: 'ing feeds,\nunable to meet TF min all PO P:Cont to follow wt and exam.\nMonitor to feeds. Offer bottle as 'ed.\n\n#4: conts with stable temps while swaddled in an open\ncrib. He is stirring-waking for feeds. /active with\ncares. Tiring with bottling. MAE. Fonts soft/flat. Conts\nto have mod-lg thick yellow drainage from right eye. Eye is\nnot red or inflammed. assessed. Cleansing\neye and applying warm compresses with gentle massage to tear\nduct as needed. Sat up in bouncy seat this afternoon. A:\nAGA P:Cont to support dev needs.\n\n#5: Mom called this am, update given. Mom informed of need\nfor NG tube replacement. Mom states that she and will\nbe in for 20care. A: Involved, family P:Cont to\nsupport and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-21 00:00:00.000",
"description": "Report",
"row_id": 1702355,
"text": "NPN nights\n\n\nFEN: Weight 3220g up 15grams. total fluids MIN of\n130cc/k/d of E24 or BM 24(with enfamil powder). Offered\nbottle Q feed. Taking 19-61cc (of 69cc , Q4) Gavaged\nremainder of feedings. Abdomen is soft, pink, active bowel\nsounds, no loops. Max asp 1.2cc, no spits. Voiding , no\nstool this shift. Soft small umbilival hernia, pink and\nreducable. Tolerating feedings well. Will continue to\nmonitor closely. Continue to encourage po feedings.\n\nG&D: Infant in open air crib, co-bedding with twin, temps\nare stable. and active, waking for feeds. Sleeping\nwell between cares, sucks on pacifier. Will continue to\nsupport developmental needs.\n\nParenting: Mother and father in tonight, independent with\ncares. Father gave infant a bath (no assistance needed).\n and involved , continue to update and\nsupport family.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-21 00:00:00.000",
"description": "Report",
"row_id": 1702356,
"text": "Neonatology NP Note\nPE\nswaddled in open crib, cobedding with brother\n, sutures approximated\nrespirations unlabored, lungs clear=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondisteneded, small umbilical hernia\ngood \n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-21 00:00:00.000",
"description": "Report",
"row_id": 1702357,
"text": "neonatology Attending Note\nWill increase TF to 150.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-21 00:00:00.000",
"description": "Report",
"row_id": 1702358,
"text": "neonatology Attending Note\nDay 76\n\nRA. RR30-60s. Cl and = BS. Mild sc rtxns. No A&Bs. HR 120-160s. No murmur. BP 77/35, 49.\n\nWt 3220, up 15 gms. TF 130 cc/k/day E24/BM24. PO/PG. well. Nl voiding and stooling.\n\nReports of eye drainage.\n\nIn open crib.\n\nA/P:\nProgressing well. Awaiting mature po skills.\nWill begin ilotycin\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-06 00:00:00.000",
"description": "Report",
"row_id": 1702294,
"text": "NPN\n\n\n#3FEN:\nO: Wt 2.790(+25) On 150cc/k/d PE24. Abd. exam benign.\nBottled 1 full feed. gavage well. No asp or spits.\nVoiding qs\nA/P:Cont to offer po\n\n#4G@D:\nO: temps stable in crib, cobedding. and active ,waking\nfor cares. MAE\nA/P: Cont to support G@D\n\n#5Parenting:\no: No contact this shift\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-06 00:00:00.000",
"description": "Report",
"row_id": 1702295,
"text": "Neonatology Attending\n\nDay 61- CGA 35 weeks\n\nRemains in RA. RR 40-50s. Mild nasal congestion. Clear breath sounds. Mild retractions. No bradycardia. No murmur. HR 130-160s. BP mean 60. Pink, mottles with care. Weight 2790 gms (+25). TF at 150 cc/kg/d- BM/PE 24. Alternating po/pg feeds. Put to breast. No spits. Stable temperature in open crib. Has completed two month immunizations.\n\nDoing well overall with mild residual feeding immaturity. Will continue to encourage po feeds. Monitoring for apnea. Family up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-06 00:00:00.000",
"description": "Report",
"row_id": 1702296,
"text": "Nursing Progress Note\n\n\n3. FEN O/A TF=150cc/kg/day of BM or PE24. Inf PO/PG\nfeeding this shift. feeds well, no spits, min asp thus\nfar. Belly soft, no loops. Infant is voiding, no stool\nthus far. P Cont to offer PO feeds as .\n4. DEV O/A remains in an OAC cobedding with his\ntwin. A/A w/cares, waking for feeds. Sleeping well between\ncares. P cont to assess dev needs.\n5. O/A Mom and in for visit and cares this\nAM. Updates given. independent with care of twin\nboys. P cont to support, eudcate.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-26 00:00:00.000",
"description": "Report",
"row_id": 1702378,
"text": "NPN0700-\n\n\n3. TF minimum 140cc/kg/day, BM 24 with enfamil/E 24.\nBottling with every feeding- thus far this shift, has\nbottled 80cc, 74cc respectively (needs min. of 79cc Q4).\nBelly soft, + BS, no loops. No spits, min. aspirates.\nVoiding, stooling, heme negative. Continue to monitor\ntolerance to feeds.\n\n4. Temp stable in open crib, cobedding with brother. \nand active with cares, waking for feeds inconsistently.\nSmall amount yellow drainage from right eye this afternoon-\ncontinue erythromycin ointment tid. Bathed at noon.\nConsent obtained for Hep B #2, to be administered. Continue\nto promote growth and development.\n\n5. Mom and here at noon, updated on progress and plan\nof care. Mom and independent with cares. Asking\nappropriate questions, pleased with infants progress.\nContinue to update, educate and support , continue\nd/c teaching.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-27 00:00:00.000",
"description": "Report",
"row_id": 1702379,
"text": "Nursing Progress Note\n\n\nFEN O/A: Current Wt: 3410, ^15g. TF @ min of 140cc/k/d;\nBM24/E24. bottled 30-55cc q4h overnight; gavaged\nremainder of volume. Abdomen benign, active BS. Voiding/no\nstool. P: Cont to encourage po intake.\n\nG&D O/A: Infant is cobedding with brother in an open\ncrib. Temps stable. Occasionally wakes for feeds, A/A with\ncares. Likes pacifier. Green/yellow drainage noted from\nright eye; washed with water & erythromycin applied. P: Cont\nto support developmental needs.\n\nPAR O/A: in for evening cares, independent. Asking\nappropriate questions. Invested. P: Cont to support NICU\n.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-27 00:00:00.000",
"description": "Report",
"row_id": 1702380,
"text": "NPN Adendum:\nRecombivax given in left thigh @ 0400. Consent present in chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-27 00:00:00.000",
"description": "Report",
"row_id": 1702381,
"text": "Newborn Med Attending\n\nCont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=3410 up 15, on 140 cc/kg/d BM24 PO/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-27 00:00:00.000",
"description": "Report",
"row_id": 1702382,
"text": "NPN 0700-1900\n\n\n1. FEN: TF remain at a min of 140 cc/kg/day of BM/E24.\nAttempting to PO q care. Infant has bottled between 30-80\ncc thus far with good coordination. Tolerating feedings\nwell; abd exam benign, no spits, and min asp. Voiding qs and\nno stool noted. Infant continues on ferinsol. P: Cont. to\nsupport nutritional needs.\n\n2. G/D: Temps stable swaddled cobedding in open crib with\nsibling. and active with cares. Settles well in\nbetween cares. Appropriately brings hands to face and sucks\non pacifier to comfort self. AFSF. AGA. Infant received\nsynagis today. P: Cont. to support developmental needs.\n\n3. : Mom called today. Updated on infant's condition\nand plan of care. Asking appropriate questions. ,\ninvolved . will be in for this afternoon's\ncares and to pick up twin. P: Cont. to support and update\n.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-23 00:00:00.000",
"description": "Report",
"row_id": 1702096,
"text": "NPN 1900-0700\n\n\nRESP: Infant continues on NP CPAP 5, 21-23% FiO2, increasing\nwith cares. RR 30-60's, mild IC/SC rtx. LS clear and equal.\nSxn'd q4hrs, sm amt from ETT, lg amt of nasal secretions. On\ncaffeine. No spells thus far.\n\nFEN: wt=1000g TF=150cc/kg/d of BM/PE26. Equals 25cc q4hrs,\ngavaged over 30min. Tolerating well. Belly soft, +BS, AG\nstable, no loops, no spits, voiding, UO=2cc/kg/hr X8hrs, no\nstool thus far. On vit E and Fe.\n\nG&D: Tmax 101.9, d/t temp probe dislodged and isolette temp\n37. Following temps stable, nested on sheepskin in\nservo-controlled isolette. Alert and active with cares.\nSleeps well between. Hands to face. Likes belly. Some clear\neye drainage noted from both eyes, cleaned with sterile\nwater.\n\n: Dad called X1, updated over the phone. Mom in\nbriefly, brought up some breastmilk. Updated at bedside.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-23 00:00:00.000",
"description": "Report",
"row_id": 1702097,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of NPCPAP and 21%. On caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-23 00:00:00.000",
"description": "Report",
"row_id": 1702098,
"text": "Neonatology Attending\n\nDay 17\n\nRemains on CPAP at 5cm with fio2 0.21. RR 30-50s. No bradycardia on caffeine. Suctioned for large yellow secretions. No murmur. BP mean 49. Weight 1000 gms (+15). TF at 150 cc/kg/d- BM/PE 26 pg. Minimal aspirates. Urine output 2 cc/kg/hr. Stable temperature on servo-controlled incubator.\n\nAcceptable breathing control. Monitoring for apnea. Will consider trial off CPAP tomorrow if continues to do well. Adding Promod today. Family in to visit.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-23 00:00:00.000",
"description": "Report",
"row_id": 1702099,
"text": "Nursing NICU Note.\n\n\n1. Resp. O/Pt remains on NP CPAP of 5, FiO2 21% primarily\nthus far this shift. Please refer to flowsheet for remainder\nof shift. Remains on caffeine. No spell noted thus far.\nA/Resp status appears stable on CPAP. P/Cont. to monitor.\n\n3. F/N. O/TF/enteral feeds remain at 150cc/k/d PNGT. Diet\nadvanced to PE24PM/BM24PM. Please refer to flowsheet for\nexaminations of pt from this shift. A/Appears to be\ntolerating present feeding regimen thus far this shift.\nP/Cont. to monitor for s/s of feeding intolerance.\n\n4. Dev. O/Temp stable thus far on servo control in a covered\nisolette. Awake and alert this am during care times. Rooting\nnoted. Sucked eagerly on pacifier. A/Alt. in G/D. P/cont. to\nsupport pt's growth and dev. needs.\n\n5. . O/Father called this am and was updated on pt's\nstatus and plan of care. Father stated that pt's mother\nwould be in later on today to kagaroo. A/ are\nactively involved in pt's care. P/cont. to support and\neducate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-23 00:00:00.000",
"description": "Report",
"row_id": 1702100,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal. Nl S1S2, no audible murmru. Pale, pink and mottled with exam. Abd benign, no HSM. Active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-28 00:00:00.000",
"description": "Report",
"row_id": 1702266,
"text": "Nursing progress notes.\n\n\n#3 O: Total fluids 150cc/kg/day of BM/PE24. Feeds given\nevery 4 hours over 1 hour. Breastfed by mom, did not latch\nor suck much. Abdomen benign, voiding well, trace stool\nonly. No spits or large aspirates. A: Tolerating feeds\nwell, learning to Po feed. P: Continue to offered breast or\nbottle feeding every shift.\n#4 O: Temp stable in open crib. Baby did not wake for\nfeedings and slept well between feedings in his flat crib.\nA: Appropriate for age. P: Continue to support development.\n\n#5 O: called and were in to visit and feed baby. A:\nInvolved family. P: Continue to keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-29 00:00:00.000",
"description": "Report",
"row_id": 1702267,
"text": "NPN 1900-0700\n\n\n1. FEN: Weight is 2510 gms up 85 gms. TF remain at 150\ncc/kg/day of PE/BM24. Infant bottled 40 cc this shift with\ngood coordination. Tolerating NGT feedings well; abd exam\nbenign, no spits, and min asp. Voiding qs and no stool\nnoted. Infant continues on Vit E and ferinsol. P: Cont. to\nsupport nutritional needs.\n\n2. G/D: Temps stable swaddled in open crib. and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n3. : Mom and in for 2100 cares. Updated at\nbedside on infant's condition and plan of care. Asking\nappropriate questions. Independent with diapering, taking\ntemp, and handling infants. , involved . P:\nCont. to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-29 00:00:00.000",
"description": "Report",
"row_id": 1702268,
"text": "Neonatology\nDoing well. REmains in RA. No spells. Comfortable apeparing.\nOff caffeine.\n\nWt 2510 up 85. Tolerating feeds at 150 cc/k/d. Abdomen benign. STill req gavage. Poing once per shift. Moderate size non-bilious aspirates.\n\nACtivity normal. Moving all 4 well. Skin w/o leisons.\n\nRepeat eye exam for Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-29 00:00:00.000",
"description": "Report",
"row_id": 1702269,
"text": "NPN 7a7p\n\n\nFen\nInfant on TF 150 cc/k/d of BM/PE 24. Gavaged over 1 hr and\noffered breast or bottle x 1 q shift. Bottled entire amt\ntoday at mid day with frequent burps. No spits. Abd soft,\nround with active BS. Had lrg asp overnight reported. Today\nasp max of 4 cc, benign. Voiding but not stooled today yet.\nTolerating total feeds. Learning to PO. Monitor weight and\nexam.\nG/D\nInfant in OAC with stable temps. A/A with cares and sleeping\nwell between. FS&F. MAEs. Due for F/U eye exam on Monday.\nAGA. Monitor and support milestones.\nParenting\nMom called this am for update and to convey her plans. Hopes\nto bathe boys at visit tonight. asking appropiate questions.\nInvested and . Support and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-30 00:00:00.000",
"description": "Report",
"row_id": 1702270,
"text": "NPN NOCS\n\n\n3. O: Wt up 50gms. TF at 150cc/kg of BM/PE24. Gavaged over\n50min. Bottling 1x/shift-took 44cc. Abd benign. No spits.\nVoiding, no stool. A: Working on po feeds. P: Continue with\nplan.\n\n4. O: and active with cares. Temp stable in open crib.\nRight eye with yellow drainage- cleansed and warm soak\napplied. A: AGA. P: Continue to support dev needs.\n\n5. O: in for eve cares. Updated. Independent with\ncares. Gave a bath. A: Involved family. P: Continue to\nupdate daily.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-08 00:00:00.000",
"description": "Report",
"row_id": 1702171,
"text": "NPN 1900-0730\n\n\n1. RECEIVED INFANT IN RA. RR 40'S -80'S. SAO2 IN THE HIGH\n90'S, OCCASSIONALLY DRIFTING WITH FEEDING, WITH QSR. LS\nCLEAR AND EQUAL. MILD ICR/SCR. NO INCREASED WOB NOTED. PLAN;\nCONT. TO MONITOR RESP/ STATUS.\n\n3. WT 1.540GMS UP 50GMS SINCE YESTERDAY. TF CONT, AT\n150CC/K/D OF BM OR PE28 WITH PROMOD, , ABD SOFT, NO LOOPS,\n+BS, NO SPITS OR ASP. VOIDING WELL, NO STOOL SO FAR THIS\nSHIFT. PLAN; CONT. TO FOLLOW WT GAIN ON CURRENT CALS.\n\n4. REMAINS IN AIR ISOLLETTE. TEMPS STABLE. A/A WITH CARES.\nNOT WAKING FOR CARES. +MOTTLING WITH CARES. REMAINS ALL PG\nFEEDS. PLAN; CONT. TO SUPPORT G/D.\n\n5. NO CONTACT FROM THIS SHIFT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-08 00:00:00.000",
"description": "Report",
"row_id": 1702172,
"text": "Neonatology Attending Note\nDay 33\n\nRA. On caffeine. No A&Bs. Pale/pink. HR 140-150s.\n\nWt 1540, up 50 gms. TF 150 cc/k/day BM/PE28 w promod. well. Nl voiding and stooling.\n\nIn isolette.\n\nA/P:\nGrowing preterm infant Cont current plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-08 00:00:00.000",
"description": "Report",
"row_id": 1702173,
"text": "NPN\n\n\nBaby tolerating feeds well, no spits. Temp stable, swaddled\nin air controlled Isolette.\nMom in at 1200, dresssed baby. very pleased with his\nprogress.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-08 00:00:00.000",
"description": "Report",
"row_id": 1702174,
"text": "NEonatology- PRogress NOte\n\nPE: in his isolette, in room air, bbs cl=, rrr s1s2no murmur,abd soft, nontender, V&S, afso, active with care, hemangioma on abd & back unchanged\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-09 00:00:00.000",
"description": "Report",
"row_id": 1702175,
"text": "NPN\n\n\n#1Resp:\n O: Remains in RA with sast 95-100. Color pale/pink. RR\n40's, lungscl=. No spells on caffeine.\nA/P: Cont to monitor\n\n#3FEN:\nO: Wt 1.540(+20 gms) On 150cc/k/d PE 28 with prom. Abd. exam\nbenign. No asp, mod spit X1. Voiding qs, lg stool, guiac\nneg. Bottled x1 well, full amt.Well coordinated.\nA: Adequate nutritional support\nP: Cont to pg feed. Offerpo/breastfeed X1/day.\n\n#4 G@D:\nO: Temps stable with infant swaddled in heated\nisolette.Alert and active with cares, waking for feeds. Ant.\nfont soft and flat. MAE\nA/P: Cont to support dev.\n\n#5Parenting:\nO: Dad in to visit. Handling infant well. held infant.\nA/P: Cont to support and inform.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-09 00:00:00.000",
"description": "Report",
"row_id": 1702176,
"text": "Neonatology\nDoing well. RA. Comfortable appearing. No spells. On caffeine\n\nWt 1560 up 20 grams. TF at 150 cc/k/d of 28 cal. Abdomen benign. Taking po full volumes last night, slower this am. COntinues to require gavage this am.\n\nTemp stable in isollette.\n\nCOntinue to await maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-09 00:00:00.000",
"description": "Report",
"row_id": 1702177,
"text": "Neonatology\nPink active non-dysmorphic. Well perfuse. Cor nl s1s2 w/o murmurs.A bdomen benign. Neuro non-focal and age appropriate.\nSkin w/o lesions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-27 00:00:00.000",
"description": "Report",
"row_id": 1702260,
"text": "NPN 0700-1900\n\n\n#3 FEN\nO: TF=150cc/kg/day of BM/PE24=61cc q4hr gavaged over 1hr. PO\nonce a shift. Infant BF for about 10min at 1200. No spits.\nMinimal aspirates. AG=25-26.5cm. Voiding. No stool. Abdomen\nbenign. Active bowel sounds. A: Tolerating feeds. P: Cont to\nmonitor and encourage PO feeds.\n#4 G&D\nO: Infant remains in OAC. Swaddled. Temp stable. A/A with\ncares. Not waking for feeds. Sucks on pacifier. Sleeps well\nin between cares. AFOF. MAE. A: AGA. P: Cont to monitor and\nsupport G&D.\n#5 Parenting\nO: Mom in for 12pm cares. Asking appropriate questions.\nUpdated at bedside. Independent with cares. BF infant. A:\nInvolved, . P: Cont to support and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-19 00:00:00.000",
"description": "Report",
"row_id": 1702348,
"text": "PCA Note\n\n\nFEN: O-Weight 3200, ^5gm. TF min 130cc/k/d of ENF/BM 24.\n69cc Q4H. PO/PG. Offering PO feeding with each care. See\nflowsheet for specifics. is voiding, no stool as of\nthis progress note. +. Abdomen is soft, full. No spits.\nMinimal residuals.\n A-Tolerating feeds.\n P-Continue to encourage PO feeds.\n\nG/D: O-Cobedding with brother. is stable. Waking for\nfeeds. and active with cares. Sleeping peacefully.\nMAE. Curious nature. Awake for longer periods of time.\n A-AGA.\n P-Continue to monitor for developmental milestones.\n\n: O-Mom and grandmother in this shift. Updated at\nbedside. Completely inde with cares. Would like to get\n done as soon as possible.\n A- and involved.\n P-Continue to support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-19 00:00:00.000",
"description": "Report",
"row_id": 1702349,
"text": "Newborn Med Attending\n\nCont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. Wt=3200 up 5, on E24 Po/PG.\nA/P: Growing infant woirking up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-19 00:00:00.000",
"description": "Report",
"row_id": 1702350,
"text": "NPN 0700-\n\n\n1. FEN: TF are at at min of 130 cc/kg/day of E24/BM24. NGT\nwas pulled at 1200; plan is to let infant PO adlib without\ngavaging the remainders and look at intake over a 24 hour\nperiod. Infant has bottled between 45-62 cc q 4 hours with\ngood coordination. Tolerating feedings well; abd exam\nbenign, no spits. Voiding qs and stooling heme neg. Infant\ncontinues on ferinsol. P: Cont. to support nutritional\nneeds.\n\n2. G/D: Temps stable swaddled cobedding in open crib with\nsibling. and active with cares. Settles well in\nbetween cares. Appropriately brings hands to face and sucks\non pacifier to comfort self. AFSF. AGA. Yellow drainage\nnoted from right eye - warm soaks done q care. P: Cont. to\nsupport developmental needs.\n\n3. : called x 1. He was updated on infant's\ncondition and plan of care. Asking appropriate questions.\nWill be in later today for cares. , involved .\nP: Cont. to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-20 00:00:00.000",
"description": "Report",
"row_id": 1702351,
"text": "PCA NOTE\n\n\nFEN: O-Weight 3205, ^5gm. TF min 130cc/k/d of BM/E 20. PO.\n69cc Q4H. Taking roughly of required amount thus far.\nSee flowsheet for details. is voiding, no stool. +.\nAbdomen is unremarkable. No spits.\n A-Tolerating feeds.\n P-Continue to encourage PO feeds.\n\nG+D: O-Temp is stable, cobedding with brother. Waking for\nfeeds. and active with cares. Sleeping peacefully.\nMAE. AF-flat. Warm compresses to affected eye area. Sweet\nnatured.\n A-AGA.\n P-Continue to monitor for developmental milestones.\n\n: No contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-20 00:00:00.000",
"description": "Report",
"row_id": 1702352,
"text": "NPN NOCS\nI have examined infant and agree with above note by , PCA. Infant on all po trial and not meeting minimum. aware. Will continue with plan, possibly may need NGT today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1702007,
"text": "Social Work\n\nCovering for LICSW, attended family meeting today, with parents , RN and this worker. All medical issues reviewed, parents with very appropriate questions, they appear to be coping extremely well with preterm delivery of twins, and to have a good understanding of present medical needs. also beginning to project into the future, and good questions. Mother is planning to return to work within a month. Couple state that they have good extended family support network.\nDoing well, are looking forward to beginning kangaroo care.\nParents given parent packet, also SSI forms.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-10 00:00:00.000",
"description": "Report",
"row_id": 1702008,
"text": "NPN 7p-7a\n\n\nResp: Infant remains on NP cpap 6cm. fio2 21%. Ls clr/=. RR\n30-50's. Fio2 21%. Sxn for sm via np tube. mod cloudy\norally. Brady x1 see flowsheet. No desats so far this shift.\nConts on caffiene. Abg this am 7.31/32/67/17/-9. Cont to\nmonitor.\n\nCV: Infant conts with soft murmur. Pale. Hr 130-150's. BP\nmeans 35-45. Cuff bp 56/36/(44). Rec 2nd dose of indocin as\nordered. Total bld out 4.5cc. cont to monitor.\n\nFen: Wt tonoc .805kg (+10gms). Remains NPO conts on tf\n140cc/kg. Rec 1/2ns with 1/2 unit heparing/cc via uac.\nPNd8.5 with il infusing dluvc. Dstick 57. aware. Abd\nsoft. Hypoactive bs. NO loops noted. See flowsheet for u.o.\nNo stool thus far. am lytes 138/40/110/16. AG 16cm. Cont\nwith current plan.\n\nG&D: Temp stable in servo isolette. Alert and acitve with\ncares. Irritable at times. Nested in sheepskin with\nboundries in place. Bruising between shoulders. Reddened\nareas on elbows and feet. Aquaphor applied.\n\nParenting: No contatc from parents so far this shift.\n\nSepsis: Day of amp and gent. Bld cx neg to date. No new\nsigns of sepsis noted.\n\nbili: Conts under single phototx. Am bili 2.4/0.5/1.9\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-10 00:00:00.000",
"description": "Report",
"row_id": 1702009,
"text": "Respiratory Care\nBaby continues on NPCPAP 6, 21%. BS clear. Sxn for minimal secretions as per flowsheet.RR 30's-60's with IC/SCR. ABG: 7.31/31/67/17/-9. One mild stim brady this shift. On caffeine. Rec'd 2nd dose Indocin tonight. Will cont to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-10 00:00:00.000",
"description": "Report",
"row_id": 1702010,
"text": "Neonatology Attending\n\nDay 4\n\nRemains on CPAP at 6cm with fio2 0.21. RR 30-50s. Mild retractions. On caffeine with one apnea episode over last 24 hours. ABG 7.31/32/67. Murmur heard this morning. Has received two doses of indomethacin. HR 130-150s. BP means 37-45. Pulses pressures ~20. Hct 34.6. Weight 805 gms (+10). TF at 140 cc/kg/d. NPO. On PN 8 and lipids. Benign abdomen. Urine output 3 cc/kg/hr. Lytes 138/4.0/110/16. Blood glucose 57. Bilirubin 2.4 under single phototherapy. On ampicillin and gentamicin- day . Culture negative. Stable temperature. Family meeting yesterday.\n\nAcceptable respiratory status on CPAP. Murmur still present in middle of indomethacin course. Will follow this and continue close cardio-respiratory monitoring. Will discontinue UAC and add sodium acetate to PN to address metabolic acidosis. Completing antibiotic course. Family up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-22 00:00:00.000",
"description": "Report",
"row_id": 1702089,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on NP CPAP 5 FiO2 21%. Suctioned NP tube for mod amt of white/yellow secretions. Breath sounds are clear. RR 30-50's two spells so far tonight QSR. Stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-27 00:00:00.000",
"description": "Report",
"row_id": 1702261,
"text": "NPN 0700-1900\nI have read and agree with the above note written by .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-28 00:00:00.000",
"description": "Report",
"row_id": 1702262,
"text": "PCA NOTE\n\n\nFEN: O-Weight 2425, ^5gm. TF 150cc/k/d of BM/PE 24. 61cc\nQ4H. Dominating PG feeds. See flowsheet for further\nexamination of this shift. is voiding, no stool thus\nfar. Abdomen is unremarkable. Minimal residuals. No spits.\n A-Tolerating feeds.\n P-Continue to follow current regimen as ordered.\n\nG/D: O-In RA. OAC. Temp is stable. Swaddled. Slowly waking\nfor feeds. Semi and active with cares. Sleeping\npeacefully. MAE. AFSF. Sweet natured.\n A-AGA.\n P-Continue to monitor for developmental milestones.\n\n: O-Mom and in this shift. Updated by nurse,\n on status and immediate plan.\n A- and involved.\n P-Continue to support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-28 00:00:00.000",
"description": "Report",
"row_id": 1702263,
"text": "NPN 1900-0700\nI have examined infant and agree with above note and assessments per flowsheet by PCA, . were in for 2100 cares. Independent with diapering, taking temp, and handling infants. Updated at bedside on infant's condition and plan of care by this RN. Asking appropriate questions. , involved .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-28 00:00:00.000",
"description": "Report",
"row_id": 1702264,
"text": "Neonatology Attending Note\nDay 53\n\nRA. RR40-60s. Cl and =. 1 brady on days. HR 130-160s. No murmur. BP 70/43, 48.\n\nWt 2425, up 5 gms. TF 150 cc/k/day PE/BM24 po/pg. Nl voiding. No stool.\n\nIn open crib.\n\nA/P:\nawaiting cardioresp maturity\nimmature feeding skills\nno changes to current medical plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-28 00:00:00.000",
"description": "Report",
"row_id": 1702265,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\naFOF. breath sounds clear and equal> nl s1S2, no audible murmur. pink and well perfused. Abd engin, no SHM. aCtive bowel sounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-18 00:00:00.000",
"description": "Report",
"row_id": 1702344,
"text": "Clinical Nutrition\nAddendum:\nError in above calculation of protein intake. Actual intake is ~1.9 to 2.4 g pro/kg/d. The higher range represents what infant takes when he receives formula, which is the majority of feeds. Therefore infant is meeting full weaned protein recs of ~2.2 g/kg/d.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-08 00:00:00.000",
"description": "Report",
"row_id": 1702301,
"text": "NPN 1900-0700\n\n\n1. FEN: Weight is 2880 gms up 45 gms. TF remain at 150\ncc/kg/day of BM/PE24. Infant is alt PO/PG. Infant has\nbottled 55 cc thus far with good coordination. Tolerating\nfeedings well; abd exam benign, no spits, and min asp.\nVoiding qs and stooling heme neg.\n\n2. G/D: Temps stable swaddled cobedding in open crib with\nsibling. and active with cares. Settles well in\nbetween cares. Appropriately brings hands to face and sucks\non pacifier to comfort self. AFSF. AGA. P: Cont. to\nsupport developmental needs.\n\n3. : Mom and were in for cares. Independent\nwith diapering, taking temp, bottling, and handling infants.\nUpdated at bedside on infant's condition and plan of care.\nAsking appropriate questions. , involved . P:\nCont. to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-08 00:00:00.000",
"description": "Report",
"row_id": 1702302,
"text": "NICU Attending Note\n\nDOL # 63 = 35 2/7 weeks CGA learning to PO feed.\n\nPlease see full .\n\nCVR/RESP: RRR without murmur, mild subcostal retractions, no A/B. Will continue to monitor.\n\nFEN: Abd benign, weight today 2880, up 45 gm on TF of 150 cc/kg/d PE/MM 24 PO/PG. Will continue current diet, encourage PO intake.\n\nNEURO/DEV'T: AFSOF, awake and , stable temp co-bedding with twin.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-28 00:00:00.000",
"description": "Report",
"row_id": 1702383,
"text": "NICU NURSING PROGRESS NOTE:\n\nFEN.O: Weight=3.480kg,^70gm. Infant is on min140cc/k/d of BM\n24 with enfamil powder or E24, 80cc Q4 hrs. All feeds are\nPO. Bottling relatively full voluem of required. Taking\nbetween 60-80cc each time. Bottling well, slightly\nuncoordinated. Abd exam is soft, no loops. BS active.\nVoiding, no stool. No spits. Min aspirates. Tolerating\nfeeds and gaining weight.\nP: Continue to encourage PO feeding.\n\nG/D.O: Baby is swaddled in open crib. Temp is stable.\nActive and with cares. Wakes to eat every 3-4 hrs.\nLikes his pacifier. Appropriate behavior. P: Cont to support\ndevelopmentally.\n\nParenting: No contact from to the time of note. Cont\nto support and inform.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-28 00:00:00.000",
"description": "Report",
"row_id": 1702384,
"text": "NURSING ADDENDUM\n\nI have examined and observed this infant and agree with the above assessment and plan of care. Will discuss lowering minimum intake requirement to hopefully facilitate full bottling.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-28 00:00:00.000",
"description": "Report",
"row_id": 1702385,
"text": "Neonatology Attending\nAddendum - Physical Examination\nvery well-appearing infant\nHEENT AFSF\nCHEST no retractions; good bs bilat; no crackles\nCVS well-perfused; RRR; fmeoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active\nCNS active, , resp to stim; axial and appendicular normal and symm; moving all ext symm; suck/root/gag normal; grasp/Moro symm\nINTEG normal\nMSK normal\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-28 00:00:00.000",
"description": "Report",
"row_id": 1702386,
"text": "Neonatology Attending\nDOL 83\n\n remains in room air with no distress and no cardiorespiratory events.\n\nNo murmur. BP 76/37 (51).\n\nWt 3480 (+70) on min TFI 140 cc/kg/day BM24/E24, with intake 104 cc/kg/day. Bottling up to full volumes, but not consistently.\n\nA&P\n26-3/7 week GA infant with feeding immaturity\n-Continue to await maturation of oral feeding skills\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-29 00:00:00.000",
"description": "Report",
"row_id": 1702388,
"text": "NICU NURSING PROGRESS NOTE:\n\nFEN.O: Weight=3.495kg, ^15 gm. Infant remains on min\n140cc/k/d of BM 24 or E 24, 81cc Q4 hrs. All feeds are PO.\nBottling well slightly uncoordinated. Taking between\n45-90cc. Abd exam is soft, no loops. Voiding no stool. No\nspits, min aspirates. feeding tube is pulled out by infant\nat mednight, and hasn't replaced yet, cuz he bottled 90cc\nafter taken the tube out. Tolerating feeds and gainging\nweight. P: Continue to encourage Po feeding and support\nfeeding plan.\n\nG/D.O: is in open crib. Temp is stable. Swaddled.\nactive and with cares. Wakes to eat every 3-4 hrs.\nLiks his pacifier. Staring at pictures around him.\nA: Well appereance. P: Cont to support developmentally.\n\nParenting: Mom was in for the 8pm cares. Uptaded regarding\ninfant's plan of cares and weight by RN . Mom did the\ncare and bottled the baby. She stayed with him for while.\nMom handles the care well. and involving .\nP: Cont to support and inform.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-29 00:00:00.000",
"description": "Report",
"row_id": 1702389,
"text": "NPN\nSpoke with Mother re: possible tomorrow; indicated that would like to be present. Contact OB on day shift.\n\nAgree with above note by PCA .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-29 00:00:00.000",
"description": "Report",
"row_id": 1702390,
"text": "Attending Note\nDay of life 84\nstable in room air 30-60\nno spells\nHr 130-160\nweight 3495 up 15 on min of 140 cc/kg/day\nof BM or E 24 cal/oz\nPg tube removed last night. This am taking\nreasonable volume.\nvoiding and stooling\nin open crib\ns/p synagis and Hep B\n\nPlan to encourge po feeds\nWill try to get circumcision.\nWill consider discharge if po\nfeeds continue to go well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-29 00:00:00.000",
"description": "Report",
"row_id": 1702391,
"text": "Physical Exam\nGen baby resting in bed in no\napparent distress\nskin mottled\nLung clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds small\nsoft loops\nGU freshly circumcised with mod swelling\nand two stiches in place. no active bleeding\nExt warm well perfused with brisk cap refill\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-29 00:00:00.000",
"description": "Report",
"row_id": 1702392,
"text": "NPN 0700-1900\n\n\n1. FEN: TF remain at a min of 140 cc/kg/day of BM/E24.\nInfant is bottling adlib amt q 4 hours. Infant has bottled\nbetween 65-80 cc thus far with good coordination.\nTolerating feedings well; abd exam benign, no spits.\nVoiding qs and no stool noted thus far. Infant continues on\nferinsol. P: Cont. to support nutritional needs.\n\n2. G/D: Temps stable swaddled in open crib. and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. Circumcision done by Dr. \ntoday. Infant has two sutures and silver nitrate was used\nsec to bleeding. No bleeding has been noted since time of\n. Tylenol was given for pain management. P: Cont. to\nsupport developmental needs.\n\n3. ; Mom called x 2 thus far. She was updated on\ninfant's condition and plan of care. Asking appropriate\nquestions. Will be in for 1600 cares. , involved\n. P: Cont. to support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1701998,
"text": "NPN 7p-7a\n\n\nResp: Infant remains on np cpap 6cm. Fio2 24-29%. RR\n30-60's. LS clr/=. IC/SC retractions noted. Sxn x1 for sm\ncloudy secretions. No spells or desats so far this shift.\nconts on caffiene. Cont to wean 02 as tol.\n\nCV: No murmur noted. Pale mottles with cares. Bp means\n34-38. See flowsheet for bp's. Hr 130-160's. total bld out\n3.7cc. UAC in place. Cont to monitor.\n\nFen: Wt tonoc .795kg (-110gms). Conts on tf 120cc/kg. Rec\npnd7 via 2luvc with il. 1/2ns with .5unit hep/cc via uac.\nAbd soft. Hypoactive bs. Mec stool with each diaper change.\nSee flowsheet for u.o. am lytes 142/3.5/117/1.9. Ag stable\n17-18cm. Cont with current plan.\n\nG&D; Temp stable in servo isolette. Alert and active with\ncares. Nested in sheepskin boundries in place. Irritable at\ntimes. Occasioanlly sucks on pacifier. Cont to support\ndevelopmental milestones.\n\nParenting: Mom in briefly with visitor this evening. Updated\nat bedside. Asking appropriate questions. Cont to support\nand update.\n\nSepsis: Infant d of amp and gent. Peak gent level 6.9.\nNo new signs of sepsis noted.\n\nBili: Infant conts under single phototx 2.7/0.6/2.1\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1701999,
"text": "Respiratory Care Note\nPt. continues on 6cmH2O of NPCPAP and 24-30% FIO2 BS are clear. On caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1702000,
"text": "NPN 7p-7a\n\n\nADD: Infant's bld cx + for gram cocci. repeat bld cx sent\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1702001,
"text": "Neonatology Attending\n\nDay 3\n\nRemains on CPAP after caffeine bolus. Fio2 0.23-0.3. ABG 7.32/41/53/22. No bradycardia overnight. Murmur heard this morning. HR 130-150s. BP means 34-38. BP 42/24, 30. Blood out 3.7 cc. Weight 795 gms (-110). TF at 120 cc/kg/d. UAC and UVC in place. Benign abdomen. Urine output 3.8 cc/kg/hr. Passing meconium stools. 142/3.5/117/19. Bilirubin 2.7/0.6. Blood culture positive for gram positive cocci. Gent level 6.9. Stable temperature.\n\nAdequate breathing control on current regimen. Monitoring cardio-respiratory status closely. Will treat presumed PDA. M4etabolically well. Spoke with mother yesterday. Family meeting today at 1400. HUS today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1702002,
"text": "SOCIAL WORK\nInitial Eval:Parents known to me from mother's 6S admission and will cont to follow. These are 1st infants to this 46yo mother, father has 6yo daughter from previous relationship. Family lives in and has good family support. Today mother visiting w/sister in law and appeared optimistic about twin's conditions. She presents as hopeful and optimistic by nature. Parents own and operate a commercial balloon business and have a small group of employees to help when they are visiting NICU. Gave mother info for reduced and SSI info. Parents looking forward to family mtg today, I will not be able to attend, will ask my colleague to attend in my absence. Will cont to follow. \n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1702003,
"text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21 to 24%. Pt's respiratory rates 40's to 60's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-05 00:00:00.000",
"description": "Report",
"row_id": 1702160,
"text": "Clinical Nutrition\nO:\n~30 wk CGA BB on DOL 30.\nWT:1405g(+60)(~25th-50th %ile); birth wt: 936g. Average wt gain over past week ~25g/kg/d.\nHC: 26.5cm(~10th-25th %ile); last wk: 26cm\nLN: 38.5cm(~25th-50th %ile); last wk: 37.5cm\nMeds include Fe & Vit.E\n due this week\nNutrition: 150cc/kg/d as BM/PE 30 w/ promod, pg over 40mins. Average of past 3d intake ~151cc/kg/d, providing 151kcals/kg/d and ~4.1-4.4g pro/kg/d.\nGI: Abdomen benign; BM g neg.\n\nA/Goals:\nTolerating feeds without GI problems, pg over extended feeding time. due this week. Current feeds & supps meeting recommendations for Kcals/pro/vits/mins. Growth is meeting recs for WT/HC/LN gains. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-05 00:00:00.000",
"description": "Report",
"row_id": 1702161,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining her O2 sats\ngreater than 97%. Lung sounds clear/=. RR 50-70's. IC/SCR\nnoted. Infant continues on caffeine. No spells noted thus\nfar. P: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 150 cc/kg/day of BM/PE30 with promod.\nTolerating NGT feedings well; abd exam benign, no spits, AG\nstable, and min asp. Voiding qs and no stool noted thus\nfar. Infant continues on Vit E and ferinsol. Nutrition\n due in am. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. HUS planned for\ntomorrow. AFSF. AGA. P: Cont. to support developmental\nneeds.\n\n4. : Mom was in for 1200 cares. Independent with\ndiapering, taking temp, and gaining confidence with handling\ninfants. Updated at bedside on infant's condition and plan\nof care. Asking appropriate questions. Kangarooed with\n for 75 minutes. , involved . P: Cont. to\nsupport and update .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-06 00:00:00.000",
"description": "Report",
"row_id": 1702162,
"text": "NURSING PROGRESS NOTE\n\n\n1. RESPIRATORY\nCONTINUES IN ROOM AIR. NO EPISODES OF DESATURATION. BBS\nCLEAR, RR 40-80.\n3. F/N\nTONIGHT'S WEIGHT UP 65 GRAMS TO 1.47KG. TOLERATING 150CC/KG\nOF BM/PE30 WITH PROMOD. ABD FULL, SOFT. PASSED LARGE STOOL\nAT 0400.\n4. G&D\nTEMP VARIABLE TONIGHT, CHANGED TO AIR CONTROL ISOLETTE.\nAWAKE AND ALERT.\n5. \nNO CONTACT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-06 00:00:00.000",
"description": "Report",
"row_id": 1702163,
"text": "Neonatology Attending Note\nDay 31\n\nRA. RR50-80s. +ic/sc rtxns. No A&Bs. On caffeine. No murmur. Pale/pink. HR 150-180s. BP 56/29, 37.\n\nWt 1470, up 65. TF 150 cc/k/day BM/PE30 w promod. well. Nl voiding and stooling.\n\nCa 10.2/P6.3/BUN 10/Cr 0.4/Alk phos 331\n\nIn air control isolette.\n\nA/P:\n-- Monitor AOP on caffeine\n-- No change to nutritional feedings\n-- d30 HUS today\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-06 00:00:00.000",
"description": "Report",
"row_id": 1702164,
"text": "Neonatology- PRogress Note\n\nPE: in his isolette in room air, bbs cl=, rrr s1s2no murmur abd soft,nontender, V&S, hemangioma on chest and back, afso, active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-06 00:00:00.000",
"description": "Report",
"row_id": 1702165,
"text": "Neonatology- PRogress Note\nTeam met witih to review clinical course and issues and discussed criteria for d/s, Pleased with progress and will continue to keep informed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-28 00:00:00.000",
"description": "Report",
"row_id": 1702387,
"text": "NPN 0700-\n\n\n3. TF min 140cc/kg/day, BM 24 with Enfamil/E24. Bottling\nevery feed. At 8am, took only 40cc with remainder gavaged\nin for total of 81cc. At 12pm, 4pm, bottled 78cc and 73cc\nrespectively. Belly soft, + BS, no loops. Min aspirates,\none small spit. Voiding, large brown stool this afternoon.\nContinue to monitor tolerance to feeds.\n\n4. Temp stable in open crib. and active with cares,\nrests well between cares. Sleepy while bottling. Continue\nto promote growth and development.\n\n5. Mom called this AM, updated on progress and plan of\ncare. will visit this evening, with 8pm cares.\nContinue to update, educate and support .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701992,
"text": "Clinical Nutrition\nAddendum:\nInfant's gestational age is 26 , not 26 .\ndopamine infusing @ 0.21cc/hr in D5\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-20 00:00:00.000",
"description": "Report",
"row_id": 1702075,
"text": "npn 1900-0700\n5: \nmom and dad in for 8pm care. and involved.resp: infant weaned to cpap of 5. tolerating well. no spells mom did the temp and change the diaper. asking appropriate . remains at 21%.questions. updated by this rn. Plan to continue to support family needs\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-20 00:00:00.000",
"description": "Report",
"row_id": 1702076,
"text": "npn 1900-0700\n5: \nmom and dad in for 8pm care. and involved.resp: infant weaned to cpap of 5. tolerating well. no spells mom did the temp and change the diaper. asking appropriate . remains at 21%.questions. updated by this rn. Plan to continue to support family needs\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-20 00:00:00.000",
"description": "Report",
"row_id": 1702077,
"text": "Respiratory Care Note\nPt. began shift on 6cmH2O of NPCPAP and 21%. BS clear. Pt. sx'd for mod. thick yellow/bld-tinged secretions. CPAP decreased to 5cmH2O. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-20 00:00:00.000",
"description": "Report",
"row_id": 1702078,
"text": "NICU Attending not\nDay life 14\nCPAP of 5 FiO2 21% no spells\nHR 140-160 68/43 mean 62\nweight 952 down 3 grams on 150\ncc/kg/day of PE 22 no spits\nmin aspirate stooling heme neg\nd stick 92\nNa 138 K 5.6 Cl 108 CO2 19\nstill with some yellow eye drainage\n\nPlan to continue CPAP will\nincrease to 24 cal/oz\nbegin vit E and iron\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-20 00:00:00.000",
"description": "Report",
"row_id": 1702079,
"text": "Neonatology- Physical Exam\n\nInfant remains on CPAP. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, strawberry hemangioma on left abdomen, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-20 00:00:00.000",
"description": "Report",
"row_id": 1702080,
"text": "NPN\n\n\n1.Resp: Infant remains of NP CPAP 5 requiring 21% Fi02.\nLung sounds are clear and equal with SC/IC retractions, RR\n30s-50s. Infant suctioned for large amount of secretions\nfrom both ETT and mouth. Infant remains on caffeine, no\nspells. Continue to monitor respiratory status.\n\n3.FEN: Infant remains on TF 150cc/kg/day of PE/BM 24cal/oz\n(increased from PE/BM 22). She is tolerating feeds well, no\nspits, minimal aspirates. Abdominal exam is remarkable for\na soft transient loop. Abdominal girths consistent between\n18-19cm. He is voiding (3.8cc/kg/hr), no stool thus far\nthis shift. D/S this morning 94. Lytes this morning\nunremarkable. Continue to monitor FEN status.\n\n4.DEV: Infant is nested in a servo isolette with borderline\ntemps. Infant is active and alert with cares, fiesty and\nirritable at times. Infant does have small amount of yellow\neye drainage from both eyes. Continue to support growth and\ndevelopment.\n\n5.Parenting: Mom in this afternoon to visit with babies.\nMom informed of newborn screen and Hep B vaccine and updated\non status of infant. Plans to visit later with dad and hold\nbaby 2. Continue to support and keep informed.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-20 00:00:00.000",
"description": "Report",
"row_id": 1702081,
"text": "Respiratory Care\nPt remains on NP-CPAP +5cm's with the fio2 21%. PT suctioned for a moderated amt of thick cloudy secretions. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-25 00:00:00.000",
"description": "Report",
"row_id": 1702248,
"text": "Neonatology- PRogress NOte\n\nPE: remains in his open crib, in room air, bbs cl=, rrr s1s2no murmur,abd soft, nontender, V&S, hemangioma on abdomen, afso, pale, pink, gavage tube in place\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-25 00:00:00.000",
"description": "Report",
"row_id": 1702249,
"text": "NPN 0700-1900\n\n\n#3: O: Total fluid minimum 150ml/kg/d. of breastmilk or\nPE24, 59cc q4 hours. Po feed once a day usually with mom.\nBreastfed this afternoon for about 10 minutes with lactation\nconsultant present. Abdomen benign, no spits, bowel sounds\nactive. A: Infant tolerating feeds. P: Continue with current\nfeeding plan.\n\n#4: O: Temperature remains stable in open air crib. Sucks\npacifier when offered, brings hands to face for comfort.\nWakes for feeds, and active, sleeps well between\ncares. A: AGA. P: Continue to support growth and\ndevelopment.\n\n#5: O: Mom in this afternoon. Independant with feeds and\ncares. A: parent. P: Continue to support in\nthe care of their infant, especially mom with breastfeeding.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-25 00:00:00.000",
"description": "Report",
"row_id": 1702250,
"text": "Addendum NPN\nI agree with the above written statement by .\n\nResp: Infant remains in room air. Lung sounds are clear and equal with mild subcostal retractions. He is no longer on caffeine, has had two spells today with HRs in the 70s and desats to the 70-80s. He resolves quickly with mild stimulation, both occurred after feeding. Continue to monitor.\n\nFEN: Infant offered bottle at 1600 care time by , took 19 cc po. Continue to monitor.\n\nSOC: in to visit, very independent and appropriate with infant. Continue to support and keep informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-25 00:00:00.000",
"description": "Report",
"row_id": 1702251,
"text": "Addendum NPN\n may have been exposed to communicable disease by 7 year old daughter. tested for exposure, results pending. are wearing masks at bedside during visits.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-26 00:00:00.000",
"description": "Report",
"row_id": 1702252,
"text": "PCA Progress Note, 7p-7a\n\n\nFEN:\n TF:150cc/kg/D of PE24. Total volumes are being gavaged over\n50 mins Q4hrs. Tolerating feeds well w/ minimal aspirates w/\nnoted sm brown flecs, and no spits. ABd is benign w/ active\nBS. Voiding w/ each diaper chg, no stool. Remains on Fe and\nVit E. Please refer to Pt's chart for additional Fen data.\nContinue to encourage and support current FEN status and\nplan of care.\n\nDEV:\n Infant's temp remains stablw hwile swaddled in OAC. Infant\nis aslert and active w/ cares, wakes for feeds and sleeps\nwell in between cares. Sucks on pacifier for comfort.\nContinue to encourage and support developmental milestones.\n\nPAR:\n No contact from so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-26 00:00:00.000",
"description": "Report",
"row_id": 1702253,
"text": "Nursing addendum note\nI have examined infant and agree with coworker care of infant. Infant had nl abd. exam, non tender, abd. soft, active BS, no loops. no spits.Brown flecks in aspirate probably due to NG tube irritation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-26 00:00:00.000",
"description": "Report",
"row_id": 1702254,
"text": "NEONATOLOGY\nDOING WELL. REMAINS IN RA. NO SPELLS. COMFORTABLE APEPARING. FEW desats Comfortable apeparing.\n\nWT 2390 up 45. Tolearting feeds well at 150 cc/k/d of 24 cal. Abdomen benign. STill requiring gavage.\n\nTemp stable in open crib.\n\nCOntinue to await maturation of resp contorl and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701993,
"text": "Clinical Nutrition\nO:\n26 wk gestational age BB, AGA, now on DOL 2.\nBirth WT: 936g(~50%ile); current WT: 905(-31)(down ~3% from birth wt.)\nHC: 24.5cm(25-50%ile)\nLN: 35.5cm(~50%ile)\nLabs noted\nNutrition: TF @ 120cc/kg/d. PN started on DOL 1 via DLUVC. UAC infusing 1/2 NS @ 1cc/hr, D5 infusing @ 1cc/hr but plan to D/C today. Projected intake for next 24hrs from PN 50kcal/kg/d, ~3g pro/kg/d & ~1g fat/kg/d. Glucose infusion rate from PN ~5.6mg/kg/min.\nGI: Abdomen benign; hypoactive bowel sounds.\n\nA/Goals:\nTolerating PN with good BS control. Remains NPO w/UAL still intact. Labs noted and PN adjusted accordingly. Initial goal for PN is ~90-110kcal/kg/d, ~3-3.5g pro/kg/d and ~3g fat/kg/d. Advancing as per protocol. When able to start feeds, initial goal is 150cc/kg/d PE/BM 24, providing 120kcal/kg/d and 3.3-3.6g pro/kg/d. Except PN to taper as EN feeds advance. Appropriate to start Fe & Vit.E supps when feeds reach initial goal. Further advances in feeds as per growth and tolerance. Growth goals after initial diuresis are ~15 to 20g/kg/d for WT gain, ~1cm/wk for LN gain, and ~0.5-1cm/wk for HC gain. Will follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701994,
"text": "NPN 0700-1900\n\n\n1. Resp: Received infant orally intubated on SIMV settings\nof 18/5 with a rate of 14. Infant was electively extubated\nat 1200 to NP CPAP 6. FiO2 requirement thus far has been\n23-25% to maintain his O2 sats greater than 88%. ABG at 1600\n7.32/41/53/22-4. Infant was sxn q 4 hours for mod amts of\nwhite secretions from ETT/NP tube. Lung sounds clear/=. RR\n40-60's. No bradys thus far. Infant has had some occ\ndrifts to mid 80's - QSR. Infant was loaded with caffeine\nat 1000. P: Cont. to moitor resp. status, follow BG, and\nwean fiO2 as tolerated.\n\n2. CV: No murmur audible this shift. Infant is pale pink/\nwell perfused. HR 130-160's. Infant has been off Dopamine\nsince 1200. Art. means have been between 33-40. B/P cuff\n52-29 m38. CVP 1-4. Blood out thus far 3.1 cc. Pulses\nwnl. Cap refill brisk. P: Cont. to monitor cv status.\n\n3. FEN: TF were increased to 120 cc/kg/day. UAC has 1/2 NS\nwith 1/2 unit hep/cc, DUVC prim has D5W with 1/2 unit hep/cc\nand sec has PND5 running at 50 cc/kg. PND7 will be running\nthrough prim and sec ports with IL as of 1800. D/S 89. Abd\nsoft, flat, hypoactive BS. UO for past 12 hours has been\n7.8 cc/kg/hr. Trace protein and Ph 7.5 noted in urine. No\nstool. Lytes drawn at 1600 pending. P: Cont. to support\nnutritional needs and check a set of lytes in am.\n\n4. G/D: Temps stable on servo-warmer. Infant is nested in\nsheepskin with boundaries & tent in place. Alert and active\nwith cares. Settles well in between. Bruising noted\nbetween shoulder blades and on r leg. HUS planned for\ntomorrow. AFSF. AGA. P: Cont. to support developmental\nneeds.\n\n5. Parents: Mom and Dad in throughout shift. Updated at\nbedside on infant's condition and plan of care by this RN\nand team. Asking appropriate questions. Parents were told\ncare times and came up for 1600 cares to watch.\nParents did not feel comfortable assisting with cares as of\nyet. Family meeting scheduled for tomorrow at 1400. P:\nCont. to support and update parents.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701995,
"text": "NPN Cont'd\n\n\n6. I/D: Infant is day of ampi and gent tx. Repeat CBC\ndone this am. Please see flowsheet for further details. BC\nneg to date. P: Cont. to administer abx as ordered, follow\nBC, and monitor for s/s of infection.\n\n7. Hyperbili: Infant remains under single phototherapy with\neye shields in place. Bili this am was 4.6/0.3. P: Check a\nbili in am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701996,
"text": "Neonatology - Progress Note\n\n is active with good tone, AFOF. He is pink, well perfused, no murmur auscultated. He has weaned off Dopamine. BP stable. He was successfully extubated to CPAP today. Breath sounds clear and equal. No spells. Total fluids increased to 120cc/kg/day. PN/IL infusing via DLUVC. UAC intact. DS stable in 80 range. UO ~5.8cc/kg/hr. Lytes today @ 4pm Na-147, K-3.7, Cl-117, TCO2-20. Bili under single phototherapy 3.7/0.5. Abd soft, hypoactive bowel sounds, no loops. No stool yet. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701997,
"text": "Respiratory Care\nPt recieved on SIMV, rate of 14, pressures of 18/5, with the fio2 21%. Pt extubated from PPV, placed on NP-CPAP +6cm's with the fio2 21 to 25%. Pt suctioned for a mod amt of cloudy secretions. Blood gas obtained with good results. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-19 00:00:00.000",
"description": "Report",
"row_id": 1702069,
"text": "Respiratory Care\nBaby continues on NPCPAP 6, 21%. BS clear. NPT sxn x2 for mod amts thick yellow secretions, naris sxn for sm white x1. Lg thick OP secretions. RR 30's-50's with mild IC/SCR. No spells noted. On caffeine. Plan cont present management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-04 00:00:00.000",
"description": "Report",
"row_id": 1702155,
"text": "Nursing NICU Note.\n\n\n1. Resp. O/Pt remains in RA. Please refer to flowsheet for\nA/B noted this shift. Remains on caffeine. A/Resp status\nstable in RA. P/Cont. to monitor for evidence of resp\ndistress. Cont. to monitor for A/B and intervene as pt\nneeds.\n\n3. F/N. O/TF remain at 150cc/k/d of BM30/pE30PM PNGT. Please\nrefer to flowsheet for examinations of pt from this shift.\nVoiding. No stool passed this shift as of yet. A/Appears to\nbe tolerating present feeding regimen. P/Cont. to monitor\nfor s/s of feeding intolerance.\n\n4. G/D. O/Temp remains stable on servo control in a covered\nisolette. Awake and alert with cares and sleeping well in\nbetween. Intermittently sucking on pacifier. Warm soak\napplied to Left eye for light yellow eye drainage noted.\nA/Alt. in G/D. P/Cont. to support pt's growth and dev needs.\n\n5. . O/Mother in this afternoon with aunt. Mother\nupdated on pt's status and plan of care. Mother participated\nin cares by taking pt's temp and changing pt's diaper.\nMother stated that she would be back this evening with her\nhusband to kangaroo. A/ are actively involved in pt's\ncare. P/Cont. to support and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-05 00:00:00.000",
"description": "Report",
"row_id": 1702156,
"text": "NPN 1900-0700\n\n\nRESP: Infant remains in RA. O2sat 95-100%. RR 40-70's. LS\nclear and equal. Mild IC/SC rtx. One spell thus far this\nshift, requiring mod stim. On caffeine.\n\nFEN: wt=1405g (up 60g). TF=150cc/kg/d of BM/PE30 with\npromod. Equals 35cc q4hrs, gavaged over 40min. Tolerating\nwell. Abdominal exam benign. +BS, AG stable, no loops, no\nspits, max asp 3.2cc, voiding, no stool thus far. On vit E\nand Fe.\n\nG&D: Temps stable, nested on sheepskin in servo-controlled\nisolette. Alert and active with cares. Sleeps well between.\nHands to face. Likes being prone.\n\n: Both in for cares. Updated at bedside.\nDad providing cares independently. and involved.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-05 00:00:00.000",
"description": "Report",
"row_id": 1702157,
"text": "Neonatology Attending Note\nDay 30\nCGA 30 5\n\nRA. 95-100%. Cl and =. RR40-70s. Mild sc rtxns. On caffeine. 3 A&Bs past 24h.\n\nNo murmur. HR160-180s.\n\nWy 1405, up 60 gms. TF 150 cc/k/day BM/PE30 w promod. well. On Vit E and Fe.\n\nIn servo isolette.\n\nA/P:\n-- monitor AOP on caffeine\n-- no change to nutritional plan\n-- day 30 HUS \n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-05 00:00:00.000",
"description": "Report",
"row_id": 1702158,
"text": "Neonatology - Progress NOte\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. Occ spells on caffeine. He is tolerating full volume feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in heated isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-05 00:00:00.000",
"description": "Report",
"row_id": 1702159,
"text": "Clinical Nutrition\nAddendum:\nGrowth is exceeding recommendations of ~15-20g/kg/d of wt gain, will follow long term trends.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-24 00:00:00.000",
"description": "Report",
"row_id": 1702241,
"text": "NICU NPN 1900-0700\n\n\nFEN O: Tf remain at 150cc/k/d. Weight 2315g, up60g.\nTolerating feeds of pe/bm24 well. Botling 1x/shift, took\n20cc's at 8pm. Abdominal exam benign, voiding and stooling.\nNo spits, min ngt aspirates.\n\nDEV O: temps are stable, swaddled in crib. He is\n and active with cares, sleeps well in between cares.\nFontanells are soft and flat.\n\nParenting O: Mom in for 8pm cares, independent.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-15 00:00:00.000",
"description": "Report",
"row_id": 1702332,
"text": "NPN NOCS\n\n\n3. O: Wt down 20gms. TF at min 130cc/kg of E24/BM24.\nOffering bottle with each feeding. Bottled - full amts\ntonight. Abd benign. No residuals, no spits. Voiding, no\nstool. A: Working on po feeds. P: Continue with plan.\n\n4. O: and active with cares. Temp stable in open crib.\nCobedding with sibling. Waking for feedings. A: AGA. P:\nContinue to support dev needs.\n\n5. O: in for eve cares. Updated. Independent with\ncares. A: Involved family. P: Continue to update daily.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-15 00:00:00.000",
"description": "Report",
"row_id": 1702333,
"text": "Neonatology Attending\n\nDOL 70 CGA 36 3/7 weeks\n\nStable in RA. No A/B. Last .\n\nOn BM 24 at 130 cc/kg/d po/pg. Voiding. Stooling. Wt 3105 grams (down 20).\n\nR eye drainage being treated with warm soaks.\n\nEyes today immature zone 3 f/u 3 weeks.\n\n in and up to date.\n\nA: Stable. On countdown D2. Still needing significant pg feeds. Blocked duct being treated.\n\nP: Monitor\n Encourage pos as tolerated\n Increase to 150 cc/kg/d\n f/u eye exam\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-15 00:00:00.000",
"description": "Report",
"row_id": 1702334,
"text": "Nursing Progress Note\n\n\n3. FEN O/A TF incr today to 150cc/kg/day of BM24 or\nPE24. Offering PO feeds at each feed. Inf taking only\n10-25cc PO thus far. Belly soft, no loops. Inf voiding,\nstooling. P cont to offer PO feeds as .\n4. DEV O/A remains in an OAC cobedding with his\ntwin. TEmp stable. A/A w/cares. Eye exam today immature\nzone 3, F/U in 3 weeks. Right eye yel/gr drainage, team\naware, applying warm soaks. P cont to assess dev needs.\n5. o/A Mom and in for quick visit. Updates\ngiven. P plan to visit at 1600 cares.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-15 00:00:00.000",
"description": "Report",
"row_id": 1702335,
"text": "Neonatology: Progress NOte\n\nPE: Remains in room air, bbs cl=, rrr s1s2no murmur, abd soft, nontender, V&S, afso, active with care\n\nSee attending note for plan\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-16 00:00:00.000",
"description": "Report",
"row_id": 1702336,
"text": "NPN NOCS\n\n\n3. O: Wt up 45gms. TF at min 150cc/kg of E24/BM24. OFfering\nbottle with each feeding, taking ~ feeding with remainder\nneeded gavaged. No spits. Abd benign. Voiding, no stool. A:\nWorking on po feeds. P: Continue with plan.\n\n4. O: and active with cares. Temp stable in open crib.\nCobedding with sibling. Continues with yellow-green right\neyd drainage, warm soaks applied with each care. A: AGA. P:\nContinue to support dev needs.\n\n5. No contact thus far this shift.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-16 00:00:00.000",
"description": "Report",
"row_id": 1702337,
"text": "Neonatology Attending\n\nDay 71\n\nRemains in RA. RR 30-60s. No bradycardia. No murmur. HR 150-160. Pale, pink. Weight 3150 gms (+45). TF at 150 cc/kg/d- E/BM 24 with Enfamil. Offered bottles with each feed. Taking half to three-quarter of volume. Benign abdomen. Stable temperature in open crib. Eyes immature to zone 3.\n\nDoing well overall. Relatively mature breathing. Continuing to monitor. Still with feeding immaturity. Will continue to encourage po feeding. Will need follow up eye exam in three weeks.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701990,
"text": "7 Hyperbili\n\n#1Resp\nBaby remains intubated. Settings have weaned gradually over\nthe night. ABG at 0415was 4.29/36/49/18/-8. Weaned at 0530\nto current settings of 19/5 with rate 14. FIO2 has been 21%\nover course of night. Briefly needed increase to 23% due to\nsat drift to mid 80's. RR40-60's. lungs coarse. suctioned q4\nfor mod amt white secretions from ETT. Mod amts of oral\nsecreions. No spells.\nA. Settings weaned with minimal O2 requirement.\nP. Cont to monitor.\n#2CV\nBlood transfusion finished at . Dopamine weaned slowly\nover the shift. Baby had been at Dopa 8mcg/kg but now down\nto 5mcg/kg. HR140-150's. no murmur heard. Color pale pink.\nHct this am was 34.6. Plt 110. BP mean on art line mostly\n30-35. Occ up to high 30's and breif drift in mean to 28-29.\nA. Dopa weaning slowly.\nP.Cont to monitor. Wean Dopa as able.\n#3FEN\nWt 905g. Wt down 31g. Baby cont on TF at 100cc/kg. Dstick 83\nat 2400. TPN D5 infusing at 50cc/kg. with Dopa piggybacked.\nD5W with hep infusing via primary port. 1/2 NS with Hep\ninfusing via UVC. NPO. Bowel sounds not audible. Abd flat\nand soft. AG 17. Lytes sent at 0400 as well as BUN and\ncreat. IoCa .96. UAC and UVC infusing without problem.\nPerfusion good to lower extremities.Voiding but no stool.\nA. Adequate Dstick. Lytes have been stable.\nP. Cont to monitor.\n#4Dev\nNested on warmer with servo. Nested in sheepskin with\nboundaries with tent over. Restless at times but settles\nnicely.\nA. appropriate\nP. Plan HUS on Wed.\n#5parent\nMom called for an update.\n#6sepsis\nBaby cont to receive day treatment of amp and gent.\nPre gent level was 1.0. amp and gent given. CBC repeated\nthis am.\nA. adequate pre gent level. Will need yo obatin a post with\nnext dose.\n#7Bili\nBili at .9/0.3/4.6. Phototherapy strted with mask on at\n2130. Bili pend from this am. mask on.\nP. Check results of bili this am.\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701991,
"text": "Neonatology Attending\n\nDay 2\n\nRemains on simv with settings- x14, 18/5, 0.21-0.25. ABG 7.29/36/49/18. Rate decreased in response. Suctioned for moderate white secretions. No bradycardia. HR 140-150s. No murmur. Dopamine weaned to 4.5 mcg/kg/min. BP means 38. Transfused with PRBcs yesterday. Hct 34.6 after transfusion. Weight 905 gms (-31). On PN 5. Blood glucose 87, 83. Urine output 5.8 cc/kg/hr. No stool passed. Lytes 144/4.8/114/20. BUN 27 creat 0.8. Remains under single phototherapy. Bilirubin 4.6. On ampicillin and gentamicin. Gent pre level 1.0. Normal activity.\n\nWeaned to low settings with mild increase in fio2. Will trial on CPAP after caffeine bolus. Following closely for murmur. Acceptable fluid/electrolyte status at present. Will increase fluids to 120 cc/kg/d. Following lytes twice daily. Tracking bilirubin for apparent exaggerated physiologic hyperbilirubinemia. Continuing antibiotics. Not much of a bump with red cell transfusion. Head ultrasound scheduled for tomorrow. Family up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-19 00:00:00.000",
"description": "Report",
"row_id": 1702070,
"text": "NPN\n\n\n1.Resp: Infant remains on NP CPAP 6 on 21%. RR 30-40s and\n02 sats 92-99%. Lung sounds are clear and equal with IC/SC\nretractions. Suctioned for mod-large amount of yellow\nsecretions from both nares and mouth. He remains on\ncaffeine, no spells thus far this shift. Continue to\nmonitor respiratory status.\n\n3.FEN: Infant remains on TF 150cc/kg/day of PE/BM 22\n(increased today from PE/BM 20). Infant is tolerating\nfeedings well, no spits. D/S this am was 53 (at 0800)\nfollowed by 90 (at 1200). Abdominal exam is remarkable for\na soft transient loop. Max. aspirate 3.4 cc of non-bilious\nundigested formula. Abdomen is pink, soft, and with\nconsistent abdominal girths. He is voiding (2.0cc/kg/hr)\nbut has not stooled this shift. Continue to monitor FEN\nstatus.\n\n4.DEV: Infant is nested in a servo isolette with stable\ntemps. He is alert and active with cares, irritable and\nfiesty at times. He has a small amount of yellow drainage\nfrom the left eye. Continue to support growth and\ndevelopment and monitor eye drainage.\n\n5.Parenting: Mom and several friends in this afternoon to\nvisit with infant. Mom is back in-house for abdominal\ninfection. Dad plans on visiting later this evening to hold\nbaby. Continue to support and keep informed.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-19 00:00:00.000",
"description": "Report",
"row_id": 1702071,
"text": "Neonatology- Physical Exam\n\nInfant remains on CPAP. Active, alert in an isolette, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, small strawberry hemangioma on left abdomen. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-19 00:00:00.000",
"description": "Report",
"row_id": 1702072,
"text": "Respiratory Care\nPt recieved on NP-CPAP +6cm's with the fio2 21%. Pt's respiratory rates 30's to 40's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-19 00:00:00.000",
"description": "Report",
"row_id": 1702073,
"text": "Neonatology\nRemnains on CPAP 6, Low Fio2. Comfortable appearing.\n\nTolerating feeds at 150 cc/k/d. Advanced to 22 cal this am. Abdomen benign. Few non-bilious aspirates.\n\nTemp stable in isollette.\n\nCOntinue resp care and advancement of nutrition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-20 00:00:00.000",
"description": "Report",
"row_id": 1702074,
"text": "npn 1900-0700\n\n\n1resp\nremains on cpap of 6. 21%. rr 40-60's. no spells. occational\ndrifts requiring increase in fo2. lung sounds course to\nclear with suctioning. infant with mild\nsubcostal/intercostal retractions. no increased wob noted.\ncontinues on caffeine. continue to monitor for changes.\n\n3: fen\ncurrent weight 952gms down 3. total fluids remain at\n150cc/kilo/day of bm/pe 22. enteral feeds tolerated. minimal\naspirates. one small spit. abd soft with no loops. voiding\nand stooling hem neg. stool. girths stable. dstick 93.\nlytes pending. continue to monitor for changes.\n\n4: g/d\ntemps stable in an servo heated isolette. alert and active\nwith cares. sleeps well inbetween. brings hands to face.\naga.fontanells soft and flat. Continue to monitor for\ndevelopmental milestones.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-03 00:00:00.000",
"description": "Report",
"row_id": 1702149,
"text": "Neonatology - Progress Note\n\n is sleepy with exam, but responds appropriately to stimuli. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. He is tolerating full volume, pg feeds. Abd soft, active bowel sounds, no loops, voiding and stooling. Stable temp in heated isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-24 00:00:00.000",
"description": "Report",
"row_id": 1702242,
"text": "Neonatology Attending\n\nDay 49\n\nRemains in RA. RR 40-60s. Clear breath sounds. No bradycardia. HR 130-160s. Off caffeine. Weight 2315 gms (+60). PE/BM 24 po once per shift. Put to breast. Passing stool. No spits. Stable temperature in open crib. very involved. Received hepatitis B vaccine.\n\nFeeding immaturity persists but improving. Will continue to monitor closely. Tolerating feeds well. Will continue to encourage po.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-24 00:00:00.000",
"description": "Report",
"row_id": 1702243,
"text": "NPn 0700-1900\n\n\n#3: O: Total fluid minimum 150ml/kg/d. of breastmilk or PE\n24, 58cc q4 hours. Infant is PO fed once a shift, usually by\nmom in the afternoon for the day shift. Minimal aspirates,\nno spits. Voiding, no stools, abdomen benign, bowel sounds\nactive. A: Tolerating feeds. P: Continue with feeding plan\nand support PO feeding.\n\n#4: O: Temperature stable in OAC. Settles with pacifier,\nwakes early for feeds. Brings hands to face for comfort.\n and active, sleeps well between cares. A: AGA. P:\nContinue to support growth and development.\n\n#5: O: No contact yet this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-24 00:00:00.000",
"description": "Report",
"row_id": 1702244,
"text": " Physical Exam Note\nSee Dr. Note for plan of care as discussed on rounds.\n\nInfant is active and in an open crib. Sucking on fingers. Color pink. Nasogastric tube in place.\n\nAFSF, Sutures approximated.\nLungs are clear and equal with good aeration. mild subcostal retractions. Symmetrical chest movement.\nNo murmur, normal S1 S2, RRR. Brisk capillary refill. Peripheral pulses +2/equal.\nAbdomen is soft, +BS, no loops, no HSM. Hemangioma on LLQ.\nNormal uncirced male genitalia. Patent anus.\nMoving all extremeties equally, symmetrical . +Moro, +suck, +grasp.\n , SNNP\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-24 00:00:00.000",
"description": "Report",
"row_id": 1702245,
"text": " Physical Exam Note\nExamined infant and agree with above\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-25 00:00:00.000",
"description": "Report",
"row_id": 1702246,
"text": "NICU NPN 1900-0700\n\n\nFEN O: Tf remain at 150cc/k/d. Tolerating feeds of bm/pe 24\nwell. Abdominal exam benign, voiding, no stool, no spits.\nLearning to po/bf. Gaining weight.\n\nDEV O: Temps are stable, swaddled in crib. is and\nactive with cares, sleeps well in between cares. Fontanells\nare soft and flat. Takes pacifier for comfort.\n\nParenting O: Mom and in for cares, independent with\ncares, gave baths independently to boys. Asking appropriate\nquestions.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-25 00:00:00.000",
"description": "Report",
"row_id": 1702247,
"text": "Neonatology\nDoing well. RA. Single spell overnight. COmfortable appearing.\nOff caffeine\n\nWt 2345 up 30. TF at 150 cc/k/d of 24 cal. Abdomen benign.\nGiven glycerin over weekend. Mostly gavage.\n\nTemp stable in open crib\n\nEye exam for next week.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-14 00:00:00.000",
"description": "Report",
"row_id": 1702330,
"text": "Neonatology\nDoing well. Remains in RA. No spells overnight. Had yesterday.. Comfortable appearing.\n\nWt 3125 up 20. Tolerating feeds well. Abdomen benign. Took full po feed eysterday. Still requiring gavage. On 24 cal.\n\nTemp stable co-bedding.\n\nEye drainage improved. Local rx.\n\nAwaiting maturation of resp control and feeds.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701987,
"text": "NPN 7a-7p cont'ed\n#4Cont'ed: assessed and thinks it is a bruise, and will cont to monitor. Infant has been opening eyes today. A: appropr 25 wk infant. P:Cont to support dev needs. Limit stim as much as possible. HUS on dol 3.\n\n#5: Parents in for visits today. Dad was here numerous times, staying as long as 2hr stretch. Brought in several visitors. Did explain that at times there is just to much environmental stim and infant does not tol well. Family verbalized understanding. Mom in x2, update given. Both parents did get to touch infant briefly. Both asking appropr. questions. A: Involved, loving family P:Cont to support and educate.\n\n#6: Blood cultures remain negative to date. Temps stable. Conts on Ampi and Genta as ordered. Appropr. behavior. A: stable on antbx P:Cont for at least 7day course of antbx. Monitor for s&s of infection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701988,
"text": "Neonatology- Physical Exam\n\nInfant remians intubated. Active, alert, AFOF, sutures opposed, good tone, labile with exam. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended, hypoactive bowel sounds, no HSM, NPO. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-08 00:00:00.000",
"description": "Report",
"row_id": 1701989,
"text": "RESPIRATORY CARE NOTE\nBaby #1 received intubated on vent settings 18/5 Rate 20 FiO2 21%. Weaned the Rate to 16. Abg PO2 59 CO2 47 PH 7.28. No vent changes made. Suctioned ETT for mod amt of white secretions. Breath sounds are coarse. Stable on current vent settings cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-17 00:00:00.000",
"description": "Report",
"row_id": 1702058,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF, sutures overriding. Breath sounds clear and equal. Nl S1S2, no audible murmur. pink and well perfused. Abd benign, no HSM. Active BS. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-18 00:00:00.000",
"description": "Report",
"row_id": 1702063,
"text": "Neonatology\nNeeded to go back on CPAP for increased spells. THis has decreased since back on CPAP 6 RA now.\n\nWt 922 up 27. Tolerating efeds at 130 cc/k/d out of TF of 150 cc/k/d. ABdomen benign. Should advance to full feeds later today. Monitoring tolerance. PICC to be dced over weekend if remains stable.\n\nHct 24.5 this am. To be transfused with PRBCs this am.\n\nMother admitted with wound infection.\n\nWill monitor spells and resp status willplan to evaluate possibility of infection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-18 00:00:00.000",
"description": "Report",
"row_id": 1702064,
"text": "Neonatology- PRogress Note\n\nPE: remains in his isolette, on CPAP 6 >21 , bbs cl=, rrr s1s 2no murmur, abd soft, nontender, V^S, afso, active with care, picc line and gavage tube inplace\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-18 00:00:00.000",
"description": "Report",
"row_id": 1702065,
"text": "Neonatology- Procedure Note\n\nPRocedure: PICC line removal\n\nUsing sterile technique, picc line removed without incident\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-18 00:00:00.000",
"description": "Report",
"row_id": 1702066,
"text": "Respiratory Care\nBaby continues on cpap 6, fio2 21%, bs clear sx small cloudy secretions, rr 30-50's, on caffeine, had one spell on this shift thus far. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-18 00:00:00.000",
"description": "Report",
"row_id": 1702067,
"text": "NPN 0700-\n\n\n1. NP CPAP 6, 21%, changed from prongs at 16:30 for desat\nto 42%, HR 74 requiring vigorous stim and bag \nventilation. Total of 3 spells this shift. RR 30-50 with\nperiodic breathing at times. O2 sats 94-100%. LSC and\nequal, with SC/IC retractions. Recieved PRBC's per order\nfor HCT 24.5, tolerated transfusion without incident.\nContinues on caffeine. Continue to monitor resp status,\nmonitor for spells/desats.\n\n3. TF 150cc/kg/day. Advanced to full feeds at noon; PE\n20/BM 20. Belly soft, + BS, no loops, no spits. Girth\nstable at 18cm. 2.2cc light green aspirate at 16:00- \n, . Aspirate discarded and feeding continued. D\nstick- 76. Lg, green heme neg stool. Voiding- 8hr u/o\n2.3cc/kg. Continue to monitor tolerance to feeds.\n\n4. Temp stable in servo isolette. Drowsy, sleepy and\nhypotonic this AM. More active and alert, tone improved\nwith blood transfusion. Straw hemangioma to LUQ of abdomen\nunchanged. Continue to promote growth and development.\n\n5. Mom in for 12:00 care, updated on plan of care. Mom in\nhouse on 6S for uterine abscess- drains placed . Mom\nwearing and aware of need to limit contact with baby\ndue to risk of infection. Dad at home, not feeling well.\nMom coping well, social work involved. Continue to update,\nsupport and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-19 00:00:00.000",
"description": "Report",
"row_id": 1702068,
"text": "NICU NSG NOTE\n\n\n#1. Resp. O/ conta on NPT CPAP 6 21%. LS clear and equal. RR\n30-50's. IC/SubC retractions. Sx'd for lg yellow secretions.\nNo spells thus far. On caffeine. A/ Stable on CPAP. P/ Cont\nto monitor resp status closely. Monitor for increased\neffort/support.\n\n#3. FEN. O/ Wt up 33g. TF 150cc/k/d PE/BM. Receiving q4h\nvolumes via gavage over 50 mins. Abd soft and round. Sm spit\nx1. Max asp 2.5cc. AG stable. Transitional stool. UO\n3.5cc/k/h thus far. A/ Tolerating feeds. P/ Cont to monitor\nfor feeding intolerances. Daily wts.\n\n#4. G&D. O/ Awake and alert with cares. Temps stable in\nservo isolette. MAE. Nested on sheepskin. Brings hands to\nface. A/ AGA. P/ Cont to support developmental needs of\ninfant.\n\n#5. Parenting. No contact with family thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-03 00:00:00.000",
"description": "Report",
"row_id": 1702150,
"text": "NICU Attending Note\n\nDOL # 28 = 30 4/7 weeks gestation with A/B, issues of growth and nutrition.\n\nPlease see full Rivers\n\nCVR/RESP: RRR with no murmur, mild subcostal retractions, in RA on caffeine, with 3 episodes of A/B in last 24 hours. Will continue to monitor, continue caffeine.\n\nFEN: Abd benign, weight today 1340 gm, up 45 gm, on TF of 150 cc/kg/d MM/PE 30 with PM, all PG. Will continue current diet.\n\nENV'T: Stable temp in isolette.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-03 00:00:00.000",
"description": "Report",
"row_id": 1702151,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 30-80's, sat >97%. BSCE\nbilat. On caffeine no brady's today. A: Breathing\ncomfortably. p: cont to follow.\nFEN\nO: TF of 150cc/k/d of PE 30 w/ promod, or bm 30 w/ promod.\nAbd. pink, no loops, active bs. Voiding / stooling heme (-).\nGirth 22cm. While kangarooing with mom went to breast and\nlatched on briefly. Mom requesting lactation consult. A:\nSTable p: cont to follow.\nGD\nO: Temp stable in covered isolette on servo control. Active\nand sleepy with cares. Opens eyes and quietly alert. Calms\nwith containment and pacifier. MAE. fonts soft, flat. A: AGA\np: cont to support dev. milestones.\nParenting\nO: Mom and dad in and updated at bedside, verbalizing\nunderstanding. Mom kangarooed for 90\"/ well tolerated.\nA: and involved family. P: cont to support, update,\neducate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-04 00:00:00.000",
"description": "Report",
"row_id": 1702152,
"text": "NPN 1900-0700\n\n\n1. RESP: Pt remains in RA with RR 50-70's. Lung sounds\nare clear. Mild IC/SC retractions. No spells noted so far\nthis shift. Pt is on caffeine.\n\n3. F&N: TF remain at 150cc/k/d of BM/PE30 with promod.\nFeeds gavaged in over 40 minutes. Abd benign. BS+. A/G\nstable. No spits and minimal aspirates noted. Voiding and\npassing green stool X1. Weight gain 5 grams.\n\n4. DEV: is active and alert during his cares. Temp\nstable nested on sheepskin in servo-controlled isolette.\n\n5. PAR: No contact from so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-04 00:00:00.000",
"description": "Report",
"row_id": 1702153,
"text": "Neonatology Attending Note\nDay 29\n\nRA. Cl and = BS. 1 A&B/24h. On caffeine. No murmur. HR 150-170s. Pale/pink. BP 64/32, 42.\n\nWt 1345, up 5 gms. TF 150 cc/k/day BM/PE 30 w promod. well. Nl voiding and stooling.\n\nIn isolette.\n\nA/P:\n-- Monitor AOP\n-- No change to nutritional plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-04 00:00:00.000",
"description": "Report",
"row_id": 1702154,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. Nl S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-14 00:00:00.000",
"description": "Report",
"row_id": 1702331,
"text": "NPN\n\n\nResp: Infant remain in RA, pulse oximeter d/c'd. Lung\nsounds are clear and equal with mild SC retractions, RR\n30s-60s. No spells thus far this shift. Continue to\nmonitor.\n\nCV: Infant is pale pink, well perfused with normal pulses.\nHe mottles with cares. No murmur heard on auscultation.\nHRs 130s-170s with BP 74/54(61). Continue to monitor.\n\n3.FEN: Infant feeding po ad lib demand with minimum\nrequirement of 130cc/kg/day of E24 or BM 24 with Enfamil\npowder. He bottled 41cc and 25cc, respectively at the first\ntwo cares. Supplemental gavage feedings given via NGT in\nright nare at 20cm. He is tolerating feeds well with no\nspits, max. aspirate 1.4cc. Abdomen is soft and round, no\nloops. He is voiding and stooling (guiac negative).\nVitamin E d/c'd today. He continues on Fe+ supplements.\nContinue to monitor FEN status and encourag po feeding as\ntolerated.\n\n4.DEV: Infant is cobedded in an open crib with twin,\nswaddled with stable temps. He is and active with\ncares, wakes for feeds. He has a strawberry hemangioma on\nhis left abdomen. Umbilical hernia remains soft and\nreducable. Small amount of green drainage from right eye\npresent, team aware. Car seat is present in room, needs to\nbe assembled for car seat test. Infant is due for follow up\neye exam on Monday (). Continue to support growth and\ndevelopment.\n\n5.: called for update this morning. \nplan to visit at the care times. Continue to monitor.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-17 00:00:00.000",
"description": "Report",
"row_id": 1702059,
"text": "Respiratory Care Note\nPt. off CPAP this am. 3 spells after tube removal. Placed on 200cc flow at 21%. BS clear. RR 40-60. On caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-17 00:00:00.000",
"description": "Report",
"row_id": 1702060,
"text": "NPN 7a-7p\n\n\n1) infant received on NP CPAp 5 in RA. no desats or brady's\nwhile on cpap. Trialed off CPAP since 10 am to RA. Infant\nhas had 4 brady's since with apnea. Placed infant on NC RA\nin 200cc flow at 3pm. BS clear. Mild i/c s/c retractions\nwith RR 40-60's. Breathing cmfortably. Infant remains on\ncaffeine. continue to observe closely.\n3) TF 150cc/kg/day. Advancing on feeds. Now at 120cc/kg\nPE/BM 20 gavaged every 4 hours. No asp. one spit. Abdomen\nsoftly rounded. AG stable. IVF of PND10 infusing via pic.\nWill change to D10 2nacl/1kcl this evening. Voiding well. nO\nstool thus far. Continue to advance on feedings 10c/kg \nas tolerated.\n4) infant alert and active with cares. sleeping well between\nnested in sheepskin. Temps stable in a servo isolette.\nfontanelle soft and flat. continue to support dev.needs.\n5) Mom in to visit with grandparents. Unable to hold infants\nas per oB. She will readdress with OB tomorrow. Mom asking\nappropriate questions. Update given. We can now use mom's\nBreastmilk as . Father will not be in this evening\nrelated to an illness. continue to support.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-18 00:00:00.000",
"description": "Report",
"row_id": 1702061,
"text": "Respiratory Care\nbaby placed on prong cpap 5 for multiple spells,incresed to cpap 6 for continued spells.BS clear throughout,sx nares for mod white->pale yellow secs.cbc,diff,bld cx sent,results pending.Currently on cpap 6 21%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-18 00:00:00.000",
"description": "Report",
"row_id": 1702062,
"text": "NPN\n\n\nNPN#1 O=received on NC 200cc in 21%..infant with several\nspells with apnea with HR into 70's-80's ..restarted CPAP of\n5cm at 2200..cont with spells..CPAP ^ to 6cm..spells\ncontinued with HR now into 50's requiring stimm..CBC with\ndiff/ blood cx drawn Hct= 24.5 RR 40's-50's LS clear &equal\nwith mild IC/SCR, cont on caffeine as ordered A= ^\nspells..back on CPAP, ^ spells ? r/t collapse off CPAP vs\nanemia or combo of both\nP= cont to monitor # & severity of spells, consult with team\nre: need to transfuse\n\nNPN#3 O= WT up 27gms to 922, TF at 150cc/kg/d of enteral\nfeeds at 130cc/kg/d ( adv feeds 10cc/kg / )..tol well, no\nspits, asp=o, AG 17.5cm Abd exam softly rounded & benign, no\nloops + active BS, no stool, uo= 2.8cc/kg/d, IVF at KVO\ninfusing well via PIC, DS= 72A= tol feeds P= cont per plan/\nmonitor tolerance of feeds\n\nNPN#4O= temp stable on servo in heated isolette, AF soft &\nflat, active with cares but less fiesty, nested in sheepskin\nwith boundaries in place, CBC with diff/blood cx drawn for\ncontinued ^ spells A=less fiesty/ no reserve P= cont to\nassess & support dev needs\n\nNPN#5 O= mom up x1 overnight wearing mask/ not touching\ninfants until OB has cleared her after final cx results\nback..mom feeling much better s/p drain placement for\nuterine abcesses/ will be on prolonged Abx coverage..dad\n't visit yesterday..not feeling well..updated..aware\ninfant may need to go back on CPAP A= involved mom P= \nteach/ update & support\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-01 00:00:00.000",
"description": "Report",
"row_id": 1702144,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 40-60's, sat's >93%, mild\nic/sc ret. BSCE bilat. On caffeine, one brady today QSR. A:\nBreathing comforably. Stable P: cont to follow.\nFEN\nO: TF of 150cc/k/d of BM or PE 30 with promod, gavaged. Abd\npink, no loops, active bs. Voiding/ stooling heme (-). No\nspits. max asp of 0.4c. A: Stable P: cont to follow.\nGD\nO: temp stable in servo controlled isolette, active and\nalert with cares, MAE. Fonts soft, flat. A: AGA P: cont to\nsupport dev. milestones.\nParenting\nNo contact thus far today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-02 00:00:00.000",
"description": "Report",
"row_id": 1702145,
"text": "NPN 1900-0700\n\n\n1. RESP: Pt remains in RA with RR 40-60's. Lung sounds\nare clear. Mild IC/SC retractions. No spells noted so far\nthis shift.\n\n3. F&N: TF remain at 150cc/k/d of BM/PE30 with promod.\nFeeds gavaged in over 40 minutes. Abd benign. BS+. A/G\nstable. No spits and max asp was 2 cc of nonbilious,\npartially digested formula. Voiding well. No stool so far\nthis shift. Weight gain 20 grams.\n\n4. DEV: is active and alert during his cares. Temp\nstable nested on sheepskin in servo-controlled isolette.\n kanagroo care X 1 hour well.\n\n5. PAR: in to do cares at . Mom with\ncares. Dad gave kangaroo care. They stated that they are\npleased with weight gain.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-02 00:00:00.000",
"description": "Report",
"row_id": 1702146,
"text": "Newborn Med Attending\n\nDOL#27. Cont in RA, occ spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=1295 up 20, on 150 cc/kg/d BM30 with PM PG.\nA/P: Growing infant with AOP. Monitor for spells. Cont current feeding plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-02 00:00:00.000",
"description": "Report",
"row_id": 1702147,
"text": "NICU nursing progress note\n\n\nPlease refer to flowsheet for specific info.\nResp\nO: remains in room air, RR 30-80's, sat's >93%, bsce\nbilat. Ic/sc ret. On caffeine and one brady today req mild\nstim. A: Stable P: cont to follow and support.\nFN\nO: TF of 150cc/k/d of BM /PE 30w/ promod , gavaged over 40\".\nAbd. pink, no loops, active bs. Voiding/ stooling heme (-).\nMax asp of 3cc, partially digested formula. A: Stable P:\ncont to follow.\nGD\nO: Mom in and with / well. Clear eye drainage\nnoted from right eye. Warm soaks applied. MAE. fonts, soft,\nflat. Calms with containment and pacifier. A: AGA P: cont\nto support dev. milestones.\nParenting\nO: Mom and dad in and updated at bedside. Verbalizing\nunderstanding. A: Involved and invested . P: cont to\nupdate, support, educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-03 00:00:00.000",
"description": "Report",
"row_id": 1702148,
"text": "NPN 1900-0730\n\n\n1. RECEIVED INFANT ON RA. SAO2 >96%. LS CL/=. CONT. WITH\nMILD IC/SC RETRACTIONS. NO NCREASED WOB NOTED. PLAN; CONT.\nTO MONITOR STATUS ON RA.\n\n3. WT 1.340 GMS. WT. UP 45GMS FROM YESTERDAY. TF CONT. AT\n150CC/K/D OF PE20. TOLERATING WELL. NO SPITS NOTED. ABD SOFT\n, NO LOOPS, +BS. MIN. ASP. B/T 1-2CC DIGESTED FORMLA, MED\nMEDS STOOL X1, VOIDING WELL. PLAN; CONT. TO MONITOR\nTOLERANCE TO INCREASING FEEDS.\n\n4. REMAINS IN SERVO ISOLETTE WITH TEMPS STABLE. A/A WITH\nCARES BUT NOT WAKING FOR CARES. CLEAR DRAINGE FROM R EYE\nCLEANED WITH WATER/ PLAN; CONT. TO SUPPORT G.D\n\n5, NO CONTACT FROM THIS SHIFT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-22 00:00:00.000",
"description": "Report",
"row_id": 1702236,
"text": "NPN 1620\n\n\n#3 F/N: Infant remains on 24 cal br. milk/PE 150cc/kg/d,\n55cc q 4 hrs. Infant put to breast w/ minimal\nlatch/interest. Offered po by bottle at 4pm. Abd full, soft.\nBowel snds present. Voiding well, no stool today.\nRemains on Vit E and Iron.\nA: Tolerating feeds well, no spits or aspirates.\nP: Cont to encourage breast feeding when mother visiting,\nbottle other per day.\n#4 G/D: Infant remains swaddled in an open crib, temps wnl.\nInfant awake and w/ cares. Hep B vaccine given today\nat 4pm. Area Early Intervention called in today,\nmother aware.\nA: AGA\nP: Cont dev. supports.\n#5 : Mother in at 12pm through the 4pm feedings.\nAsking appropriate questions. Participating in care of\nbabies. Mother hopes to increase br. milk supply. Encouraged\nto increased pumpings per day--currently pumping\nX4/day--back up to 7-8X/day. Mo. yielding 100cc per day now.\nA: Invested mother, involved and participating in care.\nP: Cont parent support. Private pedi is , MD \n.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-23 00:00:00.000",
"description": "Report",
"row_id": 1702237,
"text": "NICU NPN\n\n\n3. F/N: Infnat remains on 150cc/k/d of BM/PE24 taking\n55ccq4hours via gavage over 1 hour. Infant tolerating well.\nminimal asp. no spits. Abd. benign, voiding, no stool thus\nfar in shift. A: +wt gain 2255(+55), tolerating feeds P:\nCont per current feeding plan.\n\n4. G/D: TEmp. stable in open crib. Infant awake and \nw/ cares, sleeping well between, Infant turned and\nrepostioned q4hours. A: stable P: COnt. to support G/D\n\n5. : No contact thus far in shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-23 00:00:00.000",
"description": "Report",
"row_id": 1702238,
"text": "Neonatology Attending Progress Note\n\nNow day of life 48.\nIn RA, RR 40-60s.\nHR - 140-150s\n\nWt. 2255gm up 55gm on 150cc/kg/d of MM or PE24\nFeedings well tolerated by gavage.\nNormal urine and stool output.\n\nAssessment/plan:\nEncouraging progress continues.\nWill continue with current management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-23 00:00:00.000",
"description": "Report",
"row_id": 1702239,
"text": "Neonatology - NP Physical Exam\nAwake and with cares, temp stable in open crib. Bs clear and equal with mild subcostal retractions, color pink. RRR, without murmur, pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Without rashes, hemangioma on left side of abdomen. Noncirced male, testes down bilaterally. Good , AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-23 00:00:00.000",
"description": "Report",
"row_id": 1702240,
"text": "Nursing progress note\n\n\n#3 O: Abdomen softly full with active BS without\nloops/nontender, mom here for 1600 care and put son to\nbreast without real interest noted in with feeding,\notherwise tolerating ng feedings without spits or aspirates,\nvoiding without stool passed this shift A: Tolerating feeds\nwell learning to orally feed slowly P: wt. daily and cont.\nwith plan\n#4 O: Quiet awake and with cares, loves to suck\npacifier with feedings, sleeping well between cares A: AGA\nP: cont. with developmental care and interventions\n#5 O: in for 1600 care, independant with son,\nupdated at bedside A: Involved P: support, teach and keep\ninformed\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-31 00:00:00.000",
"description": "Report",
"row_id": 1702139,
"text": "PCA Progress Note, 7a-7p\n\n\nRESP:\n Infant remains in RA. O2 sats are >95%. LS:cl/=. Mild IC/SC\nretrax. No desats or spells so far this shift. Please refer\nto Pt's chart for additional RESP data. Continue to monitor\nand support RESp status. Continue to support and monitor for\na's and b's.\n\nFEN:\n TF: 150cc/kg/D of PE/BM30. All feedings are being gavaged\nover 40mins. Infant is tolerating feeds well w/ minimal\naspirites and no spits so far the shift. Abd is benign w/\nactive BS. AG is stable. Infant is voiding w/ each diaper\nchg, no stool so far this shift. Please refer to Pt's chart\nfor additional FEN data. Continue to monitor and support\ncurrent FEN status.\n\nDEV:\n Infant's temp remains stable while nested in servo\nisolette. Infant is alert and active w/ cares, and sleeps\nwell in between them. Infant brings hands to mouth and sucks\non fingers and pacifier for comfort. Continue to encourage\nand support develomental milestones.\n\nPAR:\n Mom and Dad were both in today for afternoon care. Dad\ntook temp and did the diaper chg today. He is independent w/\ncares, and is very attentive and towards the infant.\nContinue to update and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-31 00:00:00.000",
"description": "Report",
"row_id": 1702140,
"text": "PCA Progress Note, 7a-7p\nThis RN examined infant. Agree with above written by A. , PCA\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-01 00:00:00.000",
"description": "Report",
"row_id": 1702141,
"text": "NPN 1900-0700\n\n\n1. RESP: Pt remains in RA with RR 30-70. Lung sounds are\nclear. Sats >94%. Mild retractions noted. One spell so\nfar this shift. Pt is on caffeine.\n\n3. F&N: TF remain at 150cc/k/d of BM/PE30 with promod.\nFeeds gavaged in over 40 minutes. Abd benign. BS+. A/G\nstable. Max asp was 3cc of nonbilious, partially digested\nformula. Voiding well. No stool noted so far this shift.\nWeight gain 60 grams.\n\n4. DEV: is active and alert during his cares. Temp\nstable nested on sheepskin in servo-controlled isolette.\nFontanels are soft and flat.\n\n5. PAR: in to do cares. They asked appropriate\nquestions and spoke lovingly to .\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-01 00:00:00.000",
"description": "Report",
"row_id": 1702142,
"text": "Neonatal NP-Exam\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. NL S1S2, no audible murmur. Pink and well perfused. Abd benign, no HSM. Active bowel sounds. Infant active and alert with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-01 00:00:00.000",
"description": "Report",
"row_id": 1702143,
"text": "Neonatology Attending\n\nDay 26\n\nRemains in RA. RR 30-60s. Clear breath sounds. On caffeine. Had one bradycardia episode over 24 hours. BP mean 49. Weight 1275 gms (+60). TF at 160 cc/kg/d- BM/PE 30 with Promod. Tolerating feeds well. Minimal aspirates. Passing stool. Stable temperature in servo-controlled incubator.\n\nContinues to do well in RA with acceptable breathing control on caffeine. Gaining weight well. No changes planned for now.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-21 00:00:00.000",
"description": "Report",
"row_id": 1702231,
"text": "NPN\n\n\n#3 No changes made in FEN. Continues on 150cc/kg/day of\nPE/BM 24. Mom with decreased mild supply, appointment with\nlactation consultant scheduled for Monday, advice given.\nTolerating feeds, abd soft and , no loops, BS active,\nstooling heme negative, voiding qs, no spits, minimal asp.,\nfeeds pver 1 hour. Continues on vit E and iron.\n\n#4 Active and with cares, appropriate response to\nstimuli. Temp stable in open crib, swaddled iwth hat on and\n2 blanket covering. Attempting to BF, showing interest and\nattempting to latch on.\n\n#5 Mom in to visit, hold, participate in cares and BF. Mom\nasked about stepdaughter's recent diagnosis of parovirus \n from infection control, mom states that she was\ndiagnosed yesterday and has not been in for a month. This RN\nwill pass info to IC.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-22 00:00:00.000",
"description": "Report",
"row_id": 1702232,
"text": "PCA 1900-0700\n\n\n#3 infant's current weight 2200g up 20g. infant remains on\nTF 150cc/kg/d of PE24 or BM24=55cc q4h gavaged over 60\nminutes. abd soft, no loops, girth stable 26.5, bs+,\ninfant voiding qs, no stool thus far. P:cont. to support\nnutritional needs.\n\n#4 infant remains swaddled in OAC. temp. stable. infant\nis a/a with cares, wakes for feeds and settles well in\nbetween cares. infant brings hands to mouth to comfort\nself. P:cont. to support dev. needs.\n\n#5 no known contact thus far.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-22 00:00:00.000",
"description": "Report",
"row_id": 1702233,
"text": "NPN\nagree with above note, FESo4 given this shift as ordered. No contact with this shift, but visit daily.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-22 00:00:00.000",
"description": "Report",
"row_id": 1702234,
"text": "Neonatology\nDOing well. Remains in RA. No spells. Copmfortable appearing.\n\nWt 2200 up 20. Tolerating feeds at 150 cc/k/d of 24 cal. Abdomen benign.\n\nTemp stable in open crib.\n\nEYe exam for two weeks.\n\nAwiting maturation of feeds.\n\nParvo titres pending for mother.\n\nWIll obtain HBV consent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-22 00:00:00.000",
"description": "Report",
"row_id": 1702235,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: sleeping infant in open crib, room air\nSkin: warm and dry; color pink\nHEENT: anterior fontanel open, level; sutures open/opposed\nChest: breath sounds clear/=\nCV: RRR without murmur; normal S1 S2; femoral pulses +2\nAbd: soft; no masses; + bowel sounds; umbilicus healed\nGU: Testes descending bilaterally\nExt: moving all\nNeuro: easily roused to drowsy state, calms easily; + suck; + grasps\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Report",
"row_id": 1702320,
"text": "PCA NOTE\n\n\nF/N: O-Weight 3075, ^60gm. TF 150cc/k/d of BM/PE 24. 77cc\nQ4H. Alternating PO/PG. See flowsheet. is voiding, no\nstool thus far. Active . Abdomen is unremarkable.\nMinimal residuals. No spits.\n A-Tolerating feeds.\n P-Continue to encourage PO feeds, follow regimen as\nordered.\n\nG/D: O-In RA. Co-bedding with brother. Waking for feeds.\n and active with cares. Sleeping peacefully. Curious\ndisposition.\n A-AGA.\n P-Continue to monitor for developmental milestones.\n\n: O-Mom and in this shift. Completely independent\nwith cares. Updated at bedside.\n A-, invested .\n P-Continue to support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Report",
"row_id": 1702326,
"text": "NPN 1900-0700\n\n\n1. FEN: Weight is 3105 gms up 30 gms. TF remain at 150\ncc/kg/day of PE/BM24. Infant is alt PO/PG. Infant has\nbottled 55 cc thus far with good coordination. Tolerating\nfeedings well; abd exam benign, no spits, and min asp.\nVoiding qs and no stool noted. Infant continues on Vit E and\nferinsol. P: Cont. to support nutritional needs.\n\n2. G/D: Temps stable swaddled cobedding in open crib. \nand active with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. : Mom and were in for cares. Independent\nwith diapering, taking temp, and handling infants. Updated\nat bedside on infant's condition and plan of care. Asking\nappropriate questions. , involved . P: Cont.\nto support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Report",
"row_id": 1702327,
"text": "Newborn Med Attending\n\nCont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=3105 up 30, on 150 cc/kg/d BM24 PO/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Report",
"row_id": 1702328,
"text": "Nursing progress notes.\n\n\n#3 O: Total fluids decreased to min 130cc/kg/day. Feeds\nchanged to BM24 with enfamil or E24. Feeds given every 4\nhours. Bottles offered at alternate feeds, 45cc taken\ntoday. Abdomen benign, voiding well, no stool today. Small\naspirates, no spits. A: Learning to PO feed. P: Continue\nto encourage Po feeding as tolerated.\n#4 O: Temp stable in open crib while co-bedding with\nsibling. Baby wakes at feeding time and sleeps well between\nfeedings. Baby bottle feeds well but falls asleeps before\ncompleting feedings. Baby had 1 while sleeping today\nwhich was self resolved. A: Appropriate for age. P:\nContinue to support development.\n#5 O: Mother called this morning for an update and expects\nto visit this evening. A: Involved family preparing for\ndischarge home when baby learns to eat. P: Continue to keep\ninformed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-14 00:00:00.000",
"description": "Report",
"row_id": 1702329,
"text": "NPN 1900-0700\n\n\n3. FEN\nO: Current wgt= 3125g (+20). TF min 130cc/kg/day of E24 or\nBM24 w/enf powder. Offering bottles as interested this\nshift. Bottled full volume x1 and only took 10cc when\noffered next. Received one full gavage this shift. Abd soft,\n+BS, no loops. Spit x1. Asps 1-1.2cc, nonbilious & refed.\nVoiding, no stool yet this shift. A: Tolerating feeds. P:\nCont to monitor po intake, monitor nutritional status.\n\n4. G&D\nO: is /active with cares. Waking for feeds. Temps\nstable cobedding in OAC. Cont w/green R eye drainage; warm\nsoaks/H2O applied. , . A: AGA. P: Cont to provide dev\nappropriate care.\n\n5. \nO: in for care. held and bottled while\nMom visited w/twin. Updated on plan of care. Pleased\nw/infant's progress. A: Attentive, family. P: Cont to\nsupport and educate family.\n\nSee flowsheet for details..\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-20 00:00:00.000",
"description": "Report",
"row_id": 1702226,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 95%. RR 40-70's. Lung sounds clear/=. Mild\nSCR noted. No spells noted thus far. Caffeine D/C'd today.\nProblem resolved.\n\n2. FEN: TF remain at 150 cc/kg/day of PE24/BM24. Infant is\nattempting to breastfeed or bottle once q shift. Infant\nbottled 20 cc thus far with good coordination. Tolerating\nNGT feedings well; abd exam benign, no spits, AG stable, and\nmin asp. Voiding qs and stooling heme neg. Infant\ncontinues on Vit E and ferinsol. P: Cont. to support\nnutritional needs.\n\n3. G/D: Temps stable swaddled in open crib. and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. : Mom in for 1200 and 1600 cares. Independent\nwith diapering, taking temp, and bottling infant. Required\nsome verbal assistance while bottling infant. Updated at\nbedside on infant's condition and plan of care. Asking\nappropriate questions. , involved . P: Cont.\nto support and update .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-20 00:00:00.000",
"description": "Report",
"row_id": 1702227,
"text": "1 Respiratory\n\nREVISIONS TO PATHWAY:\n\n 1 Respiratory; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-21 00:00:00.000",
"description": "Report",
"row_id": 1702228,
"text": "PCA Progress Note, 7p-7a\n\n\nFEN:\n TF: 150cc/kg/D of BM/PE24. Total volumes are being gavaged\nover 1 hour. Tolerating feeds well w/ minimal aspirates and\nno spits so far this shift. Abd is benign w/ active BS.\nVoiding and stooling. Remains on Vit E and Fe. Please refer\nto PT's chart for additional FEN data. Continue to encourage\nand support current FEN plan.\n\nDEV:\n Pt's temp remains stable while swaddled in OAC. Infant is\nwaking at care times, is and active w/ cares, and\nsleeps well in between cares. Settles well w/ pacifier and\nseems to be more comfortable on laying on his right side.\nContinue to encourage and support developmental milestones.\n\nPAR:\n No contact from so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-21 00:00:00.000",
"description": "Report",
"row_id": 1702229,
"text": "Neonatology\nDoing well. RA. No spells. Comfortable apeparing. Off caffeine\n\nWt 2180 up 50. Tolerating efeds at 150 cc/k/d of 24 cal. Abdomen benign. Still mainly gavage.\n\nTempo stable in open crib.\n\nCont to await maturation of resp contorl and fedes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-21 00:00:00.000",
"description": "Report",
"row_id": 1702230,
"text": "Neonatology - Progress Note\n\n is active with good . AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. No spells. Off caffeine yesterday. He is tolerating full volume po/pg feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Report",
"row_id": 1702321,
"text": "NPN 1900-0700\nI have examined infant and agree with above note and assessments per flowsheet by PCA, .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Report",
"row_id": 1702322,
"text": "Newborn Med Attending\n\nCont in RA, no spells. AF flat clear BS, no murmur, abd soft, MAE. WT=3075 up 60 on BM24 Po/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Report",
"row_id": 1702323,
"text": "Student Nursing Note\nI have read and agree with the above note written by .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Report",
"row_id": 1702324,
"text": "Student Nursing Note\n\n\n3- O:Total fluid intake 150cc/k of breast milk/PE24,\nalternating PO and NG feedings, offered bottle at 8am\nfeeding, took 34cc remainder was gavashed, one small spit,\nvoiding, stooling, minimal aspirates, tummy benign\nA:Learning to bottle feed\nP:Continue to offer bottle\n4- O:Temps stable, cobedding in open crib, wakes for feeds,\nsleeps well in between feeds\nA:Development appropriate for gestational age\nP:Continue to encourage and support development\n5- O:Mommy called this AM, plans to be in for a visit at 8pm\nA: and supportive family\nP:Continue to support and keep informaed of plan of\ncare\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Report",
"row_id": 1702325,
"text": "Student Nursing Note\n\n\n3- O:150cc/kilo, alternating PO and PG, offered botttle at\n8am, took 55cc gavaged remaining, voiding, stooling, one\nsmall spit, no aspirates, abdomen benign\nA:Learning to bottle feed\nP: Continue to offer bottles\n4- O: cobedding in open crib, temps stable, due for eye\nappointment on Monday \nA: Development appropriate for gestational age\nP: Continue to support/encourage development\n5-O: Mommy called this AM, planning to visit at 8pm\nA: /supportive family\nP: Continue to support family and keep informed of plan of\ncare\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701982,
"text": "Respiratory Care\nBaby is twin #1 0f 26 week .Born by c/s for breech presentation.please see Neonatology admit note for hx.Apgars 6+7,intubated in d.r. for severe resp ditress.2.5 ett placed taped @ 6cm,trans to nicu.SIMv 25 20/5 100%.Quickly weaned,fio2.2 doses of 4cc survanta given,tol well.BS = coarse.Current settings r28 19/5 28%.Last abg @4am 7.26/52/63/24/-4,will follow with another gas,@ 6am.Given 2 NS bolus then started on dopa.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701983,
"text": "Nursing progress note\nReceived infant orally intubated on warmer. See flow sheet for vent settings. Breath sounds equal & coarse with IC/SC retractions. Several blood gases done & vent settings adjusted. OP suctioned X's 2 for lg cldy secretions. Infant received 2nd dose of survanta. Color is pale pink, mottled at times. No murmur heard. Remains on dopamine. Present BP mean is 34 on 13 mcg/k/m. Total fluids are 100cc/k/d. UAC &DUV infusing well. DS 37 X's 1. Received 2cc/k of D10W IVP. DS now 65. Voided X's 1. No stool. Abd soft, flat. Inaudible bowel sounds. Lytes & repeat CBC with diff sent. Remains nested on sheepskin on warmer with heat shield in place.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701984,
"text": "Neonatology Attending\n\nDay 1\n\nRemains on simv with settings- x26, 19/5, 0.21. Received two doses surfactant. ABG 7.27/44/50/21. Rate decreased. Coarse breath sounds. Cloudy secretions. Mild retractions. No murmur. Received two normal saline bolues. On dopamine at 15 mcg/kg/min. Blood out 3.8 cc. On ampicillin and gentamicin. CBC repeat: Plt 125k WBC repeat 7.7 with 24p 19b Hct 34.1. Birth weight 936 gms. On IV dextrose via UA and UV catheters. Blood glucose 122 after one dextrose bolus. Stable girth. No stool passed. Lytes 139/5.0/107/22. Rate ecchymoses. Parents in this morning.\n\nRespiratory distress syndrome responding to current regimen. Monitoring closely. Will administer third surfactant dose. Hypotensive. Weaning dopamine as allowed. Anemic. Given severity of illness, will opt to transfuse with PRBCs. Plan one week antibiotic course. Will continue to keep family updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701985,
"text": "Respiratory Care\nPt recieved on SIMV, rate of 28, pressures of 19/5 with the fio2 21 to 30%. Pt given 3rd dose of surfactant at 9:30, tolerated well. Pt weaned down on ventilator settings this shift with good ABG results. Pt remains on Simv, rate of 20, pressures of 18/5 with the fio2 21%. Plan is to follow, wean ventilator as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701986,
"text": "NPN 7a-7p\n\n\n#1: Received infant on settings 19/5x28. Able to wean\nthroughout the day, based on ABG's, to current settings of\n18/5x20. FIO2= 21%. Did get one dose of bicarb this am,\nand 3rd dose of Surf. RR 28-60's. Breathing with mild IC/Sc\nretractions. BBS coarse, mild improvement after sx'ing.\nSX'ed x3 for mod amts of cloudy secretions. No apnea/brady\nspells noted. A: Weaning on settings P:Cont to monitor and\nwean as tol'ed. Provide support as needed.\n\n#2: Hr stable= 130's-160's. No murmur noted thus far. Pale\nin color with initial Hct 33.4. Transfused today 9cc PRBC's\nx1. Tol'ed well. Received infant on 15mcg of Dopamine.\nFluccuated with means throughout the day, especially during\ncare times & with ^'ed stimulation in the room. Was able to\nwean to current dose of 7.5mcg. Nml pulses and brisk cap.\nrefill noted. A: Weaning on dopa P:Cont to follow closely.\nWean dopa as tol'ed. Monitor for murmur.\n\n#3: TF: 100cc/k/d. Remains NPO. D/S stable. Lytes stable.\nConts on 1/2NS with 1/2uhep/cc via patent UAC. D5W with\n1/2uhep/cc via primary port of UVC, and PND5 with 1/2u/cc\nhep at 50cc/k/d, via secondary port of UVC. Abd soft and\nflat. No loops noted. AG 17.5cm. Late afternoon did hear\nfaint . No stool since birth. U/O: 4.1cc/k/hr in past\n12hrs. Bili today 4.9/0.3/4.6. No phototherapy at this\ntime. Will F/ with . A: NPO P:Cont to monitor. Lytes\nin bili in am. Follow wt and exam.\n\n#4: Temps stable while nested on sheepskin on an open\nwarmer. has been alert and irritable with cares. Does\nnot tol manipulation or too much environmental stim well.\nDid best when cares were short and stim was min. Settled\nbest with no handling, nested in boundaries with tent over\nand blanket over blocking out light and noise. Also with\nroom lights off. Once settle slept well. MAE. Fonts\nsoft/flat. Does have bruising on left elbow, left leg,\nright upper thigh, and top of left big toe at nailbed. Also\nnoted red mark on upper \n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-16 00:00:00.000",
"description": "Report",
"row_id": 1702052,
"text": "Neonatology- PRogress Note\n\nPE: remains in his isolette, pale, pink, on CPAP5 .21, bbs sl cse=, rrr s1s2no murmur, abd soft, nontender, full V&S, afso, active with care, hemangioma on back\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Report",
"row_id": 1702315,
"text": "NPN 1900-0730\n\n\n3. FEN\nO: Current wgt= 3015g (+55). TF 150cc/kg/day of BM24/PE24.\nAlt feeds po/pg. Bottled 34cc of 75cc minimum when offered.\nGavaging remainder. Abd soft, +BS, no loops. Mod spit x1.\nMin asps. Voiding and stooling (heme-). A: Tolerating feeds.\nP: Cont to monitor for s/s feeding intolerance, encourage\npo's.\n\n4. G&D\nO: is /active with cares. Waking for care times.\nTemps stable cobedding in OAC. , . Mod amt green\ndrainage noted in R eye; warm soaks applied. Next eye exam\n. A: AGA. P: Cont to provide dev appropriate care.\n\n5. \nNo contact w/family thus far this shift. in\nyesterday for CPR.\n\nSee flowsheet for details.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Report",
"row_id": 1702316,
"text": "Newborn Attending\n\nDOL#66. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=3015 up 55, on PO/PG cc/kg/d PE24.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Report",
"row_id": 1702317,
"text": "Clinical Nutrition\nO:\n~36 wk CGA BB on DOL 66.\nWT: 3015 g (+55)(~75th to 90th %ile); birth wt: 936 g. Average wt gain over past wk ~41 g/d.\nHC: 33.25 cm (~75th %ile); last: 32.5 cm\nLN: 46.5 cm (~50th %ile); last: 46.5 cm\nMeds include Fe and Vit E\n not needed\nNutrition: 150 cc/kg/d PE/BM 24, alternating po/pg. Infant takes < volume when po feeds. Average of past 3 d intake ~150 cc/kg/d, providing ~120 kcal/kg/d and ~3.2 to 3.6 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems. not needed. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is exceeding recommended wt gain of ~20 to 35 g/d. However, infant still requires current feeds to provide adequate amounts of vits and mins. HC gain is meeting recs. LN shows no change over past wk; will monitor long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Report",
"row_id": 1702318,
"text": "npn\n\n\n#3 continues on PE24/BM24 at 150cc/k/d. small spit x 1\nno stool or significant aspirates.bottled at 12 for 20cc's.\nContinue to attempt every other bottle/breast\n#4 remains in open crib cobedding with his\nbrother.semi- for noon cares.\n#5 mom called and states that they will be in for the 8pm\ncares tonight and plan on breastfeeding the boys.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Report",
"row_id": 1702319,
"text": "NPn 1500-2300\nBaby boy and active, VSS, no resp distress noted. . gavage feeding well, no spits. No contact from . NO significant changes in 4 hours.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-16 00:00:00.000",
"description": "Report",
"row_id": 1702053,
"text": "NPN DAYS\n\n\nRespiratory: Remains on NP with FiO2 21% all shift\nwith O2 sats >98%. LS clear and equal. Mild IC/SC\nretractions noted. No spells. Remains on Caffeine. Will\ncontinue to monitor closely.\n\nFluid and Nutrition: TF 150cc/kg/day. 100cc/kg/day PE20/BM20\ngavaging over 40mins. 50cc/kg/day PND10 and lipids via PIC\nline. Urine out 2.7cc/kg/hr. No stool. Belly benign. Will\ncheck d/stick with next set of cares.\n\nGrowth and Dev: Temp stable in servo isolette. Awake and\nquietly alert with cares. Sleeping well between cares. HUS\ntoday normal. Nested on sheepskin with boundaries in place.\nwill continue to provide for developmental needs.\n\nParenting: Mom in to visit briefly. She is inpatient with a\nquestion of an abcess. Dad to visit tonight. Continue to\nprovide support and teaching.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-16 00:00:00.000",
"description": "Report",
"row_id": 1702054,
"text": "Respiratory Care\nPt remains on NP-CPAP +5cm's with the fio2 21%. Pt resp rates 40s' to 60's with clear B/S. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-17 00:00:00.000",
"description": "Report",
"row_id": 1702055,
"text": "NPN 1900-0700\n\n\n1. Resp: Received infant on NP CPAP 5 cm, no changes made\nthis shift. FiO2 requirement this shift has been 21%. Lung\nsounds clear/=. RR 40-60's. IC/SCR noted. One spell thus\nfar - please see flowsheet for further details. Infant\ncontinues on caffeine. P: Cont. to monitor resp. status.\n\n2. FEN: Weight is 895 gms up 15 gms. TF remain at 150\ncc/kg/day. Ent feedings of PE20/BM20 are currently at 110\ncc/kg and are being advanced by 10 cc/kg/ at 12/24. IV\nfluids are currently at 40 cc/kg of PND10 running through a\npatent PICC line without incidence. Tolerating feedings\nwell; abd exam benign, no spits, AG stable, and min asp. UO\nfor past 24 hours has been 3.2 cc/kg/day. No stool noted\nthus far. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. AFSF. AGA. P:\nCont. to support developmental needs.\n\n4. : Mom and Dad in to visit last evening. Updated\non infant's condition and plan of care. Asking appropriate\nquestions. Mom is in house on . , involved\n. P: Cont. to support and update .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-17 00:00:00.000",
"description": "Report",
"row_id": 1702056,
"text": "Respiratory Care\nBaby remains on cpap 5 21%.RR 30-60's.Nptube plugged,replaced with new 2.5.Sx for mod cldy->pale yellow secs.BS clear throughout.1 spell documented this shift,on caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-17 00:00:00.000",
"description": "Report",
"row_id": 1702057,
"text": "Neonatology Attending Note\nDay 11\n\nNP CPAP 5, 21%. On caffeine. RR30-60s. No murmur. HR 150-170s. Pale-pink/mottles w/ care.\n\nWt 895, up 15 gms. TF 150 cc/k/day of PN at 40, eneteral feedings at 110. Tol well. Nl voidings. d/s 84. No stool overnight.\n\nIn isolette.\n\nA/P:\n - progressing well, will try off CPAP today\n - con't feeding advancement\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-31 00:00:00.000",
"description": "Report",
"row_id": 1702136,
"text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WITH SATS 92-98%. BS CLEAR. RESP RATE 64-92\nWITH IC/SC RETRACTIONS. NOTIFIED OF INTERMITTENT\nTACHYPNEA. BABY IS VERY COMFORTABLE WITHOUT G/F, OCCASSIONAL\nSPELLS, NO DESATS AND IC/SC RETRACTIONS. HAS HAD 2 BRADYS\nTHIS SHIFT WHILE KANGAROOING WITH DAD\nA:INTERMITTENT TACHYPNEA WITHOUT INCREASED SPELLS\nP:MONITOR RESP STATUS CLOSELY\n\n#3F/E/N\nO:TF AT 150CC/KG BM30/PE30 30CC Q4HR GAVAGE OVER 40\".\nABDOMEN SOFT, FULL WITH GOOD B.S. NO LOOPS AND NO SPITS.\nASPIRATES <1.2CC NONBILIOUS. VOIDING WELL; NO STOOLS\nOVERNIGHT. WT UP 15GM TO 1215GM\nA:TOLERATING FEEDS WELL; GAINING WT\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, MONITOR WT GAIN\n\n#4G&D\nO:IN SERVO CONTROL ISOLETTE WITH STABLE TEMPERATURE. NESTED\nON SHEEPKIN W/BOUNDARIES. ACTIVE/ALERT WITH CARES; SLEEPING\nWELL BETWEEN. FONTANEL SOFT AND FLAT;SUTURES SMOOTH\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nO: IN FOR 8PM CARES. INDEPENDENT WITH TEMP/DIAPER\nCHANGING. ASSISTED IN MOVING BABIES FROM ISOLETTE TO SCALE.\n READY FOR FAMILY MEETING BUT NEED TO GET BACK TO US\nABOUT A TIME FOR NEXT WEEK. DAD HELD #1 X90\" AND BOTH\nTOLERATED WELL. ASKING APPROPRIATES QUESTIONS.\nA:INVOLVED, INVESTED \nP:CONTINUE TO SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-31 00:00:00.000",
"description": "Report",
"row_id": 1702137,
"text": "Neonatology Attending\n\nDay 25\n\nRemains in RA. RR 70-90s. Mild retractions. Has had three bradycardia episodes over last 24 hours. No murmur. Pale, pink. HR 150-170s. BP mean 40. Weight 1215 gms (+15). TF at 150 cc/kg/d- BM/PE 30 with Promod. Tolerating gavage feedings. Benign abdomen. On vitamin E and iron. Stable temperature in servo-controlled incubator.\n\nDoing well overall with mild tachypnea noted. Will continue to monitor cardio-respiratory status closely. Gaining weight well. Tolerating feeds well. Family meeting today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-31 00:00:00.000",
"description": "Report",
"row_id": 1702138,
"text": "Neonatology - PRogress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. 3 spells noted over last 24 hours. He is tolerating full volume pg feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in heated isolette. Plans for family meeting today. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-20 00:00:00.000",
"description": "Report",
"row_id": 1702220,
"text": "PCA Progress Note, 7p-7a\n\n\nRESP:\n Infant remains in RA. o2 sats are stable. LS: cl/=. Mild sc\nretrax. No spells so far this shift. Remains on caffeine.\nPlease rfer to Pt's chart for additional RESP data. Continue\nto monitor and support RESP status.\n\nFEN:\n TF:150cc/kg/D of PE26 w/PM. Total volumes are being gavaged\nover 1 hour. Tolerating feeds well w/ minimal aspirates and\nno spits. Abd is benign w/ active BS. Voiding w/ each diaper\nchg, no stool so far this shift.Remains on Vit E and Fe.\nPlease refer to PT's chart for additional FEN data. Continue\nto encourage and support FEN status.\nDEV:\n Pt's temp remains atable while swaddled in OAC. Infant is\n and active w/ cares, and sleeps well in between cares.\nSucks on pacifier for comfort. Continue to encourage and\nsupport develomental milestones.\n\nPAR:\n no contact w/ so far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-20 00:00:00.000",
"description": "Report",
"row_id": 1702221,
"text": "I have assessed this infant and agree with above documentation by PCA \n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-06 00:00:00.000",
"description": "Report",
"row_id": 1701978,
"text": "Neonatology Attending\n\n936 gram 26 week twin # 1 male admitted secondary to prematurity and resp distress.\n\n936 gram 26 week twin # 1 male born to a 45 yo G2 P0->2 White female\nPNS: O-/Ab-/RI/RPR NR/HBsAg-/hep C -/HIV-/GBS unknown\nMat h/o hypothyroidism on synthroid, ureteral reflux s/p repair, fibroid s/p resection, HSV with last lesions .\nIVF pregnancy with donor eggs (donor 26 yo). Pregnancy remarkable for:\n 1. dichorionic diamniotic twins with concordant growth\n 2. cervical shortening diagnosed at 21 weeks treated with bedrest at home then admitted . Beta complete .\n 3. premature labor treated with terb then MgSO4 \n 4. ? PROM \n 5. Today noted to have advanced cervical dilation with breech/breech presentation. Intrapartum antibiotics given. C/S under spinal anesthesia. This twin with initial cry but then poor resp effort req BMV. Intubated by . Wet bs with copious secretions. Poor perfusion. Apgars . To NICU.\n\nExam Premature male orally intubated, poor perfusion\nT 96.8 P 168 R vent BP 40/27 mean 31 O2 sat 98% in 50% O2\nWt 936 grams (50%) Lt 35.5 cm (50%) HC 24.5 cm (50%)\nAF soft, flat, nondysmorphic, intact palate, fair aeration, crackly bs, no murmur, soft abd, 3 vessel cord, no hsm, 1+ pulses, normal male genitalia, testes high in canal, patent anus, no sacral dimple, no hip click, bruising on arms, ~1.5 cm x 5 cm birthmark vs bruise on back mid thoracic region.\n\nA: 26 week twin with RDS, R/O sepsis, poor perfusion\n\nP: Monitor\n Mechanical ventilation\n Survanta up to 4 doses as clinically indicated\n UAC and UVC for access and monitoring\n Babygram\n Monitor BP. Volume and/or dopamine as needed to maintain MAP >31.\n Vigilance for PDA and early treatment if present\n D5W at 100 cc/kg/d\n Close monitoring of electrolytes and DS with adjustment of fluids as needed\n Follow bili\n Check BT/Coombs as mother is \n likely need early phototherapy\n Check CBC, BC.\n A/G with course dependent on labs and clinical status\n HUS at 3-7 days depending on clinical course\n Support parents--I updated them in L&D and at bedside\n Pediatrician will be at Pediatrics\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701979,
"text": "NURSING ADMISSION NOTE\n\nRECEIVED INFANT FROM OR, ORALLY INTUBATED, PLACED ON WARMER AND VENTILATOR, SEE FLOW SHEET FOR SETTINGS. APGARS 7&8. PLEASE REFER TO NEONATOLOGY NOTE ABOVE FOR MATERNAL HISTORY AND OR COURSE.\n\nON ADMISSION INFANT'S COLOR PALE/PINK WITH CSE/= BS AND NO MURMER. INITIAL BP 40/27-31. SURVANTA GIVEN BY RT. UAC & DOUBLE LUMEN UVC PLACED BY , AND PLACEMENT CHECKED BY XRAY. BOTH LINES PULLED BACK ACCORDING TO XRAY RESULTS. ETT IN GOOD PLACEMENT. WEANED ON VENT AS TOLERATED. INITIAL ABG 7.32/39/81. D-STICK 61. CBC & BLOOD CULTURES SENT. BABY MEDS AND ANTIBIOTICS GIVEN AS ORDERED. TOTAL FLUIDS MAINTAINED AT 100CC/KG/D. RECEIVED 9CC NS BOLUS X2 FOR LOW BP AND DOPAMINE STARTED AT 10MCG/KG/\" AT 2330 FOR MAP'S <28. WEANED TO 7.5MCG BY 2400. PARENTS AT BEDSIDE AND UPDATED BY NEONATOLOGIST.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701980,
"text": "1 Respiratory\n2 CV\n3 Fluid & nutrition\n4 Growth & dvevlopment\n5 Parenting\n6 Infant with Potential Sepsis\n\nREVISIONS TO PATHWAY:\n\n 1 Respiratory; added\n Start date: \n 2 CV; added\n Start date: \n 3 Fluid & nutrition; added\n Start date: \n 4 Growth & dvevlopment; added\n Start date: \n 5 Parenting; added\n Start date: \n 6 Infant with Potential Sepsis; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-20 00:00:00.000",
"description": "Report",
"row_id": 1702222,
"text": "Neonatology- Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good . BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-20 00:00:00.000",
"description": "Report",
"row_id": 1702223,
"text": "Neonatology- Physical Exam\nWill decrease to 24 cal and monitor growth. caffeine to be dced.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-20 00:00:00.000",
"description": "Report",
"row_id": 1702224,
"text": "Neonatology\nDOing well. REmains in RA. No spells. Comfortable apeparing.\n\nWT 2130 up 65. Abdomen bneign. Still re gavage. Abdomen bneign.\nBF once per day.\n\nCOntinue to await maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-20 00:00:00.000",
"description": "Report",
"row_id": 1702225,
"text": "Clinical Nutrition\nO:\n~33 wk CGA BB on DOL 45.\nWT: 2130 g (+65)(~75th %ile); birth wt: 936 g. Average wt gain over past wk ~26 g/kg/d.\nHC: 29.5 cm (~25th to 50th %ile); last: 28.5 cm\nLN: 42.5 cm (~25th to 50th %ile); last: 40 cm\nMeds include Fe and Vit E\n not needed.\nNutrition: 150 cc/kg/d PE/BM 24, pg over 1 hr due to hx of spits. Infant also breastfeeds 1x d. Feeds just decreased today for good wt gain; projected intake for next 24 hrs ~120 kcal/kg/d, ~3.3 to 3.6 g pro/kg/d.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds without GI problems over extended feeding time. Breastfeeds well. not needed. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for HC gain. Wt gain and LN gain are exceeding recommended ~15 to 20 g/kg/d for wt gain and ~1 cm/wk for LN gain; feeds decreased in response. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Report",
"row_id": 1702309,
"text": "NPN 1900-0730\n\n\n3. FEN\nO: Current wgt= 2960g (+65). TF 150cc/kg/day of PE24/BM24.\nAlt feeds po/pg. Bottled 30cc of 74cc minimum when offered.\nGavaging remainder. Abd soft, +BS, no loops. Med spit x1.\nMax asp 3.7cc, nonbilious, refed. Voiding, no stool yet this\nshift. A: Tolerating feeds. P: Cont to monitor po intake,\nmonitor for s/s feeding intolerance.\n\n4. G&D\nO: is /active with cares. Temps stable cobedding\nw/twin in OAC. , . Likes pacifier. Brings hands to\nface. Strawberry hemanginoma remains on abd. A: AGA. P: Cont\nto provide dev appropriate care.\n\n5. \nNo contact w/family thus far this shift. Due to come in for\n1600 care today. scheduled to take CPR today as\nwell.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Report",
"row_id": 1702310,
"text": "Neonatology Attending\n\nDay 65\n\nRemains in RA. RR 40-60s. Mild retractions. HR 130-160s. No murmur. Pale, pink. Weight 2960 gms (+65). On BM/PE 24 at 150 cc/kg/d. Alternating po/pg feeds. Taking ~30 cc/74 cc per feed. Benign abdomen. Small spits. Stable temperature in open crib. up to date. Will take CPR today.\n\nDoign well overall. Awaiting increased feeding maturity for discharge. Gaining weight well. Next eye exam on .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Report",
"row_id": 1702311,
"text": "Neonatology NP note\nPE swaddled in open crib, cobeddding with brother, , sutures opposed, mild subcostal retractions in room air, lungs clear/=, RRr, no murmur, pink and well perfused, abdomen soft, good .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-15 00:00:00.000",
"description": "Report",
"row_id": 1702044,
"text": "Neonatology Attending\n\nDay 11\n\nRemains on CPAP with fio2 0.21. RR 40-60s. Suctioned for marked secretions. Had one bradycardia this morning. Clear breath sounds. No murmur. HR 140-160s. Pale, pink. BP mean 70. Weight 850 gms. TF at 150 cc/kg/d. On breast milk. Blood glucose 100. Enteral feeds at 70 cc/kg/d. PN and lipids at 80 cc/kg/d. Stable temperature on servo-controlled incubator.\n\nRemains on CPAP. Will consider trial off CPAP over next few days. Monitoring closely. Continuing feeding advance by 10 cc/kg twice daily. Head ultrasound tomorrow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-07 00:00:00.000",
"description": "Report",
"row_id": 1701981,
"text": "Neonatology NP Procedure note\nEndotracheal Intubation\nIndication: severe respiratory distress\n2.5 ETt passed orally through cords under direct laryngoscopy. tube secured with 6 at upper lip. good chest wall movement and equal breath sounds present. CXr shows tip of ett 2 cm above carina.\n\n\nPlacement of umbilical arterial and venous catheters\nIndication: need for continuous blood pressure monitoring and IV fluid administration.\numbilical area prepped and draped. 3.5 umbilical catheter inserted into umbilical artery and threaded to 14 cm. Xray shows tip of catheter at T5- pulled back 1.5 cm.\n\n\n3.5 double lumen catheter inserted into umbilical vein and threaded to 8 cm. CXR shows tip of catheter 7. line pulled back 1 cm.\n\nboth lines draw back and flush easily. Infant tolerated procedures well. No complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-15 00:00:00.000",
"description": "Report",
"row_id": 1702046,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. He is pink/mottled complexion. Well perfused, no murmur auscultated. He is comfortable on CPAP with fio2 21%. Breath sounds clear and equal. Minimal spells on caffeine. He is tolerating advancing feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. PICC line in right arm intact. Stable temp in servo isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-15 00:00:00.000",
"description": "Report",
"row_id": 1702047,
"text": "Respiratory Care\nPt recieved on NP CPAP +5cm's with the fio2 21%. Pt's respiratory rates 30's to 50's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-15 00:00:00.000",
"description": "Report",
"row_id": 1702048,
"text": "Rehab/OT\n\nMet dad at the bedside. Discussed the role of OT, infant stress signals, and ways to maximize infant comfort. Care plans to be posted after observational evaluations are completed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-16 00:00:00.000",
"description": "Report",
"row_id": 1702049,
"text": "NPN 1900-0700\n\n\n1. Resp: Received infant in NP CPAP 5 cm, no changes made\nthis shift. FiO2 has been 21% this shift. Infant was sxn q\n4 hours for sm amts of cloudy secretions from NP tube and\nmod amts orally. RR 40-60's. Lung sounds clear/=. IC/SCR\nnoted. No spells noted thus far. Infant continues on\ncaffeine. P: Cont. to monitor resp. status.\n\n2. FEN: Weight is 880 gms up 30 gms. TF remain at 150\ncc/kg/day. Ent feedings are at 90 cc/kg/day of PE/BM20\nwhich are being advanced by 10 cc/kg/ at 12/24. IV\nfluids are currently at 60 cc/kg/day of PND10 and IL.\nTolerating NGT feedings well; abd exam benign, no spits, AG\nstable, and min asp. UO for past 24 hours has been 4.5\ncc/kg/hr. No stool noted thus far. P: Cont. to support\nnutritional needs and check rebound bili in am.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. AFSF. AGA. HUS\nplanned for today. P: Cont. to support developmental needs.\n\n4. : Mom called x 1. She was updated on infant's\ncondition and plan of care. Asking appropriate questions.\nMother is currently admitted on the 6 th floor for abdominal\npain and fever. , involved . P: Cont. to\nsupport and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-16 00:00:00.000",
"description": "Report",
"row_id": 1702050,
"text": "Respiratory Care\nBaby remains on cpap 5 21%.Sx nptube for sm. cldy secs.RR 40-60's.No spells documented this shift,on caffeine.BS clear throughout.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Report",
"row_id": 1702312,
"text": "PCA Progress Note, 7a-7p\n\n\nFEN:\n TF:150cc/kg/D of PE24. Infant is alt PO/PG. Infant is\nbottling partial feeding while the remainder is being\ngavaged. Total feedings are being gavaged over 1hr.\nTolerating feeds well w/ min aspirates and no spits so far\nthis shift. Abd is benign w/ active BS. Voiding w/each\ndiaper chg, no stool this shift. Please refer to Pt's chart\nfor additional FEN data. Continue to encourage and support\nPO feeds.\n\nDEV:\n Pt's temp remains stable while swaddled and co-bedded in an\nOAC w/ sibling. Infant is and active w/ cares, wakes\nfor feeds and sleeps well in between cares. Sucks on\npacifier for comfort, and settles well w/ containment.\nContinue to encourage and support developmental milestones.\n\nPAR:\n Mom, , and both Grandma's were in for last cares this\nshift. bathed and helped w/ care. The \ntogether are independent w/cares. They are very attentive\nand particular w/ cleaning and caring for the infants.\nContinue to update and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Report",
"row_id": 1702313,
"text": "PCA Progress Note, 7a-7p\nI have read and agree with the above note written by .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Report",
"row_id": 1702314,
"text": "Nursing Note 1900\n and grandmothers here to take infant CPR class. All participants practiced compressions, breaths and choking maneuvers on the mannikin. Video viewed and written handout given.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-30 00:00:00.000",
"description": "Report",
"row_id": 1702393,
"text": "Nursing Progress Note\n\n\nFEN O/A: Current Wt: 3.525kg, ^30gms. TF Ad lib with a min\nof 140cc/k/d; BM24, E24. bottles 60-75cc q4-4.5 hours.\nAbdomen benign, active BS. One small spit. Voiding/no stool.\nP: Cont to encourage po intake as tolerated.\n\nG&D O/A: is swaddled in an open crib; temp stable.\nWakes for feeds. MAE, A/A with cares. site red/pink\nwith mild bloody drainage noted in diaper. Applying gauze &\nvaseline qdiaper change. Receives tylenol Q6-8h for\ndiscomfort. Mild green/yellow drainage noted from right eye;\nerythromycin applied. P: Cont to monitor site. Support\ndevelopmental needs.\n\nPAR O/A: No contact from thus far tonight.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-30 00:00:00.000",
"description": "Report",
"row_id": 1702394,
"text": "Nursing Progress notes.\n\n\n#3 O: Baby continues to feed ad lib demand with BM24/E24.\nBaby woke every 3 to 5 hours and fed well taking 55 to 75cc.\n Abdomen soft, bowel sounds active, no loops, voiding well,\nlast stool on . No spits today. A: Po feeding well\ntoday. P: Continue with ad lib feeds at home.\n#4 O: Temp stable in open crib. Baby is and active\nduring cares and baby bottle feeds vigorously initially,\nslowly at end. Baby sleeps well between feeds and wakes on\nhis own for feedings. A: Appropriate for age. P: Discharge\nhome with early intervention follow up.\n#5 o: Mother called for an update. She was informed that\nbaby could go home today. will be in after work.\nmom called for further information about feeding and follow\nup eye exams. VNA referal called in and faxed and early\nintervention called to confirm. Infant follow up referal\nfaxed. aware of all referals. Mother will make a\npedi appointment for Friday. A: Involved family preparing\nfor discharge home. P: Continue to keep informed and\ndischarge home this evening.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-15 00:00:00.000",
"description": "Report",
"row_id": 1702045,
"text": "NPN 0700-1900\n\n\n1. RESP\nO: Remains in NP FiO2 21%. Requires increased FiO2\n(30%) w/cares. Breathing 40s-60s, sats 96-100%. Mild IC/SCR\nnoted. No increased WOB noted. LS clr/=. Suctioning q4 for\nsm amts cldy secretions and mod-lg amts thick oral\nsecretions. Spell x1 thus far this shift: HR51 SAT77 req mod\nstim. Receiving caffeine as ordered. A: Stable in current\nresp support. P: Cont to monitor for s/s resp distress, wean\nresp support as tolerated.\n\n3. FEN\nO: TF 150cc/kg/day. Currently receiving 70cc/kg PN D10 @\n2.4cc/hr & IL @ 0.3cc/hr via non-central PICC. Infusing\nwell. Receiving 80cc/kg of PE20/BM20 (13cc) q4h via NGT.\nAdvancing feeds by 10cc/kg @ 1200/2400 as tolerated. Abd\nsoft, +BS, no loops. A/G 17.5-18cm. No spits. Minimal asps.\nUO x8hrs = 4.9cc/kg/hr. Lg mec x1 (heme-). Plan to check D/S\nw/next care. Rebound bili to be drawn in AM. A: Tolerating\ncurrent feeding regime. P: Cont to monitor for s/s feeding\nintolerance, advance feeds as tolerated.\n\n4. G&D\nO: is alert/active with cares. Temps stable in servo\nisolette. Nested in sheepskin. Kangaroo'ed x90 mins and\ntolerated it well. Sleeping well b/w care times. Calms\nw/boundaries and pacifier. Brings hands to face. Scheduled\nfor HUS tomorrow. Sm red, flat area noted on infant's L\nlower abd (1cm in size). Slightly larger red, flat area\nnoted on infant's upper back (2cm in size). Team aware\n(?hemanginoma). A: AGA. P: Cont to provide dev appropriate\ncare.\n\n5. \nO: Dad in for 1200 care w/visitors. Changed and\nkangaroo'ed x90 mins. Updated @ bedside by this RN. Mom was\nin-house for an app't today but has not been feeling well\nand did not visit w/Dad. A: Attentive, family. P:\nCont to support and educate family.\n\nSee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-29 00:00:00.000",
"description": "Report",
"row_id": 1702127,
"text": "1900-0730\n\n\n1. RECEIVED INFANT ON RA. NO CHANGE. RR 40'S TO 80'S. RR UP\nOVER 100 AT TIMES. NO INCREASED WOB NOTED. CONT. WITH MILD\nSC/IC RETRACTIONS. SAO2 B/T 93-97%. LS CL/=. PLAN; CONT. TO\nMONITOR RESP. STATUS. MONITOR FOR INCREASED WOB WITH BOUTS\nOF TACHYPNEA.\n\n3. WT 1.155 GRAMS. UP 65 GRAMS FROM YESTERDAY. TF CONT. AT\n150CC/K/D OF BM OR PE30 WITH PROMOD. NOW TAKING 29CC Q 4HRS.\nINFANT ALL PG FEEDS. ABD SOFT, NO LOOPS,+BS. GIRTH STEADY AT\n21.5CM. MED GREEN GUIAC- STOOL. VOIDING WELL. MAX ASP. 3CC\nOF PARTIALLY DIGESTED BM. NO SPITS NOTED. PLAN; CONT. TO\nMONITOR TOLERANCE TO INCREASING FEEDS.\n\n4. REMAINS IN SERVO ISOLLETTE. TEMPS STABLE AT 98.2. A/A\nWITH CARES. MOVING ALL EXTREMETIES. REMAINS ALL PG FEEDS.\nSLEPING WELL B/T CARES. PLAN; CONT. TO SUPPORT G/D.\n\n5. MOM IN FOR CARES. INDEPENDANT WITH DIAPER CHANGE\nAND TEMP TAKING. NO HOLDING DONE THIS CARE. MOM APPEARS VERY\n AND CARING. PLAN; CONT. TO SUPPORT AND EDUCATE\n.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-29 00:00:00.000",
"description": "Report",
"row_id": 1702128,
"text": "Neonatology Attending\n\nDay 23\n\nRemains in RA. RR 40s-80s. Mild retractions. SaO2 93-100%. Had two bradycardia episodes over last 24 hours. BP mean 37. Weight 1155 gms (+65). On BM/PE 30 with Promod. Minimal aspirates. Passing stool. Stable temperature in incubator. Mother may be discharged today.\n\nAcceptable respiratory status on current regimen. Will continue to monitor closely. Gaining weight well. Tolerating feeds well. up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-16 00:00:00.000",
"description": "Report",
"row_id": 1702051,
"text": "Neonatology Attending\n\nDay 10\n\nRemains on CPAP at 5cm with fio2 0.21. Suctioned for small secretions. RR 40-60s. Sats in high 90s. Mild retractions. No bradycardia overnight on caffeine. BP mean 42. Weight 880 gms (+30). TF at 150 cc/kg/d. Enteral feeds at 90 cc/kg/d- BM/PE20. Increasing by 10 cc/kg twice daily. PN 10 and lipids supplementation at 60 cc/kg/d. Rebound bilirubin 2.7. Stable temperature in servo-controlled incubator. Mother readmitted for fever and abdominal pain yesterday.\n\nDoing well overall on current respiratory management. Will continue to monitor closely. Will consider trial off CPAP. Tolerating feeding advance well. Discontinuing lipids today. Bilirubin in acceptable range.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-30 00:00:00.000",
"description": "Report",
"row_id": 1702132,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 92%. Lung sounds clear/=. RR 40-70's. IC/SCR\nnoted. No spells thus far. Infant continues on caffeine.\nP: Cont. to monitor resp. status.\n\n2. FEN: Weight is 1200 gms up 45 gms. TF remain at 150\ncc/kg/day of BM/PE30 with promod. Tolerating NGT feedings\nwell; abd exam benign, no spits, AG stable, and min asp.\nVoiding qs and no stool thus far. Infant continues on Vit E\nand ferinsol. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. AFSF. AGA. P:\nCont. to support developmental needs.\n\n4. : Mom was up for the cares. Independent with\ndiapering, taking temp, and handling infants. Updated at\nbedside on infant's condition and plan of care. Asking\nappropriate questions. Mom is being discharged home\ntomorrow with VNA. , involved . P: Cont. to\nsupport and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-30 00:00:00.000",
"description": "Report",
"row_id": 1702133,
"text": "Neonatology Attending\n\nDay 24- CGA 29 6/7 weeks\n\nRemains in RA. Sats >92%. Mild retractions. RR 40-70s. Has had three bradycardia episodes over last 24 hours. No murmur. Pink, well-perfused. BP mean 40. Weight 1200 gms (+45). TF at 150 cc/kg/d- BM/PE 30 with Promod. Benign abdomen. No spits, aspirates. Passing stool. Stable temperature in servo-controlled incubator. Mother in frequently. Discharged today.\n\nDoing well overall. Monitoring for apnea. Following weight gain. No changes planned for today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-30 00:00:00.000",
"description": "Report",
"row_id": 1702134,
"text": "NPN\n\n\n1.Resp: Infant remains in RA with 02 sats 93-100%. Lung\nsounds are clear and equal with IC/SC retractions. RR\n40s-60s. He remains on caffeine and has had 1 spell thus\nfar this shift. Continue to monitor respiratory status.\n\n3.FEN: Infant remains on TF 150cc/kg/day of BM/PE 30 with\npromod. He is tolerating feeds well, no spits, minimal\naspirates. Abdomen is pink, soft, no loops, and consistent\nabdominal girths. He is voiding, has not stooled overnight.\n Infant remains on vit. E and Fe+ supplements. Continue to\nmonitor FEN status.\n\n4.DEV: Infant is nested on sheepskin in a covered servo\nisolette with stable temps. He is alert and active with\ncares, wakes for feeds and brings hands to face. Continue\nto support growth and development.\n\n5.: Mom and dad in this morning for 0800 cares. Mom\ndischarged today from hospital with a PICC line in place.\nVNA will be involved in mother's care. plan to\nreturn this evening for cares. Continue to support \nand keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-30 00:00:00.000",
"description": "Report",
"row_id": 1702395,
"text": "Nursing Discharge Note\n\n\n in to take baby home at 1800. Baby just waking up\nto feed. decided to take bottle home with them.\nDischarge teaching completed. signed baby\nidentification page and placed baby in car seat. \nstarted that they had no further questions and baby\ndischarged home.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1702004,
"text": "Neonatal NP-Exam.\n\nSee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. breath sounds clear and equal> Nl S1S2, grade murmur audible. Pale, pink and well perfused. Abd benign, no HSM. Active bowel sounds. infant active with exam.\n\n\nMet with parents to review hospitalization up to this point with projected plan of care for next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-29 00:00:00.000",
"description": "Report",
"row_id": 1702129,
"text": "PAC Progress note, 7a-7p\n\n\nRESP:\n Infant remains in RA. Please see flow sheet for a and b\ndata. Mils sc/ic retrax. LS: cl/=. Continues on caffeine.\nPlease refer to Pt's chart for additional RESP data.\nContinue to monitor and support RESP status.\n\nFEN:\n TF:150cc/kg/D of PE/BM 30w/PM. Full volumes are being\ngavaged over 40 mins. Infant is tolerating feeds well, w/ no\nspits and minimal aspirates. Infant is voiding w/ each\ndiaper chg, no stool so far this shift. Ag is stable. Abd is\nbenign w/ active BS. Applying H2O to eyes for cl to yellow\ndrainage. RN aware. Remains on vit E and Fe. Please refer to\nPt's chart for additional FEN data. Continue to encourage\nand support FEN status.\n\nDEV:\n Infant's temp remains stable while nested in servo\nisolette. Infant is alert and active w/ cares, and sleeps\nwell in between each care. Infant brings hands to face for\ncomfort. Continue to encourage and support developmental\nmilestones.\n\nPAR:\n Mom and Dad were in today for both afternoon cares. Both\n are becoming more comfortable w/ turning and\nrepositioning infant. Independent w/ diaper chg and temps.\n seem and involved. Continue to update and\nsupport.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-29 00:00:00.000",
"description": "Report",
"row_id": 1702130,
"text": "Nursing NICU Note\nPlease refer to CoW's note. This nurse also in to examine pt at care times. This nurse on pt's status and plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-29 00:00:00.000",
"description": "Report",
"row_id": 1702131,
"text": "Neonatology - PRogress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air. Breath soundsclear and equal. 2 spells over last 24 hours. He is tolerating full volume feeds. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in servo isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-18 00:00:00.000",
"description": "Report",
"row_id": 1702211,
"text": "NICU nursing Note 1900-0700\n\n\n#1 Respiratory\nRemains in RA, RR 30-60's. clear and equal with mild\nsubcostal retractions. Well aerated. No spells, continues on\ncaffeine as ordered. Stable in RA, continue to follow.\n\n#3 FEN\nWeight tonight 2005gm (+65). Tf 150 cc/kg/day of BM/PE\n26w/Pm. PG fed over 1hour. Abd benign as charted, see\nflowsheet. No spits, min aspirates. Voiding and stooling.\nTolerating feeds well, continue to follow.\n\n#4 G&D\nTemp stable in open crib. and active with cares,\nsymmetrical , . AFSF. Sleeping well between cares.\nAGA. Continue to promote developmental growth.\n\n#5 Parenting\nNo contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-18 00:00:00.000",
"description": "Report",
"row_id": 1702212,
"text": "Neonat9ology\nDoing well. RA. No spells. Comfortable appearing.\n\nWt up 65. Tolerating feeds at 150 cc/k/d of 26 cal. Abdomen benign. Still requiring gavage.\n\nTemp stable in open crib.\n\nEye exam shows immature Zone 2.\n\nAwaiting maturation of resp control and feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-18 00:00:00.000",
"description": "Report",
"row_id": 1702213,
"text": "NEonatology- PRogress Note\n\nPE: remains in his open crib, in room air, bbs cl=, rrr s1sn2o murmur,abd soft nontender, V&S, afso, active with care\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-30 00:00:00.000",
"description": "Report",
"row_id": 1702135,
"text": "Neonatal NP-Exam\n\nsee Dr. note for details and plan of care as discussed in rounds this am.\n\nAFOF. Breath sounds clear and equal. nl S1S2, no audible murmur. pink and well perfused. Abd benign, no HSM. active bowel sounds. infant active with exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-19 00:00:00.000",
"description": "Report",
"row_id": 1702216,
"text": "PCA, Progress Note, 7p-7a\n\n\nRESP:\n Infant remains in RA. O2 sats are >97%. LS: cl/=. SC\nretrax. Continues on caffeine. No spells or desats so far\nthis shift. Please refer to Pt's chart for additional RESP\ndata. Continue to encourage and support RESP status.\n\nFEN:\n TF:150cc/kg/d of PE26w/PM. All feedings are being gavaged\nover 1 hour. Tolerating feeds well w/ minimal aspirates and\nno spits. Abd benign w/active BS. Voiding w/ each diaper\nchg, no stool so far this shift. Remains on Vit E and Fe.\nPLease refer to PT's chart for additional FEN data. Continue\nto encourage and support current FEN plan, and PO feeds.\n\nDEV:\n Infant's temp remains stable while swaddled in OAC. Infant\nis and active w/ cares, and sleeps well in between.\nInfant comforts easily w/ pacifier, and brings hands and\nfingers to mouth. Continue to enocurage and support\ndevelopmental milestones.\n\nPAR:\n Mom and were in for 1st are this shift. Both \ntook turns holding the infant and is twin brother. did\ncare and is becoming more independent w/ each care. Mom\ntried , although infant became uninterested\nimmeadiatly. are asking appropriate questions and\nare attentive and involved. COntinue to update and support.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-19 00:00:00.000",
"description": "Report",
"row_id": 1702217,
"text": "NURS\n\n\nI have examined and I agree with the above note by\n ,PCA.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-19 00:00:00.000",
"description": "Report",
"row_id": 1702218,
"text": "Neonatology\nDOing well. Remains in RA. Comfortable apeparing. No murmru.\n\nWt Tolerating efeds at 150 cc/k/d of 26 cal. Abdomen benign.\nStarting po. BF once per day.\n\nTemp stable in open crib.\n\nAwaiting maturation of resp control and feeds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-19 00:00:00.000",
"description": "Report",
"row_id": 1702219,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains on RA, maintaining her O2 sats\ngreater than 97%. Lung sounds clear/=. RR 40-70's. Mild\nSCR noted. No spells noted thus far. Infant continues on\ncaffeine. P: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 150 cc/kg/day of BM/PE26 with promod.\nTolerating NGT feedings well; abd exam benign, no spits, AG\nstable, and min asp. Voiding qs and no stool noted thus\nfar. Infant continues on Vit E and ferinsol. P: Cont. to\nsupport nutritional needs.\n\n3. G/D: Temps stable swaddled in open crib. and\nactive with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. : Mom in for 1200 cares. Updated on infant's\ncondition and plan of care. Asking appropriate questions.\nIndependent with cares. , involved . P: Cont.\nto support and update .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1702005,
"text": "NPN 0700-1900\n\n\n1. Resp: Received infant in NP CPAP 6 cm, no changes made\nthis shift. FiO2 requirement this shift has been 21%.\nInfant was sxn q 4 hours for mod amts of white secretions\nfrom NP tube. Lung sounds clear/=. RR 40-60's. IC/SCR\nnoted. No desats or bradycardias noted. Infant continues\non caffeine. P: Cont. to monitor resp. status, wean FiO2,\nand follow BG.\n\n2. CV: Loud murmur present at 0800 care. Hyperactive\nprecordium. Infant was given first dose of indocin at 1030.\n Infant is pale pink/ well perfused. Infant mottles. B/P\nmeans have been 37-41. Cuff pressure - 52/31 m37. Total\nbld out 3.7 cc. Pulses wnl, cap refill brisk. P: Cont. to\nmonitor cv status.\n\n3. FEN: TF were increased to 140 cc/kg/day. Infant remains\nNPO. UAC has 1/2 NS with 1/2 unit hep/cc running, and\nThrough the prim and sec ports of DUVC is PND7 with IL. Abd\nsoft, flat, hypoactive bs. UO for past 8 hours has been 5.3\ncc/kg/hr. No stool noted thus far. P: Cont. to support\nnutritional needs and check lytes in am.\n\n4. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Water pillow made for\ninfant. Alert and active with cares. Settles well in\nbetween cares. AFSF. AGA. HUS done today - WNL. Bruising\nnoted between shoulder blades, and on l elbow. Skin\nbreakdown noted on left foot and right thigh. Aquaphor was\nordered. P: Cont. to support developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 1702006,
"text": "NPN 0700-1900\n\n\n1. Parents: Mom and Dad up throughout day. Mom in for this\nafternoon's cares. Did not feel comfortable participating\nyet. Updated at bedside on infant's condition and plan of\ncare by this RN and team. Aware of HUS results. Family\nmeeting was held this afternoon with , SW \nWoldsdorf, parents, and this RN. Parents were encouraged to\nask questions. They were given parent packet and parking\ninformation. Loving, involved parents. P: Cont. to support\nand update parents.\n\n6. I/D: Infant is day of abx treatment. Ampi was given\nas ordered. Repeat BC was sent o/n - results pending. P:\nCont. to administer ampi/gent, follow BC, and monitor for\ns/s of infection.\n\n7. Hyperbili: Infant remains under single phototherapy with\neye shields in place. Bili this am was 2.7/0.6 down from\n3.7/0.5. Plan is to recheck bili in am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-18 00:00:00.000",
"description": "Report",
"row_id": 1702214,
"text": "NPN 0700-1900\n\n\n#1: O: Infant remains in room air, saturations 99-100%.\nLung sounds clear and equal, respiratory rate 40's-60's.\nInfant has mild subcostal retractions and is still on\ncaffeine. No spells. A: Infant stable in room air. P:\nContinue to monitor respiratory status.\n\n#3: O: Total fluid minimum 150ml/kg of breastmilk or PE 26\nwith promod, 50cc q4 hours. Breastfed once a day. Abdomen\nbenign, voiding, no stools today. No spells, minimal\naspirates. No spits. A: Infant tolerating feeds. P: Continue\ngavage feeding with 1 breastfeed a day.\n\n#4: O: Temperature stable in OAC. Sucks pacifier, brings\nhands to face for comfort. and active with cares,\nsleeps well between. Does not wake for feeds, remains\nswaddled in crib. A: AGA. P: Continue to support growth and\ndevelopment.\n\n#5: O: Mom in today. Breast fed and held infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-11-18 00:00:00.000",
"description": "Report",
"row_id": 1702215,
"text": "NPN 0700-1900\nI have read and agree with the above note written by .\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-07 00:00:00.000",
"description": "Report",
"row_id": 1702297,
"text": "PCA 1900-0700\n\n\n3 infant's CW 2835g up 45g, remains on TF min 150cc/kg/d of\nBM24 or PE24=71cc q4h, infant alt PO/PG feeds, bottling with\ngood coordination, abd. soft, no loops, bs+, no spits,\nvoiding qs, no stool this shift, max asp. 10cc. P:cont. to\nsupport nutritional needs.\n\n4 infant remains swaddled in OAC, cobedding with sibbling,\ntemp. stable, a/a with cares, settles well in between, like\nto suck on pacifier. P:cont. to support dev. needs.\n\n5 no known contact this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-07 00:00:00.000",
"description": "Report",
"row_id": 1702298,
"text": "NPN 1900-700\nI have examined infant and agree with above note by Cowkr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-07 00:00:00.000",
"description": "Report",
"row_id": 1702299,
"text": "Newborn Med Attending\n\nDOL#62. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. WT=2835 up 45, on 150 cc/kg/d PE24 PO/PG.\nA/P: Growing infant working up on PO feeds.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-07 00:00:00.000",
"description": "Report",
"row_id": 1702300,
"text": "NPN 0700-\n\n\n3. TF 150cc/kg/day PE/BM 24. Alternating PO/PG feeds- took\n36cc at 12pm with remainder gavaged in. Belly soft, +BS, no\nloops. No spits, min aspirates. Voiding, stool times one\ntoday. Continue to monitor tolerance to feeds, bottle every\nother feed.\n\n4. Temp stable in open crib, cobedding with brother. \nand active with cares, rests well between cares. MAE,\nbrings hands to face, AFSF. Continue to promote growth and\ndevelopment.\n\n5. Mom called this afternoon, updated on progress and plan\nof care. Mom and plan to visit this evening for 8pm\ncare. Continue to update, educate and support .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-08 00:00:00.000",
"description": "Report",
"row_id": 1702303,
"text": "NPN 0700-\n\n\n3. TF 150cc/kg/day BM/PE 24, alternating PO/PG. Bottled at\nnoon- took 51cc of 72cc with remainder gavaged. Belly soft,\n+ BS, no loops. No spits, min aspirates. Voiding, no stool\nthis shift. Continue to monitor tolerance to feeds,\nincrease frequency of bottlefeeding as tolerated.\n\n4. and active, rests well between cares. Temp stable,\ncobedding with brother in open crib. MAE, brings hands to\nface. Continues with yellow drainage from right eye-\ncontinue warm soaks/clean with sterile H2O. Continue to\npromote growth and development.\n\n5. Mom called this afternoon, updated on progress and plan\nof care. planning to visit this evening. Continue\nto update, educate and support .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-08 00:00:00.000",
"description": "Report",
"row_id": 1702304,
"text": "Neonatology- Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good . BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Report",
"row_id": 1702305,
"text": "Nursing Progress Note 1900-0700\n\n\nF/N:Infant cont's on TF 150cc's/kg/day,rec.PE24/BM24 72CC'S\nQ 4 hrs.alt.po/pg feeds.Infant bottled 57cc's with a yellow\nnipple.Weight=2.895 up 15 grams.Abd.soft,pos bs,no loops or\nspits,minimal aspirates.Infant voiding no stool thus\nfar.A:Adequate Weight Gain.P:Cont. to assess tolerance of\nfeeds and monitor weight gain.\n\nG/D:AFSF.Infant and active with cares;sleeping well\nb/t cares.Infant bringing hands to face and\nmouth;intermitently sucking on pacifier.Infant presently\nswaddled and co-bedding with brother;temp stable.A/P:Cont.\nto support growth and dev.\n\nParenting: in tonight very independent with cares\nasking appropriate questions. very and\ninvested.A/P:Cont. to update,support,and educate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Report",
"row_id": 1702306,
"text": "Newborn Med Attending\n\nDOL#64. Cont in RA, no spells. AF flat, clear BS, no murmur, abd soft, MAE. Wt=2895 up 15, on 150 cc/kg/d BM24 Po/PG.\nA/P: Growing infant working up on PO feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Report",
"row_id": 1702307,
"text": "Neonatology- Physical Exam\n\n remains in RA. Active, in an open crib, AFOF, sutures opposed, good . BBS clear and equal with good air entry. No murmur,pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Report",
"row_id": 1702308,
"text": "NPN\n\n\n#3 Continues on 150cc/kg/day of BM/PE 24. Alt. po/pg, taking\nin volume with po feed. Abd soft and benign, no spits,\nminimal asp., voiding, no stool, BS active.\n\n#4 Active and with cares, awakened for cares. Swaddled\nin open crib co-bedding with sibling. Seen by EIP today.\n\n#5 Mom in to visit, care for, hold and feed infant. MEt with\nEIP.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-21 00:00:00.000",
"description": "Report",
"row_id": 1702082,
"text": "NPN 0700-1900\n\n\n1. Resp: Received infant in NP CPAP 5 cm, no changes made\nthis shift. FiO2 requirement this shift has been 21%.\nInfant was sxn q 4 hours for mod amts of white secretions.\nLung sounds clear/=. IC/SCR noted. RR 30-60's. One spell\nnoted thus far - please see flowsheet for further details.\nInfant continues on caffeine. P: Cont. to monitor resp.\nstatus.\n\n2. FEN: Weight is 975 up 23 gms. TF remain at 150 cc/kg/day\nof PE24/BM24. Tolerating NGT feedings well; abd exam\nbenign, no spits, min asp, and AG stable. UO for 24 hours\nyesterday was 2.9 cc/kg/hr. No stool noted thus far this\nshift. Infant continues on Vit E and ferinsol. P: Cont. to\nsupport nutritional needs.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. Alert and active with\ncares. Settles well in between cares. AFSF. AGA. P:\nCont. to support developmental needs.\n\n4. : Dad in for cares. Independent with\ndiapering and taking temp. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nMother is feeling better, she still remains in house on . , involved . P: Cont. to support and\nupdate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-21 00:00:00.000",
"description": "Report",
"row_id": 1702083,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on NP CPAP 5 FiO2 21%. Suctioned NP tube for mod amt of white/yellow secretions. Breath sounds are clear. RR 30-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-21 00:00:00.000",
"description": "Report",
"row_id": 1702084,
"text": "Neonatology\nRemains on CPAP. Comfortable apeparing. FEw spells. WIll cpontinue on CPAP for next few days.\n\nWt 975 up 23. TF at 150 cc/k/d of 24 cal. Tolerating gavage. Abdomen benign. WIll advance to 26 cal.\n\nTemp stable in isollette.\n\nContinue current resp support and nutritional advancement\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-21 00:00:00.000",
"description": "Report",
"row_id": 1702085,
"text": "Nursing Note\nSee flow sheet for additional details reguarding assessments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-21 00:00:00.000",
"description": "Report",
"row_id": 1702086,
"text": "Nursing Note\n\n\n1. Remains on NP CPAP of 5, FiO2 21%. Tolerating well. No\ndrifts or spells thus far. Suctioned x1 this shift for\ncloudy white sectretions. See flowsheet for details. Lungs\nsounds c/=, ic/sc retractions. Continues on caffine.\nContinue to monitor resp. progress.\n3. TF requirements remain unchanged. TOlerating well wwith\nno spits, abd unremarkable, stable girth, v/s heme neg. See\nflowsheet for details of assessment. Contninue to monitor\nand support fn requirements.\n4. Temp stable in cirvo iso. a/a with cares. Sleeps well\nbetween. AFOSF, PFOSF, MAE, Clear eye drainage from L eye.\nWarm soak applied. Continue to monitor and support GD.\n5. Mom plans on visiting at 1pm. Will update and educate at\nbedside.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-21 00:00:00.000",
"description": "Report",
"row_id": 1702087,
"text": "Neonatology- Progress Note\n\nPE: remains in his isolette, on NP CPAP .sa, bbs cl=, rrr s1s2 no murmur, abd soft, nontender, V&S, afs, sutures approximated, pale, pink, active with care, hemangioma unchanged\n\nSee attending note for plan\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-10-21 00:00:00.000",
"description": "Report",
"row_id": 1702088,
"text": "Respiratory Care Note\nPt. remains on +5 CPAP, O2 21%. BS clear. Suctioned for sm amount cloudy secretions. On caffeine. One QSR spell today.\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-09 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 803618,
"text": " 7:19 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: r/o ivh\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 26 3/7 weeks gestation, now 3 days old\n REASON FOR THIS EXAMINATION:\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE NEONATAL HEAD ULTRASOUND:\n\n HISTORY: 3-day-old-boy who was born prematurely at about 26 and 1/2 weeks\n EGA. Rule out intraventricular hemorrhage.\n\n COMPARISON STUDIES: None are available.\n\n FINDINGS: Portable real time son of the neonatal head was performed in\n the NICU. The brain parenchyma has normal echogenicity without evidence for\n mass, hemorrhage, or structural abnormality. The degree of sulcation is\n consistent with the patient's EGA equivalent. The ventricles appear normal\n without evidence for germinal matrix hemorrhage or hydrocephalus. No abnormal\n extra-axial fluid collections.\n\n IMPRESSION: Normal neonatal head ultrasound.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-06 00:00:00.000",
"description": "P BABYGRAM (CHEST & ABDOMEN) PORT",
"row_id": 803429,
"text": " 9:40 PM\n BABYGRAM (CHEST & ABDOMEN) PORT Clip # \n Reason: check placement of ett and uac and uvc\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 26 weeks gestation\n REASON FOR THIS EXAMINATION:\n check placement of ett and uac and uvc\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM:\n\n An umbilical venous line terminates in the right atrium. Umbilical arterial\n line terminates at T4-5. ETT is 1.5 cm above the carina. Hazy density is\n noted within relatively normally aerated lungs. Findings may reflect\n early/mild hyaline membrane disease. The heart size and pulmonary vascularity\n are normal. No pneumothorax is seen. The gas pattern is grossly normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-11 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 803889,
"text": " 3:01 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: picc line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with newly placed picc line\n REASON FOR THIS EXAMINATION:\n picc line placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: PICC placement.\n\n FINDINGS: This film was made available for interpretation on .\n Single frontal portable view of the chest was performed. There is a PICC from\n a right upper extremity approach, whose distal tip projects over the expected\n location of the right atrium. Nasogastric tube tip terminates at the region\n of the GE junction, and could advanced several mm. UVC tip projects over the\n expected location of the right atrium. Hazy opacification throughout both\n lungs is seen. Lung volumes are relatively normal. Visualized air-filled\n loops of bowel are unremarkable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-11 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 803901,
"text": " 3:47 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: picc line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with adjusted picc line\n REASON FOR THIS EXAMINATION:\n picc line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC placement.\n\n FINDINGS: Single frontal portable view of the chest is performed. This film\n was made available for interpretation on . Since the prior study\n performed earlier on the same day, right upper extremity PICC has been\n withdrawn. Tip now terminates in the expected location of the right innominate\n vein. NG tube tip terminates just below the GE junction, and could be advanced\n several mm. UVC tip terminates in the right atrium. No other interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-16 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 804338,
"text": " 7:32 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: r/o ivh\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 26 3/7 weeks gestation, now 10 days old\n REASON FOR THIS EXAMINATION:\n r/o ivh\n ______________________________________________________________________________\n FINAL REPORT\n This baby born at about 27 weeks gestation had a head ultrasound on which\n was normal. Today's exam continues to be normal with no evidence of\n intraventricular hemorrhage, ventriculomegaly or parenchymal abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-27 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 811435,
"text": " 7:38 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: evaluate ventricular size and white matter\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 26 3/7 weeks gestation, now 36 weeks PMA\n REASON FOR THIS EXAMINATION:\n evaluate ventricular size and white matter\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 26 and 3/7th week premature twin now 36 weeks adjusted gestational\n age.\n\n Compared to a prior normal ultrasound study dated .\n\n FINDINGS: Examination of the cranium through the anterior fontanelle and the\n mastoid foramen demonstrated no intracranial abnormalities. When compared to\n the normal study dated , there has been no change.\n\n IMPRESSION: Normal head ultrasound.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-11-06 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 806387,
"text": " 7:15 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT, R/O PVL\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 26 3/7 weeks gestation, now 1 month old\n REASON FOR THIS EXAMINATION:\n r/o pvl\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant born at 26 3/7 weeks gestation. Now one month old. Rule out\n PDL.\n\n Comparison is made to prior exam of . The ventricles are symmetric\n bilaterally. There is no evidence of intraventricular or parenchymal\n hemorrhage. There are no signs of periventricular leukomalacia.\n\n IMPRESSION: Normal cranial ultrasound.\n\n"
}
] |
27,855 | 141,179 | Assessment/Plan: Pt is a 31 yo woman w/ h/o asthma, recently dx MS who p/w asthma exacerbation, fevers, tachycardia w/ initial concern for thyroid storm, but TFTs nl. . # Hypoxia/resp status: Pt presented w/ c/o "asthma exacerbation" w/ noted wheezing on initial exam. Evaluated w/ CXR which was unremarkable. However, after o/n treatment w/ nebulizer treatments and steroids, pt with increased vs decreased O2 requirement. CTA chest was done to r/o PE (even though d dimer < 500), neg for PE or parenchymal consolidation. DFA done on returned positive for influenza. Plan to: - steroid burst - pred 60mg x 5 days (started ) - albuterol nebs PRN - continue outpt advair - continue tamiflu x 5 days (started ) - continue azithro x 5 days (started ) The patient was transferred to the floor with quick improvement of her respiratory status. She did not require nebs the last 24 hours of her hospital stay, and sats were normal and stable upon discharge. . # Elevated lactate/AG acidosis: Pt w/ elevated lactate 3.5 in ED, rechecked, and elevated to 4.5. Also w/ noted decreased HCO3 to 19, with AG 16 on admission. Pt appeared to be well perfused, nl renal fxn, nl LFTs. Received IVF. Concern for influenza given prior presentations for increased lactate. As above, DFA positive. Plan to: - mangagement as above - moniter HCO3 The patient's anion gap acidosis resolved prior to discharge. . # Fever: Presumabley flu. Afebrile here. | TachycardiaHeight: (in) 62Weight (lb): 130BSA (m2): 1.59 m2BP (mm Hg): 124/90HR (bpm): 120Status: InpatientDate/Time: at 16:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with <35%decrease during respiration (estimated RAP (10-20mmHg).LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). Indeterminate PAsystolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is normal in size. pmicu nursing progress 7a-3preview of systemsCV-has continued to be very tachycardic to the 130's even while at rest.can be slightly higher with activity, anxiety.no c/o chest pain, palps.bp has been stable. GIVEN 1MG ATIVAN WITH LITTLE EFFECT. HAD PUMPED IN ED, BREAST PUMP IN ROOM FOR PT COMFORT. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Tricuspid valve not well visualized. The mitral valve appears structurally normalwith trivial mitral regurgitation. team.on droplet precautions until flu r'd/o. pt is currently on po prednisone & started po Azithromycin.Resp: Pt alternates using nasal cannula & cool neb mask for O2 therapy. ALBUTEROL NEB WITH SOME EFFECT. rr 20's-40.GI/GU: abd soft, nondistended, + bs, small bm, formed. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Sinus tachycardiaDiffuse nonspecific ST-T wave abnormalitiesClinical correlation is suggestedNo previous tracing available for comparison Did given neb x 1 per pt request though was not wheezey. has a metabolic acidosis with lactate 4.5.GI-abd soft with positive bowel sounds.had a small stool. WHEN IT WAS DETERMINED IT WAS NOT THYROID STORM ESMOLOL WAS SHUT OFF. WAS ABLE TO GET HR DOWN TO <110 FROM 120'S ON THIS AMOUNT. c/o HA pain-medicated with percocet and given ativan x 2 and benadryl as sleep aid.CV: ST with hr 100-140's. NURSING PROGRESS NOTE 0700-1900PT STABLE THIS SHIFT. Also being worked up for MS.NEURO: A & O x3, pleasant, cooperative, indep from bed to commode. LS WITH INSP WHEEZES. ONE SET BLOOD CX'S SENT. C/O HEADACHE WITH 7/10 PAIN - MEDICATED W/1 TAB PERCOCET WITH THERAPEUTIC EFFECT. NO CURRENT ABX THERAPY.SKIN: W/D/I.ACCESS: PIV X2.SOCIAL/DISPO: ASTHMA EXACERBATION IN SETTING OF POSSIBLE VIRAL INFXN. LYTES PER CAREVUE. There is no pericardial effusion.IMPRESSION: Normal biventricular cavity sizes with preserved globalbiventricular systolic function. Normalaortic arch diameter. has a cardiac echo planned for this afternoon to be followed by a CT to check for PE.RESP-wearing o2 3L nasal cannula her o2 sats were ~95-98%, when o2 off and pt speaking, sats down to high 80's%.was uncomfortable with the prongs, changed to a cool neb and pt preferred that.sats currently 97% while pt napping.her lungs are clear with few insp wheezes this am.receiving nebs as per RT. bp stable 110/80's- 120/80's. O2 sats 91-92% RA - much improved, from previous, mild cough, non-productiveCardiac: Pt continues with tachycardia, HR 110's, increases 130-140's with increased activity. The aortic root is mildly dilated at thesinus level. Suboptimal technical quality, a focal LV wall motion abnormalitycannot be fully excluded. STATED SHE FELT WIRED (?D/T STEROIDS GIVEN IN ED). HR 95-134 SR/ST WITH NO ECTOPY. MD AWARE OF ^^HR AND LACTATE, NO NEW ORDERS, WILL DISCUSS IN ROUNDS. CONT TO HAVE BURSTS OF ST WITH ACTIVITY WITH HR 1TEENS-130'S - MICU TEAM AWARE, HOWEVER FEEL IT IS O2 STATUS. No 2D or Doppler evidence of distal arch coarctation.AORTIC VALVE: Normal aortic valve leaflets. PT ENCOURAGED TO CDB. also, a nasal flu aspirate was done by RT.has a strong productive cough.is on prednisone po.ID-afebrile. Nsg note 3p-7p:Pt is & Oriented X3, cooperative, following commands, frequently falls asleep, easily arousable, denies any c/o pain. Mildly dilated ascending aorta. Sinus tachycardiaDiffuse nonspecific ST-T wave abnormalitiesClinical correlation is suggestedSince previous tracing of the same date, sinus tachycardia rate faster PATIENT/TEST INFORMATION:Indication: Shortness of breath. HAS REMOVED O2 AS SHE SAYS IT WAS DRYING HER NOSE. VOIDING VIA COMMODE, YELLOW AND CLEAR.FEN: NS @125CC/HR. ALSO GIVEN HER ADVAIR FOR WHICH SHE HAS NOT TAKEN IN SEVERAL DAYS. STATED FEELING SLIGHT SOB, N/C 2L APPLIED WITH SATS UP TO 98%. ORDERED FOR 4 MORE DAYS OF PREDNISONE.GI/GU: ABD SOFT WITH +BS. THIS MORNING HR CLIMBING TO 130'S WITH STABLE BP. HYPERREFLEXIA PER MICU TEAM. 2 SVC's noted. taking po fluids well. Urinates clear, yellow on commode.SKIN: intact-no issue.ID: afebrile. Right ventricular chamber sizeand free wall motion are normal. Pt ruled in for flu via nasal aspirate - team still deciding if going to treat. OOB TO COMMODE INDEPENDENTLY. HR STAYED 100'S UNTIL ALBUTEROL NEB RX AND HR BACK TO 120. Pt had ct scan with IV contrast today - (-) for PE, ? URINE CLEAN IN THE ED. source.also hypoxiaP-will work up with cardiac echo and CT today to r/o PE. The aortic valve leafletsappear structurally normal with good leaflet excursion. DENIES SOB. MD AWARE. NBP >90's and maps >60.RESP: on 40% cool neb-was satting in low 90's with nc but felt very dry to pt and she much prefers the mask. Left ventricular wall thickness, cavity size, and systolic functionare normal (LVEF>55%). THIS MORNING C/O RESTLESSNESS AND UNEASY BUT NOT ANXIOUS. EVENTUALLY FELL ASLEEP @0530. continues with IVF NS@125/HR. ORDER FOR HOUSE DIET, TAKING PO'S WELL.ID: TMAX 98.2 WITH WBC 8. The ascending aorta is mildly dilated. assess response to azithro. Nursing Progess Note: 1900-0700:** full code** allergy: asa, motrin, multiple food allergies** access: 2 piv's.pls see carevue for fhp/admit hxPt with + flu. voiding pale yellow urine into commode.no peripheral edema noted. PERISTENT DRY COUGH. On antivirals. CXR FROM ED SHOWED NO SIGNS OF AN ACUTE PROCESS. NO SIGNS OF BLEEDING.RESP: RECEIVED ON ROOM AIR WITH SATS 95%. The estimated right atrial pressure is10-20mmHg. Productive cough. med with percocet for headache and ativan for anxiety prn. Please note pt should not breast feed for 48hours post ct scan.GI: pt on house diet eating & tolerating well, no n/v/d noted. | 8 | [
{
"category": "Nursing/other",
"chartdate": "2138-03-03 00:00:00.000",
"description": "Report",
"row_id": 1626419,
"text": "MICU NPN\nPLEASE REFER TO FHP FOR DETAILS REGARDING HISTORY AND ADMISSION.\n\nNEURO: AAOX3. DENIED PAIN. MAE. NO DEFICITS NOTED. HYPERREFLEXIA PER MICU TEAM. STATED SHE FELT WIRED (?D/T STEROIDS GIVEN IN ED). GIVEN 1MG ATIVAN WITH LITTLE EFFECT. MADE SEVERAL CALLS TO HUSBAND AS SHE TRYING TO MAKE ALTERNATE ARRANGEMENTS FOR THEIR TRIP TO . TALKATIVE TO STAFF, COULDN'T FALL ASLEEP. THIS MORNING C/O RESTLESSNESS AND UNEASY BUT NOT ANXIOUS. MD AWARE. EVENTUALLY FELL ASLEEP @0530. ON EFFEXOR FOR DEPRESSION.\n\nCARDIAC: RECEIVED ON ESMOLOL GTT @50MCG. WAS ABLE TO GET HR DOWN TO <110 FROM 120'S ON THIS AMOUNT. WHEN IT WAS DETERMINED IT WAS NOT THYROID STORM ESMOLOL WAS SHUT OFF. HR STAYED 100'S UNTIL ALBUTEROL NEB RX AND HR BACK TO 120. THIS MORNING HR CLIMBING TO 130'S WITH STABLE BP. HR 95-134 SR/ST WITH NO ECTOPY. BP 102-114/64-76. PPP. HCT 34 FROM 40 S/P 4L IVF. NO SIGNS OF BLEEDING.\n\nRESP: RECEIVED ON ROOM AIR WITH SATS 95%. STATED FEELING SLIGHT SOB, N/C 2L APPLIED WITH SATS UP TO 98%. RR 17-29 AND SATS 91-98%. HAS REMOVED O2 AS SHE SAYS IT WAS DRYING HER NOSE. LS WITH INSP WHEEZES. ALBUTEROL NEB WITH SOME EFFECT. ALSO GIVEN HER ADVAIR FOR WHICH SHE HAS NOT TAKEN IN SEVERAL DAYS. PERISTENT DRY COUGH. CXR FROM ED SHOWED NO SIGNS OF AN ACUTE PROCESS. HAS BEEN UP TO COMMODE AND SHE STATES THAT WHEN SHE RETURNS TO BED SHE IS MORE SOB. ORDERED FOR 4 MORE DAYS OF PREDNISONE.\n\nGI/GU: ABD SOFT WITH +BS. VOIDING VIA COMMODE, YELLOW AND CLEAR.\n\nFEN: NS @125CC/HR. LYTES PER CAREVUE. ORDER FOR HOUSE DIET, TAKING PO'S WELL.\n\nID: TMAX 98.2 WITH WBC 8. ONE SET BLOOD CX'S SENT. URINE CLEAN IN THE ED. NO CURRENT ABX THERAPY.\n\nSKIN: W/D/I.\n\nACCESS: PIV X2.\n\nSOCIAL/DISPO: ASTHMA EXACERBATION IN SETTING OF POSSIBLE VIRAL INFXN. PT STATES HUSBAND AND CHILDREN HAVE BEEN SICK WITH VIRAL URI. FULL CODE. HUSBAND ARRIVED WITH PT. FAMILY WAS D/T GO TO THIS AM. PT STATES THAT HER HUSBAND WILL GO TODAY WITH SON AND SHE WILL FOLLOW ON WEDNESDAY WITH DAUGHTER AND MOTHER. HAS 2 YOUNG CHILDREN, STILL BREAST FEEDING YOUNGEST. HAD PUMPED IN ED, BREAST PUMP IN ROOM FOR PT COMFORT. MD AWARE OF ^^HR AND LACTATE, NO NEW ORDERS, WILL DISCUSS IN ROUNDS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-03-03 00:00:00.000",
"description": "Report",
"row_id": 1626420,
"text": "pmicu nursing progress 7a-3p\nreview of systems\nCV-has continued to be very tachycardic to the 130's even while at rest.can be slightly higher with activity, anxiety.no c/o chest pain, palps.bp has been stable. has a cardiac echo planned for this afternoon to be followed by a CT to check for PE.\n\nRESP-wearing o2 3L nasal cannula her o2 sats were ~95-98%, when o2 off and pt speaking, sats down to high 80's%.was uncomfortable with the prongs, changed to a cool neb and pt preferred that.sats currently 97% while pt napping.her lungs are clear with few insp wheezes this am.receiving nebs as per RT. also, a nasal flu aspirate was done by RT.has a strong productive cough.is on prednisone po.\n\nID-afebrile. wbc=8.1. received loading dose of 500 mgs po azithromycin\nwill receive 250 mgs po the next 4 days.started on droplet precautions for r/o flu.\n\nNEURO-is alert and oriented x 3, has admitted to being anxious and was tx with ativan 1 mg po once she realized her infant would not be coming in.sleeping in naps.has had a headache all day, tx with 650 mgs po tylenol with little effect, can have percocet prn.\n\nF/E- receiving ivf at 125/hr. taking po fluids well. voiding pale yellow urine into commode.no peripheral edema noted. has a metabolic acidosis with lactate 4.5.\n\nGI-abd soft with positive bowel sounds.had a small stool. eating food brought from home.has multiple food allergies.\n\nIV ACCESS-has 2 peripheral heplocks\n\nSOCIAL-husband and 3 son have left for .pt hoping that she, baby daughter and mother will be able to go on wed. seems unlikely.visited by mother while pt's father watched baby.\n\na- still with extreme tachycardia of ? source.also hypoxia\n\nP-will work up with cardiac echo and CT today to r/o PE. **is allergic to shellfish but no premed needed for CT as per rad. team.on droplet precautions until flu r'd/o. assess response to azithro. med with percocet for headache and ativan for anxiety prn. as she is \"pumping and dumping\" breast milk need to keep well hydrated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-03-03 00:00:00.000",
"description": "Report",
"row_id": 1626421,
"text": "Nsg note 3p-7p:\nPt is & Oriented X3, cooperative, following commands, frequently falls asleep, easily arousable, denies any c/o pain. Pt ruled in for flu via nasal aspirate - team still deciding if going to treat. pt is currently on po prednisone & started po Azithromycin.\n\nResp: Pt alternates using nasal cannula & cool neb mask for O2 therapy. O2 sats 91-92% RA - much improved, from previous, mild cough, non-productive\n\nCardiac: Pt continues with tachycardia, HR 110's, increases 130-140's with increased activity. no ectopy noted. bp stable 110/80's- 120/80's. continues with IVF NS@125/HR. Pt also continues to pump & dump breast milk for 11 month baby @ home. Pt had ct scan with IV contrast today - (-) for PE, ? 2 SVC's noted. Please note pt should not breast feed for 48hours post ct scan.\n\nGI: pt on house diet eating & tolerating well, no n/v/d noted. Pt also with small bm on commode x1\n\nGU: Pt also voiding large amounts yellow urine on bedside commode.\n\nAccess: Pt with two peripheral IV's patent & flushes well.\n\nSocial: father visited briefly this evening. husband & son left for planned trip to today, talking via cell phone.\n\nPlan: continue droplet precautions for flu, await teams decision for additional treatment plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2138-03-04 00:00:00.000",
"description": "Report",
"row_id": 1626422,
"text": "Nursing Progess Note: 1900-0700:\n** full code\n\n** allergy: asa, motrin, multiple food allergies\n\n** access: 2 piv's.\n\npls see carevue for fhp/admit hx\n\nPt with + flu. Also being worked up for MS.\n\nNEURO: A & O x3, pleasant, cooperative, indep from bed to commode. ^^ anxious. Feels antsy and homesick. Eager to go home as she is scheduled to go on trip to with her family on Wednesday. c/o HA pain-medicated with percocet and given ativan x 2 and benadryl as sleep aid.\n\nCV: ST with hr 100-140's. HR bursts up to 130's-140's with any activity. No ectopy. NBP >90's and maps >60.\n\nRESP: on 40% cool neb-was satting in low 90's with nc but felt very dry to pt and she much prefers the mask. Does c/o sob. Lungs sound clear. Did given neb x 1 per pt request though was not wheezey. Productive cough. Sats 91-94%. rr 20's-40.\n\nGI/GU: abd soft, nondistended, + bs, small bm, formed. On house diet. Urinates clear, yellow on commode.\n\nSKIN: intact-no issue.\n\nID: afebrile. On antivirals. Droplet precautions for FLU.\n\nSOCIAL: spouse, 11 month old, 3 year old. 11 month old is with her mother who lives downstairs from her. 3 year old is already in with his Dad.\n\nPLAN: -pt is called out to floor with transfer note done but high probability to trigger with ^^ HR\n -cont med regimen and icu supportive care.\n -\n"
},
{
"category": "Echo",
"chartdate": "2138-03-03 00:00:00.000",
"description": "Report",
"row_id": 76747,
"text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath. Tachycardia\nHeight: (in) 62\nWeight (lb): 130\nBSA (m2): 1.59 m2\nBP (mm Hg): 124/90\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 16:30\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: Increased IVC diameter (>2.1cm) with <35%\ndecrease during respiration (estimated RAP (10-20mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality\ncannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Normal\naortic arch diameter. No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. The estimated right atrial pressure is\n10-20mmHg. Left ventricular wall thickness, cavity size, and systolic function\nare normal (LVEF>55%). Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Right ventricular chamber size\nand free wall motion are normal. The aortic root is mildly dilated at the\nsinus level. The ascending aorta is mildly dilated. The aortic valve leaflets\nappear structurally normal with good leaflet excursion. No aortic stenosis or\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved global\nbiventricular systolic function. Mildly dilated ascending aorta.\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": "Nursing/other",
"chartdate": "2138-03-04 00:00:00.000",
"description": "Report",
"row_id": 1626423,
"text": "NURSING PROGRESS NOTE 0700-1900\nPT STABLE THIS SHIFT. CONT TO HAVE BURSTS OF ST WITH ACTIVITY WITH HR 1TEENS-130'S - MICU TEAM AWARE, HOWEVER FEEL IT IS O2 STATUS. SATS ON RA 91-95%, INCREASES TO HIGH 90'S ON COOL NEB WITH 40% FIO2. DENIES SOB. PT ENCOURAGED TO CDB. C/O HEADACHE WITH 7/10 PAIN - MEDICATED W/1 TAB PERCOCET WITH THERAPEUTIC EFFECT. OOB TO COMMODE INDEPENDENTLY. PT EXPRESSING CONCERN REGARDING D/C-HAS PLANE TICKETS TO TOMORROW. SW IN TO SEE PT TO ASSIST WITH OBTAINING INFORMATION IF FLIGHT NDS TO BE CHANGED. CALLED OUT TO THE FLOOR. PT HAS A BED, AWAITING TRANSFER ORDERS. FULL CODE.\n"
},
{
"category": "ECG",
"chartdate": "2138-03-02 00:00:00.000",
"description": "Report",
"row_id": 193463,
"text": "Sinus tachycardia\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nSince previous tracing of the same date, sinus tachycardia rate faster\n\n"
},
{
"category": "ECG",
"chartdate": "2138-03-02 00:00:00.000",
"description": "Report",
"row_id": 193464,
"text": "Sinus tachycardia\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested\nNo previous tracing available for comparison\n\n"
}
] |
16,389 | 171,935 | 1. Shortness of breath: Pt with very complicated pulmonary picture. Severe underlying emphysema with a history of small cell lung CA. Pt also has radiation fibrosis of the right lower lobe. Pt underwent bronchoscopy on with removal of a large amount of mucous. Following this, pt had an episode of repiratory distress and was found to have a right sided pneumothorax. A chest tube was placed and the pt was transferred to the MICU for closer monitoring. Her respiratory status stabalized and she was transferred back to the floor on the following day. She remained stable from a respiratory standpoint with a good oxygen saturation on nasal canula and transtracheal catheter. Chest tube was pulled on . On , pt had an expanding pneumo so chest tube was replaced. Pt improved with this and the chest tube was pulled on with an X-ray confirming re-expanding lung and pt has been doing well since. She was gradually weaned off the nasal canula and is currently relying only on 4L via her transtracheal catheter. During the hospital course, she was started and continued on Levofloxacin 500mg a day for treatment of a likely pneumonia, presumed by the appearance of the mucous plugs. Today she is on day of the antibiotic course. She will need to take one more dose. The pt was continued on her outpatient COPD medications which include spiriva, salmeterol, albuterol and atrovent nebs. She was continued on Prednisone 40mg. She will follow-up with her pulmonologist in a week. Pt needs to have the 1cm right upper lobe spiculated mass seen on Chest CT followed up as an outpatient. Patient received aggressive pulmonary care throughout her hospital course, with catheter washings and changings twice a day. She received aggressive teaching about how she could do this herself and was feeling comfortable about changing her own on discharge. * 2. Anxiety:Pt had several episodes of anxiety which contributed to her respiratory distress. She was given Lorazepam with good effect during these episodes. She takes Lorazepam at home as well as needed for her anxiety. . 3. Chronic back pain- Pt with a long history of chronic back pain for which she takes multiple narcotics. She was continued on Acetominophen and acetominophen/oxycodone as needed and has not complained of her back pain. * 4. Type 2 DM- Metformin was held during this admission and pt's glucose was covered with regular insulin on a sliding scale. Her fingersticks showed good sugar contol throughout the admission. * 5. Depression- Zoloft was continued during this admission. * 6. Nutrition: Pt. was maintained on a diabetic diet which she tolerated well throughout the admission . 7. Prophylaxis: Pt received Heparin subcutaneously to prevent DVT. 8. Code- Patient was DNR/DNI during this admission. There was an extensive discussion with the pt during which she confirmed her code status. | IMPRESSION: Small residual right basal pneumothorax noted. A very small residual pneumothorax is noted at the right base laterally. There is a small residual pneumothorax present laterally at the right lung base. A trace residual pneumothorax is present. A trace residual pneumothorax is present at the extreme apex. IMPRESSION: Significant but incomplete re-expansion of the right lung with a persistent small right pneumothorax and linear atelectasis at the right lung base. IMPRESSION: Very slight interval increase in right basilar pneumothorax, which may be secondary to positional or inspiratory phase differences. Background emphysema again noted. There is probably a slight increase to the right lateral pneumothorax. Check status of pneumothorax. Chest tube in the right hemithorax, unchanged in position. IMPRESSION: Unchanged appearance of small right-sided basal pneumothorax. 7:33 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate right pneumothorax progression. Some patchy atelectasis is noted in the basal segments of the right lower lobe. IMPRESSION: Marked improvement in right pneumothorax following chest tube placement. Stable appearance of bilateral upper lobe lucency, consistent with longstanding emphysema. A small bore tracheostomy catheter is noted. A chest tube remains in place in the right hemithorax. Aspiration catheter again noted with its tip in the pleura of the right apex. REASON FOR THIS EXAMINATION: Evaluate for interval change of right apical pneumo FINAL REPORT HISTORY: Severe COPD. There is again evidence of background emphysema with bullous changes in the right upper lobe. REASON FOR THIS EXAMINATION: please evaluate right pneumothorax progression. There is a very slight increase in the right basal loculated pneumothorax, which may be partially due to positional and inspiratory phase differences. Emphysematous changes, most prominent in the right upper lobe. Evaluate for pneumothorax. There is again evidence of generalized pulmonary emphysema, slightly worse on the right side. The lungs appear emphysematous, notably in the right upper lobe. IMPRESSION: Severe upper lobe emphysema. Pleural catheter overlies right upper hemithorax. IMPRESSION: Severe emphysema. INDICATION: S/P chest tube placement for pneumothorax. Status post right lung carcinoma resection. There has been significant re-expansion of the right lung with a persistent small right pneumothorax and linear atelectasis in the right mid- and right lower zones. IMPRESSION: The large pneumothorax demonstrated previously has been evacuated with a small apical pigtail catheter. There are improving atelectatic changes within the right lung with residual atelectasis at the right base. Status post decompression. Pneumothorax. The heart shows slight LV enlargement. Evaluate for change of pneumothorax. Some atelectatic changes are still present in the right lower lobe. AP CHEST, ONE VIEW: Since the prior exam of , there has been interval removal of the right pleural catheter. Produced scant amt of bloody sputum X 1. Pneumothorax, status-post decompression. PCXR revealed pneumothorax, R apical CT with Heimleck valve placed in PACU, placed to -20cm suction. IMPRESSION: Right pneumothorax and atelectasis in the right lower lobe. IMPRESSION: Slight interval increase in right-sided pneumothorax. Turns STS with minimal assist.Resp: Pt rec'ing O2 via NC @ 3 l/min and transtracheal cath @ 2 l/min. Secretions cleared with bronchoscopy, trans to PACU. 0700-1500 NPNSee carevue for subjective/objective data.Neuro: Remains A+Ox3. CHEST, SINGLE AP FILM: There is a right pneumothorax with atelectasis in the right lower lobe. Right pneumothorax. Skin generally dry/flaking.Access: Periph IV's X 2 patent.Plan: Cont aggressive pulm tx, encouraging C&DB. AM labs pndg.GI: Abd soft/obese with + bowel snds, flatus. There is emphysema with focal streaky density at the right base and change since the prior study of . IMPRESSION: Emphysema most marked in upper lobes. REASON FOR THIS EXAMINATION: s/p extubation FINAL REPORT HISTORY: COPD and right small cell lung CA. Started on Levoquin and Solu-Medrol in PACU, trans to MICU at 1815.CURRENT STATUSSee carevue for subjective/objective data.Neuro: A+Ox3. SOB with minimal exertion, HOB elevated @ 45degrees. There has been significant reexpansion of the right lung since the previously noted pneumothorax. Sinus tachycardiaPoor R wave progression - ? Lungs with diminished breath snds throughout, initial exp wheezes responded well to neb tx. There is a small right apical pneumothorax seen medially. She was treated with chemo and RT for her ca; per pt ca is "gone". Dyspnic with even minimal exertion with sats dropping to high 80's--sats take approx 1min to return to baseline. COMPARISON: AP upright chest film of . Breath sounds scattered exp wheezes this AM; clear upper lobes, diminished lower lobes this afternoon. Pt again rec'd Percocet 2 tabs @ 0420 for C/O back pain with good resolution. MAE ad lib.CV/Pulm: MP=ST, no ectopy noted. MAE ad lib.CV/Pulm: MP=NSR-ST, no ectopy noted. Linear atelectases are present at the right lung base. There has been a slight interval increase in the right-sided pneumothorax, seen basally, apically, and medially. R apical CT in place, secured to anterior chest, placed to -20cm wall suction. LOS balance -350ml.Skin: Multiple hematomas bilat on UE, especially @ anticubes. PCXR done, med with Fentanyl and Versed in PACU. U/O per foley.Integ: Multiple ecchymotic areas noted on arms, trunk. Pt c/o back pain, med with Fent 50mcg x2 with some effect--less dyspnic after med for back pain. PMH/PSH significant for emphysema, sm cell ca, fibrosis RLL, former smoker. Sent to OR for bronchoscopy, found lg mucous plug around transtracheal catheter. | 21 | [
{
"category": "Radiology",
"chartdate": "2160-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847420,
"text": " 8:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change of ptx\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA w/\n pneumothorax s/p decompression\n REASON FOR THIS EXAMINATION:\n assess interval change of ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe COPD. Status post right lung carcinoma resection. Check\n status of pneumothorax.\n\n FINDINGS: A single AP upright image is provided. Comparison study taken 6\n hours earlier on the same day. There is again evidence of background\n emphysema with bullous changes in the right upper lobe. Some patchy\n atelectasis is noted in the basal segments of the right lower lobe. Some\n apical scarring may be present at the left apex. The lungs are otherwise\n clear. No definite pleural effusion is identified. The right upper lobe and\n middle lobe now appear to be well inflated. A small pigtail catheter overlies\n the lung apex, presumably in the pleural cavity. The previous large\n pneumothorax has been almost completely evacuated. A trace residual\n pneumothorax is present at the extreme apex.\n\n IMPRESSION: The large pneumothorax demonstrated previously has been evacuated\n with a small apical pigtail catheter. A trace residual pneumothorax is\n present. Some atelectatic changes are still present in the right lower lobe.\n No other significant cardiopulmonary abnormality is identified. Background\n emphysema again noted.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847427,
"text": " 7:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change of ptx\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA w/\n pneumothorax s/p decompression\n REASON FOR THIS EXAMINATION:\n assess interval change of ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe COPD s/p right small cell cancer with pneumothorax.\n Evaluate for change.\n\n AP UPRIGHT CHEST: Compared to AP upright film of . There is a very\n slight increase in the right basal loculated pneumothorax, which may be\n partially due to positional and inspiratory phase differences. Aspiration\n catheter again noted with its tip in the pleura of the right apex. Bibasilar\n atelectasis. Emphysematous changes, most prominent in the right upper lobe. No\n evidence of infiltrate or CHF.\n\n IMPRESSION: Very slight interval increase in right basilar pneumothorax, which\n may be secondary to positional or inspiratory phase differences. Follow up is\n recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847468,
"text": " 10:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P chest tube remooval on the Rt.\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA w/\n pneumothorax s/p decompression\n REASON FOR THIS EXAMINATION:\n S/P chest tube remooval on the Rt.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP UPRIGHT FILM DATED , 10:45 A.M.: Since the previous\n film of the same day, 8:20 A.M., the right chest tube has been removed. There\n is probably a slight increase to the right lateral pneumothorax. A small\n apical pneumothorax is also present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847743,
"text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change of pneuomo\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA\n w/ pneumothorax s/p decompression\n REASON FOR THIS EXAMINATION:\n evaluate for interval change of pneuomo\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Severe COPD and s/p resection of small right lung CA. Evaluate for\n change of pneumothorax.\n\n FINDINGS: Single AP semi-upright image is provided. Comparison study dated\n . A very small residual pneumothorax is noted at the right base\n laterally. The appearances are otherwise unchanged. Some atelectatic changes\n are noted at both bases. No other focal pulmonary abnormality is identified.\n The lungs appear emphysematous, notably in the right upper lobe. The heart\n shows slight LV enlargement. There is no evidence of cardiac failure.\n\n IMPRESSION: Small residual right basal pneumothorax noted. Otherwise,\n unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847330,
"text": " 3:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval lung reexpansion\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA w/\n pneumothorax s/p decompression\n REASON FOR THIS EXAMINATION:\n please eval lung reexpansion\n ______________________________________________________________________________\n FINAL REPORT\n History of COPD, lung cancer, pneumothorax.\n\n Pleural catheter overlies right upper hemithorax. There has been significant\n re-expansion of the right lung with a persistent small right pneumothorax and\n linear atelectasis in the right mid- and right lower zones. Atelectasis is\n present at the left lung base.\n\n IMPRESSION: Significant but incomplete re-expansion of the right lung with a\n persistent small right pneumothorax and linear atelectasis at the right lung\n base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847833,
"text": " 5:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA\n w/pneumothorax s/p decompression.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD and lung cancer, evaluate for pneumothorax.\n\n COMPARISON: .\n\n AP PORTABLE UPRIGHT CHEST: There has been no interval change in the small\n right-sided basal pneumothorax. There remains subtle bibasilar atelectasis,\n without evidence of focal infiltrate or significant pleural effusion. Heart\n size is within normal limits. Mediastinal and hilar contours are unremarkable.\n\n IMPRESSION: Unchanged appearance of small right-sided basal pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847701,
"text": " 6:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: new chest tube placed\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA w/\n pneumothorax s/p decompression\n REASON FOR THIS EXAMINATION:\n new chest tube placed\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST:\n\n Compared to previous study of earlier the same day.\n\n INDICATION: S/P chest tube placement for pneumothorax.\n\n A right pigtail pleural catheter has been placed, with marked interval\n improved expansion of the right lung. There is a small residual pneumothorax\n present laterally at the right lung base. There are improving atelectatic\n changes within the right lung with residual atelectasis at the right base.\n There is otherwise no significant change compared to the earlier study of the\n same date.\n\n IMPRESSION: Marked improvement in right pneumothorax following chest tube\n placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848216,
"text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change of right apical pneumo\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA\n w/pneumothorax s/p decompression.\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change of right apical pneumo\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe COPD. Right small cell lung CA. Pneumothorax. Follow up.\n\n PORTABLE AP CHEST, 1 VIEW: Comparison , 8:53. No definite pneumothorax\n is seen on the current exam, however, the patient is rotated and soft tissues\n from the patient's chin partially obscure the right apex and a small right\n apical pneumothorax could be obscured. Repeat study with better positioning\n could be performed for further evaluation. No other changes are noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848299,
"text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate right pneumothorax progression. thank you.\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA\n w/pneumothorax s/p decompression.\n REASON FOR THIS EXAMINATION:\n please evaluate right pneumothorax progression. thank you.\n ______________________________________________________________________________\n FINAL REPORT\n\n DATE: \n\n CHEST:\n\n INDICATION: Severe COPD and status post right small cell lung carcinoma with\n pneumothorax. Status post decompression.\n\n FINDINGS: A single AP upright image. Comparison study dated . There is again evidence of generalized pulmonary emphysema, slightly\n worse on the right side. This is associated with lung hyperinflation and\n vascular attenuation. No focal pulmonary infiltrate is identified. No\n definite effusion is seen. A small bore tracheostomy catheter is noted.\n\n IMPRESSION: Severe emphysema. No focal pulmonary or pleural abnormalities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848058,
"text": " 12:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess the rt side for a pneumotx\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA\n w/pneumothorax s/p decompression.\n REASON FOR THIS EXAMINATION:\n assess the rt side for a pneumotx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe COPD with small cell lung cancer, please assess\n pneumothorax.\n\n AP UPRIGHT CHEST: Comparison to AP upright of . Chest tube in the right\n hemithorax, unchanged in position. No pneumothorax identified. Stable\n appearance of bilateral upper lobe lucency, consistent with longstanding\n emphysema. There is bibasilar linear atelectasis. Size is within normal\n limits. Lungs are otherwise clear.\n\n IMPRESSION:\n\n 1. No pneumothorax identified.\n 2. Severe emphysema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847904,
"text": " 9:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess the rt lung for a ptx\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA\n w/pneumothorax s/p decompression.\n REASON FOR THIS EXAMINATION:\n Assess the rt lung for a ptx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Lung cancer. Evaluate for pneumothorax.\n\n A chest tube remains in place in the right hemithorax. There is severe\n emphysema present which likely accounts for the hyperlucency of the right\n upper lobe as well as the left upper lobe. No definite pneumothorax is\n identified on this portable study. Cardiac and mediastinal contours are\n stable.\n\n IMPRESSION: Severe upper lobe emphysema. No definite pneumothorax. However, if\n clinical suspicion for pneumothorax is high, dedicated PA and lateral chest\n radiograph within the department may be helpful for more complete assessment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847680,
"text": " 3:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess the Rt lung for a pneumo\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA w/\n pneumothorax s/p decompression\n REASON FOR THIS EXAMINATION:\n Assess the Rt lung for a pneumo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD and history of small cell lung cancer, with recent\n pneumothorax.\n\n COMPARISON: AP upright chest film of . There has been a slight\n interval increase in the right-sided pneumothorax, seen basally, apically, and\n medially. Heart size is within normal limits. Otherwise, the lungs are clear\n without evidence of infiltrate or effusion. Mediastinal and hilar contours\n are unremarkable.\n\n IMPRESSION: Slight interval increase in right-sided pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847280,
"text": " 9:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA. Now with\n increased SOB.\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM.\n\n History of COPD with lung cancer and increasing shortness of breath.\n\n There is emphysema with focal streaky density at the right base and change\n since the prior study of .\n\n IMPRESSION:\n Emphysema most marked in upper lobes. No change in right basilar density\n since prior study of . No new lung lesion. old healed fracture\n left 6th rib.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847319,
"text": " 1:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA. Now with\n increased SOB.\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of COPD, lung cancer, and increased shortness of breath.\n\n CHEST, SINGLE AP FILM: There is a right pneumothorax with atelectasis in the\n right lower lobe. No shift of heart or mediastinum. The left lung remains\n clear.\n\n IMPRESSION: Right pneumothorax and atelectasis in the right lower lobe.\n\n Findings were discussed with , by telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847404,
"text": " 3:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval chg of ptx\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA w/\n pneumothorax s/p decompression, w/chest tube\n REASON FOR THIS EXAMINATION:\n interval chg of ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Lung cancer and pneumothorax.\n\n Tip of the catheter is present in the right upper hemithorax. There has been\n significant reexpansion of the right lung since the previously noted\n pneumothorax. There is probably some residual pneumothorax difficult to\n evaluate because of the marked bullous emphysema in the right upper zone.\n Linear atelectases are present at the right lung base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848145,
"text": " 8:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p extubation\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA\n w/pneumothorax s/p decompression.\n REASON FOR THIS EXAMINATION:\n s/p extubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD and right small cell lung CA. Pneumothorax, status-post\n decompression.\n\n AP CHEST, ONE VIEW: Since the prior exam of , there has been interval\n removal of the right pleural catheter. There is a small right apical\n pneumothorax seen medially. No other changes are noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 847491,
"text": " 1:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: follow rt pneumo\n Admitting Diagnosis: TRACHEAL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with severe COPD and s/p right small cell lung CA w/\n pneumothorax s/p decompression\n REASON FOR THIS EXAMINATION:\n follow rt pneumo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe COPD and right small-cell lung Ca. Right pneumothorax.\n\n Since the previous exam of 10:45 on the same day, there has been no\n significant change to the right apical or the right lateral pneumothorax. The\n rest of the lungs are unchanged as well.\n\n IMPRESSION: No interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2160-12-19 00:00:00.000",
"description": "Report",
"row_id": 195579,
"text": "Sinus tachycardia\nPoor R wave progression - ? lead placement\nSince previous tracing, QRS changes in V3 - ? lead placement\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-12-21 00:00:00.000",
"description": "Report",
"row_id": 1476831,
"text": "Nursing Progress Note 1900-0700\nReview of Systems:\n\nNeuro: Pt initially very weepy/anxious->tx'd with reassurance and Percocet 2 tabs for back pain and pain from bronch. Pt again rec'd Percocet 2 tabs @ 0420 for C/O back pain with good resolution. Pt X 3, cooperative and following commands consistantly. Turns STS with minimal assist.\n\nResp: Pt rec'ing O2 via NC @ 3 l/min and transtracheal cath @ 2 l/min. husband to bring in cleaning, etc equipment for transtracheal cath. Sating 93-95% with RR 14-19. SOB with minimal exertion, HOB elevated @ 45degrees. Lungs with diminished breath snds throughout, initial exp wheezes responded well to neb tx. Strong, congested cough. Produced scant amt of bloody sputum X 1. CT dsg intact. CT to 20cm H2O, no leak or crepitus.\n\nCV: HR 95-108SR without ectopy. BP 113/71-140/88. Afebrile. AM labs pndg.\n\nGI: Abd soft/obese with + bowel snds, flatus. Pt eating/drinking small amt on /consistant carbohydrate diet. Required Insulin 2units @ MN.\n\nGU: Urine yellow/clear via foley @ 25-60ml/hr. LOS balance -350ml.\n\nSkin: Multiple hematomas bilat on UE, especially @ anticubes. Skin generally dry/flaking.\n\nAccess: Periph IV's X 2 patent.\n\nPlan: Cont aggressive pulm tx, encouraging C&DB. Encourage po fluid intake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-12-21 00:00:00.000",
"description": "Report",
"row_id": 1476832,
"text": "0700-1500 NPN\nSee carevue for subjective/objective data.\nNeuro: Remains A+Ox3. Speech clear. MAE ad lib.\n\nCV/Pulm: MP=NSR-ST, no ectopy noted. Remains on transtracheal O2 at 4l with np at 2l. Sats at rest 91-96%. Dyspnic with even minimal exertion with sats dropping to high 80's--sats take approx 1min to return to baseline. Breath sounds scattered exp wheezes this AM; clear upper lobes, diminished lower lobes this afternoon. R apical CT remains in place, changed from wall suction to water seal. CT dsg D+I.\n\nGI/GU: Tol PO's fair--sats dropped to 80's at times while eating. Pt instructed to take small bites with approx 60seconds between bites--pt agrees to this. No flatus, no BM. Abd round, soft, non-tender, bowel sounds present. U/O per foley this AM--foley DC'd at 1230.\n\nInteg: No open areas noted. Multiple ecchymotic areas noted on arms, legs. OOB to chair at 1300 with 2 assists tol fair--very SOB following pivot to chair; once settled in chair tol sitting up well. Remains in chair at this time.\n\nID/Endo: Remains on Levoquin. Afebrile. Sliding scale coverage for fingersticks, restarted on oral .\n\nPsychosocial/Plan: Emotional support given to pt and fam. Husband and family in to visit. Plan is to trans to floor this afternoon, cont'd O2, cont CT, CXR today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-12-20 00:00:00.000",
"description": "Report",
"row_id": 1476830,
"text": "NSG ADMISSION NOTE\nMs. is a 52yo female admitted to OSH 3days PTA with increasing SOB. PMH/PSH significant for emphysema, sm cell ca, fibrosis RLL, former smoker. She was treated with chemo and RT for her ca; per pt ca is \"gone\". She had a transtracheal catheter placed four months ago for home O2. She was at home with husband and dog until 3 days ago when she developed increasing SOB and inability to manage at home. OSH trans to for further evual and workup. Sent to OR for bronchoscopy, found lg mucous plug around transtracheal catheter. Secretions cleared with bronchoscopy, trans to PACU. Initially in PACU SBP 140-160 with sats mid 90's, plan was to trans pt to medical floor. This afternoon pt c/o SOB, dyspnea, sats dropped to 75%, breath sounds diminished, HR elevated to 140, using accessory muscles. PCXR done, med with Fentanyl and Versed in PACU. PCXR revealed pneumothorax, R apical CT with Heimleck valve placed in PACU, placed to -20cm suction. Following insertion of CT RR returned to 18-20 (from 30's), sat 93%, HR 110. Placed on 40% closed face mask aerosol (want to keep pt humidified as much as possible). Total 2l fluid rec'd between OR and PACU, 200 urine output OR and PACU. Started on Levoquin and Solu-Medrol in PACU, trans to MICU at 1815.\n\nCURRENT STATUS\nSee carevue for subjective/objective data.\nNeuro: A+Ox3. Speech clear. MAE ad lib.\n\nCV/Pulm: MP=ST, no ectopy noted. BP 120's/60's. Arrived on np at 4l for transport, placed back on 40% closed face mask upon arrival. Transtracheal catheter clamped. R apical CT in place, secured to anterior chest, placed to -20cm wall suction. No air leak, no crepitus noted. BS scattered exp wheezes, especially in lower lobes. Using accessory muscles to breathe. Sats mid 90's. Pt c/o back pain, med with Fent 50mcg x2 with some effect--less dyspnic after med for back pain. Tight, non-productive cough noted.\n\nGI/GU: Abd soft, round, non-tender, bowel sounds present. No flatus, no BM. Requesting PO's. U/O per foley.\n\nInteg: Multiple ecchymotic areas noted on arms, trunk. No open areas noted.\n\nID/Endo: Afebrile. To cont on Levoquin (started in PACU). Sliding scale coverage for fingersticks (on steroids).\n\nPsychosocial/Plan: Emotional support given to pt. No visitors with pt at this time. Plan is to cont to med for pain MD orders, provide resp support, maintain CT, monitor I+O.\n"
}
] |
10,328 | 126,417 | The patient was admitted for a thymectomy with a medial sternotomy which she tolerated well and was transferred to the ICU in stable condition. The patient had one chest tube placed in the right pleural space and one chest tube placed in the left pleural space. The patient also had drain placed in each pleural space. Neurology was consulted to provide recommendations regarding post-op care. Serial ABG's, negative inspiratory forces, and vital capacities were obtained to monitor the patient for hypercarbia. As her pain became better controlled, her ABG's also improved. This was likely a product of an improvement in her ability to take deeper breaths with better pain control. Cellcept and cyclosporine were continued for immunosuppression. Serial chest x-rays were obtained to monitor for hemothorax. The patient was transferred to the floor on the post-op day 3. The following day, she was transfused one unit of packed red blood cells for a Hct of 22.6. Both chest tubes were able to be pulled. The patient was started on PO Keflex as empiric antibiotic therapy to prevent empyema while she had her drains in. She was discharged in stable condition with her drains. At discharge, her pain was well controlled, she was tolerating a regular diet, and she was able to ambulate without assistance. Her negative inspiratory forces and vital capacities were in the normal range throughout her admission and she did not display any symptoms of myasthenia . | AFEBRILE.RESP: LS CLR, BASES DIM. A small right effusion with mild right basilar atelectasis is visualized. DRAINS TO BULB SXN, SCAN SEROUS DRAINAGE NOTED.GI/GU/ENDO: PT TOLERATES CLR LIQS & PO MEDS. abd soft, +bowel sounds. VSS, other then hypotension w/MSO4 administration. Intermittent c/o nausea, subsides by self. Repeat gas slightly improved see carevue. Persistent moderate left and small right pleural effusions. Rt pleural CT d/c. LUNGS CLEAR, DIMINSHED R BASE. Monitor resp. BILATERAL CT TO SX DRAINED SCANT AMT SEROSANGUINOUS, BILATERAL JP DRAINS INTACT, MINIMAL SANGUINOUS DRAINAGE.CV: NSR-ST, 88-115. minimal B/ drainage to thoracic. IMPRESSION: AP chest compared to : Mild edema and moderate left lower lobe atelectasis are new. COMPRESSION SLEEVES & SC HEPARIN FOR DVT PROPH. Mediastinum has a normal postoperative appearance. IMPRESSION: Unchanged appearance of bilateral pleural effusions and tiny left apical pneumothorax. Peripheral pulses palpable w/ease. Minimal serosanguinous drainage. Resp Care: NIF and vital capacity done. IMPRESSION: Small bilateral pleural effusions with bibasilar atelectasis. Moderate left pleural effusion is probably unchanged allowing for positional differences, as well as a small right pleural effusion. Mild-to-moderate dextroscoliosis in the thoracic spine is present. Using PCA dilaudid. Resp. Moderate left pleural effusion and left basilar atelectasis and consolidation are unchanged. BILATERAL PLEURAL TUBES TO LWS, RT PLEURAL TUBE DRAINING SCANT SEROUSY/STRAW COLORED FLUID. NO HX DM.GI: ABDOMEN SOFTLY DISTENDED, HYPACTIVE BS. Small right pleural effusion has decreased. FINDINGS: Tiny left apical pneumothorax is unchanged. EXTREMITIES W/D. Neuro team following closely d/t dx of MG. PERRLA.CV: RSR->ST w/o ectopy. Right chest tube is unchanged. There is a small right pleural effusion. TOLERATING LIQUIDS. Mg repleted 4gm as ordered.Resp: LS clear diminished. Chest tube removal. +PERRL.CV: ST 110s-120s, NO ECTOPY. ABD SOFT, NT. Monitor, tx, support and comfort. CDB, I.S. Better pain controle w/dilaudid after attempts w/MSO4. Mild left basilar atelectasis with a tiny effusion is also seen. Good cough. Pulmonary hygeine. + RESP ACIDOSIS. ENCOURAGE MOVEMENT, COUGH, DB. percocet po given q4hrs for pain with some effect. A chest tube has been removed from the left hemithorax, and there is a new very small left apical pneumothorax present. No resp distress noted, = rise and fall of chest.GI: H2 blocker for GI prophylaxis. TYLENOL Q4H FOR PAIN CONTROL, SMALL AMTS DILAUDID ONCE MORE AWAKE. +BS. tolerating po's well.plan: 2. ND. Pain well controlled with percocets. IMPRESSION: New very small left pneumothorax following chest tube removal. Perrla. ABGS REFLECT IMPROVED RESP ACIDOSIS. , RRT JP to bulb suction draining serosang. BP STABLE 110s-120s. Pt voided. NIF: -35 VC 1.0-1.1L. RESPIRATORY CARE NOTEPatient seen for NIF and VC. ABGs w/Resp Acidosis. Pulmonary toilet. CT bilat to suction, right draining serous drainage, left w/ scant amt of serosang, no air leaks, no crepitus. Heparin sq and p boots for DVT prophylaxis.Resp: Lungs clear o2 weaned to 2 L np. acidosis 7.30 PCO2 55, NP aware, dilaudid pca dose decreased. SBP 95-120s. INDICATION: Thymectomy. NIF=32, VC=1.7 liters. Cardiomediastinal silhouette is stable. C/o of pain.ROS:Neuro: Sleepy but arouses w/ease. There is a fluid component (thus a hydropneumothorax) which is likewise stable. ABG's show improving respiratory acidosis. Cardiac and mediastinal contours are stable. Monitor ABGs. NO DIFFICULTY W/SWALLOWING. Two drains overlying the chest are unchanged in position. Nursing Progress Note:Pt x3. There is approximately 12 mm of maximal visceral and parietal pleural separation. USES I.S. ADEQUATE HUO, CLR YELLOW. NEURO: PT IS A&OX3, CALM BUT TEARFUL AT TIMES, RE: PAIN -> "I JUST CAN'T GET COMFORTABLE"; PT USING PCA DILAUDED APPROPRIATELY. COMPARISON: . COMPARISON: . speech clear.cv: remains ST without ectopy. Lt pleural CT to water seal. Two drains overlie the chest, crossing the midline, unchanged in position. palpable pulses to all extremities.resp: ls clear bilat, uses IS, coughs, deep breathes. 250CC NS FOR SBP 88 AND LOW UO WITH IMPROVEMENT. acidosis as noted above in Neuro note, see carevue for abgs. NO C/O NAUSEA. IMPRESSION: No significant interval change in small left apical pneumothorax. Has right radial abp line. status. Right middle lobe atelectasis is also identified. PLAN: continue to monitor ABG's and respiratory mechanics Q8. Pain mngt. + palpable pulses. Moderate effort given that she is hesitant to go full force d/t pain. Will transfer when bed is available in 2 and d/c Lt pleural CT. sbp 100-110's. Bilateral pleural drains in place in the upper chest. Monitor ability to swallow and cough and other signs of changing weakness. amd with steady gait. OOB to chair with minimal assistance. Swallowing and coughing w/o difficulties. bilat JP's draining minimal drainage, left chest tube minimal drainage, no airleak.endo: RISSgi/gu: voids to the comode, sufficient amts clear yellow urine. RESP RATE 10s. MAE. Given tylenol po for HA, pt states HA/migraine common for pt, light turned off in room.CV: HR 100-120s. Eyes droopy. Transfer orders written. LCTA decreased at bases. MONITOR PAIN, ASSESS FOR NEUROMUSCULAR WEAKNESS, ABILITY TO SWALLOW. BS 140'S-160'S. There may be a new or increased moderate left pleural effusion and accompanying substantial left lower lobe atelectasis. SBP 88-130'S. Tolerating regular diet. CONTINUE SUPPORT & UPDATE PT/FAMILY RE: STATUS & PLAN OF CARE. PALPABLE PULSES. 7a-7pNeuro: Pt alert and oriented, normal strength to all extremeties. Needs much encouragement w/ IS and coughing and deep breathing. PT MOUTH BREATHES WHEN ASLEEP, ADDED 2L NC AFTER SATS DECREASED TO LOW 90s~SATS NOW >97%. Foley draining clear yellow urine adequate amts.Endo: RISS.Plan: Monitor hemodynamics. PALPABLE PEDAL PULSES. Abd soft w/o bowel sounds.GU: Foley patent draining clear yellow urine in QS.Heme: Hct stable 27.5Social: Husband and at side, very supportive.Plan: Frequent IS. FINDINGS: Within slight differences in positioning, there has been no significant interval change in the small left apical pneumothorax previously described. On 8 L o2 via mask. HISTORY: Thymectomy. MAE with equal strength, follows commands. 7p-7aneuro: alert, oriented x3. BS MONITORED PER CSRU PROTOCOL. S/P THYMECTOMY FOR MANAGEMENT OF MYASTHENIA . | 13 | [
{
"category": "Nursing/other",
"chartdate": "2169-02-02 00:00:00.000",
"description": "Report",
"row_id": 1398790,
"text": "Nursing Progress Note:\nPt x3. MAE. OOB to chair with minimal assistance. No neuro deficits noted. LCTA decreased at bases. Sats 96% on RA. No c/o sob. Rt pleural CT d/c. Lt pleural CT to water seal. minimal B/ drainage to thoracic. Minimal serosanguinous drainage. Good cough. Tolerating regular diet. Pt voided. Pain well controlled with percocets. Transfer orders written. Will transfer when bed is available in 2 and d/c Lt pleural CT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-03 00:00:00.000",
"description": "Report",
"row_id": 1398791,
"text": "7p-7a\nneuro: alert, oriented x3. MAE with equal strength, follows commands. percocet po given q4hrs for pain with some effect. amd with steady gait. speech clear.\n\ncv: remains ST without ectopy. sbp 100-110's. palpable pulses to all extremities.\n\nresp: ls clear bilat, uses IS, coughs, deep breathes. bilat JP's draining minimal drainage, left chest tube minimal drainage, no airleak.\n\nendo: RISS\n\ngi/gu: voids to the comode, sufficient amts clear yellow urine. abd soft, +bowel sounds. tolerating po's well.\n\nplan: 2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-03 00:00:00.000",
"description": "Report",
"row_id": 1398792,
"text": "RESPIRATORY CARE NOTE\n\nPatient seen for NIF and VC. NIF=32, VC=1.7 liters. Moderate effort given that she is hesitant to go full force d/t pain.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-01 00:00:00.000",
"description": "Report",
"row_id": 1398787,
"text": "Resp Care: NIF and vital capacity done. NIF: -35 VC 1.0-1.1L. Pt hesitant due to pain. ABG's show improving respiratory acidosis. PLAN: continue to monitor ABG's and respiratory mechanics Q8.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-01 00:00:00.000",
"description": "Report",
"row_id": 1398788,
"text": "7a-7p\nNeuro: Pt alert and oriented, normal strength to all extremeties. Perrla. Pt more awake at beginning of shift, c/o pain, teams (Csurg and thoracic) aware on rounds, pca diludid increased, pt became more sleepy, ABG showing resp. acidosis 7.30 PCO2 55, NP aware, dilaudid pca dose decreased. Repeat gas slightly improved see carevue. Given tylenol po for HA, pt states HA/migraine common for pt, light turned off in room.\n\nCV: HR 100-120s. NP aware of HR at 1200-1300 120s ST no ectopy, no new orders. SBP 95-120s. MAP>60. + palpable pulses. Mg repleted 4gm as ordered.\n\nResp: LS clear diminished. CT bilat to suction, right draining serous drainage, left w/ scant amt of serosang, no air leaks, no crepitus. JP to bulb suction draining serosang. Resp. acidosis as noted above in Neuro note, see carevue for abgs. Needs much encouragement w/ IS and coughing and deep breathing. Sats >94, on RA.\n\nGI/GU: ABd soft, hypoactive BS, tolerating sips on soup and juice, does not want any solid foods yet. Intermittent c/o nausea, subsides by self. Foley draining clear yellow urine adequate amts.\n\nEndo: RISS.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Pulmonary hygeine. Pain control, start po pain meds tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-02 00:00:00.000",
"description": "Report",
"row_id": 1398789,
"text": "NEURO: PT IS A&OX3, CALM BUT TEARFUL AT TIMES, RE: PAIN -> \"I JUST CAN'T GET COMFORTABLE\"; PT USING PCA DILAUDED APPROPRIATELY. SLEPT INTERMITTENTLY, EASILY AROUSES TO VOICE; MAES EQUALLY TO COMMAND, NO DEFICITS. DIFFICULTY W/TURNS DUE TO DISCOMFORT FROM BILATERAL CTs. +PERRL.\n\nCV: ST 110s-120s, NO ECTOPY. BP STABLE 110s-120s. PALPABLE PULSES. EXTREMITIES W/D. COMPRESSION SLEEVES & SC HEPARIN FOR DVT PROPH. AFEBRILE.\n\nRESP: LS CLR, BASES DIM. O2SATs 92-96% ON RA. RESP RATE 10s. PT MOUTH BREATHES WHEN ASLEEP, ADDED 2L NC AFTER SATS DECREASED TO LOW 90s~SATS NOW >97%. WEAK COUGH~PT BECOMES TEARFUL WHEN ATTEMPT TO COUGH DUE TO PAIN \"I JUST CAN'T, IT HURTS TOO MUCH\". USES I.S. TO 500. ABGS REFLECT IMPROVED RESP ACIDOSIS. BILATERAL PLEURAL TUBES TO LWS, RT PLEURAL TUBE DRAINING SCANT SEROUSY/STRAW COLORED FLUID. NO DRAINING NOTED FROM LEFT PLEURAL TUBE. DRAINS TO BULB SXN, SCAN SEROUS DRAINAGE NOTED.\n\nGI/GU/ENDO: PT TOLERATES CLR LIQS & PO MEDS. NO DIFFICULTY W/SWALLOWING. NO C/O NAUSEA. +BS. ABD SOFT, NT. ND. ADEQUATE HUO, CLR YELLOW. D5.45 NS @ 50CC/HR CONTINUES. BS MONITORED PER CSRU PROTOCOL. NO RSSI COVERAGE REQUIRED OVERNIGHT.\n\nSOCIAL: NO TELEPHONE CALLS FROM FAMILY THIS SHIFT.\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS. MONITOR PAIN, ASSESS FOR NEUROMUSCULAR WEAKNESS, ABILITY TO SWALLOW. MONITOR LABS, CT OUTPUT. CDB, I.S. CONTINUE SUPPORT & UPDATE PT/FAMILY RE: STATUS & PLAN OF CARE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-01-31 00:00:00.000",
"description": "Report",
"row_id": 1398785,
"text": "Admitted post op from the OR via bed post thymectomy for mngt of myasthenia . On 8 L o2 via mask. Sleepy but awake and oriented. C/o of pain.\n\nROS:\n\nNeuro: Sleepy but arouses w/ease. Better pain controle w/dilaudid after attempts w/MSO4. Using PCA dilaudid. Swallowing and coughing w/o difficulties. Eyes droopy. Neuro team following closely d/t dx of MG. PERRLA.\n\nCV: RSR->ST w/o ectopy. VSS, other then hypotension w/MSO4 administration. Peripheral pulses palpable w/ease. Has right radial abp line. Heparin sq and p boots for DVT prophylaxis.\n\nResp: Lungs clear o2 weaned to 2 L np. ABGs w/Resp Acidosis. IS being done q 15 w/near constant stimulation to keep awake. When left to sleep has periods of apnea and RR drops < 8 BPM. No resp distress noted, = rise and fall of chest.\n\nGI: H2 blocker for GI prophylaxis. Taking chips/sip and now jello. No c/o N/V. Abd soft w/o bowel sounds.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nHeme: Hct stable 27.5\n\nSocial: Husband and at side, very supportive.\n\nPlan: Frequent IS. Monitor ability to swallow and cough and other signs of changing weakness. Notify neuro team prior to any invasive ventilation. Pulmonary toilet. Monitor ABGs. Pain mngt. Monitor, tx, support and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-02-01 00:00:00.000",
"description": "Report",
"row_id": 1398786,
"text": "S/P THYMECTOMY FOR MANAGEMENT OF MYASTHENIA . SEE CAREVUE FOR Q1H VS, I&O, Q2-4H CV ASSESSMENTS, LABS AND ALL OTHER OBJECTIVE DATA.\n\nNEURO: \"IT HURTS SO BAD I CAN'T BREATHE.\" LETHARGIC, SLEEPS WHEN NO ONE IS IN ROOM, AWAKENS EASILY, O X 3, MAE, GOOD STRENGTH ALL EXTREMITIES, SWALLOWING WNL, ABLE TO SWALLOW ALL PILLS. TYLENOL 650MG PO Q4H FOR PAIN CONTROL, SCANT AMTS DILAUDID PCA ADMINISTERED BY THIS NURSE(TOTAL 0.2MG) ONCE PCO2 < 50.\n\nPULM: O2 WEANED OFF D/T PO2 155 ON 1 LITER BUT PO2 DROPPED TO 66 ON RA. + RESP ACIDOSIS. USING IS TO 500CC, POOR COUGH. LUNGS CLEAR, DIMINSHED R BASE. BILATERAL CT TO SX DRAINED SCANT AMT SEROSANGUINOUS, BILATERAL JP DRAINS INTACT, MINIMAL SANGUINOUS DRAINAGE.\n\nCV: NSR-ST, 88-115. SBP 88-130'S. 250CC NS FOR SBP 88 AND LOW UO WITH IMPROVEMENT. PALPABLE PEDAL PULSES. D51/2NS WITH 20 KCL @ 50CC/HR.\n\nENDO: NOT ON SSRI COVERAGE. BS 140'S-160'S. NO HX DM.\n\nGI: ABDOMEN SOFTLY DISTENDED, HYPACTIVE BS. TOLERATING LIQUIDS. BRIEF C/O NAUSEA AFTER ICED FLUIDS.\n\nGU: FOLEY TO CD DRAINING CLEAR YELLOW-AMBER URINE.\n\nSOCIAL: FAMILY UNTIL ~ .\n\nPLAN: CONTINUE AGGRESSIVE PULM HYGIENE, MONITOR ABG Q2-4H. TYLENOL Q4H FOR PAIN CONTROL, SMALL AMTS DILAUDID ONCE MORE AWAKE. ENCOURAGE MOVEMENT, COUGH, DB. OOB TO CHAIR TODAY.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943712,
"text": " 4:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PLEASE PERFORM AT 4PM TODAY?PTX\n Admitting Diagnosis: MYASTHENIA /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with s/p thymectomy, n/w chest tube in L chest removed &\n right-sided tube to water seal\n REASON FOR THIS EXAMINATION:\n PLEASE PERFORM AT 4PM TODAY?PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Thymectomy. Chest tube removal.\n\n A chest tube has been removed from the left hemithorax, and there is a new\n very small left apical pneumothorax present. Moderate left pleural effusion\n is probably unchanged allowing for positional differences, as well as a small\n right pleural effusion. Cardiac and mediastinal contours are stable. Two\n drains overlie the chest, crossing the midline, unchanged in position.\n\n IMPRESSION: New very small left pneumothorax following chest tube removal.\n Persistent moderate left and small right pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943756,
"text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval cxr\n Admitting Diagnosis: MYASTHENIA /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with s/p thymectomy, n/w chest tube in L chest removed &\n right-sided tube to water seal\n REASON FOR THIS EXAMINATION:\n interval cxr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old female status post thymectomy, now with removal of\n left chest tube.\n\n COMPARISON: .\n\n FINDINGS: Tiny left apical pneumothorax is unchanged. Right chest tube is\n unchanged. Moderate left pleural effusion and left basilar atelectasis and\n consolidation are unchanged. There is a small right pleural effusion.\n Cardiomediastinal silhouette is stable. Two drains overlying the chest are\n unchanged in position.\n\n IMPRESSION: Unchanged appearance of bilateral pleural effusions and tiny left\n apical pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943785,
"text": " 9:43 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o pneumothorax\n Admitting Diagnosis: MYASTHENIA /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with s/p thymectomy, n/w chest tube in L chest removed &\n right-sided tube removed as well.\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST at 10:14 a.m.\n\n HISTORY: Post-thymectomy and chest tube manipulation.\n\n COMPARISON: Multiple priors, the most recent dated at 5:07 hours.\n\n FINDINGS: Within slight differences in positioning, there has been no\n significant interval change in the small left apical pneumothorax previously\n described. There is approximately 12 mm of maximal visceral and parietal\n pleural separation. There is a fluid component (thus a hydropneumothorax)\n which is likewise stable. Right middle lobe atelectasis is also identified.\n Otherwise, the study is stable since earlier same day.\n\n IMPRESSION: No significant interval change in small left apical pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943459,
"text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: MYASTHENIA /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with s/p thymectomy\n\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:27 A.M. .\n\n HISTORY: Thymectomy.\n\n IMPRESSION: AP chest compared to :\n\n Mild edema and moderate left lower lobe atelectasis are new. There may be a\n new or increased moderate left pleural effusion and accompanying substantial\n left lower lobe atelectasis. Small right pleural effusion has decreased.\n There is no pneumothorax. Mediastinum has a normal postoperative appearance.\n Bilateral pleural drains in place in the upper chest. No pneumothorax.\n Stomach is severely distended with gas. Dr. was paged to report these\n findings, at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-01-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 943373,
"text": " 1:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P thymectomy\n Admitting Diagnosis: MYASTHENIA /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with\n REASON FOR THIS EXAMINATION:\n S/P thymectomy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post thymectomy.\n\n COMPARISON: .\n\n CHEST AP: Median sternotomy sutures are present along with four chest tubes,\n two on each side. A small right effusion with mild right basilar atelectasis\n is visualized. Mild left basilar atelectasis with a tiny effusion is also\n seen. Mild-to-moderate dextroscoliosis in the thoracic spine is present.\n\n IMPRESSION: Small bilateral pleural effusions with bibasilar atelectasis.\n\n\n"
}
] |
82,722 | 138,836 | 80F h/o colon CA s/p colectomy c/b enterocutaneous fistulas, COPD with massiv duodenal bleed transferred for embolization. She was hypotensive on arrival and continued to be so until her death. Although she had an embolization of a bleeding vessel by IR on transfer, she continued to bleed via her OGT despite attempts to correct her coagulopathy via FFB, cryoprecipitate and platelets and up to 20 U of PRBC. Her family did not wish for surgical intervention and asked for her to be made comfort measures. She died shortly thereafter. . # UGIB: Duodenal ulcer on EGD. Failed endoscopic control, transferred for IR embolization. Hemodynamically unstable. - IR to evaluate - CVL and PIVs - T&X 9 units - IV protonix and octreotide gtt - q4h hct - continue levophed gtt - stat coags on arrival, FFP for goal INR<1.5 - Consider GI and surgery evaluations | # Hypocalcemia: Likely secondary to citrate in blood products - replete per sliding scale . # Hyperphosphatemia: Likely secondary to hypoperfusion - Will consult renal regarding management - Will likely need CVVH . Hypotensive on levophed gtt. Hypotensive on levophed gtt. Hypotensive on levophed gtt. Hypotensive on levophed gtt. Hypotensive on levophed gtt. # Acute renal failure: Likely secondary to ATN given prolonged hypoperfusion. Admitted to OSH today from rehab after syncopal event described as diphoresis and 'twitching'. Admitted to OSH today from rehab after syncopal event described as diphoresis and 'twitching'. Admitted to OSH today from rehab after syncopal event described as diphoresis and 'twitching'. Admitted to OSH today from rehab after syncopal event described as diphoresis and 'twitching'. Admitted to OSH today from rehab after syncopal event described as diphoresis and 'twitching'. # Hyperkalemia: Likely secondary to hypoperfusion. Developed coffee ground emesis and underwent EGD which revealed clot, which was dislodged revealing bleeding duodenal ulcer. Developed coffee ground emesis and underwent EGD which revealed clot, which was dislodged revealing bleeding duodenal ulcer. Developed coffee ground emesis and underwent EGD which revealed clot, which was dislodged revealing bleeding duodenal ulcer. Developed coffee ground emesis and underwent EGD which revealed clot, which was dislodged revealing bleeding duodenal ulcer. Developed coffee ground emesis and underwent EGD which revealed clot, which was dislodged revealing bleeding duodenal ulcer. # UGIB: Duodenal ulcer on EGD. # UGIB: Duodenal ulcer on EGD. # UGIB: Duodenal ulcer on EGD. # UGIB: Duodenal ulcer on EGD. Also zosyn for leukocytosis. Chief Complaint: UGIB HPI: 80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, transfer from for IR embolization of bleeding duodenal ulcer. - Transfused platelets, cryoprecipitate, and FFP - Treat infection . 80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, transfer from for IR embolization of bleeding duodenal ulcer. 80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, transfer from for IR embolization of bleeding duodenal ulcer. 80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, transfer from for IR embolization of bleeding duodenal ulcer. 80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, transfer from for IR embolization of bleeding duodenal ulcer. EGD showed clot in duodenum which was dislodged and bleeding ensued. PROCEDURE: Celiac and superior mesenteric angiogram with coil and Gelfoam embolization of bleeding lesion. An angiogram was performed at this level, which (Over) 1:09 AM MESSENERTIC Clip # Reason: embolization of known bleeding duodenal ulcer Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED Contrast: VISAPAQUE Amt: 110 FINAL REPORT (Cont) demonstrated active contrast extravasation from the proximal aspect of the gastroduodenal artery. # Coagulopathy: Low Fibrinogen, increased PTT, PT and INR, and decreased platelets likely secondary to overwhelming infection, likely DIC. # FEN: NPO, replete 'lytes prn # PPX: p-boots, PPI # Access: CVL, A-line # Code: DNR (confirmed with rehab facility who has signed sheet on file and HCP), but intubated # Dispo: deferred # Communication: (son) ; (daughter) ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 12:17 AM Arterial Line - 12:18 AM 20 Gauge - 12:19 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR (do not resuscitate) Disposition: She now has again opened up with a precipitous drop in hct. A 0.018 Nitinol wire was passed through needle and into the aortic bifurcation. Her lactate rose substantially suggesting tissue ischemia and she became anuric suggesting ATN. 1:09 AM MESSENERTIC Clip # Reason: embolization of known bleeding duodenal ulcer Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED Contrast: VISAPAQUE Amt: 110 ********************************* CPT Codes ******************************** * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER * * -51 MULTI-PROCEDURE SAME DAY EA 1ST ORDER ABD/PEL/LOWER EXT * * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION * * F/U STATUS INFUSION/EMBO VISERAL SEL/SUPERSEL A-GRAM * * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM * * -59 DISTINCT PROCEDURAL SERVICE * **************************************************************************** MEDICAL CONDITION: 80 year old woman with hematemesis hypotensive, on pressors REASON FOR THIS EXAMINATION: embolization of known bleeding duodenal ulcer FINAL REPORT DIAGNOSIS: Bleeding duodenal ulcer. | 18 | [
{
"category": "Radiology",
"chartdate": "2161-11-26 00:00:00.000",
"description": "EMBO NON NEURO",
"row_id": 1055516,
"text": " 1:09 AM\n MESSENERTIC Clip # \n Reason: embolization of known bleeding duodenal ulcer\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n Contrast: VISAPAQUE Amt: 110\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE TRANCATHETER EMBOLIZATION *\n * F/U STATUS INFUSION/EMBO VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with hematemesis hypotensive, on pressors\n REASON FOR THIS EXAMINATION:\n embolization of known bleeding duodenal ulcer\n ______________________________________________________________________________\n FINAL REPORT\n DIAGNOSIS: Bleeding duodenal ulcer.\n\n INDICATION: Massive upper GI bleed.\n\n ANESTHESIA: General.\n\n PROCEDURE: Celiac and superior mesenteric angiogram with coil and Gelfoam\n embolization of bleeding lesion.\n\n PHYSICIANS: Drs. and , Dr. was the attending\n physician, present and supervising throughout the entire procedure.\n\n FLUORO TIME: 53.2 minutes.\n\n CONTRAST: 110 cc Visipaque.\n\n COMPLICATIONS: Minor complication of nontarget coil deployment within small\n branch of profunda femoral artery (clinically insignificant).\n\n TECHNIQUE AND FINDINGS: After the risks, benefits, and alternatives of the\n proposed procedure were thoroughly explained to the patient's family, informed\n consent was obtained. The patient was taken to the angiography suite and\n placed in the supine position. The right groin was prepped and draped in the\n usual sterile fashion. A pre-procedure time-out was performed. Next, a\n micropuncture needle was used to assess the right common femoral artery. A\n 0.018 Nitinol wire was passed through needle and into the aortic bifurcation.\n A skin was made over the needle and the needle was then removed. A\n micropuncture sheath was then placed over the wire and the inner introducer\n and wire were then removed. A 0.035 wire was then passed through the\n sheath and into the mid abdominal aorta. The micropuncture sheath was then\n exchanged for a 5-French vascular sheath. The sidearm was connected to\n continuous saline flush. Next, a combination of wires and catheters was used\n to assess the celiac axis. An angiogram was performed at this level, which\n (Over)\n\n 1:09 AM\n MESSENERTIC Clip # \n Reason: embolization of known bleeding duodenal ulcer\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n Contrast: VISAPAQUE Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n demonstrated active contrast extravasation from the proximal aspect of the\n gastroduodenal artery. Given these findings, it was felt appropriate to\n proceed with embolization of the bleeding structure. A transcend wire\n Renegade Hi- microcatheter was then passed through the existing SOS omni\n catheter and into the proximal gastroduodenal artery. A -type\n embolization was then performed at this level proceeding from a distal or\n proximal direction as close as possible to the lesion. A total of 2 mm x 2 cm\n coils were deployed with Gelfoam slurry embolized between the coils. Repeat\n angiogram at the level of the celiac axis demonstrated presistent though much\n reduced bleeding from this vessel so that the GDA was re-selected and\n embolization to stasis of flow was completed with a glefoam slurry\n until adequate embolization was accomplished without any residual hemorrhage\n from the lesion. The microcatheter wire was then removed and the SOS omni was\n used to select the superior mesenteric artery. Repeat angiogram was performed\n at this level in multiple projections and demonstrated minimal residual\n bleeding. However, it was believed that the preceeding embolization should\n result in stabilization of the patient's blood pressure but instead the\n patient's blood pressure dropped precipitously despite the preceeding\n successful embolization. After consultation with the team it was decided that\n the patient is likely in DIC and that further angiographic treatment may be\n deferred until stabilization would have been accomplished. A second pressor\n was added to the patient's medication regiment at tha time.\n The wires and catheters were then removed and sterile dressing was applied.\n\n Of note, a third coil which was being deployed, did not deployed properly from\n the catheter and was then directed towards a branch of the profunda artery\n with no clinical sequela.\n\n IMPRESSION: Celiac and superior mesenteric angiograms demonstrating a\n bleeding active contrast extravasation from the proximal gastroduodenal\n artery. Successful coil and Gelfoam embolization with repeat angiogram\n demonstrating satisfactory embolization.\n\n PLAN: The patient is to return to the intensive care unit in guarded\n condition.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1055515,
"text": " 12:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tubes and lines\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with gi bleed, intubated on pressors\n REASON FOR THIS EXAMINATION:\n eval tubes and lines\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old female with GI bleed and intubated on pressors.\n Evaluate tubes and lines.\n\n No comparison studies.\n\n SINGLE AP SUPINE PORTABLE CHEST RADIOGRAPH: An endotracheal tube tip\n terminates 1 cm from the carina. A nasogastric tube extends below the field\n of view with side port well below the GE junction. A right internal jugular\n catheter tip terminates in the lower SVC. The cardiomediastinal silhouette is\n within normal limits. There is atelectasis and a small effusion within the\n left base. Pneumonia cannot be excluded within this area.\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Report",
"row_id": 241881,
"text": "Sinus tachycardia with a premature atrial contraction. Consider\ninferior myocardial infarction, age indeterminate. Non-specific\ninferolateral T wave changes. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653753,
"text": " attending MD:\n Pt had a massive GI bleed requiring extensive transfusions of PRBC,\n factor replacement, platelets, crystalloid, and pressors. Through the\n morning she continued to bleed despite previous nights\n coiling. EGD\n unable to identify a discrete bleeding site. Her lactate rose\n substantially suggesting tissue ischemia and she became anuric\n suggesting ATN. Despite multiple consultants she continued to\n deteriorate. She again opened up with a precipitous drop in hct. Based\n on conversations MD\ns and her son and her previous wishes, @ 1400\n we made her comfort our exclusive goal and discontinued other life\n prolonging treatments. We then started her on a continuous Morphine\n drip for comfort, and placed her on passive O2 via her ETT. At 1440 she\n was pronounced expired, and the MICU team informed the son via phone.\n"
},
{
"category": "Respiratory ",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 653643,
"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 Reason: Respiratory Failure\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Bloody / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Hyperventilating pt MD for\n severe acidosis.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n IR\n 1:30\n none\n"
},
{
"category": "General",
"chartdate": "2161-11-26 00:00:00.000",
"description": "ICU Event Note",
"row_id": 653738,
"text": "Clinician: Resident\n Called to bedside as patient had died. On exam, no breath or heart\n sounds. Pupils fixed and dilated. Time of death: 02:40 pm on .\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653752,
"text": "Rec\nd this 80yo woman on Vasopressin, Levophed, and Neosynephrine, as\n well as Octreotide and Protonix cont infusions. Despite multiple\n infusions of Plasma (total 6 bags), PRBC\ns (12 units), Platelets (3\n bags), and Cryo (2 bags) pt cont to have\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653695,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:58 PM\n MULTI LUMEN - START 12:17 AM\n ARTERIAL LINE - START 12:18 AM\n Events:\n - Pt required angiography and embolization of the gastroduodenal\n artery. Complicated by loss of one of the coils during the procedure\n into small branch of the femoral.\n - Pt required triple pressor therapy, aggressive iv fluid resuscitation\n and multiple blood transfusions to maintain blood pressures at MAP of\n 65 or above.\n - Coagulation studies showed elevated INR, PTT, decreased platelets,\n most likely secondary to overwhelming infections.\n - Pt received platelets, cryoprecipitate, and FFP X2\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 06:00 AM\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 33.6\nC (92.4\n Tcurrent: 33.2\nC (91.7\n HR: 103 (95 - 107) bpm\n BP: 84/62(71) {81/52(64) - 104/69(83)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 87%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 8,188 mL\n PO:\n TF:\n IVF:\n 4,555 mL\n Blood products:\n 3,533 mL\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 8,163 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 601 (501 - 601) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 20 cmH2O\n SpO2: 87%\n ABG: 6.98/23/217/10/-25\n Ve: 18.1 L/min\n PaO2 / FiO2: 434\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, intubated\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: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, tender, Distended, large ventral hernia, right sided\n colectomy bag with melena, left sided enterocutaneous fistula\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Cool, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 73 K/uL\n 10.7 g/dL\n 424 mg/dL\n 1.5 mg/dL\n 10 mEq/L\n 5.6 mEq/L\n 37 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.3 %\n 23.6 K/uL\n [image002.jpg]\n 12:00 AM\n 12:11 AM\n 12:40 AM\n 04:40 AM\n 05:59 AM\n WBC\n 29.4\n 22.9\n 23.6\n Hct\n 32.2\n 35.3\n 30.3\n Plt\n 63\n 47\n 73\n Cr\n 1.2\n 1.5\n TCO2\n 12\n 6\n Glucose\n 561\n 424\n Other labs: PT / PTT / INR:20.2/121.4/1.9, ALT / AST:46/65, Alk Phos /\n T Bili:39/0.7, Amylase / Lipase:87/83, Differential-Neuts:76.0 %,\n Band:4.0 %, Lymph:12.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:124 mg/dL,\n Lactic Acid:13.1 mmol/L, Albumin:1.1 g/dL, LDH:393 IU/L, Ca++:5.8\n mg/dL, Mg++:1.8 mg/dL, PO4:11.2 mg/dL\n Assessment and Plan\n 80F h/o colon CA s/p colectomy c/b enterocutaneous fistulas, COPD with\n duodenal bleed transferred for embolization.\n .\n # UGIB: Duodenal ulcer on EGD. Failed endoscopic control, transferred\n for IR embolization. Hemodynamically unstable on admission, pt put out\n at least 3L of BRB per OGT overnight. Pt is s/p gastroduodenal artery\n embolization, however continues to bleed. Consulted GI here for\n further eval and scope.\n - CVL and PIVs in place for aggressive volume replacement\n - T&X 9 units at OSH, total of 11 units overnight, total 20 units in\n - IV protonix and octreotide gtt\n - q4h hct\n - continue pressor support gtt for goal MAP > 65\n - Replaced coags given elevated coagulation studies\n .\n # Metabolic acidosis: Multifactorial including lactic acidosis,\n uremic acidosis, hyperchloremia, and hyperphosphatemia.\n - Will change IV fluids from NaCL to NaBicarb\n - Will continue mechanical ventilation\n - will treat electrolyte imbalances\n - will attempt to reperfuse tissues\n - will treat empirically for possible sepsis with vancomycin and zosyn\n - will likely need CVVH to correct\n .\n # Coagulopathy: Most likely secondary to consumption given multiple\n transfusions, however could be secondary to DIC given low Fibrinogen,\n increased PTT, PT and INR, and decreased platelets.\n - Will transfuse platelets, cryoprecipitate, and FFP\n - will transfuse activated factor 7\n - will empirically treat for underlying infection\n .\n # Acute renal failure: Likely secondary to ATN given prolonged\n hypoperfusion. Likely the patient will need CVVH to correct renal\n function given lack of UOP.\n .\n # Leukocytosis: be stress related, or patient may have underlying\n infection\n - treat empirically with vancomycin and zosyn\n .\n # Respiratory compromise/COPD: Pt intubated for respiratory protection\n in the setting of hematemesis. However, increased RR in the setting of\n metabolic acidosis.\n .\n # Hyperkalemia: Likely secondary to hypoperfusion.\n - Monitor serial EKGs\n - Continue insulin drip and bicarb\n .\n # Hyperphosphatemia: Likely secondary to hypoperfusion\n - Will consult renal regarding management\n - Will likely need CVVH\n .\n # Hypocalcemia: Likely secondary to citrate in blood products\n - replete per sliding scale\n .\n # Pain Control: Will use morphine for pain control and monitor blood\n pressures closely.\n .\n # FEN: NPO, replete 'lytes prn\n # PPX: p-boots, PPI\n # Access: CVL, A-line, will place second line today\n # Code: DNR (confirmed with rehab facility who has signed sheet on file\n and HCP), but intubated\n # Dispo: ICU\n # Communication: (son) ; (daughter)\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:17 AM\n Arterial Line - 12:18 AM\n 20 Gauge - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653683,
"text": "80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, \n transfer from for IR embolization of bleeding\n duodenal ulcer.\n Admitted to OSH today from rehab after syncopal event described as\n diphoresis and 'twitching'. Also complained of LUQ abdominal pain.\n Developed coffee ground emesis and underwent EGD which revealed clot,\n which was dislodged revealing bleeding duodenal ulcer. The bleeding was\n unable to be endoscopically managed and surgery was consulted, who\n refused intervention. Hct decreased from 34 to 18 despite 6 units PRBC\n at OSH. Hypotensive on levophed gtt. Also receiving IV protonix and\n octreotide gtt. Coags notable for INR 2. IR contact and accepted\n patient for embolization. Transfer to ICU.\n Upon arrival to unit pt becoming hemodynamically unstable, requiring\n additional pressor, transfused with total of 12 units PRBC overnight, 2\n units FFP, 1 unit cryo and 1 unit platelets. Unable to obtain accurate\n sat since admission due to pt\ns cold, mottled skin. Taken to IR where\n massive arterial bleed was embolized however pt continued to put out\n large amounts of dark red blood via OGT, approximately ~3L out. At end\n of procedure pt becoming very hypotensive to 50s, bolused with 3L NS\n since return from IR. All coags continue to be elevated, however HCT\n stable at ~30, received total 2 amps bicarb for acidotic ABG. K\n elevated. Started on IV ABX which she received this morning. At this\n writing maxed out on levophed, phenylephrine and vasopressin with SBP\n in 90s. Pt\ns BP ok while blood products infusing however drop once\n done. Unable to visualize any active bleeding during bedside scope.\n Plan is to see if pt is able to be weaned off pressors and re-scope\n later.\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653678,
"text": "80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, \n transfer from for IR embolization of bleeding\n duodenal ulcer.\n Admitted to OSH today from rehab after syncopal event described as\n diphoresis and 'twitching'. Also complained of LUQ abdominal pain.\n Developed coffee ground emesis and underwent EGD which revealed clot,\n which was dislodged revealing bleeding duodenal ulcer. The bleeding was\n unable to be endoscopically managed and surgery was consulted, who\n refused intervention. Hct decreased from 34 to 18 despite 6 units PRBC\n at OSH. Hypotensive on levophed gtt. Also receiving IV protonix and\n octreotide gtt. Coags notable for INR 2. IR contact and accepted\n patient for embolization. Transfer to ICU.\n Upon arrival to unit pt becoming hemodynamically unstable, requiring\n additional pressor, transfused with total of 12 units PRBC overnight, 2\n units FFP, 1 unit cryo and 1 unit platelets. Unable to obtain accurate\n sat since admission due to pt\ns cold, mottled skin. Taken to IR where\n massive arterial bleed was embolized however pt continued to put out\n large amounts of dark red blood via OGT, approximately ~3L out. At end\n of procedure pt becoming very hypotensive to 50s, bolused with 3L NS\n since return from IR. All coags continue to be elevated, however HCT\n stable at ~30, received total 2 amps bicarb for acidotic ABG. K\n elevated. Started on IV ABX which she received this morning. At this\n writing maxed out on levophed, phenylephrine and vasopressin with SBP\n in 90s. Pt\ns BP ok while blood products infusing however drop once\n done. Unable to visualize any active bleeding during bedside scope.\n Plan is to see if pt is able to be weaned off pressors and re-scope\n later.\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653670,
"text": "80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, \n transfer from for IR embolization of bleeding\n duodenal ulcer.\n Admitted to OSH today from rehab after syncopal event described as\n diphoresis and 'twitching'. Also complained of LUQ abdominal pain.\n Developed coffee ground emesis and underwent EGD which revealed clot,\n which was dislodged revealing bleeding duodenal ulcer. The bleeding was\n unable to be endoscopically managed and surgery was consulted, who\n refused intervention. Hct decreased from 34 to 18 despite 6 units PRBC.\n Hypotensive on levophed gtt. Also receiving IV protonix and octreotide\n gtt. Coags notable for INR 2. IR contact and accepted patient for\n embolization. Transfer to ICU.\n Upon arrival to unit pt becoming hemodynamically unstable, requiring\n additional pressor, transfused with total of 10 units PRBC overnight, 2\n FFP, 1 cryo and 1 platelets. Taken to IR where massive arterial bleed\n was embolized however pt continued to put out large amounts of dark red\n blood via OGT\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653671,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:58 PM\n MULTI LUMEN - START 12:17 AM\n ARTERIAL LINE - START 12:18 AM\n Events:\n - Pt required angiography and embolization of the gastroduodenal\n artery. Complicated by loss of one of the coils during the procedure\n into small branch of the femoral.\n - Pt required triple pressor therapy, aggressive iv fluid resuscitation\n and multiple blood transfusions to maintain blood pressures at MAP of\n 65 or above.\n - Coagulation studies showed elevated INR, PTT, decreased platelets,\n most likely secondary to overwhelming infections.\n - Pt received platelets, cryoprecipitate, and FFP\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 06:00 AM\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 33.6\nC (92.4\n Tcurrent: 33.2\nC (91.7\n HR: 103 (95 - 107) bpm\n BP: 84/62(71) {81/52(64) - 104/69(83)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 87%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 8,188 mL\n PO:\n TF:\n IVF:\n 4,555 mL\n Blood products:\n 3,533 mL\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 8,163 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 601 (501 - 601) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 20 cmH2O\n SpO2: 87%\n ABG: 6.98/23/217/10/-25\n Ve: 18.1 L/min\n PaO2 / FiO2: 434\n Physical Examination\n General Appearance: Overweight / Obese\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: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Cool, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 73 K/uL\n 10.7 g/dL\n 424 mg/dL\n 1.5 mg/dL\n 10 mEq/L\n 5.6 mEq/L\n 37 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.3 %\n 23.6 K/uL\n [image002.jpg]\n 12:00 AM\n 12:11 AM\n 12:40 AM\n 04:40 AM\n 05:59 AM\n WBC\n 29.4\n 22.9\n 23.6\n Hct\n 32.2\n 35.3\n 30.3\n Plt\n 63\n 47\n 73\n Cr\n 1.2\n 1.5\n TCO2\n 12\n 6\n Glucose\n 561\n 424\n Other labs: PT / PTT / INR:20.2/121.4/1.9, ALT / AST:46/65, Alk Phos /\n T Bili:39/0.7, Amylase / Lipase:87/83, Differential-Neuts:76.0 %,\n Band:4.0 %, Lymph:12.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:124 mg/dL,\n Lactic Acid:13.1 mmol/L, Albumin:1.1 g/dL, LDH:393 IU/L, Ca++:5.8\n mg/dL, Mg++:1.8 mg/dL, PO4:11.2 mg/dL\n Assessment and Plan\n 80F h/o colon CA s/p colectomy c/b enterocutaneous fistulas, COPD with\n duodenal bleed transferred for embolization.\n .\n # UGIB: Duodenal ulcer on EGD. Failed endoscopic control, transferred\n for IR embolization. Hemodynamically unstable on admission, pt put out\n at least 3L of BRB per OGT overnight. Pt is s/p gastroduodenal artery\n embolization, however continues to bleed. Consulted GI here for\n further eval and scope.\n - CVL and PIVs in place for aggressive volume replacement\n - T&X 9 units at OSH, total of 9 units overnight, total 18 units in\n - IV protonix and octreotide gtt\n - q4h hct\n - continue levophed, vasopressin and phenylephrine gtt for goal MAP >\n 65\n - FFP given for elevated INR at 2.1\n .\n # Sepsis: Patient is hypotensive, hypothermic, has leukocytosis.\n Likely source of infection eroded duodenal ulcer may have had\n perforated or caused bacteremia. BCx pending.\n - Continue aggressive fluid resuscitation\n - Continue pressor support for MAP > 65\n - Continue vancomycin and zoysn for broad coverage.\n .\n # Metabolic acidosis: Lactic acidosis secondary to sepsis.\n - Mechanical ventilation\n - Bicarb PRN\n .\n # Coagulopathy: Low Fibrinogen, increased PTT, PT and INR, and\n decreased platelets likely secondary to overwhelming infection, likely\n DIC.\n - Transfused platelets, cryoprecipitate, and FFP\n - Treat infection\n .\n # Respiratory compromise/COPD: Pt intubated for respiratory protection\n in the setting of hematemesis. However, increased RR in the setting of\n metabolic acidosis.\n .\n # FEN: NPO, replete 'lytes prn\n # PPX: p-boots, PPI\n # Access: CVL, A-line\n # Code: DNR (confirmed with rehab facility who has signed sheet on file\n and HCP), but intubated\n # Dispo: deferred\n # Communication: (son) ; (daughter)\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:17 AM\n Arterial Line - 12:18 AM\n 20 Gauge - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Generic Note",
"row_id": 653604,
"text": "TITLE:\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 80W with DM, COPD\n active smoker, remote colon cancer\n s/p resection,\n post-op issues with enterocutaneous fistulas\n admitted with COPD flare\n in and treated with steroids. Admitted to with\n unresponsiveness and coffee ground emesis. EGD showed clot in duodenum\n which was dislodged and bleeding ensued. Hct fell from 34 to 25 and\n received 9 units. Given PPI and octreotride, levophed. Intubated with\n ABG 7.1/39/215. Not thought to be a surgical candidate so transferred\n for IR intervention. Also zosyn for leukocytosis.\n Currently her BP is fully dependent upon the continuation of blood\n transfusions. When PRBC\ns are stopped her SBP falls below 75 despite\n high dose levophed.\n Exam notable for Tm 92 (oral) HR 94 BP 84/62 RR 20 with ? sat on\n AC16/500/5/.6 7.05/41/141\n Fresh blood from GT, intubated, unresponsive\n Lung distant\n Hrt rrr\n Abd\n ventral hernia, colostomy with melena, left fistula\n Extrem - cool\n Labs notable for WBC 29K, HCT 32 , Na ,K+ , HCO3 ,Cr ,lactate 9.3\n Imaging: CXR clear from \n Problems: UGIB from DU, respiratory failure, shock, DM, COPD,\n leukocytosis, lactic acidosis\n Agree with plan to IR intervention, PPI, octreotide, follow Hct,\n continue vent support\n increase RR, levophed, insulin, zosyn for\n leukocytosis, follow for signs of visceral perforation\n Plan discussed with son who seems realistic about grim prognosis. Case\n discussed at length with IR. She is DNR at this point.\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 41 min\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 653605,
"text": "Chief Complaint: UGIB\n HPI:\n 80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, \n transfer from for IR embolization of bleeding\n duodenal ulcer.\n .\n Admitted to OSH today from rehab after syncopal event described as\n diphoresis and 'twitching'. Also complained of LUQ abdominal pain.\n Developed coffee ground emesis and underwent EGD which revealed clot,\n which was dislodged revealing bleeding duodenal ulcer. The bleeding was\n unable to be endoscopically managed and surgery was consulted, who\n refused intervention. Hct decreased from 34 to 25 despite 6 units pRBC.\n Hypotensive on levophed gtt. Also receiving IV protonix and octreotide\n gtt. Coags notable for INR 2, receiving FFP en route. IR contact and\n accepted patient for embolization. Transfer to ICU.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 12:34 AM\n Other medications:\n Meds at rehab:\n neurontin 600 \n lasix 10 daily\n lisinopril 10 daily\n cymbalta 30 daily\n aspirin 81 daily\n glipizide\n prednisone\n protonix\n advair\n insulin sc sliding scale\n .\n Meds at transfer:\n Octreotide gtt\n Protonix gtt\n Solumedrol IV\n Zosyn\n Fentanyl\n Levophed gtt\n Vitamin K 10mg\n Past medical history:\n Family history:\n Social History:\n Colon CA s/p colectomy c/b intracutaneous fistula\n COPD\n DM\n Obesity\n Mild dementia\n NC\n Current smoker. No EtOH or illicits. Lives currently at rehab.\n Review of systems: unable to assess due to sedation\n Flowsheet Data as of 01:06 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 33.6\nC (92.4\n Tcurrent: 33.6\nC (92.4\n HR: 96 (95 - 96) bpm\n BP: 92/52(64) {92/52(64) - 102/55(70)} mmHg\n RR: 17 (16 - 24) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,968 mL\n PO:\n TF:\n IVF:\n 2,017 mL\n Blood products:\n 902 mL\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,943 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 601 (501 - 601) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 28 cmH2O\n Plateau: 20 cmH2O\n ABG: 7.05/41/131//-19\n Ve: 11.8 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: Overweight / Obese\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: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Cool, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 10.9 g/dL\n 1.2 mg/dL\n 38 mg/dL\n 113 mEq/L\n 144 mEq/L\n 32.2 %\n 29.4 K/uL\n [image002.jpg]\n \n 2:33 A1/8/ 12:00 AM\n \n 10:20 P1/8/ 12:11 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 29.4\n Hct\n 32.2\n Cr\n 1.2\n TC02\n 12\n Other labs: PT / PTT / INR:/150/2.1, Lactic Acid:9.3 mmol/L, Mg++:1.9\n mg/dL\n Assessment and Plan\n 80F h/o colon CA s/p colectomy c/b enterocutaneous fistulas, COPD with\n duodenal bleed transferred for embolization.\n .\n # UGIB: Duodenal ulcer on EGD. Failed endoscopic control, transferred\n for IR embolization. Hemodynamically unstable.\n - IR to evaluate\n - CVL and PIVs\n - T&X 9 units\n - IV protonix and octreotide gtt\n - q4h hct\n - continue levophed gtt\n - stat coags on arrival, FFP for goal INR<1.5\n - Consider GI and surgery evaluations\n .\n # Leukocytosis: Consider bacterial gut translocation as likely source,\n cover with zosyn for now. Send blood cultures.\n .\n # COPD: No acute issue, nebs prn.\n .\n # FEN: NPO, replete 'lytes prn\n # PPX: p-boots, PPI\n # Access: CVL, A-line\n # Code: DNR (confirmed with rehab facility who has signed sheet on file\n and HCP)\n # Dispo: deferred\n # Communication: (son) ; (daughter)\n \n .\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Multi Lumen - 12:17 AM\n Arterial Line - 12:18 AM\n 20 Gauge - 12:19 AM\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 , Family\n meeting held Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 653672,
"text": "80F h/o colon CA s/p colectomy c/b intracutaneous fistula, COPD, \n transfer from for IR embolization of bleeding\n duodenal ulcer.\n Admitted to OSH today from rehab after syncopal event described as\n diphoresis and 'twitching'. Also complained of LUQ abdominal pain.\n Developed coffee ground emesis and underwent EGD which revealed clot,\n which was dislodged revealing bleeding duodenal ulcer. The bleeding was\n unable to be endoscopically managed and surgery was consulted, who\n refused intervention. Hct decreased from 34 to 18 despite 6 units PRBC.\n Hypotensive on levophed gtt. Also receiving IV protonix and octreotide\n gtt. Coags notable for INR 2. IR contact and accepted patient for\n embolization. Transfer to ICU.\n Upon arrival to unit pt becoming hemodynamically unstable, requiring\n additional pressor, transfused with total of 10 units PRBC overnight, 2\n units FFP, 1 unit cryo and 1 unit platelets. Taken to IR where massive\n arterial bleed was embolized however pt continued to put out large\n amounts of dark red blood via OGT, approximately ~3L out. At end of\n procedure pt becoming very hypotensive to 50sAll coags continue to be\n elevated, however HCT stable at ~30, received total 2 amps bicarb for\n acidotic ABG. Started on IV ABX which she received this morning.\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653660,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:58 PM\n MULTI LUMEN - START 12:17 AM\n ARTERIAL LINE - START 12:18 AM\n Events:\n - Pt required angiography and embolization of the gastroduodenal\n artery. Complicated by loss of one of the coils during the procedure.\n - Pt required two pressors, iv fluid resuscitation and blood\n transfusions to maintain blood pressures at MAP of 65 or above.\n - Coagulation studies showed elevated INR, PTT, decreased platelets,\n most likely secondary from overwhelming infections.\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 06:00 AM\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 33.6\nC (92.4\n Tcurrent: 33.2\nC (91.7\n HR: 103 (95 - 107) bpm\n BP: 84/62(71) {81/52(64) - 104/69(83)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 87%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 8,188 mL\n PO:\n TF:\n IVF:\n 4,555 mL\n Blood products:\n 3,533 mL\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 8,163 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 601 (501 - 601) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 20 cmH2O\n SpO2: 87%\n ABG: 6.98/23/217/10/-25\n Ve: 18.1 L/min\n PaO2 / FiO2: 434\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 73 K/uL\n 10.7 g/dL\n 424 mg/dL\n 1.5 mg/dL\n 10 mEq/L\n 5.6 mEq/L\n 37 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.3 %\n 23.6 K/uL\n [image002.jpg]\n 12:00 AM\n 12:11 AM\n 12:40 AM\n 04:40 AM\n 05:59 AM\n WBC\n 29.4\n 22.9\n 23.6\n Hct\n 32.2\n 35.3\n 30.3\n Plt\n 63\n 47\n 73\n Cr\n 1.2\n 1.5\n TCO2\n 12\n 6\n Glucose\n 561\n 424\n Other labs: PT / PTT / INR:20.2/121.4/1.9, ALT / AST:46/65, Alk Phos /\n T Bili:39/0.7, Amylase / Lipase:87/83, Differential-Neuts:76.0 %,\n Band:4.0 %, Lymph:12.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:124 mg/dL,\n Lactic Acid:13.1 mmol/L, Albumin:1.1 g/dL, LDH:393 IU/L, Ca++:5.8\n mg/dL, Mg++:1.8 mg/dL, PO4:11.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:17 AM\n Arterial Line - 12:18 AM\n 20 Gauge - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 653663,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 11:58 PM\n MULTI LUMEN - START 12:17 AM\n ARTERIAL LINE - START 12:18 AM\n Events:\n - Pt required angiography and embolization of the gastroduodenal\n artery. Complicated by loss of one of the coils during the procedure.\n - Pt required two pressors, iv fluid resuscitation and blood\n transfusions to maintain blood pressures at MAP of 65 or above.\n - Coagulation studies showed elevated INR, PTT, decreased platelets,\n most likely secondary from overwhelming infections.\n Allergies:\n Codeine\n Unknown;\n Last dose of Antibiotics:\n Piperacillin - 06:00 AM\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Phenylephrine - 0.5 mcg/Kg/min\n Vasopressin - 2.4 units/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 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 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 33.6\nC (92.4\n Tcurrent: 33.2\nC (91.7\n HR: 103 (95 - 107) bpm\n BP: 84/62(71) {81/52(64) - 104/69(83)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 87%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 8,188 mL\n PO:\n TF:\n IVF:\n 4,555 mL\n Blood products:\n 3,533 mL\n Total out:\n 0 mL\n 25 mL\n Urine:\n 25 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 8,163 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 601 (501 - 601) mL\n RR (Set): 30\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 33 cmH2O\n Plateau: 20 cmH2O\n SpO2: 87%\n ABG: 6.98/23/217/10/-25\n Ve: 18.1 L/min\n PaO2 / FiO2: 434\n Physical Examination\n General Appearance: Overweight / Obese\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: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Cool, No(t) Rash: , No(t) Jaundice\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 73 K/uL\n 10.7 g/dL\n 424 mg/dL\n 1.5 mg/dL\n 10 mEq/L\n 5.6 mEq/L\n 37 mg/dL\n 109 mEq/L\n 141 mEq/L\n 30.3 %\n 23.6 K/uL\n [image002.jpg]\n 12:00 AM\n 12:11 AM\n 12:40 AM\n 04:40 AM\n 05:59 AM\n WBC\n 29.4\n 22.9\n 23.6\n Hct\n 32.2\n 35.3\n 30.3\n Plt\n 63\n 47\n 73\n Cr\n 1.2\n 1.5\n TCO2\n 12\n 6\n Glucose\n 561\n 424\n Other labs: PT / PTT / INR:20.2/121.4/1.9, ALT / AST:46/65, Alk Phos /\n T Bili:39/0.7, Amylase / Lipase:87/83, Differential-Neuts:76.0 %,\n Band:4.0 %, Lymph:12.0 %, Mono:3.0 %, Eos:0.0 %, Fibrinogen:124 mg/dL,\n Lactic Acid:13.1 mmol/L, Albumin:1.1 g/dL, LDH:393 IU/L, Ca++:5.8\n mg/dL, Mg++:1.8 mg/dL, PO4:11.2 mg/dL\n Assessment and Plan\n 80F h/o colon CA s/p colectomy c/b enterocutaneous fistulas, COPD with\n duodenal bleed transferred for embolization.\n .\n # UGIB: Duodenal ulcer on EGD. Failed endoscopic control, transferred\n for IR embolization. Hemodynamically unstable.\n - IR to evaluate\n - CVL and PIVs\n - T&X 9 units\n - IV protonix and octreotide gtt\n - q4h hct\n - continue levophed gtt\n - stat coags on arrival, FFP for goal INR<1.5\n - Consider GI and surgery evaluations\n .\n # Leukocytosis: Consider bacterial gut translocation as likely source,\n cover with zosyn for now. Send blood cultures.\n .\n # COPD: No acute issue, nebs prn.\n .\n # FEN: NPO, replete 'lytes prn\n # PPX: p-boots, PPI\n # Access: CVL, A-line\n # Code: DNR (confirmed with rehab facility who has signed sheet on file\n and HCP)\n # Dispo: deferred\n # Communication: (son) ; (daughter)\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 12:17 AM\n Arterial Line - 12:18 AM\n 20 Gauge - 12:19 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2161-11-26 00:00:00.000",
"description": "ICU Event Note",
"row_id": 653733,
"text": "Clinician: Attending\n Critical Care\n Massive GI bleed apparently from a DU requiring extensive transfusions\n of PRBC, factor replacement, platelets, crystalloid, and pressors.\n Through the morning she has continued to bleed despite last nights\n coiling. EGD unable to identify a discrete bleeding site. Her lactate\n has risen substantially suggesting tissue ischemia and she has been\n anuric suggesting ATN. Despite multiple consultants she has continued\n to deteriorate. She now has again opened up with a precipitous drop in\n hct. Based on conversationbs with her son and her previous wishes we\n are going to make her comfort our exclusive goal and will discontinue\n other life prolonging treatments.\n Total time spent: 120 minutes\n Patient is critically ill.\n"
}
] |
5,476 | 199,622 | Patient presented with an acute change in mental status with hypercapnic respiratory distress. Appeared to be in setting of septic shock with potential sources being PNA and UTI. She was initially admitted on BPAP with pressure settings of 15/8. Initially, ABG showed improved ventilation and acidemia, although repeat ABG in the ICU showed worsening CO2 retention and acidemia despite high levels of pressure support (20/8). She was continued on broad antibiotics with vanco/cefepime/levofloxacin/ metronidazole and received 125mg IV methylprednisolone. She had arrived on peripheral norepinephrine, but was transitioned to IVF boluses when the PIV infusing norepinephrine was lost. Family meeting was held with her 3 sons and they wished to observe for improvement in the next few hours before deciding on how aggressive to treat her, but agreed to DNR/DNI, no CVC and no Aline at that time. Her BP continued to trend down to SBP in 70s with minimal UOP, and IVF were stopped given O2 sat 90% on 100% FiO2. Her RR was in 40s-60s initially, and she received a dose of 1mg IV morphine for symptom control. After about 4 hrs from admission, her RR trended down to 10-12 suggesting she was unable to maintain appropriate ventilation. Her family then agreed that comfort was the priority and prn morphine was ordered; the patient expired shortly after and autopsy was declined. | Since the previous tracingof ventricular ectopy is now seen. Underlying atrial fibrillation with ventricular pacingand frequent ventricular premature beats. | 1 | [
{
"category": "ECG",
"chartdate": "2139-12-05 00:00:00.000",
"description": "Report",
"row_id": 300102,
"text": "Baseline artifact. Underlying atrial fibrillation with ventricular pacing\nand frequent ventricular premature beats. Since the previous tracing\nof ventricular ectopy is now seen.\n\n"
}
] |
14,677 | 119,917 | as described above | Median sternotomy wires are again noted. Normal interatrial septum.LEFT VENTRICLE: Symmetric LVH. There is symmetric left ventricularhypertrophy. Trace aorticregurgitation is seen. He had recently been placed on extracorporealmembrane oxygenation (ECMO).LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The mitral valve leaflets are mildly thickened.Mild-moderate mitral regurgitation is suggested.There is no pericardialeffusion.IMPRESSION: ECMO catheter tip in the SVC. Trivial aortic regurgitation. The remaining walls of the left ventricle are akinetic. Hypoxia post-bronchoscopy. Bibasilar pleural effusions layering posteriorly with associated atelectasis unchanged. The ETT terminates at the level of the thoracic inlet. LVAD REASON FOR THIS EXAMINATION: assess for infiltrates/effusions FINAL REPORT PORTABLE SUPINE CHEST OF . The ascending, transverse and descending thoracic aorta arenormal in diameter and free of atherosclerotic plaque. Swan-Ganz catheter terminates just distal to the pulmonary valve. Mild to moderate (+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. IMPRESSION: Interval reexpansion of the right upper lobe with small amount of residual atelectasis demonstrated. There has been interval reexpansion of the right upper lobe with small amount of residual atelectasis demonstrated. There is a small right pleural effusion. post bronchoscopy FINAL REPORT INDICATION: Status post ECMO placement. pt continues on vasopressin gtt at 0.04 u/min. LATEST ACT 188, PTT 113 AFTER HEPARIN BOLUSES.RESP: PAO2 WNL. BS NOTED TO BE VERY DIMINISHED ON R SIDE, > THAN IN A.M. CXR DONE AND PT KEPT ON FIO2 1.0 FOR NOW. SX FOR SCANT SEC. Abuterol given inline with vent. PT RESOLVED OXYGENATION. SCANT MINUTE PLUG REMOVED. PERRL.CV: HR 100-110's a fib. LASIX/NATRECOR GTTS REMAIN UNCHANGE AU/O CONT > 110. REQUIRED ^ IN LEVO DOSE. ACT's 180->176 w/ PTT 70.8. LFT's remain hight by seem to be decreasing.GU; u/o down to <100cc/hr x 2 hrs. MOD AMT OF ORAL SEC.GI/GU~OGT LCS->BILIOUS DRAINAGE. DP's palpable and PT's by doppler NA down to 125 this am.resp: LS ronchi with inspir wheezing. CCO RECAL SVO2NOW LOW 60'S. Skin moist occasionally.Skin: Scant amt serousang dng noted at inferior postion of incsion line. t bili up with lft's- added direct and in direct bili- d.bili 8.3.? resp care notePt still on R VAD and is vented on ACx 11 x 800, 50% + 10 , Sx yield ssmall to scant amts, pt has some wheezing and gets ALB MDI Q4, MILrinione, Epi, Vasopresin, Amiodarone, Natrecor, Lasix unchanged. Suctioned w/ return of small amt secretions. levo gtt titrated to keep MAP > 60. levo weaned to 0.10 mcg/kg/min. CONT ON CONTINUOUS LASIX DRIP.SKIN: INTACT BUT DIAPHORETIC TODAY. ELIX FOR TMAX 101. M S/P MI cardiogenic shock Now on LVAD. CI's > 2.0. CONT ON FENT & VERSED GTTS. no bmgu: creat 1.7, u/o dips slightly to day- pt tx with both fluid/lasix0 goal u/o .60cc/hr.inc: intact.plan: follow act closely for heparin, start natracor today-albumin q 8hrs. updateD: pt cont on multiple drips-weaned levo as need for sbp>90, map >60- titrated from .08-.25 mcq, vasopressin remainsat .04, cisatricurium weaned to .39 to obtain 2 eye twitches, heparin cont at 2800 with ptt 71 and act 197-210, amiodarone unchanged at .5 mg, lasix titrated up to 9mg/hr to obtain u/o >105cc/hr- natracor unchanged.pt with temp and inc wbc, pt cultured and left cco changed over a wire- new introducer and cco swan- procedured complicated with dip in bp-corrected with inc levo and pt receiving pc for hct 29.--please note prior to changing line pt temp appeared to be rising, sbp dipped as did svo2-pt given rbc with improvement and levo titrated upward as noted.neuro: pt paralysed as noted- cont on fentanyl 200mcq, versed at 2.5 mg- on .39 cisatricurium --geting 2 twitches. MVO2's, LVAD flows, and CVP's stable off epi. ventricular ectopyCArdiac: pt noted to be in a-flutter this am-upon further investigation with eval of ekg- decided nsr- rate 110 prolonged pr-pt appeared to convert back to a fluteer varying rate 1:1- 1:2-at 1300 new iv site obtained-via right IJ-pt tol well. LVAD WEANED @ 1130 TO 0 FLOW BRIEFLY W/ SVO2 AND MAP BOTH MAINTAINED 60 OR >. 3rd repeat episode at which time pt bronched->minimal thin secretions noted MD. pt given an additional amiodarone bolus 150mg and another lido bolus 75mg with a lido drip initiated at 2mg--pt has experienced less ectopy to at this time pt remains in nsr.presently pt on levo .25mcq, vasopressin restarted as noted at .03unit, maintaining a sbp >100/, VAD flows 5.2- able to wean vacumm doen to 50 today- plan to wean flow tomorrow and eval pt own heart- CARDIAC: SR 70-90'S WITH ISOLATED PVC NOTED, K, MAG AND CALCIUM REPLACED, SBP 90-100 UPON ARRIVAL LEVO TO .17MCQ WITH SBP 70-80 AND MAPS 60'S HCT 26.6 RECIEVED 2UPC REPEAT HCT 32. updateD: pt cont with hypotension sbp80's-titrated levo up to .32 mcq-A: restarted vasoopressin at .03 units--per dr with d/c vasopressin- Na remains 125.D: ? DP's palpable and PT's by dopplerresp: LS coases with inspir and exp wheezing. pt in sr vs aflutter 1:1-A: ekg doneR: eval-pt in NSRNo amiodarone bolus PUPILS3-4 EQUAL RX TO LIGHT.CARDIAC: PT IN AFIB THIS AM APPEARED TO SWITCH TO AFLUTTER THIS AFTERNOON- AT TIME PT NOTED TO DROP SBP TO 80'S- VASOPRESSIN OFF- LEVO TITRATED UPWARD. Last ABG 7.39,47,95. pt continues on mida and fentanyl gtt's. levo gtt titated to to keep map > 60. levo gtt currently at 0.28 mcg/kg/min. PLAN TO WEAN EPI TO OFF AS TOL.PT WARM, DOPPLERABLE PULSES. pt was receiving volume at time and drips were being adjusted to improve flow rate when pt suddenly became asytolic with only p waves running across screen. RESP: RUL COLLAPSE, 1830 TOLERATED RECRUITMENT BREATHS. RECIEVED 9UPC,10UFFP,5PKPLT,7.5LCRYSTALLOID.OUT ON MILRINONE @.3MCQ,EPI @ .3,LEVO @ .15, INSULIN AT 3 UNITS/HR,PROPOFOL @10MCQ AND LIDO @ 2 MG. IABP NOT DC'D IN OR ,1:1 WITH FAIR AUGMENTATION,LVAD 4.9TRANSIENTLY WITH HYPOTENSION, MAPS 60'S WITH FLOW 5.1-6.1, HR 50-67. ACIDOTIC RECIEVED 2 AMPS BICARB X3 , REPEAT ABG PENDING. Lungs coarse rhonchi bilat at start of shift. adm to csruD: pt adm to csru from cath lab- evolving a lg mi- coded in cath lab- iabp placed left fem, and ecmo inserted via the right fem- -stent was placed on right side- all vessels down but circ at initation of case.pt with v-fib/v tach- defib x 4, amiodarone/lido started- upon adm to caru- d/c amiodarone due to junctional rhythm with retrograde p's vs CHB--heparin started at 1000u/hr0 titrated to maintain act 180--presently at 900u/hr with act 182.iabp set a t 1:2- , vent weaned to 50% from 100%- pt on ecmo thus receieving 70% fio2 with adeq abg's- ecmo flow 4.2-4.3.neuro: pt adm to csru on versed drip at 8- mae at this time- switched to 30 mcq propofol with good effect, pupils 3cm equal and rx to light. | 67 | [
{
"category": "Echo",
"chartdate": "2192-09-07 00:00:00.000",
"description": "Report",
"row_id": 79469,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Cardiogenic shock.\nHeight: (in) 73\nWeight (lb): 235\nBSA (m2): 2.31 m2\nStatus: Inpatient\nDate/Time: at 14:45\nTest: Portable TEE (Complete)\nDoppler: Color Doppler only\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nAn emergency TEE was performed in the cardiac catheterization lab. The patient\nwas intubated and sedated. He had recently been placed on extracorporeal\nmembrane oxygenation (ECMO).\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. Normal interatrial septum.\n\nLEFT VENTRICLE: Symmetric LVH. Small LV cavity. Severely depressed LVEF.\n\nRIGHT VENTRICLE: Small RV cavity. Severe global RV free wall hypokinesis.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: ?# aortic valve leaflets. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\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. No TEE related\ncomplications. Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nTEE imaging was initially used to help guide an ECMO catheter into the SVC.\n\nThe left atrium is mildly dilated. There is symmetric left ventricular\nhypertrophy. The left ventricular cavity is unusually small. Overall left\nventricular systolic function is severely depressed. There is severe\nhypokinesis of the inferolateral wall and the most basal portion of the\nanterior wall. The remaining walls of the left ventricle are akinetic. The\nright ventricular cavity is unusually small with severe global free wall\nhypokinesis. The ascending, transverse and descending thoracic aorta are\nnormal in diameter and free of atherosclerotic plaque. An intra-aortic balloon\npump was seen in the descending aorta with correct positioning of the balloon\ntip. The number of aortic valve leaflets cannot be determined. Trace aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild-moderate mitral regurgitation is suggested.There is no pericardial\neffusion.\n\nIMPRESSION: ECMO catheter tip in the SVC. Markedly severe biventricular\nfunction. Trivial aortic regurgitation. Mild-moderate mitral regurgitation.\nProper locatio of the IABP tip.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 878033,
"text": " 2:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and cabg x1/\n ins. LVAD\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 2:50 P.M.\n\n INDICATION: Postoperative film.\n\n The intraaortic balloon pump tip terminates approximately 3.7 cm below the tip\n of the aortic arch. An ECMO extends vertically along the right upper abdomen\n and extends medially into the region of the right atrium. Swan-Ganz catheter\n terminates just distal to the pulmonary valve. There is a mediastinal chest\n tube and a chest tube at the left lung base. An NGT terminates in the upper\n stomach. The ETT terminates at the level of the thoracic inlet. A right\n apical density is likely to be collapse of the right upper lobe since .\n There is pulmonary venous cephalization in the left upper lobe.\n\n IMPRESSION: Collapse of the right upper lobe. The nurse caring for the\n patient was notified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 878126,
"text": " 1:39 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and cabg x1/\n ins. LVAD\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 2:00 P.M.\n\n INDICATION: Line placement.\n\n There is improved aeration in the right upper lobe since . The\n Swan-Ganz catheter and IABP have been removed. A left subclavian catheter is\n present and the catheter may extend into the right ventricle, although it is\n difficult to visualize. Bilateral effusions are present with increasing\n opacity in the medial aspect of the left base. Other tubes and lines remain\n unchanged since .\n\n IMPRESSION:\n\n Removal of the IABP, insertion of a left subclavian catheter, exact point of\n termination is difficult to assess, improved aeration in the right upper lobe,\n and increasing opacity at the left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 878322,
"text": " 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxic\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and cabg\n x1/ ins. LVAD\n REASON FOR THIS EXAMINATION:\n hypoxic\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG. On ECMO.\n\n AP bedside chest. Cardiovascular status difficult to assess on this semierect\n patient. The heart is enlarged and the mediastinum is prominent. There are\n bilateral substantial effusions layering in semierect position with associated\n atelectasis in the left lower lobe (I cannot exclude a consolidation in this\n area). Satisfactorily positioned ET tube and large caliber SG catheter with\n its tip in the right main pulmonary artery. There is an unusual tube\n overlying the right heart which may reflect ventricular assist device. No\n demonstrable PTX. Allowing for differences in positioning there is little\n change from supine study one day ago.\n\n IMPRESSION: Little short interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 877985,
"text": " 6:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess line placement\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement\n REASON FOR THIS EXAMINATION:\n assess line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man with coronary artery disease status post ECMO\n placement. Assess line placement.\n\n COMPARISON: None.\n\n AP SUPINE PORTABLE CHEST X-RAY: An endotracheal tube is seen at the level of\n the clavicles. The nasogastric tube terminates within the stomach fundus. A\n Swan-Ganz catheter arises inferiorly and terminated with the left proximal\n pulmonary artery. An intraaortic balloon pump is 1 cm below the aortic knob.\n The cardiac silhouette is within normal limits. The mediastinum appears\n slightly widened. The pulmonary vasculature is normal. The right costophrenic\n angle is not seen. The imaged lungs are unremarkable. The surrounding soft\n tissue and osseous structures are unremarkable.\n\n IMPRESSION:\n 1. Intraaortic balloon pump 1 cm below aortic knob, 2 cm above standard\n placement.\n 2. Additional lines and tubes as indicated above.\n\n These findings were called to Dr. at 11:02pm .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-11 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 878345,
"text": " 9:08 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: r/o dvt\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man w/LVAD\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND.\n\n There is no comparison exam.\n\n CLINICAL HISTORY: Left ventricular assist device. Evaluate for DVT.\n\n FINDINGS: Grayscale and Doppler son of the left and right common\n femoral, superficial femoral, and popliteal veins were performed. Normal\n flow, augmentation, compressibility, and waveforms are demonstrated. There is\n no intraluminal thrombus.\n\n IMPRESSION: There is no evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 878201,
"text": " 8:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrates/effusions\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and cabg x1/\n ins. LVAD\n REASON FOR THIS EXAMINATION:\n assess for infiltrates/effusions\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST OF .\n\n COMPARISON: .\n\n INDICATION: Left ventricular assist device following coronary artery bypass\n surgery.\n\n The patient is status post median sternotomy. An endotracheal tube remains in\n place, currently terminating about 1.5 cm above the carina with the neck in a\n flexed position. A Swan-Ganz catheter terminates in the right ventricle and a\n nasogastric tube courses below the diaphragm. The radiodense portion of the\n left ventricular assist device is again demonstrated and unchanged in\n position, as well as a mediastinal drain. Cardiac and mediastinal contours\n are stable allowing for patient rotation. There is an increasing right\n pleural fluid collection tracking to the right lung apex. Note is also made\n of persistent atelectasis in the right upper lobe. Within the left lung,\n there is layering left pleural effusion and persistent left lower lobe\n atelectasis. Hazy appearance of the right hemidiaphragm likely reflects\n pleural effusion in this area as well.\n\n IMPRESSION:\n 1. Low position of endotracheal tube and Swan-Ganz catheter, as communicated\n to the clinical house staff caring for the patient on the date of the study.\n 2. Persistent right upper lobe atelectasis and right effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 878715,
"text": " 3:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS FOR PTX\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and\n cabg x1/ ins. LVAD\n REASON FOR THIS EXAMINATION:\n ASSESS FOR PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post ECMO. CABG. Assess for pneumothorax.\n\n IMPRESSION: AP chest compared to at 5:44 p.m.\n\n Moderate-sized bilateral pleural effusions, right greater than left, have\n increased. There is no pneumothorax. Left atrial cannula is unchanged in\n position. With the chin flexed, tip of the endotracheal tube is more than 6\n cm from the carina, 3 cm above optimal placement. Swan-Ganz catheter tip\n projects over the right pulmonary artery. Nasogastric tube passes below the\n diaphragm and out of view. No pneumothorax. Widened cardiomediastinal\n silhouette is stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-17 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 879090,
"text": " 7:52 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; DUPLEX DOPP ABD/PEL PORT Clip # \n Reason: cause of jaundice\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with LVAD post op Jaundice\n REASON FOR THIS EXAMINATION:\n cause of jaundice\n ______________________________________________________________________________\n FINAL REPORT\n There is no comparison exam.\n\n CLINICAL HISTORY: Jaundice, patient on left ventricle assist device. Evaluate\n for cause of jaundice.\n\n FINDINGS: The liver echo texture and echogenicity are normal. There is no\n intrahepatic biliary dilatation. There is no focal hepatic mass.\n\n The portal vein is patent. The portal venous blood flow is hepatopetal. The\n hepatic veins demonstrate hyperdynamic triphasic waveforms, which is not\n unexpected given the fact the patient is on an LV assist device.\n\n The gallbladder contains sludge and 2 shadowing stones. There is no wall\n thickening. There is no pericholecystic fluid. The common duct is not\n dilated measuring 6 mm in diameter at its greatest point.\n\n The right kidney measures 12.4 cm in length. 2 simple cysts are present in the\n mid portion of the kidney. The left kidney measures 14.9 cm in length. Two\n large simple cysts are present in the left kidney, the larger measures 5.9 x\n 5.3 cm. The measurement of the left kidney may be somewhat inaccurate due to\n overlying dressings. The spleen is mildly enlarged measuring 13.3 cm in\n length.\n\n There is a small right pleural effusion. There is a small amount of ascites.\n\n IMPRESSION: There is no biliary dilatation as clinically questioned. 2)\n Sludge in the gallbladder. Cholelithiasis. No son evidence of\n cholecystitis. 3) Mild splenomegaly. 4) The hepatic veins and portal vein\n are patent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 878303,
"text": " 7:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post bronchoscopy for RUL collapse\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and cabg\n x1/ ins. LVAD\n REASON FOR THIS EXAMINATION:\n post bronchoscopy for RUL collapse\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Coronary artery disease status post ECMO and CABG. Status post\n right upper lobe bronchoscopy for collapse.\n\n COMPARISON: at 8:41.\n\n SUPINE AP VIEW OF THE CHEST: The endotracheal tube has been slightly\n withdrawn in the interval and now lies with tip approximately 5.2 cm from the\n carina. The Swan-Ganz catheter has been slightly advanced in the interval\n with the tip now lying within the proximal right pulmonary artery. There has\n been interval reexpansion of the right upper lobe with small amount of\n residual atelectasis demonstrated. Again seen are bibasilar opacities with\n bilateral layering pleural effusions, which are not significantly changed in\n the interval. The pattern of pulmonary vascular congestion is stable since\n the prior exam. There is no pneumothorax. An LVAD device is partially\n imaged. Median sternotomy wires are again noted.\n\n IMPRESSION: Interval reexpansion of the right upper lobe with small amount of\n residual atelectasis demonstrated. Continued congestive heart failure with\n bilateral layering pleural effusions and bibasilar atelectasis.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 878561,
"text": " 5:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia. post bronchoscopy\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and cabg\n x1/ ins. LVAD\n REASON FOR THIS EXAMINATION:\n hypoxia. post bronchoscopy\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post ECMO placement. Hypoxia post-bronchoscopy.\n\n COMPARISON: .\n\n SUPINE AP CHEST: The patient is post-median sternotomy. The endotracheal\n tube is in an unchanged position at the thoracic inlet. A left subclavian\n approach Swan-Ganz catheter tip again overlies the right main pulmonary\n artery. An NG tube overlies the stomach. ECM device again overlies the right\n heart. The heart size and mediastinum are unchanged since prior film.\n Bibasilar pleural effusions layering posteriorly with associated atelectasis\n unchanged. No pneumothorax is identified. Please note that the left lateral\n costophrenic angle was excluded from the image.\n\n IMPRESSION: No significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 878359,
"text": " 10:31 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: R/O PTX\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and cabg\n x1/ ins. LVAD\n REASON FOR THIS EXAMINATION:\n R/O PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: CABG.\n\n Endotracheal tube is 5 cm above carina. Tip of Swan-Ganz catheter overlies\n right main pulmonary artery. NG tube is in stomach. ECM M-mode device\n overlies right heart. Heart size and mediastinum are unchanged since the prior\n film of the same date. There are bilateral pleural effusions with associated\n bibasilar atelectases. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 879145,
"text": " 1:26 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and\n cabg x1/ ins. LVAD\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man with coronary artery disease status post echmo\n placement. Recent insertion of a left ventricular assist device.\n\n A single AP supine view of the chest was reviewed and compared with serial\n chest radiographs from to the most recent of .\n\n The film quality is suboptimal limiting interpretation of the study. The tip\n of an endotracheal tube is located 5 cm above the level of the carina. Again,\n note is made of moderate cardiomegaly and mediastinal widening, which appear\n unchanged from prior films. Compared to , lines and tubes remain in\n place without change in position. There is no pneumothorax. Moderate\n bilateral pleural effusions are stable. Pulmonary vascular markings are not\n significantly different.\n\n IMPRESSION: Limited study. No evidence of pneumothorax. Lines and tubes\n remain unchanged in position. Moderate bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-11 00:00:00.000",
"description": "P CAROTID SERIES COMPLETE PORT",
"row_id": 878405,
"text": " 2:14 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: S/P MI, HX CVA\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man w/LVAD\n REASON FOR THIS EXAMINATION:\n r/o stenosis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Stroke.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. No\n plaque was identified. Of note, all waveforms throughout both carotid systems\n are dampened with a tardus parvus appearance. This is either consistent with\n severe cardiac disease or multiple arch/inflow disease.\n\n On the right, peak systolic velocities are 31, 32, 31 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 0.96. This is consistent with no\n stenosis.\n\n On the left, peak systolic velocities are 21, 31, 31 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 0.7. This is consistent with no\n stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: No evidence of stenosis in either carotid artery. Of note, there\n appears to either be severe cardiac dysfunction or inflow disease as described\n above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 878933,
"text": " 1:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: re-eval effusion\n Admitting Diagnosis: ACUTE MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cad s/p ecmo placement , now s/p rem. ECMO and\n cabg x1/ ins. LVAD\n REASON FOR THIS EXAMINATION:\n re-eval effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure. Reevaluate with attention to effusion.\n\n COMPARISON: at 16:06.\n\n FINDINGS:\n Compared to the prior study lines and tubes remain in place. There is less\n fluid in the minor fissure but increasing amount of bilateral pleural\n effusions. The extent to which positioning differences contribute is unknown.\n No new consolidations are visualized. Marked cardiomegaly is unchanged.\n\n IMPRESSION:\n Worsening effusions bilaterally. Pulmonary vascular markings not\n significantly different.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2192-09-17 00:00:00.000",
"description": "Report",
"row_id": 211552,
"text": "Regular narrow complex tachycardia - probably atrial flutter with 2:1 response\nAnteroseptal myocardial infarct, age indeterminate - possible acute\nDiffuse ST-T wave abnormalities\nSince previous tracing of , regular narrow complex tachycardia/probably\natrial flutter now present\n\n"
},
{
"category": "ECG",
"chartdate": "2192-09-11 00:00:00.000",
"description": "Report",
"row_id": 211553,
"text": "Accelerated junctional rhythm with probable AV dissociation, sinus rhythm and a\ncapture beat\nAnteroseptal myocardial infarct, age indeterminate - possible acute\nDiffuse ST-T wave abnormalities\nSince previous tracing of same date, atrial fibrillation now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2192-09-11 00:00:00.000",
"description": "Report",
"row_id": 211554,
"text": "Atrial fibrillation\nAnteroseptal infarct - age undetermined - possible acute\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing of , right bundle branch block absent and further\nprecordial ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2192-09-07 00:00:00.000",
"description": "Report",
"row_id": 211778,
"text": "Complete heart block with markedly diminished sinus rate and probable\njunctional escape with occasional premature junctional beats. Q waves in\nleads VI-V2 consistent with anteroseptal myocardial infarction. Compared to the\nprevious tracing some atrial activity has returned. Otherwise, no diagnostic\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2192-09-07 00:00:00.000",
"description": "Report",
"row_id": 211779,
"text": "Probable accelerated junctional rhythm with right bundle-branch block and left\nanterior fascicular block. QS deflections in leads VI-V2 suggest prior\nanteroseptal myocardial infarction. Q waves in leads III and aVF suggest prior\ninferior wall myocardial infarction. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2192-09-09 00:00:00.000",
"description": "Report",
"row_id": 211555,
"text": "Atrial fibrillation with occasional ventricular premature contractions.\nUnderlying right bundle-branch block with Q waves in leads VI-V4 consistent\nwith anterior wall myocardial infarction. Compared to tracing #3 atrial\nfibrillation is new.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2192-09-08 00:00:00.000",
"description": "Report",
"row_id": 211556,
"text": "Normal sinus rhythm. Right bundle-branch block. Prominent Q waves in\nleads VI-V3 suggesting anterior wall myocardial infarction. Compared to the\nprevious tracing the heart block is no longer present and sinus rhythm has\nreturned.\nTRACING #3\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-10 00:00:00.000",
"description": "Report",
"row_id": 1453773,
"text": "resp care\npt remains intub/vented on full ventilatory support, c/w high fio2/peep requirements. ett pulled back per N.P, sxned for copious bld tinged thick sputum, cxr revealed rul collapse,,pt bronched by ct for same. refer to flow sheet for further data.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-11 00:00:00.000",
"description": "Report",
"row_id": 1453774,
"text": "NEURO-SEDATED ON FENTANYL/VERSED. PARALYZED ON CISATRACURIUM INCREASED TO 0.18MG/KG/HR FOR TOF=.PT WITH NO GAG REFLEX,FACIAL GRIMACING, OR SPONTANEOUS MOVEMENT. PERLA @3MM.\n\nCV- WENT INTO AFIB AT SHIFT CHANGE AND CONTINUED TO REMAIN IN AFIB WITH RATE 110-130. AMIODARONE BOLUS WITH HELD AT FIRST D/T HX OF CHB BUT LATER GIVEN D/T INCREASED RATE WITH FREQUENT MULTIFOCAL PVC'S NO AMIODARONE GTT ORDERED.LEVO TITRATED TO SUPPORT HYOPTENSION.HEPARIN GTT INCREASED TO 1100U/HR FOR ACT < 160. REPEAT ACT= 200.LVAD FLOW=6.1 LPM,SV02=57% CO=5.9.\n\nRESP- UNPRECIPITATED EPISODE ( LASTING 45MINS ) OF HYPOXIA WITH SV02 DECREASING TO 33% AND SP02 =67%, HYPOTENSIVE TO 70/40.LEVO TITRATED, FIO2 INCREASED TO 100%,STAT LABS,CXR, AND BRONCH DONE. SCANT MINUTE PLUG REMOVED. PT RESOLVED OXYGENATION. REPEAT ABG/MVBG WNL.\n\nGI-ABD SOFT.-BS, OGT WITH MOD. AMT. BILIOUS SECRETIONS.\n\nGU- DIURESING WELL FROM LASIX FTT. APPRX. 400CC/HR.\n\nLABS- K+/CA+ REPLETED PRN.\n\nENDO- INSULIN GTT @ 5U/HR WITH GLUCOSE LEVELS 100-105.\n\nPLAN-CONTINUE TO MONITOR HEMODYNAMICS, WEAN GTTS AS TOLERATED. GOAL ACT 180-200 U/O > 200cc/HR MONITOR LVAD SITE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-11 00:00:00.000",
"description": "Report",
"row_id": 1453775,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, fully vent supported on AC. FiO2 increased overnoc to 100% for an episode of PaO2=45 and hypotension. Little change in ventilation status during episode, airway pressures remained low and no changes noted in RR. BS's continue to be coarse with scattered wheezes. Sx'd small amts thick brown plugs, then performed bedside bronchoscopy to further pulm hygiene. Episode resolved slowly, seemingly independent of interventions. FiO2 is now slowly being weaned. See flowsheet for further pt data.\nPlan: Will follow, maintain vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-16 00:00:00.000",
"description": "Report",
"row_id": 1453792,
"text": "7am-7pm update\nneruo: pt remains on nimbex gtt. eyelid twitches with TOF (NP) -> nimbex gtt not increased becauses oxygenation stable, pt not overbreathing the vent ( NP). pt remains on midaz gtt at 2.5 mg/hr. continues on fentanyl gtt for pain control. PERRL\n\nCV: pt remains on afib, HR 90-100's. continues on amio gtt at 0.5 mg/min. levo gtt titrated to keep MAP > 60. levo weaned to 0.10 mcg/kg/min. pt continues on vasopressin gtt at 0.04 u/min. svo2 60-70. CI 3.56-2.16. L VAD flows 5.8-6.2 LPM. continues on heparin gtt -> currently running at 2900 u/hr. hct stable. DP's palpable and PT's by doppler NA down to 125 this am.\n\nresp: LS ronchi with inspir wheezing. suctioning for scant tan sputum. no vent changes made overnight. pt continues on CMV 50% with 10 peep, 800 x 11.\n\ngi: BS absent. ogt draining billious fluid. no stool left remains elvated although trending down with the exception of the total bil -> total bili up to 13.8 this am\n\ngu: foley draining clear amber urine. UO > 100 cc/hr. creatinine up to 1.9 this am (1.6 yesterday). pt continues on lasix and natracor gtt's\n\nendo: pt continues on insulin gtt. insulin gtt titrated per protocol\n\nID: wbc's up to 29.0 this am (up from yesterday). blood cultures sent last night off of new PA line (1 sent off proximal port and 1 set off distal port). pt continues on vanco and zoysn\n\nplan: monitor hemodynamics, titrate levo gtt to keep MAP > 60, monitor renal/monitor creatinine, continue current gtt's, contiues antibiotics, monitor ptt/act q6h (goal act ~ 200, goal PTT > 80), pulm toliet, montior LVAD flows, skin care\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-16 00:00:00.000",
"description": "Report",
"row_id": 1453793,
"text": "resp care note\n\nPt still on R VAD and is vented on ACx 11 x 800, 50% + 10 , Sx yield ssmall to scant amts, pt has some wheezing and gets ALB MDI Q4,\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-16 00:00:00.000",
"description": "Report",
"row_id": 1453794,
"text": "update\nD: after morning rounds- decision was to cut vasopressin in half-due to low NA+ levels-titrate levo upward as necessary. wbc up to 29-added diff to am labs. t bili up with lft's- added direct and in direct bili- d.bili 8.3.? hemolysis of cell??due to VAD.\nD: dr made rounds later--intially epi to off/lasix cut in half-felt creat up to 1.9, bun>50 due to \"drying out of pt\"--after further discussion- decision made to wean vasopressin to off first- then wean epi to off. turn off cisatricurium per dr - and if possible wean versed- spoke with - told with pt's elevated liver enzymes- it might take 24 hours to clear versed, fentanyl should clear quickly- avoid propofol.\nA: cisatricurium to off- prior to this pt having 4 twitches--but not over breathing vent---once off pt responsive within approx 15mins, moving head and eyebrows, pt was able to move hand- slight grip right side and move right toes when asked. no movement noted on left side during this short time period. pt began overbreathing vent- coughing- bs coarse through out- sounding \"junky'- sx for nothing--sat dropped to 78-80-abg checked on 50%- with pao2 41- sat 80%-\nA: pt placed on 100%\nR: sat uo tp 89%,\nA: aware-ordered cart to room.-cisatricurium restarted.\npresently, pt 0/4 twitches on .39 cisatricurium.--awaiting bronch..\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-13 00:00:00.000",
"description": "Report",
"row_id": 1453785,
"text": "UPDATE\nCV: NSR 79-80 W/ OCC PAC. LVAD WEAN ATTEMPT SUCCESSFUL FOR SHORT PERIOD(SEE ABOVE NOTE). SBP DIPPED TO 80'S W/ INTERMITTENT EPISODES OF HYPOXEMIA. BIL TOES SL COOLER THIS AFTERNOON > THAN THIS A.M. BUT PULSES STILL EASILY DOPPLERABLE. SVO2 50'S-LOW 60'S EXCEPT FOR ABOVE EPISODES WHEN HE DROPS TO 40'S. LATEST ACT 188, PTT 113 AFTER HEPARIN BOLUSES.\n\nRESP: PAO2 WNL. SPO2 IN HIGH 90'S BUT PT HAVING MULT EPISODES OF DESATURATION ASSOC W/ DROP IN SVO2 AND BP. PT / LAVAGED AND OCC AMBUED EACH TIME. ONLY SM AMT OF THICK, TAN SECRETIONS OBTAINED, NO PLUGS. THIS AFTERNOON HOWEVER, SPO2 NOT RECOVERING AS BEFORE. BS NOTED TO BE VERY DIMINISHED ON R SIDE, > THAN IN A.M. CXR DONE AND PT KEPT ON FIO2 1.0 FOR NOW. SPO2 CURRENTLY 98%.\n\nNEURO: NO CHANGES IN NEURO STATUS OR SEDATION-SEE FLOW SHEET.\n\nG.I.: MOD AMT BRIGHT GREEN DRNG VIA OGT. NO BS, NO B.M.\n\nG.U.: UO 100-300ML/HR. CONT ON CONTINUOUS LASIX DRIP.\n\nSKIN: INTACT BUT DIAPHORETIC TODAY. TEMP COMING DOWN FROM EARLY A.M. RASHY AREAS L AXILLA AND PERIANAL AREAS(?YEAST).\n\nI.D. WBC COMING DOWN SLOWLY. LATEST BLD CX STILL PENDING. SPUTUM GM STAIN -, URINE CX -. TEMPS 99-100 RANGE TODAY.\n\nSOCIAL: WIFE UPDATED ON RESULTS OF WEAN BY PHONE.\n\nA/P: TOLERATED LVAD WEAN WELL BRIEFLY. PLAN TO KEEP PT HERE AND RETRY WEAN EARLY NEXT WEEK TO ASSESS NATIVE VENTRICLE. ACT GOAL NOW 200-250. LEAVE EPI ON FOR NOW. CONT TO HAVE DESATURATION EPISODES FOR UNKNOWN ETIOLOGY. SEEMS TO GET BETTER AFTER AMBU AND INCREASED FIO2 TEMPORARILY. CXR RESULTS PENDING. CONT CURRENT MONITORING AND SUPPORT.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-14 00:00:00.000",
"description": "Report",
"row_id": 1453786,
"text": "Neuro: pt sedated paralyzed no changes made overnight. Pupils remain equal and reactive.\nResp: no episodes of desaturation. Sats 96-100% Fio2 weaned to 50%.\nSuctioned for scant amounts Breath sounds with rhonchi on the right side.\nC/V: Pt in NSR all night until 0500 when he went back in to Afib rate of 100-120. with Svo2 down to 53-55 Bp slightly lower requiring levo up to .08 form .07 No change in LVAD flows Ho aware no treatment ordered for this. MILrinione, Epi, Vasopresin, Amiodarone, Natrecor, Lasix unchanged. See Flow sheet for rates. Heparin increased to 2300 to increase Ptt to 80 Will repeat Ptt at 2200. ACT up to 213 this am. LVAD flows >6.0. Temp up to 101 treated with tylenol.\nGI: OGt draining bilious fluid.\nEndo: Insulin gtt at 6u/hr.\nGU: Adequate urine outputs on lasix drip 100-200cc/hr.\nSkin: pt has red rash on back only Special SHeets used on bed.\nIncisions clean and dry no drainage.\nPlan: ? possibly waking pt in next several days.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-14 00:00:00.000",
"description": "Report",
"row_id": 1453787,
"text": "CARDIAC~CONT IN AFIB~106 W/ BURSTS TO 140 NP. AWARE GIVEN LOPRESSOR 2.5 MG IV X1, BRIEFLY SLOWED RATE, THOUGH PT DID NOT TOL DRUG. DROP IN SBP 80'S SVO2->48 RECOVERED FAIRLY QUICKLY OVER 15-20 MIN. REQUIRED ^ IN LEVO DOSE. CURRENTLY ON .12 UCG/KG/MIN. MILNIRONE/ VASOPRESSIN/EPI & AMIO ALL REMAIN UNCHANGED. LVAD FLOW RATES >6.0 REMAIN UNCHANGED NO TX REQUIRED. HEPARIN ^ FROM 2300 TO 2500 UNITS/HR @ 1100 PTT->59.7/67.1. 1700 PTT PENDING ACT~>200. ELECTROLYTES REPLETED.POS PEDAL PULSES BILAT.LEFT TOE COOL SKIN NORMAL.\n\nNEURO~REMAINS PARALIZED. CIST ^ @ 1500 .3MG/KG/HR PT LIGHTLY COUGHED WITH SX. TOF . CONT ON FENT & VERSED GTTS. ELIX FOR TMAX 101. FAMILY IN TODAY SPOKE W/ ,NP AND DR. .\n\nRESP CONT ON CMV SVO2 LOW 50'S ATTEMPTED TO DECREASE PEEP TO 8 PT DID NOT TOL CHANGE PLACED BACK ON 10 PEEP. TOL WELL. SEE FLOW SHEET FOR VENT SETTINGS. CCO RECAL SVO2\nNOW LOW 60'S. LUNGS->RLL ATELECTASIS,OTHERWISE CLEAR. SX FOR SCANT SEC. MOD AMT OF ORAL SEC.\n\nGI/GU~OGT LCS->BILIOUS DRAINAGE. LASIX/NATRECOR GTTS REMAIN UNCHANGE AU/O CONT > 110. DULCOLAX SUPP.\n\nSKIN~ RASH TO BACK UNCHANGED.\n\nA/P~PLAN TO LEAVE PT SEDATED TONIGHT POSSIBLY WAKE TOMORRROW PER DR. . CONT TO MONITOR HEMODYNAMICS CURRENTLY STABILE. CONT W ICU INTERVENTIONS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-15 00:00:00.000",
"description": "Report",
"row_id": 1453788,
"text": "Respiratory care:\n67 y.o. M S/P MI cardiogenic shock Now on LVAD. Patient remains intubated and mechanically vented. Patient with Problems oxygenation and unable to ventilate this eve. Patient lavaged and ambued for 2 large one brown and one bloody plugs. Breathsounds remain coarse. Abuterol given inline with vent. Pao2 decreased. Patient bronched. Please see carvue for further data.\nPlan: Continue mechanical ventilation and aggressive pulmonary toilet.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-15 00:00:00.000",
"description": "Report",
"row_id": 1453789,
"text": "CSRU NPN\n\nNeuro: Midazolam increased to 2.5mg/hr for increased BP w/ activity. Pt noted to have abdominal movement with ETT suctioning. MD aware. Cisatricurium increased MD recommendations. Currently w/ twitches and no abdominal movement w/ suctioning. PERRL.\n\nCV: HR 100-110's a fib. Having episodes of increased HR to 130's last evening w/ stable BP and LVAD flows. No change in treatment at that time MD. Amiodarone cont's. Lytes repleted. PAD's 22-26. Weaning levo slowly as BP tolerates. Mvo2's 55-low 60's. CI's > 2.0. LVAD flows 6.1-6.3. Received 2 units PRBC's for hct 27->post hct ~30. ACT's 180->176 w/ PTT 70.8. Heparin increased MD orders.\n\nResp: BS variable but w/ adequate ventilation. Remains on AC ventilation. Had episode where O2 sats dropping to low 90's. Suctioned w/ return of small amt secretions. Pa O2 68 w/ O2 sats of 91-93%. Then noted pt not getting tidal volumes via ventilator. Lavaged and ambued for very large thick mucous plug. Bronch done by MD->no signifcant secretions noted per report. On 100% for a couple of hours. PaO2 improved. Is retaining some CO2 which MD is aware of. No vent changes at this time. O2 sats good on 50% rest of night.\n\nGI: Abd softly distended. No BS heard. No results from dulcolax. Sclera slightly jaundiced. LFT's remain hight by seem to be decreasing.\n\nGU; u/o down to <100cc/hr x 2 hrs. Lasix up to 10mg/hr w/ good effect. Decreased slightly d/t u/o 400cc x 1 hr.\n\nEndo: Insulin gtt titrated accordingly.\n\nID: T max 38.8. Skin moist occasionally.\n\nSkin: Scant amt serousang dng noted at inferior postion of incsion line. Back/buttocksw/ red rash.\n\nSocial: No call from family tonight.\n\nA: Hemodynamically stable. Continue w/ anticoagulation. Episode of hypoxia d/t mucous plugging. ? address metabolic alkalosis to prevent CO2 retaining.. Full hemodynamic and respiratory upport. Monitor skin closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-15 00:00:00.000",
"description": "Report",
"row_id": 1453790,
"text": "CSRU NPN\n\nCV: Occasional native beats noted in a line trace throughout shift.\n\nSkin: Dsg to LVAD cannulas changed->no dng, redness. Left heel purplish area unchanged from wednesday. Skin intact, no increase in size.\n\nID: WBC up to 23 this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-15 00:00:00.000",
"description": "Report",
"row_id": 1453791,
"text": "update\nD: pt cont on multiple drips-weaned levo as need for sbp>90, map >60- titrated from .08-.25 mcq, vasopressin remainsat .04, cisatricurium weaned to .39 to obtain 2 eye twitches, heparin cont at 2800 with ptt 71 and act 197-210, amiodarone unchanged at .5 mg, lasix titrated up to 9mg/hr to obtain u/o >105cc/hr- natracor unchanged.\npt with temp and inc wbc, pt cultured and left cco changed over a wire- new introducer and cco swan- procedured complicated with dip in bp-corrected with inc levo and pt receiving pc for hct 29.--please note prior to changing line pt temp appeared to be rising, sbp dipped as did svo2-pt given rbc with improvement and levo titrated upward as noted.\n\nneuro: pt paralysed as noted- cont on fentanyl 200mcq, versed at 2.5 mg- on .39 cisatricurium --geting 2 twitches. pupuils 3-4cm equal and rx to light. pt does not cough with sx.\n\ncardiac: pt cont in afib 90-110, no other ectopy noted, pt cont on vasopressor as noted, vad cont with flows >6 most of shift except when sbp dips- native ejections noted at times, co excellent, svo2 in 60;s did dip to low 50's with temp elevation in afternoon and dip in sbp. dopplerable pedal pulses.\n\nresp: no changes on vent, pt sx for not secretions, lavage without secretions.\n\ngi: pt remains npo at present, considering feeding fut-yet pt with lg ogt output approx 300cc bilious material today- ogt clamped at 1800- will eval --ppi cont. abd soft, no obvious bs. dulcolax given last eve with small amt of musous discharge this am.\n\ngu: foley intact draining amber urine u/a, c&s sent, u/o cont >100cc/hr- intially lasix frip at 7mg/hr inc to 8 and then to 9mg as day progressed to obtain u/o >105- u/o did dip with hypotension, natracor cont-no changes made--na low/ creat 1.4 today.\n\nskin: intact , rash noted a skin folds and back- nistatin power applied, small dark area noted left heel- boots on.\n\nplan: lasix to maintain u/o >105, map >60, ptt >+80, with act around 200.\n? starting to feed gut if ogt residual adeq.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-12 00:00:00.000",
"description": "Report",
"row_id": 1453778,
"text": "Respiratory Care\nPatient remains intubated and fully ventilated on a/c with no remarkable changes overnight. Sats, abgs stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-12 00:00:00.000",
"description": "Report",
"row_id": 1453779,
"text": "Respiratory Care\n\n Pt remains on full ventilatory support. B/S ess clear dim in bases. No changes in ventilation planned. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-12 00:00:00.000",
"description": "Report",
"row_id": 1453780,
"text": "Respiratory Care ADDENDUM\n\n\n Pt acutely desaturated sx'd thick blood tinged yellow secretions. Pt bronched for minimal thin secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-12 00:00:00.000",
"description": "Report",
"row_id": 1453781,
"text": "CSRU NPN\n\nNeuro: Sedated. Cisatricurium increased for eye twitches and abdominal movements noted w/ ETT suctioning. Improved to eye twitches and no abdominal movement noted w/ ETT suctioning. PERRL.\n\nCV: Initially v paced at rate of 92 w/ occ NSR beats and occ PAC's. Epi turned off this am-> SBP down to high 70's shortly after turned off->improved w/ slight increase in levo. MVO2's, LVAD flows, and CVP's stable off epi. Converted to RAF initially 120's. Immediate decrease in SBP to 70's, MVO2's to 40's, LVAD flows to 2.5L. NP into eval. Cardioverted w/ 200->initial rhythm appeared to be v pacing then quickly back into afib w/ rates 110's. BP, MVO2's, and LVAD flows stable w/ afib at these rates. Given amiodarone bolus x 1.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-12 00:00:00.000",
"description": "Report",
"row_id": 1453782,
"text": "CSRU NPN cont'd.\n\nCV: LVAD flows mostly in 5L range. CI's consistently > 2.0. Down to 1.9 x 1->PRBC's given. Heparin gtt initially 1100u/hr->gradually increased to 1800 over course of day for goal PTT of atleast 70.\n\nResp: BS clear, slightly decreased at bases. VT decreased to 650cc to treat resp alkalosis. Suctioned for minimal amts secretions throughout day. This afternoon, noted dropping O2 sats into low 80's, MVO2's into 40's, SBP's into high 60's-70's, and LVAD flows into mid 2L range. Ambued and suctioned for small scant mucous plugs with improvement in resp and cardiac numbers. Then approximately 15 mins later, pt w/ repeat episode of hypoxia and cardiac compromise. Ambued and suctioned for large thick mucous plug w/ improvement. 3rd repeat episode at which time pt bronched->minimal thin secretions noted MD. Pt remained on 100% FiO2. CXR obtained. Interventional pulmonary consult obtained->felt ? atlectasis. Suggested increased tidal volumes with decreased resp rate to maintain adequate ventilation. ABG on 800x11 wnl. No further episodes of resp and cardiac compromise since. Per report, CXR wnl.\n\nGI: Abd soft. No BS. OGT w/ bilious dng.\n\nGU: Excellent u/o on natrecor and lasix gtts.\n\nEndo: Insulin gtt titrated accordingly.\n\nID: Febrile and diaphoretic in am->tylenol w/ good effect. Urine Cx sent.\n\nSkin: Scant serousang dng at distal portion chest dsg. MD aware. Buttocks without breakdown. Area of purple discoloration noted left heel->elevated off bed.\n\nComfort: Fentanyl gtt.\n\nSocial: Family into visit. Spoke w/ Dr. .\n\nA: Poor toleration of new onset AF. Hypoxia followed by cardiac compromise in afternoon. Diuresing well.\n\nP: Cont cardiac support w/ pressors, inotropes, and LVAD. ? attempt LVAD wean tommorrow per team. Cont anticoagulation. Monitor pulmonary status closely. Suction prn to prevent plugging. Monitor temp curve. Sputum cx when possible. Monitor left heel for breakdown. Diuresis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-13 00:00:00.000",
"description": "Report",
"row_id": 1453783,
"text": "Neuro: pt remains on Cisatracurium, Fentanyl and Versed. TOF 2 twitches no coughing or movement seen. Pupils equal and reactive.\nResp: Vent settings unchanged. No desaturations until this morning sats dropped down to 92% without Bp drop. Pt suctioned and lavaged for moderate thick rust colored seretion, Specimen sent to lab for culture.\nC/V: levo increased slightly early in shift but Hct returned 28 so 1 unit of Prbc's given and levo weaned back down to 0.08mcg. All other drips remain unchanged. Svo2 49 up to 60 this am. CO>5.0 LVAD with good flows . Heparin drip increased to 2100units to obtain Ptt 80-90 and ACt around 250. pt was in an afib rate 100 to 110 until about 1:45 am when he went into a sinus rhythm rate in the 70-80's\npacer turned down to demand of 70. Lytes treated as ordered.\nGI: Ogt patent draining bilious fluid.\nEndo: Blood sugars well controlled on insulin drip at 5units/hr.\nGU: urine outputs 100-300cc/hr on lasix drip at 5u/hr.\nSkin: Incisions clean no change in marking on chest dsg. left leg incision open to air. Back and buttocks area red slightly rash ? heat rash or reaction to sheets pt placed on unbleached sheets for now.\nPlan: ? wean LVAD to see function of ventricle, ? transfer to for transplant if excepted.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-13 00:00:00.000",
"description": "Report",
"row_id": 1453784,
"text": "UPDATE\nEPI RESTARTED AND MILRINONE INCREASED IN ANTICIPATION OF LVAD WEAN. ADDITIONAL HEPARIN BOLUSES (7000UNITS TOTAL) GIVEN TO BRING ACT NEAR 300. LVAD WEANED @ 1130 TO 0 FLOW BRIEFLY W/ SVO2 AND MAP BOTH MAINTAINED 60 OR >. HR STABLE NSR IN 70'S W/ NO ECTOPY. TEE DONE DURING WEAN REPORTEDLY SHOWED LVEF 5-10%. FLOW THEN RETURNED TO 6 AND MILRINONE BACK TO FORMER DOSE. EPI SHUT OFF PER DR. BUT SBP DROPPED TO 89'S AND SVO2 TO 50 SO BACK ON @ LOWER DOSE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-11 00:00:00.000",
"description": "Report",
"row_id": 1453776,
"text": "UPDATE\nCV: AMIO REBOLUSED AND DRIP STARTED TODAY. EPI DOSE HALVED. HR IN AFIB UNTIL 1635 WHEN HR CHANGED TO CHB VS JUNCTIONAL W/ RETROGRADE P WAVES-EKG RESULTS PENDING. SBP DROPPPED TO 70'S, SVO2 TO 40'S. V-PACING INITIATED @ 90 AND FLUID BOLUS GIVEN. PT RECOVERED BP AND SVO2 IMPROVED TO 50'S. MAGSULFATE GIVEN. LVAD FLOW IN LOW 5 RANGE W/RATES ~ 60. SVO2 SLOW TO RECOVER AFTER ANY ACTIVITY. BIL LE AND CAROTID US DONE AS PART OF TRANSPLANT W/U. C.I. BY T.D. >2.0. MEDIASTINAL CT'S D/C'D. WEANING LEVOPHED SLOWLY. HEPARIN DOSE TO 1000U/HR. NEW PERIPHERAL IV'S PLACED R ARM FOR INCREASED ACCESS.\n\nRESP: LUNG SOUNDS COARSE BUT DIMINISHED @ BASES. HAD EPISODE OF DESATURATION (SPO2 TO 79%) ASSOC W/ DROP IN SVO2(33%) AND HYPOTENSION(SBP 70'S). PT PLACED ON 100% FIO2, SUX/LAVAGED AND FOUND TO HAVE MULT, THICK, PLUGS. ALL PARAMETERS IMPROVED AFTER SUX DONE. BRONCH LATER DONE BUT SCANT SECRETIONS OBTAINED. FIO2 LATER WEANED TO .50 W/ SPO2 CURRENTLY 99%.\n\nNEURO: IN A.M. BP CLIMBING TO 140-150'S W/ ANY STIMULATION. FENTANYL AND VERSED SEDATION INCREASED W/ SOME IMPROVEMENT. CISATRACURIUM DOSE INCREASED THIS EVE WHEN TWITCHES=4. PERL. NO MVMT OR SPONTANEOUS BREATHS.\n\nG.I.: +BS THIS A.M., NOW QUIETER. MOD AMT BILIOUS DRNG VIA OGT.\n\nG.U.: EXCELLENT DIURESIS ON IV LASIX DRIP @ 5MG/HR. I&O CURRENTLY >2L NEGATIVE. REPLETING K+ FREQUENTLY.\n\nSKIN/DRSGS: INTACT. OCCLUSIVE LVAD DRSG AND FROM OTHER INCISIONS.\n\nENDO: GLUCOSE WNL ON INSULIN DRIP PER PROTOCOL.\n\nSOCIAL: WIFE AND CHILDREN IN TO VISIT AND UPDATED. DAUGHTER TO BRING IN COPY OF MEDICAL PROXY FORM(WIFE IS TOMORROW.\n\nA/P: BP IMPROVED TODAY BUT W/ OCC INSTABILITY, NOW STABILIZED IN NEW RHYTHM W/ PACING. LVAD EFFECTIVELY SUPPORTING C.I. DIURESING WELL W/ LASIX. OXYGENATION IMPROVED BUT NEEDS SUX/LAVAGE @ LEAST 2X/SHIFT TO PREVENT PLUGGING. CONT CURRENT MONITORING.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-12 00:00:00.000",
"description": "Report",
"row_id": 1453777,
"text": "Neuro: Pt. kept paralyzed and sedated; TOF with 3-4 twitches despite increase in Cisatracurium. No signs of overbreathing vent or change in vs on current doses of sedation and paralytic.\n\nCV: hemodynamically stable with brief drops in BP when LVAD re-tests. Rhythm is v-paced with underlying rhythm nodal. LVAD with flows > 5liters and CI >2.2. See flow sheet for all drips and dosages.\nOne BC sent for Temp. >101, Pedal pulses all by doppler.\n\nPulm: Sao2 dropped to 87% x1; sx for thick blood tinged plugs. Sao2 recovered to 97%. No vent changes. Continues on 50% fio2 and 10 peep.\n\nGI: Protonix for Gi bleed coverage,\n\nGU: Excellent huo on lasix drip at 5mg.hr.>200cc/hr.\n\nEndocrine: BS's in good control on stable dose insulin 6u/hr.\n\nLabs: K+ repleted prn.\n\nHeme: Hct stable and heparin titrated to get PTT ~ 60. ACT kept within 180-200.\n\nPlan: maintain current meds,Titrate Leophed only. Sx prn and bronch if necessary. Maintain LVAD flows >5l/min.\n\nPlan:\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-18 00:00:00.000",
"description": "Report",
"row_id": 1453803,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for scant amt secretions. MDI'S given.Worseing PaO2 78.Paralyzed and sedated.Getting levophed,lidocaine,lasix,heparin,midazolam,and pitressin. Remains on LVAD.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-18 00:00:00.000",
"description": "Report",
"row_id": 1453804,
"text": "NEURO-PARALYZED/SEDATED WITH NIMBEX/VERSED/FENTANYL GTTS. TOF=0/4 TWITICHES. (NERVE STIMULATOR DOESN'T SEEM TO BE SENSING APPROPRIATELY. BATTERY CHANGED). NO FACIAL GRIMACING OR CHANGE IN VS WITH ACTIVITY. NOT OVERBREATHING VENT OR GAGGING WHEN SXD.\n\nCV- NSR.NO ECTOPY. HEMODYNAMICS STABLE ON CURRENT GTTS. LEVO WEANED TO 0.23MCGKGMIN WITH MAP=86. CO/CI 6.0/2.8 LVAD FLOW RATE=5.1 SV02=57%.HEPARIN GTT INCREASED TO 3000U/HR FOR GOAL PTT 80-100. 93.0 THIS AM. NO HYPOXIA/HYPOTENSION WHEN TURNED. INCREASED SCLERAL EDEMA AND JAUNDICE,BUN^67/2,4 T-MAX=99.1-> 400MG MOTRIN WBC=36.0 CONTINUES ON FLAGY/ZOSYN/VANCO\n\nRESP- CONTINUES ON CMV 60% 800X10X11. SATS=96%, LS COURSE THROUGHOUT. NO SECRETIONS WHEN SXD.PA02= 78.\n\nGI-ABD SOFT DISTENDED. UNBLE TO HEAR BS D/T LVAD. DULCOLAX SUPP GIVEN WITH NO RESULTS.OGT WITH THIN BRB DRG D/T INCREASE IN HEPARING GTT TO 3OOO/HR\n\nGU- DIURESING WELL FROM LASIX GTT. GOAL U/O- 90-150CC/HR.NA+ 124. ALL GTSS MIXED IN NS.BUN/CR 67/2.4\n\nLABS- K+.CA+ REPLACED PRN. LIVER ENZYMES PENDING.\n\nPLAN- WEAN GTTS AS TOLERATED. WEAN LVAD VACCUM/FLOW RATE. PLACE DOBHOFF FOR FEEDING.SUPPORT RENAL/RESP/I.D.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-18 00:00:00.000",
"description": "Report",
"row_id": 1453805,
"text": "PT STABLE FOR TRANSFER TO CARDIAC SICU. AMBULANCE CRITICAL CARE TEAM ARRIVED FOR TRANSFER TO . SEE FLOWSHEET FOR DETAILS PRIOR TO TRANSFER.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-09 00:00:00.000",
"description": "Report",
"row_id": 1453769,
"text": "update\nD: pt with liable bp dips to 60's improved with vol and titration of drips- pt receieved 250 lr/500 hesoan and started 250 5% albumin ATC- levo up to .3, voasopressin remains at .02, milinone at .2, epi at .02-cisatricurium at 1.2 with 4 facial twitches-0 baseline current 80??- pt not over breathing vent, not coughing with sx- this drip not inc. pt with runs v tach this am- some fusion beats- lido cont at 2 mg, amiodarone bolus given x 1-pt at 90 with ma 22.- pt cont on propofol which was weaned to 35 per dr . mso4 or perocet given for pain relief.\nNew left sub cordis placed and cco inserted, left fem swan and sheaths d/c, left fem IABP d/c- pt then started on heparin thereafter0 bolus 1500u followed with a 700u/hr drip 0 act up to 192.\nVAD: flows dip with hypotension yet remained >4 most of day () rate 50's- with vacuum pressure 89-90. as noted pt started on heparin with first act 192. inr 1.3.\nneuro: pt paralyzed on cisatricurium- 4 twitches noted with ma 8- (Baseline per hx)- pupils equal rx to light. pt weaned to propofol 35 and getting percocet ATC.\ncardiac; pt with LVAD-tol well at present- note flows above-pt with multiple pvc's/fusion beats-lido at 2 mg- amiodarone bolus given this am- pt underlying rhythm CHB- EP following pt. states topace him as we are- 2 v wires intact- after swan inserted- svo2 50--plan to started natracor.\ngi: pt npo- ogt in place draining cl fluid, h2 blocker , abd soft, slight distended, diff hearingBS due to iabp/VAD. no bm\ngu: creat 1.7, u/o dips slightly to day- pt tx with both fluid/lasix0 goal u/o .60cc/hr.\ninc: intact.\nplan: follow act closely for heparin, start natracor today-albumin q 8hrs.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-10 00:00:00.000",
"description": "Report",
"row_id": 1453770,
"text": "Neuro: pt remains paralyzed and sedated, 4 twitches present on TOF drip increased to 0.14 2nd to overbreathing by breathes intermittently. NOt seen since increase although 4 twitches still present. Pupils still equal and reactive.\nResp: pt fully vented. Po2s dropped to 61 Fio2 increased to 70% with improvement of po2 to 116. Suctioned for scant amounts sputum spec sent to lab for culture. Chest tubes patent\nC/V: pt remains V Paced at rate of 90 with occasional break though beats. No runs of vtach noted. Hemodynmically stable on Epi 0.02, milrinione 0.2, vasopressin 0.2 Lidocaine 2mg and levo. No changes made excep Levo decreased to 0.23 from 0.28 Blood pressure >100, Flows >4.5 from LVAD Pt continues to receive Albumin 250cc of 5% every 8 hurs Svo2 50-60 with CO 5.o and CI>2.0 Hct stable. Pt on heparin increased to 900u/hr to maintain ACT around 180. Pt started on Natrecor Pulses present by doppler in both feet.\nGI: OGT draining bilious fluild no bolwel sounds heard.\nEndo: Insulin gtt per protocol.\nGU: pt received 20 mg lasix last night for urine output of 22cc with good response urines have been 90-200 all night.\nSkin: Incisions clean and dry no drainage or reddness.\nActivity. Pt turned side to side and toleerated it with no dips in bp\nSocial: Family updated last evening will call again in am before leaving to come to hospital\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-17 00:00:00.000",
"description": "Report",
"row_id": 1453801,
"text": "ventricular ectopy\nCArdiac: pt noted to be in a-flutter this am-upon further investigation with eval of ekg- decided nsr- rate 110 prolonged pr-pt appeared to convert back to a fluteer varying rate 1:1- 1:2-\nat 1300 new iv site obtained-via right IJ-pt tol well. old cco swan d/c- original coris remained in place until new swan obtained- upon insertion of new swan- line only at 20cm- pt went into vtach--line pulled back without effect- pt given 100mg lido and defib at 200 joules,pt conversed to a slower rate 70;s nsr additonal 150mg bolus amiodarone given- pt settled out and swan then inserted without ill effects- post insertion- pt experieced 3 more spidosed of persistent v-tach- defib each episode with 200 joules with conversion. pt given an additional amiodarone bolus 150mg and another lido bolus 75mg with a lido drip initiated at 2mg--pt has experienced less ectopy to at this time pt remains in nsr.\npresently pt on levo .25mcq, vasopressin restarted as noted at .03unit, maintaining a sbp >100/, VAD flows 5.2- able to wean vacumm doen to 50 today- plan to wean flow tomorrow and eval pt own heart-\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-17 00:00:00.000",
"description": "Report",
"row_id": 1453802,
"text": "update\nneuro: pt cont on cisatricurium at .39 mcq with 2 twitches- pt not over breathing vent- but does appear to clench teeth at times- pt cont on versed down to 2mg today to aid in bp support, and fentanyl cont at 200 mcq. pupile equal and rx to light.\n\ncardiac; as noted above-pt aflutter-ns- episodes v-tach- defib with success-please refer to above note-co>6 with CI>3, svo2 >60.\n\nresp;, pt cont with coarse bs- sc for tan thick sputum this am--bs coarse in upper lobes, inspir wheezes noted in bases bilat. pt sat dipped- sx for mod amt thich tan sputum- pluggs- sat only up to 92%- abd with pa02 60's- inc fio2 60.\nPlan: ? need for bronch to evac plugs/thick sputum. pending culture report of spec sent .\n\ngi: pt abd sl distended, bs absent, difficult to eval due to VAD sounds- ogt drainig bilious material 300cc today- fleets given po this am- pt receivie dulcolax this eve- plan ft placement in am, US neg- done due to elev -persistent elvation of LFT's.\n\ngu: foley in place draining icteric yellow urine, ranging in u/o 20-120cc/hr- titrated lasix up to 10mg with u/o at approx 100cc- team want u/o 150cc/hr ? if they want dose inc further--creat 2.0 today with BUN >60.\n\nskin: intact, small discolored area noted on left heel- splint remaining in place thru out day, not skin breakdown noted, pt with raisied red rash at skin folds and on back (note-rash present prior to antiobotics)\n\nplan: dulcolax tonight....? fleets, ft to be inserted tomorrow. wean flow on VAD tomorrow to eval pt own cardiac function. family aware of plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-09 00:00:00.000",
"description": "Report",
"row_id": 1453766,
"text": "Neuro: pt paralyzed with Cistracurium ToF 2 twitches most of night until this am up to 4 dose increased to 0.08. Pupils equal react to light\nResp: ABG's improved Fio2 weaned down to 50% and rate decreased to 16. pt remains on peep of 10 THis am po2 76 fio2 increased to 60% will repeat abg. Suctioned for scant amounts Breath sounds clear diminished in bases. Chest tube patent draining old sanguinious drainage small amounts.\nC/V: Lvad flow rate started around 5.4 in begining of shift and slow decreased to low 4.0s over night. pt received 2 units of PRBC's with no change in flows. Pa NUmbers unchanged with low flow and blood. Epi, milrinione, vasopressin, levo, lido drips unchanged. Around 4 am SVo2 returned 53 with PO2 76 flows at that time were 3.8-4.0 and Map runninga round 60-64. urines had dropped off to 30-40cc/hr. Fellow called at bedside with pt. Rhythm starting to change pt had been in 1st degree AV block all night then sinus and looking like junctional rhythm. pt was receiving volume at time and drips were being adjusted to improve flow rate when pt suddenly became asytolic with only p waves running across screen. LVAD flow in the low 4's Pacer turned on and pt V paced at a rate of 80 with immediate improvement in all numbers Bp up to 120 Flow rate up to 5's. pt started to compete with pacer and pacer turned back down to back up rate of 58. Pt underlying rhythm noted to be Complete heart block with good perfusion. Pacer left at V demand of 58 .\nGI: OGT draining bilious fluid.\nEndo: pt on insulin drip rate of 10u/hr with good blood sugars per CSRU protocol.\nGU: pt had fair response to lasix last evening rate decreasing down to 30cc/hr now if pt remains stable will give more lasix per fellow,\nSkin: dsg intact small amounts of drainage noted. Pedal pulses present by doppler. feet cool\nSocial: Daughter and son in to visit last evening\nPlan: Continue present drips plan lasi if remains stable\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-09 00:00:00.000",
"description": "Report",
"row_id": 1453767,
"text": "RESP CARE: Pt remains intubated/on vent. Recruitment breath done x1 at start of shift and PEEP increased to 10. Plat pressures remain 22-24.SEE CAREVUE FOR SPECIFICS. Lungs clear/dim bases. Continue full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-09 00:00:00.000",
"description": "Report",
"row_id": 1453768,
"text": "Resp Care\n\nPt remains intubated and currently vented on full ventilatory support with no changes made to settings. BS essentially dim/clear sxing for minimal secretions. ETT advanced 2cm with bilateral BS. CXR pending. Last ABG WNL with good oxygenation. Will cont with vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-17 00:00:00.000",
"description": "Report",
"row_id": 1453797,
"text": "resp care note\n\n Fio2 weaned to 50%. Pt on AC 11x800,+10. Pt has LVAD in place . Last ABG 7.39,47,95. BP is labile, plan is to wean from VAD today if possible\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-07 00:00:00.000",
"description": "Report",
"row_id": 1453761,
"text": "adm to csru\nD: pt adm to csru from cath lab- evolving a lg mi- coded in cath lab- iabp placed left fem, and ecmo inserted via the right fem- -stent was placed on right side- all vessels down but circ at initation of case.\npt with v-fib/v tach- defib x 4, amiodarone/lido started- upon adm to caru- d/c amiodarone due to junctional rhythm with retrograde p's vs CHB--heparin started at 1000u/hr0 titrated to maintain act 180--presently at 900u/hr with act 182.\niabp set a t 1:2- , vent weaned to 50% from 100%- pt on ecmo thus receieving 70% fio2 with adeq abg's- ecmo flow 4.2-4.3.\n\nneuro: pt adm to csru on versed drip at 8- mae at this time- switched to 30 mcq propofol with good effect, pupils 3cm equal and rx to light. prior to tranfer to unit- pt responding to cath lab team- blinking when asked, mae.\n\ncardiac: pt on ecmo/iabp-hr 70's- junctional-CHB-means 80's via ecmo.\n\nresp: pt weaned on vent as noted to 50%- nopte pt on ecmo- 70% wh/ is perfusing his blood- vent to provide min support- bs dim though out.\n\ngi: abd soft, ogt placed- cl secretions. ppi started.\n\ngu: creat 1.4- foley placed at end of cath lab case- 500cc urine- urimeter placed with u/o >60cc/hr-\n\nskin: intact, pt ozzing from right fem ecmo cannulation site- stitch placed- with improvement- drsg d&i, left fem site with min ozzing.\n\nplan; ecmo to provide suppost tonight- in am0 to or- wean echo- tee to visualized wall motion--??placing vad.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-08 00:00:00.000",
"description": "Report",
"row_id": 1453762,
"text": "Respiratory Therapy\nPt presents orally intubated on A/C, IABP, ECMO. BS clear, diminished bilaterally. Sx for scant secretions. Plan: OR today for VAD placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-17 00:00:00.000",
"description": "Report",
"row_id": 1453798,
"text": "7pm-7am update\nneuro: pt continues on nimbex gtt. TOF initally showed 3 twitches -> nimbex gtt increased now TOF shos 2 twiches (with MA of 40). pt continues on mida and fentanyl gtt's. PERRL\n\nCV: pt remains in afib/aflutter. HR 90-110's. continues on amio gtt at 0.5 mg/min. levo gtt titated to to keep map > 60. levo gtt currently at 0.28 mcg/kg/min. pt had 1 episode of hypotension at 6 am after turning side to side -> SBP down into the 60's -> levo gtt increased and fluid bolus given. epi gtt weaned off last night. svo2 in the 70's. CI 2.37-3.05. L VAD flows 5.2-5.5 LPM. NA remains 125. hct stable. DP's palpable and PT's by doppler\n\nresp: LS coases with inspir and exp wheezing. pt remains on AC 800 x 11, 10 peep. fio2 weaned for 80% to 50%. (see flowsheets for abg's). pt suctioned for small amount of thick tan\n\ngi: bs absent. ogt draining billious fluid. dulcolax given last pm -> no stool. LFT' elvatated. total up from yesterady\n\ngu: foley draining amber urine. initally lasix gtt titrated to keep UO 50-100 cc/hr. urine output begining to drop to 30-40 cc/hr x the past 4 hours -> lasix gtt left at 7.5 mg/hr (lasix gtt not increased becauses BUN and Creatinine up from yesterday) BUN 62 and creatinine 2.2\n\nendo: contiues on insulin gtt.\n\nID: WBC's up to 38.1 this am. T max 99.1. pt continues on vanco and zoysn\n\nplan: monitor cultures/wbc's, ID consult, montior LFT/BUN and creatinine, titrated levo to keep MAP > 60, contiune current gtt's, continue VAD support, pulm toliet, skin care, contiue antibiotics\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-17 00:00:00.000",
"description": "Report",
"row_id": 1453799,
"text": "update\nD: pt cont with hypotension sbp80's-titrated levo up to .32 mcq-\nA: restarted vasoopressin at .03 units--per dr with d/c vasopressin- Na remains 125.\nD: ? pt in sr vs aflutter 1:1-\nA: ekg done\nR: eval-pt in NSR\nNo amiodarone bolus\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-17 00:00:00.000",
"description": "Report",
"row_id": 1453800,
"text": "Resp Care\n\nPt remains intubated and vented on full ventilatory support with increase in FiO2 made due to periods of desaturation earlier this shift. Pt lavaged and sxed for thick tan secretions and few plugs noted. BS remains slightly course. Bronchodilators given x4 with good effect. Last abg WNL with good oxygenation. Will cont with vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-08 00:00:00.000",
"description": "Report",
"row_id": 1453763,
"text": "NEURO: PT SEDATED WITH PROPOFOL, OCCASIONALLY MOVING IN BED PROPOFOL INCREASED TO 50MCG. PUPILS EQUAL AND REACT TO LIGHT. MOVEMENT SEEN IN ALL EXTREMITIES WHEN LIGHT.\nRESP: VENT DECREASD TO 40% PEEP 5 AND RATE OF 8 FOR MINIMAL SUPPORT WHILE ON ECMO. SUCTIONED FOR SCANT AMOUNT OF CLEAR SECRETIONS. ABG'S STABLE WITH PO2 150-180.\nC/V: PT REMAINS ON ECMO WITH FLOW RATES OF 4.2-4.4 MAP 70-80 NO PRESSURES NEEDED. HEART RATE 60 COMPLETE HEART BLOCK, PT HAD A 9 BEAT RUN OF VTACH WITH FREQUENT PVC'S LAST EVENING. MAG AT TIME 1.5 TREATED WITH 2GMS MAG SULFATE AND LIDO DRIP INCREASED TO 1MG. PVC'S DECREASED SIGNIFICANTLY ONLY SEEN RARE TO OCCASIONAL PT HAD ONE MORE RUN IN MIDDLE OF NIGHT LABS AT TIME OK. PHOS LOW TREATED WITH KPHOS 15mmol OVER 6HOURS WITH PHOS INCREASING TO 3.5 FROM 0.5. HEPARIN RUNNING AT STEADY 1000U TO MAINTAIN ACT AROUND 180. PT HAS PALPABLE RADIAL AND PEDAL PULSES. FEET COOL WITH NORMAL COLOR ARMS WARM\nGI: OGT DRAINING BILIOUS FLUID.\nENDO: BLOOD SUGAR CONTROLLED WITHOUT INSULIN.\nGU: URINE OUTPUTS ADEQUATE 100CC/HR DOWN TO 35CC/HR. CR STABLE AT 1.3\nSKIN: INTACT\nPLAN: OR THIS AM FOR POSSIBLE VAD PLACEMENT\n\nSKIN\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-08 00:00:00.000",
"description": "Report",
"row_id": 1453764,
"text": "RESP CARE\n\nPT RECEIVED FROM OR THIS AM S/P VAD PROCEDURE. CURRENTLY VENTED ON FULL VENTILATORY SUPPORT WITH MULTIPLE VENT CHANGES MADE TO CORRECT ACIDOSIS AND OXYGENATION STATUS. BS DIM TO SLIGHTLY COURSE SXING FOR MOD AMTS OF THICK BLOOD TINGED TO TAN SECRETIONS. WILL CONT WITH VENT SUPPORT AND ADJUST CHANGES ACCORDINGLY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-08 00:00:00.000",
"description": "Report",
"row_id": 1453765,
"text": "S/P CABG X 1 , REMOVAL ECMO LVAD PLACEMENT\nO: TO OR @ 0715 FOR REMOVAL OF ECMO AND PLACEMENT OF LVAD,RECIEVED VANCO AND LEVO 500 MG AT 0800. RECIEVED 9UPC,10UFFP,5PKPLT,7.5LCRYSTALLOID.OUT ON MILRINONE @.3MCQ,EPI @ .3,LEVO @ .15, INSULIN AT 3 UNITS/HR,PROPOFOL @10MCQ AND LIDO @ 2 MG. IABP NOT DC'D IN OR ,1:1 WITH FAIR AUGMENTATION,LVAD 4.9TRANSIENTLY WITH HYPOTENSION, MAPS 60'S WITH FLOW 5.1-6.1, HR 50-67.\n CARDIAC: SR 70-90'S WITH ISOLATED PVC NOTED, K, MAG AND CALCIUM REPLACED, SBP 90-100 UPON ARRIVAL LEVO TO .17MCQ WITH SBP 70-80 AND MAPS 60'S HCT 26.6 RECIEVED 2UPC REPEAT HCT 32. LEVO INCREASED TO .5 MAX, EPI INCREASED TO .05MCQ VASOPRESSIN ADDED @ .02 UNITS/MIN WITH SBP >90, LEVO PRESENTLY @ .1,EPI @ .02MCQ.. WITH SBP>100 AND MAPS 80. NBP CORRELATES WITH A LINE.FLOWS 5.5-6.1, HR 50-67. MVO2 PENDING.LIDO@2MG. PAD'S(FROM DIAGNOSTIC CATH LAB SWAN) HIGH 20'S-LO30'S,FEET COOL TO TOUCH DOPP PP, LEFT FOOT SLIGHTLY WARMER,DSGS WITH SMALL SANGUINOUS STAINING NO FURTHER INCREASE.300 ML CT DRAINAGE TOTAL. RECIEVED 2L LR. IABP WITH SOME AUGMENTATION. ECMO SITE SOFT WITH SMALL AMOUNT OF SANGUINOUS DRAINAGE. LEFT FEM SITE IABP DSG D+I.\n RESP: RUL COLLAPSE, 1830 TOLERATED RECRUITMENT BREATHS. CXR TO BE REPEATED, COURSE UPPER LOBES CLEARED WITH SUCTIONING THICK TAN BLOOD TINGED SPUTUM, CLEAR UPPER PRESENTLY AND DIMINISHED BIBASILAR. ACIDOTIC RECIEVED 2 AMPS BICARB X3 , REPEAT ABG PENDING. VENT SETTINGS PER FLOW. NO CHEST TUBE LEAK NOTED.\n NEURO: CISATURCURIUM @ .06MCQ BASELINE 4 TWITCHES 80, PROPOFOL AT 50 MCQ, PERL, NOT ATTEMPTED TO WAKE, .\n GI: OGT DRAINING GREEN BILIOUS DRAINAGE, + PLACEMENT. ABD SOFT OBESE, ABSENT BOWEL SOUNDS.\n GU: UO ADEQUATE HOWEVER DECREASED WITH HYPOTENSION, RECIEVED 20 MG LASIX WITH 300 ML TOTAL DIURESIS SINCE. CREAT 1.3 POST OP TO 1.6 AT 1800.\n ENDO: INSULIN GTT\n ID: TO RECIEVE VANCO\n SOCIAL: WIFE AND DAUGHTER INTO SEE PT AND UPDATED.\nA: REQUIRING VASO, MILRINONE,EPI,LEVO, PROPOFOL, CISATURCURIUM, INSULIN, RUL COLLAPSE,. LVAD,\nP: MONITOR COMFORT, HR AND RYTHYM, LVAD+ FLOWS, MVO2 PENDING, CT DRAINAGE, DSGS, PP, RESP STATUS-WEAN FIO2, NEURO STATUS-TOF, I+O, LABS. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-16 00:00:00.000",
"description": "Report",
"row_id": 1453795,
"text": "BRONCH\nD: PT WITH WAKING, ? MOBILIZING SECRETIONS-SAT 88% ON 100%-\nA: PT BRONCH FOR COPIOUS AMTS OF THICK, STRINGY TAN-BROWN SPUTUM- -PT SAT DROPPED DURING BRONCH TO 88%-HR UP TO 150'S AFIB WIOTH SBP 117/\nPT WITH VESED AND PT ALLOWED TO RECUP AT TIMES DURING BRONCH- LAST APPROX 90 MINS IN TOTAL. POST PT SBP DIPPED TO 80'S- TITRATED LEVO UO TO .3 MCQ -WITH TIMES SBP UP TO 90'S, U/O DROPPED WITH HYPOTENSION, VAD FLOWS REMAINED >5.9.- AS SBP INCREASED, U/O REMAINED LOW- LASIX INC BACK TO 10 PER .\nPT EVENTUALLY WEANED TO 80%-WITH SAT 97%- ABG WITH PAO2 80- WILL CONT TO WEAN FIO2 AS TOL. SPUTUM SENT FOR CULTURE.\nPLAN: ? NEED TO RE-BRONCH IN AM\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-16 00:00:00.000",
"description": "Report",
"row_id": 1453796,
"text": "UPDATE\nNEURO: PT LIGHTENED AS NOTED PREVIOUSLY-DID MOVE RIGHT SIDE, FOLLOWED COMMANDS- RE-PARALYZED DUE TO RESP COMPROMISE-CONT ON FENTANYL /VERSED- SPOKE WITH - PROPOFOL NOT A GOOD MED FOR ANYONE WITH ALTERED LFT'S. PUPILS3-4 EQUAL RX TO LIGHT.\n\nCARDIAC: PT IN AFIB THIS AM APPEARED TO SWITCH TO AFLUTTER THIS AFTERNOON- AT TIME PT NOTED TO DROP SBP TO 80'S- VASOPRESSIN OFF- LEVO TITRATED UPWARD. PLAN TO WEAN EPI TO OFF AS TOL.\nPT WARM, DOPPLERABLE PULSES. CO/CI EXCELLENT-SVO2 DID DIP WITH HYPOXIA BUT BACK TO 70'S THEREAFTER. PT ? HEMOLYSIS FOR RED CELLS DUE TO VAD- VACCUME TO OBTAIN FLOWS OF 5.3 AND BETTER.\n\nRESP: AS NOTED ABOVE. PT CONT WITH COARSE BS THROUGHOUT. SAT 9&% ON 80%- CONT TO WEAN FIO2 AS TOL. ? NEED FOR CXR POST BRONCH.\n\nGI: PT REMAINS NPO WITH OGT IN PLACE-BILIOUS MATERIAL- TEAM PLAN TO FEED PT AFTER ULTRASOUND TOMORROW (RUQ US FOR ELEVATED ) TEAM WANT POST-PYLORIC FT PLACED--THEN TO START FEEDINGS THEREAFTER.\n\nGU: LASIX WEANED DOWN TO 5 FROM 10 THIS AM- DUE TO ELEVATED CREAT 1.9 AND BUN>50-ONCE LAB RESPUN CREAT DUE TO ICTERIC CONDITION- CREAT 1.6- U.O DID DIP WITH HYPOTENSION AND REMAINS DOWN THEREAFTER- LASIX INC BACK TO 10 WITH GOOD INC IN U/O.\n\nINC: INTACT,\nSKIN: PT CONT WITH RAISED RED RASH AT SKIN FOLDS AND BACK.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-10 00:00:00.000",
"description": "Report",
"row_id": 1453771,
"text": "RESP CARE: pt remains intubated/on vent sedated,on paralytic. FI02 increased for low Pa02 of 61 with increase to 113 on .70 FI02. Lungs coarse rhonchi bilat at start of shift. Sxd mod amt thick bld tinged sputum. Sample sent for C&S. Plan is to continue full vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2192-09-10 00:00:00.000",
"description": "Report",
"row_id": 1453772,
"text": "Neuro: sedated and paralized on cisatra, midaz, and fent gtt's, has 4 out of 4 eye twitchs on tof, not overbreatrhing vent, pupils are equal and reactive to light.\n\nCardiac: nsr in the 70's with no ectopy noted, continues epi, levo, vasopressin, milrinine, natracore and lido gtt, have been able to wean levo gtt down throughout shift, did in am go up on pitt gtt, goal to keep sbp>90 and maps >60, ci's all wnls, svo2s running in the 50's team aware, did drop svo2s down to the 40's while on right side, did also drop bp while on right side requiring an increase in levo, dopplerable pedial pulses, skin is warm dry and intact, +3 edema in extremities, running temps cultures are pending, continues heparin gtt with goal to keep act 180-200 range, continues lvad with flow rates from with rate in the 50's.\n\nResp: lungs on right are coarse, left side is dim in base, np pt has right side effusion on xray, has ct to sxn with no air leak draining scant serosang, awaiting bronch, did sxn for scnt to moderte thick tan, was able to wean o2 down slightly and abgs are ok, did desate into the 80's while on right side and did not tolerate.\n\nSkin: chest with dsd that is cdi, ct dsd is cdi, left leg ace is cdi, right fem dsd is cdi.\n\nGi/Gu: npo, og-tube to lwsxn draining moderate billeous, abd is soft round with no bowel sounds yet, on riss gtt, did start lasix gtt and making good u/o.\n\nPLan: wean levo if tolerates, bronch later in shift, continue lasix gtt with goal to make 200 or more/hr of u/o, monitor acts, monitor blood glucose, do not role onto right side md due to implantation sites of lvad becoming ? occluded.\n"
}
] |
68,687 | 129,878 | The patient is a 33 year-old woman who presented with two weeks of malaise and a three day history of worsening abdominal pain, fever, diarrhea, and vomiting. She was admitted to the ICU for septic shock related to E coli bacteremia. She was treated initially with Unasyn and Vancomycin empirically. However, vancomycin was discontinued once culture data returned. The source of the Ecoli sepsis was unclear. liver ultrasound was normal; transthoracic echocardiography did not reveal vegetation; and abdominal/pelvic CT did not show any acute intra-abdominal process. Despite low suspicion for pelvic inflammatory disease, her intrauterine device was removed, but her urine culture and gonococcal/chlamydia cervical sample were both negative. She also did not have purulent cervical discharge, nor marked cervical motion tenderness. Her normal liver ultrasound and tests along with unremarkable CT abdomen lowered the possibility of biliary source of infection. Taken altogether, the E. coli sepsis was likely acquired as a consequence of infectious gastroenteritis, possibly through mild ulceration of the colonic surface allowing bacterial translocation. She became afebrile and her abdominal pain improved. Her WBC was 24 on admission and was normal on discharge. She was seen by the ID service. She was discharged on Cefpodoxime to finish a course of 14 days of antibiotics. She was instructed to see her PCP at the end of her antibiotic therapy on . | CT abd/pelvis w/o contrast: prelim read: study limited by lack of oral and IV contrast. .H/O hypotension (not Shock) Assessment: Pt was hypotensive in ED,levophed was started Action: Pt was already received 7 L fluid in ED,levophed @ 0.09 mic/kg/mt Response: NBP remains low but stable Plan: Haemodinamic monitoring Titrate levophed. .H/O hypotension (not Shock) Assessment: Pt was hypotensive in ED,levophed was started Action: Pt was already received 7 L fluid in ED,levophed @ 0.09 mic/kg/mt Response: NBP remains low but stable,unable to wean since NBP still remains border line. Since the prior CT and pelvic U/S examinations, interval removal of an IUD. Since the prior CT and pelvic U/S examinations, interval removal of an IUD. Since the prior CT and pelvic U/S examinations, interval removal of an IUD. Since the prior CT and pelvic U/S examinations, interval removal of an IUD. Plan: Haemodinamic monitoring Titrate levophed as tolerated. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). R femoral line remains in place but if stable overnoc will d/c in the am. # Access: R femoral CVL, peripherals - if able to wean levophed, will d/c femoral line in AM . # Access: R femoral CVL, peripherals - if able to wean levophed, will d/c femoral line in AM . Unchanged nonobstructive right renal calculi with probable bilateral simple renal cysts. Unchanged nonobstructive right renal calculi with probable bilateral simple renal cysts. Unchanged nonobstructive right renal calculi with probable bilateral simple renal cysts. Unchanged nonobstructive right renal calculi with probable bilateral simple renal cysts. Covered with Vanco/Flagyl Will r/o H1N1 with fever/resp sx's Isolated, start on Tamiflu No evidence of UTI, intra-abdom infection; cultures pending Wean levophed - push fluids Details of plan in HO note Time Spent - 45 minutes ------ Protected Section Addendum Entered By: , MD on: 06:29 ------ Denies headache, sinus tenderness, rhinorrhea or congestion. There is a calcified degenerated fibroid in the posterior aspect of the uterus (2:83), unchanged. Normal main PA. NoDoppler evidence for PDAPERICARDIUM: No pericardial effusion.Conclusions:The left atrium is mildly dilated. CT abd/pelvis w/o contrast: prelim read: study limited by lack of oral and IV contrast. CT abd/pelvis w/o contrast: prelim read: study limited by lack of oral and IV contrast. No MS.Normal LV inflow pattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal ascending aortadiameter. Unchanged nonobstructive right renal calculi with probable bilateral simple renal cysts. Unchanged nonobstructive right renal calculi with probable bilateral simple renal cysts. unchanged non- obstructive right renal calculi, normal appendix. unchanged non-obstructive right renal calculi, normal appendix. unchanged non-obstructive right renal calculi, normal appendix. Denied chest pain or tightness, palpitations. Denied chest pain or tightness, palpitations. PATIENT/TEST INFORMATION:Indication: EndocarditisHeight: (in) 67Weight (lb): 242BSA (m2): 2.19 m2BP (mm Hg): 98/65HR (bpm): 78Status: InpatientDate/Time: at 11:23Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). The mitral valve appears structurally normal with trivialmitral regurgitation. R femoral line remains in place but if stable overnoc will d/c in the am. Tissue Doppler imaging suggests a normal leftventricular filling pressure (PCWP<12mmHg). Denies headache, sinus tenderness, rhinorrhea or congestion. Denies headache, sinus tenderness, rhinorrhea or congestion. Since the prior CT and pelvic U/S examinations, interval removal of an IUD. Since the prior CT and pelvic U/S examinations, interval removal of an IUD. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Denied constipation. Denied constipation. There is a small focus of calcification within the posterior myometrium, unchanged. TDI E/e' < 8, suggesting normal PCWP (<12mmHg).No resting LVOT gradient. There is an approximate 2.8 cm hypodensity in the medial portion of the right kidney, unchanged from prior examination and is likely a simple renal cyst. No masses orvegetations on aortic valve.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No dysuria. No dysuria. No dysuria. No dysuria. No dysuria. No dysuria. No dysuria. No dysuria. No acute intra-abdominal pathology. No acute intra-abdominal pathology. No recent travel or sick contacts Fever, unknown origin (FUO, Hyperthermia, Pyrexia) Assessment: Action: Response: Plan: .H/O hypotension (not Shock) Assessment: Action: Response: Plan: The mitral valve appears structurally normal with trivial mitral regurgitation. no acute intrabdominal pathology. no acute intrabdominal pathology. no acute intrabdominal pathology. There is a poorly defined hypodensity in the region of the superior pole of the left kidney (2:37), which appears stable to prior examination and likely represents a simple cyst. Pelvic ultrasound was negative. | 29 | [
{
"category": "Physician ",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 687640,
"text": "Chief Complaint: Fever and abdominal pain\n 24 Hour Events:\n - GNR in BCx x2\n - SBPs in 80s, off levo, with good UOP and asyx in afternoon, pt held\n course\n - repleted K, P, Ca, Mg\n - spiked to 102.1 at 10pm --> Bcx x2\n - was -500cc since admission, was given 1000cc NS bolus at 11pm\n Allergies:\n Iodine\n Anaphylaxis; Ra\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ampicillin - 04:28 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:35 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 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.9\nC (102\n HR: 87 (78 - 90) bpm\n BP: 93/54(64) {62/43(47) - 107/65(71)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10,579 mL\n 1,820 mL\n PO:\n 960 mL\n 220 mL\n TF:\n IVF:\n 2,519 mL\n 1,600 mL\n Blood products:\n Total out:\n 6,370 mL\n 1,840 mL\n Urine:\n 4,870 mL\n 1,840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,209 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 9.2 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 113 mEq/L\n 139 mEq/L\n 27.9 %\n 14.2 K/uL\n [image002.jpg]\n TTE: The left atrium is mildly dilated. The right atrium is\n moderately dilated. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF 70%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). There is no ventricular septal defect. 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. No masses or vegetations are seen on the aortic\n valve. The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. No mass or vegetation\n is seen on the mitral valve. Moderate [2+] tricuspid regurgitation is\n seen. The estimated pulmonary artery systolic pressure is normal. No\n vegetation/mass is seen on the pulmonic valve. There is no pericardial\n effusion.\n CT abd/pel:\n 1. No acute intra-abdominal pathology. No abdominal fluid collections.\n No\n evidence for appendicitis or colitis; however, study is limited by lack\n of\n intravenous and oral contrast.\n 2. Unchanged nonobstructive right renal calculi with probable bilateral\n simple renal cysts.\n 3. Since the prior CT and pelvic U/S examinations, interval removal of\n an\n IUD.\n 10:30 PM\n 05:39 AM\n 03:55 PM\n 04:09 AM\n WBC\n 9.1\n 24.0\n 14.2\n Hct\n 29.9\n 29.5\n 27.9\n Plt\n 166\n 155\n 137\n Cr\n 0.8\n 0.9\n 0.7\n 0.7\n Glucose\n 116\n 227\n 95\n 97\n Other labs: PT / PTT / INR:16.9/40.6/1.5, ALT / AST:21/26, Alk Phos / T\n Bili:53/0.7, Amylase / Lipase:/17, Differential-Neuts:80.4 %,\n Lymph:13.2 %, Mono:4.1 %, Eos:1.9 %, D-dimer:4255 ng/mL, Fibrinogen:417\n mg/dL, Lactic Acid:1.9 mmol/L, Albumin:3.0 g/dL, Ca++:6.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:1.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O HYPOTENSION (NOT SHOCK)\n # Hypotension: Most likely secondary to hypovolemia in the setting of\n overwhelming infection/sepsis, high fevers, and decreased PO intake.\n Currently on a low dose of levophed.\n - cont IVF boluses in attempt to wean levophed\n - maintain adequate IV access\n .\n # Fever/Malaise: The clinical picture of high-grade fever, chills,\n and myalgias, in the absence of a leukocytosis or clear source makes a\n viral etiology high on the differential. Given her abdominal pain,\n cannot rule out a GI or GU process, however CT abdomen/pelvis was\n unremarkable (though limited without contrast) and pelvic ultrasound\n was also unremarkable. CXR clear. UA negative.\n - f/u blood cx, urine cx\n - cont to monitor fever curve, WBC count\n - tylenol prn\n - IVF bolus prn for MAP<60 or UOP<30cc/h\n - encourage PO fluids as she is able to tolerate\n - zofran prn nausea\n - hold on further antibiotics overnight without a clear source\n .\n # Abdominal pain: No clear etiology at this point. Abdominal CT scan\n and pelvic ultrasound were both negative. LFTs and lipase were wnl.\n She did have some CMT and adnexal tenderness per exams performed in the\n ED, which could raise concern for PID. IUD was removed, although felt\n by OB/Gyn to be unlikely the source of her illness.\n - tylenol prn\n - cont to monitor\n .\n # FEN: IVF as above, replete electrolytes prn, clears, advance diet as\n tolerated\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: R femoral CVL, peripherals\n - if able to wean levophed, will d/c femoral line in AM\n .\n # Code: full\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:46 AM\n 18 Gauge - 01:48 AM\n 20 Gauge - 01:48 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": "2156-07-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 687691,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Update: Gram neg rods in blood, Blood cultures repeated overnight for\n temp spike to 102.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt states she\nfeels better\n this morning. Temp 99.7 and VS stable off\n pressors\n Action:\n Plan discussed on rounds with adjustments to antibiotics. Right femoral\n central line and foley catheter dc\nd. Pt assisted oob to chair.\n Response:\n Former femoral central line clean and dry, Pt transferred to chair\n without any orthostatic symptoms and is voiding large volumes of urine\n on bsc.\n Plan:\n Cotninue antibiotic coverage and follow culture data. Notify team of\n recurrence of fevers or hemodynamic instability. Transfer out of ICU\n and ABD US ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 687693,
"text": "Chief Complaint: Fever and abdominal pain\n 24 Hour Events:\n - GNR in BCx x2\n - SBPs in 80s, off levo, with good UOP and asyx in afternoon, pt held\n course\n - repleted K, P, Ca, Mg\n - spiked to 102.1 at 10pm --> Bcx x2\n - was -500cc since admission, was given 1000cc NS bolus at 11pm\n Allergies:\n Iodine\n Anaphylaxis; Ra\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ampicillin - 04:28 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:35 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 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.9\nC (102\n HR: 87 (78 - 90) bpm\n BP: 93/54(64) {62/43(47) - 107/65(71)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10,579 mL\n 1,820 mL\n PO:\n 960 mL\n 220 mL\n TF:\n IVF:\n 2,519 mL\n 1,600 mL\n Blood products:\n Total out:\n 6,370 mL\n 1,840 mL\n Urine:\n 4,870 mL\n 1,840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,209 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 9.2 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 113 mEq/L\n 139 mEq/L\n 27.9 %\n 14.2 K/uL\n [image002.jpg]\n TTE: The left atrium is mildly dilated. The right atrium is\n moderately dilated. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF 70%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). There is no ventricular septal defect. 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. No masses or vegetations are seen on the aortic\n valve. The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. No mass or vegetation\n is seen on the mitral valve. Moderate [2+] tricuspid regurgitation is\n seen. The estimated pulmonary artery systolic pressure is normal. No\n vegetation/mass is seen on the pulmonic valve. There is no pericardial\n effusion.\n CT abd/pel:\n 1. No acute intra-abdominal pathology. No abdominal fluid collections.\n No\n evidence for appendicitis or colitis; however, study is limited by lack\n of\n intravenous and oral contrast.\n 2. Unchanged nonobstructive right renal calculi with probable bilateral\n simple renal cysts.\n 3. Since the prior CT and pelvic U/S examinations, interval removal of\n an\n IUD.\n 10:30 PM\n 05:39 AM\n 03:55 PM\n 04:09 AM\n WBC\n 9.1\n 24.0\n 14.2\n Hct\n 29.9\n 29.5\n 27.9\n Plt\n 166\n 155\n 137\n Cr\n 0.8\n 0.9\n 0.7\n 0.7\n Glucose\n 116\n 227\n 95\n 97\n Other labs: PT / PTT / INR:16.9/40.6/1.5, ALT / AST:21/26, Alk Phos / T\n Bili:53/0.7, Amylase / Lipase:/17, Differential-Neuts:80.4 %,\n Lymph:13.2 %, Mono:4.1 %, Eos:1.9 %, D-dimer:4255 ng/mL, Fibrinogen:417\n mg/dL, Lactic Acid:1.9 mmol/L, Albumin:3.0 g/dL, Ca++:6.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:1.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O HYPOTENSION (NOT SHOCK)\n # Fever/Malaise: Blood Cx are growing GNRs sensitive to Unasyn. Pt.\n still spiking fevers (102.1 last night), her WBC is trending down from\n 24 yesterday to 14 today. Given her abdominal pain, cannot rule out a\n GI or GU process, however CT abdomen/pelvis was unremarkable (though\n limited without contrast) and pelvic ultrasound was also unremarkable.\n CXR clear. UA negative.\n - cont unasyn\n - vancomycin dc\n - will talk to radiology about abd/pel CT\n - wil repeat RUQ US\n - f/u blood cx, urine cx\n - cont to monitor fever curve, WBC count\n - tylenol prn\n - encourage PO fluids as she is able to tolerate\n - zofran prn nausea\n # Hypotension: Most likely secondary to hypovolemia in the setting of\n overwhelming infection/sepsis, high fevers, and decreased PO intake.\n Levophed was stopped yesterday, pt w/ stable BPs 90/100s/60s.\n - maintain adequate IV access\n .\n .\n # Abdominal pain: No clear etiology at this point. Abdominal CT scan\n and pelvic ultrasound were both negative. LFTs and lipase were wnl.\n She did have some CMT and adnexal tenderness per exams performed in the\n ED, which could raise concern for PID, although tests were (-) for GC\n and Chlamidia. IUD was removed, although felt by OB/Gyn to be unlikely\n the source of her illness. Her abd pain is greatly improved today,\n only reproducible w/ deep palpation.\n - tylenol prn\n - cont to monitor\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:48 AM\n 20 Gauge - 01:48 AM\n Prophylaxis:\n DVT: pneumo boots, SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfered to regular floor\n"
},
{
"category": "Physician ",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 687694,
"text": "Chief Complaint: Fever and abdominal pain\n 24 Hour Events:\n - GNR in BCx x2\n - SBPs in 80s, off levo, with good UOP and asyx in afternoon, pt held\n course\n - repleted K, P, Ca, Mg\n - spiked to 102.1 at 10pm --> Bcx x2\n - was -500cc since admission, was given 1000cc NS bolus at 11pm\n Allergies:\n Iodine\n Anaphylaxis; Ra\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ampicillin - 04:28 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:35 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 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.9\nC (102\n HR: 87 (78 - 90) bpm\n BP: 93/54(64) {62/43(47) - 107/65(71)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10,579 mL\n 1,820 mL\n PO:\n 960 mL\n 220 mL\n TF:\n IVF:\n 2,519 mL\n 1,600 mL\n Blood products:\n Total out:\n 6,370 mL\n 1,840 mL\n Urine:\n 4,870 mL\n 1,840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,209 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 9.2 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 113 mEq/L\n 139 mEq/L\n 27.9 %\n 14.2 K/uL\n [image002.jpg]\n TTE: The left atrium is mildly dilated. The right atrium is\n moderately dilated. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF 70%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). There is no ventricular septal defect. 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. No masses or vegetations are seen on the aortic\n valve. The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. No mass or vegetation\n is seen on the mitral valve. Moderate [2+] tricuspid regurgitation is\n seen. The estimated pulmonary artery systolic pressure is normal. No\n vegetation/mass is seen on the pulmonic valve. There is no pericardial\n effusion.\n CT abd/pel:\n 1. No acute intra-abdominal pathology. No abdominal fluid collections.\n No\n evidence for appendicitis or colitis; however, study is limited by lack\n of\n intravenous and oral contrast.\n 2. Unchanged nonobstructive right renal calculi with probable bilateral\n simple renal cysts.\n 3. Since the prior CT and pelvic U/S examinations, interval removal of\n an\n IUD.\n 10:30 PM\n 05:39 AM\n 03:55 PM\n 04:09 AM\n WBC\n 9.1\n 24.0\n 14.2\n Hct\n 29.9\n 29.5\n 27.9\n Plt\n 166\n 155\n 137\n Cr\n 0.8\n 0.9\n 0.7\n 0.7\n Glucose\n 116\n 227\n 95\n 97\n Other labs: PT / PTT / INR:16.9/40.6/1.5, ALT / AST:21/26, Alk Phos / T\n Bili:53/0.7, Amylase / Lipase:/17, Differential-Neuts:80.4 %,\n Lymph:13.2 %, Mono:4.1 %, Eos:1.9 %, D-dimer:4255 ng/mL, Fibrinogen:417\n mg/dL, Lactic Acid:1.9 mmol/L, Albumin:3.0 g/dL, Ca++:6.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:1.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O HYPOTENSION (NOT SHOCK)\n # Fever/Malaise: Blood Cx are growing GNRs sensitive to Unasyn. Pt.\n still spiking fevers (102.1 last night), her WBC is trending down from\n 24 yesterday to 14 today. Given her abdominal pain, cannot rule out a\n GI or GU process, however CT abdomen/pelvis was unremarkable (though\n limited without contrast) and pelvic ultrasound was also unremarkable.\n CXR clear. UA negative.\n - cont unasyn\n - vancomycin dc\n - will talk to radiology about any small abnormalities on abd/pel CT\n - wil repeat RUQ US\n - f/u blood cx, urine cx\n - cont to monitor fever curve, WBC count\n - tylenol prn\n - encourage PO fluids as she is able to tolerate\n - zofran prn nausea\n # Hypotension: Most likely secondary to hypovolemia in the setting of\n overwhelming infection/sepsis, high fevers, and decreased PO intake.\n Levophed was stopped yesterday, pt w/ stable BPs 90/100s/60s.\n - maintain adequate IV access\n .\n .\n # Abdominal pain: Greatly improved today, only reproducible w/ deep\n palpation. Abdominal CT scan and pelvic ultrasound were both\n negative. LFTs and lipase were wnl. She did have some CMT and adnexal\n tenderness per exams performed in the ED, which could raise concern for\n PID, although tests were (-) for GC and Chlamidia. IUD was removed.\n - tylenol prn\n - cont to monitor\n .\n ICU Care\n Nutrition: Regular\n Glycemic Control:\n Lines:\n 18 Gauge - 01:48 AM\n 20 Gauge - 01:48 AM\n Prophylaxis:\n DVT: pneumo boots, SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfered to regular floor\n"
},
{
"category": "Physician ",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 687695,
"text": "Chief Complaint: Fever and abdominal pain\n 24 Hour Events:\n - GNR in BCx x2\n - SBPs in 80s, off levo, with good UOP and asyx in afternoon, pt held\n course\n - repleted K, P, Ca, Mg\n - spiked to 102.1 at 10pm --> Bcx x2\n - was -500cc since admission, was given 1000cc NS bolus at 11pm\n Allergies:\n Iodine\n Anaphylaxis; Ra\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ampicillin - 04:28 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:35 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 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.9\nC (102\n HR: 87 (78 - 90) bpm\n BP: 93/54(64) {62/43(47) - 107/65(71)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10,579 mL\n 1,820 mL\n PO:\n 960 mL\n 220 mL\n TF:\n IVF:\n 2,519 mL\n 1,600 mL\n Blood products:\n Total out:\n 6,370 mL\n 1,840 mL\n Urine:\n 4,870 mL\n 1,840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,209 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 9.2 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 113 mEq/L\n 139 mEq/L\n 27.9 %\n 14.2 K/uL\n [image002.jpg]\n TTE: The left atrium is mildly dilated. The right atrium is\n moderately dilated. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF 70%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). There is no ventricular septal defect. 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. No masses or vegetations are seen on the aortic\n valve. The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. No mass or vegetation\n is seen on the mitral valve. Moderate [2+] tricuspid regurgitation is\n seen. The estimated pulmonary artery systolic pressure is normal. No\n vegetation/mass is seen on the pulmonic valve. There is no pericardial\n effusion.\n CT abd/pel:\n 1. No acute intra-abdominal pathology. No abdominal fluid collections.\n No\n evidence for appendicitis or colitis; however, study is limited by lack\n of\n intravenous and oral contrast.\n 2. Unchanged nonobstructive right renal calculi with probable bilateral\n simple renal cysts.\n 3. Since the prior CT and pelvic U/S examinations, interval removal of\n an\n IUD.\n 10:30 PM\n 05:39 AM\n 03:55 PM\n 04:09 AM\n WBC\n 9.1\n 24.0\n 14.2\n Hct\n 29.9\n 29.5\n 27.9\n Plt\n 166\n 155\n 137\n Cr\n 0.8\n 0.9\n 0.7\n 0.7\n Glucose\n 116\n 227\n 95\n 97\n Other labs: PT / PTT / INR:16.9/40.6/1.5, ALT / AST:21/26, Alk Phos / T\n Bili:53/0.7, Amylase / Lipase:/17, Differential-Neuts:80.4 %,\n Lymph:13.2 %, Mono:4.1 %, Eos:1.9 %, D-dimer:4255 ng/mL, Fibrinogen:417\n mg/dL, Lactic Acid:1.9 mmol/L, Albumin:3.0 g/dL, Ca++:6.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:1.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O HYPOTENSION (NOT SHOCK)\n # Fever/Malaise: Blood Cx are growing GNRs sensitive to Unasyn. Pt.\n still spiking fevers (102.1 last night), her WBC is trending down from\n 24 yesterday to 14 today. Given her abdominal pain, cannot rule out a\n GI or GU process, however CT abdomen/pelvis was unremarkable (though\n limited without contrast) and pelvic ultrasound was also unremarkable.\n CXR clear. UA negative.\n - cont unasyn\n - vancomycin dc\n - will talk to radiology about any small abnormalities on abd/pel CT\n - wil repeat RUQ US\n - f/u blood cx, urine cx\n - cont to monitor fever curve, WBC count\n - tylenol prn\n - encourage PO fluids as she is able to tolerate\n - zofran prn nausea\n # Hypotension: Most likely secondary to hypovolemia in the setting of\n overwhelming infection/sepsis, high fevers, and decreased PO intake.\n Levophed was stopped yesterday, pt w/ stable BPs 90/100s/60s.\n - maintain adequate IV access\n .\n .\n # Abdominal pain: Greatly improved today, only reproducible w/ deep\n palpation. Abdominal CT scan and pelvic ultrasound were both\n negative. LFTs and lipase were wnl. She did have some CMT and adnexal\n tenderness per exams performed in the ED, which could raise concern for\n PID, although tests were (-) for GC and Chlamidia. IUD was removed.\n - tylenol prn\n - cont to monitor\n .\n ICU Care\n Nutrition: Regular\n Glycemic Control:\n Lines:\n 18 Gauge - 01:48 AM\n 20 Gauge - 01:48 AM\n Prophylaxis:\n DVT: pneumo boots, SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfered to regular floor\n ------ Protected Section ------\n Physical Examination:\n General: Alert, awake, obese Asian female, no acute distress\n HEENT: Sclera anicteric, mildly dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tenderness to deep palpation with greatest\n tenderness in the suprapubic region and LLQ, non-distended, normal\n bowel sounds, no rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n ------ Protected Section Addendum Entered By: , MD\n on: 13:32 ------\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 687684,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Update: Gram neg rods in blood, Blood cultures repeated overnight for\n temp spike to 102.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt states she\nfeels better\n this morning. Temp 99.7 and VS stable off\n pressors\n Action:\n Plan discussed on rounds with adjustments to antibiotics. Right femoral\n central line and foley catheter dc\nd. Pt assisted oob to chair.\n Response:\n Former femoral central line clean and dry, Pt transferred to chair\n without any orthostatic symptoms and is voiding large volumes of urine\n on bsc.\n Plan:\n Cotninue antibiotic coverage and follow culture data. Notify team of\n recurrence of fevers or hemodynamic instability. Transfer out of ICU\n and ABD US ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 687432,
"text": "Chief Complaint: Fever and abdominal pain\n HPI:\n 33 yo female with no significant past medical history presents with 3\n days of fevers and malaise. She reports her symptoms started 3 days\n ago and have been gradually progressing. She has had headache, fevers,\n chills, night sweats, myalgias, cough productive of green sputum,\n nausea/vomiting (non-bloody, up to 7x per day), diarrhea (non-bloody,\n up to 5x per day). She notes generalized abdominal pain, worst in the\n suprapubic region. Also decreased PO intake. No chest pain or SOB. No\n dysuria. No recent travel or sick contacts.\n .\n In the ED, initial vs were: T 104.5, P 129, BP 122/74, R 20, O2 sat 96%\n RA. Exam was notable for tenderness in the RLQ and LLQ, +CMT, and\n moderate white cervical discharge. She became progressively\n hypotensive and tachycardic with systolic BP down to the 70s. Received\n 6L IVF. R femoral CVL was placed and levophed was initiated. OB/Gyn\n was consulted out of concern for PIC. Pelvic ultrasound was negative.\n Her IUD was removed. CXR clear. CT abd/pelvis was also unremarkable\n for acute pathology. She received unasyn and doxycycline initially for\n abx coverage. When she clinically worsened, vanco and clinda were\n added. In addition, she was given zofran, tylenol, and toradol. As\n the patient had been sexually active on the morning of admission and\n her IUD was removed, she was also given plan B. She was then admitted\n to the for close monitoring.\n .\n On arrival to the , she feels very warm as if she is spiking a temp\n and complains of overall fatigue.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis; Ra\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Other medications:\n None\n Past medical history:\n Family history:\n Social History:\n - ED visit with abdominal pain - treated empircally for\n PID, subsequently GC cultures all negative. Found adnexal cyst.\n -s/p 2 vaginal deliveries\n -s/p TAB x 1\n -Gestational Diabetes\n -Kidney stones\n Non-contributory.\n Occupation: Works as a hairdressor at .\n Drugs: None.\n Tobacco: Nonsmoker.\n Alcohol: Drinks one drink per week (glass of wine, )\n Other: Moved to US from 20 yrs ago. Lives with husband and 2\n daughters, 3 and 2 yo.\n Review of systems: (+) Per HPI\n (-) Denies recent weight loss or gain. Denies headache, sinus\n tenderness, rhinorrhea or congestion. Denied shortness of breath.\n Denied chest pain or tightness, palpitations. Denied constipation. No\n recent change in bladder habits. No dysuria.\n Flowsheet Data as of 03:21 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.6\nC (103.2\n Tcurrent: 39.6\nC (103.2\n HR: 96 (96 - 105) bpm\n BP: 100/58(67) {100/58(67) - 104/71(78)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,031 mL\n PO:\n TF:\n IVF:\n 31 mL\n Blood products:\n Total out:\n 0 mL\n 2,340 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,691 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n Vitals: T: 103.2, BP: 100/63, P: 105, R: 18, O2: 94% on 2L\n General: Sleepy but arousable and appropriate, obese Asian female, no\n acute distress\n HEENT: Sclera anicteric, mildly dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales,\n ronchi\n CV: Tachy, regular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild diffuse tenderness to palpation with greatest\n tenderness in the suprapubic region, non-distended, notably decreased\n bowel sounds, no rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 166 K/uL\n 9.7 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 12 mg/dL\n 18 mEq/L\n 112 mEq/L\n 2.8 mEq/L\n 141 mEq/L\n 29.9 %\n 9.1 K/uL\n [image002.jpg]\n \n 2:33 A7/14/ 10:30 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 9.1\n Hct\n 29.9\n Plt\n 166\n Cr\n 0.8\n Glucose\n 116\n Other labs: PT / PTT / INR:14.5/51.9/1.3, ALT / AST:21/26, Alk Phos / T\n Bili:53/0.7, Amylase / Lipase:/17, Differential-Neuts:91.1 %, Lymph:7.5\n %, Mono:0.7 %, Eos:0.5 %, Lactic Acid:1.9 mmol/L, Albumin:3.0 g/dL\n Imaging: CXR: No acute cardiopulmonary abnormality.\n .\n CT abd/pelvis w/o contrast: prelim read: study limited by lack of oral\n and IV contrast. no acute intrabdominal pathology. unchanged\n non-obstructive right renal calculi, normal appendix. IUD has been\n removed from uterus.\n .\n Pelvic ultrasound: prelim read: Unchanged son evaluation of the\n pelvis, with normal uterus, endometrium and ovaries. no pelvic fluid.\n no adnexal masses.\n Microbiology: Blood cx pending\n Urine cx pending\n Cervical swab for GC/Chlamydia pending\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O HYPOTENSION (NOT SHOCK)\n This is a 33 year old healthy female who presents with 3 days of fever,\n malaise, and hypotension.\n .\n # Hypotension: Most likely secondary to hypovolemia in the setting of\n overwhelming infection/sepsis, high fevers, and decreased PO intake.\n Currently on a low dose of levophed.\n - cont IVF boluses in attempt to wean levophed\n - maintain adequate IV access\n .\n # Fever/Malaise: The clinical picture of high-grade fever, chills,\n and myalgias, in the absence of a leukocytosis or clear source makes a\n viral etiology high on the differential. Given her abdominal pain,\n cannot rule out a GI or GU process, however CT abdomen/pelvis was\n unremarkable (though limited without contrast) and pelvic ultrasound\n was also unremarkable. CXR clear. UA negative.\n - f/u blood cx, urine cx\n - cont to monitor fever curve, WBC count\n - tylenol prn\n - IVF bolus prn for MAP<60 or UOP<30cc/h\n - encourage PO fluids as she is able to tolerate\n - zofran prn nausea\n - hold on further antibiotics overnight without a clear source\n .\n # Abdominal pain: No clear etiology at this point. Abdominal CT scan\n and pelvic ultrasound were both negative. LFTs and lipase were wnl.\n She did have some CMT and adnexal tenderness per exams performed in the\n ED, which could raise concern for PID. IUD was removed, although felt\n by OB/Gyn to be unlikely the source of her illness.\n - tylenol prn\n - cont to monitor\n .\n # FEN: IVF as above, replete electrolytes prn, clears, advance diet as\n tolerated\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: R femoral CVL, peripherals\n - if able to wean levophed, will d/c femoral line in AM\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:46 AM\n 18 Gauge - 01:48 AM\n 20 Gauge - 01:48 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Given high suspicion for viral process, will send DFA and start\n oseltamavir.\n ------ Protected Section Addendum Entered By: , MD\n on: 03:52 ------\n 33 yr woman with 3 days fever, malaise, productive cough with green\n sputum. Nausea, vomiting diarrhea with suprapubic pain.\n In ED temp 104. Hemodynamics initially stable. Seen by Gyn - no PID.\n Became hypotensive in ED and put in groin line and started levophed\n which she continues to require with BP 100/58. Mentating and making\n copious urine.\n CXR clear, abdom CT negatve.\n Vanco, Clinda started.\n Transferred to MICU.\n In , similar ED admit with ? of PID, but w/u negative and\n thought to be viral syndrome\n On exam, obese woman, NAD, Lungs clear, Cor S1S2 nl, no murmurs, Abdom\n soft, tender, no rebound, no edema\n Plan: PID unlikely with Gyn exam/consult.\n Covered with Vanco/Flagyl\n Will r/o H1N1 with fever/resp sx's\n Isolated, start on Tamiflu\n No evidence of UTI, intra-abdom infection; cultures pending\n Wean levophed - push fluids\n Details of plan in HO note\n Time Spent - 45 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 06:29 ------\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 687572,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with gm neg rods in blood cxs. Source of fever/infection unclear\n . CT and U/S done on admit neg for any possible source.\n Action:\n Fever curve monitored. Repeat blood cultures send . Pt now started on\n vacomycin and ampicillin for gm neg rod coverage.\n Response:\n Max temp 102 but wbc remains elevated.\n Plan:\n Continue to follow fever curve and administer antibiotics as ordered.\n Await final results of all cx data. Pt denies pain and diet has been\n advanced to clear liqs and will advance as tolerated.\n .H/O hypotension (not Shock)\n Assessment:\n SBP has ranged from 83-99, hypotension most likey related to\n infection. HR in the 80\ns. pt asymptomatic with bp in the 90\ns and has\n uo that is ~ 300cc\n Action:\n will tolerate sbp in the 80\ns as long as uo remains adequate and pt is\n asymptomatic. pg given 1500cc NS X 5hrs . Electrolytes repleted as\n needed.\n Response:\n Pt off pressors with excellent uo via foley.\n Plan:\n Continue to follow hemodynamics and fluid balance. If hourly uo drops\n off and pt\ns bp is in the 80\ns would then consider bolusing pt\ns with\n ivf. R femoral line remains in place but if stable overnoc will d/c in\n the am.\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 687424,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n New admission from ED,pt AO X 3,MAE,T max 103 HR 100-105\n UO adequate,pt had nausea on admission,resolved without any meds.\n LSCTA,productive cough\nthick yellow sputum.\n Action:\n Pt was cultured in ED,Tylenol 650 mg/PO\n Monitoring continued,onn droplet precautions, tamiflu stat dose given\n after nasopharengeal aspirate\n Lytes repleted..\n Response:\n Fever trending down slowly\n Plan:\n On droplet precautions,monitor fever curve.\n Fullow up on culture results.\n Tylenol PRN\n Clear liquid diet can be advanced to full diet as tolerated.\n .H/O hypotension (not Shock)\n Assessment:\n Pt was hypotensive in ED,levophed was started\n Action:\n Pt was already received 7 L fluid in ED,levophed @ 0.09 mic/kg/mt\n Response:\n NBP remains low but stable,unable to wean since NBP still remains\n border line.\n Plan:\n Haemodinamic monitoring\n Titrate levophed as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 687613,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with GNR in blood cxs. CT and U/S done on admit neg for any\n possible source.\n Action:\n Fever curve monitored. Repeat blood cultures send . Pt on vacomycin\n and ampicillin for gm neg rod coverage.\n Response:\n Max temp 102 but wbc remains elevated.\n Plan:\n Continue to follow fever curve and administer antibiotics as ordered.\n Await final results of all cx data. Pt denies pain and diet has been\n advanced to clear liqs and will advance as tolerated.\n Tylenol PRN\n .H/O hypotension (not Shock)\n Assessment:\n SBP was maintained systolic in 90,s throughout the night. HR in the\n 80\ns. pt asymptomatic with bp in the 90\ns and has uo that is ~ 300cc\n Action:\n SBP in the 80\ns acceptable as long as output remains adequate and pt\n is asymptomatic, given 1500cc NS X 5hrs . Electrolytes repleted as\n needed.\n Response:\n Pt off pressors with good uo via foley.\n Plan:\n Continue to follow hemodynamics and fluid balance. If hourly UO drops\n off and pt\ns bp is in the 80\ns would then consider bolusing pt\ns with\n IVF\n R femoral line remains in place but if stable overnoc will d/c in the\n am.\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 687748,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Update: Gram neg rods in blood, Blood cultures repeated overnight for\n temp spike to 102.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n SEPSIS\n Code status:\n Full code\n Height:\n Admission weight:\n 109.5 kg\n Daily weight:\n Allergies/Reactions:\n Iodine\n Anaphylaxis; Ra\n Precautions: Droplet\n PMH:\n CV-PMH:\n Additional history: - ED visit with abdominal pain - treated\n empircally for\n PID, subsequently GC cultures all negative. Found adnexal cyst.\n -s/p 2 vaginal deliveries\n -s/p TAB x 1\n -Gestational Diabetes\n -Kidney stones\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:67\n Temperature:\n 101\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 3,240 mL\n 24h total out:\n 5,150 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:09 AM\n Potassium:\n 3.4 mEq/L\n 04:09 AM\n Chloride:\n 113 mEq/L\n 04:09 AM\n CO2:\n 21 mEq/L\n 04:09 AM\n BUN:\n 5 mg/dL\n 04:09 AM\n Creatinine:\n 0.7 mg/dL\n 04:09 AM\n Glucose:\n 97 mg/dL\n 04:09 AM\n Hematocrit:\n 27.9 %\n 04:09 AM\n Finger Stick Glucose:\n 104\n 12:00 PM\n Valuables / Signature\n Patient valuables: Clothing and cell phone, purse and wallet\n 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:\n Transferred to:\n Date & time of Transfer:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt states she\nfeels better\n this morning. Temp 99.7 and VS stable off\n pressors\n Action:\n Plan discussed on rounds with adjustments to antibiotics. Right femoral\n central line and foley catheter dc\nd. Pt assisted oob to chair.\n Response:\n Former femoral central line clean and dry, Pt transferred to chair\n without any orthostatic symptoms and is voiding large volumes of urine\n on bsc.\n Plan:\n Cotninue antibiotic coverage and follow culture data. Notify team of\n recurrence of fevers or hemodynamic instability. Transfer out of ICU\n and ABD US ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 687750,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Update: Gram neg rods in blood, Blood cultures repeated overnight for\n temp spike to 102.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n SEPSIS\n Code status:\n Full code\n Height:\n Admission weight:\n 109.5 kg\n Daily weight:\n Allergies/Reactions:\n Iodine\n Anaphylaxis; Ra\n Precautions: Droplet\n PMH:\n CV-PMH:\n Additional history: - ED visit with abdominal pain - treated\n empircally for\n PID, subsequently GC cultures all negative. Found adnexal cyst.\n -s/p 2 vaginal deliveries\n -s/p TAB x 1\n -Gestational Diabetes\n -Kidney stones\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:67\n Temperature:\n 101\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 3,240 mL\n 24h total out:\n 5,150 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:09 AM\n Potassium:\n 3.4 mEq/L\n 04:09 AM\n Chloride:\n 113 mEq/L\n 04:09 AM\n CO2:\n 21 mEq/L\n 04:09 AM\n BUN:\n 5 mg/dL\n 04:09 AM\n Creatinine:\n 0.7 mg/dL\n 04:09 AM\n Glucose:\n 97 mg/dL\n 04:09 AM\n Hematocrit:\n 27.9 %\n 04:09 AM\n Finger Stick Glucose:\n 104\n 12:00 PM\n Valuables / Signature\n Patient valuables: Clothing and cell phone, purse and wallet\n 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:\n Transferred to:\n Date & time of Transfer:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt states she\nfeels better\n this morning. Temp 99.7 and VS stable off\n pressors\n Action:\n Plan discussed on rounds with adjustments to antibiotics. Right femoral\n central line and foley catheter dc\nd. Pt assisted oob to chair.\n Response:\n Former femoral central line clean and dry, Pt transferred to chair\n without any orthostatic symptoms and is voiding large volumes of urine\n on bsc.\n Plan:\n Continue antibiotic coverage and follow culture data. Notify team of\n recurrence of fevers or hemodynamic instability. Transfer out of ICU\n and ABD US ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 687404,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n New admission from ED,pt AO X 3,MAE,T max 103 HR 100-105\n Action:\n Pt was cultured in ED,Tylenol 650 mg/PO\n Monitoring continued,onn droplet precautions, tamiflu stat dose given\n after nasopharengeal aspirate.\n Response:\n Fever trending down slowly\n Plan:\n On droplet precautions,monitor fever curve.\n Fullow up on culture results.\n .H/O hypotension (not Shock)\n Assessment:\n Pt was hypotensive in ED,levophed was started\n Action:\n Pt was already received 7 L fluid in ED,levophed @ 0.09 mic/kg/mt\n Response:\n NBP remains low but stable\n Plan:\n Haemodinamic monitoring\n Titrate levophed.\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 687722,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Update: Gram neg rods in blood, Blood cultures repeated overnight for\n temp spike to 102.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt states she\nfeels better\n this morning. Temp 99.7 and VS stable off\n pressors\n Action:\n Plan discussed on rounds with adjustments to antibiotics. Right femoral\n central line and foley catheter dc\nd. Pt assisted oob to chair.\n Response:\n Former femoral central line clean and dry, Pt transferred to chair\n without any orthostatic symptoms and is voiding large volumes of urine\n on bsc.\n Plan:\n Cotninue antibiotic coverage and follow culture data. Notify team of\n recurrence of fevers or hemodynamic instability. Transfer out of ICU\n and ABD US ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 687724,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Update: Gram neg rods in blood, Blood cultures repeated overnight for\n temp spike to 102.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n SEPSIS\n Code status:\n Full code\n Height:\n Admission weight:\n 109.5 kg\n Daily weight:\n Allergies/Reactions:\n Iodine\n Anaphylaxis; Ra\n Precautions: Droplet\n PMH:\n CV-PMH:\n Additional history: - ED visit with abdominal pain - treated\n empircally for\n PID, subsequently GC cultures all negative. Found adnexal cyst.\n -s/p 2 vaginal deliveries\n -s/p TAB x 1\n -Gestational Diabetes\n -Kidney stones\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:67\n Temperature:\n 101\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 3,240 mL\n 24h total out:\n 5,150 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:09 AM\n Potassium:\n 3.4 mEq/L\n 04:09 AM\n Chloride:\n 113 mEq/L\n 04:09 AM\n CO2:\n 21 mEq/L\n 04:09 AM\n BUN:\n 5 mg/dL\n 04:09 AM\n Creatinine:\n 0.7 mg/dL\n 04:09 AM\n Glucose:\n 97 mg/dL\n 04:09 AM\n Hematocrit:\n 27.9 %\n 04:09 AM\n Finger Stick Glucose:\n 104\n 12:00 PM\n Valuables / Signature\n Patient valuables: Clothing and cell phone 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:\n Transferred to:\n Date & time of Transfer:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt states she\nfeels better\n this morning. Temp 99.7 and VS stable off\n pressors\n Action:\n Plan discussed on rounds with adjustments to antibiotics. Right femoral\n central line and foley catheter dc\nd. Pt assisted oob to chair.\n Response:\n Former femoral central line clean and dry, Pt transferred to chair\n without any orthostatic symptoms and is voiding large volumes of urine\n on bsc.\n Plan:\n Cotninue antibiotic coverage and follow culture data. Notify team of\n recurrence of fevers or hemodynamic instability. Transfer out of ICU\n and ABD US ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 687729,
"text": "Chief Complaint: Fever and abdominal pain\n 24 Hour Events:\n - GNR in BCx x2\n - SBPs in 80s, off levo, with good UOP and asyx in afternoon, pt held\n course\n - repleted K, P, Ca, Mg\n - spiked to 102.1 at 10pm --> Bcx x2\n - was -500cc since admission, was given 1000cc NS bolus at 11pm\n Allergies:\n Iodine\n Anaphylaxis; Ra\n Last dose of Antibiotics:\n Vancomycin - 07:57 PM\n Ampicillin - 04:28 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 03:35 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 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102.1\n Tcurrent: 38.9\nC (102\n HR: 87 (78 - 90) bpm\n BP: 93/54(64) {62/43(47) - 107/65(71)} mmHg\n RR: 23 (12 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 10,579 mL\n 1,820 mL\n PO:\n 960 mL\n 220 mL\n TF:\n IVF:\n 2,519 mL\n 1,600 mL\n Blood products:\n Total out:\n 6,370 mL\n 1,840 mL\n Urine:\n 4,870 mL\n 1,840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,209 mL\n -20 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 137 K/uL\n 9.2 g/dL\n 97 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 113 mEq/L\n 139 mEq/L\n 27.9 %\n 14.2 K/uL\n [image002.jpg]\n TTE: The left atrium is mildly dilated. The right atrium is\n moderately dilated. Left ventricular wall thickness, cavity size and\n regional/global systolic function are normal (LVEF 70%). Tissue Doppler\n imaging suggests a normal left ventricular filling pressure\n (PCWP<12mmHg). There is no ventricular septal defect. 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. No masses or vegetations are seen on the aortic\n valve. The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is no mitral valve prolapse. No mass or vegetation\n is seen on the mitral valve. Moderate [2+] tricuspid regurgitation is\n seen. The estimated pulmonary artery systolic pressure is normal. No\n vegetation/mass is seen on the pulmonic valve. There is no pericardial\n effusion.\n CT abd/pel:\n 1. No acute intra-abdominal pathology. No abdominal fluid collections.\n No\n evidence for appendicitis or colitis; however, study is limited by lack\n of\n intravenous and oral contrast.\n 2. Unchanged nonobstructive right renal calculi with probable bilateral\n simple renal cysts.\n 3. Since the prior CT and pelvic U/S examinations, interval removal of\n an\n IUD.\n 10:30 PM\n 05:39 AM\n 03:55 PM\n 04:09 AM\n WBC\n 9.1\n 24.0\n 14.2\n Hct\n 29.9\n 29.5\n 27.9\n Plt\n 166\n 155\n 137\n Cr\n 0.8\n 0.9\n 0.7\n 0.7\n Glucose\n 116\n 227\n 95\n 97\n Other labs: PT / PTT / INR:16.9/40.6/1.5, ALT / AST:21/26, Alk Phos / T\n Bili:53/0.7, Amylase / Lipase:/17, Differential-Neuts:80.4 %,\n Lymph:13.2 %, Mono:4.1 %, Eos:1.9 %, D-dimer:4255 ng/mL, Fibrinogen:417\n mg/dL, Lactic Acid:1.9 mmol/L, Albumin:3.0 g/dL, Ca++:6.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:1.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O HYPOTENSION (NOT SHOCK)\n # Fever/Malaise: Blood Cx are growing GNRs sensitive to Unasyn. Pt.\n still spiking fevers (102.1 last night), her WBC is trending down from\n 24 yesterday to 14 today. Given her abdominal pain, cannot rule out a\n GI or GU process, however CT abdomen/pelvis was unremarkable (though\n limited without contrast) and pelvic ultrasound was also unremarkable.\n CXR clear. UA negative.\n - cont unasyn\n - vancomycin dc\n - will talk to radiology about any small abnormalities on abd/pel CT\n - wil repeat RUQ US\n - f/u blood cx, urine cx\n - cont to monitor fever curve, WBC count\n - tylenol prn\n - encourage PO fluids as she is able to tolerate\n - zofran prn nausea\n # Hypotension: Most likely secondary to hypovolemia in the setting of\n overwhelming infection/sepsis, high fevers, and decreased PO intake.\n Levophed was stopped yesterday, pt w/ stable BPs 90/100s/60s.\n - maintain adequate IV access\n .\n .\n # Abdominal pain: Greatly improved today, only reproducible w/ deep\n palpation. Abdominal CT scan and pelvic ultrasound were both\n negative. LFTs and lipase were wnl. She did have some CMT and adnexal\n tenderness per exams performed in the ED, which could raise concern for\n PID, although tests were (-) for GC and Chlamidia. IUD was removed.\n - tylenol prn\n - cont to monitor\n .\n ICU Care\n Nutrition: Regular\n Glycemic Control:\n Lines:\n 18 Gauge - 01:48 AM\n 20 Gauge - 01:48 AM\n Prophylaxis:\n DVT: pneumo boots, SC heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfered to regular floor\n ------ Protected Section ------\n Physical Examination:\n General: Alert, awake, obese Asian female, no acute distress\n HEENT: Sclera anicteric, mildly dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild tenderness to deep palpation with greatest\n tenderness in the suprapubic region and LLQ, non-distended, normal\n bowel sounds, no rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n ------ Protected Section Addendum Entered By: , MD\n on: 13:32 ------\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: 33F abd pain, GNR sepsis of unclear etiology.\n Echo normal.\n Exam notable for Tm 102.0 BP 98/50 HR 70-90 RR 18 with sat 99 on RA. WD\n woman NAD. CTA B. RRR s1s2. Soft +BS. No edema. Labs notable for WBC\n 14K (from 24K), HCT 27, K+ 3.4, Cr 0.7. CXR with clear lungs.\n Agree with plan to manage GNR sepsis with unasyn for now. Off pressors,\n can d/c CVL. Await stool cultures and repeat UCx. Focus of infection\n remains unclear - will review with radiology and consider repeat\n imaging for ? liver abscess - given contrast allergy, RUQ USG is\n probably best modality, could also consider MRI or nuc med scan. Other\n sources (dental given recent tooth cleaning, IUD, diarrheal illness\n possible, will continue to f/u BCx). Remainder of plan as outlined\n above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 17:21 ------\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 687400,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 687599,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with gm neg rods in blood cxs. CT and U/S done on admit neg for\n any possible source.\n Action:\n Fever curve monitored. Repeat blood cultures send . Pt on vacomycin\n and ampicillin for gm neg rod coverage.\n Response:\n Max temp 102 but wbc remains elevated.\n Plan:\n Continue to follow fever curve and administer antibiotics as ordered.\n Await final results of all cx data. Pt denies pain and diet has been\n advanced to clear liqs and will advance as tolerated.\n Tylenol PRN\n .H/O hypotension (not Shock)\n Assessment:\n SBP was maintained systolic in 90,s throughout the night. HR in the\n 80\ns. pt asymptomatic with bp in the 90\ns and has uo that is ~ 300cc\n Action:\n SBP in the 80\ns acceptable as long as output remains adequate and pt\n is asymptomatic, given 1500cc NS X 5hrs . Electrolytes repleted as\n needed.\n Response:\n Pt off pressors with excellent uo via foley.\n Plan:\n Continue to follow hemodynamics and fluid balance. If hourly UO drops\n off and pt\ns bp is in the 80\ns would then consider bolusing pt\ns with\n IVF\n R femoral line remains in place but if stable overnoc will d/c in the\n am.\n"
},
{
"category": "Physician ",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 687388,
"text": "Chief Complaint: Fever and abdominal pain\n HPI:\n 33 yo female with no significant past medical history presents with 3\n days of fevers and malaise. She reports her symptoms started 3 days\n ago and have been gradually progressing. She has had headache, fevers,\n chills, night sweats, myalgias, cough productive of green sputum,\n nausea/vomiting (non-bloody, up to 7x per day), diarrhea (non-bloody,\n up to 5x per day). She notes generalized abdominal pain, worst in the\n suprapubic region. Also decreased PO intake. No chest pain or SOB. No\n dysuria. No recent travel or sick contacts.\n .\n In the ED, initial vs were: T 104.5, P 129, BP 122/74, R 20, O2 sat 96%\n RA. Exam was notable for tenderness in the RLQ and LLQ, +CMT, and\n moderate white cervical discharge. She became progressively\n hypotensive and tachycardic with systolic BP down to the 70s. Received\n 6L IVF. R femoral CVL was placed and levophed was initiated. OB/Gyn\n was consulted out of concern for PIC. Pelvic ultrasound was negative.\n Her IUD was removed. CXR clear. CT abd/pelvis was also unremarkable\n for acute pathology. She received unasyn and doxycycline initially for\n abx coverage. When she clinically worsened, vanco and clinda were\n added. In addition, she was given zofran, tylenol, and toradol. As\n the patient had been sexually active on the morning of admission and\n her IUD was removed, she was also given plan B. She was then admitted\n to the for close monitoring.\n .\n On arrival to the , she feels very warm as if she is spiking a temp\n and complains of overall fatigue.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis; Ra\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Other medications:\n None\n Past medical history:\n Family history:\n Social History:\n - ED visit with abdominal pain - treated empircally for\n PID, subsequently GC cultures all negative. Found adnexal cyst.\n -s/p 2 vaginal deliveries\n -s/p TAB x 1\n -Gestational Diabetes\n -Kidney stones\n Non-contributory.\n Occupation: Works as a hairdressor at .\n Drugs: None.\n Tobacco: Nonsmoker.\n Alcohol: Drinks one drink per week (glass of wine, )\n Other: Moved to US from 20 yrs ago. Lives with husband and 2\n daughters, 3 and 2 yo.\n Review of systems: (+) Per HPI\n (-) Denies recent weight loss or gain. Denies headache, sinus\n tenderness, rhinorrhea or congestion. Denied shortness of breath.\n Denied chest pain or tightness, palpitations. Denied constipation. No\n recent change in bladder habits. No dysuria.\n Flowsheet Data as of 03:21 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.6\nC (103.2\n Tcurrent: 39.6\nC (103.2\n HR: 96 (96 - 105) bpm\n BP: 100/58(67) {100/58(67) - 104/71(78)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,031 mL\n PO:\n TF:\n IVF:\n 31 mL\n Blood products:\n Total out:\n 0 mL\n 2,340 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,691 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n Vitals: T: 103.2, BP: 100/63, P: 105, R: 18, O2: 94% on 2L\n General: Sleepy but arousable and appropriate, obese Asian female, no\n acute distress\n HEENT: Sclera anicteric, mildly dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales,\n ronchi\n CV: Tachy, regular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild diffuse tenderness to palpation with greatest\n tenderness in the suprapubic region, non-distended, notably decreased\n bowel sounds, no rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 166 K/uL\n 9.7 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 12 mg/dL\n 18 mEq/L\n 112 mEq/L\n 2.8 mEq/L\n 141 mEq/L\n 29.9 %\n 9.1 K/uL\n [image002.jpg]\n \n 2:33 A7/14/ 10:30 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 9.1\n Hct\n 29.9\n Plt\n 166\n Cr\n 0.8\n Glucose\n 116\n Other labs: PT / PTT / INR:14.5/51.9/1.3, ALT / AST:21/26, Alk Phos / T\n Bili:53/0.7, Amylase / Lipase:/17, Differential-Neuts:91.1 %, Lymph:7.5\n %, Mono:0.7 %, Eos:0.5 %, Lactic Acid:1.9 mmol/L, Albumin:3.0 g/dL\n Imaging: CXR: No acute cardiopulmonary abnormality.\n .\n CT abd/pelvis w/o contrast: prelim read: study limited by lack of oral\n and IV contrast. no acute intrabdominal pathology. unchanged\n non-obstructive right renal calculi, normal appendix. IUD has been\n removed from uterus.\n .\n Pelvic ultrasound: prelim read: Unchanged son evaluation of the\n pelvis, with normal uterus, endometrium and ovaries. no pelvic fluid.\n no adnexal masses.\n Microbiology: Blood cx pending\n Urine cx pending\n Cervical swab for GC/Chlamydia pending\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O HYPOTENSION (NOT SHOCK)\n This is a 33 year old healthy female who presents with 3 days of fever,\n malaise, and hypotension.\n .\n # Hypotension: Most likely secondary to hypovolemia in the setting of\n overwhelming infection/sepsis, high fevers, and decreased PO intake.\n Currently on a low dose of levophed.\n - cont IVF boluses in attempt to wean levophed\n - maintain adequate IV access\n .\n # Fever/Malaise: The clinical picture of high-grade fever, chills,\n and myalgias, in the absence of a leukocytosis or clear source makes a\n viral etiology high on the differential. Given her abdominal pain,\n cannot rule out a GI or GU process, however CT abdomen/pelvis was\n unremarkable (though limited without contrast) and pelvic ultrasound\n was also unremarkable. CXR clear. UA negative.\n - f/u blood cx, urine cx\n - cont to monitor fever curve, WBC count\n - tylenol prn\n - IVF bolus prn for MAP<60 or UOP<30cc/h\n - encourage PO fluids as she is able to tolerate\n - zofran prn nausea\n - hold on further antibiotics overnight without a clear source\n .\n # Abdominal pain: No clear etiology at this point. Abdominal CT scan\n and pelvic ultrasound were both negative. LFTs and lipase were wnl.\n She did have some CMT and adnexal tenderness per exams performed in the\n ED, which could raise concern for PID. IUD was removed, although felt\n by OB/Gyn to be unlikely the source of her illness.\n - tylenol prn\n - cont to monitor\n .\n # FEN: IVF as above, replete electrolytes prn, clears, advance diet as\n tolerated\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: R femoral CVL, peripherals\n - if able to wean levophed, will d/c femoral line in AM\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:46 AM\n 18 Gauge - 01:48 AM\n 20 Gauge - 01:48 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Given high suspicion for viral process, will send DFA and start\n oseltamavir.\n ------ Protected Section Addendum Entered By: , MD\n on: 03:52 ------\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 687507,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with gm neg rods form blood cxs. Source of fever/infection unclear\n . wbc jumped form 8 to 26. ct and u/s done on admit neg for any\n possible source.\n Action:\n Fever curve monitored. Repeat u&a/c&s sent off to microbiology. Pt now\n started on vacomycin and ampicillin for gm rod coverage. Tte done\n at bedside.\n Response:\n Max temp=99.8 but wbc remains elevated.\n Plan:\n Continue to follow fever curve and administer antibiotics as ordered.\n Await final results of all cx data. Pt denies pain and diet has been\n advanced to clear liqs and will advance as tolerated.\n .H/O hypotension (not Shock)\n Assessment:\n Received pt on norepepinephrine gtt.sbp has ranged from 83-99.\n hypotension most likey related to infection. Hr in the 80\ns. pt\n asymptomatic wth bp in the 80\ns and has uo that is > 100cc\n and even as\n much as 240cc\ns/hr.\n Action:\n Norepinephtine gtt weaned to off and will tolerate sbp in the 80\ns as\n long as uo remains adequate and pt is asymptomatic. pg given 500cc ns\n bolus x1 during our weaning of pressors. Electrolytes repleted as\n needed.\n Response:\n Pt off pressors with excellent uo via foley.\n Plan:\n Continue to follo hemodynamics and fluid balance. If hourly uo drops\n off and pt\ns bp is in the 80\ns would then consider bolusing pt\ns with\n ivf. R femoral line remains in place but if stable overnoc will d/c in\n the am.\n"
},
{
"category": "Physician ",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 687381,
"text": "Chief Complaint: Fever and abdominal pain\n HPI:\n 33 yo female with no significant past medical history presents with 3\n days of fevers and malaise. She reports her symptoms started 3 days\n ago and have been gradually progressing. She has had headache, fevers,\n chills, night sweats, myalgias, cough productive of green sputum,\n nausea/vomiting (non-bloody, up to 7x per day), diarrhea (non-bloody,\n up to 5x per day). She notes generalized abdominal pain, worst in the\n suprapubic region. Also decreased PO intake. No chest pain or SOB. No\n dysuria. No recent travel or sick contacts.\n .\n In the ED, initial vs were: T 104.5, P 129, BP 122/74, R 20, O2 sat 96%\n RA. Exam was notable for tenderness in the RLQ and LLQ, +CMT, and\n moderate white cervical discharge. She became progressively\n hypotensive and tachycardic with systolic BP down to the 70s. Received\n 6L IVF. R femoral CVL was placed and levophed was initiated. OB/Gyn\n was consulted out of concern for PIC. Pelvic ultrasound was negative.\n Her IUD was removed. CXR clear. CT abd/pelvis was also unremarkable\n for acute pathology. She received unasyn and doxycycline initially for\n abx coverage. When she clinically worsened, vanco and clinda were\n added. In addition, she was given zofran, tylenol, and toradol. As\n the patient had been sexually active on the morning of admission and\n her IUD was removed, she was also given plan B. She was then admitted\n to the for close monitoring.\n .\n On arrival to the , she feels very warm as if she is spiking a temp\n and complains of overall fatigue.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine\n Anaphylaxis; Ra\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.09 mcg/Kg/min\n Other ICU medications:\n Other medications:\n None\n Past medical history:\n Family history:\n Social History:\n - ED visit with abdominal pain - treated empircally for\n PID, subsequently GC cultures all negative. Found adnexal cyst.\n -s/p 2 vaginal deliveries\n -s/p TAB x 1\n -Gestational Diabetes\n -Kidney stones\n Non-contributory.\n Occupation: Works as a hairdressor at .\n Drugs: None.\n Tobacco: Nonsmoker.\n Alcohol: Drinks one drink per week (glass of wine, )\n Other: Moved to US from 20 yrs ago. Lives with husband and 2\n daughters, 3 and 2 yo.\n Review of systems: (+) Per HPI\n (-) Denies recent weight loss or gain. Denies headache, sinus\n tenderness, rhinorrhea or congestion. Denied shortness of breath.\n Denied chest pain or tightness, palpitations. Denied constipation. No\n recent change in bladder habits. No dysuria.\n Flowsheet Data as of 03:21 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.6\nC (103.2\n Tcurrent: 39.6\nC (103.2\n HR: 96 (96 - 105) bpm\n BP: 100/58(67) {100/58(67) - 104/71(78)} mmHg\n RR: 17 (17 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 7,031 mL\n PO:\n TF:\n IVF:\n 31 mL\n Blood products:\n Total out:\n 0 mL\n 2,340 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 4,691 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///18/\n Physical Examination\n Vitals: T: 103.2, BP: 100/63, P: 105, R: 18, O2: 94% on 2L\n General: Sleepy but arousable and appropriate, obese Asian female, no\n acute distress\n HEENT: Sclera anicteric, mildly dry MM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales,\n ronchi\n CV: Tachy, regular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, mild diffuse tenderness to palpation with greatest\n tenderness in the suprapubic region, non-distended, notably decreased\n bowel sounds, no rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 166 K/uL\n 9.7 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 12 mg/dL\n 18 mEq/L\n 112 mEq/L\n 2.8 mEq/L\n 141 mEq/L\n 29.9 %\n 9.1 K/uL\n [image002.jpg]\n \n 2:33 A7/14/ 10:30 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 9.1\n Hct\n 29.9\n Plt\n 166\n Cr\n 0.8\n Glucose\n 116\n Other labs: PT / PTT / INR:14.5/51.9/1.3, ALT / AST:21/26, Alk Phos / T\n Bili:53/0.7, Amylase / Lipase:/17, Differential-Neuts:91.1 %, Lymph:7.5\n %, Mono:0.7 %, Eos:0.5 %, Lactic Acid:1.9 mmol/L, Albumin:3.0 g/dL\n Imaging: CXR: No acute cardiopulmonary abnormality.\n .\n CT abd/pelvis w/o contrast: prelim read: study limited by lack of oral\n and IV contrast. no acute intrabdominal pathology. unchanged\n non-obstructive right renal calculi, normal appendix. IUD has been\n removed from uterus.\n .\n Pelvic ultrasound: prelim read: Unchanged son evaluation of the\n pelvis, with normal uterus, endometrium and ovaries. no pelvic fluid.\n no adnexal masses.\n Microbiology: Blood cx pending\n Urine cx pending\n Cervical swab for GC/Chlamydia pending\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n .H/O HYPOTENSION (NOT SHOCK)\n This is a 33 year old healthy female who presents with 3 days of fever,\n malaise, and hypotension.\n .\n # Hypotension: Most likely secondary to hypovolemia in the setting of\n overwhelming infection/sepsis, high fevers, and decreased PO intake.\n Currently on a low dose of levophed.\n - cont IVF boluses in attempt to wean levophed\n - maintain adequate IV access\n .\n # Fever/Malaise: The clinical picture of high-grade fever, chills,\n and myalgias, in the absence of a leukocytosis or clear source makes a\n viral etiology high on the differential. Given her abdominal pain,\n cannot rule out a GI or GU process, however CT abdomen/pelvis was\n unremarkable (though limited without contrast) and pelvic ultrasound\n was also unremarkable. CXR clear. UA negative.\n - f/u blood cx, urine cx\n - cont to monitor fever curve, WBC count\n - tylenol prn\n - IVF bolus prn for MAP<60 or UOP<30cc/h\n - encourage PO fluids as she is able to tolerate\n - zofran prn nausea\n - hold on further antibiotics overnight without a clear source\n .\n # Abdominal pain: No clear etiology at this point. Abdominal CT scan\n and pelvic ultrasound were both negative. LFTs and lipase were wnl.\n She did have some CMT and adnexal tenderness per exams performed in the\n ED, which could raise concern for PID. IUD was removed, although felt\n by OB/Gyn to be unlikely the source of her illness.\n - tylenol prn\n - cont to monitor\n .\n # FEN: IVF as above, replete electrolytes prn, clears, advance diet as\n tolerated\n .\n # Prophylaxis: Subcutaneous heparin, pneumoboots\n .\n # Access: R femoral CVL, peripherals\n - if able to wean levophed, will d/c femoral line in AM\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 01:46 AM\n 18 Gauge - 01:48 AM\n 20 Gauge - 01:48 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 687495,
"text": "33 yo female with no significant past medical history presents with 3\n days of fevers and malaise, her symptoms started 3 days ago and have\n been gradually progressing, had headache, fevers, chills, night sweats,\n myalgias, cough productive of green sputum, nausea/vomiting\n (non-bloody, up to 7x per day), diarrhea (non-bloody, up to 5x per\n day), generalized abdominal pain, worst in the suprapubic region. Also\n decreased PO intake. No chest pain or SOB. No dysuria. No recent\n travel or sick contacts\n She became progressively hypotensive and tachycardic with systolic BP\n down to the 70s. Received 6L IVF. R femoral CVL was placed and\n levophed was initiated. OB/Gyn was consulted out of concern for PIC.\n Pelvic ultrasound was negative. Her IUD was removed. CXR clear. CT\n abd/pelvis was also unremarkable for acute pathology. She received\n unasyn and doxycycline initially for abx coverage\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2156-07-28 00:00:00.000",
"description": "MICU Attending Progress Note",
"row_id": 687500,
"text": "TITLE: 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 would emphasize\n the following points: 33F abd pain, GNR sepsis.\n Exam notable for Tm 103.2 BP 98/50 HR 72 RR 18 with sat 99 on RA. WD\n woman NAD. CTA B. RRR s1s2. Soft +BS. No edema. Labs notable for WBC\n 24K (from 9K), HCT 29, K+ 3.4, Cr 0.9, lactate 1.9. CXR with clear\n lungs.\n Agree with plan to manage GNR sepsis with unasyn and vanco for now.\n Will wean off pressors and try to run even. Will check cultures,\n including stool cx, repeat UA and will check CT c oral and rectal\n contrast, as well as TTE. Focus of infection remains unclear. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n"
},
{
"category": "Echo",
"chartdate": "2156-07-28 00:00:00.000",
"description": "Report",
"row_id": 81199,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis\nHeight: (in) 67\nWeight (lb): 242\nBSA (m2): 2.19 m2\nBP (mm Hg): 98/65\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 11:23\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.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg).\nNo resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or\nvegetation on mitral valve. Normal mitral valve supporting structures. No MS.\nNormal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Normal tricuspid valve supporting structures. No TS. Moderate\n[2+] TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\nDoppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF 70%). Tissue Doppler imaging suggests a normal left\nventricular filling pressure (PCWP<12mmHg). There is no ventricular septal\ndefect. 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. No masses or vegetations are seen on\nthe aortic valve. The mitral valve appears structurally normal with trivial\nmitral regurgitation. There is no mitral valve prolapse. No mass or vegetation\nis seen on the mitral valve. Moderate [2+] tricuspid regurgitation is seen.\nThe estimated pulmonary artery systolic pressure is normal. No vegetation/mass\nis seen on the pulmonic valve. There is no pericardial effusion.\n\nIMPRESSION: no definite vegetations seen (but best evaluated by\ntransesophageal echocardiography)\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-07-29 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1088848,
"text": ", F. MED 3:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Source of infection\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with sepsis, BCx- GNRs\n REASON FOR THIS EXAMINATION:\n Source of infection\n ______________________________________________________________________________\n PFI REPORT\n 1. Normal appearance to liver and gallbladder.\n 2. Small right pleural effusion. No fluid in the abdomen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-07-27 00:00:00.000",
"description": "P PELVIS, NON-OBSTETRIC PORT",
"row_id": 1088527,
"text": " 7:25 PM\n PELVIS, NON-OBSTETRIC PORT; PELVIS U.S., TRANSVAGINAL PORT Clip # \n Reason: eval for , for IUD placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with fever, pelvic pain, IUD in place\n REASON FOR THIS EXAMINATION:\n eval for , for IUD placement\n ______________________________________________________________________________\n WET READ: AJy TUE 8:49 PM\n Unchanged son evaluation of the pelvis, with normal uterus,\n endometrium and ovaries. no pelvic fluid. no adnexal masses.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 32-year-old female with fever and pelvic pain.\n\n COMPARISON: .\n\n FINDINGS: Transabdominal and endovaginal son imaging of the pelvis\n was performed, the latter to better evaluate the endometrium and adnexa. The\n uterus is anteverted measuring 9.1 x 4.7 x 5.3 cm. The uterus is unchanged in\n appearance, with an IUD in satisfactory position. The endometrium is normal.,\n measuring 4mm. There is a small focus of calcification within the posterior\n myometrium, unchanged.\n\n Bilateral ovaries are normal in size and appearance. Small follicles are\n noted bilaterally. Normal arterial waveforms are present in the left ovary.\n Evaluation of the vasculature of the right ovary was limited due to\n technically difficulty. There is no free fluid in the pelvis. There is no\n hydronephrosis.\n\n IMPRESSION:\n\n 1. IUD in satisfactory position.\n\n 2. No change in appearance of the uterus and ovaries, with no adnexal mass\n identified.\n\n 3. No free fluid in the pelvis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-07-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088516,
"text": " 5:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with fever to 105\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever to 105 degrees.\n\n COMPARISON: Chest radiograph, .\n\n UPRIGHT AP VIEW OF THE CHEST: Cardiac silhouette is top normal in size. The\n mediastinal and hilar contours are normal. The lungs are clear. No pleural\n effusion or pneumothorax is identified. The osseous structures are within\n normal limits.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-07-29 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1088847,
"text": " 3:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Source of infection\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with sepsis, BCx- GNRs\n REASON FOR THIS EXAMINATION:\n Source of infection\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 8:16 PM\n 1. Normal appearance to liver and gallbladder.\n 2. Small right pleural effusion. No fluid in the abdomen.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 33-year-old woman with sepsis, and blood cultures growing gram-\n negative rods. Evaluate for source of infection.\n\n ABDOMINAL ULTRASOUND:\n\n COMPARISON: CT abdomen .\n\n FINDINGS: The liver appears normal in echotexture without focal masses or\n lesions. There is normal hepatopetal flow within the main portal vein. The\n gallbladder appears normal without evidence for stones, sludge, or gallbladder\n distention. The CBD measures 4 mm. The pancreas was not well visualized due\n to overlying bowel gas. The spleen appears normal in echotexture measuring\n 13.9 cm. There is a trace right pleural effusion. No fluid in the abdomen.\n\n IMPRESSION:\n 1. Normal appearance to liver and gallbladder.\n 2. Small right pleural effusion. No fluid in the abdomen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-07-27 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1088538,
"text": " 10:26 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for abnormal fluid collection, colitis, appy, non-contr\n Admitting Diagnosis: SEPSIS\n Field of view: 48\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 33 year old woman with sepsis, hypotension\n REASON FOR THIS EXAMINATION:\n eval for abnormal fluid collection, colitis, appy, non-contrast, pt has severe\n contrast allergy\n CONTRAINDICATIONS for IV CONTRAST:\n allergy\n ______________________________________________________________________________\n WET READ: JMGw TUE 11:20 PM\n study limited by lack of oral and IV contrast. no acute intrabdominal\n pathology. unchanged non- obstructive right renal calculi, normal appendix.\n IUD has been removed from uterus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 33-year-old woman with sepsis and hypotension. Evaluate for\n abnormal fluid collections, colitis, appendicitis. The patient has severe\n contrast allergy.\n\n CT ABDOMEN AND PELVIS: Helical imaging was performed from the lung bases\n through the pubic symphysis without IV or oral contrast. IV contrast was not\n administered secondary to patient's severe contrast allergy. Sagittal and\n coronal reformations were prepared.\n\n COMPARISON: CT abdomen and pelvis . Pelvic ultrasound \n\n CT ABDOMEN: The partially visualized lung bases demonstrate mild bibasilar\n dependent atelectasis. There are no pleural effusions. The partially\n visualized heart appears normal.\n\n Lack of IV and oral contrast limits evaluation of solid intra-abdominal organs\n and bowel. The spleen, adrenals, pancreas, liver all appear unremarkable\n without obvious masses or lesions. The gallbladder appears mildly distended,\n but no fluid around the gallbladder or stones within the gallbladder to\n suggest the presence of cholecystitis. There is a poorly defined hypodensity\n in the region of the superior pole of the left kidney (2:37), which appears\n stable to prior examination and likely represents a simple cyst. In the\n superior pole of the right kidney is a 5-mm non-obstructive calculus which is\n stable. In the interpolar region of the right kidney is a 2-mm nonobstructing\n calculus (2:43). Also in the interpolar region of the right kidney is a 2-mm\n nonobstructing calculus (2:47). There is an approximate 2.8 cm hypodensity in\n the medial portion of the right kidney, unchanged from prior examination and\n is likely a simple renal cyst. There is no evidence for hydronephrosis in\n either kidney. The abdominal aorta and its branches appear unremarkable.\n There is no free air or free fluid in the abdomen. There are scattered\n mesenteric nodes, unchanged since prior examination and of uncertain\n significance but may reflect underlying inflammatory process. There is no\n retroperitoneal lymphadenopathy. Stomach and abdominal loops of small bowel\n (Over)\n\n 10:26 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for abnormal fluid collection, colitis, appy, non-contr\n Admitting Diagnosis: SEPSIS\n Field of view: 48\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appear normal without evidence for obstruction.\n\n CT PELVIS: There is a right femoral line catheter in position (2:80). There\n is a calcified degenerated fibroid in the posterior aspect of the uterus\n (2:83), unchanged. On the prior scans, the patient had an IUD in place, which\n has now been removed. The uterus and adnexa appear grossly unremarkable but\n evaluation is limited by lack of contrast. The rectum, sigmoid colon, and\n pelvic loops of small and large bowel appear normal. There is a normal\n visualized appendix (2:71). There is a Foley in a partially decompressed\n bladder. There is no inguinal lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious sclerotic or lytic lesions.\n\n IMPRESSION:\n\n 1. No acute intra-abdominal pathology. No abdominal fluid collections. No\n evidence for appendicitis or colitis; however, study is limited by lack of\n intravenous and oral contrast.\n\n 2. Unchanged nonobstructive right renal calculi with probable bilateral\n simple renal cysts.\n\n 3. Since the prior CT and pelvic U/S examinations, interval removal of an\n IUD.\n\n The results of this study were posted on the emergency department dashboard.\n\n\n"
}
] |
10,529 | 146,680 | Impression: 76yo woman transferred from OSH where she received iv tPA following a R-MCA stroke. She developed asystole, bradycardia and HTN, and was found to have hemorrhage into the stroke. See hospital course below for details: | Chest PT done with a little result. EKG and CXR done. Normal tricuspid valvesupporting structures. Moderate (2+) aortic regurgitation is seen. Mild mitralannular calcification. Lungs coarse rhonchi noted R>L. HR Spontaneously returned to sinus rhythm. While ppf off pt had brief episode of junctional rhythm/asystole. Otherwise, probably normal ECG. Normal aortic arch diameter. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Nursing Note 7p-7a:Nursing Assessment:Febrile 100.6 po, team aware. Repeat CXR done for ET-Tube placement. PERLA.Lungs clear in uppers and coarse in lowers. addendum: to previous notepatient moves right side to command, withdraws LEFT side to painful stimulation only. RESP CARE: pt remains intubated/on vent with settings per carevue. Mild thickening of mitral valve chordae. BEDSIDE SWALLOW EVAL DONE, POOR RESULTS, WILL KEEP NPO AND REASSESS TOMORROW.GI--NGT REPLACED. SBP 100S-130S, SEE ORDERS FOR SPECIFIC PARAMETERS, HOLD LABETOLOL DRIP PER DR. FOR LOW HR. ABG ok MD .Abdomen soft, Bowel sounds present. No MS.TRICUSPID VALVE: Normal tricuspid valve leaflets. Start of shift only w/drawing rarm and lower extremities. The IVC is normal in diameter with appropriate phasic respiratorvariation.LEFT VENTRICLE: Normal LV wall thickness. WITHDRAWS RIGHT SIDE TO PAIN ONLY. Abd soft, (+) bowel sounds. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Focal calcifications in aortic root. Condition UpdateVSS. Sedated on ppf. Dilaudid .2mg IVP given for H/A with minimal relief. Sinus rhythmConsider left ventricular hypertrophy by voltageModest nonspecific ST-T wave changesSince previous tracing of , modest ST-T wave changes present Nursing Note 7p-7a:Nursing Assessment:Tmax 101.1, pan cultured. Normal LV cavity size. Turns minimized d/t recent occurances of asystole on turning. The leftventricular cavity size is normal. Abdomen remains soft.POC: keep family updated. Moderate (2+)AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. OFF.SOCIAL--FAMILY SUPPORTIVE, UPDATED BY NEURO TEAMA/P--CONTINUE WITH GOOD PULMONARY TOILET. DEFIB PADDLES CHANGED, STILL ON, YET DEBIF. There is nopericardial effusion.Compared with the findings of the prior study (images reviewed) of , no major change is evident. Hypertension.Height: (in) 67Weight (lb): 140BSA (m2): 1.74 m2BP (mm Hg): 132/41HR (bpm): 63Status: InpatientDate/Time: at 13:06Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No vent changes this shift with acceptable ABG's. IV FLUID NS WITH 40 K AT 80CC HR (K RUNNING LOW, WILL REPLACE ONCE NGT PLACEMENT CONFIRMED).ID--FEBRILE STILL, TYELNOL GIVEN, TEAMS AWARE. Right ventricular chamber size and freewall motion are normal. O2 sats 98-100% adn pt denies difficulty breathing. Pt then became asystolic converted back to SR 74bpm on own. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Spec sent for C/S. O2 Sat acceptable on current settings. Pupils equal and reactive bilat. Same vent settings. By 0455 pt began to have dry heaves and was turned to her left side. Shakes head yes and no only rarely. Head CT today. FOCUS: CONDITION UPDATED: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS.RESP--PATIENT WEANED AND EXTUBATED FROM VENT THIS AM WITHOUT DIFFICULTY. FINDINGS: The intraparenchymal hemorrhage involving the right lateral lenticulostriate territory is similar in appearance to prior examination. IMPRESSION: Stable intraparenchymal hemorrhage in the area of infarction involving the right lateral lenticulostriate territory. No contraindications for IV contrast FINAL REPORT INDICATION: Patient with right middle cerebral artery infarct, post TPA with increasing obtundation, nausea and headache. FINDINGS: There is absence of flow signal within the M1 segment of the right middle cerebral artery. Stable effacement of the frontal of the right lateral ventricle and subfalcine shift. REASON FOR THIS EXAMINATION: Check DHT placement FINAL REPORT INDICATION: Right MCA stroke, check DHT placement. Loss of flow signal is demonstrated within the right M1 segment of the middle cerebral artery. There continues to be effacement of the adjacent frontal of the right lateral ventricle. NON-CONTRAST HEAD CT SCAN: There is new hemorrhage involving the area of acute infarction of the territory of the right lateral lenticulostriate arteries. The infarction and hemorrhage result in mass effect upon the right lateral ventricle, and slight (1-2 mm of) leftward subfalcine shift of the midline structures. Both intracranial internal carotid arteries, anterior cerebral arteries, anterior communicating artery, left middle cerebral artery, posterior cerebral arteries, basilar artery, and distal vertebral arteries demonstrate normal flow signal without significant stenoses or aneurysmal dilatation present. Persistent retrocardiac left lower lobe opacity consistent with atelectasis. Remaining portions of the major intracranial cerebral vessels demonstrate normal flow signal. IMPRESSION: AP chest compared to : Pulmonary vascular congestion has cleared. There is obscuration of the left hemidiaphragm. Slight increase in amount of hemorrhage within the occipital of the right lateral ventricle. There is a small right pleural effusion. HISTORY: Right MCA stroke. FINDINGS: Single portable supine abdominal radiograph reviewed. Abnormal diffusion signal within the right basal ganglia and posterior limb of the internal capsule with corresponding hypointensity on the ADC map is consistent with acute infarction in the distribution of the right lateral lenticulostriate arteries. IMPRESSION: AP chest compared to : Mild cardiomegaly is new and pulmonary vasculature is engorged, but there is no pulmonary edema, and the lungs are clear. There is a small amount of fluid in the sphenoid sinus, likely secondary to the patient being intubated. 5:56 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: Is ETT in correct position? The degree of subfalcine herniation is not significantly changed from prior examination. | 23 | [
{
"category": "Echo",
"chartdate": "2100-08-17 00:00:00.000",
"description": "Report",
"row_id": 100173,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Hypertension.\nHeight: (in) 67\nWeight (lb): 140\nBSA (m2): 1.74 m2\nBP (mm Hg): 132/41\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 13:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler. The IVC is normal in diameter with appropriate phasic respirator\nvariation.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Hyperdynamic\nLVEF. No resting LVOT gradient. No LV mass/thrombus. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in aortic root. Focal calcifications in ascending\naorta. Normal aortic arch diameter. Focal calcifications in aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Moderate (2+)\nAR.\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.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Left ventricular systolic function is\nhyperdynamic (EF 80%). No masses or thrombi are seen in the left ventricle.\nThere is no ventricular septal defect. Right ventricular chamber size and free\nwall motion are normal. There are focal calcifications in the aortic arch. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. There is no\npericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , no major change is evident.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-16 00:00:00.000",
"description": "Report",
"row_id": 1401559,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT IS 76 YO FEMALE, S/P ISCHEMIC STROKE, GIVEN IV TPA AT OSH W/IN 3HR WINDOW. TRANSFERED TO FOR POSSIBLE IA TPA.\nPT A&O X3, DROWSY SINCE ARRIVAL TO SICU. CONT LEFT FACIAL DROOP, DECREASED SENSATION/HEMIPARESIS TO LEFT SIDE, NO MOTOR/SENSORY DEFICIT TO RIGHT SIDE. C/O RLE SCIATICA PAIN. HR 40S-60S, SB, NEURO TEAM AWARE. SBP 100S-130S, SEE ORDERS FOR SPECIFIC PARAMETERS, HOLD LABETOLOL DRIP PER DR. FOR LOW HR. LUNGS CLEAR, O2 SATS >93% ON 2L. LGE FAMILY TO VISIT PT, SUPPORTIVE.\n CONT FREQUENT BP, NEURO CHECKS, HOB<30, REPEAT HEAD CT .\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-17 00:00:00.000",
"description": "Report",
"row_id": 1401560,
"text": "Right sided CVA\nNeuro: data prior to 0500 s/p TPA at 11am . Pt awake alert ox3 with L hemiparesis flexes L leg slightly to command no movement l arm to command if arm lifted off bed by RN it flexes toward chest. PERRLA size 2mm each. L facial droop. Pt NPO awaiting swallow study .\nAt 0445 pt c/o severe right temporal headache, Dr at bedside and aware. Dilaudid .2mg IVP given for H/A with minimal relief. By 0455 pt began to have dry heaves and was turned to her left side. Pt then became asystolic converted back to SR 74bpm on own. Pt had 3 more episodes of asystloic periods converting self back to SR. External pacing instituted MA-10 and demand rate 40. EKG and CXR done. pt ox3 up to point of intub and following commands. Pt intubated by Dr and placed on vent see carevue for settings. Propofol gtt started at 30mcg/kg/min. Repeat CXR done for ET-Tube placement. Pt transported to CT. Family notified by Dr of condition change. Neurosurg consult placed and pt examined by neurosurg team.\nPlan:Continue to support.\nFamily meeting today\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-18 00:00:00.000",
"description": "Report",
"row_id": 1401565,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS.\nRESP--PATIENT WEANED AND EXTUBATED FROM VENT THIS AM WITHOUT DIFFICULTY. DOES HAVE MOD-LARGE AMOUNT OF THICK WHITE SECRETIONS WHICH PATIENT DOES COUGH, BUT NEEDS HELP SUCTIONING OUT OF MOUTH. CPT DONE Q 4 HRS. WITH GOOD RESULTS. LUNG FIELDS CLEAR ABOVE AND COARSE AT BASES. ABGS PER FLOW SHEET. ON 4L NSASL PRONGS WITH GOOD SATS.\nNEURO--PATIENT AWAKE AND AROUSABLE TO VOICE, YET DOES SLEEP A LOT DURING THE DAY. FOLLOWS COMMANDS WITH RIGHT SIDE AND RECOGNIZES FAMILY. CAN VERBALIZE, USUALLY \"LEAVE ME ALONE\", YET WILL CARRY ON CONVERSATION WITH FAMILY. PUPILS EQUAL AND REACTIVE. WITHDRAWS RIGHT SIDE TO PAIN ONLY. BEDSIDE SWALLOW EVAL DONE, POOR RESULTS, WILL KEEP NPO AND REASSESS TOMORROW.\nGI--NGT REPLACED. WAITING XRAY FOR CONFIRMATION TO GIVE MEDS AND REUSME FEEDS IF NEEDED. IV FLUID NS WITH 40 K AT 80CC HR (K RUNNING LOW, WILL REPLACE ONCE NGT PLACEMENT CONFIRMED).\nID--FEBRILE STILL, TYELNOL GIVEN, TEAMS AWARE. NO ANTIBIOTICS YET.\nGU--FOLEY, CLEAR YELLOW URINE.\nCARDIO-STABLE, HEART RATE NSR NO ECTOPY OR PAUSES. DEFIB PADDLES CHANGED, STILL ON, YET DEBIF. OFF.\nSOCIAL--FAMILY SUPPORTIVE, UPDATED BY NEURO TEAM\nA/P--CONTINUE WITH GOOD PULMONARY TOILET.\n CONTIUE TO CHECK NEURO STATUS, CALL HO WITH ANY CHANGES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-18 00:00:00.000",
"description": "Report",
"row_id": 1401566,
"text": "addendum: to previous note\npatient moves right side to command, withdraws LEFT side to painful stimulation only.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-19 00:00:00.000",
"description": "Report",
"row_id": 1401567,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nFebrile 100.6 po, team aware. Pt easily awakens to voice and following commands, conversing slightly. Recognizes family and reverend when enter room and knows she is in the hospital, although not which one. Unsure if patient knows why she is in the hospital, when asked stated \"I do not care.\" Reorientated frequently. Patient is able to state when she is in pain and treated with dilaudid for head, neck, and back pain with good effect.\nHR NSR occasionally brady in 50s. Potassium po with good results and phosporous repleted this morning. Pacer off but paddles on. Blood pressure within goal and will restart home antihypertensives this morning. Urine output adequate.\nLungs coarse esp in bases and patient coughs weakly often not productive. Importance of coughing and deep breathing reiterated frequently and patient nods head in understanding. Chest PT done with a little result. Breathing and cough sounds very congested adn sputum thick tan to thick white. O2 sats 98-100% adn pt denies difficulty breathing. Nasal prongs at 5 liters per minute.\nTube feeds remain off for the night until morning, NGT clamped for meds only. Xray confirmed position. Abdomen remains soft.\nPOC: keep family updated. Monitor HR and ? ok to remove pacer pads (48 hours without any furthur episodes of asystole). ?Head CT today. Restart tube feeds and home antihypertensives. Continue with chest pt and coughing and deep breathing. Monitor potassium and phosphorous levels. reorientate frequently and q 2hour neuro checks.\nPlease refer to carevue for all further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-17 00:00:00.000",
"description": "Report",
"row_id": 1401561,
"text": "Condition Update\nVSS. Lowgrade temp. Tmax 100.6 p.o. Sedated on ppf. Start of shift only w/drawing rarm and lower extremities. Consult by neurosurgery. Orders to turn ppf off. While ppf off pt had brief episode of junctional rhythm/asystole. HR Spontaneously returned to sinus rhythm. TCP pads remain on, pacer on demand mode. No further such episodes noted. As shift progressed pt following commands on rside (squeezing hand, wiggling toes), w/drawing lle. Eventually this p.m. pt intermittently w/drawing lue. Spontaneous movement noted rside. Pupils equal and reactive bilat. No vent changes this shift. O2 Sat acceptable on current settings. Suctioned x1 for thick tan sputum. Lungs clear to auscultation throughout. Started on tfeeds via OGT w/o incident. Abd soft, (+) bowel sounds. U/o qs via foley. CtScan done at 5pm results pending. Large family present.\nCont close neuro monitoring. Monitor for s/s of worsening bleed. Close cardiac monitor. Pt family teaching and support. Cont current ICU care and assessments.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-17 00:00:00.000",
"description": "Report",
"row_id": 1401562,
"text": "BS CTAB. No vent changes this shift with acceptable ABG's. To CT for repeat head scan (24hr post TPA), with possible mild improvement. Responding to some commands and moving right side.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-18 00:00:00.000",
"description": "Report",
"row_id": 1401563,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nTmax 101.1, pan cultured. Following commands intermittently on propofol, squeezing hand on right and wiggles toes on right. Shakes head yes and no only rarely. Left side responds to painful stimuli only, only light stimuli needed for left lower. PERLA.\nLungs clear in uppers and coarse in lowers. Suctioned thick tan secretions. Same vent settings. ABG ok MD .\nAbdomen soft, Bowel sounds present. NO stool. Tube feeds increased toward goal and tolerated well.\nHR NSR 60s and pacer pads remain on for HR less than 40. SBP remains within goal lower than 130-140. Following cuff pressures. Potassium level back 2.9 and treated with 40meq kcl po thus far and will recheck and give second dose 40meq po if needed. Pt has peripherals only and ogt. Turns minimized d/t recent occurances of asystole on turning. Pt's skin non red and no breakdown noted on back or coccyx. Bruise to hip from fall previous to admition. Urine output adequate.\nFamily in earlier in night and updated with cT results by MD.\nPlan: recheck potassium. recheck HCT later today (4 points lower now 27.4 on am labs). Chest xray this am (d/t thick yellow sputum and pt on vent). Head CT today. Emotional support for family and patient. Neuro exams continue Q 1 hour.\nPlease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2100-08-18 00:00:00.000",
"description": "Report",
"row_id": 1401564,
"text": "RESP CARE: pt remains intubated/on vent with settings per carevue. No changes made this shift. Lungs coarse rhonchi noted R>L. Sxd thick yellow sputum. Spec sent for C/S. RSBI attempted this am but no spont resp effort noted at this time. Most likely due to sedation.\n"
},
{
"category": "ECG",
"chartdate": "2100-08-20 00:00:00.000",
"description": "Report",
"row_id": 283397,
"text": "Sinus rhythm\nConsider left ventricular hypertrophy by voltage\nModest nonspecific ST-T wave changes\nSince previous tracing of , modest ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2100-08-16 00:00:00.000",
"description": "Report",
"row_id": 283398,
"text": "Sinus bradycardia. Otherwise, probably normal ECG. Since the previous tracing\nof no significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 924895,
"text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o aspiration and baseline\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with right MCA stroke\n REASON FOR THIS EXAMINATION:\n r/o aspiration and baseline\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:11 A.M., .\n\n HISTORY: Right MCA stroke. Rule out aspiration.\n\n IMPRESSION: AP chest compared to :\n\n Mild cardiomegaly is new and pulmonary vasculature is engorged, but there is\n no pulmonary edema, and the lungs are clear. There is no pleural abnormality.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 924899,
"text": " 5:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Any evidence of hemorrhage into known R MCA territory infarc\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with right MCA stroke, s/p IV tPA, now with increasing\n obtundation, nausea, headache.\n REASON FOR THIS EXAMINATION:\n Any evidence of hemorrhage into known R MCA territory infarct?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with right middle cerebral artery infarct, post TPA with\n increasing obtundation, nausea and headache. Evaluate for hemorrhage.\n\n COMPARISON: MR of the brain of .\n\n NON-CONTRAST HEAD CT SCAN: There is new hemorrhage involving the area of\n acute infarction of the territory of the right lateral lenticulostriate\n arteries. The acute hemorrhage spans 5.0 x 3.1 cm within the brain\n parenchyma, and extends into both lateral ventricles as well as the third and\n fourth ventricles. There is hypodensity of the brain tissues within the area\n of infarction. The infarction and hemorrhage result in mass effect upon the\n right lateral ventricle, and slight (1-2 mm of) leftward subfalcine shift of\n the midline structures. The paranasal sinuses for the most part are well\n aerated with minimal mucosal thickening within the left maxillary sinus, and a\n small mucus retention cyst or polyp in the right maxillary sinus. Osseous and\n soft tissue structures are unremarkable.\n\n IMPRESSION: Acute hemorrhage within the area of infarction involving the\n right lateral lenticulostriate territory, with intraventricular extension of\n hemorrhage into both lateral ventricles, the third and fourth ventricles.\n Minimal leftward subfalcine shift of midline structures is noted.\n\n The findings were called to Dr. at the immediate conclusion of the\n exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 924900,
"text": " 5:56 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Is ETT in correct position?\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with right MCA stroke, now s/p intubation.\n\n REASON FOR THIS EXAMINATION:\n Is ETT in correct position?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:02 A.M. .\n\n HISTORY: Stroke. Check ET tube position.\n\n IMPRESSION: AP chest compared to 5:11 a.m. and :\n\n ET tube tip at the level of the sternal notch, in standard position. Heart\n size mildly enlarged. Lungs grossly clear. No pneumothorax or pleural\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-19 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 925284,
"text": " 5:30 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Check DHT placement\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with right MCA stroke,febrile w/ sputum production.\n\n REASON FOR THIS EXAMINATION:\n Check DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate Dobbhoff tube placement.\n\n Comparison is made with prior study performed six hours before.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST: The tip of the feeding tube is still\n curled up within the esophagus and the tip is in the mid-to-superior thoracic\n region. Persistent retrocardiac left lower lobe opacity consistent with\n atelectasis. There is a small right pleural effusion. Cardiomediastinal\n contour is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-20 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 925365,
"text": " 10:11 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: 76 year old woman with stroke needs placement of post pylori\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with stroke needs placement of post pyloric feeding tube\n REASON FOR THIS EXAMINATION:\n 76 year old woman with stroke needs placement of post pyloric feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please place post-pyloric feeding tube.\n\n FLUOROSCOPIC GUIDED INSERTION OF POST-PYLORIC FEEDING TUBE: A 14-French\n - feeding tube was inserted under fluoroscopic guidance into\n the fourth portion of the duodenum. Approximately, 10 mL of Optiray contrast\n was injected to confirm placement.\n\n IMPRESSION: Successful post-pyloric tube placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 925005,
"text": " 5:03 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: stroke s/p IV tPA please perform exam @ 1600\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with R MCA stroke s/p IV tPA\n REASON FOR THIS EXAMINATION:\n stroke s/p IV tPA please perform exam @ 1600\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old woman with right MCA stroke, status post TPA with\n intracranial hemorrhage.\n\n COMPARISON: at 6:02 a.m.\n\n FINDINGS: The intraparenchymal hemorrhage involving the right lateral\n lenticulostriate territory is similar in appearance to prior examination.\n There continues to be effacement of the adjacent frontal of the right\n lateral ventricle. Blood is again seen in the occipital of the right\n lateral ventricle, the third ventricle, and fourth ventricle. The amount of\n hemorrhage in the occipital of the right lateral ventricle has slightly\n increased compared to prior examination. The degree of subfalcine herniation\n is not significantly changed from prior examination. The ventricular size is\n stable. No new areas of hemorrhage are identified. There is a small amount\n of fluid in the sphenoid sinus, likely secondary to the patient being\n intubated. Minimal bilateral ethmoid sinus mucosal thickening is also seen.\n Osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: Stable intraparenchymal hemorrhage in the area of infarction\n involving the right lateral lenticulostriate territory. Stable effacement of\n the frontal of the right lateral ventricle and subfalcine shift. Slight\n increase in amount of hemorrhage within the occipital of the right\n lateral ventricle.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 925223,
"text": " 11:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: feeding tube position\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with right MCA stroke,febrile w/ sputum production.\n\n REASON FOR THIS EXAMINATION:\n feeding tube position\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right MCA stroke, now afebrile, check position of feeding\n tube.\n\n CHEST: The tip of the feeding tube has curled up within the esophagus and the\n tip now lies in the mid thoracic region. An attempt to place this in a better\n position should therefore be made.\n\n There is obscuration of the left hemidiaphragm. The presence of an effusion\n and/or consolidation in the left lower lobe should be considered. Surgical\n team informed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 925033,
"text": " 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneu,onia\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with right MCA stroke, now s/p intubation, febrile w/\n sputum\n REASON FOR THIS EXAMINATION:\n r/o pneu,onia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:18 A.M., \n\n HISTORY: Stroke. Febrile following intubation.\n\n IMPRESSION: AP chest compared to :\n\n Pulmonary vascular congestion has cleared. There are no findings to suggest\n active pneumonia. Heart size top normal. ET tube and NG tube in standard\n placements. No pneumothorax or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-18 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 925143,
"text": " 6:18 PM\n PORTABLE ABDOMEN Clip # \n Reason: Extubated, now w/ NGTube\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with right MCA stroke,febrile w/ sputum production.\n\n REASON FOR THIS EXAMINATION:\n Extubated, now w/ NGTube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female with stroke and NG tube placed.\n\n No prior studies for comparison.\n\n FINDINGS: A nasogastric tube courses down into the lower abdomen. The stomah\n is likely dilated. The bowel gas pattern is unremarkable.\n\n IMPRESSION: Nasogastric tube in lower abdomen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-19 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 925270,
"text": " 3:47 PM\n PORTABLE ABDOMEN Clip # \n Reason: Check DHT placement\n Admitting Diagnosis: STROKE/TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with right MCA stroke,febrile w/ sputum production.\n\n REASON FOR THIS EXAMINATION:\n Check DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right MCA stroke, check DHT placement.\n\n COMPARISON: .\n\n Please check DHT placement.\n\n FINDINGS: Single portable supine abdominal radiograph reviewed. There is no\n evidence for nasogastric tube overlying the abdomen. Correlation or imaging\n of the chest may be warranted. No dilated small bowel loops are identified.\n\n IMPRESSION: No evidence for nasogastric tube. Chest X-ray may be warranted.\n\n These findings discussed with Dr. at 5 o'clock on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2100-08-16 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 924815,
"text": " 2:00 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please stroke protocol with perfusion and diffusion studies\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with R-MCA stroke; s/p IV tPA, question whether we'll do ia\n TPA in addition\n REASON FOR THIS EXAMINATION:\n please stroke protocol with perfusion and diffusion studies STAT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right MCA stroke, status post intravenous TPA.\n\n COMPARISON: MRI of the brain .\n\n TECHNIQUE: Multiplanar T1 and T2-weighted images of the brain were obtained\n without intravenous contrast along with diffusion-weighted images.\n\n MRI OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: Study is limited by patient\n motion. Abnormal diffusion signal within the right basal ganglia and\n posterior limb of the internal capsule with corresponding hypointensity on the\n ADC map is consistent with acute infarction in the distribution of the right\n lateral lenticulostriate arteries. No corresponding T2 signal abnormality is\n demonstrated within this region. There is no mass effect, shift of midline\n structures, or hydrocephalus. The sulci, ventricles, and basal cisterns\n appear unremarkable. No susceptibility artifact is present to indicate the\n presence of blood products. Loss of flow signal is demonstrated within the\n right M1 segment of the middle cerebral artery. Remaining portions of the\n major intracranial cerebral vessels demonstrate normal flow signal. The\n paranasal sinuses appear clear.\n\n IMPRESSION: Acute infarction involving the territory of the right lateral\n lenticulostriate arteries.\n\n MRA OF THE CIRCLE OF :\n\n TECHNIQUE: Three-dimensional time of flight imaging with multiplanar\n reformatted images.\n\n FINDINGS: There is absence of flow signal within the M1 segment of the right\n middle cerebral artery. There is restoration of flow signal within the M2\n segment of the right middle cerebral artery distally. Both intracranial\n internal carotid arteries, anterior cerebral arteries, anterior communicating\n artery, left middle cerebral artery, posterior cerebral arteries, basilar\n artery, and distal vertebral arteries demonstrate normal flow signal without\n significant stenoses or aneurysmal dilatation present. Within the limits of\n the study, no arteriovenous malformation is demonstrated.\n\n IMPRESSION: No flow signal demonstrated within the M1 segment of the right\n middle cerebral artery.\n DFDdp\n (Over)\n\n 2:00 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please stroke protocol with perfusion and diffusion studies\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
}
] |
80,024 | 129,024 | # Sepsis secondary to pyelonephritis secondary to obstructing left ureteral stone: UA was grossly positive and she received vancomycin, levofloxacin, piperacillin-tazobactam. CT scan showed a 6 x 9 x 12 mm obstructing proximal left ureteral stone, with moderate hydroureteronephrosis, peripheral wedge-shaped hypodensity along the lower pole is suggestive of focal pyelonephritis, and enhancement of the ureteral wall is compatible with infection. Urology was consulted and they recommended urostomy placement. The pt, however, declined all interventions, including central line placement and percutaneous nephrostomy tube. In discussions with ED staff and MICU staff, the patient explained that she understands that the ramifications of her declining additional care or intervention may lead to possible deterioration and death and states that she does not want anything else done. The HCP was and agreed with the patient's refusal of further intervention as consistent with her wishes prior to this hospitalization. Urine culture was positive for pansensitive Proteus, pt started on 14 day course TMP-SMX. For pain, pt started on phenazopyridine for dysuria, tylenol, and morphine. . # Afib RVR: Pt was given digoxin in MICU, metoprolol was increased to 12.5 tid. On the floor, however, digoxin was discontinued as rate was well controlled with metoprolol. Pt continued on home warfarin dose, and her INR was difficult to maintain at therapuetic level. On discharge, INR was 4.4. Pt will followup with nursing home care for monitoring of her INR. . # Acute renal failure: Cr 1.5 on admission likely prerenal vs secondary to pyelonephritis/post renal unilateral obstruction. Pt given IV fluids and lisinopril was discontinued initially. Pt renal funtion improved and pt restarted her lisinopril once blood pressure stabilized. Cr was 0.7 on discharge. . # Hypoxia: Pt was noted to have O2 sats in low 90s on room air which was stable for her. She was admitted and discharged without any external O2 requirement and should not require supplemental O2 unless she clinically deteriorates. . # DM: Pt was started on sliding scale insulin with minimal requirements during admission. Pt will followup with PCP monitoring of her diabetes. She is on no home meds for glycemic control. . # HTN/CAD: Pt continued on aspirin and atorvastatin, metoprolol was increased to 12.5 TID due to afib. Home lisinopril was initially discontinued due to acute renal failure, but was restarted once her Cr normalized and BP not hypotensive. Pt will follow up with PCP for monitoring of her hypertension and coronary artery disease. . # Psych: Pt was continued on home fluoxetine, mirtazapine, namenda, carbidopa/levodopa. Pt will follow up with her psychiatrist for treatment of her depression. . # FEN: Pt was resumed on her normal home diet early during admission but still had overall poor PO intake due to early satiety presumably from her ureteral pain. She was encouraged to continue PO intake and was given minimal fluid boluses prn if she became slightly hypotensive (SBP 100). Continued encouragement of liberal PO fluid and food intake will be important at her nursing home. . | In ED, patient was hypotensive. HPI: 83F with DM and atrial fibrillation, presented from NH with fever, leukocytosis, tachycardia and hypotension found to have ureteral stone with hydro, likely pyelo, declining invasive measures, now improved with abx and fluids. Renal failure, acute (Acute renal failure, ARF) Dx includeds obstruction vs hypoperfusion in the setting of sepsis (prerenal) or ATV vs renal infarction Assessment: Bun/Cr 38/1.4 (unclear of baseline) pt had foley in ED but self dc and refused another one. ECG: afib rvr 180s Assessment and Plan 84F with DM and atrial fibrillation who presents from NH with fever, leukocytosis, tachycardia and hypotension found to have ureteral stone but is declining invasive measures. ECG: afib rvr 180s Assessment and Plan 84F with DM and atrial fibrillation who presents from NH with fever, leukocytosis, tachycardia and hypotension found to have ureteral stone but is declining invasive measures. ECG: afib rvr 180s Assessment and Plan 84F with DM and atrial fibrillation who presents from NH with fever, leukocytosis, tachycardia and hypotension found to have ureteral stone but is declining invasive measures. ECG: afib rvr 180s Assessment and Plan 84F with DM and atrial fibrillation who presents from NH with fever, leukocytosis, tachycardia and hypotension found to have ureteral stone but is declining invasive measures. Patient declined central venous access. Patient declined central venous access. Patient declined central venous access. Patient declined central venous access. Review of sytems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Review of sytems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Review of sytems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Review of sytems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. - If stable blood pressure will consider nodal agents carefully - hold warfarin # Acute renal failure: Dx includes obstruction vs hypoperfusion in the setting of sepsis (pre renal) or even ATN vs renal infarction. - If stable blood pressure will consider nodal agents carefully - hold warfarin # Acute renal failure: Dx includes obstruction vs hypoperfusion in the setting of sepsis (pre renal) or even ATN vs renal infarction. - If stable blood pressure will consider nodal agents carefully - hold warfarin # Acute renal failure: Dx includes obstruction vs hypoperfusion in the setting of sepsis (pre renal) or even ATN vs renal infarction. HPI: 83F with DM and atrial fibrillation, presented from NH with fever, leukocytosis, tachycardia and hypotension found to have ureteral stone with hydro, likely pyelo, declining invasive measures, now improved with abx and fluids. Sepsis, Severe (with organ dysfunction) UTI/pyelo- R ureteral stone Assessment: T-max 98.4 abd soft distended + BS tenderness to palpation. Last Digoxin 0.25 rfecieved @0100 coumadin held for elevated INR Response: HR controlled Afib s/p lopressor. Last Digoxin 0.25 rfecieved @0100 coumadin held for elevated INR Response: HR controlled Afib s/p lopressor. ECG: afib rvr 180s Assessment and Plan 84F with DM and atrial fibrillation who presents from NH with fever, leukocytosis, tachycardia and hypotension found to have ureteral stone but is declining invasive measures. 4. few colonic diverticulae, w/o inflammatory change. 4. few colonic diverticulae, w/o inflammatory change. Review of sytems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Incont Urine Action: Cont abx Vancomycin d/c. Incont Urine Action: Cont abx Vancomycin d/c. Incont Urine Action: Cont abx Vancomycin d/c. Incont Urine Action: Cont abx Vancomycin d/c. Will hold pt home cardiac meds for now to hypotension. Will hold pt home cardiac meds for now to hypotension. received abx vancomycin/zosyn. received abx vancomycin/zosyn. received abx vancomycin/zosyn. received abx vancomycin/zosyn. 9:29 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: LLQ pain and shock, eval for free air. Renal failure, acute (Acute renal failure, ARF) Dx includeds obstruction vs hypoperfusion in the setting of sepsis (prerenal) or ATV vs renal infarction Assessment: Bun/Cr 38/1.4 (unclear of baseline). Renal failure, acute (Acute renal failure, ARF) Dx includeds obstruction vs hypoperfusion in the setting of sepsis (prerenal) or ATV vs renal infarction Assessment: Bun/Cr 38/1.4 (unclear of baseline). - If stable blood pressure will consider nodal agents carefully - hold warfarin # Acute renal failure: Dx includes obstruction vs hypoperfusion in the setting of sepsis (pre renal) or even ATN vs renal infarction. There is mild stranding surrounding (Over) 9:29 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: LLQ pain and shock, eval for free air. | 27 | [
{
"category": "Physician ",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 693159,
"text": "Chief Complaint:\n 24 Hour Events:\n - Started patient's home meds (aside from BB and Lisinopril)\n - Gave Tylenol for leg pain\n - Started digoxin (250 mcg x2)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 112 (100 - 152) bpm\n BP: 98/55(65) {61/39(47) - 112/81(91)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 7,740 mL\n 249 mL\n PO:\n 240 mL\n TF:\n IVF:\n 5,100 mL\n 249 mL\n Blood products:\n Total out:\n 100 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 7,640 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 126 K/uL\n 10.8 g/dL\n 87 mg/dL\n 1.3 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 114 mEq/L\n 140 mEq/L\n 33.7 %\n 11.8 K/uL\n [image002.jpg]\n 05:27 AM\n 03:44 AM\n WBC\n 11.0\n 11.8\n Hct\n 33.3\n 33.7\n Plt\n 122\n 126\n Cr\n 1.4\n 1.3\n Glucose\n 215\n 87\n Other labs: LDH:179 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 84F with DM and atrial fibrillation who presents from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n but is declining invasive measures.\n # Sepsis: Source is UTI/Pyelo compounded by obstructive stone. Pt\n decline aggressive care. HCP confirms. She aggrees with IVF and\n antibiotics. Urine culture this morning was positive for Proteus.\n - Continue Zosyn for day course and d/c Vanc today\n - F/U sensitivities for Ucx\n - Continue IVFs as needed\n - monitor respiratory status in response to IVF\n # A fib RVR: Started on dig but still RVR.\n - Continue to monitor on telemetry\n - Restart Metoprolol 12.5 mg daily\n - Continue Warfarin\n # Acute renal failure: Creatinine continues to improve. She is\n incontinent of urine, but continues to have UOP. DDx includes\n hypovolemia vs ATN.\n - IVF overnight\n - Continue to monitor cre, urine output\n # DM: stable\n - ISS\n # HTN\n - Hold home antihypertensives\n ICU Care\n Nutrition: Regular diet, IVFs as needed, replete electrolytes\n Glycemic Control:\n Lines:\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: Therapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: HCP: \n Code status: DNR / DNI\n Disposition: To floor\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 693161,
"text": "Chief Complaint:\n 24 Hour Events:\n - Started patient's home meds (aside from BB and Lisinopril)\n - Gave Tylenol for leg pain\n - Started digoxin (250 mcg x2)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 112 (100 - 152) bpm\n BP: 98/55(65) {61/39(47) - 112/81(91)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 7,740 mL\n 249 mL\n PO:\n 240 mL\n TF:\n IVF:\n 5,100 mL\n 249 mL\n Blood products:\n Total out:\n 100 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 7,640 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n General: Alert, oriented self place time, shivering, able to relate\n history without difficulty\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, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, tender to palpation on flanks, non-distended, bowel\n sounds present, no rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 126 K/uL\n 10.8 g/dL\n 87 mg/dL\n 1.3 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 114 mEq/L\n 140 mEq/L\n 33.7 %\n 11.8 K/uL\n [image002.jpg]\n 05:27 AM\n 03:44 AM\n WBC\n 11.0\n 11.8\n Hct\n 33.3\n 33.7\n Plt\n 122\n 126\n Cr\n 1.4\n 1.3\n Glucose\n 215\n 87\n Other labs: LDH:179 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 84F with DM and atrial fibrillation who presents from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n but is declining invasive measures.\n # Sepsis: Source is UTI/Pyelo compounded by obstructive stone. Pt\n decline aggressive care. HCP confirms. She aggrees with IVF and\n antibiotics. Urine culture this morning was positive for Proteus.\n - Continue Zosyn for day course and d/c Vanc today\n - F/U sensitivities for Ucx\n - Continue IVFs as needed\n - monitor respiratory status in response to IVF\n # A fib RVR: Started on dig but still RVR.\n - Continue to monitor on telemetry\n - Restart Metoprolol 12.5 mg daily\n - Continue Warfarin\n # Acute renal failure: Creatinine continues to improve. She is\n incontinent of urine, but continues to have UOP. DDx includes\n hypovolemia vs ATN.\n - IVF overnight\n - Continue to monitor cre, urine output\n # DM: stable\n - ISS\n # HTN\n - Hold home antihypertensives\n ICU Care\n Nutrition: Regular diet, IVFs as needed, replete electrolytes\n Glycemic Control:\n Lines:\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: Therapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: HCP: \n Code status: DNR / DNI\n Disposition: To floor\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 692818,
"text": "Chief Complaint: fevers\n HPI:\n This is a 83 year old female with DM, HTN, AFib presents with sudden\n onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM today\n when pt. was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2 Lt IVF and her blood pressure rose to 110s. UA\n was grossly positive and she received vanc/levo/ pip-tazo. She\n complained of abdominal pain and a abdominal CT was done showing\n obstructive stone in right ureter. Urology was consulted and they\n recomended urostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement, DCCV\n and usostomy tube placement. She apparently indicated that would\n perhaps reconsider urostomy in am. The ED team discussed with the\n patient's HCP who agrees with the patients decisions regarding her\n care. Prior to transfer to floor she pulled foley and decline\n replacement after repeated attempts.\n Prior to transfer her vitals were 99.7 179 130/80 23 95RA 4Lt\n .\n On the floor, she feels tired. She still decline central venous acces\n or urostomy tube placement. She understands the risk of death from\n infection or her afib and states \"I have lived a long and comfortable\n life, if my time has come let it be\".\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness. Denied\n nausea, vomiting, diarrhea, constipation. No recent change in bowel or\n bladder habits. No dysuria. Denied arthralgias or myalgias.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa 81\n lisinopril 2.5\n metoprolol 12.5\n warfarin 1.5\n prozac 20\n docusate 100\n namenda 10\n carvodopa-levidopa 25-100 TID\n lipitor 20\n Mirtazapin 30\n Past medical history:\n Family history:\n Social History:\n DM\n Atrial fibrillation\n hypercholesterolemia\n hypertension\n arthritis\n depression\n ? CAD, NSTEMI-pt denied, recorded in EMS note\n ? CM 30%-pt denied, recorded in EMS note\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Nursing home resident. No smoke, etoh, drugs.\n Review of systems:\n Flowsheet Data as of 02:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\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 Physical Examination\n General: Alert, oriented self place time, shivering, able to relate\n history without difficulty\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, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, tender to palpation on flanks, non-distended, bowel\n sounds present, no rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n CBC 11.8>37<163 N91 B3\n Chem 137/5.1/108/18/43/1.5<208 gap=11 Cr was 0.8 \n ALT 11, AST 39, ALKp 87, Tbil 0.7, Lip 15\n CK 38 Tropn 0.04\n Lactate 2.7\n INR 2.0, PTT 29.6\n UA 1.023 7.0 lg bld, mod leuk, 100 prot, 15 ket, 21-50 rbc, >50 wbc,\n many bacteria, 0-2 epis\n Micro:\n urine culture pending\n Images:\n CXR: no acute process\n CT abd/pelvis:\n 1. 6 x 9 x 12 mm prox Rt ureteral stone causes mod hydro, with\n hypoperfusion of left kidney, surrounding stranding, and 1cm peripheral\n wedge shaped hypodensity in lower pole of right kidney which could\n indicate infection or infarction.\n 2. trace fluid along inferior tip of liver.\n 3. gallbladder not well seen d/t motion.\n 4. few colonic diverticulae, w/o inflammatory change.\n 5. atherosclerotic disease.\n 6. RML nodule.\n ECG: afib rvr 180s\n Assessment and Plan\n 84F with DM and atrial fibrillation who presents from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n but is declining invasive measures.\n # Sepsis: Source is UTI/Pyelo compounded by obstructive stone. Patient\n declined central venous access. D/W attending and with patient, and pt\n is aware of the consequences of declining care including death. She\n aggrees with IVF and antibiotics at this time and will consider CMO\n option in am.\n - vanc, pip-tazo, levo\n - bcx ucx\n - ivf\n - monitor respiratory status in response to IVF\n # A fib RVR: Given sepsis and severe hypotension on presentation\n controlling ventricular rate with nodal blockers becomes problem.\n declined cardioversion and she again she was aware of the\n possibility of death.\n - Will montitor for now.\n - If stable blood pressure will consider nodal agents carefully\n - hold warfarin\n # Acute renal failure: Dx includes obstruction vs hypoperfusion in the\n setting of sepsis (pre renal) or even ATN vs renal infarction.\n - IVF overnight\n - pt pulled foley\n - Monitor cre, urine output\n # DM: stable\n - ISS\n # HTN\n - Hold home antihypertensives\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: therapeutic inr\n Access: peripherals 18, 20\n Code: DNR DNI\n Communication: Patient, HCP: \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 692822,
"text": "Chief Complaint: fevers\n HPI:\n This is a 83 year old female with DM, HTN, AFib presents with sudden\n onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM today\n when pt. was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2 Lt IVF and her blood pressure rose to 110s. UA\n was grossly positive and she received vanc/levo/ pip-tazo. She\n complained of abdominal pain and a abdominal CT was done showing\n obstructive stone in right ureter. Urology was consulted and they\n recomended urostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement, DCCV\n and usostomy tube placement. She apparently indicated that would\n perhaps reconsider urostomy in am. The ED team discussed with the\n patient's HCP who agrees with the patients decisions regarding her\n care. Prior to transfer to floor she pulled foley and decline\n replacement after repeated attempts.\n Prior to transfer her vitals were 99.7 179 130/80 23 95RA 4Lt\n .\n On the floor, she feels tired. She still decline central venous acces\n or urostomy tube placement. She understands the risk of death from\n infection or her afib and states \"I have lived a long and comfortable\n life, if my time has come let it be\".\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness. Denied\n nausea, vomiting, diarrhea, constipation. No recent change in bowel or\n bladder habits. No dysuria. Denied arthralgias or myalgias.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa 81\n lisinopril 2.5\n metoprolol 12.5\n warfarin 1.5\n prozac 20\n docusate 100\n namenda 10\n carvodopa-levidopa 25-100 TID\n lipitor 20\n Mirtazapin 30\n Past medical history:\n Family history:\n Social History:\n DM\n Atrial fibrillation\n hypercholesterolemia\n hypertension\n arthritis\n depression\n ? CAD, NSTEMI-pt denied, recorded in EMS note\n ? CM 30%-pt denied, recorded in EMS note\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Nursing home resident. No smoke, etoh, drugs.\n Review of systems:\n Flowsheet Data as of 02:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n 98 75/40, 160, 25, 94% 5LT\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 Physical Examination\n General: Alert, oriented self place time, shivering, able to relate\n history without difficulty\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, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, tender to palpation on flanks, non-distended, bowel\n sounds present, no rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n CBC 11.8>37<163 N91 B3\n Chem 137/5.1/108/18/43/1.5<208 gap=11 Cr was 0.8 \n ALT 11, AST 39, ALKp 87, Tbil 0.7, Lip 15\n CK 38 Tropn 0.04\n Lactate 2.7\n INR 2.0, PTT 29.6\n UA 1.023 7.0 lg bld, mod leuk, 100 prot, 15 ket, 21-50 rbc, >50 wbc,\n many bacteria, 0-2 epis\n Micro:\n urine culture pending\n Images:\n CXR: no acute process\n CT abd/pelvis:\n 1. 6 x 9 x 12 mm prox Rt ureteral stone causes mod hydro, with\n hypoperfusion of left kidney, surrounding stranding, and 1cm peripheral\n wedge shaped hypodensity in lower pole of right kidney which could\n indicate infection or infarction.\n 2. trace fluid along inferior tip of liver.\n 3. gallbladder not well seen d/t motion.\n 4. few colonic diverticulae, w/o inflammatory change.\n 5. atherosclerotic disease.\n 6. RML nodule.\n ECG: afib rvr 180s\n Assessment and Plan\n 84F with DM and atrial fibrillation who presents from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n but is declining invasive measures.\n # Sepsis: Source is UTI/Pyelo compounded by obstructive stone. Unlikely\n cardiac shock. No evidence of bleed. Patient declined central venous\n access. D/W attending and with patient, and pt is aware of the\n consequences of declining care including death. She aggrees with IVF\n and antibiotics at this time and will consider CMO option in am.\n - vanc, pip-tazo\n - bcx ucx\n - ivf\n - monitor respiratory status in response to IVF\n # A fib RVR: Given sepsis and severe hypotension on presentation\n controlling ventricular rate with nodal blockers becomes problem.\n declined cardioversion and she again she was aware of the\n possibility of death.\n - Will montitor for now.\n - If stable blood pressure will consider nodal agents carefully\n - hold warfarin\n # Acute renal failure: Dx includes obstruction vs hypoperfusion in the\n setting of sepsis (pre renal) or even ATN vs renal infarction.\n - IVF overnight\n - pt pulled foley\n - Monitor cre, urine output\n # DM: stable\n - ISS\n # HTN\n - Hold home antihypertensives\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: therapeutic inr\n Access: peripherals 18, 20\n Code: DNR DNI\n Communication: Patient, HCP: \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 692823,
"text": "Chief Complaint: fevers\n HPI:\n This is a 83 year old female with DM, HTN, AFib presents with sudden\n onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM today\n when pt. was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2 Lt IVF and her blood pressure rose to 110s. UA\n was grossly positive and she received vanc/levo/ pip-tazo. She\n complained of abdominal pain and a abdominal CT was done showing\n obstructive stone in right ureter. Urology was consulted and they\n recomended urostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement, DCCV\n and usostomy tube placement. She apparently indicated that would\n perhaps reconsider urostomy in am. The ED team discussed with the\n patient's HCP who agrees with the patients decisions regarding her\n care. Prior to transfer to floor she pulled foley and decline\n replacement after repeated attempts.\n Prior to transfer her vitals were 99.7 179 130/80 23 95RA 4Lt\n .\n On the floor, she feels tired. She still decline central venous acces\n or urostomy tube placement. She understands the risk of death from\n infection or her afib and states \"I have lived a long and comfortable\n life, if my time has come let it be\".\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness. Denied\n nausea, vomiting, diarrhea, constipation. No recent change in bowel or\n bladder habits. No dysuria. Denied arthralgias or myalgias.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa 81\n lisinopril 2.5\n metoprolol 12.5\n warfarin 1.5\n prozac 20\n docusate 100\n namenda 10\n carvodopa-levidopa 25-100 TID\n lipitor 20\n Mirtazapin 30\n Past medical history:\n Family history:\n Social History:\n DM\n Atrial fibrillation\n hypercholesterolemia\n hypertension\n arthritis\n depression\n CAD, NSTEMI\n CM 30%\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Nursing home resident. No smoke, etoh, drugs.\n Review of systems:\n Flowsheet Data as of 02:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n 98 75/40, 160, 25, 94% 5LT\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 Physical Examination\n General: Alert, oriented self place time, shivering, able to relate\n history without difficulty\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, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, tender to palpation on flanks, non-distended, bowel\n sounds present, no rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n CBC 11.8>37<163 N91 B3\n Chem 137/5.1/108/18/43/1.5<208 gap=11 Cr was 0.8 \n ALT 11, AST 39, ALKp 87, Tbil 0.7, Lip 15\n CK 38 Tropn 0.04\n Lactate 2.7\n INR 2.0, PTT 29.6\n UA 1.023 7.0 lg bld, mod leuk, 100 prot, 15 ket, 21-50 rbc, >50 wbc,\n many bacteria, 0-2 epis\n Micro:\n urine culture pending\n Images:\n CXR: no acute process\n CT abd/pelvis:\n 1. 6 x 9 x 12 mm prox Rt ureteral stone causes mod hydro, with\n hypoperfusion of left kidney, surrounding stranding, and 1cm peripheral\n wedge shaped hypodensity in lower pole of right kidney which could\n indicate infection or infarction.\n 2. trace fluid along inferior tip of liver.\n 3. gallbladder not well seen d/t motion.\n 4. few colonic diverticulae, w/o inflammatory change.\n 5. atherosclerotic disease.\n 6. RML nodule.\n ECG: afib rvr 180s\n Assessment and Plan\n 84F with DM and atrial fibrillation who presents from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n but is declining invasive measures.\n # Sepsis: Source is UTI/Pyelo compounded by obstructive stone. Unlikely\n cardiac shock. No evidence of bleed. Patient declined central venous\n access. D/W attending and with patient, and pt is aware of the\n consequences of declining care including death. She aggrees with IVF\n and antibiotics at this time and will consider CMO option in am.\n - vanc, pip-tazo\n - bcx ucx\n - ivf\n - monitor respiratory status in response to IVF\n # A fib RVR: Given sepsis and severe hypotension on presentation\n controlling ventricular rate with nodal blockers becomes problem.\n declined cardioversion and she again she was aware of the\n possibility of death.\n - Will montitor for now.\n - If stable blood pressure will consider nodal agents carefully\n - hold warfarin\n # Acute renal failure: Dx includes obstruction vs hypoperfusion in the\n setting of sepsis (pre renal) or even ATN vs renal infarction.\n - IVF overnight\n - pt pulled foley\n - Monitor cre, urine output\n # DM: stable\n - ISS\n # HTN\n - Hold home antihypertensives\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: therapeutic inr\n Access: peripherals 18, 20\n Code: DNR DNI\n Communication: Patient, HCP: \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 693170,
"text": "Chief Complaint: pyelo\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 83F with DM and atrial fibrillation, presented from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n with hydro, likely pyelo, declining invasive measures, now improved\n with abx and fluids.\n 24 Hour Events:\n -dig loaded, hr down\n -bp up and stable\n -cr improved\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:03 AM\n Other medications:\n s/p dig, vanco, mirtazipine, arorvastatin, carbidopa-levodopa, namenda,\n docusate, fluoxetine, asa, warfarin, zosyn, s/p 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 Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.6\nC (97.9\n HR: 110 (100 - 152) bpm\n BP: 107/64(70) {62/42(47) - 118/81(89)} mmHg\n RR: 16 (12 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 7,740 mL\n 432 mL\n PO:\n 240 mL\n 150 mL\n TF:\n IVF:\n 5,100 mL\n 282 mL\n Blood products:\n Total out:\n 100 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 7,640 mL\n 432 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: No(t) PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Tender: mildly throughout\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed, Completely oriented\n Labs / Radiology\n 10.8 g/dL\n 126 K/uL\n 87 mg/dL\n 1.3 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 114 mEq/L\n 140 mEq/L\n 33.7 %\n 11.8 K/uL\n [image002.jpg]\n 05:27 AM\n 03:44 AM\n WBC\n 11.0\n 11.8\n Hct\n 33.3\n 33.7\n Plt\n 122\n 126\n Cr\n 1.4\n 1.3\n Glucose\n 215\n 87\n Other labs: LDH:179 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Imaging: no new\n Microbiology: ucx: proteus >100K\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 83F with DM and atrial fibrillation, presented from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n with hydro, likely pyelo, declining invasive measures, now improved\n with abx and fluids. Better rate control now with initiation of\n digoxin, and BP is now improved and stable to restart home beta blocker\n at low dose. Should be able to stop digoxin. Given positive urine\n culture will narrow abx, awaiting final sensitivies tomorrow. Improved\n Cr is reassuring. Will discuss with urology other management options\n for the kidney stone given decline of all invasive procedures.\n ICU Care\n Nutrition: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 692816,
"text": "Chief Complaint: Hypotension, tachycadia, acute renal failure,\n pyelonephritis\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 Elderly woman who resides in a nursing home. Came to ED today after\n being found to have fever, tachycardia at the nursing home. In ED,\n patient was hypotensive. Was given 2L of IV fluids with improvement in\n BP to 110 systolic, but remains tachycardic.\n CT scan obtained and patient found to have obstruction of right kidney\n with hypoperfusion of left kidney. Patient was offered a nephrostomy\n tube, which she refused. She also refused a central line placement.\n I spoke with her in the ED. I explained that she might die tonight\n without the interventions described above. She indicated that she had\n \"lived a long life and didn't want any pain.\" The healthcare\n proxy was called by the staff; she indicated that she thought this\n was consistent with the patient's previously expressed sentiments. The\n patient has no family or friends whom she wanted us to call.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hypertension\n DM\n Afib\n Not contributory\n Occupation: Book-keeper\n Drugs:\n Tobacco: Distant hx\n Alcohol:\n Other: Never married. Youngest of 10 children.\n Review of systems:\n Flowsheet Data as of 01:08 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n 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 ABG: ////\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic, Thirsty\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal tube, No(t)\n NG tube, No(t) OG tube\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: 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),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , Bronchial: At left\n base, No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n 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 edema, Left lower\n extremity edema: Absent, 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, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology: CXR\n no infiltrates or effusions. Normal size heart.\n 163\n 37.0\n 208\n 1.5\n 43\n 18\n 108\n 5.1\n 137\n 11.8\n [image002.jpg]\n Assessment and Plan\n HYPOTENSION\n ACUTE RENAL FAILURE\n HYDRONEPRHOSIS\n AFIB/TACHYCARDIA\n =====================\n Patient with probable hypotension from severe infection due to\n obstruction of right kidney. No evidence of GI bleeding or heart\n failure. She is receiving antibiotics and fluids via peripheral IV's.\n She does not want nephrostomy tube or central line at this time. She\n understands that she may die tonight without more aggressive\n interventions. She is not in pain and denies dyspnea at this time. She\n continues to look volume depleted by physical exam. Will support with\n IV fluids. Will not give vasopressors without central line.\n Renal failure likely combination of obstruction and volume depletion.\n Fluids as above.\n Tachycardia probably related to ongoing stress from fever and\n hypovolemia. No evidence of CHF now. Will give fluids as above.\n Consider calcium blocker or beta blocker if persistent tachycardia\n despite fluids and control of fever.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: Not indicated\n VAP:\n Comments: Not applicable\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 692819,
"text": "Chief Complaint: fevers\n HPI:\n This is a 83 year old female with DM, HTN, AFib presents with sudden\n onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM today\n when pt. was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2 Lt IVF and her blood pressure rose to 110s. UA\n was grossly positive and she received vanc/levo/ pip-tazo. She\n complained of abdominal pain and a abdominal CT was done showing\n obstructive stone in right ureter. Urology was consulted and they\n recomended urostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement, DCCV\n and usostomy tube placement. She apparently indicated that would\n perhaps reconsider urostomy in am. The ED team discussed with the\n patient's HCP who agrees with the patients decisions regarding her\n care. Prior to transfer to floor she pulled foley and decline\n replacement after repeated attempts.\n Prior to transfer her vitals were 99.7 179 130/80 23 95RA 4Lt\n .\n On the floor, she feels tired. She still decline central venous acces\n or urostomy tube placement. She understands the risk of death from\n infection or her afib and states \"I have lived a long and comfortable\n life, if my time has come let it be\".\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness. Denied\n nausea, vomiting, diarrhea, constipation. No recent change in bowel or\n bladder habits. No dysuria. Denied arthralgias or myalgias.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa 81\n lisinopril 2.5\n metoprolol 12.5\n warfarin 1.5\n prozac 20\n docusate 100\n namenda 10\n carvodopa-levidopa 25-100 TID\n lipitor 20\n Mirtazapin 30\n Past medical history:\n Family history:\n Social History:\n DM\n Atrial fibrillation\n hypercholesterolemia\n hypertension\n arthritis\n depression\n ? CAD, NSTEMI-pt denied, recorded in EMS note\n ? CM 30%-pt denied, recorded in EMS note\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Nursing home resident. No smoke, etoh, drugs.\n Review of systems:\n Flowsheet Data as of 02:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\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 Physical Examination\n General: Alert, oriented self place time, shivering, able to relate\n history without difficulty\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, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, tender to palpation on flanks, non-distended, bowel\n sounds present, no rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n CBC 11.8>37<163 N91 B3\n Chem 137/5.1/108/18/43/1.5<208 gap=11 Cr was 0.8 \n ALT 11, AST 39, ALKp 87, Tbil 0.7, Lip 15\n CK 38 Tropn 0.04\n Lactate 2.7\n INR 2.0, PTT 29.6\n UA 1.023 7.0 lg bld, mod leuk, 100 prot, 15 ket, 21-50 rbc, >50 wbc,\n many bacteria, 0-2 epis\n Micro:\n urine culture pending\n Images:\n CXR: no acute process\n CT abd/pelvis:\n 1. 6 x 9 x 12 mm prox Rt ureteral stone causes mod hydro, with\n hypoperfusion of left kidney, surrounding stranding, and 1cm peripheral\n wedge shaped hypodensity in lower pole of right kidney which could\n indicate infection or infarction.\n 2. trace fluid along inferior tip of liver.\n 3. gallbladder not well seen d/t motion.\n 4. few colonic diverticulae, w/o inflammatory change.\n 5. atherosclerotic disease.\n 6. RML nodule.\n ECG: afib rvr 180s\n Assessment and Plan\n 84F with DM and atrial fibrillation who presents from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n but is declining invasive measures.\n # Sepsis: Source is UTI/Pyelo compounded by obstructive stone. Unlikely\n cardiac shock. No evidence of bleed. Patient declined central venous\n access. D/W attending and with patient, and pt is aware of the\n consequences of declining care including death. She aggrees with IVF\n and antibiotics at this time and will consider CMO option in am.\n - vanc, pip-tazo\n - bcx ucx\n - ivf\n - monitor respiratory status in response to IVF\n # A fib RVR: Given sepsis and severe hypotension on presentation\n controlling ventricular rate with nodal blockers becomes problem.\n declined cardioversion and she again she was aware of the\n possibility of death.\n - Will montitor for now.\n - If stable blood pressure will consider nodal agents carefully\n - hold warfarin\n # Acute renal failure: Dx includes obstruction vs hypoperfusion in the\n setting of sepsis (pre renal) or even ATN vs renal infarction.\n - IVF overnight\n - pt pulled foley\n - Monitor cre, urine output\n # DM: stable\n - ISS\n # HTN\n - Hold home antihypertensives\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: therapeutic inr\n Access: peripherals 18, 20\n Code: DNR DNI\n Communication: Patient, HCP: \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 693110,
"text": "Chief Complaint:\n 24 Hour Events:\n - Started patient's home meds (aside from BB and Lisinopril)\n - Gave Tylenol for leg pain\n - digoxin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 112 (100 - 152) bpm\n BP: 98/55(65) {61/39(47) - 112/81(91)} mmHg\n RR: 19 (12 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 7,740 mL\n 249 mL\n PO:\n 240 mL\n TF:\n IVF:\n 5,100 mL\n 249 mL\n Blood products:\n Total out:\n 100 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 7,640 mL\n 249 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 126 K/uL\n 10.8 g/dL\n 87 mg/dL\n 1.3 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 114 mEq/L\n 140 mEq/L\n 33.7 %\n 11.8 K/uL\n [image002.jpg]\n 05:27 AM\n 03:44 AM\n WBC\n 11.0\n 11.8\n Hct\n 33.3\n 33.7\n Plt\n 122\n 126\n Cr\n 1.4\n 1.3\n Glucose\n 215\n 87\n Other labs: LDH:179 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 84F with DM and atrial fibrillation who presents from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n but is declining invasive measures.\n # Sepsis: Source is UTI/Pyelo compounded by obstructive stone. Pt\n decline aggressive care. HCP confirms. She aggrees with IVF and\n antibiotics.\n - vanc, pip-tazo\n - bcx NGTD ucx + proteus\n - ivf\n - monitor respiratory status in response to IVF\n # A fib RVR: Started on dig but still RVR.\n - Will montitor for now.\n - If stable blood pressure will consider nodal agents carefully\n - hold warfarin\n # Acute renal failure: Improving. Hypovolemia vs ATN.\n - IVF overnight\n - pt pulled foley\n - Monitor cre, urine output\n # DM: stable\n - ISS\n # HTN\n - Hold home antihypertensives\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: therapeutic inr\n Access: peripherals 18, 20\n Code: Full (discussed with patient)\n Communication: Patient, HCP: \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 693065,
"text": "This is an 83 year old female with DM, HTN, AFib who presents with\n sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n Rapid afib with HR 110s-160\ns BP range 74-112/40\ns-60\n Asymptomatic with this HR and BP. Denies any chest pain, dizziness or\n SOB.\n Action:\n Pt given digoxin x2 for rapid afib.\n Response:\n Heart rate came down to the low 100\ns and bp stayed > 100 sys, no\n cardiac related symptoms, mentating appropriately.\n Plan:\n Cont to monitor, pt is a DNR/DNI and refusing most interventions.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt with UTI/pyelo compounded by obstructive stone in ureter seen on\n CT. HR and BP as above. Afebrile. Pt is slightly tremulous but on\n sinemet at NH and likely parkinsons history. Temp max 99.9 rectally,\n Action:\n Pt in need of perc nephrostomy but refusing this procedure. Pt\n understands the severity of the situation. No iv fluid tonight, Vanco\n and Zosyn IV,\n Response:\n Pt incontinent of mod to lrg amt\n of amber colored urine in the diaper.\n Plan:\n Cont to monitor, No further intervention at this time.\n Renal failure, acute (Acute renal failure, ARF) Dx includeds\n obstruction vs hypoperfusion in the setting of sepsis (prerenal) or ATV\n vs renal infarction\n Assessment:\n Cont with mod to lrg amt of amber colored urine.\n Action:\n No extra fluid, able to take sips of water with meds.\n Response:\n On-going\n Plan:\n Monitor labs. Urine output.\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 693222,
"text": "This is an 83 year old female with Parkinsions, DM, HTN, AFib who\n presents with sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n HR 100-130 Afib controlled. NBP 90-120/40-60. MAPS>60, Denies CP SOB\n palpitations. O2 3l/min NC Sats 98-100% Lungs clear. Coumadin Held\n INR 6.0 @ 1545 episode rapid Afib>150 BP 98/ pt c/o feeling tired no\n c/o palpation. received Lopressor 5mg IVP with responding HR 85-110\n controlled afib.\n Action:\n Lopressor 5mg IVP for rapid Afib, started metoprolol . Last\n Digoxin 0.25 rfecieved @0100 coumadin held for elevated INR\n Response:\n HR controlled Afib s/p lopressor. Hymodynamically stable.\n Plan:\n Cont to monitor, pt is a DNR/DNI and refusing most interventions.\n Continue to monitor on telemetry\n Restart Metoprolol 12.5 mg daily\n Continue Warfarin monitor INR for therapeudic range\n Sepsis, Severe (with organ dysfunction) UTI/pyelo- R ureteral stone\n Assessment:\n T-max 98.4 abd soft distended + BS tenderness to palpation. c/o lower\n abd pain intermittent when urinates. Received Tylenol 650 x1.\n received abx vancomycin/zosyn. IV access 2PIV NS KVO received FB 250\n for SBP<100. Awake alert oriented x3 follows commands MAE random LE\n weak. Appetite poor pt stats no hungry. Incont Urine\n Action:\n Cont abx Vancomycin d/c. afebrile WBC 11.8.\n Response:\n Voiding Diaper mod\nlg amts amber. Cont to have pain upon urination\n Source is UTI/Pyelo compounded by obstructive stone. Pt decline\n aggressive care. HCP confirms. She aggrees with IVF and antibiotics.\n Urine culture this morning was positive for Proteus.\n Creatinine continues to improve\n Plan:\n Continue Zosyn for day course\n F/U sensitivities for Ucx\n Continue IVFs as needed\n monitor respiratory status in response to IVF\n Continue to monitor cre, urine output\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 692880,
"text": "This is a 83 year old female with DM, HTN, AFib presents with sudden\n onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM today\n when pt. was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2 Lt IVF and her blood pressure rose to 110s. UA\n was grossly positive and she received vanc/levo/ pip-tazo. She\n complained of abdominal pain and a abdominal CT was done showing\n obstructive stone in right ureter. Urology was consulted and they\n recommended urostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement, DCCV\n and urostomy tube placement. She apparently indicated that she would\n perhaps reconsider urostomy in am. The ED team discussed with the\n patient's HCP who agrees with the patients decisions regarding her\n care. Prior to transfer to floor she pulled foley and declined\n replacement after repeated attempts.\n Prior to transfer her vitals were 99.7 179 130/80 23 95 %RA 4Lt\n .\n On the floor, she feels tired. She is still declining central venous\n access or urostomy tube placement. She understands the risk of death\n from infection or her afib and states \"I have lived a long and\n comfortable life, if my time has come let it be\".\n Atrial fibrillation (Afib)\n Assessment:\n Rapid afib with HR 150\ns-200 with pvc\ns. BP range 60-127/40\ns-60\n Asymptomatic with this HR and BP. Denies any chest pain or cardiac\n related symptoms.\n Action:\n Cont to monitor heart rhythm and VS.\n Response:\n No cardiac related symptoms.\n Plan:\n Cont to monitor and to address intervention if clinical status changes\n and/or if pt will allow.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt with UTI/pyelo compounded by obstructive stone. HR and BP as\n above. Afebrile here. Pt is slightly tremulous; however, resident\n unclear as to whether this is not from ? of parkinsons.\n Action:\n Pt in need of emergent perc nephrostomy but refusing this procedure and\n seems that pt understands the gravity of the situation. Fluid bolused\n 6L thus far.\n Response:\n Responds to the fluid with increase in bp but then trends down again.\n 6^th liter infusing now. Remains tachy and with labile BP but no\n further intervention at this time.\n Plan:\n Cont to monitor, support with fluid. No further intervention at this\n time.\n Renal failure, acute (Acute renal failure, ARF) Dx includeds\n obstruction vs hypoperfusion in the setting of sepsis (prerenal) or ATV\n vs renal infarction\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 692884,
"text": "This is a 83 year old female with DM, HTN, AFib presents with sudden\n onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM today\n when pt. was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2 Lt IVF and her blood pressure rose to 110s. UA\n was grossly positive and she received vanc/levo/ pip-tazo. She\n complained of abdominal pain and a abdominal CT was done showing\n obstructive stone in right ureter. Urology was consulted and they\n recommended urostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement, DCCV\n and urostomy tube placement. She apparently indicated that she would\n perhaps reconsider urostomy in am. The ED team discussed with the\n patient's HCP who agrees with the patients decisions regarding her\n care. Prior to transfer to floor she pulled foley and declined\n replacement after repeated attempts.\n Prior to transfer her vitals were 99.7 179 130/80 23 95 %RA 4Lt\n .\n On the floor, she feels tired. She is still declining central venous\n access or urostomy tube placement. She understands the risk of death\n from infection or her afib and states \"I have lived a long and\n comfortable life, if my time has come let it be\".\n Atrial fibrillation (Afib)\n Assessment:\n Rapid afib with HR 150\ns-200 with pvc\ns. BP range 60-127/40\ns-60\n Asymptomatic with this HR and BP. Denies any chest pain or cardiac\n related symptoms.\n Action:\n Cont to monitor heart rhythm and VS.\n Response:\n No cardiac related symptoms.\n Plan:\n Cont to monitor and to address intervention if clinical status changes\n and/or if pt will allow.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt with UTI/pyelo compounded by obstructive stone. HR and BP as\n above. Afebrile here. Pt is slightly tremulous; however, resident\n unclear as to whether this is not from ? of parkinsons.\n Action:\n Pt in need of emergent perc nephrostomy but refusing this procedure and\n seems that pt understands the gravity of the situation. Fluid bolused\n 6L thus far.\n Response:\n Responds to the fluid with increase in bp but then trends down again.\n 6^th liter infusing now. Remains tachy and with labile BP but no\n further intervention at this time.\n Plan:\n Cont to monitor, support with fluid. No further intervention at this\n time.\n Renal failure, acute (Acute renal failure, ARF) Dx includeds\n obstruction vs hypoperfusion in the setting of sepsis (prerenal) or ATV\n vs renal infarction\n Assessment:\n Bun/Cr 38/1.4 (unclear of baseline) pt had foley in ED but self dc\n and refused another one. Prior to pulling out pt had approx 100cc of\n muddy urine. Since admit to MICU 1a-7a pt has only been incontinence x\n 1 for small to med amt urine (approx 75cc)\n Action:\n Ivf-bolused with 6l thus far.\n Response:\n On-going\n Plan:\n Monitor labs. Urine output.\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 692986,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 692993,
"text": "This is an 83 year old female with DM, HTN, AFib who presents with\n sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n Rapid afib with HR 110s-140s. BP range 60-112/40\ns-60\ns. Asymptomatic\n with this HR and BP. Denies any chest pain, dizziness or SOB.\n Action:\n Vitals checked, pt given total of 1500cc NS in divided boluses\n throughout shift. Restarted on home dose coumadin. Will hold pt\n home cardiac meds for now to hypotension.\n Response:\n No cardiac related symptoms, mentating appropriately.\n Plan:\n Cont to monitor, pt is a DNR/DNI and refusing most interventions.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt with UTI/pyelo compounded by obstructive stone in ureter seen on\n CT. HR and BP as above. Afebrile. Pt is slightly tremulous but on\n sinemet at NH and likely parkinsons history.\n Action:\n Pt in need of perc nephrostomy but refusing this procedure. Pt\n understands the severity of the situation. Fluid bolused 1.5L this\n shift. Vanco and Zosyn IV.\n Response:\n Minimally responds to the fluid with increase in bp but then trends\n down again. Remains tachy and with labile BP.\n Plan:\n Cont to monitor, support with fluid. No further intervention at this\n time.\n Renal failure, acute (Acute renal failure, ARF) Dx includeds\n obstruction vs hypoperfusion in the setting of sepsis (prerenal) or ATV\n vs renal infarction\n Assessment:\n Bun/Cr 38/1.4 (unclear of baseline). Pt with brief incontinent of\n small to medium amounts of dark urine.\n Action:\n Fluid boluses as noted above, labs monitored.\n Response:\n On-going\n Plan:\n Monitor labs. Urine output.\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 693224,
"text": "This is an 83 year old female with Parkinsions, DM, HTN, AFib who\n presents with sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n HR 100-130 Afib controlled. NBP 90-120/40-60. MAPS>60, Denies CP SOB\n palpitations. O2 3l/min NC Sats 98-100% Lungs clear. Coumadin Held\n INR 6.0 @ 1545 episode rapid Afib>150 BP 98/ pt c/o feeling tired no\n c/o palpation. received Lopressor 5mg IVP with responding HR 85-110\n controlled afib.\n Action:\n Lopressor 5mg IVP for rapid Afib, started metoprolol . Last\n Digoxin 0.25 rfecieved @0100 coumadin held for elevated INR\n Response:\n HR controlled Afib s/p lopressor. Hymodynamically stable.\n Plan:\n Cont to monitor, pt is a DNR/DNI and refusing most interventions.\n Continue to monitor on telemetry\n Restart Metoprolol 12.5 mg daily\n Continue Warfarin monitor INR for therapeudic range\n Sepsis, Severe (with organ dysfunction) UTI/pyelo- R ureteral stone\n Assessment:\n T-max 98.4 abd soft distended + BS tenderness to palpation. c/o lower\n abd pain intermittent when urinates. Received Tylenol 650 x1.\n received abx vancomycin/zosyn. IV access 2PIV NS KVO received FB 250\n for SBP<100. Awake alert oriented x3 follows commands MAE random LE\n weak. Appetite poor pt stats no hungry. Incont Urine\n Action:\n Cont abx Vancomycin d/c. afebrile WBC 11.8.\n Response:\n Voiding Diaper mod\nlg amts amber. Cont to have pain upon urination\n Source is UTI/Pyelo compounded by obstructive stone. Pt decline\n aggressive care. HCP confirms. She aggrees with IVF and antibiotics.\n Urine culture this morning was positive for Proteus.\n Creatinine continues to improve\n Plan:\n Continue Zosyn for day course\n F/U sensitivities for Ucx\n Continue IVFs as needed\n monitor respiratory status in response to IVF\n Continue to monitor cre, urine output\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n FEVER\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 59.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Arrhythmias, CAD, Hypertension\n Additional history: DM, afib, hyperchol, htn, arthritis, depression,\n CAD, NSTEMI, CM 30%.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:96\n D:60\n Temperature:\n 98.5\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 Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,098 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 03:44 AM\n Potassium:\n 4.3 mEq/L\n 03:44 AM\n Chloride:\n 114 mEq/L\n 03:44 AM\n CO2:\n 18 mEq/L\n 03:44 AM\n BUN:\n 33 mg/dL\n 03:44 AM\n Creatinine:\n 1.3 mg/dL\n 03:44 AM\n Glucose:\n 87 mg/dL\n 03:44 AM\n Hematocrit:\n 33.7 %\n 03:44 AM\n Finger Stick Glucose:\n 139\n 06:00 PM\n Valuables / Signature\n Patient valuables: n/a\n Other valuables:\n Clothes: Sent home with: none\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: n/a\n Transferred from: MICU7\n Transferred to: CC715\n Date & time of Transfer: 1900\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 693225,
"text": "This is an 83 year old female with Parkinsions, DM, HTN, AFib who\n presents with sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n HR 100-130 Afib controlled. NBP 90-120/40-60. MAPS>60, Denies CP SOB\n palpitations. O2 3l/min NC Sats 98-100% Lungs clear. Coumadin Held\n INR 6.0 @ 1545 episode rapid Afib>150 BP 98/ pt c/o feeling tired no\n c/o palpation. received Lopressor 5mg IVP with responding HR 85-110\n controlled afib.\n Action:\n Lopressor 5mg IVP for rapid Afib, started metoprolol . Last\n Digoxin 0.25 rfecieved @0100 coumadin held for elevated INR\n Response:\n HR controlled Afib s/p lopressor. Hymodynamically stable.\n Plan:\n Cont to monitor, pt is a DNR/DNI and refusing most interventions.\n Continue to monitor on telemetry\n Restart Metoprolol 12.5 mg daily\n Continue Warfarin monitor INR for therapeudic range\n Sepsis, Severe (with organ dysfunction) UTI/pyelo- R ureteral stone\n Assessment:\n T-max 98.4 abd soft distended + BS tenderness to palpation. c/o lower\n abd pain intermittent when urinates. Received Tylenol 650 x1.\n received abx vancomycin/zosyn. IV access 2PIV NS KVO received FB 250\n for SBP<100. Awake alert oriented x3 follows commands MAE random LE\n weak. Appetite poor pt stats no hungry. Incont Urine\n Action:\n Cont abx Vancomycin d/c. afebrile WBC 11.8.\n Response:\n Voiding Diaper mod\nlg amts amber. Cont to have pain upon urination\n Source is UTI/Pyelo compounded by obstructive stone. Pt decline\n aggressive care. HCP confirms. She aggrees with IVF and antibiotics.\n Urine culture this morning was positive for Proteus.\n Creatinine continues to improve\n Plan:\n Continue Zosyn for day course\n F/U sensitivities for Ucx\n Continue IVFs as needed\n monitor respiratory status in response to IVF\n Continue to monitor cre, urine output\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 692988,
"text": "This is an 83 year old female with DM, HTN, AFib who presents with\n sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 692974,
"text": "Chief Complaint: fevers\n HPI:\n This is a 83 year old female with DM, HTN, AFib presents with sudden\n onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM today\n when pt. was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2 Lt IVF and her blood pressure rose to 110s. UA\n was grossly positive and she received vanc/levo/ pip-tazo. She\n complained of abdominal pain and a abdominal CT was done showing\n obstructive stone in right ureter. Urology was consulted and they\n recomended urostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement, DCCV\n and usostomy tube placement. She apparently indicated that would\n perhaps reconsider urostomy in am. The ED team discussed with the\n patient's HCP who agrees with the patients decisions regarding her\n care. Prior to transfer to floor she pulled foley and decline\n replacement after repeated attempts.\n Prior to transfer her vitals were 99.7 179 130/80 23 95RA 4Lt\n .\n On the floor, she feels tired. She still decline central venous acces\n or urostomy tube placement. She understands the risk of death from\n infection or her afib and states \"I have lived a long and comfortable\n life, if my time has come let it be\".\n .\n Review of sytems:\n (+) Per HPI\n (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness. Denied\n nausea, vomiting, diarrhea, constipation. No recent change in bowel or\n bladder habits. No dysuria. Denied arthralgias or myalgias.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa 81\n lisinopril 2.5\n metoprolol 12.5\n warfarin 1.5\n prozac 20\n docusate 100\n namenda 10\n carvodopa-levidopa 25-100 TID\n lipitor 20\n Mirtazapin 30\n Past medical history:\n Family history:\n Social History:\n DM\n Atrial fibrillation\n hypercholesterolemia\n hypertension\n arthritis\n depression\n CAD, NSTEMI\n CM 30%\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Nursing home resident. No smoke, etoh, drugs.\n Review of systems:\n Flowsheet Data as of 02:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n 98 75/40, 160, 25, 94% 5LT\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 Physical Examination\n General: Alert, oriented self place time, shivering, able to relate\n history without difficulty\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, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, tender to palpation on flanks, non-distended, bowel\n sounds present, no rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n CBC 11.8>37<163 N91 B3\n Chem 137/5.1/108/18/43/1.5<208 gap=11 Cr was 0.8 \n ALT 11, AST 39, ALKp 87, Tbil 0.7, Lip 15\n CK 38 Tropn 0.04\n Lactate 2.7\n INR 2.0, PTT 29.6\n UA 1.023 7.0 lg bld, mod leuk, 100 prot, 15 ket, 21-50 rbc, >50 wbc,\n many bacteria, 0-2 epis\n Micro:\n urine culture pending\n Images:\n CXR: no acute process\n CT abd/pelvis:\n 1. 6 x 9 x 12 mm prox Rt ureteral stone causes mod hydro, with\n hypoperfusion of left kidney, surrounding stranding, and 1cm peripheral\n wedge shaped hypodensity in lower pole of right kidney which could\n indicate infection or infarction.\n 2. trace fluid along inferior tip of liver.\n 3. gallbladder not well seen d/t motion.\n 4. few colonic diverticulae, w/o inflammatory change.\n 5. atherosclerotic disease.\n 6. RML nodule.\n ECG: afib rvr 180s\n Assessment and Plan\n 84F with DM and atrial fibrillation who presents from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n but is declining invasive measures.\n # Sepsis: Source is UTI/Pyelo compounded by obstructive stone. Unlikely\n cardiac shock. No evidence of bleed. Patient declined central venous\n access. D/W attending and with patient, and pt is aware of the\n consequences of declining care including death. She aggrees with IVF\n and antibiotics at this time and will consider CMO option in am.\n - vanc, pip-tazo\n - bcx ucx\n - ivf\n - monitor respiratory status in response to IVF\n # A fib RVR: Given sepsis and severe hypotension on presentation\n controlling ventricular rate with nodal blockers becomes problem.\n declined cardioversion and she again she was aware of the\n possibility of death.\n - Will montitor for now.\n - If stable blood pressure will consider nodal agents carefully\n - hold warfarin\n # Acute renal failure: Dx includes obstruction vs hypoperfusion in the\n setting of sepsis (pre renal) or even ATN vs renal infarction.\n - IVF overnight\n - pt pulled foley\n - Monitor cre, urine output\n # DM: stable\n - ISS\n # HTN\n - Hold home antihypertensives\n FEN: No IVF, replete electrolytes, regular diet\n Prophylaxis: therapeutic inr\n Access: peripherals 18, 20\n Code: DNR DNI\n Communication: Patient, HCP: \n Disposition: pending clinical improvement\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: Patient declines pneumoboots and heparin SQ\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-24 00:00:00.000",
"description": "ICU Progress Note",
"row_id": 692981,
"text": "Clinician: Attending\n Urosepsis with hypotension/tachycardia due to pyelonephritis with\n obstruction of left kidney by ureteral stone. She is receiving\n antibiotics and fluids via peripheral IV's. She does not want\n nephrostomy tube, central line or foley catheter at this time. She is\n not in pain and denies dyspnea. Continue support with IV fluids.\n Currently, no resp distress, denies pain or dyspnea, abd soft but mild\n flank tenderness, 1+ LE edema.\n Renal failure likely combination of obstruction and volume depletion.\n Received 6 L total since ED.\n Tachycardia probably related to ongoing stress from sepsis/hypovolemia.\n Tachycardia improving but still in 120s. No evidence of CHF. Sat 97% on\n 4L/min O2. Will give digoxin for rate control of afib.\n We spoke to Ms . She is agreeable to once daily blood draws\n but not more.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 693192,
"text": "This is an 83 year old female with Parkinsions, DM, HTN, AFib who\n presents with sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n HR 100-130 Afib controlled. NBP 90-120/40-60. MAPS>60, Denies CP SOB\n palpitations. O2 3l/min NC Sats 98-100% Lungs clear. Received\n Coumadin per PT/INR parameters\n Action:\n Received Digoxin and coumadin per parameters.\n Response:\n HR controlled Afib Hymodynamically stable.\n Plan:\n Cont to monitor, pt is a DNR/DNI and refusing most interventions.\n Sepsis, Severe (with organ dysfunction) UTI/pyelo- R ureteral stone\n Assessment:\n T-max 98.4 abd soft distended + BS tenderness to palpation. c/o lower\n abd pain intermittent when urinates. Received Tylenol 650 x1.\n received abx vancomycin/zosyn. IV access 2PIV NS KVO received FB 250\n for SBP<100. Awake alert oriented x3 follows commands LE\n weak. Appetite poor. Pt not wanting to eat. Incont Urine\n Action:\n Cont abx Vancomycin d/c. afebrile WBC 11.8.\n Response:\n Voiding Diaper mod\nlg amts amber. Cont to have pain upon urination\n Plan:\n Cont to monitor, No further intervention at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 693193,
"text": "This is an 83 year old female with Parkinsions, DM, HTN, AFib who\n presents with sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n HR 100-130 Afib controlled. NBP 90-120/40-60. MAPS>60, Denies CP SOB\n palpitations. O2 3l/min NC Sats 98-100% Lungs clear. Received\n Coumadin per PT/INR parameters\n Action:\n Received Digoxin and coumadin per parameters.\n Response:\n HR controlled Afib Hymodynamically stable.\n Plan:\n Cont to monitor, pt is a DNR/DNI and refusing most interventions.\n Continue to monitor on telemetry\n Restart Metoprolol 12.5 mg daily\n Continue Warfarin monitor INR for therapeudic range\n Sepsis, Severe (with organ dysfunction) UTI/pyelo- R ureteral stone\n Assessment:\n T-max 98.4 abd soft distended + BS tenderness to palpation. c/o lower\n abd pain intermittent when urinates. Received Tylenol 650 x1.\n received abx vancomycin/zosyn. IV access 2PIV NS KVO received FB 250\n for SBP<100. Awake alert oriented x3 follows commands LE\n weak. Appetite poor. Pt not wanting to eat. Incont Urine\n Action:\n Cont abx Vancomycin d/c. afebrile WBC 11.8.\n Response:\n Voiding Diaper mod\nlg amts amber. Cont to have pain upon urination\n Source is UTI/Pyelo compounded by obstructive stone. Pt decline\n aggressive care. HCP confirms. She aggrees with IVF and antibiotics.\n Urine culture this morning was positive for Proteus.\n Creatinine continues to improve\n Plan:\n Continue Zosyn for day course\n F/U sensitivities for Ucx\n Continue IVFs as needed\n monitor respiratory status in response to IVF\n Continue to monitor cre, urine output\n"
},
{
"category": "Nursing",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 693023,
"text": "This is an 83 year old female with DM, HTN, AFib who presents with\n sudden onset fever and chills.\n She was in her usual state of health at nursing home until 5 PM on \n when pt was noted to be shaking and was febrile with temp of 102. She\n was brought in by EMS to ED where she was noted to have HR in 150-200\n range. ECG showed afib with rvr in 200s. Her BP was in the 60s. 02 sat\n 91%. She was given 2L IVF and her blood pressure rose to 110s. UA was\n grossly positive and she received vanc/levo/ pip-tazo. She complained\n of abdominal pain and an abdominal CT was done showing obstructive\n stone in right ureter. Urology was consulted and they recommended\n nephrostomy placement.\n The patient is DNR/DNI. While in the ED she was alert and oriented x3\n and per report was able to comprehend the severity of her state. She\n has been refusing interventions including central line placement and\n nephrostomy tube placement. The ED team discussed with the patient's\n HCP who agrees with the patients decisions regarding her care. Prior to\n transfer to floor she pulled foley and declined replacement after\n repeated attempts.\n Pt does understand the risk of death from infection or her afib and\n states \"I have lived a long and comfortable life, if my time has come\n let it be.\"\n Atrial fibrillation (Afib)\n Assessment:\n Rapid afib with HR 110s-140s. BP range 60-112/40\ns-60\ns. Asymptomatic\n with this HR and BP. Denies any chest pain, dizziness or SOB.\n Action:\n Vitals checked, pt given total of 1500cc NS in divided boluses\n throughout shift. Restarted on home dose coumadin. Will hold pt\n home cardiac meds for now to hypotension.\n Response:\n No cardiac related symptoms, mentating appropriately.\n Plan:\n Cont to monitor, pt is a DNR/DNI and refusing most interventions.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt with UTI/pyelo compounded by obstructive stone in ureter seen on\n CT. HR and BP as above. Afebrile. Pt is slightly tremulous but on\n sinemet at NH and likely parkinsons history.\n Action:\n Pt in need of perc nephrostomy but refusing this procedure. Pt\n understands the severity of the situation. Fluid bolused 1.5L this\n shift. Vanco and Zosyn IV.\n Response:\n Minimally responds to the fluid with increase in bp but then trends\n down again. Remains tachy and with labile BP.\n Plan:\n Cont to monitor, support with fluid. No further intervention at this\n time.\n Renal failure, acute (Acute renal failure, ARF) Dx includeds\n obstruction vs hypoperfusion in the setting of sepsis (prerenal) or ATV\n vs renal infarction\n Assessment:\n Bun/Cr 38/1.4 (unclear of baseline). Pt with brief incontinent of\n small to medium amounts of dark urine.\n Action:\n Fluid boluses as noted above, labs monitored.\n Response:\n On-going\n Plan:\n Monitor labs. Urine output.\n"
},
{
"category": "Physician ",
"chartdate": "2116-09-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 693182,
"text": "Chief Complaint: pyelo\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 83F with DM and atrial fibrillation, presented from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n with hydro, likely pyelo, declining invasive measures, now improved\n with abx and fluids.\n 24 Hour Events:\n -dig loaded, hr down\n -bp up and stable\n -cr improved\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:03 AM\n Other medications:\n s/p dig, vanco, mirtazipine, arorvastatin, carbidopa-levodopa, namenda,\n docusate, fluoxetine, asa, warfarin, zosyn, s/p 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 Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Ear, Nose, Throat: No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain\n Nutritional Support: No(t) NPO\n Respiratory: No(t) Cough, Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.6\nC (97.9\n HR: 110 (100 - 152) bpm\n BP: 107/64(70) {62/42(47) - 118/81(89)} mmHg\n RR: 16 (12 - 25) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 7,740 mL\n 432 mL\n PO:\n 240 mL\n 150 mL\n TF:\n IVF:\n 5,100 mL\n 282 mL\n Blood products:\n Total out:\n 100 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 7,640 mL\n 432 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: No(t) PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Tender: mildly throughout\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3,\n Movement: Not assessed, Tone: Not assessed, Completely oriented\n Labs / Radiology\n 10.8 g/dL\n 126 K/uL\n 87 mg/dL\n 1.3 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 33 mg/dL\n 114 mEq/L\n 140 mEq/L\n 33.7 %\n 11.8 K/uL\n [image002.jpg]\n 05:27 AM\n 03:44 AM\n WBC\n 11.0\n 11.8\n Hct\n 33.3\n 33.7\n Plt\n 122\n 126\n Cr\n 1.4\n 1.3\n Glucose\n 215\n 87\n Other labs: LDH:179 IU/L, Ca++:7.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Imaging: no new\n Microbiology: ucx: proteus >100K\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n 83F with DM and atrial fibrillation, presented from NH with fever,\n leukocytosis, tachycardia and hypotension found to have ureteral stone\n with hydro, likely pyelo, declining invasive measures, now improved\n with abx and fluids. Better rate control now with initiation of\n digoxin, and BP is now improved and stable to restart home beta blocker\n at low dose. Should be able to stop digoxin. Given positive urine\n culture will narrow abx, awaiting final sensitivies tomorrow. Improved\n Cr is reassuring. Will discuss with urology other management options\n for the kidney stone given decline of all invasive procedures.\n ICU Care\n Nutrition: regular\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: Not indicated\n VAP: HOB elevation\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "ECG",
"chartdate": "2116-09-23 00:00:00.000",
"description": "Report",
"row_id": 261907,
"text": "Atrial fibrillation, mean ventricular rate 188. Low QRS voltage. Diffuse\nnon-diagnostic repolarization abnormalities. Compared to the previous\ntracing of the ventricular rate is markedly increased, now with low\nQRS voltage and more pronounced repolarization abnormalties.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-09-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1094153,
"text": " 7:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with fever, tachy to 200s, hypotension\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY.\n\n HISTORY: 83-year-old female with fever and tachycardia and hypotension.\n\n COMPARISON: .\n\n FINDINGS: A semi-supine AP view of the chest was obtained. The\n cardiomediastinal silhouette is stable in appearance. The lungs are clear\n bilaterally. There are no pleural effusions or pneumothorax. No acute\n osseous abnormalities are identified. Multilevel degenerative changes are\n noted throughout the spine.\n\n IMPRESSION:\n\n No evidence of acute intrathoracic process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-09-23 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1094168,
"text": " 9:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: LLQ pain and shock, eval for free air.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with LLQ pain and shock\n REASON FOR THIS EXAMINATION:\n LLQ pain and shock, eval for free air.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AGLc WED 10:54 PM\n 1. 6 x 9 x 12 mm prox Rt ureteral stone causes mod hydro, with hypoperfusion\n of left kidney, surrounding stranding, and 1cm peripheral wedge shaped\n hypodensity in lower pole of right kidney which could indicate infection or\n infarction.\n 2. trace fluid along inferior tip of liver.\n 3. gallbladder not well seen d/t motion.\n 4. few colonic diverticulae, w/o inflammatory change.\n 5. atherosclerotic disease.\n 6. RML nodule.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old female with left lower quadrant pain and shock. Here to\n assess for free air.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT axial imaging was performed through the abdomen and pelvis\n after administration of 130 mL of IV Optiray. Multiplanar reformatted images\n were then obtained. No oral contrast was administered.\n\n CT ABDOMEN WITH IV CONTRAST: A 6 x 8 x 3 mm irregular density is noted in the\n right middle lobe (2:3) having ground-glass attenuation on axial imaging, but\n solid and flat appearance on coronal images. Given morphology, this\n is felt not to represent true pulmonary nodule. Dependent atelectatic changes\n are noted in the lung bases. No pleural or pericardial effusion is seen.\n Coronary artery calcifications are noted particularly along the LAD and RCA.\n Aortic valvular calcifications are mild, of indeterminate hemodynamic\n significance. Mitral annular calcifications are also noted.\n\n The study is degraded by motion. Allowing for this, no definite focal lesion\n is seen within the liver, spleen, pancreas, or adrenal glands. The\n gallbladder wall is indistinct in part due to patient motion. Trace fluid is\n noted along the inferior tip of the liver. There are dense splenic artery\n calcifications.\n\n A 6 x 9 x 12 mm calculus within the proximal left ureter (2:41, 300b:23)\n causes upstream moderate hydroureteronephrosis, with associated decreased\n perfusion of the left kidney. Tiny subcentimeter areas of hypodensity within\n the left kidney are too small to accurately characterize. A 1-cm peripherally\n located wedge- shaped region within the lower pole of the left kidney,\n suggestive of focal pyelonephritis. Enhancement of the proximal left ureteral\n wall is also suggestive of ureteritis. There is mild stranding surrounding\n (Over)\n\n 9:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: LLQ pain and shock, eval for free air.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the left kidney.\n\n No hydronephrosis is seen in the right kidney. Subcentimeter hypodensities are\n too small to accurately characterize also in the right kidney. The non-\n opacified stomach and small bowel appear unremarkable. Colonic diverticuli are\n noted, without inflammatory change. No free air is seen within the abdomen.\n Mural calcifications are noted along the abdominal aorta, without aneurysmal\n dilatation, as well as the origin of the major abdominal arteries. No lymph\n node enlargement is seen meeting CT size for adenopathy.\n\n CT PELVIS WITH IV CONTRAST: The urinary bladder is empty, with Foley catheter\n in place. The rectum contains a large amount of stool but the sigmoid colon\n is decompressed. Pelvic loops of small bowel appear unremarkable. An\n appendix is not discretely identified; however, no right lower quadrant\n changes are noted to suggest acute appendicitis. No pelvic free fluid, free\n air, or adenopathy is noted. Atherosclerotic calcifications are present along\n the iliac arteries, without aneurysmal dilatation.\n\n OSSEOUS STRUCTURES: Lucency is noted within the incompletely imaged T6 and in\n T9, with thickened trabeculae, likely representing vertebral hemangiomas.\n There is S-shaped scoliosis of the thoracolumbar spine, with associated\n multilevel degenerative change. There is partial sacralization of L5 with\n pseudoarticulation of the left transverse process with the sacrum.\n\n IMPRESSIONS:\n 1. 6 x 9 x 12 mm obstructing proximal left ureteral stone, with moderate\n hydroureteronephrosis. Peripheral wedge-shaped hypodensity along the lower\n pole is suggestive of focal pyelonephritis, and enhancement of the ureteral\n wall is compatible with infection.\n 2. Trace fluid along the inferior tip of the liver. Gallbladder not well\n defined due to motion.\n 3. Colonic diverticulae, without diverticulitis seen.\n\n\n"
}
] |
26,751 | 133,185 | Patient was admitted to neurosurgery for a subarachnoid hemorrhage. Angiography revealed the presence of both a basilar and anterior communicating artery (ACOMM) aneurysms. She was preoped and consented for embolization of the basilar and anterior communicating artery anyeurysms. Patient went to to the angio suite on for coiling of the basilar artery aneurysm. She tolerated the procedure well, was extubated, and returned the SICU for Q1hour neurochecks. She underwent coiling for the ACOMM aneurysm on . She again tolerated the procedure well, was extubated, and returned to the SICU for Q1hr neuro checks. She was placed on nimodipine 60mg Q4 hours for vasospasm prophylaxis. Her neuro exam was stable during her entire SICU stay. On she underwent a CT perfusion study of the brain, which showed minimal cerebral vasospasm and a resolving SAH. On she was transferred to the neuro step down unit for Q2 hour neuro checks. She continued to do well wihout signs or symptoms of cerebral vasospasm. She did continue to have a headache with photophobia, but was well-controlled with IV dilaudid and oxycodone. Neuro exam prior to discharge: she had no focal neurodeficits continued with persistent headache. Her angio site was well healed. She was tolerating a regular diet and voiding without difficultly a UA was sent prior to discharge which was negative. She was ambulating without difficulty. | + PP.RESP: LCTAB. +palpable pulses.Resp: LS clear. OOB as tolerates. Prophylactic dilantin. Dilantin bolus on hold at 1015a MD . Monitor resp. LCTAB. LCTAB. OOB as tol. OOB as tol. ATC Nimodipine. DIET ADVANCED TO REG, SO FAR TOLERATING CLEAR LIQ'S. No BM.ENDO: RISS, requiring min. MD aware of Dilantin loading dose. MAE w/normal strength. CTA. MD aware at that time. SICU NN: SEE CAREVUE FOR SPECIFICS. SICU NN: SEE CAREVUE FOR SPECIFICS. + PP. NPO after midnoc. GOAL BP PARAMETERS LIBERALIZED POST PROCEDURE. ND. ND. ND. + BS. + BS. + BS. + BS. Right femoral sheath site cdi, soft. PERRL. PERRL. DENIES HEADACHE. BP WNL. BP WNL. NURSING UPDATECV: NSR, NO ECTOPY, BP W/IN ACCEPTABLE PARAMETERS. NPO.GU: Foley patent draining adequate light CYU.SKIN: Intact. See flowsheetGI/GU: Abd soft, +BS. C/O mild HA x1, given Oxycodone w/effect. LUNGS CLEAR TO AUSC. Commode at BS.SKIN: Intact. Abdomen soft, NT, ND. RSR. RSR. LEVEL STILL<THERAPEUTIC @ 5.2 THIS AM. NURSING UPDATENEURO: EXAM INTACT. No SOB.CV: NSR HR 80-90. SBP 120-150.RESP: LCTAB. status. RR WNL. NEURO CHECKS Q1H. Small amount emesis, resolved, now denies nausea. HO aware of above, notify w/any changes. HO aware of above, notify w/any changes. HO aware of above, notify w/any changes. SBP 115-140.GI: Abdomen soft. Denies headache.CV: HR 70-80s SR no ectopy. TAKEN TO OSH WHERE HEAD CT REVEALED SAH. NT. NT. NT. Tolerating clears, ok for solid foods. Head CTA with perfusion ordered, currently no time scheduled. HOB to remain >30.CV: Afebrile. Aline placed upon arrival, sbp ranging 110-130. Reassured. RIGHT GROIN ANGIO SIGHT CDI SOFT WITHOUT ECCHYMOSIS. To restart Buspar. ALERT AND ORIENTED X 3. ALERT AND ORIENTED X 3. PT STATED VOMITING X1 W/NEAR SYNCOPE EVENT. In RA, NAD with stable SAT. VSS. VSS. Sat's 97-100% RA. No c/o SOB.GI: Abd soft. No c/o SOB.GI: Abd soft. Diet advanced to Regular, tolerating well. Patient alert, oriented. PIV'S X 2. Goal to maintain SBP <140. C/O SLIGHT HEADACHE RELIEVED WITH DILAUDID PRN. MAE EQUALLY. MAE EQUALLY. NSR HR 70-80. NSR 70-80. MAE. SPEECH CLEAR. SPEECH CLEAR. NSR 70. ? MAE, normal strength. MAE, normal strength. ABDOMEN SOFT, BOWEL SOUNDS PRESENT, NO BM. RIGHT FEMORAL SHEATH REMAINS, TRANSDUCED, TEGADERM DSG, CDI, SOFT, NO ECCHYMOSIS OR HEMATOMA. Restart Dilantin bolus MD but at slower rate. + Femoral pulse.RESP: Sat's 97-100% RA. No c/o pain. Pain/comfort. Hourly neuro checks. DENIES PAIN. ALINE. See and carevue for detaield documentationRec'd patient alert, orieted. C/O mild HA & backpain, recieving Tylenol & Oxycodone with effect. POTASSIUM REPLETED AS ORDERED. MD at bedside at 1015am and aware of above. SBP 100-140s. Regular diet tolerating well.ENDO: RISS requiring minimal coverage.GU: Voiding light CYU, using commode.SKIN: Intact. Normal speech. ABD SOFT NONTENDER WITH BOWEL SOUNDS PRESENT. Mild HA recieving Oxycodone 10MG x2 and Tylenol 650MG x1; given w/effect. Monitor pain/comfort. Monitor pain/comfort. NSR HR 55-70. REGIMEN CHANGED TO KEPPRA.ID: TMAX 100 ORALLY. SYSTOLIC 100-200 ACCEPTABLE PER DR. . FINDINGS: In comparison with a prior study, on the non-contrast CT of the head, residual diffuse subarachnoid hemorrhage with layering of hemorrhage in the dependent region of the lateral ventricles is again visualized. FINDINGS: Left vertebral artery arteriogram shows that the previously seen basilar aneurysm remains coiled. Post-coiling arteriogram shows very faint filling of the aneurysm. A small amount of subarachnoid hemorrhage within the right sylvian fissure and prepontine cisterns. A small amount of subarachnoid hemorrhage within the right sylvian fissure and prepontine cisterns. FINDINGS: Right internal carotid artery arteriogram demonstrates normal filling of the distal cervical, petrous, cavernous and supraclinoid portion of the carotid. There is a small 1-2 mm infundibulum at the origin of the (Over) 1:36 PM CTA HEAD W&W/O C & RECONS Clip # Reason: SAH Admitting Diagnosis: STROKE;TIA Contrast: OPTIRAY Amt: FINAL REPORT (Cont) right posterior communicating artery. PROCEDURE PERFORMED: Left vertebral artery arteriogram, left common carotid artery arteriogram, right internal carotid artery arteriogram. PROCEDURE PERFORMED: Right common carotid artery arteriogram, right internal carotid artery arteriogram, left internal carotid artery arteriogram, left common carotid artery arteriogram, left vertebral artery arteriogram. IMPRESSION: Residual diffuse subarachnoid hemorrhage with layering of hemorrhage in the dependent region of the lateral ventricles bilaterally. Focal outpouching is identified at the origin of the right posterior communicating artery, likely consistent with a prominent infundibulum as visualized on the prior study dated . TECHNIQUE: Noncontrast head CT followed by CT angiogram of the head and circle of with Optiray IV contrast, multiplanar reformats and 3D reconstructions. HEAD CT DONE THIS AM.RESP: LUNG SOUNDS CLEAR BILATERALLY. INTERVENTIONAL PROCEDURE PERFORMED: Coiling of right anterior communicating artery aneurysm. Left internal carotid artery arteriogram demonstrates normal filling of the cervical internal carotid artery and the petrous, cavernous and supraclinoid segments. page neurosurg for Admitting Diagnosis: STROKE;TIA Contrast: OPTIRAY Amt: 110 FINAL REPORT (Cont) filling defects are demonstrated. NONCONTRAST HEAD CT: A small amount of intraventricular hemorrhage is noted within the fourth ventricle and there is a tiny amount of blood layering in the occipital horns of the lateral ventricles. | 21 | [
{
"category": "Nursing/other",
"chartdate": "2140-07-05 00:00:00.000",
"description": "Report",
"row_id": 1612581,
"text": "npn\nresults from wet read on head ct indicative of mild vasospasm\n\nneuro: aox3, following commands, perrla at 4mm, cont to c/o headache mild 3 to 4, had severe ha at 12am with dr. and pt given dilaudid 1mg ivp for breakthrough pain with excellent affect. with above event pt seemed to have an anxiety component that added to\n\npain experience. pt slept after receiving dilaudid.\npain pt receiving oxycodone, tylenol and dilaudid for pain. at 12am with ha and anxiety pt also c/o back pain r/t old surgeries, warm compress applied with good affect.\n\ncad hr 70-80's sr no ectopy noted, abp 150-160's/70's with maps 96-115, no isses\n\nresp lscta, sats 93-99% on ra. no issues\n\ngi: bs +, tolerating po fluids, no flatus noted, no bm\n\ngu: voiding on commode, clear yellow urine, approx 950 over last 12 hours, am k+ 4.0,\n\nid: temp max 100.7 wbc 12.1, on no antibiotics\n\nendo: ssi coverage given\n\nplan: cont q 1 hr neuro checks, inc activity as tolerated, medicate for pain prn. provide emotional support, ? if pt needs some antianxiety medication. ? if she takes depression meds at baseline.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-03 00:00:00.000",
"description": "Report",
"row_id": 1612578,
"text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: A&OX3 however slightly more lethargic today, pt stating \"more tired\". Mild HA recieving Oxycodone 10MG x2 and Tylenol 650MG x1; given w/effect. One episode in afternoon where pt, per family, had told same story two or three times (new for pt) >> Upon exam pt strength & pupils remained unchanged however became oriented x2 to self and place, unable to recall date requiring much encouragement. NSurg/Dr notified >> assessed pt, Dr stated per her exam pt unchanged from this am >> continue closely monitoring MS, if changes again ? CTA. Also to monitor SBP at time if/when MS changes to ? need for increased perfusion. MAE, normal strength. PEERLA at 3mm. OOB to chair w/minimal assistance.\nCV: Remains w/low grade fever, TMAX 100. NSR HR 70-80. No viewed ectopy. SBP 120-150.\nRESP: LCTAB. Sat's 97-100% RA. No c/o SOB.\nGI: Tolerating Regular diet, good appetite. Abdomen soft, NT, ND. + BS. No BM.\nENDO: RISS, requiring min. coverage.\nGU: Foley removed, DTV between 2200-2400. Commode at BS.\nSKIN: Intact. No breakdown noted.\nSOCIAL: Husband at bedside for majority of day, multiple family members into visit.\n\nPOC: Hourly Neuro exams. Monitor pain/comfort. OOB as tol. DTV 2200-2400. Provide emotional support to pt & family. HO aware of above, notify w/any changes.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-06-30 00:00:00.000",
"description": "Report",
"row_id": 1612572,
"text": "Shift Update\nNeuro:Pt alert and oriented, speech clear, mae equally, perrla, smile symmetrical, tongue midline. See flowsheet for neuro assessments. Medicated x1 w/ morphine 1mg ivp for c/o back pain w/ relief. Refusing pain med at present time. Denies headache.\n\nCV: HR 70-80s SR no ectopy. SBP 100-140s. Arterial sheath dc'd at 0945 by Neuro IR NP. After about 10minutes of pressure held at site by NP, SBP to 90s. Also Dilantin 1000mg iv bolus at that time. Pt also c/o back pain and brief episode of nausea. MD aware at that time. MD at bedside at 1015am and aware of above. Dilantin bolus on hold at 1015a MD . Restart Dilantin bolus MD but at slower rate. MD aware of Dilantin loading dose. Continue to keep scheduled dose of dilantin due at 1600 MD . Right femoral sheath site cdi, soft. +palpable pulses.\n\nResp: LS clear. Sats >97% on RA. RR WNL. See flowsheet\n\nGI/GU: Abd soft, +BS. Tolerating clears, ok for solid foods. To be NPO after midnoc tonight for procedure Friday am. Foley draining clear yellow urine large amts, see flowsheet for details.\n\nEndo: Pt own scale started.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Monitor neuro status. NPO after midnoc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-04 00:00:00.000",
"description": "Report",
"row_id": 1612579,
"text": "NURSING UPDATE\nNEURO: EXAM INTACT. INCREASED HEADACHE AND ANXIETY IN PM, N/ TEAM NOTIFIED. OXYCODONE 10MG W/O EFFECT, MSO4 4MG IV W/FAIR EFFECT ONLY. PT CALLED HUSBAND TO COME IN, AS SOON AS SHE KNEW HE WAS COMING ANXIETY AND HEADACHE WAS ALLEVIATED. SETTLED AND SLEPT IN LONG NAPS.\nPO DILANTIN LOAD 1000MG GIVEN IN INCREMENTS LATE PM. LEVEL STILL<THERAPEUTIC @ 5.2 THIS AM. REGIMEN CHANGED TO KEPPRA.\nID: TMAX 100 ORALLY. WBC 11.7 THIS AM.\nGU: OOB TO VOID ON COMMODE.\nALL OTHER SYSTEMS STABLE WNL.\nPT MONITORED CONTINUOUSLY.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-04 00:00:00.000",
"description": "Report",
"row_id": 1612580,
"text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS. (Day #3 post 2nd coil)\n\nNEURO: A&Ox3. Sleepy in morning, NSurg at bedside during assessment & aware; to continue monitoring. OOB to chair x2, to walk unit before dinner; requiring minimal assistance w/movement. PEERLA at 4mm. C/O mild HA & backpain, recieving Tylenol & Oxycodone with effect. To restart Buspar. Head CTA with perfusion ordered, currently no time scheduled. Continuing Dilantin wean to Keppra.\nRESP: Sat's 96-98% RA. LCTAB. No SOB.\nCV: NSR HR 80-90. No viewed ectopy. SBP 115-140.\nGI: Abdomen soft. NT. ND. + BS. No BM. Regular diet tolerating well.\nENDO: RISS requiring minimal coverage.\nGU: Voiding light CYU, using commode.\nSKIN: Intact. No breakdown, no redness on backside.\nSOCIAL: Husband at bedside for duration of day. Mulitple family members & friends into visit.\n\nPOC: Hourly Neuro checks. CTA w/perfusion for future. OOB as tol. Monitor pain/comfort. Emotional support to pt & family. HO aware of above, notify w/any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-01 00:00:00.000",
"description": "Report",
"row_id": 1612573,
"text": "SICU NN: SEE CAREVUE FOR SPECIFICS. NO NEUROLOGICAL DEFECITS. NO NEURO CHANGES. ALERT AND ORIENTED X 3. SPEECH CLEAR. PERRL. MAE EQUALLY. DENIES HEADACHE. ROOM AIR. RSR. BP WNL. TEMP 101, SICU RESIDENT NOTIFIED, TYLENOL GIVEN, BLOOD AND URINE CULTURES SENT AS ORDERED. PALP PEDALS. RIGHT GROIN ANGIO SIGHT CDI SOFT WITHOUT ECCHYMOSIS. NPO AFTER MIDNIGHT FOR ANGIO TODAY. TOL REG DIET YESTERDAY. ABD SOFT NONTENDER WITH BOWEL SOUNDS PRESENT. FOLEY WITH ADEQUATE LIGHT YELLOW URINE. DENIES PAIN. SPOKE WITH HUSBAND ON PHONE, UPDATED. PLAN: ANGIO TODAY FOR POSSIBLE INTERVENTION ON SECOND ANEURYSM, NEURO CHECKS, MONITOR HEMODYNAMICS, FOLLOW CULTURE DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-01 00:00:00.000",
"description": "Report",
"row_id": 1612574,
"text": "See and carevue for detaield documentation\n\nRec'd patient alert, orieted. MAE, normal strength. c/o mild HA treated with tylenol with good result. Prophylactic dilantin. In RA, NAD with stable SAT. VSS. NSR 70-80. BP 120-140. Good urine output. +bowel sounds, tol meds.\nTo IR for coiling of aneurysm. Patient reversed quickly by anesthesia-> patient reports anxiety related to reversal. Reassured. Transferred to CT with IR team, neurosurg. CAT scan stable. Patient alert, oriented. MAE. Small amount emesis, resolved, now denies nausea. c/o mild ha, no pain med per patient. VSS. NSR 70. BP 130-140.\nAngio site CDI with palpable pulses. R foot warm with good perfusion.\nFamily at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-06-29 00:00:00.000",
"description": "Report",
"row_id": 1612570,
"text": "ADMISSION NOTE\n\nSEE FHP AND CAREVUE FOR SPECIFICS\n\n57 Y/O WOMAN IN GOOD HEALTH PRIOR TO ADMISSION; ONLY HX OF DEPRESSION, BILATERAL TUBAL LIGATION, S/P SPINAL SURGERY & S/P DEVIATED SEPTUM REPAIR WHO WAS AT HOME BLOWING HER NOSE THIS MORNING WHEN EXPERIENCED A SUBSEQUENT \"WORST HA OF LIFE\". PT STATED VOMITING X1 W/NEAR SYNCOPE EVENT. TAKEN TO OSH WHERE HEAD CT REVEALED SAH. SHE WAS ADMINISTERED MORPHINE & TRANSFERRED TO FOR FURTHER CARE. PT RECEIVED ADDITIONAL HEAD CT REVEALING BASILAR LEAKING ANUERYSM. ADMITTED TO SICU FOR NEURO CHECKS, TO GO TO ANGIO FOR EMOLIZATION.\n\nNEURO: A&Ox3. Normal speech. Lethargic at times but easy to arouse. MAE w/normal strength. Pupils brisk & reactive at 3mm. No c/o pain. HOB to remain >30.\nCV: Afebrile. NSR HR 55-70. No viewed ectopy. Goal to maintain SBP <140. Aline placed upon arrival, sbp ranging 110-130. ATC Nimodipine. + PP.\nRESP: LCTAB. RA sat's 97-100%. No c/o SOB.\nGI: Abd soft. NT. ND. + BS. No BM. NPO.\nGU: Foley patent draining adequate light CYU.\nSKIN: Intact. No breakdown noted.\nSOCIAL: Family at bedside. Upon arrival pt filled out HCP form, husband to be proxy & spokesperson.\n\nPOC: SBP <140. Pain/comfort. Hourly neuro checks. To go to Angio for coiling. Emotional support to pt/family. HO aware of above, notify w/any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-06-30 00:00:00.000",
"description": "Report",
"row_id": 1612571,
"text": "SICU NN: SEE CAREVUE FOR SPECIFICS. SENT PATIENT TO AND RECEIVED PATIENT FROM ANGIO S/P COILING WITHOUT INCIDENT. NEURO CHECKS Q1H. NO DEFECITS NOTED. PERRL. SPEECH CLEAR. ALERT AND ORIENTED X 3. MAE EQUALLY. C/O SLIGHT HEADACHE RELIEVED WITH DILAUDID PRN. ROOM AIR. NO SOB OR RESPIRATORY ISSUES. LUNGS CLEAR TO AUSC. RSR. BP WNL. GOAL BP PARAMETERS LIBERALIZED POST PROCEDURE. SYSTOLIC 100-200 ACCEPTABLE PER DR. . STRONG PEDAL PULSES. ALINE. RIGHT FEMORAL SHEATH REMAINS, TRANSDUCED, TEGADERM DSG, CDI, SOFT, NO ECCHYMOSIS OR HEMATOMA. PIV'S X 2. DIET ADVANCED TO REG, SO FAR TOLERATING CLEAR LIQ'S. ABD SOFT, NONTENDER, WITH BOWEL SOUNDS PRESENT. FOLEY WITH ADEQUATE CLEAR YELLOW URINE. SKIN INTACT. POTASSIUM REPLETED AS ORDERED. FAMILY INTO VISIT LAST PM UPDATED BY MD . ZOFRAN PRN FOR NAUSEA. PLAN: RETURN TO ANGIO ?FRI FOR INTERVENTION ON A SECOND ANEURYSM, NEURO CHECKS, ?DC SHEATH TODAY, PAIN CONTROL, ADV DIET AS TOL, MONITOR LABS, EMOTIONAL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-02 00:00:00.000",
"description": "Report",
"row_id": 1612576,
"text": "NURSING PROGRESS NOTE\n\nSEE CAREVUE FOR DETAILS.\n\nNEURO: A&Ox3. MAE, OOB to chair with minimal assistance. C/O mild HA x1, given Oxycodone w/effect. C/O back slightly stiff, no additional pain than what typically experiences at baseline. Pupils brisk & reactive at 4mm.\nCV: NSR HR 60-80, no veiwed ecotpy. SBP 120-160, no BP paramaters. + PP. + Femoral pulse.\nRESP: Sat's 97-100% RA. LCTAB. No c/o SOB.\nGI: Abd soft. NT. ND. No BM. + BS. Diet advanced to Regular, tolerating well. Fluids KVO'd while PO'ing.\nENDO: RISS.\nGU: Foley patent draining adequate light CYU.\nSOCIAL: Patient had family come in early as anxious about head CT results; after spoke w/MD . Husband at bedside for majority of day.\n\nPOC: Neuro checks. Monitor pain & comfort. Provide emotional support to pt & family. OOB as tolerates. Pt to remain in ICU for total of about 6 days per Dr (currently Day 1 post second coiling).\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-03 00:00:00.000",
"description": "Report",
"row_id": 1612577,
"text": "NURSING UPDATE\nCV: NSR, NO ECTOPY, BP W/IN ACCEPTABLE PARAMETERS. PULSES PALPABLE.\nRESP: LUNG SOUNDS CTA, SATS 96-99% ON ROOM AIR.\nID:PERSISTANT LOW GRADE TEMP, TMAX 99.7, WBC 10.7.\nENDO: GLUC STABLE, NO INSULIN COVERAGE REQUIRED.\nNEURO: A&OX3, PUPILS EQUAL IN SIZE AND REACTIVITY, STRENGTH NORMAL. OXYCODONE 10MG PO X2 FOR HEADACHE WITH GOOD EFFECT.\nGI: TAKING PO FLUIDS VERY WELL. ABDOMEN SOFT, BOWEL SOUNDS PRESENT, NO BM. ZOFRAN 4MG IV X1 FOR NAUSEA WITH GOOD EFFECT. CEPACOL LOZINGE FOR C/O SORE THROAT.\nGU: ADEQUATE CLEAR YELLOW URINE VIA F/CATH.\nPLAN: CONTINUE TO MONITOR FOR REBLEED/VASOSPASM. PAIN MANAGEMENT.\nPT MONITORED CONTINUOUSLY.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-07-02 00:00:00.000",
"description": "Report",
"row_id": 1612575,
"text": "NURSING UPDATE\nCV: NSR, NO ECTOPY, BP WITHIN ACCEPTABLE PARAMETERS.\nID: TMAX 99.8\nNEURO/PAIN: ALERT AND ORIENTED, PUPILS EQUAL IN SIZE AND REACTIVITY, MAE, GOOD STRENGTH. C/O BACK PAIN AND HEADACHE INTERMITTENTLY, MORPHINE 4MG X2 AND OXYCODONE X3 WITH FAIRLY GOOD EFFECT. RT LEG IMMOBILIZED UNTIL MN. PEDAL AND FEMORAL PULSES PALPABLE. HEAD CT DONE THIS AM.\nRESP: LUNG SOUNDS CLEAR BILATERALLY. SATS 96-100% ON ROOM AIR.\nGI: TAKING PO FLUIDS WELL, THOUGH C/O NAUSEA X2, ZOFRAN 4MG IV X2 WITH GOOD EFFECT. SOFT, BOWEL SOUNDS ACTIVE, NO BM.\nGU: ADEQUATE CLEAR YELLOW HUO VIA F/CATH.\n\nPLAN: CONTINUE Q1H NEURO EXAM AS ORDERED.\nPAIN MANAGEMENT.\nENCOURAGE ADVANCEMENT OF DIET TO FULL REGULAR.\n\nPT MONITORED CONTINUOUSLY.\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Radiology",
"chartdate": "2140-07-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1022001,
"text": " 5:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for any evidence of hemorrhage.\n Admitting Diagnosis: STROKE;TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p a comm coiling.\n REASON FOR THIS EXAMINATION:\n Please assess for any evidence of hemorrhage.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc FRI 11:04 PM\n High density material diffusely through subarachnoid space; combination of\n extravasated contrast material from earlier procedure, and subarachnoid\n hemorrhage. No mass effect. Followup recommended.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old woman status post anterior communicating artery\n coiling.\n\n COMPARISON: CTA head of .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: A large amount of hyperattenuating material is seen within the\n subarachnoid space, tracking along the sulci of the medial left frontal lobe,\n temporal lobes bilaterally, the sylvian fissures, and the occipital lobe. High\n density material also fills the basilar cisterns. Metallic coils are present\n at the basilar artery and anterior communicating artery, consistent with\n recent coiling.\n\n There is no shift of normally midline structures. A small amount of high-\n density material is seen layering within the posterior horns of the lateral\n ventricles. There is no evidence of herniation. The ventricles are normal in\n contour and configuration.\n\n There is no edema, and the -white differentiation is largely preserved,\n although difficult to evaluate due to the high-attenuation material in the\n sulci.\n\n There is no fracture, and the mastoid air cells and paranasal sinuses are well\n aerated.\n\n IMPRESSION:\n 1. Diffuse subarachnoid high density material; likely a combination of\n extravasated contrast material from the vascular coiling procedure of three\n hours earlier, as well as subarachnoid hemorrhage. No evidence of mass\n effect. Followup examination recommended.\n\n Findings discussed with Dr. at the time of the examination.\n\n\n (Over)\n\n 5:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for any evidence of hemorrhage.\n Admitting Diagnosis: STROKE;TIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-07-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1022002,
"text": ", J. NSURG SICU-A 5:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please assess for any evidence of hemorrhage.\n Admitting Diagnosis: STROKE;TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p a comm coiling.\n REASON FOR THIS EXAMINATION:\n Please assess for any evidence of hemorrhage.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n High density material diffusely through subarachnoid space; combination of\n extravasated contrast material from earlier procedure, and subarachnoid\n hemorrhage. No mass effect. Followup recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-06-29 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 1021673,
"text": " 8:04 PM\n CAROT/CEREB Clip # \n Reason: evaluate for ?basilar aneurysm\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt: 100\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CAROTID/CERVICAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with acute onset ha after blowing nose; CTA showing likely\n basilar aneurysm\n REASON FOR THIS EXAMINATION:\n evaluate for ?basilar aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n PROCEDURE PERFORMED: Right common carotid artery arteriogram, right internal\n carotid artery arteriogram, left internal carotid artery arteriogram, left\n common carotid artery arteriogram, left vertebral artery arteriogram.\n\n INTERVENTIONAL PROCEDURE PERFORMED: Coiling of basilar tip aneurysm.\n\n ANESTHESIA: General.\n\n ATTENDING:\n ASSISTANT: .\n\n INDICATION: The patient is a 57-year-old female who had presented with a\n subarachnoid hemorrhage. Two aneurysms were found, one in the basilar apex\n and another in the anterior communicating segment, on CTA and therefore we\n decided to do a formal cerebral angiogram. The risks and benefits of this\n procedure were discussed at length with the patient's family.\n\n The patient was brought to the angiography suite. Anesthesia was induced in\n the supine position. Following this, both groins were prepped and draped in a\n sterile fashion. Access was gained to the right common femoral artery using a\n Seldinger technique and a 5 French vascular sheath was placed in the right\n common femoral artery. We now gained access to the aortic arch using a\n 2 catheter coaxially over an 038 Glidewire and the right internal\n carotid artery, right common carotid artery, left internal carotid artery,\n left common carotid artery and the left vertebral artery was catheterized and\n AP, lateral filming done. This did reveal a basilar apex aneurysm eccentric\n to the left, which measured 8 mm x 5 mm. It had a broad-based neck. Given\n (Over)\n\n 8:04 PM\n CAROT/CEREB Clip # \n Reason: evaluate for ?basilar aneurysm\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the fact this was an acutely ruptured aneurysm, we decided to coil it without\n a stent. At this point, the catheter, which was in the left vertebral\n artery, was exchanged out over an 038 Glidewire and a 6 French Envoy was\n placed in the left vertebral artery. The patient was fully anticoagulated\n with heparin to maintain an ACT about 250. We now were able to catheterize\n the aneurysm with an SL-10 microcatheter and a Synchro 2 standard microwire.\n Following this, the aneurysm was coiled under roadmapping guidance, starting\n with a GDC-10 360 4 mm x 8 cm coil. This was followed by a GDC-10 360 3 mm x\n 6 mm coil and then a GDC-10 2D 3 mm x 6 cm coil x2. This was followed by a\n GDC-10 ultrasoft 2 mm x 4 cm. At the end of this, the aneurysm seemed\n completely obliterated except for an area at the base. The Envoy catheter was\n now removed and the sheath was left in place. The patient was extubated and\n found to be neurologically intact.\n\n FINDINGS:\n\n Right internal carotid artery arteriogram demonstrates normal filling of the\n distal cervical, petrous, cavernous and supraclinoid portion of the carotid.\n The middle cerebral artery and the anterior cerebral artery are seen normally.\n There is a small 3-mm aneurysm at the A1 A2 junction. The anterior\n communicating segment itself was not clearly visualized. There is no cross\n fill into the left hemisphere.\n\n Right common carotid artery arteriogram demonstrates the external carotid\n artery and its branches. The carotid bifurcation does not appear to have any\n significant stenosis. There is no AV fistula visualized on this.\n\n Left internal carotid artery arteriogram demonstrates normal filling of the\n cervical internal carotid artery and the petrous, cavernous and supraclinoid\n segments. The anterior cerebral artery and the middle cerebral artery are\n seen normally without any evidence of aneurysms. On cross compression of the\n right common carotid there is cross fill into the right hemisphere and the\n anterior communicating segment is visualized, however there is no evidence of\n any aneurysm on this view.\n\n Left common carotid artery arteriogram demonstrates a normal carotid\n bifurcation with no stenosis. The left external carotid artery and its\n branches fill well. The left vertebral artery arteriogram demonstrates normal\n filling of the vertebral artery with reflux into the right vertebral artery.\n The left PICA is seen well. The right PICA is also visualized with no\n evidence of aneurysms. The basilar artery and its branches are seen well\n including both PCAs. There is a basilar apex aneurysm measuring 8 mm x 5 mm\n with a broad-based neck eccentric to the left. The left PCA has a turn which\n was thought to be an aneurysm on the CTA.\n\n (Over)\n\n 8:04 PM\n CAROT/CEREB Clip # \n Reason: evaluate for ?basilar aneurysm\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Post-coiling left vertebral artery arteriogram shows near total obliteration\n of the aneurysm with a small area at the base which still fills. This is more\n on the left side. There are two loops of the coil in the basilar apex within\n the lumen of the PCA, however, this does not cause any flow limitation and we\n did not feel the need for placing a stent for this.\n\n IMPRESSION: underwent cerebral angiography and coil embolization\n of a basilar apex aneurysm without any complications. She will be brought\n back for endovascular management of her anterior communicating artery\n aneurysm.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-07-04 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1022428,
"text": " 5:26 PM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n Reason: please perform cerebral perfusion study. page neurosurg for\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p coiling for basilar, ACA, PCOM aneurysms\n REASON FOR THIS EXAMINATION:\n please perform cerebral perfusion study. page neurosurg for questions regarding\n imaging slicing\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc MON 9:39 PM\n WET READ: Non contrast CT: Residual diffuse subarachnoid hemorrhage, with\n layering hemorrhage in the dependent region of the lateral ventricles\n bilaterally. No new foci of hemorrhage identified. CTA: Mild narrowing of\n the caliber of the circle of and tributaries compared to ,\n suggestive of mild vasospasm. Focal outpouching at the origin of the right\n PCOM likely reflects an infundibulum as noted on . FINAL REPORT will be\n issued once reconstructions available. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA of the head.\n\n CLINICAL INDICATION: 57-year-old woman, status post coiling for basilar, ACA,\n PCOM aneurysms.\n\n COMPARISON: Prior CT of the head dated .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast. Subsequently, contiguous axial images were obtained from the skull\n base to the convexity. Multiple 3D rendering rotational reconstructions were\n submitted for interpretation. Perfusion maps were also performed using\n cerebral blood volume, mean transit time, and cerebral blood flow.\n\n FINDINGS: In comparison with a prior study, on the non-contrast CT of the\n head, residual diffuse subarachnoid hemorrhage with layering of hemorrhage in\n the dependent region of the lateral ventricles is again visualized. No new\n foci of hemorrhage is identified.\n\n Mild streak artifact is also noted, related with coils located in the anterior\n communicating artery and on the tip of the basilar artery.\n\n Mucosal thickening is noted on the left frontal sinus, mild bilateral patchy\n ethmoidal mucosal thickening, the mastoid air cells and the orbits appear\n unremarkable.\n\n CTA: In comparison with the prior study dated , again mild\n narrowing in the caliber of the vessels of the circle of is noted\n suggesting mild vasospasm. Focal outpouching is identified at the origin of\n the right posterior communicating artery, likely consistent with a prominent\n infundibulum as visualized on the prior study dated . No other\n (Over)\n\n 5:26 PM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n Reason: please perform cerebral perfusion study. page neurosurg for\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n filling defects are demonstrated.\n\n IMPRESSION: Residual diffuse subarachnoid hemorrhage with layering of\n hemorrhage in the dependent region of the lateral ventricles bilaterally.\n There is no evidence of new hemorrhagic areas. The CTA demonstrates mild\n narrowing of the caliber of the vessels in the circle of suggesting\n mild vasospasm as described in detail above. Focal outpouching is identified\n at the origin of the right posterior communicating artery, likely consistent\n with a prominent infundibulum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-06-29 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1021608,
"text": " 1:36 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: SAH\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with SAH on CT from OSH\n REASON FOR THIS EXAMINATION:\n ? aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPtb WED 6:55 PM\n 1. 7-mm aneurysm of the tip of the basilar artery. 4-mm aneurysm of the\n anterior communicating artery. 4-mm aneurysm at the origin of the left\n posterior communicating artery. Small infundibula at the origins of the right\n posterior communicating artery in the right medial lenticulostriate artery.\n 2. Small amount of intraventricular hemorrhage within the fourth ventricle\n and tiny amount of blood layering within the occipital horns of the lateral\n ventricles. A small amount of subarachnoid hemorrhage within the right\n sylvian fissure and prepontine cisterns.\n\n Findings discussed with Dr. of Neurosurgery at 5:30 p.m. on .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old female with subarachnoid hemorrhage detected on outside\n hospital CT. Referred for assessment of intracranial aneurysm.\n\n COMPARISON: No prior study available at this institution.\n\n TECHNIQUE: Noncontrast head CT followed by CT angiogram of the head and\n circle of with Optiray IV contrast, multiplanar reformats and 3D\n reconstructions.\n\n NONCONTRAST HEAD CT: A small amount of intraventricular hemorrhage is noted\n within the fourth ventricle and there is a tiny amount of blood layering in\n the occipital horns of the lateral ventricles. A small amount of subarachnoid\n blood is present in the right sylvian fissure and prepontine cistern. There\n is no evidence of acute major vascular territorial infarction, mass effect,\n shift of normally midline structures or hydrocephalus. A few of the ethmoid\n air cells are opacified. There is mild right maxillary sinus mucosal\n thickening. The mastoid air cells remain clear. The bones and surrounding soft\n tissues are unremarkable.\n\n CTA OF THE HEAD AND CIRCLE OF WITH IV CONTRAST: An aneurysm is noted\n of the tip of the basilar artery which measures 7 mm long and has a 5 mm base.\n There is a suggestion of a \"blister\" at the tip of the basilar artery\n aneurysm, which may represent the source of the acute subarachnoid hemorrhage.\n An aneurysm of the anterior communicating artery measures about 4 mm long with\n a 3 mm base and also has a suggestion of a \"blister\" at the distal tip. An\n aneurysm at the origin of the left posterior communicating artery is 4 mm long\n with a 4 mm base. There is a small 1-2 mm infundibulum at the origin of the\n (Over)\n\n 1:36 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: SAH\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right posterior communicating artery. A 1 mm infundibulum is noted at the\n origin of the lateral lenticulostriate artery originating from the right\n internal carotid artery. The anterior and posterior circulations and circle of\n remain patent. There is no evidence of occlusion or significant\n stenosis.\n\n IMPRESSION:\n\n 1. 7 mm aneurysm at the apex of the basilar artery. 4 mm aneurysm of the\n anterior communicating artery. 4 mm aneurysm at the origin of the left\n posterior communicating artery. Small infundibula at the origins of the right\n posterior communicating artery and the right lateral lenticulostriate artery.\n\n 2. Small amount of intraventricular hemorrhage within the fourth ventricle\n and tiny layering intraventricular hemorrhage within the occipital horns of\n the lateral ventricles. A small amount of subarachnoid blood in the right\n sylvian fissure and prepontine cistern.\n\n Findings discussed with Dr. of Neurosurgery at 5:30 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-06-29 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1021609,
"text": ", J. NSURG SICU-A 1:36 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: SAH\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with SAH on CT from OSH\n REASON FOR THIS EXAMINATION:\n ? aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. 7-mm aneurysm of the tip of the basilar artery. 4-mm aneurysm of the\n anterior communicating artery. 4-mm aneurysm at the origin of the left\n posterior communicating artery. Small infundibula at the origins of the right\n posterior communicating artery in the right medial lenticulostriate artery.\n 2. Small amount of intraventricular hemorrhage within the fourth ventricle\n and tiny amount of blood layering within the occipital horns of the lateral\n ventricles. A small amount of subarachnoid hemorrhage within the right\n sylvian fissure and prepontine cisterns.\n\n Findings discussed with Dr. of Neurosurgery at 5:30 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-07-01 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 1021973,
"text": " 2:17 PM\n CAROT/CEREB Clip # \n Reason: Please eval for coilingAnesthesia has been book but pt is on\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt: 165\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY CAROTID/CERVICAL UNILAT *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with aneurysm\n REASON FOR THIS EXAMINATION:\n Please eval for coilingAnesthesia has been book but pt is on an add on list\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n INDICATION: Patient is a 57-year-old female who presented with subarachnoid\n hemorrhage. She was found to have a basilar tip aneurysm which we had coiled.\n She also had a smaller anterior communicating artery aneurysm and was brought\n back for coiling this . We decided to perform angiogram of the other vessels\n to make sure that there is no vasopasm.\n\n PROCEDURE PERFORMED: Left vertebral artery arteriogram, left common carotid\n artery arteriogram, right internal carotid artery arteriogram.\n\n INTERVENTIONAL PROCEDURE PERFORMED: Coiling of right anterior communicating\n artery aneurysm.\n\n PROCEDURE: The patient was brought to the angiography suite. Anesthesia was\n induced in the supine position. Following this both groins were prepped and\n draped in a sterile fashion. Access was gained to the right common femoral\n artery using a Seldinger technique. We were now able to get access into the\n aortic arch using 2 catheter and the left common carotid artery,\n right common carotid artery and the left vertebral artery was catheterized and\n AP, lateral filming done. There was no evidence of vasospasm in any of the\n arteries. The basilar aneurysm, which was previously coiled, appears to be\n occluded with no evidence of recanalization. The left internal carotid artery\n arteriogram did not demonstrate any evidence of spasm. Right internal carotid\n artery arteriogram showed the anterior communicating artery aneurysm measuring\n about 3 mm. Therefore, the 2 catheter in the right internal carotid\n artery was exchanged out for a 6 French Envoy straight 90 cm catheter.\n Following this, the aneurysm was catheterized with an Excelsior SL-10 150 cm\n microcatheter and a Synchro 2 standard 200 cm wire. We had to use a 45 degree\n angled microcatheter to get access in the aneurysm. Following this, we were\n able to coil the aneurysm with MicruSphere 3 mm coil. We tried to place a\n (Over)\n\n 2:17 PM\n CAROT/CEREB Clip # \n Reason: Please eval for coilingAnesthesia has been book but pt is on\n Admitting Diagnosis: STROKE;TIA\n Contrast: OPTIRAY Amt: 165\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n second coil in the aneurysm, however, there was immediate intraprocedure\n rupture of the aneurysm. This was treated by reversing the anticoagulation\n and the rupture site immediately closed off. Following this, the Envoy\n catheter was taken out. The right common femoral artery puncture was closed\n by applying manual pressure later.\n\n FINDINGS: Left vertebral artery arteriogram shows that the previously seen\n basilar aneurysm remains coiled. There is no evidence of vasospasm.\n\n Left internal carotid artery arteriogram shows no evidence of vasospasm. Left\n common carotid artery arteriogram shows no evidence of vasospasm.\n\n Right internal carotid artery arteriogram prior to coiling shows a 3-mm\n saccular aneurysm at the A1 A2 junction. Post-coiling arteriogram shows very\n faint filling of the aneurysm.\n\n IMPRESSION: underwent cerebral angiography and coiling of her\n anterior communicating artery aneurysm with an intraoperative rupture which\n was promptly treated by reversal of anticoagulation. The patient was\n extubated and found to be neurologically unchanged\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-07-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1022051,
"text": " 4:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for post procedure changes. please do at 6AM\n Admitting Diagnosis: STROKE;TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p coiling of cerebral aneurysm\n REASON FOR THIS EXAMINATION:\n eval for post procedure changes. please do at 6AM\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old woman status post coiling of cerebral aneurysm.\n Evaluate for change.\n\n COMPARISON: .\n\n There is interval clearance of the majority of the high-density material,\n which was seen in the subarachnoid space with trace subarachnoid high density\n noted along the left frontal convexity. There is trace remaining high-density\n material along the subarachnoid space of the left and right frontal convexity.\n There is diffuse brain edema noted. There is no evidence of midline shift.\n There is a small amount of high-density material layering within the occipital\n of the lateral ventricles bilaterally. This likely represents a small\n amount of residual hemorrhage. Aneurysm clips are noted, unchanged.\n\n The bony calvarium appears intact. The paranasal sinuses and mastoid air\n cells are grossly unremarkable except to note unchanged bilateral maxillary\n antrectomy changes and scattered ethmoid sinus thickening.\n\n IMPRESSION: Considerable reolution of SAH. No hydrocephalus or new hemorrhage.\n Changes from previous coiling.\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-06-29 00:00:00.000",
"description": "Report",
"row_id": 223020,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"
}
] |
75,420 | 114,387 | 66 y/o lady with history of SVT now with pericardial effusion s/p attempted EP ablation. . # Pericardial Effusion/PUMP: Patient was found to have a 1.4 cm anterior pericardial effusion after she became hypotensive during SVT ablation procedure on . TTE also showed mild RA collapse without any RV collapse. Emergently, patient received a right heart cath that was consistent with a non-hemodynamically signicant effusion w/o tamponade physiology, so pericardiocentesis was not felt to be indicated. (Cardiac output was preserved and there was no equalization of filling pressures.) Swan-ganz was initially left in place to monitor for development of tamponade physiology. Arterial line was also placed for blood pressure monitoring. Patient was initially hypotensive, but her blood pressure was responsive to IV fluid hydration and dopamine. Her blood pressure remained stable over the next 24 hours, and a repeat TTE on did not show worsening of the pericardial effusion. Chest pain secondary to the pericardial effusion was well-controlled with Toradol and patient was discharged on ibuprofen prn for pain. . # RHYTHM: Prior to admission, SVT was thought be a narrow complex tachycardia at 150 beats/minute with an RP interval of 100-120 msec. However, immediately post adenosine, there was evidence of sinus rhythm with a fully pre-excited QRS complex consistent with a left lateral bypass tract. In EP lab, monitors showed left lateral ventricular pre-excitation, retrograde VA block via BT at 350 msec, anterograde BT block at 300 msec, and atypical induced orthodromic AVRT, CL 400 msec via left lateral BT. During the procedure, it was difficult crossing the AV, and ablations were performed primarily at the entrent atrial acitivation site during Vpacing. Also slow pathway ablation was performed to prevent initiation of the AVRT. The ablation procedure was incomplete given hypotension as above. Rhythm was monitored on telemetry and showed predominantly sinus rhythm. . # CORONARIES: Patient has no known CAD. Chest pain while inpatient was pleuritic in nature and attributed to hemopericardium. ASA was continued. . # Extensive groin manipulation: Due to extensive groin manipulation during cardiac procedures on , patient was monitored closely for evidence of retroperitoneal bleed. In the cath lab, heparin was reversed with protamine, post cath checks were unremarkable, and a CT scan of abdomen and pelvis was negative for a retroperitoneal bleed. Hemoglobin and hematocrit remained stable throughout hospital stay. . # H/o breast CA and papillary bladder CA: Stable. Patient advised to continue outpatient follow-up per primary oncologist. . FEN: Patient was maintained on cardiac prudent diet. Electrolytes were repleted as necessary. . PROPHYLAXIS: SCD's were used for DVT prophylaxis. . CODE: FULL | Extrem: 2+ DP and PT pulses b/l, no c/c/e Tele: NSR with occasional single and paired PVCs A/P: 66 y/o lady with h/o SVT now with pericardial effusion s/p attempted ablation. PATIENT/TEST INFORMATION:Indication: Pericardial effusionHeight: (in) 64Weight (lb): 126BSA (m2): 1.61 m2BP (mm Hg): 140/67HR (bpm): 94Status: InpatientDate/Time: at 10:36Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Small LV cavity. There is mild right ventricular diastoliccollapse.IMPRESSION: Mild-moderate loculated anterior pericardial effusion withechocardiographic evidence for increased pericardial pressure. Evaluate for pericardial effusionHeight: (in) 61Weight (lb): 125BSA (m2): 1.55 m2BP (mm Hg): 118/65HR (bpm): 110Status: InpatientDate/Time: at 15:25Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: Small to moderate pericardial effusion.GENERAL COMMENTS: Results were personally reviewed with the MD caring for thepatient.Conclusions:Left ventricular wall thickness, cavity size and regional/global systolicfunction are normal (LVEF >55%). Extrem: 2+ DP and PT pulses b/l, no c/c/e Tele: NSR with occasional single and paired PVCs A/P: Hyperdynamic LVEF >75%.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; basal inferior - hypo; basal inferolateral - hypo; midinferolateral - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No TS.PERICARDIUM: Small to moderate pericardial effusion. Borderline left ventricular hypertrophy. Pericardial effusion (without tamponade) Assessment: Action: Response: Plan: # RHYTHM: Currently in sinus rhthm. PATIENT/TEST INFORMATION:Indication: Hypotensive during EP ablation. There is a small to moderate sized pericardial effusionprimarily around the right atrium and right ventricle with minimal around theapex and inferolateral wall. CARDIAC ECHO DONE ,SM PERICARDIAL EFFUSSION . CARDIAC ECHO DONE ,SM PERICARDIAL EFFUSSION . Incomplete ablation procedure as above. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. CARDIAC ECHO DONE .BS CL,SAT 93 RM AIR .TAKING PO ,POS BS ,NO STOOL.FOLEY DC 1230 DTV 830 PM. No RA or RV diastolic collapse.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left ventricular cavity is unusually small. Admit diagnosis: SUPRAVENTRICULAR TACHYCARDIA SUPRAVENTRICULAR TACHYCARDIA A Code status: Height: Admission weight: 58 kg Daily weight: Allergies/Reactions: Paxil (Oral) (Paroxetine Hcl) Unknown; Benadryl (Oral) (P-Ephed Hcl/Dp-Hydram Hcl) Unknown; Buspar (Oral) (Buspirone Hcl) Unknown; Levaquin (Oral) (Levofloxacin) Unknown; Adhesive Tape (Topical) Unknown; Precautions: PMH: CV-PMH: Arrhythmias Additional history: breast and bladder CA, SVT, anxiety, elevated cholesterol total abd hysterectomy & salpingoophrectomy ', left breast CA s/p left lumpectomy and radiation, papillary bladder ca dx s/p multiple resections and chemotherapy, finished . Pericardial effusion (without tamponade) Assessment: SVT ablation c/b 1.4 cm anterior effusion seen on TTE. Pericardial effusion (without tamponade) Assessment: SVT ablation c/b 1.4 cm anterior effusion seen on TTE. # RHYTHM: Currently in sinus rhthm. # RHYTHM: Currently in sinus rhthm. # RHYTHM: Currently in sinus rhthm. # RHYTHM: Currently in sinus rhthm. Action: o Hemodynamic monitoring- team placed radial aline. Action: o Hemodynamic monitoring- team placed radial aline. o Dopamine gtt weaned to off. o Dopamine gtt weaned to off. Patient arrived c/o CP (procedural from ablation in combination with pericardial effusion. Patient arrived c/o CP (procedural from ablation in combination with pericardial effusion. DISPO: CCU for now . CARDIAC ECHO DONE ,SM PERICARDIAL EFFUSSION . However, immediately post adenosine, there was evidence of sinus rhythm with a fully pre-excited QRS complex consistent with a left lateral bypass tract. Atypical Induced orthodromic AVRT, CL 400 msec via left lateral BT. Incomplete ablation procedure as above. Incomplete ablation procedure as above. Incomplete ablation procedure as above. Incomplete ablation procedure as above. Groin: Rt femoral swan in place. Groin: Rt femoral swan in place. Groin: Rt femoral swan in place. PA catheterization showed preserved CO, no equalization of filling pressures, and preserved Y descent on RA tracing. Also Hct drop from 39 -> 32.4 -> 28.9, so CT abd/pel obtained. Also Hct drop from 39 -> 32.4 -> 28.9, so CT abd/pel obtained. This suggested nonhemodynamically significant effusion. Her SVT with evidence of left lateral bypass tract and pre-excitation. Her SVT with evidence of left lateral bypass tract and pre-excitation. Her SVT with evidence of left lateral bypass tract and pre-excitation. Her SVT with evidence of left lateral bypass tract and pre-excitation. Pericardial effusion (without tamponade) Assessment: c/o chest discomfort with deep inspiration. EPS : Left lateral ventricular pre-excitation. Sclera anicteric. Sclera anicteric. Sclera anicteric. Sclera anicteric. - monitor for any evidence of RP bleed - CT abd/pelv this AM f/u final read . Transduced RA swan. Transduced RA swan. s/p RHC and swan ganz in place. s/p RHC and swan ganz in place. s/p RHC and swan ganz in place. s/p RHC and swan ganz in place. ACCESS: PIV's, left Aline, rt groin PA cath . ACCESS: PIV's, left Aline, rt groin PA cath . | 24 | [
{
"category": "Echo",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Report",
"row_id": 66809,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion\nHeight: (in) 64\nWeight (lb): 126\nBSA (m2): 1.61 m2\nBP (mm Hg): 140/67\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 10:36\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Small LV cavity. Hyperdynamic LVEF >75%.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - hypo; basal inferolateral - hypo; mid\ninferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No 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. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nNo echocardiographic signs of tamponade. No RA or RV diastolic collapse.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left ventricular cavity is unusually small. The inferior and posterior\nwalls are hypokinetic. The rest of the left ventricle is hyperdynamic. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nTrivial mitral regurgitation is seen. There is a small to moderate sized\npericardial effusion. The effusion appears circumferential. There are no\nechocardiographic signs of tamponade. No right atrial or right ventricular\ndiastolic collapse is seen.\n\nCompared with the findings of the prior study (images reviewed) of , the pericardial effusion appears similar in size.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2190-10-08 00:00:00.000",
"description": "Report",
"row_id": 66836,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotensive during EP ablation. Evaluate for pericardial effusion\nHeight: (in) 61\nWeight (lb): 125\nBSA (m2): 1.55 m2\nBP (mm Hg): 118/65\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 15:25\nTest: Portable TTE (Focused views)\nDoppler: No 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.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Small to moderate pericardial effusion.\n\nGENERAL COMMENTS: Results were personally reviewed with the MD caring for the\npatient.\n\nConclusions:\nLeft ventricular wall thickness, cavity size and regional/global systolic\nfunction are normal (LVEF >55%). Right ventricular chamber size and free wall\nmotion are normal. There is a small to moderate sized pericardial effusion\nprimarily around the right atrium and right ventricle with minimal around the\napex and inferolateral wall. There is mild right ventricular diastolic\ncollapse.\n\nIMPRESSION: Mild-moderate loculated anterior pericardial effusion with\nechocardiographic evidence for increased pericardial pressure.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2190-10-08 00:00:00.000",
"description": "Report",
"row_id": 145702,
"text": "Sinus rhythm. Borderline left ventricular hypertrophy. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Report",
"row_id": 145701,
"text": "Sinus rhythm with occasional ventricular premature beats. Compared to the\nprevious tracing of ectopy is new.\nTRACING #2\n\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 483377,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n TODAY SR NO ECT BP STABLE SINCE 500CC FLUID BOLLUS LAST NIGHT ,CVP 21\n . NO BLEEDING FROM EITHER GROIN ,DP DOP. CARDIAC ECHO DONE ,SM\n PERICARDIAL EFFUSSION . NO RETROPERITONEAL BLEED BY CT SCAN,INITIAL\n HCT DROP P PROCEDURE , NOW STABLE 29 .BS CL,SAT 93 RM AIR .TAKING PO\n ,POS BS ,NO STOOL.FOLEY DC 1230 DTV 830 PM. OOB TO CHAIR, AMBULATING\n IN \n,TOL WELL .ALERT ,OX3 .CO SEVERE PAIN IN CHEST DUE TO\n PROCEDURE NOT RELEIVED BY PERCOCETTE ,TORADOL IV GIVEN C RELEIF.PT\n TAKES XANAX AT HOME TID,ORDER OBTAINED FOR PRN HERE .ALSO WANTS\n SLEEPING PILL TONIGHT.\n PLAN MONITOR FOR BLEEDING ,HYPOTENSION,WORSENING OF PERICARDIAL\n EFFUSSION,PAIN CONTROL C TORADOL ,MANAGE ANXIETY .\n"
},
{
"category": "General",
"chartdate": "2190-10-09 00:00:00.000",
"description": "ICU Event Note",
"row_id": 483245,
"text": "Clinician: Resident\n CCU post-cath check\n S: Patient currently reports mild midline chest pain, worsened with\n inspiration. The pain is relieved with percocet and has not worsened\n over the past 6 hours. She denies shortness of breath, cough,\n palpitations, dizziness, and groin pain. Her only other complaint is\n insomnia, which is her baseline at home.\n .\n O:\n Vitals: BP 115/64 (88-136/41-70), HR 84 (86-99), RR 20, SaO2 99% on RA\n Gen: A&O x2, lying comfortably in bed, NAD\n CV: RRR, nl S1, S2, no murmurs, rubs or gallops appreciated\n Pulm: CTAB with scattered expiratory wheezes\n Groin: Swan catheter in place in rt femoral, bandage over left femoral\n cath site c/d/i. Nontender bilaterally, minimal ecchymoses, no\n palpable hematoma and no bruits bilaterally.\n Extrem: 2+ DP and PT pulses b/l, no c/c/e\n Tele: NSR with occasional single and paired PVCs\n A/P:\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 483387,
"text": "Demographics\n Attending MD:\n J.\n Admit diagnosis:\n SUPRAVENTRICULAR TACHYCARDIA SUPRAVENTRICULAR TACHYCARDIA A\n Code status:\n Height:\n Admission weight:\n 58 kg\n Daily weight:\n Allergies/Reactions:\n Paxil (Oral) (Paroxetine Hcl)\n Unknown;\n Benadryl (Oral) (P-Ephed Hcl/Dp-Hydram Hcl)\n Unknown;\n Buspar (Oral) (Buspirone Hcl)\n Unknown;\n Levaquin (Oral) (Levofloxacin)\n Unknown;\n Adhesive Tape (Topical)\n Unknown;\n Precautions:\n PMH:\n CV-PMH: Arrhythmias\n Additional history: breast and bladder CA, SVT, anxiety, elevated\n cholesterol\n total abd hysterectomy & salpingoophrectomy ', left breast CA s/p\n left lumpectomy and radiation, papillary bladder ca dx s/p\n multiple resections and chemotherapy, finished . uretereal\n stent\n Surgery / Procedure and date: SVT ablation ; complicated course \n hours on table to identify difficult tract, c/b hypotension requiring\n dopamine and RHC with swan placement to monitor small pericardial\n effusion.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:125\n D:62\n Temperature:\n 99.4\n Arterial BP:\n S:131\n D:66\n Respiratory rate:\n 20 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 93% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,479 mL\n 24h total out:\n 1,125 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:53 AM\n Potassium:\n 4.3 mEq/L\n 02:53 AM\n Chloride:\n 109 mEq/L\n 02:53 AM\n CO2:\n 24 mEq/L\n 02:53 AM\n BUN:\n 13 mg/dL\n 02:53 AM\n Creatinine:\n 0.7 mg/dL\n 02:53 AM\n Glucose:\n 125 mg/dL\n 02:53 AM\n Hematocrit:\n 29.1 %\n 09:18 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: ccu 623\n Transferred to: fa 314\n Date & time of Transfer: \n"
},
{
"category": "General",
"chartdate": "2190-10-09 00:00:00.000",
"description": "ICU Event Note",
"row_id": 483246,
"text": "Clinician: Resident\n CCU post-cath check\n S: Patient currently reports mild midline chest pain, worsened with\n inspiration. The pain is relieved with percocet and has not worsened\n over the past 6 hours. She denies shortness of breath, cough,\n palpitations, dizziness, and groin pain. Her only other complaint is\n insomnia, which is her baseline at home.\n .\n O:\n Vitals: BP 115/64 (88-136/41-70), HR 84 (86-99), RR 20, SaO2 99% on RA\n Gen: A&O x2, lying comfortably in bed, NAD\n CV: RRR, nl S1, S2, no murmurs, rubs or gallops appreciated\n Pulm: CTAB with scattered expiratory wheezes\n Groin: Swan catheter in place in rt femoral, bandage over left femoral\n cath site c/d/i. Nontender bilaterally, minimal ecchymoses, no\n palpable hematoma and no bruits bilaterally.\n Extrem: 2+ DP and PT pulses b/l, no c/c/e\n Tele: NSR with occasional single and paired PVCs\n A/P: 66 y/o lady with h/o SVT now with pericardial effusion s/p\n attempted ablation.\n -will repeat cath check in AM\n -close BP monitoring overnight; may need emergent pericardiocentesis if\n becomes hypotensive\n -Hct in AM\n -continue to monitor on telemetry\n -repeat TTE in AM to assess size/progression of effusion\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 483329,
"text": "Pericardial effusion (without tamponade)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 483330,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n TODAY SR NO ECT BP STABLE SINCE 500CC FLUID BOLLUS LAST NIGHT ,CVP 21\n . NO BLEEDING FROM EITHER GROIN ,DP PALP . CARDIAC ECHO DONE .BS CL,SAT\n 93 RM AIR .TAKING PO ,POS BS ,NO STOOL.FOLEY DC 1230 DTV 830 PM. OOB\n TO CHAIR,TOL WELL .ALERT ,OX3 .CO SEVERE PAIN IN CHEST DUE TO\n PROCEDURE NOT RELEIVED BY PERCOCETTE ,TORADOL IV GIVEN C RELEIF.PT\n TAKES AT HOME TID,ORDER OBTAINED FOR PRN HERE .ALSO WANTS\n SLEEPING PILL TONIGHT. AM HCT 29 ,STABLE\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 483331,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n TODAY SR NO ECT BP STABLE SINCE 500CC FLUID BOLLUS LAST NIGHT ,CVP 21\n . NO BLEEDING FROM EITHER GROIN ,DP PALP . CARDIAC ECHO DONE ,SM\n PERICARDIAL EFFUSSION . NO RETROPERITONEAL BLEED BY CT SCAN,INITIAL\n HCT DROP P PROCEDURE , NOW STABLE 29 .BS CL,SAT 93 RM AIR .TAKING PO\n ,POS BS ,NO STOOL.FOLEY DC 1230 DTV 830 PM. OOB TO CHAIR,TOL WELL\n .ALERT ,OX3 .CO SEVERE PAIN IN CHEST DUE TO PROCEDURE NOT RELEIVED BY\n PERCOCETTE ,TORADOL IV GIVEN C RELEIF.PT TAKES AT HOME TID,ORDER\n OBTAINED FOR PRN HERE .ALSO WANTS SLEEPING PILL TONIGHT.\n PLAN MONITOR FOR BLEEDING ,HYPOTENSION,WORSENING OF PERICARDIAL\n EFFUSSION,PAIN CONTROL C TORADOL ,MANAGE ANXIETY .I\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 483234,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n # Pericardial Effusion/PUMP: Complicated SVT ablation procedure with ?\n perofration. TTE focused view with 1.4 cm anterior effusion. s/p RHC\n and swan ganz in place. Heparin reversed in cath lab with protamine.\n ? difficulty crossing LV concernig for AS.\n - if RA pressure increase (currently 20) or BP drops will need emergent\n pericardiocentesis\n - repeat TTE in AM\n - post cath check\n .\n # RHYTHM: Currently in sinus rhthm. Her SVT with evidence of left\n lateral bypass tract and pre-excitation. Incomplete ablation procedure\n as above.\n - monitor on tele\n - will need full dose ASA on discharge given extensive scarring during\n the procedure\n .\n # CORONARIES: No known CAD. Her current chest pain is most likely due\n to hemopericardium.\n - holding ASA for now as above.\n .\n # Extensive groin manipulation: During the procedures today.\n - monitor for any evidence of RP bleed, low thresh-hold to scan\n .\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 483236,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n Pericardial effusion (without tamponade)\n Assessment:\n SVT ablation c/b 1.4 cm anterior effusion seen on TTE. Swan Catheter\n placed in RA. Patient arrived c/o CP (procedural from ablation in\n combination with pericardial effusion.\n Action:\n o Hemodynamic monitoring- team placed radial aline. Transduced\n RA swan.\n o BP maintained with dopamine gtt, goal MAP > 65.\n o Right and left groin sites monitored for s/s bleeding\n Response:\n o Right radial aline placed, right femoral aline d/c\nd at 1845-\n ACT 135 at that time.\n o Dopamine gtt weaned to off.\n o Right and left groin sites dry and intact- Swan and side-arm\n remains in right groin. Pedal pulses easily palpable.\n Plan:\n Continue hemodynamic monitoring. BEdrest. Monitor for c/o CP- treat, as\n well as baseline anxiety. Notify team if RA pressure > 20. Please\n collect am labs at 1205 per CCU resident request. Monitor bilateral\n groin sites and pedal pulses. Monitor for s/s RP bleed, or worsening\n effusion. To have Xray, and re-peat ECHO.\n"
},
{
"category": "Physician ",
"chartdate": "2190-10-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 483229,
"text": "Chief Complaint: Pericardial effusion s/p SVT ablation\n HPI:\n 66-year-old lady with history of breast and bladder cancers was\n admitted for elective EPS with ablation for SVT. She first noted\n palpitations approximately 16 years ago in the setting of high\n emotional distress when her son was killed while in the service.\n Since then, she has had palpitations in the setting of\n chemotherapy, and over the past years has had no more than \n episodes per year. However, on the day of her most recent\n cystoscopy on at , she\n experienced a tachycardia, which was terminated after she\n received intravenous Lopressor. The same tachycardia occurred on\n for which she presented to \n Emergency Room, where the tachycardia was terminated with\n intravenous adenosine. The tracings of the tachycardia were reviewed by\n her Electrophysiologist, Dr., and thought be a narrow\n complex tachycardia at 150 beats/minute with an RP interval of 100-120\n msec. However, immediately post adenosine, there was evidence of sinus\n rhythm with a fully pre-excited QRS complex consistent with a\n left lateral bypass tract. Since the Emergency Room visit, she\n has been on low-dose atenolol without further recurrences of the\n arrhythmia. Dr. recommended EPS with ablation and the\n patient was admitted today for the procedure.\n .\n During the procedure she developed hypotension to SBP of 77 mm HG.\n This responded to IVF and dopamine infusion to SBP of 130s. Patient\n was mentating appropriately. Focal views of TTE showed\n noncircumferential pericardial effusion with mild RA collapse without\n RV collapse. Her heparin was reversed with protamine. PA\n catheterization showed preserved CO, no equalization of filling\n pressures, and preserved Y descent on RA tracing. This suggested\n nonhemodynamically significant effusion. Patient was admitted to CCU\n with PA catheter for close hemodynamic monitoring.\n .\n On arrival patient complained of stable pleuritic chest pain which she\n had since the cath lab. She denied any shortness of breath. No other\n complaints.\n .\n REVIEW OF SYSTEMS: The patient denies fever, chills, headaches, blurred\n vision, constipation, nausea, vomitting, shortness of breath, PND,\n orhtopnea, lower extremity edema. No history of pulmonary embolus,\n DVT, stroke, melena, BRBPR, blood in urine.\n .\n Allergies:\n Paxil (Oral) (Paroxetine Hcl)\n Unknown;\n Benadryl (Oral) (P-Ephed Hcl/Dp-Hydram Hcl)\n Unknown;\n Buspar (Oral) (Buspirone Hcl)\n Unknown;\n Levaquin (Oral) (Levofloxacin)\n Unknown;\n Adhesive Tape (Topical)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Atenolol 25mg daily, last dose \n Lunesta 2mg qhs\n Alprazolam 0.25mg daily in the am, tablet at noon, 1 tablet\n at night PRN\n Simvastatin 30mg daily\n MVI daily\n Vitamin D daily\n Vitamin B12 500mcg daily\n Calcium, magnesium daily\n Fish oil 1000mg daily\n Asa 81mg daily\n Past medical history:\n Family history:\n Social History:\n 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension\n 2. CARDIAC HISTORY:\n -CABG: N/A\n -PERCUTANEOUS CORONARY INTERVENTIONS: N/A\n -PACING/ICD: N/A\n 3. OTHER PAST MEDICAL HISTORY:\n - Total abdominal hysterectomy and salpingoophrectomy r/t\n endometriosis\n - Left breast cancer diagnosed s/p Left lumpectomy and\n radiation therapy\n - Papillary bladder cancer diagnosed s/p multiple resections\n and chemotherapy, finished \n - s/p right ureteral stent, ? transitional cell cancer of\n the right ureteral orifice\n - Anxiety\n .\n Unremarkable for any cardiac disease\n .\n Lives with: husband\n Occupation: retired\n ETOH: no\n Tobacco: 35 years/ 1ppd, quit in \n Contact person upon discharge: Husband and son: \n Home Services: NO:\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.6\nC (96\n Tcurrent: 35.6\nC (96\n HR: 97 (93 - 100) bpm\n BP: 102/57(74) {96/54(71) - 106/59(76)} mmHg\n RR: 17 (17 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 13 (13 - 20)mmHg\n Total In:\n 2,166 mL\n PO:\n 120 mL\n TF:\n IVF:\n 2,046 mL\n Blood products:\n Total out:\n 0 mL\n 690 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,476 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n VS: T=96 BP=103/58 HR=97 RR=17O2 sat= 98% 2LNC\n GENERAL: Pleasant lady, in NAD. Lying down flat, Oriented x3. Mood,\n affect appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor\n or cyanosis of the oral mucosa. No xanthalesma.\n NECK: Unable to assess JVP appropriately given the patient's position.\n CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: Resp were unlabored, no accessory muscle use. CTAB in anterior\n lung fields, no crackles, wheezes or rhonchi.\n ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n EXTREMITIES: No c/c/e.\n SKIN: No stasis dermatitis.\n PULSES:\n Right: DP 2+ Left: DP 2+\n .\n LABS/STUDIES\n ECG: at 7:23 AM\n NSR, rate in 70s, nl axis, early R wave transition in precordial leads,\n no acute ST-T changes compared to\n .\n ECG: at 11:58 AM\n Narrow complex tachycardia, rate in 140s, early R wave transition. No\n acute ST-T wave changes.\n .\n TELEMETRY: N/A\n .\n 2D-ECHOCARDIOGRAM Focused Views:\n Left ventricular wall thickness, cavity size and regional/global\n systolic function are normal (LVEF >55%). Right ventricular chamber\n size and free wall motion are normal. There is a small to moderate\n sized pericardial effusion primarily around the right atrium and right\n ventricle with minimal around the apex and inferolateral wall. There is\n mild right ventricular diastolic collapse.\n IMPRESSION: Mild-moderate loculated anterior pericardial effusion with\n echocardiographic evidence for increased pericardial pressure.\n .\n ETT: N/A\n .\n PA CATH/HEMODYNAMICS: Prelim\n RAP 20, PCWP 17, Arterial oxygen 98%, RV oxygen sat 71%\n .\n EPS :\n Left lateral ventricular pre-excitation. Retrograde VA block via BT at\n 350 msec. Anterograde BT block at 300 msec. Atypical Induced\n orthodromic AVRT, CL 400 msec via left lateral BT.\n Difficulty crossing AV. Ablations were performed primarily at the\n entrent atrial acitivation site during Vpacing. Also slow pathway\n ablation were performed to prevent initiation of the AVRT. Ablation\n procedure was incomplete given hypotension as above.\n .\n LABORATORY DATA:\n See below.\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 66 y/o lady with h/o SVT now with pericardial effusion s/p attempted\n ablation.\n .\n # Pericardial Effusion/PUMP: Complicated SVT ablation procedure with ?\n perofration. TTE focused view with 1.4 cm anterior effusion. s/p RHC\n and swan ganz in place. Heparin reversed in cath lab with protamine.\n ? difficulty crossing LV concernig for AS.\n - if RA pressure increase (currently 20) or BP drops will need emergent\n pericardiocentesis\n - repeat TTE in AM\n - post cath check\n .\n # RHYTHM: Currently in sinus rhthm. Her SVT with evidence of left\n lateral bypass tract and pre-excitation. Incomplete ablation procedure\n as above.\n - monitor on tele\n - will need full dose ASA on discharge given extensive scarring during\n the procedure\n .\n # CORONARIES: No known CAD. Her current chest pain is most likely due\n to hemopericardium.\n - holding ASA for now as above.\n .\n # Extensive groin manipulation: During the procedures today.\n - monitor for any evidence of RP bleed, low thresh-hold to scan\n .\n # H/o breast CA and papillary bladder CA:\n - need out patient follow up.\n .\n FEN: NPO for now; could advance diet to cardiac heart healthy diet in\n AM if she is hemodynamically stable; replete lytes prn\n .\n ACCESS: PIV's, left Aline\n .\n PROPHYLAXIS:\n -DVT ppx: will require sc heparin once pericardial effusion is stable.\n .\n CODE: Full Code\n .\n COMM: , cell , home \n .\n DISPO: CCU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 PM\n PA Catheter - 05:30 PM\n Arterial Line - 06:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 483237,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n Pericardial effusion (without tamponade)\n Assessment:\n SVT ablation c/b 1.4 cm anterior effusion seen on TTE. Swan Catheter\n placed in RA. Patient arrived c/o CP (procedural from ablation in\n combination with pericardial effusion.\n Action:\n o Hemodynamic monitoring- team placed radial aline. Transduced\n RA swan.\n o BP maintained with dopamine gtt, goal MAP > 65.\n o Right and left groin sites monitored for s/s bleeding\n Response:\n o Right radial aline placed, right femoral aline d/c\nd at 1845-\n ACT 135 at that time.\n o Dopamine gtt weaned to off.\n o Right and left groin sites dry and intact- Swan and side-arm\n remains in right groin. Pedal pulses easily palpable.\n Plan:\n Continue hemodynamic monitoring. Bedres while lines in placet. Monitor\n for c/o CP- treat, as well as baseline anxiety. Notify team if RA\n pressure > 20. Please collect am labs at 1205 per CCU resident request.\n Monitor bilateral groin sites and pedal pulses. Monitor for s/s RP\n bleed, or worsening effusion. To have Xray, and re-peat ECHO.\n"
},
{
"category": "Physician ",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 483296,
"text": "Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 05:30 PM\n PA CATHETER - START 05:30 PM\n ARTERIAL LINE - START 06:03 PM\n NASAL SWAB - At 06:16 PM\n CORDIS/INTRODUCER - STOP 06:24 PM\n This AM, patient reports feeling well overall. Continues to have mild\n anterior chest pain, worsened with inspiration and responsive to\n percocet. Otherwise, SOB, palpitations, dizziness, groin pain\n or other issues currently.\n Post cath-checks at midnight and 6 am wnl\n No events on telemetry overnight\n Prelim read CT abd/pelv: mod pericardial effuson w/o frank collapse of\n RA, rt fem line terminating at cavoatrial junction, no rp blead or\n large hematoma in groin, L lobe hepatic cyst, mesentery\n (nonspecific, correlate w/labs re pancreatitis)\n Allergies:\n Paxil (Oral) (Paroxetine Hcl)\n Unknown;\n Benadryl (Oral) (P-Ephed Hcl/Dp-Hydram Hcl)\n Unknown;\n Buspar (Oral) (Buspirone Hcl)\n Unknown;\n Levaquin (Oral) (Levofloxacin)\n Unknown;\n Adhesive Tape (Topical)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.1\nC (98.8\n HR: 96 (84 - 100) bpm\n BP: 108/55(74) {96/54(71) - 108/59(76)} mmHg\n RR: 21 (13 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 24 (13 - 24)mmHg\n Total In:\n 2,385 mL\n 596 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,145 mL\n 596 mL\n Blood products:\n Total out:\n 830 mL\n 180 mL\n Urine:\n 280 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,555 mL\n 417 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n GENERAL: Oriented x3, NAD. Lying in bed flat, Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI.\n NECK: supple, Unable to assess JVP appropriately given the patient's\n position.\n CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: Resp were unlabored, no accessory muscle use. CTAB in posterior\n lung fields, no scattered wheezes anteriorly\n ABDOMEN: +BS, Soft, NTND. No HSM or tenderness.\n EXTREMITIES: No c/c/e.\n Groin: Rt femoral swan in place. No femoral hematomas or bruits.\n Minimal ecchymoses or tenderness to palpation bilaterally\n PULSES:\n Right: DP 2+ Left: DP 2+ Peripheral Vascular: (Right radial pulse:\n present), (Left radial pulse: present), (Right DP pulse present), (Left\n DP pulse: Present)\n Neurologic: Responds to: verbal stimuli\n Labs / Radiology\n 176 K/uL\n 9.4 g/dL\n 125 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 28.9 %\n 10.1 K/uL\n [image002.jpg]\n 02:53 AM\n WBC\n 10.1\n Hct\n 28.9\n Plt\n 176\n Cr\n 0.7\n Glucose\n 125\n Other labs: PT / PTT / INR:13.1/27.8/1.1, Mg++:1.7 mg/dL\n Assessment and Plan\n 66 y/o lady with h/o SVT now with pericardial effusion s/p attempted\n ablation.\n .\n # Pericardial Effusion/PUMP: Complicated SVT ablation procedure with ?\n perforation. TTE focused view with 1.4 cm anterior effusion. s/p RHC\n and swan ganz in place. Heparin reversed in cath lab with protamine.\n ? difficulty crossing LV concerning for AS.\n - if RA pressure increase (currently 20) or BP drops will need emergent\n pericardiocentesis\n - repeat TTE in AM\n - post cath checks wnl\n .\n # RHYTHM: Currently in sinus rhthm. Her SVT with evidence of left\n lateral bypass tract and pre-excitation. Incomplete ablation procedure\n as above.\n - monitor on tele\n - will need full dose ASA on discharge given extensive scarring during\n the procedure\n .\n # CORONARIES: No known CAD. Her current chest pain is most likely due\n to hemopericardium.\n - holding ASA for now as above.\n .\n # Extensive groin manipulation: During the procedures today.\n - monitor for any evidence of RP bleed\n - CT abd/pelv this AM\n f/u final read\n .\n # H/o breast CA and papillary bladder CA:\n - need out patient follow up.\n .\n FEN: NPO for now; could advance diet to cardiac heart healthy diet in\n AM if she is hemodynamically stable; replete lytes prn\n .\n ACCESS: PIV's, left Aline\n .\n PROPHYLAXIS:\n -DVT ppx: will require sc heparin once pericardial effusion is stable.\n .\n CODE: Full Code\n .\n COMM: , cell , home \n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 PM\n PA Catheter - 05:30 PM\n Arterial Line - 06:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 483314,
"text": "Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 05:30 PM\n PA CATHETER - START 05:30 PM\n ARTERIAL LINE - START 06:03 PM\n NASAL SWAB - At 06:16 PM\n CORDIS/INTRODUCER - STOP 06:24 PM\n This AM, patient reports feeling well overall. Continues to have mild\n anterior chest pain, worsened with inspiration and responsive to\n percocet. Otherwise, denies SOB, palpitations, dizziness, groin pain\n or other issues currently.\n Post cath-checks at midnight and 6 am wnl\n No events on telemetry overnight.\n At 3am, patient transiently Hypotensive to SBP 80s, responsive to 500cc\n IV fluid bolus. No pulsus. Also Hct drop from 39 -> 32.4 -> 28.9, so\n CT abd/pel obtained.\n Prelim read CT abd/pelv: mod pericardial effuson w/o frank collapse of\n RA, rt fem line terminating at cavoatrial junction, no rp blead or\n large hematoma in groin, L lobe hepatic cyst, mesentery\n (nonspecific, correlate w/labs re pancreatitis)\n Allergies:\n Paxil (Oral) (Paroxetine Hcl)\n Unknown;\n Benadryl (Oral) (P-Ephed Hcl/Dp-Hydram Hcl)\n Unknown;\n Buspar (Oral) (Buspirone Hcl)\n Unknown;\n Levaquin (Oral) (Levofloxacin)\n Unknown;\n Adhesive Tape (Topical)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.1\nC (98.8\n HR: 96 (84 - 100) bpm\n BP: 108/55(74) {96/54(71) - 108/59(76)} mmHg\n RR: 21 (13 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 24 (13 - 24)mmHg\n Total In:\n 2,385 mL\n 596 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,145 mL\n 596 mL\n Blood products:\n Total out:\n 830 mL\n 180 mL\n Urine:\n 280 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,555 mL\n 417 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n GENERAL: Oriented x3, NAD. Lying in bed flat, Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI.\n NECK: supple, Unable to assess JVP appropriately given the patient's\n position.\n CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: Resp were unlabored, no accessory muscle use. CTAB in\n posterior lung fields, no scattered wheezes anteriorly\n ABDOMEN: +BS, Soft, NTND. No HSM or tenderness.\n EXTREMITIES: No c/c/e.\n Groin: Rt femoral swan in place. No femoral hematomas or bruits.\n Minimal ecchymoses or tenderness to palpation bilaterally\n PULSES:\n Right: DP 2+ Left: DP 2+ Peripheral Vascular: (Right radial pulse:\n present), (Left radial pulse: present), (Right DP pulse present), (Left\n DP pulse: Present)\n Neurologic: Responds to: verbal stimuli\n Labs / Radiology\n 176 K/uL\n 9.4 g/dL\n 125 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 28.9 %\n 10.1 K/uL\n [image002.jpg]\n 02:53 AM\n WBC\n 10.1\n Hct\n 28.9\n Plt\n 176\n Cr\n 0.7\n Glucose\n 125\n Other labs: PT / PTT / INR:13.1/27.8/1.1, Mg++:1.7 mg/dL\n Assessment and Plan\n 66 y/o lady with h/o SVT now with pericardial effusion s/p attempted\n ablation.\n .\n # Pericardial Effusion/PUMP: Complicated SVT ablation procedure with ?\n perforation. TTE focused view with 1.4 cm anterior effusion. s/p RHC\n and swan ganz in place. Heparin reversed in cath lab with protamine.\n ? difficulty crossing LV concerning for AS. TTE in am (prelim read)\n shows small anterior pericardial effusion, not amenable to intervention\n at present\n - if RA pressure increase (currently 20) or BP drops will need emergent\n pericardiocentesis\n - f/u TTE read\n - will likely pull groin line this AM\n .\n # RHYTHM: Currently in sinus rhthm. Her SVT with evidence of left\n lateral bypass tract and pre-excitation. Incomplete ablation procedure\n as above.\n - monitor on tele\n - will need full dose ASA on discharge given extensive scarring during\n the procedure\n .\n # CORONARIES: No known CAD. Her current chest pain is most likely due\n to hemopericardium.\n - holding ASA for now as above.\n .\n # Extensive groin manipulation: During the procedures today.\n - monitor for any evidence of RP bleed\n - CT abd/pelv this AM not concerning for RP bleed on prelim\n f/u final\n read\n - Hct falling\n will continue to monitor closely\n .\n # H/o breast CA and papillary bladder CA:\n - need out patient follow up.\n .\n FEN: NPO for now; could advance diet to cardiac heart healthy diet in\n AM if she is hemodynamically stable; replete lytes prn\n -will start IVF maintenance if patient remains NPO\n .\n ACCESS: PIV's, left Aline, rt groin PA cath\n .\n PROPHYLAXIS:\n -DVT ppx: will require sc heparin once pericardial effusion is stable.\n - TEDs for now\n .\n CODE: Full Code\n .\n COMM: , cell , home \n .\n DISPO: CCU for now, possible callout to floor later today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 PM\n PA Catheter - 05:30 PM\n Arterial Line - 06:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 483233,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 483286,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n Pericardial effusion (without tamponade)\n Assessment:\n c/o chest discomfort with deep inspiration. Right groin SG line\n intact, cvp16-22. MAP < 60 x 1hr. palp pedal pulses, foot warm to\n touch. AM hct 28 (down from 32 on admission) right groin D&I, no\n bleeding/hematoma noted. Hr 80\ns sr no vea noted.\n Action:\n NS 500 cc bolus given for low MAP, CT scan for possible RP bleed.\n Percocet for chest discomfort.\n Response:\n MAP improved after fluid bolus, chest pain relieved with percocet.\n Waiting for results of ct scan.\n Plan:\n Monitor bp, keep map > 60. check hct @ 0900. check results of ct\n scan. Monitor pulses, check groin for bleeding/hematoma. Percocet for\n pain.\n"
},
{
"category": "Nursing",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 483360,
"text": "67 yo female w. pmh including SVT as well as breast and bladder CA &\n anxiety.\n - admit CCU after elective SVT ablation. Procedure duration approx.\n 8 hours, towards end patient became hypotensive requiring dopamine,\n cardiac ECHO found small pericardial effusion, RHC performed & Swan\n placed. Admitted CCU for swan management & close monitoring overnight.\n TODAY SR NO ECT BP STABLE SINCE 500CC FLUID BOLLUS LAST NIGHT ,CVP 21\n . NO BLEEDING FROM EITHER GROIN ,DP DOP. CARDIAC ECHO DONE ,SM\n PERICARDIAL EFFUSSION . NO RETROPERITONEAL BLEED BY CT SCAN,INITIAL\n HCT DROP P PROCEDURE , NOW STABLE 29 .BS CL,SAT 93 RM AIR .TAKING PO\n ,POS BS ,NO STOOL.FOLEY DC 1230 DTV 830 PM. OOB TO CHAIR, AMBULATING\n IN \n,TOL WELL .ALERT ,OX3 .CO SEVERE PAIN IN CHEST DUE TO\n PROCEDURE NOT RELEIVED BY PERCOCETTE ,TORADOL IV GIVEN C RELEIF.PT\n TAKES XANAX AT HOME TID,ORDER OBTAINED FOR PRN HERE .ALSO WANTS\n SLEEPING PILL TONIGHT.\n PLAN MONITOR FOR BLEEDING ,HYPOTENSION,WORSENING OF PERICARDIAL\n EFFUSSION,PAIN CONTROL C TORADOL ,MANAGE ANXIETY .\n"
},
{
"category": "Physician ",
"chartdate": "2190-10-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 483319,
"text": "Chief Complaint:\n 24 Hour Events:\n CORDIS/INTRODUCER - START 05:30 PM\n PA CATHETER - START 05:30 PM\n ARTERIAL LINE - START 06:03 PM\n NASAL SWAB - At 06:16 PM\n CORDIS/INTRODUCER - STOP 06:24 PM\n This AM, patient reports feeling well overall. Continues to have mild\n anterior chest pain, worsened with inspiration and responsive to\n percocet. Otherwise, denies SOB, palpitations, dizziness, groin pain\n or other issues currently.\n Post cath-checks at midnight and 6 am wnl\n No events on telemetry overnight.\n At 3am, patient transiently Hypotensive to SBP 80s, responsive to 500cc\n IV fluid bolus. No pulsus. Also Hct drop from 39 -> 32.4 -> 28.9, so\n CT abd/pel obtained.\n Prelim read CT abd/pelv: mod pericardial effuson w/o frank collapse of\n RA, rt fem line terminating at cavoatrial junction, no rp blead or\n large hematoma in groin, L lobe hepatic cyst, mesentery\n (nonspecific, correlate w/labs re pancreatitis)\n Allergies:\n Paxil (Oral) (Paroxetine Hcl)\n Unknown;\n Benadryl (Oral) (P-Ephed Hcl/Dp-Hydram Hcl)\n Unknown;\n Buspar (Oral) (Buspirone Hcl)\n Unknown;\n Levaquin (Oral) (Levofloxacin)\n Unknown;\n Adhesive Tape (Topical)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.1\nC (98.8\n HR: 96 (84 - 100) bpm\n BP: 108/55(74) {96/54(71) - 108/59(76)} mmHg\n RR: 21 (13 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 24 (13 - 24)mmHg\n Total In:\n 2,385 mL\n 596 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,145 mL\n 596 mL\n Blood products:\n Total out:\n 830 mL\n 180 mL\n Urine:\n 280 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,555 mL\n 417 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///24/\n Physical Examination\n GENERAL: Oriented x3, NAD. Lying in bed flat, Mood, affect\n appropriate.\n HEENT: NCAT. Sclera anicteric. EOMI.\n NECK: supple, Unable to assess JVP appropriately given the patient's\n position.\n CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.\n LUNGS: Resp were unlabored, no accessory muscle use. CTAB in\n posterior lung fields, no scattered wheezes anteriorly\n ABDOMEN: +BS, Soft, NTND. No HSM or tenderness.\n EXTREMITIES: No c/c/e.\n Groin: Rt femoral swan in place. No femoral hematomas or bruits.\n Minimal ecchymoses or tenderness to palpation bilaterally\n PULSES:\n Right: DP 2+ Left: DP 2+ Peripheral Vascular: (Right radial pulse:\n present), (Left radial pulse: present), (Right DP pulse present), (Left\n DP pulse: Present)\n Neurologic: Responds to: verbal stimuli\n Labs / Radiology\n 176 K/uL\n 9.4 g/dL\n 125 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 13 mg/dL\n 109 mEq/L\n 140 mEq/L\n 28.9 %\n 10.1 K/uL\n [image002.jpg]\n 02:53 AM\n WBC\n 10.1\n Hct\n 28.9\n Plt\n 176\n Cr\n 0.7\n Glucose\n 125\n Other labs: PT / PTT / INR:13.1/27.8/1.1, Mg++:1.7 mg/dL\n Assessment and Plan\n 66 y/o lady with h/o SVT now with pericardial effusion s/p attempted\n ablation.\n .\n # Pericardial Effusion/PUMP: Complicated SVT ablation procedure with ?\n perforation. TTE focused view with 1.4 cm anterior effusion. s/p RHC\n and swan ganz in place. Heparin reversed in cath lab with protamine.\n ? difficulty crossing LV concerning for AS. TTE in am (prelim read)\n shows small anterior pericardial effusion, not amenable to intervention\n at present\n - if RA pressure increase (currently 20) or BP drops will need emergent\n pericardiocentesis\n - f/u TTE read\n - will likely pull groin line this AM\n .\n # RHYTHM: Currently in sinus rhthm. Her SVT with evidence of left\n lateral bypass tract and pre-excitation. Incomplete ablation procedure\n as above.\n - monitor on tele\n - will need full dose ASA on discharge given extensive scarring during\n the procedure\n .\n # CORONARIES: No known CAD. Her current chest pain is most likely due\n to hemopericardium.\n - holding ASA for now as above.\n .\n # Extensive groin manipulation: During the procedures today.\n - monitor for any evidence of RP bleed\n - CT abd/pelv this AM not concerning for RP bleed on prelim\n f/u final\n read\n - Hct falling\n will continue to monitor closely\n .\n # H/o breast CA and papillary bladder CA:\n - need out patient follow up.\n .\n FEN: NPO for now; could advance diet to cardiac heart healthy diet in\n AM if she is hemodynamically stable; replete lytes prn\n -will start IVF maintenance if patient remains NPO\n .\n ACCESS: PIV's, left Aline, rt groin PA cath\n .\n PROPHYLAXIS:\n -DVT ppx: will require sc heparin once pericardial effusion is stable.\n - TEDs for now\n .\n CODE: Full Code\n .\n COMM: , cell , home \n .\n DISPO: CCU for now, possible callout to floor later today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:00 PM\n PA Catheter - 05:30 PM\n Arterial Line - 06:03 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n per housestaff\n nothing to add\n Physical Examination\n per housestaff\n nothing to add\n Medical Decision Making\n per house staff\n nothingn to add\n Above discussed extensively with patient.\n Total time spent on patient care: 30 minutes.\n Additional comments:\n echo shows stable 1 cm effusion without evidence of tamponade by echo\n or pa line\n blood pressure stable\n pain from pericarditic irritation - treat with percocet and as needed\n toradol\n Remove pa line and a line today\n ------ Protected Section Addendum Entered By: \n on: 11:32 ------\n"
},
{
"category": "Radiology",
"chartdate": "2190-10-09 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1097635,
"text": ", J. 4:04 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for RP bleed.\n Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA\\SUPRAVENTRICULAR TACHYCARDIA ABLATION\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with complicated SVT ablation, now with decreasing BP and HCT\n concerning for RP bleed.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RP bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Mod pericardial effusion with intermediate density suggesting serosanguinous\n fluid wo/frank collapse/tamponade of RA\n\n R fem line terminates at cavoatrial junction\n\n No RP bleed, no large hematoma at 'stick' site\n\n L lobe hepatic likely cyst (could consider OP US)\n\n mesentery nonspecific - correlate with labs re pancreatitis. Consider 6\n month f/u\n\n d/ GWlms 5:30a\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-10-09 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1097634,
"text": " 4:04 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for RP bleed.\n Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA\\SUPRAVENTRICULAR TACHYCARDIA ABLATION\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with complicated SVT ablation, now with decreasing BP and HCT\n concerning for RP bleed.\n REASON FOR THIS EXAMINATION:\n Please evaluate for RP bleed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SAT 5:37 AM\n Mod pericardial effusion with intermediate density suggesting serosanguinous\n fluid wo/frank collapse/tamponade of RA\n\n R fem line terminates at cavoatrial junction\n\n No RP bleed, no large hematoma at 'stick' site\n\n L lobe hepatic likely cyst (could consider OP US)\n\n mesentery nonspecific - correlate with labs re pancreatitis. Consider 6\n month f/u\n\n d/ GWlms 5:30a\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Complicated SVT ablation, query retroperitoneal bleed.\n\n TECHNIQUE: MDCT axial images were obtained from the lung bases through the\n proximal thighs without intravenous or enteric contrast. Multiplanar\n reformats were derived.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: A right femoral intravenous line\n is seen coursing into the heart and terminating at the cavoatrial junction\n (scout image 1B, image 2). The visualized lungs demonstrate mild bibasilar\n atelectasis. There is no pleural effusion, pneumothorax, or pulmonary mass.\n The heart appears enlarged. There is a pericardial effusion with Hounsfield\n unit measurements in the range averaging approximately 30. The right atrium\n does not appear collapsed.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Evaluation of the solid organs\n is limited without intravenous contrast, but within this limitation, the\n gallbladder, spleen, adrenals, atrophic pancreas, and kidneys appear normal.\n There is a 5.0 x 4.4 cm fluid attenuating structure in the left lobe of the\n liver without obvious septation. Abdominal loops of bowel are unremarkable.\n There is no abdominal free air, free fluid, or pathologic lymphadenopathy.\n Mild mesenteric mistiness is seen, nonspecific finding itself. There is no\n abdominal lymphadenopathy. The abdominal aorta is normal in caliber and\n course demonstrates vascular calcifications.\n\n (Over)\n\n 4:04 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for RP bleed.\n Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA\\SUPRAVENTRICULAR TACHYCARDIA ABLATION\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Pelvic loops of bowel are\n unremarkable. A Foley catheter is seen within the bladder. The adnexa are\n unremarkable. There is no pelvic free air, free fluid, or pathologic\n lymphadenopathy.\n\n MUSCULOSKELETAL: There is no suspicious osteolytic or osteoblastic lesion.\n Multilevel degenerative changes are seen in the spine. Stranding is seen at\n the site of the right femoral groin stick, but there is no large hematoma.\n\n IMPRESSION:\n 1. No retroperitoneal bleed.\n 2. Mild to moderate sized pericardial effusion with indeterminate density\n measurements suggesting proteinaceous fluid or blood. No obvious right atrial\n compression. Recommend echocardiogram\n 3. Right femoral line with tip located at the cavoatrial junction.\n 4. Left lobe hepatic cyst; could consider outpatient ultrasound for further\n characterization.\n 5. No large hematoma at right femoral entry site.\n 6. Stranding in mesentery, nonspecific finding.\n\n COMMENT: These results were discussed with Dr. and by Dr. \n at 5:30 a.m.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-10-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1097604,
"text": " 9:15 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please evaluate for correct swan placement.\n Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA\\SUPRAVENTRICULAR TACHYCARDIA ABLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old woman with VT s/p unsuccessful ablation with hypotension and small\n pericardial effusion.\n REASON FOR THIS EXAMINATION:\n Please evaluate for correct swan placement.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after Swan-Ganz placement and\n with ventricular tachycardia after unsuccessful ablation.\n\n The central line inserted through the femoral approach is noted with its tip\n being most likely within the right atrium; it might be re-positioned toward\n the pulmonary arteries if precise measurement through the Swan-Ganz catheter\n needs to be undertaken. The heart size is top normal. Mediastinal position,\n contour and width are unremarkable. Lungs are essentially clear. There is no\n pleural effusion or pneumothorax.\n\n Findings were discussed with Dr. over the phone by Dr. \n at the time of dictation.\n\n"
}
] |
28,410 | 146,362 | 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD, agitated depression, and aspiration presenting from nursing home after being found unresponsive, hypotensive, hypoxic, and with evidence of GI bleed. | ARF: in setting of sepsis and hypovolemia, s/p volume resusitating. Resp distress: in setting of PNA and likely vasc leak with volume resuscitation, he is DNI and breathing has stabilized. - Correcting shock as above - Patient able to communicate with effort # Acute renal failure: likely pre-renal +/- ATN. - Correcting shock as above - Patient able to communicate with effort # Acute renal failure: likely pre-renal +/- ATN. - cautious volume resuscitation as above - abx as above 3) Acute blood loss anemia: patient has hx of severe PUD with gastritis and visible vessel now with BRBPR and decrease (although mild) in Hct. - cautious volume resuscitation as above - abx as above 3) Acute blood loss anemia: patient has hx of severe PUD with gastritis and visible vessel now with BRBPR and decrease (although mild) in Hct. ut i/pneumonia as cause] and possible GI bleed..patient is DNR/DNI and at one point was made CMO by nephew who is HCP ..CMO has now been reversed as patients condition has significantly improved .H/O decubitus ulcer (Present At Admission) Assessment: Extensive/chronic ducubs/ulcers located on left/right heels and coccyx Action: Wound care review/waffles boots applied /patient placed on kinair bed/re-position q2-4 Response: Observe daily for improvement Plan: Daily wound care as per extensive recs/wound care team to follow .H/O diabetes Mellitus (DM), Type II Assessment: Raised blood sugars > 150 Action: To commence q6 sliding scale Response: Aim for less < 150 Plan: To continue to monitor /diabetic diet .H/O dysphagia Assessment: Possible aspiration prior to admission, patient hyper extends neck/resulting in possible aspiration pneumonia Action: Speech/swallow evaluation Response: Evaluated as per save with thickened fluids pureed dirt/aspiration precautions, for which he taken thickened fluids well with assistance todayAntibiotics continue for possible pneumonia/UTI Plan: Monitor po intake with aspiration precautions..speech/swallow team to re-evauatel in 2 days .H/O gastrointestinal bleed, lower t BRBPR, GI Bleed, GIB) Assessment: Possible GI bleed on admission as PRB PR Action: Monitor serial HCTS and ghuaic all stool Response: hct stable, has not stooled since admission , b/p now stable 110=120 systolic hr 75-90bpm Plan: HCT stable at 27 [ baseline 26-28] transfuse <26, monitor b/p hr .H/O comfort care (CMO, Comfort Measures) Assessment: Patient is DNR/DNI but with poor presentation patient was made CMO Action: CMO was reversed Response: CMO was reversed because of patients response to fluids/iv antibiotics Plan: Continue to monitor patients condition and inform/update nephew who is HCP Resp distress: in setting of PNA and likely vasc leak with volume resuscitation, he is DNI and breathing has stabilized. - Correcting shock as above - Patient able to communicate with effort # Acute renal failure: likely pre-renal +/- ATN. - Correcting shock as above - Patient able to communicate with effort # Acute renal failure: likely pre-renal +/- ATN. Now treating with Vanc, Zosyn, IVF and will replete lytes. ARF: in setting of sepsis and hypovolemia, we are volume resusitating, trending UOP, CR pending. - Attempt to correct shock as above - Patient able to communicate with effort 5) Acute renal failure: likely pre-renal +/- ATN. - Attempt to correct shock as above - Patient able to communicate with effort 5) Acute renal failure: likely pre-renal +/- ATN. He is s/p aggressive volume resuscitation complicated by resp distress this resp distress has since stabilized and we will resume volume repletion 2. - Continue current management given patient appears to be clinically comfortable 3) Acute blood loss anemia on admission: patient has hx of severe PUD with gastritis and visible vessel now with BRBPR and decrease (although mild) in Hct. - Recheck labs this am, fluids prn for sepsis/hypovolemia 6) Dispo: Continue current management. - Continue current management given patient appears to be clinically comfortable - No intubation, so will bolus fluids carefully - Consider CXR today if develops increased hypoxia # Acute blood loss anemia on admission: patient has hx of severe PUD with gastritis and visible vessel now with BRBPR and decrease (although mild) in Hct. - Continue current management given patient appears to be clinically comfortable - No intubation, so will bolus fluids carefully - Consider CXR today if develops increased hypoxia # Acute blood loss anemia on admission: patient has hx of severe PUD with gastritis and visible vessel now with BRBPR and decrease (although mild) in Hct. - Continue current management given patient appears to be clinically comfortable - No intubation, so will bolus fluids carefully - Consider CXR today if develops increased hypoxia 3) Acute blood loss anemia on admission: patient has hx of severe PUD with gastritis and visible vessel now with BRBPR and decrease (although mild) in Hct. - No longer trending, patient has indwelling foley at baseline given neurogenic bladder from MS. 6) Dispo: Patient is currently comfort measures. - Continue fluids prn for sepsis/hypovolemia # Tachycardia: Has been in sinus with APCs. - Continue fluids prn for sepsis/hypovolemia # Tachycardia: Has been in sinus with APCs. | 30 | [
{
"category": "Physician ",
"chartdate": "2191-04-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322471,
"text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Family meeting and decision to make him comfort care only\n Has remianed persistently tachycardic\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 08:35 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: 36.2\nC (97.2\n HR: 125 (105 - 139) bpm\n BP: 93/46(58) {88/25(44) - 121/55(68)} mmHg\n RR: 22 (16 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,250 mL\n PO:\n TF:\n IVF:\n 1,250 mL\n Blood products:\n Total out:\n 540 mL\n 440 mL\n Urine:\n 540 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 710 mL\n -440 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG:\n Physical Examination\n Gen: lying in bed, tachypnic, but speaking\n HEENT: very dry oropharnyx\n CV: tachy RRR\n Chest: fair air movement\n Abd: soft, NT\n Ext: bilat wrapping of feet\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "ECG",
"chartdate": "2191-04-23 00:00:00.000",
"description": "Report",
"row_id": 297438,
"text": "Sinus tachycardia with premature atrial contractions. Left atrial\nabnormality. Poor R wave progression. Compared to the previous tracing\nof the ventricular rate is slightly faster.\n\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322506,
"text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Pt more alert this AM , VSS ,RR\n Action:\n Team spoke with nephew re this unexpected change\n Response:\n Decision was made for Pt to remain DNR/DNI but will receive\n antibiotics and fluid boluses as needed\n Plan:\n Cont DNR/DNI fluid bolus and antibiotics, dressing changes, Mso4 for\n comfort\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 322401,
"text": "TITLE:\n Chief Complaint: unresponsive, hypotension\n HPI:\n 80 year old man with hx of multiple sclerosis, UGIB, DM2, sacral\n pressure ulcer referred from after being found unresponsive and\n hypotensive. Early this AM he was found unresponsive by the nursing\n staff. Vital signs at the time were 98.8F, 140, 70/43 89%RA. He was put\n on 4L NC with O2sats up to 91%. He was then referred to the ED. In\n the ED he was 100.4 122 56/44 (automated) 80-100sbp on manual) and 100%\n on NRB. He received 2L of NS and 1 unit of pRBCs after being found to\n have BRBPR.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin in ED\n Zosyn in ED\n Flagyl in ED\n Infusions:\n Other ICU medications:\n Other medications:\n compazine 25 mg PR q6prn\n tylenol 325-650mg q24prn\n metoprolol 25 mg QID\n mirtazapine 30 mg qhs\n risperdal 0.5 mg qhs\n fleet enema prn\n bisacodyl 10 mg PR prn\n lorazepam 0.5-1mg q6prn\n Milk of Magnesium prn\n Vicodin 1 tab q4prn\n ground diet with pureed veg\n multivitamin with minerals\n lasix 10 mg daily\n lorazepam 0.25 mg q9am, q1pm\n pantoprazole 40 mg daily\n potassium chloride 20 mEq daily\n wellbutrin SR 150 mg \n Past medical history:\n Family history:\n Social History:\n Multiple Sclerosis\n Neurogenic bladder\n Myelodysplastic syndrome\n DM\n - PVD\n - non-healing bilateral ulcers\n Sepsis due to pneumonia\n Partial small bowel obstruction\n Upper gastrointestinal bleed ( with Ulcers in the stomach\n Ulcer in the cardia, near the GE junction (injection, thermal therapy)\n Marked friability in the stomach)\n Abdominal aortic aneurysm\n NC\n Occupation: retired\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives in . wife has advanced dementia also living\n at . nephew is HCP for both patient and patient's wife\n Review of systems:\n Unable to obtain due to mental status\n Flowsheet Data as of 12:20 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 119 (119 - 119) bpm\n BP: 96/25(44) {96/25(44) - 96/25(44)} mmHg\n RR: 21 (21 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 250 mL\n PO:\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 0 mL\n 80 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 170 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG 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: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : L>R, Wheezes : L>R, No(t) Diminished: ,\n No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Trace, Left: Trace, foot ulcers\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Cool, large sacral pressure ulcer with visible tendons\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, No(t) Sedated, No(t) Paralyzed, Tone: Normal.\n Pupils 2->1mm bilat. Oculocephalics intact. No neck stiffness or\n Kurnig\ns sign\n Labs / Radiology\n See below\n Fluid analysis / Other labs:\n Na 137 Cl 104 BUN 24 Glu 128 AGap=16\n K 5.0 CO2 17 Cr 1.4 (hemolyzed specimen)\n estGFR: 49/59 (click for details)\n CK: 63 MB: Notdone Trop-T: 0.20\n Comments: cTropnT: Notified G Camosse 1038 \n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n Ca: 8.4 Mg: 1.7 P: 5.2 D\n .\n WBC 18.9 Hb 8.4 Hct 26.4 Plt 408 MCV 103\n N:73 Band:21 L:2 M:3 E:0 Bas:0 Metas: 1\n Hypochr: 2+ Anisocy: 2+ Poiklo: OCCASIONAL Macrocy: 2+ Polychr: 1+\n Stipple: OCCASIONAL Tear-Dr: OCCASIONAL\n Comments: TOXIC GRANULATIONS\n .\n PT: 14.9 PTT: 38.8 INR: 1.3\n Imaging: : There is a small left-sided pleural effusion.\n Increased retrocardiac opacity with air bronchograms is concerning for\n a left lower lobe pneumonia. The mediastinal contours are unremarkable.\n The remainder of thelung is clear. There is no evidence of a\n pneumothorax. The osseous structures are unremarkable\n Microbiology: Blood Cx : NGTD\n ECG: sinus tach. LAD. unchanged from prior except for rate\n Assessment and Plan\n 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD,\n agitated depression, and aspiration presenting from nursing home after\n being found unresponsive, hypotensive, hypoxic, and with evidence of\n GI bleed.\n 1) Shock: currently with elevated lactate, bandemia and end-organ\n dysfunction (mental status and elevated Cr) in setting of likely\n infection, so sepsis would be most likely however co-existing GI bleed\n could be contributing as well. Sources of infection UTI, pneumonia,\n infected pressure ulcer. Patient at risk for hospital acquired\n pathogens. Given prior goal of care would prefer to avoid central lines\n if able put per HCP could be pursued.\n - IVF with peripheral lines for now\n - follow lactate\n - blood, urine cultures\n - abx: vanc/zosyn\n 2) Hypoxia: DDX pneumonia or early ARDS from urosepsis complicated by\n volume resuscitation. Currrently oxygenating well with NC and shovel\n mask.\n - cautious volume resuscitation as above\n - abx as above\n 3) Acute blood loss anemia: patient has hx of severe PUD with gastritis\n and visible vessel now with BRBPR and decrease (although mild) in Hct.\n - trend Hct q6\n - pRBC to target Hct >30\n - PPI\n 4) Altered Mental status: non-focal neuro exam in patient with history\n of agitated depression.\n - attempt to correct shock as above\n 5) Acute renal failure: likely pre-renal +/- ATN.\n - add-on urine lytes, review urine sediment\n - dose meds for GFR <20\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines: PIV\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: nephew is HCP (h)\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-23 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 322402,
"text": "TITLE: PGY 2 Admission Note\n Chief Complaint: unresponsive, hypotension\n HPI:\n 80 year old man with hx of multiple sclerosis, UGIB, DM2, sacral\n pressure ulcer referred from after being found unresponsive and\n hypotensive. Early this AM he was found unresponsive by the nursing\n staff. Vital signs at the time were 98.8F, 140, 70/43 89%RA. He was put\n on 4L NC with O2sats up to 91%. He was then referred to the ED. In\n the ED he was 100.4 122 56/44 (automated) 80-100sbp on manual) and 100%\n on NRB. He received 2L of NS and 1 unit of pRBCs after being found to\n have BRBPR.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin in ED\n Zosyn in ED\n Flagyl in ED\n Infusions:\n Other ICU medications:\n Other medications:\n compazine 25 mg PR q6prn\n tylenol 325-650mg q24prn\n metoprolol 25 mg QID\n mirtazapine 30 mg qhs\n risperdal 0.5 mg qhs\n fleet enema prn\n bisacodyl 10 mg PR prn\n lorazepam 0.5-1mg q6prn\n Milk of Magnesium prn\n Vicodin 1 tab q4prn\n ground diet with pureed veg\n multivitamin with minerals\n lasix 10 mg daily\n lorazepam 0.25 mg q9am, q1pm\n pantoprazole 40 mg daily\n potassium chloride 20 mEq daily\n wellbutrin SR 150 mg \n Past medical history:\n Family history:\n Social History:\n Multiple Sclerosis\n Neurogenic bladder\n Myelodysplastic syndrome\n DM\n - PVD\n - non-healing bilateral ulcers\n Sepsis due to pneumonia\n Partial small bowel obstruction\n Upper gastrointestinal bleed ( with Ulcers in the stomach\n Ulcer in the cardia, near the GE junction (injection, thermal therapy)\n Marked friability in the stomach)\n Abdominal aortic aneurysm\n NC\n Occupation: retired\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives in . wife has advanced dementia also living\n at . nephew is HCP for both patient and patient's wife\n Review of systems:\n Unable to obtain due to mental status\n Flowsheet Data as of 12:20 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 119 (119 - 119) bpm\n BP: 96/25(44) {96/25(44) - 96/25(44)} mmHg\n RR: 21 (21 - 21) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 250 mL\n PO:\n TF:\n IVF:\n 250 mL\n Blood products:\n Total out:\n 0 mL\n 80 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 170 mL\n Respiratory\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 100%\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG 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: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : L>R, Wheezes : L>R, No(t) Diminished: ,\n No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Bowel sounds present\n Extremities: Right: Trace, Left: Trace, foot ulcers\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Cool, large sacral pressure ulcer with visible tendons\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, No(t) Sedated, No(t) Paralyzed, Tone: Normal.\n Pupils 2->1mm bilat. Oculocephalics intact. No neck stiffness or\n Kurnig\ns sign\n Labs / Radiology\n See below\n Fluid analysis / Other labs:\n Na 137 Cl 104 BUN 24 Glu 128 AGap=16\n K 5.0 CO2 17 Cr 1.4 (hemolyzed specimen)\n estGFR: 49/59 (click for details)\n CK: 63 MB: Notdone Trop-T: 0.20\n Comments: cTropnT: Notified G Camosse 1038 \n cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi\n Ca: 8.4 Mg: 1.7 P: 5.2 D\n .\n WBC 18.9 Hb 8.4 Hct 26.4 Plt 408 MCV 103\n N:73 Band:21 L:2 M:3 E:0 Bas:0 Metas: 1\n Hypochr: 2+ Anisocy: 2+ Poiklo: OCCASIONAL Macrocy: 2+ Polychr: 1+\n Stipple: OCCASIONAL Tear-Dr: OCCASIONAL\n Comments: TOXIC GRANULATIONS\n .\n PT: 14.9 PTT: 38.8 INR: 1.3\n Imaging: : There is a small left-sided pleural effusion.\n Increased retrocardiac opacity with air bronchograms is concerning for\n a left lower lobe pneumonia. The mediastinal contours are unremarkable.\n The remainder of thelung is clear. There is no evidence of a\n pneumothorax. The osseous structures are unremarkable\n Microbiology: Blood Cx : NGTD\n ECG: sinus tach. LAD. unchanged from prior except for rate\n Assessment and Plan\n 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD,\n agitated depression, and aspiration presenting from nursing home after\n being found unresponsive, hypotensive, hypoxic, and with evidence of\n GI bleed.\n 1) Shock: currently with elevated lactate, bandemia and end-organ\n dysfunction (mental status and elevated Cr) in setting of likely\n infection, so sepsis would be most likely however co-existing GI bleed\n could be contributing as well. Sources of infection UTI, pneumonia,\n infected pressure ulcer. Patient at risk for hospital acquired\n pathogens. Given prior goal of care would prefer to avoid central lines\n if able put per HCP could be pursued.\n - IVF with peripheral lines for now\n - follow lactate\n - blood, urine cultures\n - abx: vanc/zosyn\n 2) Hypoxia: DDX pneumonia or early ARDS from urosepsis complicated by\n volume resuscitation. Currrently oxygenating well with NC and shovel\n mask.\n - cautious volume resuscitation as above\n - abx as above\n 3) Acute blood loss anemia: patient has hx of severe PUD with gastritis\n and visible vessel now with BRBPR and decrease (although mild) in Hct.\n - trend Hct q6\n - pRBC to target Hct >30\n - PPI\n 4) Altered Mental status: non-focal neuro exam in patient with history\n of agitated depression.\n - attempt to correct shock as above\n 5) Acute renal failure: likely pre-renal +/- ATN.\n - add-on urine lytes, review urine sediment\n - dose meds for GFR <20\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: Blood sugar well controlled\n Lines: PIV\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: nephew is HCP (h) \n (c) \n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-23 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 322403,
"text": "Chief Complaint: sepsis, hypotension, 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 80 yr old man with multi sclerosis was foudn this AM unresponsive at\n \n 98.8 HR 140 BP 70/40 89% RA - called EMS and brought to ED. Temp 100.4\n HR 122 BP 70/p - given 2 L NS 1 U PRBC and 100% NRB. rx with Vanco,\n Zosyn. Flagyl and sent to for further management\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Multiple Sclerosis - paraplegia and neurogenic bladder\n MDS\n Tyope 2 DM\n PVD\n bilat foot ulcers\n large sacral decub\n Hx of SBO \n EGd with bleeding visable vessel\n could not obtain\n Occupation: retired\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: lives at , as does his wife who has advanced\n dementia HCP is nephew\n Review of systems:\n Constitutional: No(t) Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Flowsheet Data as of 01:42 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 118 (117 - 121) bpm\n BP: 101/54(65) {91/25(44) - 101/55(65)} mmHg\n RR: 16 (16 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,250 mL\n PO:\n TF:\n IVF:\n 1,250 mL\n Blood products:\n Total out:\n 0 mL\n 80 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,170 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: cachetic, labored respirations\n Head, Ears, Nose, Throat: Poor dentition\n Cardiovascular: tachy RRR\n Respiratory / Chest: poor air movement,\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: large 5 cm left pedal ulcer with frankly purulent\n drainage, right heel ulcre to deep tissue but clean\n Skin: large Stage IV sacral decab with visible tendons\n Neurologic: responds minimally to voice, shakes head yes to pain\n Labs / Radiology\n 408\n 26.4\n 128\n 1.4\n 24\n 17\n 104\n 5\n 137\n 18.9\n [image002.jpg]\n Other labs: PT / PTT / INR://38.8/1.3, CK / CKMB / Troponin-T://63/\n 0.2, Differential-Neuts:73, Band:21, Ca++:8.4\n Fluid analysis / Other labs: UA > 50 WBC\n Imaging: CXR with air bronchograms in LLL\n Microbiology: Blood and Urine cultures pending\n ECG: sinus tach, LAD no acute changes\n Assessment and Plan\n 80 yr old man with hx of multipe sclerosis presents with septic shock\n and possible GI bleed.\n 1. Sepsis: Multiple potential etiologies with UTI and PNA most likely\n and possible oseto with bacteremia from left heel abscess - At this\n point, we must cover broadly with Vanco, Zosyn, pan culture, foley has\n been changed, foot films. We are given aggressive volume resustation\n with blood and IVF - however with his DNI status this is tenusous at\n best. We can trend MAP, UOP, and lactate. We have bolused with 5 L IVF\n and 2 u PRBC and he fluid responsive but is now progressing to\n resp distress. We have discussed CVL/pressors with HCP nephew who is on\n his way in to clarify goals of care but at this point it appears that\n resp distress may be most pressing and he is DNI.\n 2. Resp distress: in setting of PNA and likely vasc leak with volume\n resusitation, he is DNI and breathign is becoming labored. Again we\n will support with NRB and initae call to HCP nephew to ask to come in\n immediately. We cannot leave him in distress and will need to provide\n with medication for air hunger if he worsens.\n 3. ARF: in setting of sepsis and hypovolemia, we are volume\n resusitating, trending UOP\n 4. GI bleed: Possible recurrent gastritis, bleeding vessel, ischemia.\n At this point supportive care with blood.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 12:52 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: 2 phone calls to nephew who is HCP and en route\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322579,
"text": "Chief Complaint: sepsis, GI bleed, 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 80 yr old man with hx of multipe sclerosis presents with septic shock\n and possible GI bleed. Resp failure with hydration for resuscitation.\n 24 Hour Events:\n BLOOD CULTURED - At 09:45 AM\n PAN CULTURE - At 09:45 AM\n PCP said pt back to baseline clinically.\n Speech consult suggested thickened liquid diet.\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 05:52 AM\n Vancomycin - 07:54 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 Constitutional: No(t) Fatigue, No(t) Fever\n Respiratory: No(t) Cough, No(t) Dyspnea, breathing comfortably\n Gastrointestinal: Abdominal pain, mild,\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37\nC (98.6\n HR: 110 (90 - 128) bpm\n BP: 122/59(74) {98/39(54) - 132/70(75)} mmHg\n RR: 23 (17 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 1,183 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 1,183 mL\n Blood products:\n Total out:\n 1,070 mL\n 390 mL\n Urine:\n 1,070 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 363 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral 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 Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm, heels wrapped in gauze bandages\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful- UEs, no mvmt LEs,\n Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 289 K/uL\n 173 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 113 mEq/L\n 142 mEq/L\n 28.5 %\n 15.3 K/uL\n [image002.jpg]\n 09:32 AM\n 04:21 AM\n WBC\n 18.8\n 15.3\n Hct\n 33.1\n 28.5\n Plt\n 326\n 289\n Cr\n 1.2\n 1.1\n Glucose\n 92\n 173\n Other labs: Differential-Neuts:88.0 %, Band:7.0 %, Lymph:4.0 %,\n Mono:1.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:7.3 mg/dL, Mg++:1.9\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n 80 yr old man with hx of multipe sclerosis presents with septic shock\n and possible GI bleed.\n 1. Sepsis: Multiple potential etiologies with UTI and PNA most likely\n and possible osteo with bacteremia from left heel abscess and stage IV\n sacral decub - Covered broadly with Vanco, Zosyn, pending data from pan\n culture, foley has been changed, foot films.\n Clinically improved. He is s/p aggressive volume resuscitation\n complicated by resp distress\n this resp distress has since stabilized\n and we have resumed volume repletion.\n 2. Resp distress: in setting of PNA and likely vasc leak with volume\n resuscitation, he is DNI and breathing has stabilized. Watch carefully\n as resume hydration.\n 3. ARF: in setting of sepsis and hypovolemia, s/p volume resusitating.\n Cr improved 1.4--> 1.1.\n 4. GI bleed: Possible recurrent gastritis, bleeding vessel, ischemia.\n At this point supportive care with blood. Hct at baseline.\n 5. Code: Was CMO Saturday afternoon when severe resp distress. Now that\n he has improved we have discussed with nephew return to DNR/DNI status\n but will resume fluids, ABX and continue supportive care. Of he worsens\n again from a resp status we will readdress.\n ICU Care\n Nutrition: thickened liquids\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:19 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322581,
"text": "Chief Complaint: 80 year old male with MS, h/o UGIB, sacral and heel\n pressure ulcers admitted from with hypotension, hypoxemia, ARF and\n mental status changes.\n 24 Hour Events:\n - Managed to improve during the day. BP holding steady. Occasionally\n will become tachycardic but looks like ectopy (PVCs and APCs) - BP\n stable\n - Pan-cultured; all pending. On broad spectrum abx\n - Ordered for speech and swallow eval as he aspirates with all PO\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 11:27 AM\n Piperacillin/Tazobactam (Zosyn) - 05:52 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 121 (96 - 139) bpm\n BP: 115/59(73) {93/39(54) - 124/70(75)} mmHg\n RR: 24 (17 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 905 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 905 mL\n Blood products:\n Total out:\n 1,070 mL\n 190 mL\n Urine:\n 1,070 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 363 mL\n 715 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Abd: Soft, NTND\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: BS at\n left base), Difficult to assess\n Neuro: AAOx3\n Skin: pressure wounds on B heels, sacral decubitus ulcer\n Labs / Radiology\n 289 K/uL\n 9.5 g/dL\n 173 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 113 mEq/L\n 142 mEq/L\n 28.5 %\n 15.3 K/uL\n [image002.jpg]\n 09:32 AM\n 04:21 AM\n WBC\n 18.8\n 15.3\n Hct\n 33.1\n 28.5\n Plt\n 326\n 289\n Cr\n 1.2\n 1.1\n Glucose\n 92\n 173\n Other labs: Differential-Neuts:88.0 %, Band:7.0 %, Lymph:4.0 %,\n Mono:1.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:7.3 mg/dL, Mg++:1.9\n mg/dL, PO4:2.1 mg/dL\n Imaging: CXR : Left lower lobe retrocardiac opacity concerning for\n infection.\n Microbiology: Urine legionella pending\n Urine cx pending\n Blood cx x6: NGTD\n Assessment and Plan\n 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD,\n agitated depression, and aspiration presenting from nursing home after\n being found unresponsive, hypotensive, hypoxic, and with evidence of\n GI bleed.\n # Shock: Patient was admitted with a lactate of 5.4, bandemia (21\n bands) and signs of end-organ dysfunction (mental status and elevated\n Cr) in setting of likely infection, so sepsis is the most likely\n etiology. also be complicated by a GI bleed as patient has had\n significant UGIB in the past. Potential sources of infection include\n UTI, pneumonia, infected pressure ulcer given severiety of wound on L\n heel. Patient also at risk for hospital acquired pathogens. Initially\n started on vanc/zosyn for broad coverage. Efforts were made at\n aggressive volume resuscitation on admission with compromise of\n patient's respiratory status (increased pulmonary edema and work of\n breathing). Goals of care discussed at length with patient's HCP, his\n nephew. would not want intubation or resuscitation. Given\n his clinical state, the decision was made to pursue comfort care. The\n patient was started on low morphine. Patient maintained blood pressure\n and oxygen sat overnight, with persistent sinus tachycardia. Mental\n status improved this am. Patient able to communicate and vital signs\n stable. Given clinical improvement, discussed pursuing more aggressive\n treatment within patient\ns wishes. Patient has been clinically\n improving.\n - DNR/DNI as per his wishes\n - Restarted small fluid boluses, 100cc/hr now s/p 2 L\n - Lactate at 1.9 yesterday down from 5.4, bandemia improving\n - Restarted Vanc/Zosyn for broad sepsis coverage\n - Follow bcx, ucx, legionella urinary ag\n - Will continue close discussions with family\n # Hypoxia: DDX pneumonia or early ARDS from urosepsis complicated by\n volume resuscitation. Currrently oxygenating well with NC at 2L\n - Continue current management given patient appears to be clinically\n comfortable\n - Continue NC, titrate oxygen as needed\n - No intubation, so will bolus fluids carefully\n - Consider CXR today if develops increased hypoxia\n # Acute blood loss anemia on admission: patient has hx of severe PUD\n with gastritis and visible vessel now with BRBPR and decrease (although\n mild) in Hct. Per PCP, \n baseline is 26-28.\n - Down to 28 today though after fluid resuscitation\n - Will trend HCT, transfuse for active bleeding or >26\n - Can consider recheck Hct later today\n # Altered Mental status: non-focal neuro exam in patient with history\n of agitated depression.\n - Correcting shock as above\n - Patient able to communicate with effort\n # Acute renal failure: likely pre-renal +/- ATN. Improved to baseline.\n - Continue fluids prn for sepsis/hypovolemia\n # Tachycardia: Has been in sinus with APCs. Initially persistently in\n the 130s, now down to 110s with fluids. Likely combination of septic\n shock and hypovolemia.\n - Continue current management with gentle IVF to correct underlying\n disorder\n - Continue to monitor on telemetry\n - Can consider ECG during tachycardia\n # Wound care: Significant pressure ulcers\n - Canair bed\n - Wound care consult\n # FEN: Aspirating with PO.\n - Speech and swallow consult\n # Dispo: Continue current management. Close discussions with family\n regarding progression.\n - Will restart home medications\n - Call out to floor\n ICU Care\n Nutrition:\n Glycemic Control: adequate\n Lines:\n 18 Gauge - 05:19 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: ppi\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Call out to medicine floor\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322582,
"text": "Chief Complaint: 80 year old male with MS, h/o UGIB, sacral and heel\n pressure ulcers admitted from with hypotension, hypoxemia, ARF and\n mental status changes.\n 24 Hour Events:\n - Managed to improve during the day. BP holding steady. Occasionally\n will become tachycardic but looks like ectopy (PVCs and APCs) - BP\n stable\n - Pan-cultured; all pending. On broad spectrum abx\n - Ordered for speech and swallow eval as he aspirates with all PO\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 11:27 AM\n Piperacillin/Tazobactam (Zosyn) - 05:52 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 121 (96 - 139) bpm\n BP: 115/59(73) {93/39(54) - 124/70(75)} mmHg\n RR: 24 (17 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 905 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 905 mL\n Blood products:\n Total out:\n 1,070 mL\n 190 mL\n Urine:\n 1,070 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 363 mL\n 715 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Abd: Soft, NTND\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: BS at\n left base), Difficult to assess\n Neuro: AAOx3\n Skin: pressure wounds on B heels, sacral decubitus ulcer\n Labs / Radiology\n 289 K/uL\n 9.5 g/dL\n 173 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 113 mEq/L\n 142 mEq/L\n 28.5 %\n 15.3 K/uL\n [image002.jpg]\n 09:32 AM\n 04:21 AM\n WBC\n 18.8\n 15.3\n Hct\n 33.1\n 28.5\n Plt\n 326\n 289\n Cr\n 1.2\n 1.1\n Glucose\n 92\n 173\n Other labs: Differential-Neuts:88.0 %, Band:7.0 %, Lymph:4.0 %,\n Mono:1.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:7.3 mg/dL, Mg++:1.9\n mg/dL, PO4:2.1 mg/dL\n Imaging: CXR : Left lower lobe retrocardiac opacity concerning for\n infection.\n Microbiology: Urine legionella pending\n Urine cx pending\n Blood cx x6: NGTD\n Assessment and Plan\n 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD,\n agitated depression, and aspiration presenting from nursing home after\n being found unresponsive, hypotensive, hypoxic, and with evidence of\n GI bleed.\n # Shock: Patient was admitted with a lactate of 5.4, bandemia (21\n bands) and signs of end-organ dysfunction (mental status and elevated\n Cr) in setting of likely infection, so sepsis is the most likely\n etiology. also be complicated by a GI bleed as patient has had\n significant UGIB in the past. Potential sources of infection include\n UTI, pneumonia, infected pressure ulcer given severiety of wound on L\n heel. Patient also at risk for hospital acquired pathogens. Initially\n started on vanc/zosyn for broad coverage. Efforts were made at\n aggressive volume resuscitation on admission with compromise of\n patient's respiratory status (increased pulmonary edema and work of\n breathing). Goals of care discussed at length with patient's HCP, his\n nephew. would not want intubation or resuscitation. Given\n his clinical state, the decision was made to pursue comfort care. The\n patient was started on low morphine. Patient maintained blood pressure\n and oxygen sat overnight, with persistent sinus tachycardia. Mental\n status improved this am. Patient able to communicate and vital signs\n stable. Given clinical improvement, discussed pursuing more aggressive\n treatment within patient\ns wishes. Patient has been clinically\n improving.\n - DNR/DNI as per his wishes\n - Restarted small fluid boluses, 100cc/hr now s/p 2 L\n - Lactate at 1.9 yesterday down from 5.4, bandemia improving\n - Restarted Vanc/Zosyn for broad sepsis coverage\n - Follow bcx, ucx, legionella urinary ag\n - Will continue close discussions with family\n # Hypoxia: DDX pneumonia or early ARDS from urosepsis complicated by\n volume resuscitation. Currrently oxygenating well with NC at 2L\n - Continue current management given patient appears to be clinically\n comfortable\n - Continue NC, titrate oxygen as needed\n - No intubation, so will bolus fluids carefully\n - Consider CXR today if develops increased hypoxia\n # Acute blood loss anemia on admission: patient has hx of severe PUD\n with gastritis and visible vessel now with BRBPR and decrease (although\n mild) in Hct. Per PCP, \n baseline is 26-28.\n - Down to 28 today though after fluid resuscitation\n - Will trend HCT, transfuse for active bleeding or >26\n - Can consider recheck Hct later today\n # Altered Mental status: non-focal neuro exam in patient with history\n of agitated depression.\n - Correcting shock as above\n - Patient able to communicate with effort\n # Acute renal failure: likely pre-renal +/- ATN. Improved to baseline.\n - Continue fluids prn for sepsis/hypovolemia\n # Tachycardia: Has been in sinus with APCs. Initially persistently in\n the 130s, now down to 110s with fluids. Likely combination of septic\n shock and hypovolemia.\n - Continue current management with gentle IVF to correct underlying\n disorder\n - Continue to monitor on telemetry\n - Can consider ECG during tachycardia\n # Wound care: Significant pressure ulcers\n - Canair bed\n - Wound care consult\n # FEN: Aspirating with PO.\n - Speech and swallow consult\n # Dispo: Continue current management. Close discussions with family\n regarding progression.\n - Will restart home medications\n - Call out to floor\n ICU Care\n Nutrition:\n Glycemic Control: adequate\n Lines:\n 18 Gauge - 05:19 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: ppi\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Call out to medicine floor\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322622,
"text": ".H/O dysphagia\n Assessment:\n difficulties with swallowing prior to admission, possible aspiration\n resulting in left lower lobe pneumonia\n Action:\n Official swallow evaluation\n Response:\n After review, patient able to take thickened fluids pureed diet\n /aspiration precautions and has taken po thickened fluids well with\n assistance today..ab\ns continue for possible aspiration pneumonia/UTI\n Plan:\n Advance diet as tollerated, to be reviewed by team in 2 days.\n Aspiration precautions continue\n .H/O decubitus ulcer (Present At Admission)\n Assessment:\n Large extensive chronic ulcers/decub on left/right heel and coccyx\n Action:\n Assessed by wound care, extensive wound care recs documented and placed\n in chart to refer to/ patient placed on kinair and waffle boots\n applied, re-postioned q2-4hrly..check foot pulses\n Response:\n Patient appears far more comfortable with reduction in b/p/hr..foot\n pulses able to doppler\n Plan:\n Follow wound recs, to be changed daily, team to follow..re-postion,\n encourage high protein diet\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Raised blood sugars> 150\n Action:\n Monitor q6 aim < 150\n Response:\n Patients blood sugar this eve is < 150\n Plan:\n Continue to monitor\n .H/O dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Possible GI bleed this admission\n Action:\n Monitor b/p /hr and serial hct, ghuaic all stool\n Response:\n b/p stable @ 110-120 systolic, hr @ 75-90bpm..hct this pm stable @\n 27\nno stool as of yet today\n Plan:\n To continue to monitor the above\n .H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Patient is DNR/DNI but now not CMO\n Action:\n Continue present order\n Response:\n Plan:\n Continue to liase with team re plan of care, he has called today, aware\n of improvement and call out to floor\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322418,
"text": "Admitted from ER with sepsis, lactate 5.4, 100% non-rebreather, pt\n DNR/DNI, from , tx with fluid, antibiotics, blood in\n ER(melana stool in ER), ns fluid bolus x 3 in ICU for hr 120-130, no\n response, team able to reach HCP(nephew) & pt made CMO\n .H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Pt attempts to nod head to questions asked, appears to nod head to no\n when asked if in pain, o2 weaned down to 3 L np & 35% ofm,\n respirations slightly labored, no distress noted\n Action:\n Family in & supported, q 2 hr prn iv morphine x 2, reposition/mouth\n care q 2 hrs for comfort\n Response:\n Appears comfortable, family calm\n Plan:\n Continue to support family, prn iv morphine as needed, morphine gtt as\n needed for discomfort not controlled by prn morphine\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322618,
"text": ".H/O dysphagia\n Assessment:\n difficulties with swallowing prior to admission, possible aspiration\n resulting in left lower lobe pneumonia\n Action:\n Official swallow evaluation\n Response:\n After review, patient able to take thickened fluids pureed diet\n /aspiration precautions and has taken po thickened fluids well with\n assistance today\n Plan:\n Advance diet as tollerated, to be reviewed by team in 2 days.\n Aspiration precautions continue\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322612,
"text": "80 year old male admit from house after been found\n unresponsive on \nPMH of MS PVD AAA and UGIB\n on this admission\n patient found to be hypotensive with high lactate and had BRBPR\npatient\n admit with sepsis [ ? ut i/pneumonia as cause] and possible GI\n bleed\n..patient is DNR/DNI and at one point was made CMO by nephew who\n is HCP ..CMO has now been reversed as patients condition has\n significantly improved\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322613,
"text": "80 year old male admit from house after been found\n unresponsive on \nPMH of MS PVD AAA and UGIB\n on this admission\n patient found to be hypotensive with high lactate and had BRBPR\npatient\n admit with sepsis [ ? ut i/pneumonia as cause] and possible GI\n bleed\n..patient is DNR/DNI and at one point was made CMO by nephew who\n is HCP ..CMO has now been reversed as patients condition has\n significantly improved\n .H/O decubitus ulcer (Present At Admission)\n Assessment:\n Extensive/chronic ducubs/ulcers located on left/right heels and coccyx\n Action:\n Wound care review/waffles boots applied /patient placed on kinair\n bed/re-position q2-4\n Response:\n Observe daily for improvement\n Plan:\n Daily wound care as per extensive recs/wound care team to follow\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n Raised blood sugars > 150\n Action:\n To commence q6 sliding scale\n Response:\n Aim for less < 150\n Plan:\n To continue to monitor /diabetic diet\n .H/O dysphagia\n Assessment:\n Possible aspiration prior to admission, patient hyper extends\n neck/resulting in possible aspiration pneumonia\n Action:\n Speech/swallow evaluation\n Response:\n Evaluated as per save with thickened fluids pureed dirt/aspiration\n precautions, for which he taken thickened fluids well with assistance\n today\nAntibiotics continue for possible pneumonia/UTI\n Plan:\n Monitor po intake with aspiration precautions..speech/swallow team to\n re-evauatel in 2 days\n .H/O gastrointestinal bleed, lower t BRBPR, GI Bleed, GIB)\n Assessment:\n Possible GI bleed on admission as PRB PR\n Action:\n Monitor serial HCTS and ghuaic all stool\n Response:\n hct stable, has not stooled since admission , b/p now stable 110=120\n systolic hr 75-90bpm\n Plan:\n HCT stable at 27 [ baseline 26-28] transfuse <26, monitor b/p hr\n .H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Patient is DNR/DNI but with poor presentation patient was made CMO\n Action:\n CMO was reversed\n Response:\n CMO was reversed because of patients response to fluids/iv antibiotics\n Plan:\n Continue to monitor patients condition and inform/update nephew who is\n HCP\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322617,
"text": ".H/O dysphagia\n Assessment:\n difficulties with swallowing prior to admission, possible aspiration\n resulting in left lower lobe pneumonia\n Action:\n Official swallow evaluation\n Response:\n After review, patient able to take thickened fluids pureed diet\n /aspiration precautions and has taken po thickened fluids well with\n assistance today\n Plan:\n Advance diet as tollerated, to be reviewed by team in 2 days.\n Aspiration precautions continue\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322526,
"text": "Pt is an 80yo male resident of w/ h/o MS, DM2, PUD with\n UGIB, AAA, pressure ulcers found unresponsive by staff early am of\n , sent to ED. Hypoxic, hypotensive with BRBPR in ED. Placed on\n NRB Rec\nd volume and PRBC rescusitation and transferred to . Made\n CMO by his HCP , pt\ns mental status and VS greatly improved as day\n progressed.\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322604,
"text": ".H/O dysphagia\n Assessment:\n difficulties with swallowing prior to admission, possible aspiration\n resulting in left lower lobe pneumonia\n Action:\n Official swallow evaluation\n Response:\n After review, patient able to take thickened fluids pureed diet\n /aspiration precautions\n Plan:\n Advance diet as tollerated, to be reviewed by team in 2 days.\n Aspiration precautions continue\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322606,
"text": "80 yr old man with hx of multipe sclerosis presents with septic shock\n and possible GI bleed. Resp failure with hydration for resuscitation.\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322601,
"text": ".H/O dysphagia\n Assessment:\n difficulties with swallowing prior to admission, possible aspiration\n resulting in left lower lobe pneumonia\n Action:\n Official swallow evaluation\n Response:\n After review, patient able to take thickened fluids pureed diet\n /aspiration precautions\n Plan:\n Advance diet as tollerated, to be reviewed by team in 2 days.\n Aspiration precautions continue\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322451,
"text": "Chief Complaint: 80 year old male with MS, h/o UGIB, sacral and heel\n pressure ulcers admitted from with hypotension, hypoxemia, ARF and\n mental status changes.\n 24 Hour Events:\n - Patient with respiratory distress after fluid resuscitation\n - After discussions with HCP, effort changed to comfort care\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\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 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.3\nC (97.4\n HR: 139 (105 - 139) bpm\n BP: 104/53(63) {88/25(44) - 109/55(65)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,250 mL\n PO:\n TF:\n IVF:\n 1,250 mL\n Blood products:\n Total out:\n 540 mL\n 330 mL\n Urine:\n 540 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 710 mL\n -330 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Gen:\n Chest:\n Ext: feet wrapped, 4-5cm oozing heel ulcer on left, healing ulcer on\n right heel.\n Labs / Radiology\n No new since admission.\n Assessment and Plan\n 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD,\n agitated depression, and aspiration presenting from nursing home after\n being found unresponsive, hypotensive, hypoxic, and with evidence of\n GI bleed.\n 1) Shock: Patient was admitted with a lactate of 5.4, bandemia (21\n bands) and signs of end-organ dysfunction (mental status and elevated\n Cr) in setting of likely infection, so sepsis is the most likely\n etiology. also be complicated by a GI bleed as patient has had\n significant UGIB in the past. Potential sources of infection include\n UTI, pneumonia, infected pressure ulcer given severiety of wound on L\n heel. Patient also at risk for hospital acquired pathogens. Initially\n started on vanc/zosyn for broad coverage. Efforts were made at\n aggressive volume resuscitation on admission with compromise of\n patient's respiratory status (increased pulmonary edema and work of\n breathing).\n - Goals of care discussed at length with patient's HCP, his nephew.\n would not want intubation or resuscitation. Given his current\n clinical state, the decision was made to pursue comfort care. The\n patient was started on low morphine as he is able to acknowledge he is\n not in pain. Will accelerated to morphine gtt if patient becomes\n uncomfortable or develops increased work of breathing.\n - No further lab draws, comfort medications only\n - Will continue close discussions with family\n 2) Hypoxia: DDX pneumonia or early ARDS from urosepsis complicated by\n volume resuscitation. Currrently oxygenating well with NC and shovel\n mask.\n - Continue current management given patient appears to be clinically\n comfortable\n 3) Acute blood loss anemia on admission: patient has hx of severe PUD\n with gastritis and visible vessel now with BRBPR and decrease (although\n mild) in Hct.\n - No current management, no longer trending Hct\n 4) Altered Mental status: non-focal neuro exam in patient with history\n of agitated depression.\n - Attempt to correct shock as above\n - Patient able to communicate with effort\n 5) Acute renal failure: likely pre-renal +/- ATN.\n - No longer trending, patient has indwelling foley at baseline given\n neurogenic bladder from MS.\n 6) Dispo: Patient is currently comfort measures. Will likely be able to\n call out today to a private room. Will consider palliative care\n consult.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:52 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition: Likely call out to private room\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322453,
"text": ".H/O comfort care (CMO, Comfort Measures)\n Assessment:\n Pt for comfort measures, having shallow breathing,HR > 130\n Action:\n MORPHINE 0.5MG prn.\n Response:\n Pt looks comfortable.\n Plan:\n Continue morphine for comfort measures.\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322494,
"text": "Chief Complaint: 80 year old male with MS, h/o UGIB, sacral and heel\n pressure ulcers admitted from with hypotension, hypoxemia, ARF and\n mental status changes.\n 24 Hour Events:\n - Patient with respiratory distress after fluid resuscitation\n - After discussions with HCP, effort changed to comfort care\n - Patient with improved mental status this am with stable BP and O2 sat\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\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 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.3\nC (97.4\n HR: 139 (105 - 139) bpm\n BP: 104/53(63) {88/25(44) - 109/55(65)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,250 mL\n PO:\n TF:\n IVF:\n 1,250 mL\n Blood products:\n Total out:\n 540 mL\n 330 mL\n Urine:\n 540 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 710 mL\n -330 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ////\n Physical Examination\n Gen: Appears uncomfortable, minimally interactive\n Chest: Coarse BS throughout\n Ext: feet wrapped, 4-5cm oozing heel ulcer on left, healing ulcer on\n right heel.\n Labs / Radiology\n No new\n Assessment and Plan\n 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD,\n agitated depression, and aspiration presenting from nursing home after\n being found unresponsive, hypotensive, hypoxic, and with evidence of\n GI bleed.\n 1) Shock: Patient was admitted with a lactate of 5.4, bandemia (21\n bands) and signs of end-organ dysfunction (mental status and elevated\n Cr) in setting of likely infection, so sepsis is the most likely\n etiology. also be complicated by a GI bleed as patient has had\n significant UGIB in the past. Potential sources of infection include\n UTI, pneumonia, infected pressure ulcer given severiety of wound on L\n heel. Patient also at risk for hospital acquired pathogens. Initially\n started on vanc/zosyn for broad coverage. Efforts were made at\n aggressive volume resuscitation on admission with compromise of\n patient's respiratory status (increased pulmonary edema and work of\n breathing). Goals of care discussed at length with patient's HCP, his\n nephew. would not want intubation or resuscitation. Given\n his current clinical state, the decision was made to pursue comfort\n care. The patient was started on low morphine. Patient maintained\n blood pressure and oxygen sat overnight, with persistent sinus\n tachycardia. Mental status improved this am. Patient able to\n communicate and vital signs stable. Given clinical improvement,\n discussed pursuing more aggressive treatment within patient\ns wishes.\n - Will keep patient DNR/DNI as per his wishes\n - Restart small fluid boluses\n - Recheck labs this am including lactate and legionella urinary antigen\n - Restart Vanc/Zosyn for broad sepsis coverage\n - Recheck bcx, ucx\n - Continue NC and shovel mask, titrate oxygen as needed\n - Will continue close discussions with family\n 2) Hypoxia: DDX pneumonia or early ARDS from urosepsis complicated by\n volume resuscitation. Currrently oxygenating well with NC and shovel\n mask.\n - Continue current management given patient appears to be clinically\n comfortable\n - No intubation, so will bolus fluids carefully\n - Consider CXR today if develops increased hypoxia\n 3) Acute blood loss anemia on admission: patient has hx of severe PUD\n with gastritis and visible vessel now with BRBPR and decrease (although\n mild) in Hct.\n - Will trend HCT, transfuse for active bleeding or >30\n 4) Altered Mental status: non-focal neuro exam in patient with history\n of agitated depression.\n - Attempt to correct shock as above\n - Patient able to communicate with effort\n 5) Acute renal failure: likely pre-renal +/- ATN.\n - Recheck labs this am, fluids prn for sepsis/hypovolemia\n 6) Dispo: Continue current management. Close discussions with family\n regarding progression. Will restart home medications.\n ICU Care\n Nutrition: thickened liquids/puree diet\n Glycemic Control: adequate\n Lines:\n 18 Gauge - 12:52 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: not intubated\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU for now, consider call out\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 322498,
"text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Family meeting and decision to make him comfort care only\n Has remianed persistently tachycardic\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Flowsheet Data as of 08:35 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: 36.2\nC (97.2\n HR: 125 (105 - 139) bpm\n BP: 93/46(58) {88/25(44) - 121/55(68)} mmHg\n RR: 22 (16 - 27) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,250 mL\n PO:\n TF:\n IVF:\n 1,250 mL\n Blood products:\n Total out:\n 540 mL\n 440 mL\n Urine:\n 540 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 710 mL\n -440 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG:\n Physical Examination\n Gen: lying in bed, tachypnic, but speaking\n HEENT: very dry oropharnyx\n CV: tachy RRR\n Chest: fair air movement\n Abd: soft, NT\n Ext: bilat wrapping of feet\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 80 yr old man with hx of multipe sclerosis presents with septic shock\n and possible GI bleed.\n 1. Sepsis: Multiple potential etiologies with UTI and PNA most likely\n and possible osteo with bacteremia from left heel abscess - Covered\n broadly with Vanco, Zosyn, pan culture, foley has been changed, foot\n films.\n He is s/p aggressive volume resuscitation complicated by resp distress\n this resp distress has since stabilized and we will resume volume\n repletion\n 2. Resp distress: in setting of PNA and likely vasc leak with volume\n resuscitation, he is DNI and breathing has stabilized. Repeat CXR this\n AM and watch carefully as resume hydration.\n 3. ARF: in setting of sepsis and hypovolemia, we are volume\n resusitating, trending UOP, CR pending.\n 4. GI bleed: Possible recurrent gastritis, bleeding vessel, ischemia.\n At this point supportive care with blood.\n 5. Code: Was CMO at one point yesterday afternoon when severe resp\n distress. Now that he has improved we have discussed with return\n to DNR/DNI status but will resume fluids ABX and continue supportive\n care. Of he worsnes again from a resp status we will readdress.\n ICU Care\n Nutrition: will feed when resp status stable\n Glycemic Control: SSRI\n Lines:\n 18 Gauge - 12:52 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: with HCP \n status: DNR / DNI\n Disposition :ICU\n Total time spent: 40\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322559,
"text": "Chief Complaint:\n 24 Hour Events:\n - Managed to improve during the day. BP holding steady. Occasionally\n will become tachycardic but looks like PVCs - BP without problems\n - ; all pending. On broad spectrum abx\n - Ordered for speech and swallow eval as he aspirates with all PO\n - Possibly call out to floor this AM\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 11:27 AM\n Piperacillin/Tazobactam (Zosyn) - 05:52 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 121 (96 - 139) bpm\n BP: 115/59(73) {93/39(54) - 124/70(75)} mmHg\n RR: 24 (17 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 905 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 905 mL\n Blood products:\n Total out:\n 1,070 mL\n 190 mL\n Urine:\n 1,070 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 363 mL\n 715 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, Thin\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: Crackles : , Diminished: BS at\n left base), Difficult to assess\n Skin: Not assessed, pressure wounds on B heels\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 289 K/uL\n 9.5 g/dL\n 173 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 113 mEq/L\n 142 mEq/L\n 28.5 %\n 15.3 K/uL\n [image002.jpg]\n 09:32 AM\n 04:21 AM\n WBC\n 18.8\n 15.3\n Hct\n 33.1\n 28.5\n Plt\n 326\n 289\n Cr\n 1.2\n 1.1\n Glucose\n 92\n 173\n Other labs: Differential-Neuts:88.0 %, Band:7.0 %, Lymph:4.0 %,\n Mono:1.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:7.3 mg/dL, Mg++:1.9\n mg/dL, PO4:2.1 mg/dL\n Imaging: CXR : Left lower lobe retrocardiac opacity concerning for\n infection.\n Microbiology: Urine legionella pending\n Urine cx pending\n Blood cx x6: NGTD\n Assessment and Plan\n 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD,\n agitated depression, and aspiration presenting from nursing home after\n being found unresponsive, hypotensive, hypoxic, and with evidence of\n GI bleed.\n # Shock: Patient was admitted with a lactate of 5.4, bandemia (21\n bands) and signs of end-organ dysfunction (mental status and elevated\n Cr) in setting of likely infection, so sepsis is the most likely\n etiology. also be complicated by a GI bleed as patient has had\n significant UGIB in the past. Potential sources of infection include\n UTI, pneumonia, infected pressure ulcer given severiety of wound on L\n heel. Patient also at risk for hospital acquired pathogens. Initially\n started on vanc/zosyn for broad coverage. Efforts were made at\n aggressive volume resuscitation on admission with compromise of\n patient's respiratory status (increased pulmonary edema and work of\n breathing). Goals of care discussed at length with patient's HCP, his\n nephew. would not want intubation or resuscitation. Given\n his clinical state, the decision was made to pursue comfort care. The\n patient was started on low morphine. Patient maintained blood pressure\n and oxygen sat overnight, with persistent sinus tachycardia. Mental\n status improved this am. Patient able to communicate and vital signs\n stable. Given clinical improvement, discussed pursuing more aggressive\n treatment within patient\ns wishes.\n - DNR/DNI as per his wishes\n - Restarted small fluid boluses, 100cc/hr now s/p 2 L\n - Lactate at 1.9 yesterday down from 5.4\n - Restarted Vanc/Zosyn for broad sepsis coverage\n - Follow bcx, ucx, legionella urinary ag\n - Continue NC and shovel mask, titrate oxygen as needed\n - Will continue close discussions with family\n # Hypoxia: DDX pneumonia or early ARDS from urosepsis complicated by\n volume resuscitation. Currrently oxygenating well with NC and shovel\n mask.\n - Continue current management given patient appears to be clinically\n comfortable\n - No intubation, so will bolus fluids carefully\n - Consider CXR today if develops increased hypoxia\n # Acute blood loss anemia on admission: patient has hx of severe PUD\n with gastritis and visible vessel now with BRBPR and decrease (although\n mild) in Hct.\n - Will trend HCT, transfuse for active bleeding or >30\n - Down to 28 today though after fluid resuscitation, will consider 1u\n prbcs today\n # Altered Mental status: non-focal neuro exam in patient with history\n of agitated depression.\n - Correcting shock as above\n - Patient able to communicate with effort\n # Acute renal failure: likely pre-renal +/- ATN. Improved to baseline.\n - Continue fluids prn for sepsis/hypovolemia\n # Tachycardia: Has been in sinus with APCs. Initially persistently in\n the 130s, now down to 110s with fluids. Likely combination of septic\n shock and hypovolemia.\n - Continue current management with gentle IVF to correct underlying\n disorder\n - Continue to monitor on telemetry\n - ECG this morning.\n # Dispo: Continue current management. Close discussions with family\n regarding progression. Will restart home medications. Plan to call out\n to floor once stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 322560,
"text": "Chief Complaint: 80 year old male with MS, h/o UGIB, sacral and heel\n pressure ulcers admitted from with hypotension, hypoxemia, ARF and\n mental status changes.\n 24 Hour Events:\n - Managed to improve during the day. BP holding steady. Occasionally\n will become tachycardic but looks like PVCs - BP without problems\n - ; all pending. On broad spectrum abx\n - Ordered for speech and swallow eval as he aspirates with all PO\n - Possibly call out to floor this AM\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 11:27 AM\n Piperacillin/Tazobactam (Zosyn) - 05:52 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.5\nC (97.7\n HR: 121 (96 - 139) bpm\n BP: 115/59(73) {93/39(54) - 124/70(75)} mmHg\n RR: 24 (17 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 905 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 905 mL\n Blood products:\n Total out:\n 1,070 mL\n 190 mL\n Urine:\n 1,070 mL\n 190 mL\n NG:\n Stool:\n Drains:\n Balance:\n 363 mL\n 715 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///19/\n Physical Examination\n General Appearance: No acute distress, Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Abd: Soft, NTND\n Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: BS at\n left base), Difficult to assess\n Skin: pressure wounds on B heels, sacral decubitus ulcer\n Labs / Radiology\n 289 K/uL\n 9.5 g/dL\n 173 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 113 mEq/L\n 142 mEq/L\n 28.5 %\n 15.3 K/uL\n [image002.jpg]\n 09:32 AM\n 04:21 AM\n WBC\n 18.8\n 15.3\n Hct\n 33.1\n 28.5\n Plt\n 326\n 289\n Cr\n 1.2\n 1.1\n Glucose\n 92\n 173\n Other labs: Differential-Neuts:88.0 %, Band:7.0 %, Lymph:4.0 %,\n Mono:1.0 %, Eos:0.0 %, Lactic Acid:1.9 mmol/L, Ca++:7.3 mg/dL, Mg++:1.9\n mg/dL, PO4:2.1 mg/dL\n Imaging: CXR : Left lower lobe retrocardiac opacity concerning for\n infection.\n Microbiology: Urine legionella pending\n Urine cx pending\n Blood cx x6: NGTD\n Assessment and Plan\n 80 year old man with hx of multiple sclerosis c/b paraplegia, DM2, PUD,\n agitated depression, and aspiration presenting from nursing home after\n being found unresponsive, hypotensive, hypoxic, and with evidence of\n GI bleed.\n # Shock: Patient was admitted with a lactate of 5.4, bandemia (21\n bands) and signs of end-organ dysfunction (mental status and elevated\n Cr) in setting of likely infection, so sepsis is the most likely\n etiology. also be complicated by a GI bleed as patient has had\n significant UGIB in the past. Potential sources of infection include\n UTI, pneumonia, infected pressure ulcer given severiety of wound on L\n heel. Patient also at risk for hospital acquired pathogens. Initially\n started on vanc/zosyn for broad coverage. Efforts were made at\n aggressive volume resuscitation on admission with compromise of\n patient's respiratory status (increased pulmonary edema and work of\n breathing). Goals of care discussed at length with patient's HCP, his\n nephew. would not want intubation or resuscitation. Given\n his clinical state, the decision was made to pursue comfort care. The\n patient was started on low morphine. Patient maintained blood pressure\n and oxygen sat overnight, with persistent sinus tachycardia. Mental\n status improved this am. Patient able to communicate and vital signs\n stable. Given clinical improvement, discussed pursuing more aggressive\n treatment within patient\ns wishes.\n - DNR/DNI as per his wishes\n - Restarted small fluid boluses, 100cc/hr now s/p 2 L\n - Lactate at 1.9 yesterday down from 5.4\n - Restarted Vanc/Zosyn for broad sepsis coverage\n - Follow bcx, ucx, legionella urinary ag\n - Continue NC and shovel mask, titrate oxygen as needed\n - Will continue close discussions with family\n # Hypoxia: DDX pneumonia or early ARDS from urosepsis complicated by\n volume resuscitation. Currrently oxygenating well with NC and shovel\n mask.\n - Continue current management given patient appears to be clinically\n comfortable\n - No intubation, so will bolus fluids carefully\n - Consider CXR today if develops increased hypoxia\n # Acute blood loss anemia on admission: patient has hx of severe PUD\n with gastritis and visible vessel now with BRBPR and decrease (although\n mild) in Hct.\n - Will trend HCT, transfuse for active bleeding or >30\n - Down to 28 today though after fluid resuscitation, will consider 1u\n prbcs today\n # Altered Mental status: non-focal neuro exam in patient with history\n of agitated depression.\n - Correcting shock as above\n - Patient able to communicate with effort\n # Acute renal failure: likely pre-renal +/- ATN. Improved to baseline.\n - Continue fluids prn for sepsis/hypovolemia\n # Tachycardia: Has been in sinus with APCs. Initially persistently in\n the 130s, now down to 110s with fluids. Likely combination of septic\n shock and hypovolemia.\n - Continue current management with gentle IVF to correct underlying\n disorder\n - Continue to monitor on telemetry\n - ECG this morning.\n # Dispo: Continue current management. Close discussions with family\n regarding progression. Will restart home medications. Plan to call out\n to floor once stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:19 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Case Management ",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 322570,
"text": "Insurance information\n Primary insurance: EVERCARE\n Secondary insurance:\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: Resident at \n DME / Home O[2]:\n Functional Status / Home / Family Assessment:\n Pt. is a resident at . His wife has advanced dementia\n and is also at . He is dependent with all ADL's. The\n patient has pressure ulcers on his heel and his coccyx requiring daily\n dressing management.\n Primary Contact(s): (other) (h) and\n (c)\n Health Care Proxy: Yes - Copy of signed proxy form in medical record.\n Dialysis: Yes\n Referrals Recommended: Social Work\n Current plan: Rehab\n Return to . The patient will need to be\n rescreened/updated for placement back at . He does have a\n bed hold in Admissions at .\n Patient (s) to Discharge:\n Patient discussed with multidisciplinary team: No\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322550,
"text": "Pt is an 80yo male resident of w/ h/o MS, DM2, PUD with\n UGIB, AAA, pressure ulcers found unresponsive by staff early am of\n , sent to ED. Hypoxic, hypotensive with BRBPR in ED. Placed on\n NRB Rec\nd volume and PRBC rescusitation and transferred to . Made\n CMO by his HCP , but pt\ns mental status and VS greatly improved as\n day progressed.\n Now treating with Vanc, Zosyn, IVF and will replete with KPhos this am\n for K=3.5 and Phos=1.6. Pt with very labile HR, ST-SVT but otherwise\n Hemodynamically stable. No treatment for HR\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n AM Hct=28.5, down from 33.1. All blood pressures stable, no BRBPR this\n shift\n Action:\n Response:\n Plan:\n Guaiac all stool, monitor hct, transfuse if hct falls below 25\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n AM glu=173, pt with D5\n NS infusing at 100cc/hr\n Action:\n IVF to stop for KPhos repletion\n Response:\n Plan:\n Noon fingerstick, cover w/insulin if >200\n .H/O dysphagia\n Assessment:\n Pt with hyperextension of neck, MS, extremely weak. Currently NPO\n Action:\n Assess for swallow using ice chips\n Response:\n Able to swallow small amt successfully w/o cough but swallow noisy and\n difficult\n Plan:\n Speech and swallow consult\n .H/O decubitus ulcer (Present At Admission)\n Assessment:\n Dressings on coccyx, L heel and R heel had been changed @1400, CDI\n Action:\n Chart reviewed\ndressing changes at had been ordered for\n qday; frequent turns, heels off bed\n Response:\n Plan:\n ?wound care consult, change dressings \n Plan to call out to floor today\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 322546,
"text": "Pt is an 80yo male resident of w/ h/o MS, DM2, PUD with\n UGIB, AAA, pressure ulcers found unresponsive by staff early am of\n , sent to ED. Hypoxic, hypotensive with BRBPR in ED. Placed on\n NRB Rec\nd volume and PRBC rescusitation and transferred to . Made\n CMO by his HCP , but pt\ns mental status and VS greatly improved as\n day progressed. Now treating with Vanc, Zosyn, IVF and will replete\n lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322624,
"text": "80 year old male admit from house after been found\n unresponsive there on . In ED, patient found to be hypotensive\n with high lactate and had BRBPR, admitted to Fin MICU for sepsis [\n ?UTI/pneumonia as cause] and possible GI bleed.\n PMH significant for advanced MS, PVD, AAA, PUD w/UGIB. Patient is\n DNR/DNI and has refused PEG, OGT or NGT.\n At one point on was made by nephew who is HCP. status has\n now been reversed as patient\ns condition has significantly improved. Pt\n was visited by his PCP, . this am.\n .H/O decubitus ulcer (Present At Admission)\n Assessment:\n Extensive/chronic ducubs/ulcers located on left/right heels and coccyx\n Action:\n Wound care review/waffles boots applied /patient placed on kinair\n bed/re-position q2-4\n Response:\n Observe daily for improvement\n Plan:\n Daily wound care as per extensive recs/wound care team to follow\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n FS > 150\n Action:\n To commence q6 regular insulin sliding scale\n Response:\n Plan:\n Continue to monitor with goal FS< 150 /diabetic diet\n .H/O dysphagia\n Assessment:\n Possible aspiration prior to admission, patient hyper extends\n neck/resulting in possible aspiration pneumonia\n Action:\n Speech/swallow evaluation\n Response:\n Evaluated as per save with thickened fluids pureed diet/aspiration\n precautions, for which he taken thickened fluids well with assistance\n today\nAntibiotics continue for possible pneumonia/UTI\n Plan:\n Monitor po intake with aspiration precautions. Of particular note, neck\n requires additional support to maintain optimal position.Speech/swallow\n team to re-evaluate in 2 days\n .H/O gastrointestinal bleed, lower t BRBPR, GI Bleed, GIB)\n Assessment:\n Possible GI bleed on admission as BRB PR\n Action:\n Monitor serial HCTS and guaiac all stool\n Response:\n hct stable, has not stooled since admission , b/p now stable 110=120\n systolic hr 75-90bpm\n Plan:\n HCT stable at 27 [ baseline 26-28 as per PCP] transfuse <26, monitor\n b/p hr\n .H/O comfort care (, Comfort Measures)\n Assessment:\n Patient is DNR/DNI but with poor presentation patient was made \n Action:\n was reversed\n Response:\n was reversed because of patients response to fluids/iv antibiotics\n Plan:\n Continue to monitor patients condition and inform/update nephew who is\n HCP\n ? neglect situation given extensive pressure ulcers. require SW\n consult and review/intervention.\n"
},
{
"category": "Nursing",
"chartdate": "2191-04-25 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 322626,
"text": "80 year old male admit from house after been found\n unresponsive there on . In ED, patient found to be hypotensive\n with high lactate and had BRBPR, admitted to Fin MICU for sepsis [\n ?UTI/pneumonia as cause] and possible GI bleed.\n PMH significant for advanced MS, PVD, AAA, PUD w/UGIB. Patient is\n DNR/DNI and has refused PEG, OGT or NGT.\n At one point on was made by nephew who is HCP. status has\n now been reversed as patient\ns condition has significantly improved. Pt\n was visited by his PCP, . this am.\n .H/O decubitus ulcer (Present At Admission)\n Assessment:\n Extensive/chronic ducubs/ulcers located on left/right heels and coccyx\n Action:\n Wound care review/waffles boots applied /patient placed on kinair\n bed/re-position q2-4\n Response:\n Observe daily for improvement\n Plan:\n Daily wound care as per extensive recs/wound care team to follow\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n FS > 150\n Action:\n To commence q6 regular insulin sliding scale\n Response:\n Plan:\n Continue to monitor with goal FS< 150 /diabetic diet\n .H/O dysphagia\n Assessment:\n Possible aspiration prior to admission, patient hyper extends\n neck/resulting in possible aspiration pneumonia\n Action:\n Speech/swallow evaluation\n Response:\n Evaluated as per save with thickened fluids pureed diet/aspiration\n precautions, for which he taken thickened fluids well with assistance\n today\nAntibiotics continue for possible pneumonia/UTI\n Plan:\n Monitor po intake with aspiration precautions. Of particular note, neck\n requires additional support to maintain optimal position.Speech/swallow\n team to re-evaluate in 2 days\n .H/O gastrointestinal bleed, lower t BRBPR, GI Bleed, GIB)\n Assessment:\n Possible GI bleed on admission as BRB PR\n Action:\n Monitor serial HCTS and guaiac all stool\n Response:\n hct stable, has not stooled since admission , b/p now stable 110=120\n systolic hr 75-90bpm\n Plan:\n HCT stable at 27 [ baseline 26-28 as per PCP] transfuse <26, monitor\n b/p hr\n .H/O comfort care (, Comfort Measures)\n Assessment:\n Patient is DNR/DNI but with poor presentation patient was made \n Action:\n was reversed\n Response:\n was reversed because of patients response to fluids/iv antibiotics\n Plan:\n Continue to monitor patients condition and inform/update nephew who is\n HCP\n ? neglect situation given extensive pressure ulcers. require SW\n consult and review/intervention.\n Demographics\n Attending MD:\n Admit diagnosis:\n LOWER GI BLEED\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 77.2 kg\n Daily weight:\n Allergies/Reactions:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Precautions:\n PMH: Anemia, Diabetes - Insulin, GI Bleed\n CV-PMH: Arrhythmias, PVD\n Additional history: Multiple Sclerosis, neurogenic bladder,\n Myelodysplastic syndrome, DM,- PVD,- non-healing bilateral ulcers,\n Sepsis due to pneumonia,Partial small bowel obstruction, upper\n gastrointestinal bleed ( with Ulcers in the stomach, Ulcer in the\n cardia, near the GE junction (injection, thermal therapy),Marked\n friability in the stomach),Abdominal aortic aneurysm\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:115\n D:50\n Temperature:\n 97.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 82 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 2,517 mL\n 24h total out:\n 700 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:21 AM\n Potassium:\n 3.5 mEq/L\n 04:21 AM\n Chloride:\n 113 mEq/L\n 04:21 AM\n CO2:\n 19 mEq/L\n 04:21 AM\n BUN:\n 31 mg/dL\n 04:21 AM\n Creatinine:\n 1.1 mg/dL\n 04:21 AM\n Glucose:\n 173 mg/dL\n 04:21 AM\n Hematocrit:\n 28.9 %\n 02:27 PM\n Finger Stick Glucose:\n 137\n 06:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Fin 407\n Transferred to: R 1170\n Date & time of Transfer: 2100\n"
}
] |
54,229 | 165,594 | 73 y.o. M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted with acute on chronic L SDH complicated by right-sided weakness and epileptiform behavior, requiring ICU level care for sustained respiratory failure and sepsis. | (#) AFib: rate controlled now; seems to be in sinus rhtyhm; not on coumadin currently with recent SDH. (#) AFib: rate controlled now; seems to be in sinus rhyhm; not on coumadin currently with recent SDH. HEENT: Pupils are asymmetric, with apparent prior occular surgeries. #CAD s/p CABG -restart BB when BPs have clearly stabilized -cont statin -consider TTE to eval systolic/diastolic CHF (carvedilol invokes possible CHF history) . (#) AFib: rate controlled now; seems to be in sinus rhtyhm; not on coumadin currently with recent SDH. (#) AFib: rate controlled now; seems to be in sinus rhyhm; not on coumadin currently with recent SDH. -- cont vanco/cefepime -- will touch base with fellow first thing in am (#) AFib: rate controlled now; seems to be in sinus rhyhm; not on coumadin currently with recent SDH. #CAD s/p CABG -restart BB when BPs have clearly stabilized -cont statin -consider TTE to eval systolic/diastolic CHF (carvedilol invokes possible CHF history) . Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Hypotension (not Shock) Assessment: Action: Response: Plan: .H/O renal failure, End stage (End stage renal disease, ESRD) Assessment: Action: Response: Plan: #CAD s/p CABG -restart BB when BPs have clearly stabilized -cont statin -consider TTE to eval systolic/diastolic CHF (carvedilol invokes possible CHF history) . .H/O renal failure, End stage (End stage renal disease, ESRD) Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: IN MICU: BP stable 110s-120s. Continue to hold anti-coagulation for underlying SDH # High Bilious Output: Resolved. 1)Sepsis- Cont vanc/. to recheck, stooling, abd firm Action: Freq residual checks Response: Residual remains low, stooling Plan: Cont tube feeds Respiratory failure, acute (not ARDS/) Assessment: Remains on CPAP , appears comfortable, large amt clear oral secretions clear, mod amt. Hypotension (not Shock) Assessment: Pt received on IV Levophed gtt infusing @ 0.02mcg/kg/min. to recheck, stooling, abd firm Action: Freq residual checks Response: Residual remains low, last 80 cc stooling Plan: Cont tube feeds Respiratory failure, acute (not ARDS/) Assessment: Remains on CPAP , appears comfortable, large amt clear oral secretions clear, mod amt. - improved significantly, - attempt NG - continue PPI # ESRD: CVVH today - touch base with renal regarding when dialysis can restart, now that he is off pressors # AF: patient in NSR. - respiratory failure: continue PSV with daily , attempt to wean once HD re-initiated - volume overload: replaced temporary dialysis catheter with tunneled line vs. additional temporary catheter via IR, pressures have been stable and may be suitable for HD vs. CVVH today - pneumonia: continue vanomycin (day 8) and cefepime () for GP and GN coverage will adjust as cultures and sensitivies return - mental status: continue no sedation for further evaluation of mental status # Hypotension / Fevers: s/p axillary a-line placement with adequate pressures off pressors since line placed. 3)Renal Failure- further HD per renal 4)Sub-Dural Hematoma/Altered Mental Status- Mental status improving 5)Seizure Disorder- -Neurontin -Dilantin 6)PICC line clot: Stable by prelim read of RUE u/s. -- cont vanco/cefepime -- CVVH vs dialysis today (#) AFib: rate controlled now; seems to be in sinus rhyhm; not on coumadin currently with recent SDH. - now febrile, may be bacteremic, surveillance cultures - d/c line in RIJ after placement of temporary femoral line - touch base with renal regarding posponing dialysis until new line placement # Respiratory Distress: Problem of inability to maintain secretions, based on failure of attempted trial of extubation. Herpes DFA - negative --continue wound care 10. Herpes DFA - negative --continue wound care 7. ESRD: HD yesterday with EPO - Cont HD w/ femoral temp line - Access still L femoral line placed . Chief Complaint: 24 Hour Events: --Febrile to 102 this am, re-BCx and Myco/lytic Cx --HD yesterday --EEG --BP's increasing and Fluoronef and Midodrine tapered --Head CT with opacification of mastoids, sinus mucosal thickening; ethmoidal, L maxillary, and sphenoidal sinuses with hyperdense material in L sphenoid sinus, could be inspissated mucus vs fungal infection in sphenoid sinus --> NGT removed --Held all sedating/pain meds Allergies: Hydromorphone Unknown; Metoclopramide Unknown; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 06:57 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38.9C (102 Tcurrent: 36.2C (97.1 HR: 81 (73 - 93) bpm BP: 150/55(75) {94/22(42) - 159/85(94)} mmHg RR: 27 (20 - 37) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 87.7 kg (admission): 94.2 kg Height: 70 Inch Total In: 283 mL PO: TF: 239 mL IVF: 44 mL Blood products: Total out: 500 mL 0 mL Urine: NG: Stool: Drains: Balance: -217 mL 0 mL Respiratory support O2 Delivery Device: T-piece, Tracheostomy tube Ventilator mode: Standby Vt (Spontaneous): 556 (556 - 556) mL PS : 10 cmH2O RR (Spontaneous): 29 PEEP: 5 cmH2O FiO2: 50% PIP: 16 cmH2O SpO2: 99% ABG: ///28/ Ve: 12 L/min Physical Examination Gen: NAD, opens eyes CV: RRR Lungs: CTA anteriorly Abd: ND NT Ext: 2+ pulses Labs / Radiology 387 K/uL 8.5 g/dL 82 mg/dL 7.6 mg/dL 28 mEq/L 4.4 mEq/L 42 mg/dL 99 mEq/L 142 mEq/L 28.6 % 13.8 K/uL [image002.jpg] 04:19 AM 09:21 PM 02:26 AM 03:20 AM 02:30 AM 03:44 AM 05:18 PM 02:55 AM 03:36 AM 04:03 AM WBC 9.6 8.1 9.4 16.6 14.9 13.9 13.8 Hct 30.1 28.7 29.2 28.4 30.0 28.3 28.6 Plt 387 Cr 8.1 5.3 7.6 5.4 7.5 8.8 7.6 TCO2 29 34 Glucose 66 174 219 107 272 254 82 Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB / Troponin-T:75/2/0.28, ALT / AST:38/87, Alk Phos / T Bili:270/0.7, Amylase / Lipase:41/42, Differential-Neuts:82.4 %, Band:1.0 %, Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5 g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:3.5 mg/dL Imaging: CT HEAD: opacification of mastoids, sinus mucosal thickening; ethmoidal, L maxillary, and sphenoidal sinuses with hyperdense material in L sphenoid sinus, could be inspissated mucus vs fungal infection in sphenoid sinus Microbiology: Sputum Gram Stain: 2+ GRAM POSITIVE COCCI IN PAIRS. Now off phenytoin and switched to Kepra visible sz since switch and mental status seems sl better. UPDATE: Pt required IV Levophed gtt while on HD today to maintain MAP > 65, now weaned off s/p completion of HD treatment. ESRD: HD yesterday with EPO - Cont HD w/ femoral temp line - Access still L femoral line placed . Respiratory failure, acute (not ARDS/) Assessment: Pt received/maintained on MV support. Continue to hold anti-coagulation for underlying SDH # High Bilious Output: Resolved. Continue to hold anti-coagulation for underlying SDH # High Bilious Output: Resolved. Hypotension (not Shock) Assessment: Received patient on Levophed 0.01mcg/kg/min. Response: Temp decreased this AM to 98.8 F. Plan: Offer supportive care, follow cx data. Response: Pt is currently normotensive on 0.02mcg/kg/min IV Levophed gtt. Herpes DFA - negative --continue wound care 10. TITLE: Rehab Pt. - Continue midodrine and florinef and reduce levophed as tolerated -keep MAP > 65 -continue vancomycin given skin infection. All Bcx negative to todate, - Continue midodrine and reduce levophed as tolerated -Can try adding florinef for further BP support - f/u cultures -keep MAP > 65 -continue vancomycin given recent positive cx for MRSA to complete 10 d course # Respiratory Distress: likely secondary to PNA vs pulmonary edema. Response: Pt is currently normotensive on 0.03mcg/kg/min IV Levophed gtt. Response: Pt is currently normotensive on 0.03mcg/kg/min IV Levophed gtt. Response: Pt is currently normotensive on 0.02mcg/kg/min IV Levophed gtt. Response: Pt is currently normotensive on 0.02mcg/kg/min IV Levophed gtt. - Continue midodrine and florinef and reduce levophed as tolerated - Zosyn after HD -keep MAP > 65 -continue vancomycin given skin infection. Response: Pt is currently normotensive on 0.03mcg/kg/min IV Levophed gtt. Response: Pt is currently normotensive on 0.02mcg/kg/min IV Levophed gtt. Continue to hold anti-coagulation for underlying SDH # High Bilious Output: Resolved. Noaortic regurgitation is seen. Hypotension (not Shock) Assessment: Received pt on 0.04 mcgs/kg/min levophed gtt. The right internal jugular line is visualized in situ and terminates in the distal SVC. The right internal jugular line is visualized in situ and terminates in the distal SVC. Enlarged mediastinal lymph nodes, some of which are unchanged from prior CT and of uncertain significance. Partial opacification of right mastoid air cells. IMPRESSION: Stable appearance of right mid axillary nonocclusive thrombus surrounding central venous catheter. A right-sided hemodialysis catheter terminates in mid-to-lower SVC. Single AP chest radiograph compared to shows placement of a right PICC line, which terminates in the distal SVC. Right PIC catheter ends at the junction of brachiocephalic veins. Unchanged right frontoparietal acute subdural hematoma. Partial opacification of right mastoid air cells inferiorly is as before. Small amount of non-occlusive thrombus material seen adherent to the intravenous line which is identified within the right subclavian veins. Unchanged retrocardiac opacities, likely to suggest atelectasis. An intravenous line is identified within the right subclavian vein and there is a small amount of non-occlusive thrombus material identified along the course of the line. Left sphenoid sinus opacification. Left sphenoid sinus opacification. Left sphenoid sinus opacification. Left-sided subdural hematoma with fluid-fluid level. Left-sided subdural hematoma with fluid-fluid level. acute process CONTRAINDICATIONS for IV CONTRAST: On dialysis PFI REPORT PFI: 1. | 388 | [
{
"category": "Rehab Services",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Generic Note",
"row_id": 597602,
"text": "TITLE:\n Rehab Services-Occupational Therapy\n Consult received and appreciated. Spoke with PT and pt is not\n appropriate for therapy at this time. We will d/c for now and please\n reconsult as appropriate.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 597675,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n CODE: FULL\n ACCESS: Right double lumen PICC, Left HD cath\n SOCIAL: Contact is with daughter who works in the\n Medical Office Building.\n ROS:\n *neuro- A&Ox1 (person) and able to follow commands at times;\n moans/groans/yells out but when asked if in pain denies; pupils\n unequal, non reactive (please see below)\n *resp- satting 94-98% on 6L NC with RR 10s-20s; LS ronchorous\n throughout, congested cough present\n *CV- HR 80s SR, no ectopy; BPs ranging 100s-140s systolic; BP being\n taken on right calf as unable to take on BUE PICC on right and old\n AV fistula on left\n *GI/ pt does not make urine; HD pt M/W/F, has NGT in place to right\n nare with Nutren Pulmonary Full infusing @ 10cc/hr (starting rate), tol\n without N/V, abd S/NT/slightly distended with +BS; flexiseal in place\n draining brown liquid stool\n *act- moves all extremities on bed except RUE; when extremities lifted\n up, they fall back as pt is unable to lift and hold; did wiggle toes at\n times on command\n *endo- FSBS 148 @ 1200, 147 @ 1800 requiring no insulin coverage per\n SS; also as fixed dose which was not given this am NPO, but will be\n needed @ bedtime\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with tmax 102.5 rectal on floor; transferred to MICU for fever with\n hypotension suggesting possible sepsis. Tmax 99.5 today.\n Action:\n Pt has had multiple sets blood cx, all with NGTD. On vanc/gent coverage\n for possible line infection (PICC or HD cath) though neither line\n removed at this point extremely poor access. Neither line with s/s\n infection at insertion point.\n Response:\n Blood cx with NGTD. Tmax 99.5 this shift.\n Plan:\n Cont vanc/gent until blood cx results come back. Cont to monitor for\n fever, s/s sepsis.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with chronic RF, on HD M/W/F. Did not tolerate HD yesterday ()\n hypotension with fluid removal, so sent to MICU for further\n monitoring.\n Action:\n Pt had HD today.\n Response:\n Tolerated HD with VSS. 1L fluid removed.\n Plan:\n Cont with regularly scheduled HD.\n Altered mental status (not Delirium)\n Assessment:\n Pt had a repeat head CT yesterday which showed a stable subdural\n hematoma. Pt moaning, calling out. At beginning of shift able to state\n name, but unable to do so @ 1600 assessment, incomprehensible sounds to\n other questions. Follows simple commands but only at times s/a wiggling\n toes or opening mouth for mouth care. Right pupil 2-3mm, non reactive,\n impaired corneal reflex. Left pupil 5mm, non reactive, impaired corneal\n reflex; this is stable per team (h/o glaucoma, cataract surgery). Per\n daughter, pt was high functioning prior to fall and SDH.\n Action:\n Pt frequently reoriented, frequent checks for safety. Left arm in soft\n wrist restraint as pt pulled out NGT yesterday, pt unable to move RUE.\n EEG completed. No MRI this shift as it is unnecessary per neuro because\n it will not change treatment of bleed.\n Response:\n Pt stable and improving per neurological service.\n Plan:\n Continue to monitor mental status. Call out to neuro so pt can be f/b\n neuromed service.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n SUBDURAL HEMORRHAGE\n Code status:\n Height:\n Admission weight:\n 96.4 kg\n Daily weight:\n Allergies/Reactions:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Precautions:\n PMH: Renal Failure\n CV-PMH:\n Additional history: On hemodialysis\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:98\n D:49\n Temperature:\n 100.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 83 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 92% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 741 mL\n 24h total out:\n 1,200 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:15 AM\n Potassium:\n 4.7 mEq/L\n 04:15 AM\n Chloride:\n 95 mEq/L\n 04:15 AM\n CO2:\n 28 mEq/L\n 04:15 AM\n BUN:\n 57 mg/dL\n 04:15 AM\n Creatinine:\n 12.9 mg/dL\n 04:15 AM\n Glucose:\n 94 mg/dL\n 04:15 AM\n Hematocrit:\n 40.3 %\n 04:15 AM\n Finger Stick Glucose:\n 147\n 06:00 PM\n Valuables / Signature\n Patient valuables: Multiple eye drops sent 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: MICU 7\n Transferred to: 1118\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597620,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n Altered mental status (not Delirium)\n Assessment:\n Pt. had a repeat head CT yesterday which showed a stable subdural\n hematoma. Pt. moaning, calling out. Not agitated, but ? if patient is\n in pain. Appears uncomfortable. Following simple commands, opens\n mouth when asked for mouth care. Not moving right arm. Right arm is\n also swollen. Patient remains on continuous EEG monitoring, no seizure\n activity noted overnight.\n Action:\n Patient pulled out NGT on day shift. Left hand in soft wrist\n restraint. Not able to visualize NGT after being replaced, so\n advanced and repeat CXR pbtained. At this time able to auscultate NGT\n and placement was confirmed by repeat CXR. Given PO meds. Later in\n the evening, NGT noted to be coiled in patient\ns mouth, so was pulled\n out and not replaced per MICU resident. 0.5mg Morphine given IV \n patient appearing uncomfortable.\n Response:\n Pt. appears slightly more comfortable after Morphine.\n Plan:\n Continue to monitor mental status. MRI was ordered on the 27^th.\n Patient called for yesterday evening, but per MICU resident, patient\n does not need at the moment, will check with rest of team in am as to\n whether MRI can be d/c\n"
},
{
"category": "Nutrition",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 597629,
"text": "** See paper chart for full nutrition assessment **\n Subjective\n Moaning\n Objective\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 04:15 AM\n Glucose Finger Stick\n 148\n 12:00 PM\n BUN\n 57 mg/dL\n 04:15 AM\n Creatinine\n 12.9 mg/dL\n 04:15 AM\n Sodium\n 139 mEq/L\n 04:15 AM\n Potassium\n 4.7 mEq/L\n 04:15 AM\n Chloride\n 95 mEq/L\n 04:15 AM\n TCO2\n 28 mEq/L\n 04:15 AM\n Calcium non-ionized\n 8.7 mg/dL\n 04:15 AM\n Phosphorus\n 6.2 mg/dL\n 04:15 AM\n Magnesium\n 2.0 mg/dL\n 04:15 AM\n Phenytoin (Dilantin)\n 6.4 ug/mL\n 04:15 AM\n WBC\n 13.3 K/uL\n 04:15 AM\n Hgb\n 12.5 g/dL\n 04:15 AM\n Hematocrit\n 40.3 %\n 04:15 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Nutren Pulmonary @ 60ml/hr - not started\n GI: soft/distended, (+) bowel sounds, (+) liquid stool\n Assessment of Nutritional Status\n Specifics:\n Patient transferred to MICU due to hypotension during HD. NGT was\n pulled out by patient , replaced, but then found to coiled in\n patient\ns mouth so discontinued. New NGT just placed and ok to use.\n Patient has not had tube feed since before HD . Remains NPO.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Begin tube feed\n Nutren\n Pulmonary @ 20ml/hr, advance as tolerated to goal of 60 ml/hr = 2160\n calories and 98g protein\n Multivitamin / Mineral supplement: in tube feed\n Check chemistry 10 panel daily\n Will follow, page if questions *\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 597965,
"text": "Chief Complaint: Respiratory distress and 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 73 y.o. man CRF, HD, anuric, afib on coumadin at home, CAD, CABG, SDH.\n Fall - acute on chronic SDH on left. Seizures also complicating\n course. Loaded with dilantin on neurology following recurrent\n seizure. Last evening had acute respiratory distress with desturations\n to low 90's on 3L NC. SBP decreased to 70's - responsive to IV NS\n fluid challenge. Temp 101.9 prior to transfer. Empirically started on\n vanco/gentamycin with dialysis dosing for ?line infection. No growth\n on cultures to date.\n 24 Hour Events:\n PICC LINE - START 02:07 AM\n INVASIVE VENTILATION - START 02:20 AM\n SPUTUM CULTURE - At 03:00 AM\n FEVER - 102.2\nF - 06:00 AM\n Increased respiratory secretions\n Intubated for increasing respiratory distress; suctioned for moderate\n thick secretions.\n 7.31/47/91 on 50% Fi02 following intubation\n Hypotensive after intubation; started on levophed\n History obtained from Medical resident\n Patient unable to provide history: Unresponsive\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Norepinephrine - 0.12 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 02:15 AM\n Pantoprazole (Protonix) - 08:00 AM\n Fosphenytoin - 08:22 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 Pain: No pain / appears comfortable\n Flowsheet Data as of 09:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 39.1\nC (102.4\n HR: 96 (86 - 96) bpm\n BP: 123/17(43) {102/17(43) - 125/37(55)} mmHg\n RR: 22 (18 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 497 mL\n PO:\n TF:\n IVF:\n 207 mL\n Blood products:\n Total out:\n 0 mL\n 1,240 mL\n Urine:\n NG:\n 1,240 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n -743 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): 350 (350 - 558) mL\n RR (Set): 18\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 27 cmH2O\n Plateau: 21 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 99%\n ABG: 7.31/47/91/21/-2\n Ve: 6.5 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Breath Sounds: Crackles : dependently), slightly\n prolonged expiratory phase\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, BUE edema R>L\n Skin: Not assessed\n Neurologic: Responds to: Tactile stimuli, Movement: Purposeful, Tone:\n Not assessed\n Labs / Radiology\n 11.9 g/dL\n 254 K/uL\n 207 mg/dL\n 8.2 mg/dL\n 21 mEq/L\n 4.6 mEq/L\n 46 mg/dL\n 104 mEq/L\n 136 mEq/L\n 38.8 %\n 11.7 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n 02:49 AM\n 03:17 AM\n WBC\n 14.0\n 13.3\n 11.7\n Hct\n 37.8\n 40.3\n 38.8\n Plt\n 174\n 193\n 254\n Cr\n 11.9\n 12.9\n 8.2\n TropT\n 0.35\n TCO2\n 25\n Glucose\n 164\n 94\n 207\n Other labs: PT / PTT / INR:13.8/27.2/1.2, CK / CKMB /\n Troponin-T:147/4/0.35, Differential-Neuts:83.3 %, Lymph:8.0 %, Mono:5.6\n %, Eos:2.8 %, Lactic Acid:0.8 mmol/L, Ca++:9.6 mg/dL, Mg++:2.5 mg/dL,\n PO4:2.7 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/): Given purulent\n secretions, fever a likely component is superimposed tracheobronchitis,\n possible PNA. Will add cefipime to antibiotics. Follow vanco level,\n redose as indicated. MDIs inline with ventilator given history of\n asthma, doesn't seem tight on exam now. No steroids. Volume status\n will also be important, minimize fluids if possible.\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA): Probable PNA as\n above. Line infection seems less likely given multiple negative\n cultures including prior to starting antibiotics. Repeat clutures and\n line tip culture pending. Will follow up on these.\n HYPOTENSION: Possible sepsis on levophed, may be component of\n intravascular depletion albeit hesitant to be aggressive with fluids.\n Try to wean. If unable to wean will try gentle fluid challenge.\n ALTERED MENTAL STATUS (NOT DELIRIUM): SDH as below. Now sedated on\n propofol, also active infection will exacerbate.\n ACUTE ON CHRONIC SDH: Stable neurological exam. Repeat scan \n showed no change.\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD): Last\n dialyzed yesterday. Truncated for unclear reasons albeit they were\n apparently having trouble with flow through left subclavian dialysis\n catheter so this was also taken out. Tip sent for culture.\n DIABETES MELLITUS (DM), TYPE II: Sugars adequately controlled on\n RISS in setting of infection.\n SEIZURE, WITHOUT STATUS EPILEPTICUS: Stable on dilantin. Check\n levels.\n ASSYMETRIC UPPER EXTREMITY EDEMA: Greater on side of PICC line.\n Ultrasound to evaluate for thrombosis. be another etiology of\n fever albeit higher than would be expected unlesss infected.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:07 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-17 00:00:00.000",
"description": "ICU Attending Addendum",
"row_id": 597464,
"text": "CRITICAL CARE ATTENDING ADDENDUM\n I saw and examined Mr. with Dr. , whose note reflects my\n input. I would add/emphasize that this 73-year-old man is transferred\n from the neurology service for fever, hypotension, and altered mental\n status. Prior history includes DM, CAD s/p CABG, ESRD on HD, asthma,\n and glaucoma s/p surgery. Admitted to the neurology service after\n being transferred from for further management of a\n traumatic L SDH sustained 3 days prior to admission. There, has had\n some epileptiform activity on EEG monitoring and has received AEDs.\n Has been receiving Ativan as well.\n Had fevers yesterday (102.5 rectally) and then in hemodialysis today\n was hypotense to 70/23. Received vanc / gent, and ABG sent (7.41 / 43\n / 79). BP recovered with cessation of hemodialysis, and he was\n transferred to the ICU for further care.\n On exam here: Temp 99.9, 82, 121/33, 23, 91% on n/c. Somnolent but\n opens eyes to loud voice. Regular heart, clear breath sounds, soft\n abdomen. PICC and HD line sites intact. Labs, meds, imaging, FH, SH,\n Allergies reviewed.\n Assessment and Plan\n 73-year-old man with ESRD on HD via tunneled catheter, now with\n severe sepsis (sepsis with fluid-responsive hypotension )\n o Source is most likely line, though far from certain\n Vancomycin\n Gentamicin\n Blood cultures\n Will leave lines in place for now unless cultures (+) or\n becomes less stable\n o Evaluate other sources\n Chest x-ray; if opacities then broaden to cover HAP\n LFTs make biliary disease unlikely\n No hx of diarrhea to make c diff seem present\n If makes urine\n UA/Cx\n o Hemodynamics adequate at present, and lactate 1.0 is\n reassuring\n o No indiciations for steroids or drotrecogin\n Encephalopathy\n o Multiple potential etiologies (ativan, ICH, sepsis, etc.)\n o Appreciate neurology\ns help; discuss resumption of EEG\n monitoring.\n o Re-image with CT today to exclude extension of SDH/ICH. Hold\n BZD if possible.\n ESRD on HD\n o Received limited dialysis today\n o Likely will need dialysis tomorrow\n Other issues as per Dr. \ns note today.\n He is critically ill: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597931,
"text": "Mr. is a 73 yoM on HD-anuric, h/o AFib not currently on\n coumadin (though is on at home), who is being transferred from the\n neurology service for respiratory distress and hypoxia. He was\n admitted on after a fall resulting in acute on chronic SDH on\n the left; his course is complicated by seizure and he has been started\n on fosphenytoin & phenytoin.\n .\n This evening he was noted to be in acute respiratory distress with\n desats to the low to mid 90's on 3LNC (reportedly desatting to the mid\n 70's on room air; has had a variable O2 requirement since being\n admitted). His blood pressure dropped to the 70's systolic and was\n responsive to the 80's and then 100's after a 250 cc NS bolus. he was\n febrile to 101.9,concern was aspiration event,pt has been on on\n vanco/genta for the given recent fevers,with neg cultures\n he was briefly in MICU green on - for fevers and hypotension\n to the 70's.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with episode of resp distress on the floor RR 20-30,but no acute\n desaturation, sats mid 90\ns on 3l,concern was pul edema given pt had\n only brief HD on Saturday poor flow,and aspiration event, combined\n with poor mental status,a NG decompression with 700cc greenish output\n Action:\n Intubated with 7.5 Et tube,received 70mg vac and 16 mg etomadate prior\n to intubation,started on propofol fro sedation,mouth care q4h,head end\n elevation, on iv vano/gent as per HD protocol,sputum cx has been sent.\n Response:\n Satting 98-100% on the current settings,abg was 7.31,47,so rate\n increased to 18 from 16\n Plan:\n Will cont to monitor,daily wake up,RSBI,pt need HD access for contd\n HD,next HD on Monday,follow abg .\n Hypotension (not Shock)\n Assessment:\n Pt sbp was dropped to 70\ns on the floor received 250cc fluid bolus,at\n the time of presentation sbp was in 100\ns but dropped again to 80\n peri intubation, pt was 101.9 at floor,T current 100.7\n Action:\n Started on levophed drip via the rt arm picc line\n Response:\n Sbp currently in low 100\ns on .08mcg levo,apparently pts dbp has been\n running on the lower side 20-30\ns,so goal MAP>50,HR in 80\n Plan:\n Will cont to follow the blood pressure,goal MAP>50,titrate levophed as\n needed,no paln for fluid bolus given overloaded status\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 597944,
"text": "Chief Complaint: Reason for transfer: respiratory distress,\n hypotension\n HPI:\n Mr. is a 73 yoM on HD-anuric, h/o AFib not currently on\n coumadin (though is on at home), who is being transferred from the\n neurology service for respiratory distress and hypoxia. He was\n admitted on after a fall resulting in acute on chronic SDH on\n the left; his course is complicated by seizure and he has been started\n on fosphenytoin & phenytoin.\n .\n This evening he was noted to be in acute respiratory distress with\n desats to the low to mid 90's on 3LNC (reportedly desatting to the mid\n 70's on room air; has had a variable O2 requirement since being\n admitted). His blood pressure dropped to the 70's systolic and was\n responsive to the 80's and then 100's after a 250 cc NS bolus. he was\n febrile to 101.9. The neurology and medicine MERIT teams were\n concerned for an aspiration event vs. volume overload vs. PE. CXR is\n c/w volume overload; however it is grossly unchanged from earlier\n films. His normal schedule is M-W-F though he did not get dialyzed on\n Friday because he was having focal motor seizures. He was last\n dialyzed Saturday for a shorter cycle b/c of low blood flow\n from the HD catheter(per renal note). His mental status has been poor\n since being in the hospital.\n .\n Of note, he is currently being treated with vanco/gent for a possible\n line infection given recent fevers. Nothing has grown out of numerous\n blood cultures since yet he continues to spike. he was briefly\n in MICU green on - for fevers and hypotension to the 70's.\n .\n Since arriving to the MICU satting in the upper 90's on NRB, code\n status was confirmed with his wife on the phone and he was intubated\n with vecuronium and etomidate. He is currently on AC 500x14 with PEEP\n 5 at 50% FiO2. Peri-intubation, MAP's dropped to the 50's and he was\n started on low dose levophed through his right PICC.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 02:15 AM\n Other medications:\n MEDICATIONS ON TRANSFER:\n Gentamicin 90 mg IV QHD-- since \n Vancomycin 500 mg IV QHD-- since \n Fosphenytoin 100 mg PE IV BID\n Fosphenytoin 200 mg PE IV QHS (Q8 hours)\n Phenytoin 1000 mg IV x 1 given this afternoon\n .\n Acetaminophen 650 mg PO Q6H:PRN\n SSI + Lantus 20 Qam, 10 QHS\n Citalopram 40 mg QD\n Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing\n Simvastatin 40 mg PO DAILY\n Allopurinol 100 mg PO BID\n Calcium Acetate mg PO TID W/MEALS\n Fish Oil (Omega 3) 1000 mg PO BID\n FoLIC Acid 1 mg PO DAILY\n Fluticasone Propionate NASAL 1 SPRY NU DAILY\n Cyanocobalamin 50 mcg PO DAILY\n Lorazepam 1-2 mg IV Q4H:PRN seizure > 5 minutes\n Gabapentin 100 mg PO BID\n Neomycin/Polymyxin/Dexameth Ophth Susp. 1 DROP LEFT EYE Q6H\n Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE \n Atropine Sulfate Ophth 1% 1 DROP LEFT EYE \n Timolol Maleate 0.25% 1 DROP RIGHT EYE \n Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS\n Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n Atrial fibrillation on coumadin\n CHF-- no EF in our system\n CAD s/p CABG\n DM\n ESRD on HD\n Glaucoma\n Cataracts\n Asthma\n ? gout (per med list)\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: wife is HCP; no illicits including no tobacco\n Review of systems:\n Flowsheet Data as of 03:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 91 (86 - 91) bpm\n BP: 123/31(52) {110/31(52) - 123/37(55)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 98%\n Total In:\n 288 mL\n PO:\n TF:\n IVF:\n 38 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 288 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 558 (558 - 558) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 32 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.31/47/91//-2\n Ve: 2.5 L/min\n PaO2 / FiO2: 182\n Physical Examination\n General Appearance: Overweight / Obese, acute SOB, respirator distress\n with AM use\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No m/r/g appreciated\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: ), coarse upper\n airway breathsounds\n Abdominal: Soft, Bowel sounds present, No(t) Distended, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, trace edema of right forearm\n Skin: Warm, No(t) Rash:\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 254 K/uL\n 11.9 g/dL\n 94 mg/dL\n 12.9 mg/dL\n 57 mg/dL\n 28 mEq/L\n 95 mEq/L\n 4.7 mEq/L\n 139 mEq/L\n 38.8 %\n 11.7 K/uL\n [image002.jpg]\n \n 2:33 A9/30/ 01:04 PM\n \n 10:20 P10/1/ 04:15 AM\n \n 1:20 P10/4/ 02:49 AM\n \n 11:50 P10/4/ 03:17 AM\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 14.0\n 13.3\n 11.7\n Hct\n 37.8\n 40.3\n 38.8\n Plt\n 174\n 193\n 254\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n TC02\n 25\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6, CK / CKMB /\n Troponin-T:147/4/0.35, Differential-Neuts:83.3 %, Lymph:8.0 %, Mono:5.6\n %, Eos:2.8 %, Lactic Acid:0.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.0 mg/dL,\n PO4:6.2 mg/dL\n Imaging: CXR: vascular congestion, pulm edema; no obvious\n infiltrate; grossly unchanged from \n HEAD CT non-contrast: No significant change since the \n examination with continued evolution of the mixed-attenuation subdural\n hematoma overlying the left cerebral convexity, with minimal mass\n effect and no significant shift of the normally midline structures, and\n no new hemorrhage or evidence of acute vascular territorial infarction.\n Microbiology: Multiple blood cultures from to , NGTD\n No urine cultures since anuric\n Assessment and Plan\n ASSESSMENT/PLAN:\n 73 yoM admitted with left SDH c/b seizure, on HD w/o residual UOP, and\n possible line infection on gent/vanco. Being transferred for\n respiratory distress, hypotension & hypoxia.\n .\n .\n (#) RESPIRATORY DISTRESS: pt has been intubated for respiratory\n distress; likely some element of volume overload given anuric state &\n IVF boluses given for hypotension, it seems he may have also had a less\n aggresive HD session on due to line issues. There is some\n question as to whether he also had an aspiration event given his poor\n mental status; he does have some secretions (unclear if much more than\n baseline). He may have also has a PE given he is not currently\n anticoagulated (though he appears to be in SR on tele here now); no CTA\n was obtained given (1) unstable to go to scan right now and (2) would\n be unlikely to anticoagulate him now given recent SDH.\n -- patient intubated for respiratory distress; appears to be\n oxygenating well now\n -- no need for HD acutely given stable on the vent right now; will\n touch base first thing with HD fellow in am\n -- sent sputum culture\n -- being covered with vanco; would consider adding cefepime if\n secretions worsen\n -- cont sedation with propfol though might consider changing to\n versed/fentanyl if not going to extubate soon\n .\n (#) HYPOTENSION, FEVERS: has been problem throughout\n this admission; unclear whether he was developing sepsis with concern\n for line infection or some other process. He is being covered for a\n line infection though blood cultures have remained negative. On\n levophed now peri-intubation. Episodes seem to be transient. Does\n have known CAD & CHF, though no echo in system. No UA/UCx sent b/c\n anuric. No evidence of skin breakdown or PICC site infection.\n -- cont vanco/gent empirically\n -- f/u blood cultures\n -- wean levo as tolerated\n -- would consider non-infectious sources of fevers as well, including\n drug fever & central.\n .\n (#) ESRD, HD: line issues not exactly clear to me from the notes;\n sounds like he was supposed to have a tunneled line on ; he may\n need a temporary line on if he needs semi-emergent HD\n -- cont vanco/gent\n -- will touch base with fellow first thing in am\n .\n (#) AFib: rate controlled now; seems to be in sinus rhtyhm; not on\n coumadin currently with recent SDH.\n -- cont to follow\n -- not on rate meds currently\n .\n (#) Seizure: continues to have seizures, though no evidence of seziure\n activity now while in the ICU; on propfol for sedation on vent.\n -- cont fosphenytoin; got a phenytoin ooster earlier this afternoon\n .\n (#) SDH:\n -- neurology following\n -- holding anticoagulation now, including SQH\n .\n (#) h/o glaucoma, cataracts:\n -- cont home meds\n .\n (#) ASTHMA: does not appear to be acive as no wheezing on exam & pt\n doesn't appear super tight, thoguh may be contributing.\n -- will place on standing inhalers overnight; consider decreasing to\n PRN in am\n .\n (#) DM:\n -- cont SSI + lantus 20/10\n -- ? need for consult --> looks like neuro team was considering\n consulting them for hyperglycemia; will monitor throught morning and\n consider need for consult\n .\n (#) ACCESS: double lumen PICC on right; no HD catheter currently\n .\n (#) Nutrition: NPO currently; no IVF maintenance given c/f volume\n overload\n .\n (#) PPX: pneumoboots (no SQH with recent SDH); on PPI; no need for\n bowel regimen currently.\n .\n (#) CODE: full; confirmed with wife on admission via phone --> have not\n yet had her sign the ICU consent. Will consider readdressing with\n family during daytime\n .\n (#) DISPO: to remain in ICU while intubated; may attempt extubation\n pending improvement of volume status with HD on or \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:07 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other, not a candidate given\n recent head bleed)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: Discussed code status with wife on arrival to\n ICu; have not yet consented her.\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: 73 y/o, male, well known to the MICU service\n after being managed here recently for acute on chronic left subdural\n hematoma following a fall at home, fevers, and hypotension. The patient\n was transferred to the neuro floor service 2 days ago where he was\n being managed for seizures, ESRD on HD, had persistent fevers with ?\n line infection although all blood culturtes have been negative to date.\n While on the floor earlier tonight, he developed respiratory distress\n with hypoxia ? aspiration and/or volume overload, requiring an ICU\n transfer and intubation.\n Exam notable for Tm 38.2 BP 105/31 (on small dose levophed) HR 91 RR 20\n with sat 98% on A/C 18/500/5/50% . Intubated and sedated with Propofol.\n Lungs with bibasilar crackles. Labs notable for WBC 11.7 K, HCT 38.8 ,\n K+ 4.6 , Cr 8.2. ABG 7.31/47/91. CXR with cardiomegaly and opulmonary\n congestion.\n Agree with plan to ventilator support, sedation with propofol, follow\n ABG\ns, cover with antibiotics, follow culture results, continue with\n seizure medications (fosphenytoin) as per neuro recommendations, follow\n with nephrology re-dialysis and address the issue for need of temporary\n dialysis catheter for now vs. proceeding with original plan for a\n tunneled catheter on \n ------ Protected Section Addendum Entered By: , MD\n on: 06:39 ------\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597946,
"text": "Mr. is a 73 yoM on HD-anuric, h/o AFib not currently on\n coumadin (though is on at home), who is being transferred from the\n neurology service for respiratory distress and hypoxia. He was\n admitted on after a fall resulting in acute on chronic SDH on\n the left; his course is complicated by seizure and he has been started\n on fosphenytoin & phenytoin.\n .\n This evening he was noted to be in acute respiratory distress with\n desats to the low to mid 90's on 3LNC (reportedly desatting to the mid\n 70's on room air; has had a variable O2 requirement since being\n admitted). His blood pressure dropped to the 70's systolic and was\n responsive to the 80's and then 100's after a 250 cc NS bolus. he was\n febrile to 101.9,concern was aspiration event,pt has been on on\n vanco/genta for the given recent fevers,with neg cultures\n he was briefly in MICU green on - for fevers and hypotension\n to the 70's.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with episode of resp distress on the floor RR 20-30,but no acute\n desaturation, sats mid 90\ns on 3l,concern was pul edema given pt had\n only brief HD on Saturday poor flow,and aspiration event, combined\n with poor mental status,a NG decompression with 700cc greenish output\n Action:\n Intubated with 7.5 Et tube,received 70mg vac and 16 mg etomadate prior\n to intubation,started on propofol fro sedation,mouth care q4h,head end\n elevation, on iv vanco/gent as per HD protocol,sputum cx has been sent.\n Response:\n Satting 98-100% on the current settings,abg was 7.31,47,so rate\n increased to 18 from 16\n Plan:\n Will cont to monitor,daily wake up,RSBI,pt need HD access for contd\n HD,next HD on Monday,follow abg .?may need to attach the OG to suction\n Hypotension (not Shock)\n Assessment:\n Pt sbp was dropped to 70\ns on the floor received 250cc fluid bolus,at\n the time of presentation sbp was in 100\ns but dropped again to 80\n peri intubation, pt was 101.9 at floor,T current 102.2\n Action:\n Started on levophed drip via the rt arm picc line,blood cx and sputum\n cx sent,(doesn\nt make urine),received Tylenol ,Iv abx as per HD\n protocol\n Response:\n Sbp currently in l20- 130\ns on 0.12 mcg levo,apparently pts dbp has\n been running on the lower side initially goal MAP>50,HR in 80\n Plan:\n Will cont to follow the blood pressure,goal MAP>50,titrate levophed as\n needed,no plan for fluid bolus given overloaded status\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598146,
"text": "Chief Complaint: 73 yoM admitted with left SDH c/b seizure, on HD w/o\n residual UOP, and possible line infection on gent/vanco. Being\n transferred for respiratory distress, hypotension & hypoxia. Now\n intubated, oxygentating well, likely has PNA per chest Xray and\n fevers. Continues to require levophed. Also has h/o afib, not on\n coumadin due to recent SDH.\n 24 Hour Events:\n FEVER - 102.4\nF - 08:00 AM\n - patient now covered with vancomycin and cefepime, gentamicin\n discontinued\n - persistent large volumes of bilous return from NGT (it is properly\n placed in stomach), patient is passing flatus and has ABS (no ileus)\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 02:06 PM\n Infusions:\n Fentanyl - 35 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Midazolam (Versed) - 08:00 PM\n Fentanyl - 08:00 PM\n Fosphenytoin - 12:18 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.3\nC (99.1\n HR: 83 (80 - 99) bpm\n BP: 121/42(60) {70/17(41) - 137/77(82)} mmHg\n RR: 18 (17 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 985 mL\n 77 mL\n PO:\n TF:\n IVF:\n 555 mL\n 77 mL\n Blood products:\n Total out:\n 1,730 mL\n 450 mL\n Urine:\n NG:\n 1,730 mL\n 450 mL\n Stool:\n Drains:\n Balance:\n -745 mL\n -373 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 307 (307 - 350) mL\n RR (Set): 0\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 0 cmH2O\n Plateau: 22 cmH2O\n Compliance: 0 cmH2O/mL\n SpO2: 94%\n ABG: 7.31/44/74/23/-4\n Ve: 8.4 L/min\n PaO2 / FiO2: 185\n Physical Examination\n Cardiovascular: NAD\n RRR, no murmur\n Reduced left sided BS\n Abd benign, active BS\n Ext 1+ edema symmetrical\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 269 K/uL\n 12.2 g/dL\n 178 mg/dL\n 10.4 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 38.5 %\n 14.7 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n 02:49 AM\n 03:17 AM\n 10:02 PM\n 04:12 AM\n 05:04 AM\n WBC\n 14.0\n 13.3\n 11.7\n 14.7\n Hct\n 37.8\n 40.3\n 38.8\n 38.5\n Plt\n 174\n 193\n 254\n 269\n Cr\n 11.9\n 12.9\n 8.2\n 10.4\n TropT\n 0.35\n TCO2\n 25\n 22\n 23\n Glucose\n 164\n 94\n 207\n 178\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, Differential-Neuts:83.3 %, Lymph:8.0 %, Mono:5.6\n %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:9.8 mg/dL, Mg++:2.5 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR: opacificiation of L hemidiaphram, increased right hilar\n prominence\n Microbiology: blood cultures since , most recent on \n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yoM admitted with left SDH c/b seizure, on HD w/o residual UOP, and\n possible line infection on gent/vanco. Being transferred for\n respiratory distress, hypotension & hypoxia.\n (#) RESPIRATORY DISTRESS: pt has been intubated for respiratory\n distress; likely some element of volume overload given anuric state &\n IVF boluses given for hypotension, it seems he may have also had a less\n aggresive HD session on due to line issues. There is some\n question as to whether he also had an aspiration event given his poor\n mental status; he does have some secretions (unclear if much more than\n baseline). He may have also has a PE given he is not currently\n anticoagulated, unable to tolerate CTA, ? intervention possible if\n bleed\n -- patient intubated for respiratory distress; appears to be\n oxygenating well now\n -- no need for HD acutely given stable on the vent right now; will\n touch base first thing with HD fellow in am\n -- f/u sputum culture\n -- on vancomycin, started on cefepime yesterday\n -- oon versed/fentanyl for sedation\n .\n (#) HYPOTENSION, FEVERS: has been problem throughout\n this admission; unclear whether he was developing sepsis with concern\n for line infection or some other process. He is being covered for a\n line infection though blood cultures have remained negative. On\n levophed now peri-intubation. Episodes seem to be transient. Does\n have known CAD & CHF, though no echo in system. No UA/UCx sent b/c\n anuric. No evidence of skin breakdown or PICC site infection.\n -- cont vanco/cefepime\n -- f/u blood cultures\n -- wean levo as tolerated\n - volume challenge\n (#) High bilious output via NG tube - ? ilius vs SBO. Also concerned\n for inflammatory process in the abdomen.\n - check liver enzymes, Alk phos, bili\n - amylase lipase\n - KUB\n - RUQ u/s\n (#) ESRD, HD: he was supposed to have a tunneled line on ;\n -- cont vanco/cefepime\n -- will touch base with fellow first thing in am\n .\n (#) AFib: rate controlled now; seems to be in sinus rhyhm; not on\n coumadin currently with recent SDH.\n -- cont to follow\n -- not on rate meds currently\n .\n (#) Seizure: no evidence of seziure activity now while in the ICU\n -- cont fosphenytoin\n .\n (#) SDH:\n -- neurology following\n -- holding anticoagulation now, including SQH\n .\n (#) h/o glaucoma, cataracts:\n -- cont home meds\n .\n (#) ASTHMA: does not appear to be acive as no wheezing on exam & pt\n doesn't appear super tight, thoguh may be contributing.\n -- will place on standing inhalers overnight; consider decreasing to\n PRN in am\n .\n (#) DM:\n -- cont SSI + lantus 20/10\n .\n (#) ACCESS: double lumen PICC on right; no HD catheter currently\n .\n (#) Nutrition: NPO currently; no IVF maintenance given c/f volume\n overload\n .\n (#) PPX: pneumoboots (no SQH with recent SDH); on PPI; no need for\n bowel regimen currently.\n .\n (#) CODE: full; confirmed with wife on admission via phone\n .\n (#) DISPO: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599605,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n 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: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\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 / Moderate\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 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 Intolerant of weaning attempts, Cannot protect airway, Underlying\n illness not resolved\n Pt was reintubated after approx 4 hours post extubation due to\n worsening respiratory distress, rising CO2, and copious secretions\n which he was unable to expectorate. Intubation went smoothly, pt\n remains on CMV. Will wean as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Fellow / Physician Attending Progress Note - MICU",
"row_id": 597581,
"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 her\n note above, including assessment and plan.\n HPI:\n 73yo man with ESRD on HD, CAD s/p CAGB, A fib on Warfarin, s/p fall\n who was admitted to neuro service initially for a subdural hematoma. He\n had RUE paresis on admission after his fall. During HD he dropped his\n BP in the setting of having had a fever to 102.5. He received Vanc,\n Gent and a liter of NS. Transferred ot the MICU for further care given\n the transient hypotension and concern for possible line-related\n infection.\n Overnight, Tmax was 100.5. He was making non-specific noises\n intermittently overnight. He was given morphine 0.5mg IV x 1 for\n possible pain. He had a NG-tube replaced that was coiled in the back of\n his mouth; it was subsequently d/c\ned and currently he has no oral\n access. He does have an oxygen requirement of 4-6L NC (of note, he did\n not complete HD yesterday.)\n 24 Hour Events:\n PICC LINE - START 11:47 AM\n BLOOD CULTURED - At 01:04 PM\n PICC\n BLOOD CULTURED - At 04:37 AM\n Allergies:\n Hydromorphone\n unknown;\n Metoclopramide\n unknown.\n Last dose of Antibiotics:\n Vancomycin - 06:10 PM\n Gent 90mg per HD protocol\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Fosphenytoin - 08:30 AM\n RSSI\n Lantus 20 units qAM, 10 units qhs\n Celexa 40\n Zocor 40\n Calcium \n Fish Oil 1000 \n Folic acid 1mg\n Nasal spray\n Vitamin B 50mcg\n Neurontin 100mg \n Neomycin left eye gtt q6h\n Brimodine left eye \n Atropine left eye \n Timolol right eye \n Lantoprost right eye \n Dilantin q8\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 No changes.\n Flowsheet Data as of 09:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.9\nC (98.4\n HR: 76 (76 - 84) bpm\n BP: 110/38(52) {90/17(42) - 151/72(102)} mmHg\n RR: 18 (15 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 438 mL\n 90 mL\n PO:\n TF:\n IVF:\n 378 mL\n 90 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 438 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///28/\n Physical Examination\n General:\n HEENT:\n CV:\n Lungs:\n Ab:\n Ext:\n Neuro:\n Labs / Radiology\n 12.5 g/dL\n 193 K/uL\n 94 mg/dL\n 12.9 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 95 mEq/L\n 139 mEq/L\n 40.3 %\n 13.3 K/uL\n [image002.jpg]\n RUQ U/S: Small amount of non-occulsive thrombus material adherant to\n the PICC.\n 01:04 PM\n 04:15 AM\n WBC\n 14.0\n 13.3\n Hct\n 37.8\n 40.3\n Plt\n 174\n 193\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6,\n CK / CKMB / Troponin-T:147/4/0.35,\n Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:47 AM\n Dialysis Catheter - 09:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Fellow / Physician Attending Progress Note - MICU",
"row_id": 597582,
"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 her\n note above, including assessment and plan.\n HPI:\n 73yo man with ESRD on HD, CAD s/p CABG``, A fib on Warfarin, s/p fall\n who was admitted to neuro service initially for a subdural hematoma. He\n had RUE paresis on admission after his fall. During HD he dropped his\n BP in the setting of having had a fever to 102.5. He received Vanc,\n Gent and a liter of NS. Transferred ot the MICU for further care given\n the transient hypotension and concern for possible line-related\n infection.\n Overnight, Tmax was 100.5. He was making non-specific noises\n intermittently throughou the night. He was given morphine 0.5mg IV x 1\n for possible pain. He had a NG-tube replaced that was coiled in the\n back of his mouth; it was subsequently d/c\ned and currently he has no\n oral access. He does have an oxygen requirement of 4-6L NC (of note, he\n did not complete HD yesterday.)\n 24 Hour Events:\n PICC LINE - START 11:47 AM\n BLOOD CULTURED - At 01:04 PM\n PICC\n BLOOD CULTURED - At 04:37 AM\n Allergies:\n Hydromorphone\n unknown;\n Metoclopramide\n unknown.\n Last dose of Antibiotics:\n Vancomycin - 06:10 PM\n Gent 90mg per HD protocol\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Fosphenytoin - 08:30 AM\n RSSI\n Lantus 20 units qAM, 10 units qhs\n Celexa 40\n Zocor 40\n Calcium \n Fish Oil 1000 \n Folic acid 1mg\n Nasal spray\n Vitamin B 50mcg\n Neurontin 100mg \n Neomycin left eye gtt q6h\n Brimodine left eye \n Atropine left eye \n Timolol right eye \n Lantoprost right eye \n Dilantin q8\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 No changes.\n Flowsheet Data as of 09:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.9\nC (98.4\n HR: 76 (76 - 84) bpm\n BP: 110/38(52) {90/17(42) - 151/72(102)} mmHg\n RR: 18 (15 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 438 mL\n 90 mL\n PO:\n TF:\n IVF:\n 378 mL\n 90 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 438 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///28/\n Physical Examination\n General: Opens eyes to voice, moans non-specifically, appears to know\n his name.\n HEENT: Pupils are asymmetric, with apparent prior occular surgeries.\n Not reactive to light. Some right conjunctival hemorrhage.\n CV: S1S2 RRR w/o m/r/g\n Lungs: CTA anteriorly with good air movement.\n Ab: Positive BS\ns. Obese, NT/ND.\n Ext: Mild lower extremity edema.\n Neuro: As above, not following commands. Doesn\nt withdraw his RUE to\n noxious stimuli, but moves all other extremities to mild stimulus.\n Labs / Radiology\n 12.5 g/dL\n 193 K/uL\n 94 mg/dL\n 12.9 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 95 mEq/L\n 139 mEq/L\n 40.3 %\n 13.3 K/uL\n [image002.jpg]\n RUQ U/S: Small amount of non-occulsive thrombus material adherant to\n the PICC.\n 01:04 PM\n 04:15 AM\n WBC\n 14.0\n 13.3\n Hct\n 37.8\n 40.3\n Plt\n 174\n 193\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6,\n CK / CKMB / Troponin-T:147/4/0.35,\n Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n 73yo man with ESRD on HD, CAD s/p CABG``, A fib on Warfarin, s/p fall\n who was admitted to neuro service initially for a subdural hematoma\n here in the MICU with a fever and transient low blood pressure that has\n since resolved.\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Suspect that the primary central nervous system bleed and the recurrent\n seizure are themost likely causes of his altered MS. Need to clarify if\n the Neuro teams still want to pursue MRI/MRA/MRV which would further\n clarify his neurologic pathology. There is not compelling evidence for\n a secondary process such as a CNS infection.\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n He is undergoing dialysis today. Will follow their recs regarding\n appropriate subsequent dialysis.\n HYPOTENSION (NOT SHOCK)\n Resolved with one liter of normal saline yesterday. Suspect transient\n bacteremia in the setting of HD rather than true line infection. Will\n continue his Vanc / Gent for 48 hours; if cultures are non-revealing\n then will d/c antibiotics. There is no complling evidence for an\n alternative hypotension.\n CORONARY ARTERY DISEASE\n Will continue statin. Will restart beta-blocker after oral access is\n obtained. Review EKG this AM. Do not need to follow cardiac enzymes\n barring the development of any interval clincal changes.\n ICU Care\n Nutrition: Pending NGT placement.\n Glycemic Control: RSSI and standing Lantus.\n Lines:\n PICC Line - 11:47 AM\n Dialysis Catheter - 09:01 AM\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full.\n Disposition : ICU for now, will re-assess this afternoon after\n dialysis.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 597583,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:47 AM\n BLOOD CULTURED - At 01:04 PM\n PICC\n BLOOD CULTURED - At 04:37 AM\n -moaned overnight, thought pain, given 0.5mg morphine\n -able to say yes and no and repeat my name\n -moved all extremities except RUE\n -Right picc u/s with nonoccluding clot\n -Tm 100.5\n -NG tube removed bc could not identify below the diaphragm, then\n replaced, shot 2 films but then looked to be in good place but nurse\n found it coiled in his mouth so it was removed\n -free phenytoin level pending, neuro would like for us to discuss\n dosing with them\n -held off on MRI brain to see if neuro really wants it\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:10 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 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 07:20 AM\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: 37.1\nC (98.8\n HR: 76 (76 - 84) bpm\n BP: 151/68(45) {90/17(42) - 151/72(102)} mmHg\n RR: 19 (15 - 29) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 438 mL\n 73 mL\n PO:\n TF:\n IVF:\n 378 mL\n 73 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 438 mL\n -127 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: surgical bilaterally\n Head, Ears, Nose, Throat: Normocephalic, NG tube, EEG leads\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:\n Diminished: bilat, Rhonchorous: bilat), anterior auscultation\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: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 193 K/uL\n 12.5 g/dL\n 94 mg/dL\n 12.9 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 95 mEq/L\n 139 mEq/L\n 40.3 %\n 13.3 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n WBC\n 14.0\n 13.3\n Hct\n 37.8\n 40.3\n Plt\n 174\n 193\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6, CK / CKMB /\n Troponin-T:147/4/0.35, Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n #Hypotension\n Initial concern for line sepsis, though there have been\n no positive cultures. If they remain negative over 48 hours, will d/c\n antibiotics.\n -cont vanc/gent with HD for now. Given elevated gent level, will not\n redose. Will give 500mg IV vancomycin after HD.\n -hold antihypertensives\n # Head Bleed:\n - aspirin, coumadin (10-14 days after admission per neuro)\n - Appreciate neuro recs, re: MRI, re: dilantin level checking\n .\n #Encephalopathy - attributable to acute on chronic SDH and recurrent\n seizures\n -appreciate close neurology & epilepsy team involvement\n -cont fosphenytoin, trend levels\n -f/u MRI/MRA/MRV\n .\n # Hypoxia: likely pulmonary edema/volume overload given dialysis UF had\n recently been minimized\n #ESRD - only completed 30 min HD on \n -appreciate dialysis team involvement\n -may need extra session \n .\n #DM\n -basal, sliding scale insulin\n .\n #CAD s/p CABG\n -restart BB when BPs have clearly stabilized\n -cont statin\n -consider TTE to eval systolic/diastolic CHF (carvedilol invokes\n possible CHF history)\n .\n # FEN: tube feeds\n # PPX: pneumoboots, PPI\n # ACCESS: R PICC, L HD cath\n # CONTACT: , wife/HCP (was notified by\n neurology team of ICU transfer on )\n ICU Care\n Nutrition: TF\n Glycemic Control: Regular insulin sliding scale\n Lines: HD catheter\n PICC Line - 11:47 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598031,
"text": "Mr. is a 73 yoM on HD-anuric, h/o AFib not currently on\n coumadin (though is on at home), who is being transferred from the\n neurology service for respiratory distress and hypoxia. He was\n admitted on after a fall resulting in acute on chronic SDH on\n the left; his course is complicated by seizure and he has been started\n on fosphenytoin & phenytoin.\n .\n This evening he was noted to be in acute respiratory distress with\n desats to the low to mid 90's on 3LNC (reportedly desatting to the mid\n 70's on room air; has had a variable O2 requirement since being\n admitted). His blood pressure dropped to the 70's systolic and was\n responsive to the 80's and then 100's after a 250 cc NS bolus. he was\n febrile to 101.9,concern was aspiration event,pt has been on on\n vanco/genta for the given recent fevers,with neg cultures\n he was briefly in MICU green on - for fevers and hypotension\n to the 70's.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on ACx18/500/40%/5. LS diminished at bases. Sats\n 94-97% Pt sedated on fentanyl and versed drips. He is able to follow\n commands inconsistently.\n Action:\n Suctioned for thick copious secretions q 2-4 hours.\n Response:\n No change. Pt maintaining good saturation\n Plan:\n Wean vent as tolerated. CXR in am. ? a line placement if long term\n ventilation needed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TMAX 102.4 axillary.\n Action:\n Rectal Tylenol given. Cooling blanket placed on pt. Pt started on\n cefepime.\n Response:\n Temperature decreased to 97.9. Awaiting culture data.\n Plan:\n Administer Tylenol as needed. Continue to monitor\n Hypotension (not Shock)\n Assessment:\n HR 90\ns SR. BP 98-137/29-39. Pt remains on levophed drip to maintain\n systolic BPs >100. Pt continues to have large residual from NGT so pt\n remains NPO. Elevated FS despite being NPO. Pt is HD dependent. He\n currently does not have access.\n Action:\n Attempted to wean levophed. Able to decrease dose to .06mcgs/kg/min\n from .12mcgs/kg/min.\n Response:\n Systolic goal >100.\n Plan:\n Wean levophed to off if tolerated. Dialysis tomorrow. Pt will need\n access placed.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598038,
"text": "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 renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598039,
"text": "Mr. is a 73 yoM on HD-anuric, h/o AFib not currently on\n coumadin (though is on at home), who is being transferred from the\n neurology service for respiratory distress and hypoxia. He was\n admitted on after a fall resulting in acute on chronic SDH on\n the left; his course is complicated by seizure and he has been started\n on fosphenytoin & phenytoin.\n On he was noted to be in acute respiratory distress with desats\n to the low to mid 90's on 3LNC (reportedly desatting to the mid 70's on\n room air; has had a variable O2 requirement since being admitted). His\n blood pressure dropped to the 70's systolic and was responsive to the\n 80's and then 100's after a 250 cc NS bolus. he was febrile to\n 101.9,concern was aspiration event,pt has been on on vanco/genta for\n the given recent fevers,with neg cultures\n he was briefly in MICU green on - for fevers and hypotension\n to the 70's.\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 renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598465,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\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: 25 cmH2O\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: 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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598545,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\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": "2191-08-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 597913,
"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:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n 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 from floors.Inrcreased resp distress. Intubated and\n sedated.Will cont to monitor resp status.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 597917,
"text": "Chief Complaint: Reason for transfer: respiratory distress,\n hypotension\n HPI:\n Mr. is a 73 yoM on HD-anuric, h/o AFib not currently on\n coumadin (though is on at home), who is being transferred from the\n neurology service for respiratory distress and hypoxia. He was\n admitted on after a fall resulting in acute on chronic SDH on\n the left; his course is complicated by seizure and he has been started\n on fosphenytoin & phenytoin.\n .\n This evening he was noted to be in acute respiratory distress with\n desats to the low to mid 90's on 3LNC (reportedly desatting to the mid\n 70's on room air; has had a variable O2 requirement since being\n admitted). His blood pressure dropped to the 70's systolic and was\n responsive to the 80's and then 100's after a 250 cc NS bolus. he was\n febrile to 101.9. The neurology and medicine MERIT teams were\n concerned for an aspiration event vs. volume overload vs. PE. CXR is\n c/w volume overload; however it is grossly unchanged from earlier\n films. His normal schedule is M-W-F though he did not get dialyzed on\n Friday because he was having focal motor seizures. He was last\n dialyzed Saturday for a shorter cycle b/c of low blood flow\n from the HD catheter(per renal note). His mental status has been poor\n since being in the hospital.\n .\n Of note, he is currently being treated with vanco/gent for a possible\n line infection given recent fevers. Nothing has grown out of numerous\n blood cultures since yet he continues to spike. he was briefly\n in MICU green on - for fevers and hypotension to the 70's.\n .\n Since arriving to the MICU satting in the upper 90's on NRB, code\n status was confirmed with his wife on the phone and he was intubated\n with vecuronium and etomidate. He is currently on AC 500x14 with PEEP\n 5 at 50% FiO2. Peri-intubation, MAP's dropped to the 50's and he was\n started on low dose levophed through his right PICC.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 02:15 AM\n Other medications:\n MEDICATIONS ON TRANSFER:\n Gentamicin 90 mg IV QHD-- since \n Vancomycin 500 mg IV QHD-- since \n Fosphenytoin 100 mg PE IV BID\n Fosphenytoin 200 mg PE IV QHS (Q8 hours)\n Phenytoin 1000 mg IV x 1 given this afternoon\n .\n Acetaminophen 650 mg PO Q6H:PRN\n SSI + Lantus 20 Qam, 10 QHS\n Citalopram 40 mg QD\n Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing\n Simvastatin 40 mg PO DAILY\n Allopurinol 100 mg PO BID\n Calcium Acetate mg PO TID W/MEALS\n Fish Oil (Omega 3) 1000 mg PO BID\n FoLIC Acid 1 mg PO DAILY\n Fluticasone Propionate NASAL 1 SPRY NU DAILY\n Cyanocobalamin 50 mcg PO DAILY\n Lorazepam 1-2 mg IV Q4H:PRN seizure > 5 minutes\n Gabapentin 100 mg PO BID\n Neomycin/Polymyxin/Dexameth Ophth Susp. 1 DROP LEFT EYE Q6H\n Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE \n Atropine Sulfate Ophth 1% 1 DROP LEFT EYE \n Timolol Maleate 0.25% 1 DROP RIGHT EYE \n Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS\n Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n Atrial fibrillation on coumadin\n CHF-- no EF in our system\n CAD s/p CABG\n DM\n ESRD on HD\n Glaucoma\n Cataracts\n Asthma\n ? gout (per med list)\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: wife is HCP; no illicits including no tobacco\n Review of systems:\n Flowsheet Data as of 03:57 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 38.2\nC (100.7\n HR: 91 (86 - 91) bpm\n BP: 123/31(52) {110/31(52) - 123/37(55)} mmHg\n RR: 20 (20 - 30) insp/min\n SpO2: 98%\n Total In:\n 288 mL\n PO:\n TF:\n IVF:\n 38 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 288 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 558 (558 - 558) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 32 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.31/47/91//-2\n Ve: 2.5 L/min\n PaO2 / FiO2: 182\n Physical Examination\n General Appearance: Overweight / Obese, acute SOB, respirator distress\n with AM use\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No m/r/g appreciated\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Not assessed), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: ), coarse upper\n airway breathsounds\n Abdominal: Soft, Bowel sounds present, No(t) Distended, Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, trace edema of right forearm\n Skin: Warm, No(t) Rash:\n Neurologic: No(t) Follows simple commands, Responds to: Noxious\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 254 K/uL\n 11.9 g/dL\n 94 mg/dL\n 12.9 mg/dL\n 57 mg/dL\n 28 mEq/L\n 95 mEq/L\n 4.7 mEq/L\n 139 mEq/L\n 38.8 %\n 11.7 K/uL\n [image002.jpg]\n \n 2:33 A9/30/ 01:04 PM\n \n 10:20 P10/1/ 04:15 AM\n \n 1:20 P10/4/ 02:49 AM\n \n 11:50 P10/4/ 03:17 AM\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 14.0\n 13.3\n 11.7\n Hct\n 37.8\n 40.3\n 38.8\n Plt\n 174\n 193\n 254\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n TC02\n 25\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6, CK / CKMB /\n Troponin-T:147/4/0.35, Differential-Neuts:83.3 %, Lymph:8.0 %, Mono:5.6\n %, Eos:2.8 %, Lactic Acid:0.8 mmol/L, Ca++:8.7 mg/dL, Mg++:2.0 mg/dL,\n PO4:6.2 mg/dL\n Imaging: CXR: vascular congestion, pulm edema; no obvious\n infiltrate; grossly unchanged from \n HEAD CT non-contrast: No significant change since the \n examination with continued evolution of the mixed-attenuation subdural\n hematoma overlying the left cerebral convexity, with minimal mass\n effect and no significant shift of the normally midline structures, and\n no new hemorrhage or evidence of acute vascular territorial infarction.\n Microbiology: Multiple blood cultures from to , NGTD\n No urine cultures since anuric\n Assessment and Plan\n ASSESSMENT/PLAN:\n 73 yoM admitted with left SDH c/b seizure, on HD w/o residual UOP, and\n possible line infection on gent/vanco. Being transferred for\n respiratory distress, hypotension & hypoxia.\n .\n .\n (#) RESPIRATORY DISTRESS: pt has been intubated for respiratory\n distress; likely some element of volume overload given anuric state &\n IVF boluses given for hypotension, it seems he may have also had a less\n aggresive HD session on due to line issues. There is some\n question as to whether he also had an aspiration event given his poor\n mental status; he does have some secretions (unclear if much more than\n baseline). He may have also has a PE given he is not currently\n anticoagulated (though he appears to be in SR on tele here now); no CTA\n was obtained given (1) unstable to go to scan right now and (2) would\n be unlikely to anticoagulate him now given recent SDH.\n -- patient intubated for respiratory distress; appears to be\n oxygenating well now\n -- no need for HD acutely given stable on the vent right now; will\n touch base first thing with HD fellow in am\n -- sent sputum culture\n -- being covered with vanco; would consider adding cefepime if\n secretions worsen\n -- cont sedation with propfol though might consider changing to\n versed/fentanyl if not going to extubate soon\n .\n (#) HYPOTENSION, FEVERS: has been problem throughout\n this admission; unclear whether he was developing sepsis with concern\n for line infection or some other process. He is being covered for a\n line infection though blood cultures have remained negative. On\n levophed now peri-intubation. Episodes seem to be transient. Does\n have known CAD & CHF, though no echo in system. No UA/UCx sent b/c\n anuric. No evidence of skin breakdown or PICC site infection.\n -- cont vanco/gent empirically\n -- f/u blood cultures\n -- wean levo as tolerated\n -- would consider non-infectious sources of fevers as well, including\n drug fever & central.\n .\n (#) ESRD, HD: line issues not exactly clear to me from the notes;\n sounds like he was supposed to have a tunneled line on ; he may\n need a temporary line on if he needs semi-emergent HD\n -- cont vanco/gent\n -- will touch base with fellow first thing in am\n .\n (#) AFib: rate controlled now; seems to be in sinus rhtyhm; not on\n coumadin currently with recent SDH.\n -- cont to follow\n -- not on rate meds currently\n .\n (#) Seizure: continues to have seizures, though no evidence of seziure\n activity now while in the ICU; on propfol for sedation on vent.\n -- cont fosphenytoin; got a phenytoin ooster earlier this afternoon\n .\n (#) SDH:\n -- neurology following\n -- holding anticoagulation now, including SQH\n .\n (#) h/o glaucoma, cataracts:\n -- cont home meds\n .\n (#) ASTHMA: does not appear to be acive as no wheezing on exam & pt\n doesn't appear super tight, thoguh may be contributing.\n -- will place on standing inhalers overnight; consider decreasing to\n PRN in am\n .\n (#) DM:\n -- cont SSI + lantus 20/10\n -- ? need for consult --> looks like neuro team was considering\n consulting them for hyperglycemia; will monitor throught morning and\n consider need for consult\n .\n (#) ACCESS: double lumen PICC on right; no HD catheter currently\n .\n (#) Nutrition: NPO currently; no IVF maintenance given c/f volume\n overload\n .\n (#) PPX: pneumoboots (no SQH with recent SDH); on PPI; no need for\n bowel regimen currently.\n .\n (#) CODE: full; confirmed with wife on admission via phone --> have not\n yet had her sign the ICU consent. Will consider readdressing with\n family during daytime\n .\n (#) DISPO: to remain in ICU while intubated; may attempt extubation\n pending improvement of volume status with HD on or \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:07 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Other, not a candidate given\n recent head bleed)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments: Discussed code status with wife on arrival to\n ICu; have not yet consented her.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597664,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n CODE: FULL\n ACCESS: Right double lumen PICC, Left HD cath\n SOCIAL: Contact is with daughter who works in the\n Medical Office Building.\n ROS:\n *neuro- A&Ox1 (person) and able to follow commands at times;\n moans/groans/yells out but when asked if in pain denies; pupils\n unequal, non reactive (please see below)\n *resp- satting 94-98% on 6L NC with RR 10s-20s; LS ronchorous\n throughout, congested cough present\n *CV- HR 80s SR, no ectopy; BPs ranging 100s-140s systolic; BP being\n taken on right calf as unable to take on BUE PICC on right and old\n AV fistula on left\n *GI/ pt does not make urine; HD pt M/W/F, has NGT in place to right\n nare with Nutren Pulmonary Full infusing @ 10cc/hr (starting rate), tol\n without N/V, abd S/NT/slightly distended with +BS; flexiseal in place\n draining brown liquid stool\n *act- moves all extremities on bed except RUE; when extremities lifted\n up, they fall back as pt is unable to lift and hold; did wiggle toes at\n times on command\n *endo- FSBS 148 @ 1200, 147 @ 1800 requiring no insulin coverage per\n SS; also as fixed dose which was not given this am NPO, but will be\n needed @ bedtime\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with tmax 102.5 rectal on floor; transferred to MICU for fever with\n hypotension suggesting possible sepsis. Tmax 99.5 today.\n Action:\n Pt has had multiple sets blood cx, all with NGTD. On vanc/gent coverage\n for possible line infection (PICC or HD cath) though neither line\n removed at this point extremely poor access. Neither line with s/s\n infection at insertion point.\n Response:\n Blood cx with NGTD. Tmax 99.5 this shift.\n Plan:\n Cont vanc/gent until blood cx results come back. Cont to monitor for\n fever, s/s sepsis.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with chronic RF, on HD M/W/F. Did not tolerate HD yesterday ()\n hypotension with fluid removal, so sent to MICU for further\n monitoring.\n Action:\n Pt had HD today.\n Response:\n Tolerated HD with VSS. 1L fluid removed.\n Plan:\n Cont with regularly scheduled HD.\n Altered mental status (not Delirium)\n Assessment:\n Pt had a repeat head CT yesterday which showed a stable subdural\n hematoma. Pt moaning, calling out. At beginning of shift able to state\n name, but unable to do so @ 1600 assessment, incomprehensible sounds to\n other questions. Follows simple commands but only at times s/a wiggling\n toes or opening mouth for mouth care. Right pupil 2-3mm, non reactive,\n impaired corneal reflex. Left pupil 5mm, non reactive, impaired corneal\n reflex; this is stable per team (h/o glaucoma, cataract surgery). Per\n daughter, pt was high functioning prior to fall and SDH.\n Action:\n Pt frequently reoriented, frequent checks for safety. Left arm in soft\n wrist restraint as pt pulled out NGT yesterday, pt unable to move RUE.\n EEG completed. No MRI this shift as it is unnecessary per neuro because\n it will not change treatment of bleed.\n Response:\n Pt stable and improving per neurological service.\n Plan:\n Continue to monitor mental status. Call out to neuro so pt can be f/b\n neuromed service.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 597665,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n CODE: FULL\n ACCESS: Right double lumen PICC, Left HD cath\n SOCIAL: Contact is with daughter who works in the\n Medical Office Building.\n ROS:\n *neuro- A&Ox1 (person) and able to follow commands at times;\n moans/groans/yells out but when asked if in pain denies; pupils\n unequal, non reactive (please see below)\n *resp- satting 94-98% on 6L NC with RR 10s-20s; LS ronchorous\n throughout, congested cough present\n *CV- HR 80s SR, no ectopy; BPs ranging 100s-140s systolic; BP being\n taken on right calf as unable to take on BUE PICC on right and old\n AV fistula on left\n *GI/ pt does not make urine; HD pt M/W/F, has NGT in place to right\n nare with Nutren Pulmonary Full infusing @ 10cc/hr (starting rate), tol\n without N/V, abd S/NT/slightly distended with +BS; flexiseal in place\n draining brown liquid stool\n *act- moves all extremities on bed except RUE; when extremities lifted\n up, they fall back as pt is unable to lift and hold; did wiggle toes at\n times on command\n *endo- FSBS 148 @ 1200, 147 @ 1800 requiring no insulin coverage per\n SS; also as fixed dose which was not given this am NPO, but will be\n needed @ bedtime\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with tmax 102.5 rectal on floor; transferred to MICU for fever with\n hypotension suggesting possible sepsis. Tmax 99.5 today.\n Action:\n Pt has had multiple sets blood cx, all with NGTD. On vanc/gent coverage\n for possible line infection (PICC or HD cath) though neither line\n removed at this point extremely poor access. Neither line with s/s\n infection at insertion point.\n Response:\n Blood cx with NGTD. Tmax 99.5 this shift.\n Plan:\n Cont vanc/gent until blood cx results come back. Cont to monitor for\n fever, s/s sepsis.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with chronic RF, on HD M/W/F. Did not tolerate HD yesterday ()\n hypotension with fluid removal, so sent to MICU for further\n monitoring.\n Action:\n Pt had HD today.\n Response:\n Tolerated HD with VSS. 1L fluid removed.\n Plan:\n Cont with regularly scheduled HD.\n Altered mental status (not Delirium)\n Assessment:\n Pt had a repeat head CT yesterday which showed a stable subdural\n hematoma. Pt moaning, calling out. At beginning of shift able to state\n name, but unable to do so @ 1600 assessment, incomprehensible sounds to\n other questions. Follows simple commands but only at times s/a wiggling\n toes or opening mouth for mouth care. Right pupil 2-3mm, non reactive,\n impaired corneal reflex. Left pupil 5mm, non reactive, impaired corneal\n reflex; this is stable per team (h/o glaucoma, cataract surgery). Per\n daughter, pt was high functioning prior to fall and SDH.\n Action:\n Pt frequently reoriented, frequent checks for safety. Left arm in soft\n wrist restraint as pt pulled out NGT yesterday, pt unable to move RUE.\n EEG completed. No MRI this shift as it is unnecessary per neuro because\n it will not change treatment of bleed.\n Response:\n Pt stable and improving per neurological service.\n Plan:\n Continue to monitor mental status. Call out to neuro so pt can be f/b\n neuromed service.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597666,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n CODE: FULL\n ACCESS: Right double lumen PICC, Left HD cath\n SOCIAL: Contact is with daughter who works in the\n Medical Office Building.\n ROS:\n *neuro- A&Ox1 (person) and able to follow commands at times;\n moans/groans/yells out but when asked if in pain denies; pupils\n unequal, non reactive (please see below)\n *resp- satting 94-98% on 6L NC with RR 10s-20s; LS ronchorous\n throughout, congested cough present\n *CV- HR 80s SR, no ectopy; BPs ranging 100s-140s systolic; BP being\n taken on right calf as unable to take on BUE PICC on right and old\n AV fistula on left\n *GI/ pt does not make urine; HD pt M/W/F, has NGT in place to right\n nare with Nutren Pulmonary Full infusing @ 10cc/hr (starting rate), tol\n without N/V, abd S/NT/slightly distended with +BS; flexiseal in place\n draining brown liquid stool\n *act- moves all extremities on bed except RUE; when extremities lifted\n up, they fall back as pt is unable to lift and hold; did wiggle toes at\n times on command\n *endo- FSBS 148 @ 1200, 147 @ 1800 requiring no insulin coverage per\n SS; also as fixed dose which was not given this am NPO, but will be\n needed @ bedtime\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with tmax 102.5 rectal on floor; transferred to MICU for fever with\n hypotension suggesting possible sepsis. Tmax 99.5 today.\n Action:\n Pt has had multiple sets blood cx, all with NGTD. On vanc/gent coverage\n for possible line infection (PICC or HD cath) though neither line\n removed at this point extremely poor access. Neither line with s/s\n infection at insertion point.\n Response:\n Blood cx with NGTD. Tmax 99.5 this shift.\n Plan:\n Cont vanc/gent until blood cx results come back. Cont to monitor for\n fever, s/s sepsis.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with chronic RF, on HD M/W/F. Did not tolerate HD yesterday ()\n hypotension with fluid removal, so sent to MICU for further\n monitoring.\n Action:\n Pt had HD today.\n Response:\n Tolerated HD with VSS. 1L fluid removed.\n Plan:\n Cont with regularly scheduled HD.\n Altered mental status (not Delirium)\n Assessment:\n Pt had a repeat head CT yesterday which showed a stable subdural\n hematoma. Pt moaning, calling out. At beginning of shift able to state\n name, but unable to do so @ 1600 assessment, incomprehensible sounds to\n other questions. Follows simple commands but only at times s/a wiggling\n toes or opening mouth for mouth care. Right pupil 2-3mm, non reactive,\n impaired corneal reflex. Left pupil 5mm, non reactive, impaired corneal\n reflex; this is stable per team (h/o glaucoma, cataract surgery). Per\n daughter, pt was high functioning prior to fall and SDH.\n Action:\n Pt frequently reoriented, frequent checks for safety. Left arm in soft\n wrist restraint as pt pulled out NGT yesterday, pt unable to move RUE.\n EEG completed. No MRI this shift as it is unnecessary per neuro because\n it will not change treatment of bleed.\n Response:\n Pt stable and improving per neurological service.\n Plan:\n Continue to monitor mental status. Call out to neuro so pt can be f/b\n neuromed service.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598024,
"text": "Mr. is a 73 yoM on HD-anuric, h/o AFib not currently on\n coumadin (though is on at home), who is being transferred from the\n neurology service for respiratory distress and hypoxia. He was\n admitted on after a fall resulting in acute on chronic SDH on\n the left; his course is complicated by seizure and he has been started\n on fosphenytoin & phenytoin.\n .\n This evening he was noted to be in acute respiratory distress with\n desats to the low to mid 90's on 3LNC (reportedly desatting to the mid\n 70's on room air; has had a variable O2 requirement since being\n admitted). His blood pressure dropped to the 70's systolic and was\n responsive to the 80's and then 100's after a 250 cc NS bolus. he was\n febrile to 101.9,concern was aspiration event,pt has been on on\n vanco/genta for the given recent fevers,with neg cultures\n he was briefly in MICU green on - for fevers and hypotension\n to the 70's.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented on ACx18/500/40%/5. LS diminished at bases. Sats\n 94-97% Pt sedated on fentanyl and versed drips. He is able to follow\n commands inconsistently.\n Action:\n Suctioned for thick copious secretions q 2-4 hours.\n Response:\n No change. Pt maintaining good saturation\n Plan:\n Wean vent as tolerated. CXR in am. ? a line placement if long term\n ventilation needed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TMAX 102.4 axillary.\n Action:\n Rectal Tylenol given. Cooling blanket placed on pt. Pt started on\n cefepime.\n Response:\n Temperature decreased to 97.9. Awaiting culture data.\n Plan:\n Administer Tylenol as needed. Continue to monitor\n Hypotension (not Shock)\n Assessment:\n HR 90\ns SR. BP 98-137/29-39. Pt remains on levophed drip to maintain\n systolic BPs >100. Pt continues to have large residual from NGT so pt\n remains NPO. Elevated FS despite being NPO. Pt is HD dependent. He\n currently does not have access.\n Action:\n Attempted to wean levophed. Able to decrease dose to .06mcgs/kg/min\n from .12mcgs/kg/min.\n Response:\n Systolic goal >100.\n Plan:\n Wean levophed to off if tolerated. Dialysis tomorrow. Pt will need\n access placed.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598100,
"text": "Chief Complaint: 73 yoM admitted with left SDH c/b seizure, on HD w/o\n residual UOP, and possible line infection on gent/vanco. Being\n transferred for respiratory distress, hypotension & hypoxia. Now\n intubated, oxygentating well, likely has PNA per chest Xray and\n fevers. Continues to require levophed. Also has h/o afib, not on\n coumadin due to recent SDH.\n 24 Hour Events:\n FEVER - 102.4\nF - 08:00 AM\n - patient now covered with vancomycin and cefepime, gentamicin\n discontinued\n - persistent large volumes of bilous return from NGT (it is properly\n placed in stomach), patient is passing flatus and has ABS (no ileus)\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 02:06 PM\n Infusions:\n Fentanyl - 35 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Midazolam (Versed) - 08:00 PM\n Fentanyl - 08:00 PM\n Fosphenytoin - 12:18 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.3\nC (99.1\n HR: 83 (80 - 99) bpm\n BP: 121/42(60) {70/17(41) - 137/77(82)} mmHg\n RR: 18 (17 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 985 mL\n 77 mL\n PO:\n TF:\n IVF:\n 555 mL\n 77 mL\n Blood products:\n Total out:\n 1,730 mL\n 450 mL\n Urine:\n NG:\n 1,730 mL\n 450 mL\n Stool:\n Drains:\n Balance:\n -745 mL\n -373 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 307 (307 - 350) mL\n RR (Set): 0\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 0 cmH2O\n Plateau: 22 cmH2O\n Compliance: 0 cmH2O/mL\n SpO2: 94%\n ABG: 7.31/44/74/23/-4\n Ve: 8.4 L/min\n PaO2 / FiO2: 185\n Physical Examination\n Cardiovascular: NAD\n RRR, no murmur\n Reduced left sided BS\n Abd benign, active BS\n Ext 1+ edema symmetrical\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 269 K/uL\n 12.2 g/dL\n 178 mg/dL\n 10.4 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 57 mg/dL\n 103 mEq/L\n 139 mEq/L\n 38.5 %\n 14.7 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n 02:49 AM\n 03:17 AM\n 10:02 PM\n 04:12 AM\n 05:04 AM\n WBC\n 14.0\n 13.3\n 11.7\n 14.7\n Hct\n 37.8\n 40.3\n 38.8\n 38.5\n Plt\n 174\n 193\n 254\n 269\n Cr\n 11.9\n 12.9\n 8.2\n 10.4\n TropT\n 0.35\n TCO2\n 25\n 22\n 23\n Glucose\n 164\n 94\n 207\n 178\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, Differential-Neuts:83.3 %, Lymph:8.0 %, Mono:5.6\n %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:9.8 mg/dL, Mg++:2.5 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR: opacificiation of L hemidiaphram, increased right hilar\n prominence\n Microbiology: blood cultures since , most recent on \n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yoM admitted with left SDH c/b seizure, on HD w/o residual UOP, and\n possible line infection on gent/vanco. Being transferred for\n respiratory distress, hypotension & hypoxia.\n (#) RESPIRATORY DISTRESS: pt has been intubated for respiratory\n distress; likely some element of volume overload given anuric state &\n IVF boluses given for hypotension, it seems he may have also had a less\n aggresive HD session on due to line issues. There is some\n question as to whether he also had an aspiration event given his poor\n mental status; he does have some secretions (unclear if much more than\n baseline). He may have also has a PE given he is not currently\n anticoagulated, unable to tolerate CTA, ? intervention possible if\n bleed\n -- patient intubated for respiratory distress; appears to be\n oxygenating well now\n -- no need for HD acutely given stable on the vent right now; will\n touch base first thing with HD fellow in am\n -- f/u sputum culture\n -- on vancomycin, started on cefepime yesterday\n -- oon versed/fentanyl for sedation\n .\n (#) HYPOTENSION, FEVERS: has been problem throughout\n this admission; unclear whether he was developing sepsis with concern\n for line infection or some other process. He is being covered for a\n line infection though blood cultures have remained negative. On\n levophed now peri-intubation. Episodes seem to be transient. Does\n have known CAD & CHF, though no echo in system. No UA/UCx sent b/c\n anuric. No evidence of skin breakdown or PICC site infection.\n -- cont vanco/cefepime\n -- f/u blood cultures\n -- wean levo as tolerated\n (#) ESRD, HD: he was supposed to have a tunneled line on ;\n -- cont vanco/cefepime\n -- will touch base with fellow first thing in am\n .\n (#) AFib: rate controlled now; seems to be in sinus rhyhm; not on\n coumadin currently with recent SDH.\n -- cont to follow\n -- not on rate meds currently\n .\n (#) Seizure: no evidence of seziure activity now while in the ICU\n -- cont fosphenytoin\n .\n (#) SDH:\n -- neurology following\n -- holding anticoagulation now, including SQH\n .\n (#) h/o glaucoma, cataracts:\n -- cont home meds\n .\n (#) ASTHMA: does not appear to be acive as no wheezing on exam & pt\n doesn't appear super tight, thoguh may be contributing.\n -- will place on standing inhalers overnight; consider decreasing to\n PRN in am\n .\n (#) DM:\n -- cont SSI + lantus 20/10\n .\n (#) ACCESS: double lumen PICC on right; no HD catheter currently\n .\n (#) Nutrition: NPO currently; no IVF maintenance given c/f volume\n overload\n .\n (#) PPX: pneumoboots (no SQH with recent SDH); on PPI; no need for\n bowel regimen currently.\n .\n (#) CODE: full; confirmed with wife on admission via phone\n .\n (#) DISPO: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Generic Note",
"row_id": 598124,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with plan as outlined during multidisciplinary rounds\n this morning. Unresponsive. Increased NG output overnight.\n 96.6 77 103/32\n Unresponsive\n Chest coarse mid insp crackles\n CV w/o m\n Abd\n soft w/o apparent tenderness\n WBC 14. sputum pending\n BP remains dependent on norepi. Fluid balance is even from adm so will\n give fluid bolus and try to wean pressor. Still making copious sputum\n awaiting gr st but covering for HAP. Incr NG output concerning\n will check amylase/ lipase and RUQ U/S and KUB. No h/o abd surgery to\n suggest SBO. No improvement in resp status yet so not yet weanable.\n Will try for art line today.\n Time spent 50 min\n Critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598316,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5 and o2 40%. RR\n 20\ns wirh tv ~350-400cc. Following serial vbg\ns at the current time. Pt\n required q2-3 hour suctioning for tannish, thick, tenacious sputum.\n Continuing low dose fentayl and versed drips for comfort.\n Action:\n Pt remains intubated on psv ventilation d/t altered mental status,\n likely aspiration pnx, and possible volume overload noted on cxr today.\n Response:\n Continue mechanical ventilation.\n Plan:\n Follow lung exam, continue pulmonary toilet. Medical team to\n re-attempt arterial line placement this afternoon to assist with\n weaning, pressor titration, and blood draws.\n Hypotension (not Shock)\n Assessment:\n Afebrile. SBP 80-130\ns depending on levophed dose and degree of\n stimulation. Remains on low dose levophed.\n Action:\n Two unsuccessful attempts were made to turn off the pt\ns levophed drip\n today. SBP\ns eventually drifted into the low 90\ns to high 80\ns with\n unreliable maps. He did receive a single 500cc ns fluid bolus with\n transient improvement in his blood pressure. He received a single dose\n of vanco this afternoon following a low trough level.\n Response:\n Pt continues to be pressor dependent.\n Plan:\n Follow hemodynamic status closely; wean levophed as able, ?additional\n fluid bolus.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Temporary Quinton catheter with a sideport placed in IR this afternoon\n in anticipation of initiating CRRT tomarrow.\n Action:\n Repeat pm lytes sent this afternoon, but per micu attending, will wait\n on initiation of crrt until tomarrow.\n Response:\n ESRD with no immediate need to dialyse.\n Plan:\n Follow up on repeat lytes, anticipate crrt tomarrow if the pt remains\n pressor dependent.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 199-226. Pt received 2-4 units of insulin per hiss. Pt\n remains npo as he continues to pass large amounts of bilious drainage\n from his ogt. Total output since mn is more than 800cc. Abd is soft,\n distended with +bs.\n Action:\n OGT to lis today. LIS on hold briefly with am meds although it\n unlikely that pt absorbed any of his medications. Reason for poor\n absorbtion is unclear, ?gastroparesis. LFT\ns sent to check for\n pancreatitis. KUB obtained this afternoon to r/o ileus vs sbo.\n Response:\n Hyperglycemic requiring sliding scale insulin coverage despite npo\n status. LFT\ns unremarkable.\n Plan:\n Monitor fs qid and cover with hiss. f/u on kub results. Follow abd\n exam.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598317,
"text": "Chief Complaint: 73 yoM admitted with left SDH c/b seizure, on HD w/o\n residual UOP, and possible line infection on gent/vanco. Being\n transferred for respiratory distress, hypotension & hypoxia.\n 24 Hour Events:\n SPUTUM CULTURE - At 12:00 PM\n culture repeated\n ANGIOGRAPHY - At 03:00 PM\n temporary dialysis line placement.\n DIALYSIS CATHETER - START 04:10 PM\n sideport\n -Renal: tunneled line okay, check vanco trough daily, if trough between\n 15-20 give 500mg IV Vanco, if < 15 give 1gm.\n -lipase mildly elevated, AST, alk phos very mildly elevated; holding\n off on RUQ US\n -prelim read of KUB does not show any obstruction\n - sputum cultures - positive for GNR and G+ Cocci in Pairs\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 01:06 PM\n Vancomycin - 02:11 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 AM\n Midazolam (Versed) - 03:35 PM\n Fentanyl - 03:36 PM\n Fosphenytoin - 12:05 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 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.4\n HR: 80 (77 - 89) bpm\n BP: 108/42(56) {86/22(39) - 128/87(91)} mmHg\n RR: 19 (14 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,028 mL\n 71 mL\n PO:\n TF:\n IVF:\n 983 mL\n 71 mL\n Blood products:\n Total out:\n 450 mL\n 950 mL\n Urine:\n NG:\n 450 mL\n 950 mL\n Stool:\n Drains:\n Balance:\n 578 mL\n -879 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 602 (402 - 602) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: ///23/\n Ve: 10 L/min\n Physical Examination\n Cardiovascular: Gen: NAD, intubated, sedated\n CV: RRR, no r/g/m\n Lungs: CTAB\n Abd: soft, distended, less tense, + BS\n Ext: trace edema, 2+ DP, sacral 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 317 K/uL\n 11.2 g/dL\n 175 mg/dL\n 12.1 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 62 mg/dL\n 100 mEq/L\n 137 mEq/L\n 35.3 %\n 13.4 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n 02:49 AM\n 03:17 AM\n 10:02 PM\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n WBC\n 14.0\n 13.3\n 11.7\n 14.7\n 13.4\n Hct\n 37.8\n 40.3\n 38.8\n 38.5\n 35.3\n Plt\n 174\n 193\n 254\n 269\n 317\n Cr\n 11.9\n 12.9\n 8.2\n 10.4\n 11.4\n 12.1\n TropT\n 0.35\n TCO2\n 25\n 22\n 23\n Glucose\n 164\n 94\n \n 175\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:3.7 mg/dL\n Imaging: CXR -\n Microbiology: All blood cultures negative to date.\n Sputum Culture - positive for GNR and G+ Cocci in Pairs\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yoM admitted with left SDH c/b seizure, on HD w/o residual UOP, and\n possible line infection on gent/vanco. Being transferred for\n respiratory distress, hypotension & hypoxia.\n (#) RESPIRATORY DISTRESS: pt has been intubated for respiratory\n distress; likely some element of volume overload given anuric state &\n IVF boluses given for hypotension. There is some question as to\n whether he also had an aspiration event given his poor mental status.\n He may have also has a PE given he is not currently anticoagulated,\n unable to tolerate CTA, ? intervention possible if bleed.\n -- patient intubated for respiratory distress; appears to be\n oxygenating well now.\n -- volume overload - w/out HD yesterday, negative since ICU\n admission, but has been receiving IVF boluses prior and again this AM,\n pending possible dialysis today\n -- PNA - Gram stain with GNR and G+ Cocci in pairs , cultures\n pending. On Vanco and Cefepime. (Had been on Vanco and Gent since\n , changed to Vanc/Cefepime on ). Would restart Gent and add\n Cipo for GNR. He will need daily Vanco and Gent troughs for\n dosing.\n -- f/u sputum culture\n -- on versed/fentanyl for sedation\n (#) HYPOTENSION, FEVERS: has been problem throughout\n this admission; Sepsis high on differential from pneumonia. He has\n been treated for line infection since for fever. Central\n hypotension also possible given recent SDH. Continues to be on\n levophed, despite trying to wean. He responds only briefly to fluids.\n Other concern is lack of good measurement. Currently obtaining calf\n pressure, questionable accuracy. Has PICC in one arm, for periods.\n Episodes seem to be transient. Does have known CAD & CHF, though no\n echo in system.\n -- cont vanco/cefepime\n -- f/u blood cultures, sputum cultures\n -- wean levo as tolerated\n -- volume challenge this AM\n (#) High bilious output via NG tube - ? ilius vs SBO. Also concerned\n for inflammatory process in the abdomen. 950cc out over 25 hrs, half\n the amount yesterday. KUB benign, and pt had BM yesterday. Liver\n enzymes unimpressive.\n - improving, continue to follow.\n - recheck liver enzymes for trend\n - guaic negative aspirate\n (#) ESRD, HD: had a temp line he was supposed to have a tunneled line\n on ; volume overloaded, but about .5 L positive since ICU due to NG\n output.\n -- cont vanco/cefepime\n -- will touch base with fellow first thing in am\n (#) AFib: rate controlled now; seems to be in sinus rhyhm; not on\n coumadin currently with recent SDH.\n -- cont to follow\n -- not on rate meds currently\n (#) Seizure: no evidence of seziure activity now while in the ICU\n -- cont fosphenytoin\n (#) SDH:\n -- neurology following\n -- holding anticoagulation now, including SQH\n (#) h/o glaucoma, cataracts:\n -- cont home meds\n .\n (#) ASTHMA: does not appear to be acive as no wheezing on exam & pt\n doesn't appear super tight, thoguh may be contributing.\n -- will place on standing inhalers overnight; consider decreasing to\n PRN in am\n (#) DM:\n -- cont SSI + lantus 20/10, blood sugars increasing in setting of\n infection. will tighten sliding scale rather than basal\n (#) ACCESS: double lumen PICC on right; no HD catheter currently\n (#) Nutrition: NPO currently; no IVF maintenance given c/f volume\n overload\n (#) PPX: pneumoboots (no SQH with recent SDH); on PPI; bowel reg\n (#) CODE: full; confirmed with wife on admission via phone\n (#) DISPO: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598017,
"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 Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n 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: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use\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 Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598080,
"text": "Mr. is a 73 yoM on HD-anuric, h/o AFib not currently on\n coumadin (though is on at home), who is being transferred from the\n neurology service for respiratory distress and hypoxia. He was\n admitted on after a fall resulting in acute on chronic SDH on\n the left; his course is complicated by seizure and he has been started\n on fosphenytoin & phenytoin.\n On he was noted to be in acute respiratory distress with desats\n to the low to mid 90's on 3LNC (reportedly desatting to the mid 70's on\n room air; has had a variable O2 requirement since being admitted). His\n blood pressure dropped to the 70's systolic and was responsive to the\n 80's and then 100's after a 250 cc NS bolus. he was febrile to\n 101.9,concern was aspiration event,pt has been on on vanco/genta for\n the given recent fevers,with neg cultures\n he was briefly in MICU green on - for fevers and hypotension\n to the 70's.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed care of pt on AC 40/500 X 18/5, lung sounds with ronchi in the\n upper lobes bilaterally and diminished breath sounds in the bases. Pt\n being suctioned for small/moderate amount of thick yellow secretions\n via the ETT. SpO2 93-96%\n Action:\n Pt placed on PS 40 % at 0430\n Response:\n Pt had a VBG obtained with results of 7.31/44/74. pt lung sounds\n improve post suctioning.\n Plan:\n Continue to suction pt PRN, Continue to titrate ventilator settings\n towards goal of extubation.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Assumed care of pt with a PO temperature of 100.1 PO, skin is warm and\n dry , recent lactate 1.0\n Action:\n Cooling blanket turned on, pt given cool bed bath.\n Response:\n Last PO temperature 99.1, cooling blanket currently off. WBC 14.7\n Plan:\n Monitor temperature curve, monitor culture results.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt is on HD Monday, Wednesday, and Friday. Pt is anuric\n Action:\n AM labs obtained. K 4.8, BUN 57, CREAT 10.4\n Response:\n Plan:\n Possible temporary HD line today if temperature goes down pt may\n receive a tunnel catheter on Tuesday.\n Hypotension (not Shock)\n Assessment:\n Pt on levophed at 0.03mcg/kg/min with a NBP of 107-120\ns/40-50\ns. NBP\n being taken on pt\ns right calf PICC line in right arm and old\n fistula in left arm.\n Action:\n Attempt made to turn off levophed several times during the course of\n the night.\n Response:\n Subsequently SBP had dropped to the 80\ns and levophed was tuned back on\n to 0.03mcg.\n Plan:\n Continue to attempt to titrate levophed off while maintaining SBP above\n 100.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598062,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / 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: 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 Pt weaned down to cpap/ips.MDI\nS given.RSBI done on 0 peep 5 ips\n 79.Responds to command. Will cont to monitor resp status.? Ability to\n maintain airway.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598184,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5 and o2 40%. RR\n 20\ns wirh tv ~350-400cc. Following serial vbg\ns at the current time. Pt\n required q2-3 hour suctioning for tannish, thick, tenacious sputum.\n Continuing low dose fentayl and versed drips for comfort.\n Action:\n Pt remains intubated on psv ventilation d/t altered mental status,\n likely aspiration pnx, and possible volume overload noted on cxr today.\n Response:\n Continue mechanical ventilation.\n Plan:\n Follow lung exam, continue pulmonary toilet. Medical team to\n re-attempt arterial line placement this afternoon to assist with\n weaning, pressor titration, and blood draws.\n Hypotension (not Shock)\n Assessment:\n Afebrile. SBP 80-130\ns depending on levophed dose and degree of\n stimulation. Remains on low dose levophed.\n Action:\n Two unsuccessful attempts were made to turn off the pt\ns levophed drip\n today. SBP\ns eventually drifted into the low 90\ns to high 80\ns with\n unreliable maps. He did receive a single 500cc ns fluid bolus with\n transient improvement in his blood pressure. He received a single dose\n of vanco this afternoon following a low trough level.\n Response:\n Pt continues to be pressor dependent.\n Plan:\n Follow hemodynamic status closely; wean levophed as able, ?additional\n fluid bolus.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Temporary Quinton catheter with a sideport placed in IR this afternoon\n in anticipation of initiating CRRT tomarrow.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598186,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5 and o2 40%. RR\n 20\ns wirh tv ~350-400cc. Following serial vbg\ns at the current time. Pt\n required q2-3 hour suctioning for tannish, thick, tenacious sputum.\n Continuing low dose fentayl and versed drips for comfort.\n Action:\n Pt remains intubated on psv ventilation d/t altered mental status,\n likely aspiration pnx, and possible volume overload noted on cxr today.\n Response:\n Continue mechanical ventilation.\n Plan:\n Follow lung exam, continue pulmonary toilet. Medical team to\n re-attempt arterial line placement this afternoon to assist with\n weaning, pressor titration, and blood draws.\n Hypotension (not Shock)\n Assessment:\n Afebrile. SBP 80-130\ns depending on levophed dose and degree of\n stimulation. Remains on low dose levophed.\n Action:\n Two unsuccessful attempts were made to turn off the pt\ns levophed drip\n today. SBP\ns eventually drifted into the low 90\ns to high 80\ns with\n unreliable maps. He did receive a single 500cc ns fluid bolus with\n transient improvement in his blood pressure. He received a single dose\n of vanco this afternoon following a low trough level.\n Response:\n Pt continues to be pressor dependent.\n Plan:\n Follow hemodynamic status closely; wean levophed as able, ?additional\n fluid bolus.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Temporary Quinton catheter with a sideport placed in IR this afternoon\n in anticipation of initiating CRRT tomarrow.\n Action:\n Repeat pm lytes sent this afternoon, but per micu attending, will wait\n on initiation of crrt until tomarrow.\n Response:\n ESRD with no immediate need to dialyse.\n Plan:\n Follow up on repeat lytes, anticipate crrt tomarrow if the pt remains\n pressor dependent.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598188,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5 and o2 40%. RR\n 20\ns wirh tv ~350-400cc. Following serial vbg\ns at the current time. Pt\n required q2-3 hour suctioning for tannish, thick, tenacious sputum.\n Continuing low dose fentayl and versed drips for comfort.\n Action:\n Pt remains intubated on psv ventilation d/t altered mental status,\n likely aspiration pnx, and possible volume overload noted on cxr today.\n Response:\n Continue mechanical ventilation.\n Plan:\n Follow lung exam, continue pulmonary toilet. Medical team to\n re-attempt arterial line placement this afternoon to assist with\n weaning, pressor titration, and blood draws.\n Hypotension (not Shock)\n Assessment:\n Afebrile. SBP 80-130\ns depending on levophed dose and degree of\n stimulation. Remains on low dose levophed.\n Action:\n Two unsuccessful attempts were made to turn off the pt\ns levophed drip\n today. SBP\ns eventually drifted into the low 90\ns to high 80\ns with\n unreliable maps. He did receive a single 500cc ns fluid bolus with\n transient improvement in his blood pressure. He received a single dose\n of vanco this afternoon following a low trough level.\n Response:\n Pt continues to be pressor dependent.\n Plan:\n Follow hemodynamic status closely; wean levophed as able, ?additional\n fluid bolus.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Temporary Quinton catheter with a sideport placed in IR this afternoon\n in anticipation of initiating CRRT tomarrow.\n Action:\n Repeat pm lytes sent this afternoon, but per micu attending, will wait\n on initiation of crrt until tomarrow.\n Response:\n ESRD with no immediate need to dialyse.\n Plan:\n Follow up on repeat lytes, anticipate crrt tomarrow if the pt remains\n pressor dependent.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 199-226\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598248,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, sedated on versed 0.5mg/hr and\n fentanyl 50mcg/hr, on PSV 10, peep 5 and O2 40%. O2 sats 95-98%, RR\n 18-26, bilateral lung sounds rhonchorous, thick tenacious secretion.\n Action:\n Continued sedation for comfort, no vent changes, MDI\ns as ordered, pul\n toilet. Continue antibiotics\n Response:\n Plan:\n Cont on vent, ? wean sedation,, needs A line to monitor blood pressure\n and labs, and continue pul toilet\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with ESRD and on reg HD, now on levophed gtt, BUN/creat\n patient is anuric, fluid balance\n.. . Temporary HD line placement done\n yesterday to initiate CRRT tomorrow.\n Action:\n Continue monitor labs\n Response:\n Unable to wean levophed gtt, AM labs\n Plan:\n To start CRRT in am as the patient is on levophed gtt, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 257, patient is NPO as patient has high residual\n Action:\n Insulin, humalog SS as per finger stick\n Response:\n BS this AM\n Plan:\n ? need to increase the insulin SS dose, continue monitor blood sugar\n closely\n Hypotension (not Shock)\n Assessment:\n SBP 90-120\ns, on levophed gtt. Patient is afebrile\n Action:\n Failed to wean levophed gtt, sbp down to low 80\ns and MAP 40-50.\n continue antibiotics\n Response:\n Plan:\n F/U culture results, wean levophed gtt as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598162,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5 and o2 40%. RR\n 20\ns wirh tv ~350-400cc. Following serial vbg\ns at the current time. Pt\n required q2-3 hour suctioning for tannish, thick, tenacious sputum.\n Continuing low dose fentayl and versed drips for comfort.\n Action:\n Pt remains intubated on psv ventilation d/t altered mental status,\n likely aspiration pnx, and possible volume overload noted on cxr today.\n Response:\n Continue mechanical ventilation.\n Plan:\n Follow lung exam, continue pulmonary toilet. Medical team to\n re-attempt arterial line placement this afternoon to assist with\n weaning, pressor titration, and blood draws.\n Hypotension (not Shock)\n Assessment:\n Afebrile. SBP 80-130\ns depending on levophed dose and degree of\n stimulation. Remains on low dose levophed.\n Action:\n Two unsuccessful attempts were made to turn off the pt\ns levophed drip\n today. SBP\ns eventually drifted into the low 90\ns to high 80\ns with\n unreliable maps. He did receive a single 500cc ns fluid bolus with\n transient improvement in his blood pressure. He received a single dose\n of vanco this afternoon following a low trough level.\n Response:\n Pt continues to be pressor dependent.\n Plan:\n Follow hemodynamic status closely; wean levophed as able, ?additional\n fluid bolus.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Generic Note",
"row_id": 598163,
"text": "TITLE: Nutrition\n Patient transferred back to ICU and was intubated. OGT to suction\n c/ high output. Attempted to see patient, however, he and chart are\n off floor. Will return . Please page c/?\nS #.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598279,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: 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: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: RSBI done on 0 peep/ 45. MDI\nS given. Will cont to monitor\n resp status.\n"
},
{
"category": "General",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Generic Note",
"row_id": 598224,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with plan as outlined during multidisciplinary rounds\n this morning. Unresponsive. Increased NG output overnight.\n 96.6 77 103/32\n Unresponsive\n Chest coarse mid insp crackles\n CV w/o m\n Abd\n soft w/o apparent tenderness\n WBC 14. sputum pending\n BP remains dependent on norepi. Fluid balance is even from adm so will\n give fluid bolus and try to wean pressor. Still making copious sputum\n awaiting gr st but covering for HAP. Incr NG output concerning\n will check amylase/ lipase and RUQ U/S and KUB. No h/o abd surgery to\n suggest SBO. No improvement in resp status yet so not yet weanable.\n Will try for art line today.\n Time spent 50 min\n Critically ill\n ------ Protected Section ------\n Critical Care\n Met in person with Mr. \ns daughter and by speaker phone with\n his wife to discuss prognosis. Reviewed his multiple problems and his\n current inability to protect his airway. Dtr feels Mr. would\n not want a long term trache. Agreed we will initiate CRRT and hold all\n sedating meds and reassess in days.\n Time spent 35 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 20:18 ------\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598190,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5 and o2 40%. RR\n 20\ns wirh tv ~350-400cc. Following serial vbg\ns at the current time. Pt\n required q2-3 hour suctioning for tannish, thick, tenacious sputum.\n Continuing low dose fentayl and versed drips for comfort.\n Action:\n Pt remains intubated on psv ventilation d/t altered mental status,\n likely aspiration pnx, and possible volume overload noted on cxr today.\n Response:\n Continue mechanical ventilation.\n Plan:\n Follow lung exam, continue pulmonary toilet. Medical team to\n re-attempt arterial line placement this afternoon to assist with\n weaning, pressor titration, and blood draws.\n Hypotension (not Shock)\n Assessment:\n Afebrile. SBP 80-130\ns depending on levophed dose and degree of\n stimulation. Remains on low dose levophed.\n Action:\n Two unsuccessful attempts were made to turn off the pt\ns levophed drip\n today. SBP\ns eventually drifted into the low 90\ns to high 80\ns with\n unreliable maps. He did receive a single 500cc ns fluid bolus with\n transient improvement in his blood pressure. He received a single dose\n of vanco this afternoon following a low trough level.\n Response:\n Pt continues to be pressor dependent.\n Plan:\n Follow hemodynamic status closely; wean levophed as able, ?additional\n fluid bolus.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Temporary Quinton catheter with a sideport placed in IR this afternoon\n in anticipation of initiating CRRT tomarrow.\n Action:\n Repeat pm lytes sent this afternoon, but per micu attending, will wait\n on initiation of crrt until tomarrow.\n Response:\n ESRD with no immediate need to dialyse.\n Plan:\n Follow up on repeat lytes, anticipate crrt tomarrow if the pt remains\n pressor dependent.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 199-226. Pt received 2-4 units of insulin per hiss. Pt\n remains npo as he continues to pass large amounts of bilious drainage\n from his ogt. Total output since mn is more than 800cc. Abd is soft,\n distended with +bs.\n Action:\n OGT to lis today. LIS on hold briefly with am meds although it\n unlikely that pt absorbed any of his medications. Reason for poor\n absorbtion is unclear, ?gastroparesis. LFT\ns sent to check for\n pancreatitis. KUB obtained this afternoon to r/o ileus vs sbo.\n Response:\n Hyperglycemic requiring sliding scale insulin coverage despite npo\n status. LFT\ns unremarkable.\n Plan:\n Monitor fs qid and cover with hiss. f/u on kub results. Follow abd\n exam.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598275,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, sedated on versed 0.5mg/hr and\n fentanyl 50mcg/hr, on PSV 10, peep 5 and O2 40%. O2 sats 95-98%, RR\n 18-26, bilateral lung sounds rhonchorous, thick tenacious secretion.\n Action:\n Continued sedation for comfort, no vent changes, MDI\ns as ordered, pul\n toilet. Continue antibiotics\n Response:\n O2 sats 94-98%, moderate thick secretion, afebrile, WBC 13.4\n Plan:\n Cont on vent, ? wean sedation,, needs A line to monitor blood pressure\n and labs, and continue pul toilet\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with ESRD and on reg HD, now on levophed gtt, BUN/creat\n 59/11.4, patient is anuric, Temporary HD line placement done yesterday\n to initiate CRRT tomorrow.\n Action:\n Continue monitor labs\n Response:\n Unable to wean levophed gtt, AM labs BUN/creat 62/12.1\n Plan:\n To start CRRT in am as the patient is on levophed gtt, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 257, patient is NPO as patient has high residual\n Action:\n Insulin, humalog SS as per finger stick\n Response:\n BS this AM 195\n Plan:\n ? need to increase the insulin SS dose, continue monitor blood sugar\n closely\n Hypotension (not Shock)\n Assessment:\n SBP 90-120\ns, on levophed gtt. Patient is afebrile\n Action:\n Failed to wean levophed gtt, sbp down to low 80\ns and MAP 40-50.\n continue antibiotics\n Response:\n On levophed gtt, SBP 90-110\n Plan:\n F/U culture results, wean levophed gtt as tolerated\n Alteration in Nutrition\n Assessment:\n NPO, high residual(bilious), on low intermittent suction, abdomen soft\n distended, hypoactive bowel sounds.\n KUB done this evening\n Action:\n Continue low intermittent suction\n Response:\n At the beginning of shift NG aspirate was bilious and changed to coffee\n ground, quiac negative\n Plan:\n NPO, continue low intermittent suction\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598234,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598398,
"text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Press:\n Cuff pressure: 25 cmH2O\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: MDIs given as documented\n Secretions\n Sputum color / consistency: Rusty / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt remains orally intubated on\n PSV. No vent changes made this shift. continues on +10PSV/+5PEEP w/ Vt\n ~400 RR mid 20s.\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 Comments: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598154,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598155,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 598394,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 177 mg/dL\n 02:26 PM\n Glucose Finger Stick\n 194\n 04:00 PM\n BUN\n 69 mg/dL\n 02:26 PM\n Creatinine\n 12.6 mg/dL\n 02:26 PM\n Sodium\n 138 mEq/L\n 02:26 PM\n Potassium\n 4.5 mEq/L\n 02:26 PM\n Chloride\n 102 mEq/L\n 02:26 PM\n TCO2\n 23 mEq/L\n 02:26 PM\n PO2 (arterial)\n 78. mm Hg\n 02:28 PM\n PCO2 (arterial)\n 41 mm Hg\n 02:28 PM\n PCO2 (venous)\n 43 mm Hg\n 04:56 AM\n pH (arterial)\n 7.34 units\n 02:28 PM\n pH (venous)\n 7.31 units\n 04:56 AM\n CO2 (Calc) arterial\n 23 mEq/L\n 02:28 PM\n CO2 (Calc) venous\n 23 mEq/L\n 04:56 AM\n Calcium non-ionized\n 9.0 mg/dL\n 02:53 AM\n Phosphorus\n 3.8 mg/dL\n 02:26 PM\n Ionized Calcium\n 1.18 mmol/L\n 02:28 PM\n Magnesium\n 2.5 mg/dL\n 02:26 PM\n ALT\n 16 IU/L\n 09:35 AM\n Alkaline Phosphate\n 122 IU/L\n 09:35 AM\n AST\n 52 IU/L\n 09:35 AM\n Amylase\n 55 IU/L\n 09:35 AM\n Total Bilirubin\n 1.0 mg/dL\n 09:35 AM\n WBC\n 13.4 K/uL\n 02:53 AM\n Hgb\n 11.2 g/dL\n 02:53 AM\n Hematocrit\n 33.7 %\n 02:26 PM\n Current diet order / nutrition support: NPO\n GI: Abd: soft/distended/+bowel sounds/+bm\n Assessment of Nutritional Status\n Specifics:\n Patient transferred back to ICU and was intubated. Being treated\n for likely aspiration PNA. Patient was receiving tube feeds on floor\n prior to transfer, which were well tolerated per chart. Feeds were\n meeting 100% estimated nutrition needs. Patient is currently NPO d/t\n high NGT output. KUB was negative. Team consulted for TPN\n recommendations while unable to feed enterally. Will concentrate TPN\n as much as possible in setting of plan for fluid removal c/ CVVH.\n Patient will likely require insulin in TPN given FSBG\ns elevated at\n present.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via PN\n TPN recommendations: Will start c/ Day 1 TPN and\n advance TPN pending glycemic control to goal 1750 mL (330dextrose/95\n protein/50fat) kcals-Will enter orders for MD to sign daily\n Please check trig\n Lyte and Glucose management as you are\n Transition back to enteral feeds once gastric output\n decreased\n Following #\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598156,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on gent/vanco. Being transferred for respiratory distress,\n hypotension & hypoxia. Now intubated, oxygentating well, likely has\n PNA per chest Xray and fevers. Continues to require levophed. Also\n has h/o afib, not on coumadin due to recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598158,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 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: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Wean PS as tol and reassess for readiness to extubate daily.\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n 1445\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598270,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, sedated on versed 0.5mg/hr and\n fentanyl 50mcg/hr, on PSV 10, peep 5 and O2 40%. O2 sats 95-98%, RR\n 18-26, bilateral lung sounds rhonchorous, thick tenacious secretion.\n Action:\n Continued sedation for comfort, no vent changes, MDI\ns as ordered, pul\n toilet. Continue antibiotics\n Response:\n O2 sats 94-98%, moderate thick secretion, afebrile, WBC 13.4\n Plan:\n Cont on vent, ? wean sedation,, needs A line to monitor blood pressure\n and labs, and continue pul toilet\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with ESRD and on reg HD, now on levophed gtt, BUN/creat\n 59/11.4, patient is anuric, Temporary HD line placement done yesterday\n to initiate CRRT tomorrow.\n Action:\n Continue monitor labs\n Response:\n Unable to wean levophed gtt, AM labs BUN/creat 62/12.1\n Plan:\n To start CRRT in am as the patient is on levophed gtt, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 257, patient is NPO as patient has high residual\n Action:\n Insulin, humalog SS as per finger stick\n Response:\n BS this AM 195\n Plan:\n ? need to increase the insulin SS dose, continue monitor blood sugar\n closely\n Hypotension (not Shock)\n Assessment:\n SBP 90-120\ns, on levophed gtt. Patient is afebrile\n Action:\n Failed to wean levophed gtt, sbp down to low 80\ns and MAP 40-50.\n continue antibiotics\n Response:\n On levophed gtt, SBP 90-110\n Plan:\n F/U culture results, wean levophed gtt as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598429,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5, o2 40%. RR\n teens\ns-20\ns with TV ~400cc. Pt suctioned q3-4hrs with saline lavage\n for moderate amounts of thick, rust colored sputum. CXR c/w worsening\n pulmonary edema this morning.\n Action:\n No change in ventilatory status.\n Response:\n Pt not ready for extubation d/t fluid overload and reduced mental\n status.\n Plan:\n Follow lung exam, serial abg\ns, pulmonary toilet.\n Altered mental status (not Delirium)\n Assessment:\n Sedation turned off for\nwake up\n earlier this morning. He is grimacing\n and down during mouth care. He is opening his eyes only when\n stimulated. He is moving his legs laterally on the bed and his left arm\n off the bed. His right arm moves only reflexively to noxious\n stimulation. No purposeful movement noted.\n Action:\n Sedation turned off to assess mental status/neuro exam.\n Response:\n Neither mental status nor motor exam has changed or improved despite\n the sedation having been off for several hours now.\n Plan:\n Would continue to hold sedation as long as behavior does not interfere\n with treatments. Continue to monitor neuro/mental status for changes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 170-190\ns. Pt received sliding scale coverage per hiss. Abd\n exam unchanged. He continues to pass moderate amounts of\n bilious/coffee grounds drainage from his ogt.\n Action:\n Continue ogt to LIS. Nutrition consult placed for TPN recs.\n Response:\n Unchanged.\n Plan:\n Continue to monitor gastric output. Cover q6hr fs with hiss. Anticipate\n TPN recs from nutrition.\n Hypotension (not Shock)\n Assessment:\n A right axillary arterial line was placed this morning and found to be\n significantly higher than the noninvasive.\n Action:\n Low dose levophed drip turned off ~1300.\n Response:\n ABP continues to improve as the day has progressed.\n Plan:\n Follow hemodynamic status closely; restart levophed drip if necessary.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n CRRT initiated @1830 for worsening uremia and volume overload.\n Action:\n Although initially there was good blood return from both of the\n dialysis line ports, the blue port continues to flush well but unable\n to draw blood: dialysis lines reversed.\n Response:\n CRRT system running at the present time although access and filter\n pressures are rising.\n Plan:\n Con\nt CRRT overnoc with the goal of removing 150cc from pt hourly.\n ?transition to dialysis in the am if blood pressure continues to\n improve.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Fellow / Physician Attending Progress Note - MICU",
"row_id": 597569,
"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 PICC LINE - START 11:47 AM\n BLOOD CULTURED - At 01:04 PM\n PICC\n BLOOD CULTURED - At 04:37 AM\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:10 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Fosphenytoin - 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 09:02 AM\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: 36.9\nC (98.4\n HR: 76 (76 - 84) bpm\n BP: 110/38(52) {90/17(42) - 151/72(102)} mmHg\n RR: 18 (15 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 438 mL\n 90 mL\n PO:\n TF:\n IVF:\n 378 mL\n 90 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 438 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.5 g/dL\n 193 K/uL\n 94 mg/dL\n 12.9 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 95 mEq/L\n 139 mEq/L\n 40.3 %\n 13.3 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n WBC\n 14.0\n 13.3\n Hct\n 37.8\n 40.3\n Plt\n 174\n 193\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6, CK / CKMB /\n Troponin-T:147/4/0.35, Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:47 AM\n Dialysis Catheter - 09:01 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :\n Total time spent:\n"
},
{
"category": "Rehab Services",
"chartdate": "2191-08-17 00:00:00.000",
"description": "Generic Note",
"row_id": 597424,
"text": "TITLE:\n Rehab Services Physical Therapy\n Consult received and appreciated. At this time patient is not\n appropriate for Physical Therapy evaluation. We will sign off, please\n re-consult when status changes, and PT intervention is indicated. Thank\n you\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597444,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n Hypotension (not Shock)\n Assessment:\n Receiving HD today and found to be hypotensive down to 90s.\n Patient received HD on Monday and BP in 150s-160s during tx.\n Mental status declining since admission.\n Action:\n Received Vanco and Gentamycin in HD.\n Blood cultures sent via HD line in HD\n Unable to remove fluid in HD.\n Response:\n BP continued to be 80s-90s in HD.\n Transferred to MICU for closer monitoring.\n Plan:\n Will continue to monitor.\n IN MICU: BP stable 110s-120s.\n Head CT done to evaluate SDH.\n Mental status improving as shift advances.\n Continues on continuous EEG monitoring; no seizure\n activity noted; given additional doses of Fosphenytoin\n and Vanco.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597661,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with chronic RF, on HD M/W/F. Did not tolerate HD yesterday ()\n hypotension with fluid removal, so sent to MICU for further\n monitoring.\n Action:\n Pt had HD today.\n Response:\n Tolerated HD with VSS. 1L fluid removed.\n Plan:\n Cont with regularly scheduled HD.\n Altered mental status (not Delirium)\n Assessment:\n Pt had a repeat head CT yesterday which showed a stable subdural\n hematoma. Pt moaning, calling out. At beginning of shift able to state\n name, but unable to do so @ 1600 assessment, incomprehensible sounds to\n other questions. Follows simple commands but only at times s/a wiggling\n toes or opening mouth for mouth care. Right pupil 2-3mm, non reactive,\n impaired corneal reflex. Left pupil 5mm, non reactive, impaired corneal\n reflex. Per daughter, pt was high functioning prior to fall and SDH.\n Action:\n Pt frequently reoriented, frequent checks for safety. Left arm in soft\n wrist restraint as pt pulled out NGT yesterday, pt unable to move RUE.\n EEG completed. No MRI this shift as it is unnecessary per neuro because\n it will not change treatment of bleed.\n Response:\n Pt stable and improving per neurological service.\n Plan:\n Continue to monitor mental status. Call out to neuro so pt can be f/b\n neuromed service.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598268,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, sedated on versed 0.5mg/hr and\n fentanyl 50mcg/hr, on PSV 10, peep 5 and O2 40%. O2 sats 95-98%, RR\n 18-26, bilateral lung sounds rhonchorous, thick tenacious secretion.\n Action:\n Continued sedation for comfort, no vent changes, MDI\ns as ordered, pul\n toilet. Continue antibiotics\n Response:\n O2 sats 94-98%, moderate thick secretion\n Plan:\n Cont on vent, ? wean sedation,, needs A line to monitor blood pressure\n and labs, and continue pul toilet\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with ESRD and on reg HD, now on levophed gtt, BUN/creat\n patient is anuric, fluid balance\n.. . Temporary HD line placement done\n yesterday to initiate CRRT tomorrow.\n Action:\n Continue monitor labs\n Response:\n Unable to wean levophed gtt, AM labs\n Plan:\n To start CRRT in am as the patient is on levophed gtt, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 257, patient is NPO as patient has high residual\n Action:\n Insulin, humalog SS as per finger stick\n Response:\n BS this AM\n Plan:\n ? need to increase the insulin SS dose, continue monitor blood sugar\n closely\n Hypotension (not Shock)\n Assessment:\n SBP 90-120\ns, on levophed gtt. Patient is afebrile\n Action:\n Failed to wean levophed gtt, sbp down to low 80\ns and MAP 40-50.\n continue antibiotics\n Response:\n Plan:\n F/U culture results, wean levophed gtt as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598269,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, sedated on versed 0.5mg/hr and\n fentanyl 50mcg/hr, on PSV 10, peep 5 and O2 40%. O2 sats 95-98%, RR\n 18-26, bilateral lung sounds rhonchorous, thick tenacious secretion.\n Action:\n Continued sedation for comfort, no vent changes, MDI\ns as ordered, pul\n toilet. Continue antibiotics\n Response:\n O2 sats 94-98%, moderate thick secretion, afebrile, WBC 13.4\n Plan:\n Cont on vent, ? wean sedation,, needs A line to monitor blood pressure\n and labs, and continue pul toilet\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Patient with ESRD and on reg HD, now on levophed gtt, BUN/creat\n 59/11.4, patient is anuric, Temporary HD line placement done yesterday\n to initiate CRRT tomorrow.\n Action:\n Continue monitor labs\n Response:\n Unable to wean levophed gtt, AM labs BUN/creat 62/12.1\n Plan:\n To start CRRT in am as the patient is on levophed gtt, monitor labs\n Diabetes Mellitus (DM), Type II\n Assessment:\n Blood sugar 257, patient is NPO as patient has high residual\n Action:\n Insulin, humalog SS as per finger stick\n Response:\n BS this AM 195\n Plan:\n ? need to increase the insulin SS dose, continue monitor blood sugar\n closely\n Hypotension (not Shock)\n Assessment:\n SBP 90-120\ns, on levophed gtt. Patient is afebrile\n Action:\n Failed to wean levophed gtt, sbp down to low 80\ns and MAP 40-50.\n continue antibiotics\n Response:\n On levophed gtt, SBP 90-110\n Plan:\n F/U culture results, wean levophed gtt as tolerated\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-17 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 597420,
"text": "Chief Complaint: subdural hemorrhage\n HPI:\n Please refer to the neurology admission note and progress notes in OMR\n for full details. Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib\n on coumadin admitted to the neurology service after being\n transferred from for further management of a traumatic\n L SDH sustained 3 days prior to admission. Has had epileptiform\n behavior for which receiving continuous EEG monitoring and ativan\n boluses (1 mg IV x 3 over past 36 hours). Had PR temp 102.5 yesterday\n evening. 30 minutes into HD session today had BP 70/23. BCx drawn from\n HD catheter, given vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG\n 7.41/43/79/28. V/S prior to transfer 99.7 101/30 78 24 95%3L.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1. DM\n 2. HTN\n 3. ESRD on HD (M/W/F)\n 4. CAD s/p CABG\n 5. Asthma\n 6. Cataract surgery in and \"eye peel\" \n 7. Glaucoma\n Noncontributory.\n Occupation: Retired R&D.\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Flowsheet Data as of 02:05 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.7\nC (99.9\n HR: 82 (79 - 84) bpm\n BP: 121/33(54) {121/31(50) - 132/62(74)} mmHg\n RR: 23 (19 - 24) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: surgical bilaterally\n Head, Ears, Nose, Throat: Normocephalic, NG tube, EEG leads\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:\n Diminished: bilat, Rhonchorous: bilat), anterior auscultation\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: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: RUE U/S\n 1. No deep vein thrombosis seen in the left arm. No subcutaneous fluid\n collection identified.\n 2. Occluded left arm fistula graft.\n 3. Small amount of non-occlusive thrombus material seen adherent to the\n intravenous line which is identified within the right subclavian veins.\n .\n portable CXR\n In comparison with earlier study of this date, there has been\n placement of a nasogastric tube that appears to extend to the upper\n portion of the stomach. However, the image is extremely light in the\n upper abdomen. To better evaluate the tip of the tube, a repeat study\n could be obtained showing the lower chest and upper abdomen and using\n abdominal technique.\n Microbiology: Blood Cx NGTD; c. diff toxin neg\n ECG: @ 1249 SR @ 80 bpm NA/NI QIII,F TWI I,aVL no ST elev/depr not\n significantly changed from \n Assessment and Plan\n #Sepsis - now normotensive after discontinuation of HD and\n fluid-resuscitation x 1 L; lactate WNL; given vanc/gent for presumed\n line sepsis; other sources of fever include aspiration PNA, GI/GU, and\n SDH causing fever (but would not account for hypotension); no ischemic\n changes on EKG to invoke cardiogenic shock; no evidence on exam of\n tamponade physiology\n -cont vanc/gent with HD\n -CXR, if e/o PNA, would broaden to cefepime or zosyn for better\n nosocomial gram negative and anaerobic coverage\n -BCx from PICC\n -f/u vanc/gent trough levels\n -consider LP if neurological status continues to decline\n -hold antihypertensives, aspirin, coumadin (10-14 days after admission\n per neuro)\n .\n #Encephalopathy - attributable to acute on chronic SDH and recurrent\n seizures\n -appreciate close neurology & epilepsy team involvement\n -repeat NCCT head to eval for interval change\n -cont fosphenytoin, trend levels\n -f/u MRI/MRA/MRV read from \n .\n #ESRD - only completed 30 min HD on \n -appreciate dialysis team involvement\n -may need extra session \n .\n #DM\n -basal, sliding scale insulin\n .\n #CAD s/p CABG\n -restart BB when BPs have clearly stabilized\n -cont statin\n -consider TTE to eval systolic/diastolic CHF (carvedilol invokes\n possible CHF history)\n .\n # FEN: tube feeds\n # PPX: pneumoboots, PPI\n # ACCESS: R PICC, L HD cath\n # CONTACT: , wife/HCP (was notified by\n neurology team of ICU transfer on )\n ICU Care\n Nutrition: TF\n Glycemic Control: Regular insulin sliding scale\n Lines: HD catheter\n PICC Line - 11:47 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597427,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597429,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Receiving HD today and found to be hypotensive down to 90s.\n Patient received HD on Monday and BP in 150s-160s during tx.\n Mental status declining since admission.\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 597559,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:47 AM\n BLOOD CULTURED - At 01:04 PM\n PICC\n BLOOD CULTURED - At 04:37 AM\n -moaned overnight, thought pain, given 0.5mg morphine\n -able to say yes and no and repeat my name\n -moved all extremities except RUE\n -Right picc u/s with nonoccluding clot\n -Tm 100.5\n -NG tube removed bc could not identify below the diaphragm, then\n replaced, shot 2 films but then looked to be in good place but nurse\n found it coiled in his mouth so it was removed\n -free phenytoin level pending, neuro would like for us to discuss\n dosing with them\n -held off on MRI brain to see if neuro really wants it\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:10 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 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 07:20 AM\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: 37.1\nC (98.8\n HR: 76 (76 - 84) bpm\n BP: 151/68(45) {90/17(42) - 151/72(102)} mmHg\n RR: 19 (15 - 29) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 438 mL\n 73 mL\n PO:\n TF:\n IVF:\n 378 mL\n 73 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 438 mL\n -127 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 193 K/uL\n 12.5 g/dL\n 94 mg/dL\n 12.9 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 95 mEq/L\n 139 mEq/L\n 40.3 %\n 13.3 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n WBC\n 14.0\n 13.3\n Hct\n 37.8\n 40.3\n Plt\n 174\n 193\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6, CK / CKMB /\n Troponin-T:147/4/0.35, Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:47 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 597560,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 11:47 AM\n BLOOD CULTURED - At 01:04 PM\n PICC\n BLOOD CULTURED - At 04:37 AM\n -moaned overnight, thought pain, given 0.5mg morphine\n -able to say yes and no and repeat my name\n -moved all extremities except RUE\n -Right picc u/s with nonoccluding clot\n -Tm 100.5\n -NG tube removed bc could not identify below the diaphragm, then\n replaced, shot 2 films but then looked to be in good place but nurse\n found it coiled in his mouth so it was removed\n -free phenytoin level pending, neuro would like for us to discuss\n dosing with them\n -held off on MRI brain to see if neuro really wants it\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 06:10 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 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 07:20 AM\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: 37.1\nC (98.8\n HR: 76 (76 - 84) bpm\n BP: 151/68(45) {90/17(42) - 151/72(102)} mmHg\n RR: 19 (15 - 29) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 438 mL\n 73 mL\n PO:\n TF:\n IVF:\n 378 mL\n 73 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 438 mL\n -127 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///28/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: surgical bilaterally\n Head, Ears, Nose, Throat: Normocephalic, NG tube, EEG leads\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:\n Diminished: bilat, Rhonchorous: bilat), anterior auscultation\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: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 193 K/uL\n 12.5 g/dL\n 94 mg/dL\n 12.9 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 95 mEq/L\n 139 mEq/L\n 40.3 %\n 13.3 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n WBC\n 14.0\n 13.3\n Hct\n 37.8\n 40.3\n Plt\n 174\n 193\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6, CK / CKMB /\n Troponin-T:147/4/0.35, Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n #Sepsis - now normotensive after discontinuation of HD and\n fluid-resuscitation x 1 L; lactate WNL; given vanc/gent for presumed\n line sepsis; other sources of fever include aspiration PNA, GI/GU, and\n SDH causing fever (but would not account for hypotension); no ischemic\n changes on EKG to invoke cardiogenic shock; no evidence on exam of\n tamponade physiology\n -cont vanc/gent with HD\n -CXR, if e/o PNA, would broaden to cefepime or zosyn for better\n nosocomial gram negative and anaerobic coverage\n -BCx from PICC\n -f/u vanc/gent trough levels\n -consider LP if neurological status continues to decline\n -hold antihypertensives, aspirin, coumadin (10-14 days after admission\n per neuro)\n .\n #Encephalopathy - attributable to acute on chronic SDH and recurrent\n seizures\n -appreciate close neurology & epilepsy team involvement\n -repeat NCCT head to eval for interval change\n -cont fosphenytoin, trend levels\n -f/u MRI/MRA/MRV read from \n .\n #ESRD - only completed 30 min HD on \n -appreciate dialysis team involvement\n -may need extra session \n .\n #DM\n -basal, sliding scale insulin\n .\n #CAD s/p CABG\n -restart BB when BPs have clearly stabilized\n -cont statin\n -consider TTE to eval systolic/diastolic CHF (carvedilol invokes\n possible CHF history)\n .\n # FEN: tube feeds\n # PPX: pneumoboots, PPI\n # ACCESS: R PICC, L HD cath\n # CONTACT: , wife/HCP (was notified by\n neurology team of ICU transfer on )\n ICU Care\n Nutrition: TF\n Glycemic Control: Regular insulin sliding scale\n Lines: HD catheter\n PICC Line - 11:47 AM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 597651,
"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 her\n note above, including assessment and plan.\n HPI:\n 73yo man with ESRD on HD, CAD s/p CABG``, A fib on Warfarin, s/p fall\n who was admitted to neuro service initially for a subdural hematoma. He\n had RUE paresis on admission after his fall. During HD he dropped his\n BP in the setting of having had a fever to 102.5. He received Vanc,\n Gent and a liter of NS. Transferred ot the MICU for further care given\n the transient hypotension and concern for possible line-related\n infection.\n Overnight, Tmax was 100.5. He was making non-specific noises\n intermittently throughou the night. He was given morphine 0.5mg IV x 1\n for possible pain. He had a NG-tube replaced that was coiled in the\n back of his mouth; it was subsequently d/c\ned and currently he has no\n oral access. He does have an oxygen requirement of 4-6L NC (of note, he\n did not complete HD yesterday.)\n 24 Hour Events:\n PICC LINE - START 11:47 AM\n BLOOD CULTURED - At 01:04 PM\n PICC\n BLOOD CULTURED - At 04:37 AM\n Allergies:\n Hydromorphone\n unknown;\n Metoclopramide\n unknown.\n Last dose of Antibiotics:\n Vancomycin - 06:10 PM\n Gent 90mg per HD protocol\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Fosphenytoin - 08:30 AM\n RSSI\n Lantus 20 units qAM, 10 units qhs\n Celexa 40\n Zocor 40\n Calcium \n Fish Oil 1000 \n Folic acid 1mg\n Nasal spray\n Vitamin B 50mcg\n Neurontin 100mg \n Neomycin left eye gtt q6h\n Brimodine left eye \n Atropine left eye \n Timolol right eye \n Lantoprost right eye \n Dilantin q8\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 No changes.\n Flowsheet Data as of 09:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.9\nC (98.4\n HR: 76 (76 - 84) bpm\n BP: 110/38(52) {90/17(42) - 151/72(102)} mmHg\n RR: 18 (15 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 438 mL\n 90 mL\n PO:\n TF:\n IVF:\n 378 mL\n 90 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 438 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///28/\n Physical Examination\n General: Opens eyes to voice, moans non-specifically, appears to know\n his name.\n HEENT: Pupils are asymmetric, with apparent prior occular surgeries.\n Not reactive to light. Some right conjunctival hemorrhage.\n CV: S1S2 RRR w/o m/r/g\n Lungs: CTA anteriorly with good air movement.\n Ab: Positive BS\ns. Obese, NT/ND.\n Ext: Mild lower extremity edema.\n Neuro: As above, not following commands. Doesn\nt withdraw his RUE to\n noxious stimuli, but moves all other extremities to mild stimulus.\n Labs / Radiology\n 12.5 g/dL\n 193 K/uL\n 94 mg/dL\n 12.9 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 95 mEq/L\n 139 mEq/L\n 40.3 %\n 13.3 K/uL\n [image002.jpg]\n RUQ U/S: Small amount of non-occulsive thrombus material adherant to\n the PICC.\n 01:04 PM\n 04:15 AM\n WBC\n 14.0\n 13.3\n Hct\n 37.8\n 40.3\n Plt\n 174\n 193\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6,\n CK / CKMB / Troponin-T:147/4/0.35,\n Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n 73yo man with ESRD on HD, CAD s/p CABG, A fib on Warfarin, s/p fall who\n was initially admitted to neuro service for a subdural hematoma here in\n the MICU with a fever and transient low blood pressure in the setting\n of HD yesterday that has since resolved.\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Suspect that the primary central nervous system bleed and the recurrent\n seizure are the most likely causes of his altered MS. Need to clarify\n if the Neuro teams still want to pursue MRI/MRA/MRV which would further\n clarify his neurologic pathology. There is not compelling evidence for\n a secondary process such as a CNS infection.\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n He is undergoing dialysis today. Will follow the Renal service\ns recs\n regarding appropriate subsequent dialysis.\n HYPOTENSION (NOT SHOCK)\n Resolved with one liter of normal saline yesterday. Suspect transient\n bacteremia in the setting of HD rather than true line infection. Will\n continue his Vanc / Gent for 48 hours; if cultures are non-revealing\n then will d/c antibiotics. There is no complling evidence for an\n alternative etiology of hypotension, particularly given its very\n transient nature.\n CORONARY ARTERY DISEASE\n Will continue statin. Will restart beta-blocker after oral access is\n obtained. Review EKG this AM. Do not need to follow cardiac enzymes\n barring the development of any interval clincal changes.\n ICU Care\n Nutrition: Pending NGT placement.\n Glycemic Control: RSSI and standing Lantus.\n Lines:\n PICC Line - 11:47 AM\n Dialysis Catheter - 09:01 AM\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full.\n Disposition : ICU for now, will re-assess this afternoon after\n dialysis.\n Total time spent:\n ------ Protected Section ------\n CRITICAL CARE ATTENDING ADDENDUM\n I saw and examined Mr. with Dr. , whose note reflects\n my input. Overnight, no recurrent hypotension. Multiple placements of\n NG tubes. Tm 100.5. Oxygen now 4\n 6 L; did not receive HD\n yesterday. Exam is notable for increased alertness today.\n Labs, meds, imaging, FH, SH, Allergies reviewed.\n Assessment and Plan\n 73-year-old man with ESRD on HD via tunneled catheter, presented\n yesterday from neurology service with intra-dialytic hypotension in the\n setting of fever. Overnight, no recurrent hypotension and alertness\n has improved though he is moaning and not clearly able to converse.\n Suspect that infection/sepsis episode was likely related to line, so\n treating with vanco/gent while awaiting cultures. If any (+) cultures,\n or recrudescent hypotension, will need lines removed but reasonable to\n maintain them at present since vascular access is a key element of\n long-term management for him. Main issue today is whether he will\n tolerate dialysis. Alertness has improved, though abnormal mental\n status/encephalopathy still persists. Appreciate neurology\n recommendations.\n If he tolerates dialysis, will plan to call out to floor.\n Other issues as per Dr. \n note today.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:08 ------\n"
},
{
"category": "General",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Generic Note",
"row_id": 598348,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. Unresponsive. Temporary HD\n line placed.\n 97.8 84 107/38\n Unresponsive\n Chest\n few mid-insp crackles\n CV\n w/o m\n Abd distended but soft w/o tenderness\n WBC 13.3\n Hct 35\n CXR\n vol overload\n Remains on abx for aspiration PNA. Last sputum showed GNR and GPC\n covered with Vanco and Cefipime and will continue until cx results.\n CXR shows vol overload\n will reinitiate CRRT today and start to remove\n fluid. NG output remains high but KUB showed no cutoff and moving\n bowels. Mental status remains poor\n have discontinued all sedation\n and will discuss prognosis with Neuro. Remains hypotensive\n need to\n decide if this is real\n will place femoral art line after rds.\n Time spent 40 min\n Critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597525,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n Hypotension (not Shock)\n Assessment:\n Pt. had HD yesterday, but was hypotensive and only had 30 minutes of\n session.\n Action:\n Vanco and Gent trough sent with am labs. One set of surveilance blood\n cultures sent off of PICC this am. T-max 100.5 this shift.\n Response:\n BP 90\ns to 140\ns this shift. Taking BP on leg patient has PICC in\n right arm and old AV fistula in left arm. Pt. also has clot in right\n subclavian which is non-occlusive of the PICC line. Pt. has no other\n access, so PICC line not d/c\nd at this time and per PICC team and MICU\n resident it is still OK to use the PICC.\n Plan:\n Will continue to monitor BP, hemodynamics. ? HD again today, since\n patient did not have a full session yesterday. Of note, patient also\n had an elevated Troponin to 0.36 and then 0.35. MICU resident is\n aware, no treatment at this time, EKG was normal.\n Altered mental status (not Delirium)\n Assessment:\n Pt. had a repeat head CT yesterday which showed a stable subdural\n hematoma. Pt. moaning, calling out. Not agitated, but ? if patient is\n in pain. Appears uncomfortable. Following simple commands, opens\n mouth when asked for mouth care. Not moving right arm. Right arm is\n also swollen. Patient remains on continuous EEG monitoring, no seizure\n activity noted overnight.\n Action:\n Patient pulled out NGT on day shift. Left hand in soft wrist\n restraint. Not able to visualize NGT after being replaced, so\n advanced and repeat CXR pbtained. At this time able to auscultate NGT\n and placement was confirmed by repeat CXR. Given PO meds. Later in\n the evening, NGT noted to be coiled in patient\ns mouth, so was pulled\n out and not replaced per MICU resident. 0.5mg Morphine given IV \n patient appearing uncomfortable.\n Response:\n Pt. appears slightly more comfortable after Morphine.\n Plan:\n Continue to monitor mental status. MRI was ordered on the 27^th.\n Patient called for yesterday evening, but per MICU resident, patient\n does not need at the moment, will check with rest of team in am as to\n whether MRI can be d/c\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597486,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n Hypotension (not Shock)\n Assessment:\n Receiving HD today and found to be hypotensive down to 90s.\n Patient received HD on Monday and BP in 150s-160s during tx.\n Mental status declining since admission.\n Action:\n Received Vanco and Gentamycin in HD.\n Blood cultures sent via HD line in HD\n Unable to remove fluid in HD.\n Response:\n BP continued to be 80s-90s in HD.\n Transferred to MICU for closer monitoring.\n Plan:\n Will continue to monitor.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n IN MICU: BP stable 110s-120s.\n Head CT done to evaluate SDH.\n Mental status improving as shift advances.\n Continues on continuous EEG monitoring; no seizure\n activity noted; given additional doses of Fosphenytoin\n and Vanco.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597490,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n Hypotension (not Shock)\n Assessment:\n Pt. had HD yesterday, but was hypotensive and only had 30 minutes of\n session.\n Action:\n Vanco and Gent trough sent with am labs.\n Response:\n BP continued to be 80s-90s in HD.\n Transferred to MICU for closer monitoring.\n Plan:\n Will continue to monitor.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n IN MICU: BP stable 110s-120s.\n Head CT done to evaluate SDH.\n Mental status improving as shift advances.\n Continues on continuous EEG monitoring; no seizure\n activity noted; given additional doses of Fosphenytoin\n and Vanco.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597548,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n Hypotension (not Shock)\n Assessment:\n Pt. had HD yesterday, but was hypotensive and only had 30 minutes of\n session.\n Action:\n Vanco and Gent trough sent with am labs. One set of surveilance blood\n cultures sent off of PICC this am. T-max 100.5 this shift.\n Response:\n BP 90\ns to 140\ns this shift. Taking BP on leg patient has PICC in\n right arm and old AV fistula in left arm. Pt. also has clot in right\n subclavian which is non-occlusive of the PICC line. Pt. has no other\n access, so PICC line not d/c\nd at this time and per PICC team and MICU\n resident it is still OK to use the PICC.\n Plan:\n Will continue to monitor BP, hemodynamics. ? HD again today, since\n patient did not have a full session yesterday. Of note, patient also\n had an elevated Troponin to 0.36 and then 0.35. MICU resident is\n aware, no treatment at this time, EKG was normal.\n Altered mental status (not Delirium)\n Assessment:\n Pt. had a repeat head CT yesterday which showed a stable subdural\n hematoma. Pt. moaning, calling out. Not agitated, but ? if patient is\n in pain. Appears uncomfortable. Following simple commands, opens\n mouth when asked for mouth care. Not moving right arm. Right arm is\n also swollen. Patient remains on continuous EEG monitoring, no seizure\n activity noted overnight.\n Action:\n Patient pulled out NGT on day shift. Left hand in soft wrist\n restraint. Not able to visualize NGT after being replaced, so\n advanced and repeat CXR pbtained. At this time able to auscultate NGT\n and placement was confirmed by repeat CXR. Given PO meds. Later in\n the evening, NGT noted to be coiled in patient\ns mouth, so was pulled\n out and not replaced per MICU resident. 0.5mg Morphine given IV \n patient appearing uncomfortable.\n Response:\n Pt. appears slightly more comfortable after Morphine.\n Plan:\n Continue to monitor mental status. MRI was ordered on the 27^th.\n Patient called for yesterday evening, but per MICU resident, patient\n does not need at the moment, will check with rest of team in am as to\n whether MRI can be d/c\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598416,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598417,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 597520,
"text": "Briefly, 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin\n admitted to the neurology service after being transferred from\n for further management of a traumatic L SDH sustained 3\n days prior to admission. Has had epileptiform behavior for which\n receiving continuous EEG monitoring and ativan boluses (1 mg IV x 3\n over past 36 hours). Had PR temp 102.5 yesterday evening. 30 minutes\n into HD session today had BP 70/23. BCx drawn from HD catheter, given\n vanc 1 g IV, gent 140 mg IV, 1 L NS. ABG 7.41/43/79/28. V/S prior to\n transfer 99.7 101/30 78 24 95%3L.\n Hypotension (not Shock)\n Assessment:\n Pt. had HD yesterday, but was hypotensive and only had 30 minutes of\n session.\n Action:\n Vanco and Gent trough sent with am labs. One set of surveilance blood\n cultures sent off of PICC this am. T-max 100.5 this shift.\n Response:\n BP 90\ns to 140\ns this shift. Taking BP on leg patient has PICC in\n right arm and old AV fistula in left arm. Pt. also has clot in right\n subclavian which is non-occlusive of the PICC line. Pt. has no other\n access, so PICC line not d/c\nd at this time and per PICC team and MICU\n resident it is still OK to use the PICC.\n Plan:\n Will continue to monitor BP, hemodynamics. ? HD again today, since\n patient did not have a full session yesterday. Of note, patient also\n had an elevated Troponin to 0.36 and then 0.35. MICU resident is\n aware, no treatment at this time, EKG was normal.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Pt. had a repeat head CT yesterday which showed a stable subdural\n hematomas.\n Action:\n Response:\n Plan:\n IN MICU: BP stable 110s-120s.\n Head CT done to evaluate SDH.\n Mental status improving as shift advances.\n Continues on continuous EEG monitoring; no seizure\n activity noted; given additional doses of Fosphenytoin\n and Vanco.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-18 00:00:00.000",
"description": "Physician Fellow / Attending Progress Note - MICU",
"row_id": 597627,
"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 her\n note above, including assessment and plan.\n HPI:\n 73yo man with ESRD on HD, CAD s/p CABG``, A fib on Warfarin, s/p fall\n who was admitted to neuro service initially for a subdural hematoma. He\n had RUE paresis on admission after his fall. During HD he dropped his\n BP in the setting of having had a fever to 102.5. He received Vanc,\n Gent and a liter of NS. Transferred ot the MICU for further care given\n the transient hypotension and concern for possible line-related\n infection.\n Overnight, Tmax was 100.5. He was making non-specific noises\n intermittently throughou the night. He was given morphine 0.5mg IV x 1\n for possible pain. He had a NG-tube replaced that was coiled in the\n back of his mouth; it was subsequently d/c\ned and currently he has no\n oral access. He does have an oxygen requirement of 4-6L NC (of note, he\n did not complete HD yesterday.)\n 24 Hour Events:\n PICC LINE - START 11:47 AM\n BLOOD CULTURED - At 01:04 PM\n PICC\n BLOOD CULTURED - At 04:37 AM\n Allergies:\n Hydromorphone\n unknown;\n Metoclopramide\n unknown.\n Last dose of Antibiotics:\n Vancomycin - 06:10 PM\n Gent 90mg per HD protocol\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 03:30 AM\n Fosphenytoin - 08:30 AM\n RSSI\n Lantus 20 units qAM, 10 units qhs\n Celexa 40\n Zocor 40\n Calcium \n Fish Oil 1000 \n Folic acid 1mg\n Nasal spray\n Vitamin B 50mcg\n Neurontin 100mg \n Neomycin left eye gtt q6h\n Brimodine left eye \n Atropine left eye \n Timolol right eye \n Lantoprost right eye \n Dilantin q8\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 No changes.\n Flowsheet Data as of 09:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.9\nC (98.4\n HR: 76 (76 - 84) bpm\n BP: 110/38(52) {90/17(42) - 151/72(102)} mmHg\n RR: 18 (15 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 438 mL\n 90 mL\n PO:\n TF:\n IVF:\n 378 mL\n 90 mL\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 438 mL\n -110 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///28/\n Physical Examination\n General: Opens eyes to voice, moans non-specifically, appears to know\n his name.\n HEENT: Pupils are asymmetric, with apparent prior occular surgeries.\n Not reactive to light. Some right conjunctival hemorrhage.\n CV: S1S2 RRR w/o m/r/g\n Lungs: CTA anteriorly with good air movement.\n Ab: Positive BS\ns. Obese, NT/ND.\n Ext: Mild lower extremity edema.\n Neuro: As above, not following commands. Doesn\nt withdraw his RUE to\n noxious stimuli, but moves all other extremities to mild stimulus.\n Labs / Radiology\n 12.5 g/dL\n 193 K/uL\n 94 mg/dL\n 12.9 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 57 mg/dL\n 95 mEq/L\n 139 mEq/L\n 40.3 %\n 13.3 K/uL\n [image002.jpg]\n RUQ U/S: Small amount of non-occulsive thrombus material adherant to\n the PICC.\n 01:04 PM\n 04:15 AM\n WBC\n 14.0\n 13.3\n Hct\n 37.8\n 40.3\n Plt\n 174\n 193\n Cr\n 11.9\n 12.9\n TropT\n 0.35\n Glucose\n 164\n 94\n Other labs: PT / PTT / INR:17.5/29.1/1.6,\n CK / CKMB / Troponin-T:147/4/0.35,\n Ca++:8.7 mg/dL, Mg++:2.0 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n 73yo man with ESRD on HD, CAD s/p CABG, A fib on Warfarin, s/p fall who\n was initially admitted to neuro service for a subdural hematoma here in\n the MICU with a fever and transient low blood pressure in the setting\n of HD yesterday that has since resolved.\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Suspect that the primary central nervous system bleed and the recurrent\n seizure are the most likely causes of his altered MS. Need to clarify\n if the Neuro teams still want to pursue MRI/MRA/MRV which would further\n clarify his neurologic pathology. There is not compelling evidence for\n a secondary process such as a CNS infection.\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n He is undergoing dialysis today. Will follow the Renal service\ns recs\n regarding appropriate subsequent dialysis.\n HYPOTENSION (NOT SHOCK)\n Resolved with one liter of normal saline yesterday. Suspect transient\n bacteremia in the setting of HD rather than true line infection. Will\n continue his Vanc / Gent for 48 hours; if cultures are non-revealing\n then will d/c antibiotics. There is no complling evidence for an\n alternative etiology of hypotension, particularly given its very\n transient nature.\n CORONARY ARTERY DISEASE\n Will continue statin. Will restart beta-blocker after oral access is\n obtained. Review EKG this AM. Do not need to follow cardiac enzymes\n barring the development of any interval clincal changes.\n ICU Care\n Nutrition: Pending NGT placement.\n Glycemic Control: RSSI and standing Lantus.\n Lines:\n PICC Line - 11:47 AM\n Dialysis Catheter - 09:01 AM\n Prophylaxis:\n DVT: SCDs.\n Stress ulcer: PPI.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full.\n Disposition : ICU for now, will re-assess this afternoon after\n dialysis.\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598907,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Hypotension (not Shock)\n Assessment:\n Pt received on levophed at 0.03 mics,Mean BP stayed above 60 with\n occasional PVC\n Action:\n Levo turned off for\n hr,Systolic droped down to low 80\ns to high 70\n within 10 minutes . levo started back on 0.01 mics\n Response:\n Maintaining mean above 60 so far.\n Plan:\n Wean Levo as tolerated. Goal BP Map >60.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on PS 40% 10/5, Bilateral lung sounds clear to diminish at\n the bases. RR 20-30s. Sp02 95-97%. Pt does move extremities except\n RUE, not following commands. Did open eyes to turning, gag impaired,\n corneal reflex still intact.\n Action:\n Suctioned for small amount of clear secretions from ETT. Given Abx as\n ordered. Cont TPN,Minimal out put from OGT,tolerating Po meds. Flexi\n seal Draining green liquid stool. BS treated according to sliding\n scale.\n Response:\n No changes made on the vent..\n Plan:\n Cont pulm toileting, PRN suction, Cont Abx.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp Max 100.6 orally,pt growing MRSA in his sputum. Pt pan cultured\n yesterday for high temp.\n Action:\n Given Abx as ordered. WBC this morning is 14.3 ( 13.7)\n Response:\n Pt remains febrile. Current temp is\n Plan:\n Closely monitor temp curve.Cont abx and follow cx data.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt had HD last 2 days 9no dialysis yesterday).\n Action:\n BUN 30 (18) and Cr 8.0 (5.8).\n Response:\n Anuric.\n Plan:\n Monitor renal function closely, CRRT today?.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599006,
"text": "73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted to the\n neurology service after being transferred from for\n further management of a traumatic L SDH sustained 3 days prior to\n admission.\n Shift Events:\n Initiated insulin gtt\n Filter change crrt\n Titrating levophed to off\n Alteration in Nutrition\n Assessment:\n Tpn stopped , restart tf, abd firm, stool brown in flexiseal, bt\n present,\n Action:\n Tf to goal rate of 40cc hr with 50 cc flush q 6 hrs, check residual q\n \n Response:\n Tol. TF at goal rate with 20-30 cc residual\n Plan:\n Cont. TF, check residual q 4 hr\n Altered mental status (not Delirium)\n Assessment:\n Grimace to movement, mouth care, bath, not following commands, resist\n mouth care, cataracts bil. , withdraws to pain\n Action:\n Neuro checks with assessment, fentanyl x 1 for pain with bath\n Response:\n Tol. Movement, agitated with oral care, turning\n Plan:\n Medicate for pain as needed\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Cont. CVVHD, line site wnl, high filter pressures with reinitiation of\n new filter/treatment,\n Action:\n Line flushed easily, drsg . Goal 100 cc neg\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599445,
"text": "Events: Pt FS remaining high- 452 @ 2200 SS increased. PT wakes to\n voice/alert but not consistently following commands- large amount\n grimacing and guarding to wound care- lidocaine get and barrier cream\n to excoriated perianal and scrotum.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598674,
"text": "Chief Complaint:\n 24 Hour Events:\n - duplex US of RUEx: non-occlusive thrombus along PICC in the right\n axillary vein, with peripheral flow noted, does not propagate centrally\n into SCV, brachial veins are patent\n - PICC pulled and temporary line placed by IR and HD initiated with 2L\n taken off\n - sedation discontinued but patient remains unresponsive, no withdrawal\n of upper extremities\n - neuro: SDH alone likely not sole cause of altered MS, likely\n multifactorial secondary to infection, uremia, seizures - check daily\n dilantin levels\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:11 PM\n Cefipime - 03:14 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 02:00 PM\n Fentanyl - 02:45 PM\n Pantoprazole (Protonix) - 08:17 PM\n Fosphenytoin - 01:22 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 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.4\nC (99.3\n HR: 92 (80 - 99) bpm\n BP: 97/43(62) {84/31(47) - 151/62(95)} mmHg\n RR: 22 (18 - 36) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 290 mL\n 136 mL\n PO:\n TF:\n IVF:\n 290 mL\n 136 mL\n Blood products:\n Total out:\n 2,450 mL\n 0 mL\n Urine:\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n -2,160 mL\n 136 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 448 (331 - 448) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n : 89\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: 7.36/41/118/23/-1\n Ve: 9.1 L/min\n PaO2 / FiO2: 295\n Physical Examination\n Cardiovascular: Gen: NAD, sedated\n Peripheral 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 322 K/uL\n 10.2 g/dL\n 172 mg/dL\n 7.9 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 32 mg/dL\n 102 mEq/L\n 142 mEq/L\n 33.5 %\n 11.2 K/uL\n [image002.jpg]\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n WBC\n 14.7\n 13.4\n 11.9\n 11.2\n Hct\n 38.5\n 35.3\n 33.7\n 32.8\n 33.5\n Plt\n 22\n Cr\n 10.4\n 11.4\n 12.1\n 12.6\n 12.5\n 7.9\n TCO2\n 23\n 23\n 17\n 24\n Glucose\n 178\n 222\n 175\n 177\n 180\n 172\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:2.8 mg/dL\n Fluid analysis / Other labs: Phenytoin 5.1\n Imaging: RUE U/S : (Prelim) Nonocclusive thrombus along the PICC in the\n right axillary vein, with peripheral flow noted. Does not propagate\n centrally into the subclavian vein at this time. No thrombus noted more\n distally, brachial veins are patent.\n Microbiology: All Blood Cx negative to date.\n Sputum - + (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS.\n Growth - sparse Coag+ Staph\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: replaced temporary dialysis catheter another\n temporary catheter via IR, pressures have been stable, went for HD\n yesterday\n - pneumonia: continue vanomycin (day 9) and cefepime (9) for GP and GN\n coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status\n # Hypotension / Fevers: s/p axillary a-line placement with adequate\n pressures off pressors since line placed. This suggests that\n non-invassive pressures may have been inaccurate. Patient has remained\n afebrile since . Low grade to 100.2 overnight.\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n - repeat sputum cx\n # High Bilious Output: continued high output now 450cc per day(down\n from 1500 - 2000cc) in setting of BM suggesting now obstruction or\n ileus. This may represent inflammatory process without outflow\n obstruction. Livern enzymes do not support inflammatory process of\n gallbladder or pancreas. Hct trending down. Hct 33.5 today.\n Transfuse if < 21.\n - continue PPI with daily guiacs to evaluate for continued bleeding\n - curbside GI regarding etiologies of high NG output\n # ESRD: patient attempted CVVH yesterday but line problems prevented\n full session. Patient remains clinically volume overloaded with\n negative fluid balance while in ICU do to elevated NG output.\n - replaced temporary dialysis catheter yesterday\n - HD now with adequate pressures, dialysis again today\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: f/u duplex ultrasound to evaluate for\n DVT\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right (not functioning); axillary\n A-line, temp line for HD\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599251,
"text": "Demographics\n Day of intubation: 9\n Day of mechanical ventilation: 9\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n 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: 28 cmH2O\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: /\n Sputum source/amount:\n Comments: Pt data as above/ per Meta-V. Remains on PSV 10/5 PEEP FIO2\n .40. RSBI was 102 this AM which is a bit higher than it has been at\n between 70-80 the past few days. Did have a fever and increased WBC\n yesterday\n both improved today. Remains responsive to voice but does\n not follow commands. Remains vasopressor dependent as well and is\n anuric requiring hemodialysis. Appears comfortable on the PSV 10 w/ a\n VT of 350-450 cc and a RR of 25-30 BPM. try a modified SBT today w/\n PSV 5/5 PEEP FIO2 .40 as tolerated. Main obstacle in addition to\n respiratory failure r/t volume overload seems to be his altered mental\n status. Will c/w PSV as tolerated while awaiting improvement in mental\n status and vasopressor requirement.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600901,
"text": "Chief Complaint:\n 24 Hour Events:\n - trach from IP - a little bit of oozing at the site, which improved.\n He became agitated afterwards and tachypneic. Confirmed trach\n placement, and no PNX with radiology. Concerned about pain, increased\n his sedation. Still tachypneic, switched to AC to further increase\n sedation. Stopped overbreathing, pH improved. He continued to remain\n agitated throughout the night.\n - MRI spine: no osteo\n - CT abd: Schmorl's nodes/?osteo. Prominent mediastinal LN\n - sputum cx : sparse MRSA, sparse GNR.\n - Renal believes clotting of lines may be dilantin, don't have a\n lot of other suggestions regarding HD access at this time\n - fever 101.5F\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Vecuronium - 11:40 AM\n Fosphenytoin - 04:20 PM\n Midazolam (Versed) - 04:35 AM\n Fentanyl - 04:35 AM\n Morphine Sulfate - 06:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.1\nC (100.5\n HR: 93 (76 - 94) bpm\n BP: 167/73(97) {80/30(46) - 200/165(175)} mmHg\n RR: 27 (12 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 865 mL\n 550 mL\n PO:\n TF:\n 77 mL\n 452 mL\n IVF:\n 418 mL\n 38 mL\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -135 mL\n 550 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): 591 (334 - 591) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 5\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 16 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.58/30/133/24/7\n Ve: 14.1 L/min\n PaO2 / FiO2: 266\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 267 K/uL\n 8.8 g/dL\n 174 mg/dL\n 5.3 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.7 %\n 8.1 K/uL\n [image002.jpg]\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n WBC\n 10.0\n 8.6\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n Hct\n 28.4\n 30.2\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n Plt\n 80\n 220\n 284\n 267\n Cr\n 7.7\n 5.7\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n TCO2\n 31\n 31\n 29\n Glucose\n 183\n 116\n 155\n 114\n 300\n 66\n 174\n Other labs: PT / PTT / INR:13.3/24.6/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:72.2 %, Band:0.0 %,\n Lymph:12.3 %, Mono:8.8 %, Eos:6.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.5 g/dL, LDH:266 IU/L, Ca++:8.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.5\n mg/dL\n Imaging: CXR:\n Microbiology: Preliminary Sputum Cx: Spare growth Staph aureus coag +\n and GNR\n Catheter tip negative\n Blood cx pending, last negative \n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Fevers: Continues with fevers, not osteomyelitis by MRI. On\n vancomycin (day 7) for ?line infection although negative cultures. On\n and off pressors despite addition of midodrine and florinef. More\n likely due to abnormal autonomic dysfunction to renal failure, but\n ddx includes infectious etiology given recent h/o sepsis. With\n eosinophilia also consider drug reaction.\n - Continue midodrine and florinef and reduce levophed as tolerated\n - d/c all nonessential meds, vanc, dilantin\n - keep MAP > 65\n .\n # Respiratory Distress: Trach yesterday. Had some oozing but improved.\n Episodic aggitation and tachypnia, improved with increased sedation and\n AC.\n - monitor trach site\n - wean vent as tolerated\n - continue HD for volume overload\n - f/u sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: continue on fosphenytoin, q4d free phenytoin level\n checks.\n - touch base re: anti-seizure regimen given dilantin could be causing\n clotting in HD\n # ESRD:\n - cont HD w/ femoral temp line\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; elevated sugars in am\n - adjust SSI\n # Access: femoral line\n # FEN: tolerating TF, give phos\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n - family meeting to discuss goals of care\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 10:45 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599491,
"text": "Events: Pt FS remaining high- 452 @ 2200 SS increased. Pt wakes to\n voice/alert but not consistently following commands, bites ETT with\n oral care- large amount grimacing and guarding to wound care- lidocaine\n get and barrier cream to excoriated perianal and scrotum. T max 99.2\n Ax. NPO at MD- ? extubation post HD this AM- no vent changes and\n remains on 10/+5 overnight with thick tan secretions. Mult consults\n ordered to be eval in AM pending HD and possible extubation, Speech &\n swallow- s/p SDH on difficulty swallowing before intubation, pt needs\n PT and ? OT eval. Social work for support of family. EKG done for ? U\n wave/changes- no acute changes w/ known prolonged QT interval. AM ABG\n 7.36/48(48)/109.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes and diminished bilat lower lobes w/\n scattered crackles, suctioning thick tan secretions, no vent changes,\n sat 95-98%\n Action:\n Suctioning PRN\n Response:\n No acute changes\n Plan:\n Cont wean in AM to 5/+5, RSBI and possible extubation, holding any\n sedating medications, monitor MS\n Diabetes Mellitus (DM), Type II\n Assessment:\n 2200 FS 452\n Action:\n 16 units Regular Insulin\n Response:\n AM blood drawn FS trending down to 250\n Plan:\n NPO currently, SS increased previous day on this shift, cont to monitor\n and trend- known high Insulin requirements on FS and SS Insulin\n Hypotension (not Shock)\n Assessment:\n SBP 77-160, MAP 47- 70\ns, mul attempt to wean Levo gtt off- BP labile\n w/ pain from wound, resting, and vasculopath\n Action:\n Levo gtt currently .03mcg/kg- titrated from .01mcg/ to .05mcg\n overnight x mult\n Response:\n BP labile and balance between resting and pain\n Plan:\n Cont to wean as tolerated, monitor temp curve, monitor for temp spike-\n temp 99.2 AX\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599612,
"text": "Seizure, without status epilepticus\n Assessment:\n No seizure noted. Pt will open eyes to voice and will open mouth to\n command. Pt will also squeeze Lt hand to command, but will not release\n afterwards. Prior to intubation, pt replied he was\nall right\n when\n asked if he had any pain. No movements noted to Rt arm. No pupil\n reactions checks done D/T multiple eye drops (will not be accurate\n read). Pt moves bil legs on bed.\n Action:\n EEG continues.\n Response:\n No seizure seen/noted.\n Plan:\n Continue EEG for now. Continue freq neuron checks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS coarse bil, but clears after deep sx. Pt found at 8pm to have very\n labored breathing with very coarse LS throughout.\n Action:\n Oral sx\nd for sml amounts of clear secretions. NTS done for barely no\n secretions and no change to resp status. ABG done as noted. Family\n notified of change, and decision made to re-intubate. Pt intubated at\n 10 pm and resp status has improved since. Pt continues now to have\n copious amounts of oral secretions. HOB > 30\n. VAP protocol followed.\n Response:\n ABGs improved. O2sat 100%.\n Plan:\n Continue ventilation for now via OETT. Needs family meeting for POC.\n Hypotension (not Shock)\n Assessment:\n BP very labile anything from 70\ns to 150\ns on low dosage of levophed\n gtt. HR stable in SR between 80-90\ns with rare PVC.\n Action:\n Multiple changes made made to pressors in order to maintain MAP > 60.\n Response:\n MAP > 60 with assistance of pressors.\n Plan:\n Continue to wean levophed gtt as tolerated by pt.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Anuric. Last HD .\n Action:\n No actions at this time.\n Response:\n Pt is now + 3 liters for LOS. BUN 25 and creatine 6 this am.\n Plan:\n ? HD today.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598559,
"text": "Airway\n Airway Placement Data\n Known difficult intubation: No\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 Press:\n Cuff pressure: 25 cmH2O\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: MDIs given as documented\n Secretions\n Sputum color / consistency: Rusty / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt remains orally intubated on\n PSV; no vent changes made this shift; continues on +10PSV/+5PEEP w/ Vt\n ~400 RR mid 20s. Briefly on A/C while in IR getting dialysis catheter\n and was sedated.\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 Comments: maintain support\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n 1400\n no complications\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598904,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\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 Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved;\n Comments: Pt remain stable on current PSV settings with no issues this\n shift. Pt has strong cough and was suctioned for moderate amount of\n secretions this shift. Pt had strong showing in RSBi trial. Pt is\n oxygenating and ventilating within normal range. Pt to continue on\n current support.\n BEDSIDE RSBI- 76\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599429,
"text": "Day of mechanical ventilation: 10\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: 25 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: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n No vent changes this shift. HD held today. Pt still on levo. Some\n improvement in mental status. Possibly wean tomorrow. Sputum sent for\n C+S, stain.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599770,
"text": "Chief Complaint:\n 24 Hour Events:\n - Bolused IV phenytoin 300mg and check free dilantin in AM\n - Pt started on midodrine\n - MRV - narrowing of R Subclav and R Brachiocephalic. Narrowing of L\n subclavian and L IJ. Patent SVC and RIJ. Enlarged mediastinal LN\n unchanged from prior.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:07 PM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:00 PM\n Fentanyl - 12:24 AM\n Fosphenytoin - 12:35 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 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.1\nC (98.8\n HR: 85 (81 - 93) bpm\n BP: 131/48(79) {96/40(59) - 149/61(94)} mmHg\n RR: 77 (13 - 77) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 945 mL\n 295 mL\n PO:\n TF:\n 390 mL\n 210 mL\n IVF:\n 375 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 945 mL\n 295 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 233 (233 - 233) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n Ve: 7.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 234 K/uL\n 9.0 g/dL\n 183 mg/dL\n 7.7 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 31 mg/dL\n 104 mEq/L\n 141 mEq/L\n 28.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:59 PM\n 09:34 PM\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n WBC\n 10.4\n 10.0\n Hct\n 29.4\n 28.4\n Plt\n 185\n 234\n Cr\n 6.0\n 7.4\n 7.7\n TCO2\n 34\n 33\n 32\n Glucose\n 50\n 147\n 95\n 88\n 88\n 75\n 77\n 135\n 183\n Other labs: PT / PTT / INR:14.4/25.4/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Fluid analysis / Other labs: RPR negative\n Imaging: - MRV: narrowing of R Subclav and R Brachiocephalic.\n Narrowing of L subclavian and L IJ. Patent SVC and RIJ. Enlarged\n mediastinal LN unchanged from prior.\n Microbiology: SPUTUM\n -GRAM STAIN: 1+ GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS.\n -RESPIRATORY CULTURE (Preliminary): STAPH AUREUS COAG +. SPARSE\n GROWTH.\n CATHETER TIP: No significant growth.\n Stool: C. diff negative\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed on and off for labile BP.\n - on vancomycin / meropenem (day 7), Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for minimal Staph aureus\n - do not d/c line given lack of access for pressors, catheter tip\n culture negative. Anatomy is poor and new line will likely be\n difficult, continue tx w/ vancomycin\n - Start midodrine to wean levophed\n - ? central etiology of fever/autonomic dysfunction such as seizure\n - daily surveillance cultures.\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum positive for minimal Staph\n aureus. CXR cleared, mental status improved. Attempted trial of\n extubation. Pt failed and is reintubated. Per his lack of\n significant growth in sputum, appears more euvolemic on exam (despite\n 3.5 L + LOS), and clarity of chest Xray, would not expect pt to have\n this degree of respiratory failure. Pt may not be strong enough to\n ventilate on his own.\n - respiratory failure: pt likely will require trach, and long term\n ventilation\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 7, - Vancomycin Day 7 (after completion of 10 day course) for GP and\n GN coverage .\n #Scrotal and buttock lesions\n most likely dependent skin ulcers, RPR\n negative\n - continue wound care\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n - appears much improved today\n - Vit B12, folate, TSH all normal\n # Seizure: no gross evidence of ongoing seizure activity\n - Bolused IV phenytoin 300mg and check free dilantin in AM\n - f/u EEG\n - most recent CT scan showed stabilization of SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot, MRV\n shows narrowing of R Subclav and R Brachiocephalic. Narrowing of L\n subclavian and L IJ. Patent SVC and RIJ. Enlarged mediastinal LN\n unchanged from prior. PICC tip cultures negative. Likely clot.\n -continue to monitor\n # ESRD:\n - HD line clotting with HD, only central access, needs a new line\n - f/u renal recs\n - address goals of care\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # R renal cyst\n one complex cyst and one simple cyst on right kidney.\n Radiology rec 12 month follow up.\n - possible malignancy\n - possible abscess seems unlikely\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: axillary A-line, temp line for HD (infected)\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n - Family Meeting\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 12:25 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": "2191-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598763,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Alteration in Nutrition\n Assessment:\n Abd firm, NGT to low intermittent suction. Pt is NPO d/t chronically\n hi residuals. BS hypoactive.\n Action:\n 75 mls light green liquid removed from NGT, otherwise NGT remains on\n suction. Nutrition consult for TPN reqs. Pt had 2 lg BM today.\n Response:\n NGT remains to sux. BS present.\n Plan:\n TPN start TOMORROW! Obtain C diff cx.\n Altered mental status (not Delirium)\n Assessment:\n Pt moves LUE, bilat LLEs, no movt RUE. No sedation. Purposeful movts\n (reaching for ETT, grimacing w/ suction). Does not follow commands.\n Action:\n HD today for hemofiltration.\n Response:\n MS unchanged today.\n Plan:\n Cont to assess.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated CPAP 40%/. Sp02 95-99%. RR 20-30.\n Action:\n No vent changes today. Suction for min thick ETT secretions and\n copious oral secretions.\n Response:\n Resp status stable.\n Plan:\n Obtain sputum sample.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt has temporary HD line RIJ. K 3.5. BUN / Cre 32 / 7.9. Anuric.\n Action:\n HD today for 4 h, 1 L off (pt became hypotensive).\n Response:\n Hemodynamics stable, monitor labs / lytes.\n Plan:\n Will need permanent HD line.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp today till this afternoon spike to 101.3 oral F.\n Action:\n Cont abx and send blood cx\n Response:\n Plan:\n Follow cx data, tx w/ abx.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598989,
"text": "73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted to the\n neurology service after being transferred from for\n further management of a traumatic L SDH sustained 3 days prior to\n admission.\n Shift Events:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n . Also has h/o iddm and afib, not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599218,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.1\nF - 04:00 PM\n -CVVH filter clotted for unclear reasons; re-ordered repeat Rt upper\n extremity US (initially had clot in PICC on rt) to ensure no further\n extension however by evening still not done/no read on it\n -pressures in the AM initially low in the 80s; has not required\n levophed however as pressures rose spontaneously to 110s - 120s\n -tolerating tube feeds with normal residuals/ no biliary output\n anylonger\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 AM\n Gentamicin - 08:45 PM\n Vancomycin - 04:06 PM\n Meropenem - 08:23 PM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:49 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 07:57 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: 37.4\nC (99.4\n HR: 93 (88 - 106) bpm\n BP: 137/48(82) {89/34(52) - 142/57(295)} mmHg\n RR: 21 (20 - 60) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,641 mL\n 649 mL\n PO:\n 60 mL\n TF:\n 793 mL\n 307 mL\n IVF:\n 1,538 mL\n 242 mL\n Blood products:\n Total out:\n 762 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,879 mL\n 649 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 361 (361 - 458) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n : 102\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n Cardiovascular: Gen: sedated, will open eyes to touch.\n CV: RRR\n Lungs: CTAB\n Abd: distended ABS\n Ext: no c/c/e\n Neuro: does not respond to command\n Peripheral 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 231 K/uL\n 9.3 g/dL\n 81 mg/dL\n 6.5 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 108 mEq/L\n 140 mEq/L\n 29.0 %\n 18.1 K/uL\n [image002.jpg]\n 02:44 AM\n 06:10 AM\n 03:21 AM\n 03:44 AM\n 02:14 PM\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n WBC\n 14.3\n 16.5\n 20.4\n 18.1\n Hct\n 32.8\n 33.1\n 35.1\n 29.0\n Plt\n 31\n Cr\n 8.0\n 8.6\n 5.8\n 6.0\n 6.5\n TCO2\n 18\n 17\n 22\n 21\n 21\n Glucose\n 392\n 504\n 301\n 233\n 81\n Other labs: PT / PTT / INR:15.1/30.6/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:28/54, Alk Phos / T Bili:176/0.8,\n Amylase / Lipase:55/88, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL, LDH:240 IU/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:2.1\n mg/dL\n Imaging: CXR - Mild congestive failure. There are small bilateral\n pleural effusions\n and mild bibasilar atelectasis.\n Microbiology: Sputum - MRSA - sparse growth\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: New fever overnight. Pt was pan\n cultured. Hypotension as also noted and pt was restarted on levophed\n yesterday and has required levophed off and on. Were concerned for VAP\n given sputum GS with GPR. However no growth.\n - on vancomycin / meropenem\n - All Bcx negative/NGTD, sputum + for residual GPCs\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - is there an infection somewhere else? - line infection, sinusitis,\n intrabdominal process --> liver enzymes, amylase/lipase\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum GS significant for GNR and\n GPC; Barriers to intubation include mental status, fluid overload and\n underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 3, - Vancomycin Day 3 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters.\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # ESRD:\n - CVVH filter clotted\n - trial of HD today\n - check BPs manually on left arm to correlate to A-line since A-line\n pressures could be affected by clot on right side (?)\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will not pull out PICC as non-occlusive\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:47 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 599231,
"text": "Chief Complaint: Renal failure, respiratory failure, subdural hematoma\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 Continues on norepinephrine\n 24 Hour Events:\n FEVER - 101.1\nF - 04:00 PM\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 08:45 PM\n Vancomycin - 04:06 PM\n Meropenem - 08:23 PM\n Infusions:\n Norepinephrine - 0.08 mcg/Kg/min\n Insulin - Regular - 5.5 units/hour\n Other ICU medications:\n Fosphenytoin - 08:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Tachycardia\n Nutritional Support: Tube feeds\n Respiratory: mechanical ventilation\n Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:09 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: 37.8\nC (100.1\n HR: 98 (88 - 106) bpm\n BP: 125/57(81) {89/34(52) - 151/59(295)} mmHg\n RR: 33 (20 - 60) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,641 mL\n 985 mL\n PO:\n 60 mL\n TF:\n 793 mL\n 436 mL\n IVF:\n 1,538 mL\n 349 mL\n Blood products:\n Total out:\n 762 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,879 mL\n 985 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 450 (361 - 450) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 102\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 12.2 L/min\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered)\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, more attentive\n today\n Labs / Radiology\n 9.3 g/dL\n 231 K/uL\n 81 mg/dL\n 6.5 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 108 mEq/L\n 140 mEq/L\n 29.0 %\n 18.1 K/uL\n [image002.jpg]\n 02:44 AM\n 06:10 AM\n 03:21 AM\n 03:44 AM\n 02:14 PM\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n WBC\n 14.3\n 16.5\n 20.4\n 18.1\n Hct\n 32.8\n 33.1\n 35.1\n 29.0\n Plt\n 31\n Cr\n 8.0\n 8.6\n 5.8\n 6.0\n 6.5\n TCO2\n 18\n 17\n 22\n 21\n 21\n Glucose\n 392\n 504\n 301\n 233\n 81\n Other labs: PT / PTT / INR:15.1/30.6/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:28/54, Alk Phos / T Bili:176/0.8,\n Amylase / Lipase:55/88, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL, LDH:240 IU/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently who now has persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Sepsis-\n Cont vanc/. Elevated WBC, spiking temps - but mental status\n improved. Will not add further abx and cont to follow cultures.\n 2)Respiratory Failure- Bring down PSV to 5 today\n 3)Renal Failure- attempting HD today\n 4)Sub-Dural Hematoma/Altered Mental Status- Continue to hold sedation\n 5)Seizure Disorder-\n -Neurontin\n -Dilantin\n 6)PICC line clot: Recheck ultrasound - not done yesterday\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:47 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT: Boots\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 Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599420,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max today 100.5 F oral.\n Action:\n PICC line pulled and tip sent for cx. Sputum cx sent. Tylenol given,\n tepid bath. Cont abx: vanc / . Abd US today to pursue infex\n source.\n Response:\n Pt conts low grade temp. Mult blood cx\ns pending and stool neg for c\n diff x 3. US results pending.\n Plan:\n Follow cx data, trend fevers and WBC (also elevated). Tailor abx tx if\n necessary.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt anuric, BUN / Cre 26 / 5.8. K 4.1. HD line in place RIJ.\n Action:\n NO HD today. Hold vanc today, trough 27.5.\n Response:\n Stable.\n Plan:\n Cont HD M, W, F.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice, inconsistently follows commands (will squeeze L\n hand). No movt RUE, moves bilat LEs. Nods yes / no to question\n appropriately.\n Action:\n Freq neuro checks, admin fosphenytoin.\n Response:\n Stable.\n Plan:\n Cont sz prophylaxis, freq assess, re-image if changes.\n Hypotension (not Shock)\n Assessment:\n Received pt on 0.04 mcgs/kg/min levophed for BP support.\n Action:\n Titrate as tol. Assess R brachial a-line.\n Response:\n Waveform sharp, levo dose unchanged.\n Plan:\n Hemodynamic support.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Received pt on insulin gtt for hi BG.\n Action:\n D/c gtt and institute RISS w/ SQ insulin.\n Response:\n BG remains elevated but may resolve w/ new insulin scale.\n Plan:\n Monitor BG q 2-6 h and re-assess.\n Alteration in Nutrition\n Assessment:\n TF running at goal. BS present all 4 quads. Freq loose stools.\n Action:\n Check residual prn.\n Response:\n Stable.\n Plan:\n Cont TF.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated 40% PS 10 / 5. RSBI in 60s this AM. Sp02\n 98-100%. RR 15-33. CXR stable.\n Action:\n No vent changes today, ETT suction PRN. Sputum cx sent today.\n Response:\n Stable. ABG 7.38/48/122/2/29.\n Plan:\n Poss extubation tomorrow s/p HD.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598663,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which was neg.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rd the pt on CPAP 40%/peep 5/PSV 10.Suctioned for moderate amount of\n thick yellow secretions.\n Action:\n Pt remains intubated bcoz of fluid overload.\n Response:\n Unchanged, Bld gases stable.\n Plan:\n Not for extubation until MS improves and able to take fluid off.\n Hypotension (not Shock)\n Assessment:\n ABP ranging 90-130\ns depending on the level of stimulation.\n Action:\n None; pt normotensive.\n Response:\n Plan:\n Follow hemodynamic status closely.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 180-200,Pt remains NPO bcoz of high TF residuals.\n Action:\n Conts to be hyperglycemic inspite of being NPO.TF residuals are\n actually lot less than it has been,Advised TPN as per nutrition\n consult.\n Response:\n Pt receiving insulin as per sliding scale.\n Plan:\n Intern to\ntighten\n hiss given relative hyperglycemia while npo.\n Continue to place ogt to lis. TPN to start today.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt underwent HD yesterday and had 2lit off.\n Action:\n Will dialyse him again today.\n Response:\n Plan:\n Per renal attending, pt to be dialyzed again today.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been off of continuous sedation for 48 hours with no change in\n his mental status or motor exam until before HD.\n Action:\n Pt more awake and following commands now.\n Response:\n Improving MS.\n :\n Follow mental status, neuro exam. Will repeat dialysis treatment today.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598807,
"text": "Events: temp 102.3 PO- 1 set peripheral BC, 1 set off PICC line,\n sputum and stool sent. Given 650mg PR Tylenol- current temp 100 PO.\n Pt RR 30\ns while febrile- ABG 7.28/37/109- RR high 20\ns when temp 100.\n Pt moving all extremities except RU. Able to move left upper arm. BP\n trending down and at 0130 consistently SBP 80\ns/, BP dipping to high\n 60\ns during turning- 1x 500cc fluid bolus/1hr- transiently up to 90\n then trending down to mid 80\ns/- Levo gtt started @ 0200- titrating\n dose and currently on .02mcg/kg/min- once a-febrile- pt less\n lethargic, BP increasing when turning, noxious stimuli- suctioning,\n positioning, placement of flexiseal. LS rhonchi- suctioning thin tan\n secretions. Mult green liquid stool and flexiseal placed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.3- trending to 101.9 W/O intervention\n Action:\n Given 650mg PR Tylenol at MD-, 0400 temp 100, mild sweating but not\n diaphoretic, pt warm to touch, sputum, BC x2 and stool sample sent\n Response:\n Current temp 100 PO\n Plan:\n F/U cultures, cont IV ABX, VAP protocol\n Hypotension (not Shock)\n Assessment:\n BP borderline at beginning of shit, at MD post turning SBP 70\ns/ and\n remaining, SBP tonight 60\n Action:\n 1x 500 cc NS bolus, BP tending up to mid 80\ns/ Levo gtt started, BP\n then Labile on gtt- 70\ns/ MAP 40\ns to SBP 150 when stimulated, when\n resting requires low dose Levo gtt\n Response:\n Currently Levo gtt @ .02mcg/kg\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598811,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.3\nF - 08:00 PM\n -dilantin level within normal ranges after adjusting for low albumin\n (14)\n -sputum cultures show 2+ gram - and 1+ gram positive consistent with\n MRSA\n -no neuro recs left\n -nutrition consulted but did not leave TPN recs yet\n -fever spiked to 102.4 around 8 pm and was re-pancultured\n -around 1 AM BP fell to 70s systolic when nursing turned patient; after\n repositioning, BP failed to improve, was given a 500 cc NS bolus. Pt\n was restarted on levo to maintain pressures.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 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 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100\n HR: 105 (89 - 108) bpm\n BP: 103/42(63) {70/30(43) - 175/70(109)} mmHg\n RR: 28 (18 - 53) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 386 mL\n 573 mL\n PO:\n 60 mL\n TF:\n IVF:\n 276 mL\n 573 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 386 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 455 (394 - 488) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n : 82\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.28/34/96./17/-9\n Ve: 11.7 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Cardiovascular: Gen: unresponsive to voice/command.\n CV: RRR, nl S1/S2. no r/g/m\n Lungs: reduced BS at bases\n Abd: distended, not tense. No sign of tenderness. ABS.\n Extremiteis: no c/c/e. Sacral edema\n Neuro: Does not respond to sternal rub. Withdraws to pain stimulus in\n feet\n Labs / Radiology\n 299 K/uL\n 9.9 g/dL\n 213 mg/dL\n 5.8 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 109 mEq/L\n 142 mEq/L\n 32.4 %\n 13.7 K/uL\n [image002.jpg]\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n WBC\n 11.9\n 11.2\n 13.7\n Hct\n 33.7\n 32.8\n 33.5\n 34.6\n 32.4\n Plt\n \n Cr\n 12.6\n 12.5\n 7.9\n 5.8\n TCO2\n 23\n 17\n 24\n 18\n 17\n Glucose\n 177\n 180\n 172\n 213\n Other labs: PT / PTT / INR:23.7/40.6/2.3, ALT / AST:21/49, Alk Phos / T\n Bili:162/0.8, Amylase / Lipase:55/88, Albumin:2.6 g/dL, Ca++:8.4 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: Vanco - 16.4\n Imaging: CXR: inreased hilar density. No effusions\n Microbiology: Sputum cultures - MRSA\n All blood cultures negative to date.\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - : continue vanomycin (day 10) and cefepime (10) for GP and\n GN coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status, correct electrolyte disturbances, treat infection\n # Hypotension / Fevers: s/p axillary a-line placement with adequate\n pressures off pressors since line placed. This suggests that\n non-invassive pressures may have been inaccurate. Patient has remained\n afebrile since . Spiked temperatures overnight. Pt was pan\n cultured. Pt has known MRS . Has completed a course of vanco\n today.\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n - f/u cultures\n - CXR\n # High Bilious Output: continued output, reduced to about 300cc over\n last 24 hrs (down from 1500 - 2000cc). He is having BM and Xray\n confirmed no obstruction or ileus. This may represent inflammatory\n process without outflow obstruction. However, liver enzymes do not\n support inflammatory process of gallbladder or pancreas. Hct trending\n down. Hct 32.4 today. Transfuse if < 21.\n - continue PPI with daily guiacs to evaluate for continued bleeding\n - repeat guaic of output\n # ESRD: patient attempted CVVH yesterday but line problems prevented\n full session. Patient remains clinically volume overloaded with\n negative fluid balance while in ICU do to elevated NG output.\n - HD now with adequate pressures, dialysis again today\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - f/u with IV team regarding need to d/c PICC\n - pt has poor access\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598812,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.3\nF - 08:00 PM\n -dilantin level within normal ranges after adjusting for low albumin\n (14)\n -sputum cultures show 2+ gram - and 1+ gram positive consistent with\n MRSA\n -no neuro recs left\n -nutrition consulted but did not leave TPN recs yet\n -fever spiked to 102.4 around 8 pm and was re-pancultured\n -around 1 AM BP fell to 70s systolic when nursing turned patient; after\n repositioning, BP failed to improve, was given a 500 cc NS bolus. Pt\n was restarted on levo to maintain pressures.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 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 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100\n HR: 105 (89 - 108) bpm\n BP: 103/42(63) {70/30(43) - 175/70(109)} mmHg\n RR: 28 (18 - 53) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 386 mL\n 573 mL\n PO:\n 60 mL\n TF:\n IVF:\n 276 mL\n 573 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 386 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 455 (394 - 488) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n : 82\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.28/34/96./17/-9\n Ve: 11.7 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Cardiovascular: Gen: unresponsive to voice/command.\n CV: RRR, nl S1/S2. no r/g/m\n Lungs: reduced BS at bases\n Abd: distended, not tense. No sign of tenderness. ABS.\n Extremiteis: no c/c/e. Sacral edema\n Neuro: Does not respond to sternal rub. Withdraws to pain stimulus in\n feet\n Labs / Radiology\n 299 K/uL\n 9.9 g/dL\n 213 mg/dL\n 5.8 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 109 mEq/L\n 142 mEq/L\n 32.4 %\n 13.7 K/uL\n [image002.jpg]\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n WBC\n 11.9\n 11.2\n 13.7\n Hct\n 33.7\n 32.8\n 33.5\n 34.6\n 32.4\n Plt\n \n Cr\n 12.6\n 12.5\n 7.9\n 5.8\n TCO2\n 23\n 17\n 24\n 18\n 17\n Glucose\n 177\n 180\n 172\n 213\n Other labs: PT / PTT / INR:23.7/40.6/2.3, ALT / AST:21/49, Alk Phos / T\n Bili:162/0.8, Amylase / Lipase:55/88, Albumin:2.6 g/dL, Ca++:8.4 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: Vanco - 16.4\n Imaging: CXR: inreased hilar density. No effusions\n Microbiology: Sputum cultures - MRSA\n All blood cultures negative to date.\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - : continue vanomycin (day 10) and cefepime (10) for GP and\n GN coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status, correct electrolyte disturbances, treat infection\n # Hypotension / Fevers: Spiked temperatures overnight. Pt was pan\n cultured. Pt has known MRSA . Has completed a course of\n vanco today. Hypotension as also noted and pt was restarted on\n levophed\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n - f/u cultures\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - to evaluate for meningitis\n # High Bilious Output: continued output, reduced to about 300cc over\n last 24 hrs (down from 1500 - 2000cc). He is having BM and Xray\n confirmed no obstruction or ileus. This may represent inflammatory\n process without outflow obstruction. However, liver enzymes do not\n support inflammatory process of gallbladder or pancreas. Hct trending\n down. Hct 32.4 today. Transfuse if < 21.\n - continue PPI with daily guiacs to evaluate for continued bleeding\n - repeat guaic of output\n # ESRD: patient attempted CVVH yesterday but line problems prevented\n full session. Patient remains clinically volume overloaded with\n negative fluid balance while in ICU do to elevated NG output.\n - HD now with adequate pressures, dialysis again today\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - f/u with IV team regarding need to d/c PICC\n - pt has poor access\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598813,
"text": "Events: temp 102.3 PO- 1 set peripheral BC, 1 set off PICC line,\n sputum and stool sent. Given 650mg PR Tylenol- current temp 100 PO.\n Pt RR 30\ns while febrile- ABG 7.28/37/109- RR high 20\ns when temp 100.\n Pt moving all extremities except RU. Able to move left upper arm. BP\n trending down and at 0130 consistently SBP 80\ns/, BP dipping to high\n 60\ns during turning- 1x 500cc fluid bolus/1hr- transiently up to 90\n then trending down to mid 80\ns/- Levo gtt started @ 0200- titrating\n dose and currently on .02mcg/kg/min- once a-febrile- pt less\n lethargic, BP increasing when turning, noxious stimuli- suctioning,\n positioning, placement of flexiseal. LS rhonchi- suctioning thin tan\n secretions. Mult green liquid stool and flexiseal placed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.3- trending to 101.9 W/O intervention\n Action:\n Given 650mg PR Tylenol at MD-, 0400 temp 100, mild sweating but not\n diaphoretic, pt warm to touch, sputum, BC x2 and stool sample sent\n Response:\n Current temp 100 PO\n Plan:\n F/U cultures, cont IV ABX, VAP protocol\n Hypotension (not Shock)\n Assessment:\n BP borderline at beginning of shift, at MD post turning SBP 70\ns/ and\n remaining, SBP tonight 60\n Action:\n 1x 500 cc NS bolus, BP tending up to mid 80\ns/ Levo gtt started, BP\n then Labile on gtt- 70\ns/ MAP 40\ns to SBP 150 when stimulated, when\n resting requires low dose Levo gtt\n Response:\n Currently Levo gtt @ .02mcg/kg W/ SBP 90-113/\n Plan:\n Cont to monitor fluid status, clinically in fluid overload, wean Levo\n gtt as tolerated, F/U cultures\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599322,
"text": "Alteration in Nutrition\n Assessment:\n Abd dist and soft with + BS. Flexiseal in place at 8pm with sml amounts\n of brown loose stool. Insulin gtt for high BS , which was stopped at\n 4am.\n Action:\n TF at goal at 40 cc/hr w/o residuals. Insulin gtt stopped at 4 am D/T\n FSBS of 80. Flexiseal found out at 8pm and left out D/T no rectal tone.\n K and Mg levels replaced.\n Response:\n Pt continues to have sml amounts of loose brown stool.\n Plan:\n Continue to monitor nutritional status.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 100.7 at 8pm.\n Action:\n Tylenol given at mn along with a cool bath. IV ABXs continues. Levophed\n gtt continues for goal MAP of > 65.\n Response:\n Temp decreased to 98.4.\n Plan:\n Follow up cultures. Monitor fevers closely.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS CTA after deep sx. Pt continues to be ventilated via OETT w/o\n sedation.\n Action:\n Pt has been deep sx\nd for sml amounts of tan secretions. Oral care done\n for copious amounts of clear secretions. VAP protocol. HOB > 30\n Response:\n FiO2 98-100%.\n Plan:\n Continue to wean vent settings as pt tolerates.\n Altered mental status (not Delirium)\n Assessment:\n Pt opens eyes to voice and will follow simple commands eg open mouth,\n squeeze my hand. Pupils non checked D/T on multiple eye medications.\n Action:\n Neuro Status evaluated q 4 hrs and prn.\n Response:\n Plan:\n Continue to closely monitor MS.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598548,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Events Today: Right arm diameter notably larger than the left. US study\n obtained to r/o dvt..\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5 and o2 40%. SRR\n high 20\ns with TV ~300cc. Suctioned q2-4 hours for moderate amounts of\n thick, rust colored secretions requiring ns lavage.\n Action:\n Pt remains intubated d/t volume overload and no change in his mental\n status despite being off of sedation >24 hours now.\n Response:\n Unchanged.\n Plan:\n Monitor lung exam, saturations, serial abg\ns, continue pulmonary\n toilet. ?extubation possibly tomarrow following dialysis.\n Hypotension (not Shock)\n Assessment:\n ABP ranging 90-130\ns depending on the level of stimulation.\n Action:\n None; pt normotensive.\n Response:\n Plan:\n Follow hemodynamic status closely. Levophed at the bedside.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\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": "2191-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598808,
"text": "Events: temp 102.3 PO- 1 set peripheral BC, 1 set off PICC line,\n sputum and stool sent. Given 650mg PR Tylenol- current temp 100 PO.\n Pt RR 30\ns while febrile- ABG 7.28/37/109- RR high 20\ns when temp 100.\n Pt moving all extremities except RU. Able to move left upper arm. BP\n trending down and at 0130 consistently SBP 80\ns/, BP dipping to high\n 60\ns during turning- 1x 500cc fluid bolus/1hr- transiently up to 90\n then trending down to mid 80\ns/- Levo gtt started @ 0200- titrating\n dose and currently on .02mcg/kg/min- once a-febrile- pt less\n lethargic, BP increasing when turning, noxious stimuli- suctioning,\n positioning, placement of flexiseal. LS rhonchi- suctioning thin tan\n secretions. Mult green liquid stool and flexiseal placed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102.3- trending to 101.9 W/O intervention\n Action:\n Given 650mg PR Tylenol at MD-, 0400 temp 100, mild sweating but not\n diaphoretic, pt warm to touch, sputum, BC x2 and stool sample sent\n Response:\n Current temp 100 PO\n Plan:\n F/U cultures, cont IV ABX, VAP protocol\n Hypotension (not Shock)\n Assessment:\n BP borderline at beginning of shit, at MD post turning SBP 70\ns/ and\n remaining, SBP tonight 60\n Action:\n 1x 500 cc NS bolus, BP tending up to mid 80\ns/ Levo gtt started, BP\n then Labile on gtt- 70\ns/ MAP 40\ns to SBP 150 when stimulated, when\n resting requires low dose Levo gtt\n Response:\n Currently Levo gtt @ .02mcg/kg W/ SBP 90-113/\n Plan:\n Cont to monitor fluid status, clinically in fluid overload, wean Levo\n gtt as tolerated, F/U cultures\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598899,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Hypotension (not Shock)\n Assessment:\n Pt received on levophed at 0.03 mics,Mean stayed above 60with\n occasional PVC\n Action:\n Levo turned off for\n hr,Systolic droped down to low 80\ns to high 70\n . levo started back on 0.01 mics\n Response:\n Maintaining mean above 60 so far\n Plan:\n Wean Levo as toleratedmGoal BP Map >60.\n Altered mental status (not Delirium)\n Assessment:\n No movt RUE, pt moves all other extremities but does not follow\n commands, does not open eyes, corneal reflex intact.\n Action:\n Repeat head CT scan today, admin sz prophylaxis, admin abx.\n Response:\n MS .\n Plan:\n LP if CNS infex suspected.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp Max 100.6 orally,pt growing MRSA in his sputum. Pt pan cultured\n yrsterday for high temp.\n Action:\n Given Abx as ordered.\n Response:\n Pt remains febrile. Current temp is\n Plan:\n Closely monitor temp curve.Cont abx and follow cx data.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n HD last 2 days but pt becoming increasingly hemodynamically unstable.\n Action:\n No HD today.\n Response:\n BUN / Cre elevated, pt chronically anuric. K 3.6.\n Plan:\n Plan for CVVH tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated on PS 40% 10/5, Bilateral lun sounds cvlear to diminish\n at the bases.RR 20-30s. Sp02 95-97%. Pt does move extremities exept\n RUE, not following commands. Did open eyes to turning, gag impaired,\n corneal reflex still intact.\n Action:\n Suctioned for small amount of clear secretions from ETT. Given Abx as\n ordered. Cont TPN,Minimal out put from OGT,tolerating Po meds. Flexi\n seal Draining green liquid stool.\n Response:\n No changes made on the vent..\n Plan:\n Cont pulm toileting, PRN suction, Cont Abx.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599158,
"text": "73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted to the\n neurology service after being transferred from for\n further management of a traumatic L SDH sustained 3 days prior to\n admission.\n Alteration in Nutrition\n Assessment:\n Tube feeds restarted once residual 20 cc. after 3 hrs residual 30\n cont. to recheck, stooling, abd firm\n Action:\n Freq residual checks\n Response:\n Residual remains low, stooling\n Plan:\n Cont tube feeds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on CPAP , appears comfortable, large amt clear oral secretions\n clear, mod amt. tenacious yellow secretions, slight blood tinged. Sats\n remain 100% rr 25-28\n Action:\n Pulm care support\n Response:\n Stable on cpap\n Plan:\n Wean to extubate\n Hypotension (not Shock)\n Assessment:\n Levophed requirement cont. to increase, hr 90\n Action:\n Titrating for goal map above 65\n Response:\n Increasing requirements\n Plan:\n Titrate for goal map 65\n Diabetes Mellitus (DM), Type II\n Assessment:\n Bs decreased to 64, gtt on hold, recheck 30 min. 54,\n amp d50 given,\n tube feeding running\n Action:\n Insulin gtt with hourly and more often as needed\n Response:\n Bs returns to 106 restart insulin at 6 (\n prev. dose)\n Plan:\n Hourly bs, cont. tf and gtts\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T 100.9, no source id at this time, blood cultures done earlier today\n Action:\n Sputum sent, Tylenol for temps supportive care\n Response:\n Fever now 99\n Plan:\n Monitor temps q 2 hrs, Tylenol prn\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599477,
"text": "Events: Pt FS remaining high- 452 @ 2200 SS increased. Pt wakes to\n voice/alert but not consistently following commands, bites ETT with\n oral care- large amount grimacing and guarding to wound care- lidocaine\n get and barrier cream to excoriated perianal and scrotum. T max 99.2\n Ax. NPO at MD- ? extubation post HD this AM- no vent changes and\n remains on 10/+5 overnight with thick tan secretions. Mult consults\n ordered to be eval in AM pending HD and possible extubation, Speech &\n swallow- s/p SDH on difficulty swallowing before intubation, pt needs\n PT and ? OT eval. Social work for support of family. EKG done for ? U\n wave/changes- no acute changes known prolonged QT interval. AM ABG\n 7.36/48(48)/109.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear bilat upper lobes and diminished bilat lower lobes w/\n scattered crackles, suctioning thick tan secretions, no vent changes,\n sat 95-98%\n Action:\n Suctioning PRN\n Response:\n No acute changes\n Plan:\n Cont wean in AM to 5/+5, RSBI and possible extubation, holding any\n sedating medications, monitor MS\n Diabetes Mellitus (DM), Type II\n Assessment:\n 2200 FS 452\n Action:\n 16 units Regular Insulin\n Response:\n AM blood drawn FS trending down to 250\n Plan:\n NPO currently, SS increased previous day on this shift, cont to monitor\n and trend- known high Insulin requirements on FS and SS Insulin\n Hypotension (not Shock)\n Assessment:\n SBP 77-160, MAP 47- 70\ns, mul attempt to wean Levo gtt off- BP labile\n w/ pain from wound, resting, and vasculopath\n Action:\n Levo gtt currently .03mcg/kg- titrated from .01mcg/ to .05mcg\n overnight x mult\n Response:\n BP labile and balance between resting and pain\n Plan:\n Cont to wean as tolerated, monitor temp curve, monitor for temp spike-\n temp 99.2 AX\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598546,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\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": "2191-08-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598879,
"text": "Demographics\n Day of intubation: 6\n Day of mechanical ventilation: 6\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\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 / Moderate\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598976,
"text": "TITLE: 73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n UPDATE: CRRT initiated today per renal recs. Tube feeds started\n today. Pt moved OOB to chair for three hours with good tol. Adjusting\n Insulin coverage for persistant hyperglycemia today. Pt remains\n minimally responsive to his environment. Supportive family cont to\n visit and kept up to date with POC/ pt status. The pt remains on MRSA+\n Contact Isolation. The pt remains a Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on CPAP/PS of with 40% FiO2 in place and an\n AM RSBI value of 76. LS have been generally clear today with sm to mod\n amounts of thick tan sec. Afternoon ABG values; consistant\n with a met acidosis with good oxygenation.\n Action:\n Sxn\ned PRN today. OOB to chair to optimize resp fxn. Vanco admin @\n noon with an AM serum value of 21.1 in light of starting CRRT today.\n Response:\n Pt remains stable on current MV settings.\n Plan:\n Pt remains essentially non-responsive & non-purposeful which likely\n inability to protect airway and hence the pt will be maintained on MV\n support until his MS improves.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS values in the 400\ns today and have been high since the initiation of\n IV TPN on .\n Action:\n Following FS values closely, adjusting/admin SQ Insulins accordingly.\n Response:\n Pt has remained high today with increasing doses of SQ Insulins.\n Plan:\n Pt may require an Insulin gtt if tight glucose cntl cannot be obtained\n via the SQ route. TPN to be d/c\ned tonight in light good pt tol of\n tube feeds.\n Hypotension (not Shock)\n Assessment:\n Pt received on IV Levophed gtt infusing @ 0.02mcg/kg/min.\n Action:\n IV Levophed gtt weaned off this am with normotensive values for nearly\n four hours.\n Response:\n Unfortunately the pts ABP values began to fall in the early afternoon,\n IV Levophed gtt subsequently restarted.\n Plan:\n Cont to titrate IV Levophed gtt to maintain MAP\ns > 65.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains minimally responsive to noxious stimuli today. Pt does not\n follow commands nor does he answer simple yes/no questions by nodding\n his head. Family members did not appreciate any purposefulness from\n the pt. No psychoactive agents admin this shift. LUE wrist restrained\n to protect airway.\n Action:\n Pt freq re-oriented to person/place/time/care rationale to facilitate\n nl cognition. No psychoactive agents admin. CRRT initiated with\n uremia likely contributing to alt MS.\n Response:\n No change in MS today.\n Plan:\n Cont to re-orient pt to person/place/time/etc. Maintain CRRT to\n ameliorate uremia.\n Alteration in Nutrition\n Assessment:\n Full strength Novasource Renal tube feeds initiated today and now\n infusing @ 30ml/hr via OGT with small residuals noted.\n Action:\n Started tube feeds, following residuals, advancing rate as tol.\n Response:\n Good tolerance thus far.\n Plan:\n Will adv rate to goal of 40ml/hr as tol. Will wean off IV TPN shortly.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt remains anuric with an AM Cr value of 8.0. CRRT initiated this\n afternoon per Renal recs.\n Action:\n Primed CRRT machine, initiated therapy with hourly goal of neg 100ml.\n Access/Return lines on HD line switched 2^nd highly neg access\n pressures. Minimal clotting seen in filter at this time.\n Response:\n Pt seems to be tol CRRT well at this time with access/return lines\n reversed.\n Plan:\n Cont to adjust flow rates to achieve neg 100ml/hr as desired by Renal\n service.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598987,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. . Also has h/o iddm and afib, not on\n coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Shift Events:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n . Also has h/o iddm and afib, not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599204,
"text": "73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted to the\n neurology service after being transferred from for\n further management of a traumatic L SDH sustained 3 days prior to\n admission.\n Alteration in Nutrition\n Assessment:\n Tube feeds restarted once residual 20 cc. after 3 hrs residual 30\n cont. to recheck, stooling, abd firm\n Action:\n Freq residual checks\n Response:\n Residual remains low, last 80 cc stooling\n Plan:\n Cont tube feeds\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on CPAP , appears comfortable, large amt clear oral secretions\n clear, mod amt. tenacious yellow secretions, slight blood tinged. Sats\n remain 100% rr 25-28\n Action:\n Pulm care support\n Response:\n Stable on cpap\n Plan:\n Wean to extubate\n Hypotension (not Shock)\n Assessment:\n Levophed requirement cont. to increase, hr 90\n Action:\n Titrating for goal map above 65\n Response:\n Increasing requirements\n Plan:\n Titrate for goal map 65\n Diabetes Mellitus (DM), Type II\n Assessment:\n Bs decreased to 64, gtt on hold, recheck 30 min. 54,\n amp d50 given,\n tube feeding running\n Action:\n Insulin gtt with hourly and more often as needed\n Response:\n Bs returns to 106 restart insulin at 6 (\n prev. dose)\n Plan:\n Hourly bs, cont. tf and gtts\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T 100.9, no source id at this time, blood cultures done earlier today\n Action:\n Sputum sent, Tylenol for temps supportive care\n Response:\n Fever now 99\n Plan:\n Monitor temps q 2 hrs, Tylenol prn\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599945,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 24cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\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: Tan / Frothy\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n Pt remains intubated, vent supported. No changes made overnight. RSBI\n not performed this am secondary to pt w/o spontaneous resps.\n Administering MDI\ns as ordered. See flowsheet for further pt data.\n Will follow.\n 06:14\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598648,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which was neg.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rd the pt on CPAP 40%/peep 5/PSV 10.Suctioned for moderate amount of\n thick yellow secretions.\n Action:\n Pt remains intubated bcoz of fluid overload.\n Response:\n Unchanged, Bld gases stable.\n Plan:\n Not for extubation until MS improves and able to take fluid off.\n Hypotension (not Shock)\n Assessment:\n ABP ranging 90-130\ns depending on the level of stimulation.\n Action:\n None; pt normotensive.\n Response:\n Plan:\n Follow hemodynamic status closely.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 180-200,Pt remains NPO bcoz of high TF residuals.\n Action:\n Conts to be hyperglycemic inspite of being NPO.TF residuals are\n actually lot less than it has been,Advised TPN as per nutrition\n consult.\n Response:\n Pt receiving insulin as per sliding scale.\n Plan:\n Intern to\ntighten\n hiss given relative hyperglycemia while npo.\n Continue to place ogt to lis. TPN to start today.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt underwent HD yesterday and had 2lit off.\n Action:\n Will dialyse him again today.\n Response:\n Plan:\n Per renal attending, pt to be dialyzed again today.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been off of continuous sedation for 48 hours with no change in\n his mental status or motor exam until before HD.\n Action:\n Pt more awake and following commands now.\n Response:\n Improving MS.\n :\n Follow mental status, neuro exam. Will repeat dialysis treatment today.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598877,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598883,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Hypotension (not Shock)\n Assessment:\n Pt requiring levophed intermittently this admission.\n Action:\n Levophed running at 0.03 mcg/kg/min, goal MAPs >60.\n Response:\n Goal ABP mainained w/ pressor support.\n Plan:\n Cont pressor support, tx infex / sepsis w/ ABX, follow cx data.\n Altered mental status (not Delirium)\n Assessment:\n No movt RUE, pt moves all other extremities but does not follow\n commands, does not open eyes, corneal reflex intact.\n Action:\n Repeat head CT scan today, admin sz prophylaxis, admin abx.\n Response:\n MS .\n Plan:\n LP if CNS infex suspected.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt spiked fever to >101 F yesterday and today. Current cx data +MRSA\n in sputum.\n Action:\n Pt pan cultured, abx coverage broadened.\n Response:\n Pt remains febrile.\n Plan:\n Cont abx and follow cx data.\n Alteration in Nutrition\n Assessment:\n Pt NPO x 48 h d/t increased TF residuals. BS present, pt stooling in\n flexiseal.\n Action:\n TPN started today.\n Response:\n Stable. Min output via OGT, it is clamped.\n Plan:\n Cont TPN, monitor for ileus.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n HD last 2 days but pt becoming increasingly hemodynamically unstable.\n Action:\n No HD today.\n Response:\n BUN / Cre elevated, pt chronically anuric. K 3.6.\n Plan:\n Plan for CVVH tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated on PS 40% 10/5, SRR 20-30s. Sp02 95-97%.\n Action:\n Pt remains intubated d/t AMS and PNA, no vent changes.\n Response:\n Stable.\n Plan:\n Trend ABGs, wean as tol.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598886,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.3\nF - 08:00 PM\n -dilantin level within normal ranges after adjusting for low albumin\n (14)\n -sputum cultures show 2+ gram - and 1+ gram positive consistent with\n MRSA\n -no neuro recs left\n -nutrition consulted but did not leave TPN recs yet\n -fever spiked to 102.4 around 8 pm and was re-pancultured\n -around 1 AM BP fell to 70s systolic when nursing turned patient; after\n repositioning, BP failed to improve, was given a 500 cc NS bolus. Pt\n was restarted on levo to maintain pressures.\n - episode of aberrancy on telemetry lasting one minute, unable to\n assess on ECG. Following ECG was unchanged from prior.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 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 07:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100\n HR: 105 (89 - 108) bpm\n BP: 103/42(63) {70/30(43) - 175/70(109)} mmHg\n RR: 28 (18 - 53) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 386 mL\n 573 mL\n PO:\n 60 mL\n TF:\n IVF:\n 276 mL\n 573 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 386 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 455 (394 - 488) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n : 82\n PIP: 16 cmH2O\n SpO2: 96%\n ABG: 7.28/34/96./17/-9\n Ve: 11.7 L/min\n PaO2 / FiO2: 242\n Physical Examination\n Cardiovascular: Gen: unresponsive to voice/command.\n CV: RRR, nl S1/S2. no r/g/m\n Lungs: reduced BS at bases\n Abd: distended, not tense. No sign of tenderness. ABS.\n Extremiteis: no c/c/e. Sacral edema\n Neuro: Does not respond to sternal rub. Withdraws to pain stimulus in\n feet\n Labs / Radiology\n 299 K/uL\n 9.9 g/dL\n 213 mg/dL\n 5.8 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 109 mEq/L\n 142 mEq/L\n 32.4 %\n 13.7 K/uL\n [image002.jpg]\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n WBC\n 11.9\n 11.2\n 13.7\n Hct\n 33.7\n 32.8\n 33.5\n 34.6\n 32.4\n Plt\n \n Cr\n 12.6\n 12.5\n 7.9\n 5.8\n TCO2\n 23\n 17\n 24\n 18\n 17\n Glucose\n 177\n 180\n 172\n 213\n Other labs: PT / PTT / INR:23.7/40.6/2.3, ALT / AST:21/49, Alk Phos / T\n Bili:162/0.8, Amylase / Lipase:55/88, Albumin:2.6 g/dL, Ca++:8.4 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: Vanco - 16.4\n Imaging: CXR: inreased hilar density. No effusions\n Microbiology: Sputum cultures - MRSA\n All blood cultures negative to date.\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - pneumonia: continue vanomycin (day 10) and cefepime (10) for GP and\n GN coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status, correct electrolyte disturbances, treat infection\n # Hypotension / Fevers: Spiked temperatures overnight. Pt was pan\n cultured. Pt has known MRSA pneumonia. Has completed a course of\n vanco today. Hypotension as also noted and pt was restarted on\n levophed\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n - f/u cultures\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - CT head\n # Sinus tachy with aberrancy\n continue strict monitoring of\n electrolytes. Called renal to discuss HD or CVVH. Recommended\n starting it tomorrow. Continue monitoring on tele.\n # High Bilious Output: continued output, reduced to about 300cc over\n last 24 hrs (down from 1500 - 2000cc). He is having BM and Xray\n confirmed no obstruction or ileus. This may represent inflammatory\n process without outflow obstruction. However, liver enzymes do not\n support inflammatory process of gallbladder or pancreas. Hct trending\n down. Hct 32.4 today. Transfuse if < 21.\n - continue PPI\n # ESRD: Continue HD or CVVH as tolerated by BP\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will not pull out PICC as non-occlusive\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599061,
"text": "Chief Complaint:\n 24 Hour Events:\n \n -No bands in diff, but given hypotension, fever and elevated white\n count, recultured and broadened coverage to meropenem, Gentamycin and\n Vanco.\n - CT head - results pending\n - Hold off on LP, neuro doesn't think this is neurological as symptoms\n are improving\n - spoke with daughter: she's seen him like this before when he's\n azotemic. waiting for a few more cycles of dialysis to see if he\n improves.\n - HD or CVVH tomorrow as pt can tolerate.\n - neurology thinks he will improve with tx of infection\n - TPN started\n \n -Insulin at 420 - 450 in morning, given 10 units insulin, then 15,\n without significant effect. Blood sugar likely due to starting TPN\n yesterday.\n -Started glargine 12 QHS (first dose given now, will hold tonight).\n -Sliding scale increased.\n -nutrition recommended goal tube feeds of 60 ml/hr.\n -insulin drip started, after BS unresponsive to sliding scale.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 AM\n Gentamicin - 08:45 PM\n Vancomycin - 12:01 PM\n Meropenem - 08:00 PM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Insulin - Regular - 7 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:48 AM\n Fentanyl - 06:23 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.6\nC (97.8\n HR: 90 (83 - 100) bpm\n BP: 146/61(94) {94/41(62) - 156/63(97)} mmHg\n RR: 21 (19 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 90.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,001 mL\n 542 mL\n PO:\n TF:\n 335 mL\n 296 mL\n IVF:\n 870 mL\n 196 mL\n Blood products:\n Total out:\n 1,176 mL\n 740 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 825 mL\n -198 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 479 (380 - 479) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n : 61\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.35/37/91./22/-4\n Ve: 11.7 L/min\n PaO2 / FiO2: 230\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 10.8 g/dL\n 233 mg/dL\n 5.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 26 mg/dL\n 105 mEq/L\n 138 mEq/L\n 35.1 %\n 20.4 K/uL\n [image002.jpg]\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n 03:21 AM\n 03:44 AM\n 02:14 PM\n 02:15 PM\n 08:28 PM\n 01:43 AM\n WBC\n 13.7\n 14.3\n 16.5\n 20.4\n Hct\n 34.6\n 32.4\n 32.8\n 33.1\n 35.1\n Plt\n 299\n 314\n 310\n 287\n Cr\n 5.8\n 8.0\n 8.6\n 5.8\n TCO2\n 18\n 17\n 22\n 21\n 21\n Glucose\n 01\n 233\n Other labs: PT / PTT / INR:14.9/28.7/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:28/54, Alk Phos / T Bili:176/0.8,\n Amylase / Lipase:55/88, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL, LDH:240 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:2.1\n mg/dL\n Imaging: CXR, and CXR from not appreciably changed\n IMPRESSION: Mild pulmonary vascular congestion. Bibasilar atelectasis.\n CT head :\n 1. No significant change in evolving subdural hematoma overlying the\n left\n cerebral convexity, with minimal mass effect, unchanged from prior\n exams.\n 2. No new hemorrhage or mass effect.\n Microbiology: MRSA PNA (from sputum culture)\n blood cxs, urine cxs negative or pending\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - pneumonia, completed 10 day course\n - continue vanomycin (day 10)\n - treating for VAP (fever in setting of hypotension) - Gentamycin day\n 2, Meropenem day 2, Vancomycin Day 12 for GP and GN coverage\n will\n adjust as cultures and sensitivies return : recheck sputum cultures as\n had too many epi cells\n - checking gent level today if < 2 continue gent\n - mental status: continue no sedation for further evaluation of mental\n status, correct electrolyte disturbances, treat infection\n # Hypotension / Fevers: Fevers largely resolved. Pt was pan cultured.\n Pt has known MRSA pneumonia. Hypotension as also noted and pt was\n restarted on levophed yesterday and has required levophed off and on.\n - continue vancomycin / meropenem\n - f/u cultures\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - CT head\n # Sinus tachy with aberrancy\n continue strict monitoring of\n electrolytes. Called renal to discuss HD or CVVH. Recommended\n starting it tomorrow. Continue monitoring on tele.\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. He is having BM and Xray confirmed no obstruction or ileus.\n - improved significantly,\n - continued TF\n - continue PPI\n # ESRD:\n - touch base with renal regarding when dialysis can restart, still\n requiring pressors off and on\n -check BPs manually on left arm to correlate to A-line since A-line\n pressures could be affected by clot on right side (?)\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will not pull out PICC as non-occlusive\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 03:35 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599569,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n ABP 70-140\ns, systolic with maps 55-80. Generally, blood pressure is\n more elevated when the pt is more awake and stimulated.\n Action:\n Arterial bp continues to be quite labile requiring frequent titration\n of the levophed drip.\n Response:\n Maintaining sbp >90, maps >60 with low dose levophed.\n Plan:\n Monitor hemodynamic status closely, titrate levophed drip as pt\n tolerates.\n Seizure, without status epilepticus\n Assessment:\n Pt is more alert, opening his eyes when his name is called and +/- his\n ability to squeeze his left hand to command. He has been consistently\n unable to blink or shake his head from side to side on command. He is\n grimacing and continues to be resistant to mouth care. Pt continues to\n have transient left hand tremors. MICU ream called neurology to see the\n pt.\n Action:\n Neurology called re: hand tremor and ?seizure activity. 24hr EEG\n w/video set up at bedside.\n Response:\n Transient hand tremor w/?sz activity. No other change in neuro exam\n noted.\n Plan:\n Continue to monitor neuro/mental status exam, eeg to r/o seizure\n activity.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Hemodialysis treatment lasted 3.5 hours and 2.4 liters was removed. The\n line clotted off when the pt was repositioned and the dialysis rn was\n unable to return the blood. Also of note, dialysis was interrupted for\n approx 1 hour to instill tpa for a poorly functioning catheter.\n Action:\n Repeat hct sent this afternoon. Pt is ~1 liter fluid balance negative\n today s/p dialysis.\n Response:\n Repeat hct stable @29. Renal team has requested either a ct w/contrast\n or mrv to look at the pt\ns left arm/svc for ?clot formation.\n Plan:\n Continue qod hd but ?long term plan for hd line placement.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599570,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lung exam notable for rhonchi throughout. Pt placed on an sbt for\n approx 1 hour this afternoon and managed RR 20\ns, tv ~400-700cc. RSBI\n was 44. Suctioned w/ns lavage for a moderate amount of thick, tan\n secretions just before being extubated @1445.\n Action:\n Extubated; placed on 100% cool neb face tent.\n Response:\n Repeat abg within acceptable limits. Will reduce o2 based on pao2. Pt\n mental status is a concern; he is unable to consistently clear his\n secretions or follow commands. Breathing pattern is shallow at times.\n Plan:\n Follow lung exam, mental status exam. nts if necessary. Pt is at risk\n for reintubation.\n Hypotension (not Shock)\n Assessment:\n ABP 70-140\ns, systolic with maps 55-80. Generally, blood pressure is\n more elevated when the pt is more awake and stimulated.\n Action:\n Arterial bp continues to be quite labile requiring frequent titration\n of the levophed drip.\n Response:\n Maintaining sbp >90, maps >60 with low dose levophed.\n Plan:\n Monitor hemodynamic status closely, titrate levophed drip as pt\n tolerates.\n Seizure, without status epilepticus\n Assessment:\n Pt is more alert, opening his eyes when his name is called and +/- his\n ability to squeeze his left hand to command. He has been consistently\n unable to blink or shake his head from side to side on command. He is\n grimacing and continues to be resistant to mouth care. Pt continues to\n have transient left hand tremors. MICU ream called neurology to see the\n pt.\n Action:\n Neurology called re: hand tremor and ?seizure activity. 24hr EEG\n w/video set up at bedside.\n Response:\n Transient hand tremor w/?sz activity. No other change in neuro exam\n noted.\n Plan:\n Continue to monitor neuro/mental status exam, eeg to r/o seizure\n activity.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 220->170\ns today while pt remains npo. Pt received insulin\n per riss along with 40 units lantus at noontime.\n Action:\n FS improving with a more aggressive sliding scale; however, as pt will\n continue to be npo overnight, sliding scale halved this afternoon.\n Response:\n Unchanged.\n Plan:\n Continue to monitor fingersticks and cover with riss and lantus dosing.\n If fingersticks rise, would consider reinstituting more aggressive\n sliding scale.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Hemodialysis treatment lasted 3.5 hours and 2.4 liters was removed. The\n line clotted off when the pt was repositioned and the dialysis rn was\n unable to return the blood. Also of note, dialysis was interrupted for\n approx 1 hour to instill tpa for a poorly functioning catheter.\n Action:\n Repeat hct sent this afternoon. Pt is ~2 litesr fluid balance negative\n today s/p dialysis.\n Response:\n Repeat hct stable @29. Renal team has requested either a ct w/contrast\n or mrv to look at the pt\ns left arm/svc for ?clot formation.\n Plan:\n Continue qod hd but ?long term plan for hd line placement.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598787,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved;\n Comments: Pt remains on vent, breathing spontaneously with RR, Tidal\n volumes and vital signs all within normal range. During suctioning pt\n does breathe in the 30s bpm range, but slows back down. Pt suctioned\n for white/thick. Pt given MDIs and to be assessed by MD team for\n further evaluation.\n BEDSIDE RSBI- 82\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598792,
"text": "Events: temp 102.3 PO- 1 set peripheral BC, 1 set off PICC line,\n sputum and stool sent. Given 650mg PR Tylenol- current temp 100 PO.\n Pt RR 30\ns while febrile- ABG 7.28/37/109- RR high 20\ns when temp 100.\n Pt moving all extremities except RU. Able to move left upper arm. BP\n trending down and at 0130 consistently SBP 80\ns/, BP dipping to high\n 60\ns during turning- 1x 500cc fluid bolus/1hr- transiently up to 90\n then trending down to mid 80\ns/- LEvo gtt started @ 0200- titrating\n dose and currently on .03mcg/kg/min- once afebrile- pt less lethargic,\n BP increasing when turning, noxious stimule- suctioning, positioning,\n placement of flexiseal.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Generic Note",
"row_id": 598741,
"text": "TITLE: Nutrition\n Patient remains NPO, now x4 days. Team has not ordered TPN-noted it is\n still being considered. Will continue to enter recs daily in POE for\n signature in case team decides to begin. To prevent nutritional\n decline, patient will need some sort of nutrition in next 24-48 hours.\n #\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598742,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / 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 claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598968,
"text": "Demographics\n Day of intubation: 7\n Day of mechanical ventilation: 7\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\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 Comments: Pt data as above/ per Meta-V. Remains unresponsive and on PSV\n 10/5 PEEP FIO2 .40. ABG stable c/w a metabolic acidosis and stable\n oxygenation. possibly attempt to taper PSV to 8 today or in AM. Pt\n up OOB to chair today.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 599082,
"text": "Chief Complaint: Septic shock, respiratory failure, renal failure,\n subdural hematoma\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 CVVH had to be stopped due to clotting filters\n No change in SDH on head CT yesterday\n 24 Hour Events:\n SPUTUM CULTURE - At 03:05 PM\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 AM\n Gentamicin - 08:45 PM\n Vancomycin - 12:01 PM\n Meropenem - 07:49 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Insulin - Regular - 6 units/hour\n Other ICU medications:\n Fentanyl - 06:23 AM\n Pantoprazole (Protonix) - 07:49 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Tachycardia\n Respiratory: mechanical ventilation\n Genitourinary: Foley, Dialysis\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:45 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37.2\nC (98.9\n HR: 99 (83 - 100) bpm\n BP: 115/57(79) {94/41(62) - 156/63(97)} mmHg\n RR: 29 (19 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,001 mL\n 1,484 mL\n PO:\n TF:\n 335 mL\n 500 mL\n IVF:\n 870 mL\n 834 mL\n Blood products:\n Total out:\n 1,176 mL\n 762 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 825 mL\n 722 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 380 (380 - 479) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 61\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.35/37/91./22/-4\n Ve: 9.4 L/min\n PaO2 / FiO2: 230\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered)\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed, slightly\n more arousable today\n Labs / Radiology\n 10.8 g/dL\n 287 K/uL\n 233 mg/dL\n 5.8 mg/dL\n 22 mEq/L\n 3.3 mEq/L\n 26 mg/dL\n 105 mEq/L\n 138 mEq/L\n 35.1 %\n 20.4 K/uL\n [image002.jpg]\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n 03:21 AM\n 03:44 AM\n 02:14 PM\n 02:15 PM\n 08:28 PM\n 01:43 AM\n WBC\n 13.7\n 14.3\n 16.5\n 20.4\n Hct\n 34.6\n 32.4\n 32.8\n 33.1\n 35.1\n Plt\n 299\n 314\n 310\n 287\n Cr\n 5.8\n 8.0\n 8.6\n 5.8\n TCO2\n 18\n 17\n 22\n 21\n 21\n Glucose\n 01\n 233\n Other labs: PT / PTT / INR:14.9/28.7/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:28/54, Alk Phos / T Bili:176/0.8,\n Amylase / Lipase:55/88, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL, LDH:240 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:2.1\n mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently who now has persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Sepsis-\n Off pressors - cont vanc//gent. Completing planned 12 day course\n of vanc. Need to follow WBC --> trending up\n 2)Respiratory Failure-\n Tolerating PSV well - unfortunately, unable to continue CVVH to manage\n volume and hopefully help inprove MS. Renal team will try HD tomorrow\n 3)Renal Failure-\n HD tomorrow\n 4)Sub-Dural Hematoma/Altered Mental Status- Continue to hold sedation\n 5)Seizure Disorder-\n -Neurontin\n -Dilantin\n 6)PICC line clot: Recheck ultrasound\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 09:34 AM 40 mL/hour\n Comments: tolerating TDs\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598497,
"text": "Chief Complaint: 73 yom with anuric ESRD HD-dependent intially admitted\n s/p fall suffering an acute on chronic subdural hematoma c/b seizure,\n transferred to the MICU for respiratory distress, hypoxia, fever and\n hypotension. Patient's HD line was pulled out of concern for\n bacteremia in setting of persistent fevers and most recent sputum\n cultures show GNR and GPC on GS.\n 24 Hour Events:\n - axillary arterial line placed showing pressures higher than measured\n by non-invassive\n - CVVH started but was stopped prematurely because of line difficulties\n - clots in temporay line\n - Pharmacy dosing: Vancomycin 1gm q 24 and cefepime 1 gm q 12\n - Neuro dosing: fosphenytoin dosing 200 AM/100 PM/100 HS\n - Neuro consulted re: prognosis and could not elaborate do to co-morbid\n illnesses\n - Total HD output 60 cc\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:11 PM\n Cefipime - 02:15 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:10 PM\n Fosphenytoin - 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 06:12 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: 90 (78 - 93) bpm\n BP: 95/42(60) {94/41(60) - 135/59(89)} mmHg\n RR: 29 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 789 mL\n 80 mL\n PO:\n TF:\n IVF:\n 789 mL\n 80 mL\n Blood products:\n Total out:\n 1,460 mL\n 400 mL\n Urine:\n NG:\n 1,400 mL\n 400 mL\n Stool:\n Drains:\n Balance:\n -671 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 430 (345 - 537) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n : 89\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.31/33/163/18/-8\n Ve: 10.2 L/min\n PaO2 / FiO2: 408\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 10.2 g/dL\n 180 mg/dL\n 12.5 mg/dL\n 18 mEq/L\n 4.2 mEq/L\n 66 mg/dL\n 102 mEq/L\n 139 mEq/L\n 32.8 %\n 11.9 K/uL\n [image002.jpg]\n 03:17 AM\n 10:02 PM\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n WBC\n 11.7\n 14.7\n 13.4\n 11.9\n Hct\n 38.8\n 38.5\n 35.3\n 33.7\n 32.8\n Plt\n 12\n Cr\n 8.2\n 10.4\n 11.4\n 12.1\n 12.6\n 12.5\n TCO2\n 22\n 23\n 23\n 17\n Glucose\n 75\n 177\n 180\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:8.7 mg/dL, Mg++:2.3\n mg/dL, PO4:4.0 mg/dL\n Microbiology\n - blood Cx : pending\n - blood Cx : pending\n - sputum Cx : contamination\n - sputum Cx : 2+ GNR, 1+ GPC in pairs\n - MRSA : pending\n - C. Diff : pending\n Imaging\n - CXR : slight improvement in overall pulmonary edema, unchaged\n bibasilar atelectasis, low lung volumes\n - CXR :\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: replaced temporary dialysis catheter with tunneled\n line vs. additional temporary catheter via IR, pressures have been\n stable and may be suitable for HD vs. CVVH today\n - pneumonia: continue vanomycin (day 8) and cefepime () for GP and\n GN coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status\n # Hypotension / Fevers: s/p axillary a-line placement with adequate\n pressures off pressors since line placed. This suggests that\n non-invassive pressures may have been inaccurate. Patient has remained\n afebrile since .\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n # High Bilious Output: continued high output now 1500 cc per day in\n setting of BM suggesting now obstruction or ileus. This may represent\n inflammatory process without outflow obstruction.\n - continue PPI with daily guiacs to evaluate for continued bleeding\n - consider replacing NGT as may have migrated to inappropriate position\n # ESRD: patient attempted CVVH yesterday but line problems prevented\n full session. Patient remains clinically volume overloaded with\n negative fluid balance while in ICU do to elevated NG output.\n - replaced temporary dialysis catheter today vs. tunneled catheter\n today\n - consult renal re: CVVH vs. HD now with adequate pressures\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right (not functioning); axillary A-line\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598514,
"text": "Chief Complaint: 73 yom with anuric ESRD HD-dependent intially admitted\n s/p fall suffering an acute on chronic subdural hematoma c/b seizure,\n transferred to the MICU for respiratory distress, hypoxia, fever and\n hypotension. Patient's HD line was pulled out of concern for\n bacteremia in setting of persistent fevers and most recent sputum\n cultures show GNR and GPC on GS.\n 24 Hour Events:\n - axillary a-line placed showing pressures higher than measured by\n non-invasive\n - CVVH started but stopped prematurely because of line difficulties\n clots\n - Pharmacy: Vancomycin 1gm q 24 and cefepime 1 gm q 12\n - Neuro:: fosphenytoin dosing 200 AM/100 PM/100 HS\n - Neuro consulted re: prognosis and could not elaborate do to co-morbid\n illnesses\n - Total CVVH output 60 cc\n - NG aspirate now green again\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:11 PM\n Cefipime - 02:15 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:10 PM\n Fosphenytoin - 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 06:12 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: 90 (78 - 93) bpm\n BP: 95/42(60) {94/41(60) - 135/59(89)} mmHg\n RR: 29 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 789 mL\n 80 mL\n PO:\n TF:\n IVF:\n 789 mL\n 80 mL\n Blood products:\n Total out:\n 1,460 mL\n 400 mL\n Urine:\n NG:\n 1,400 mL\n 400 mL\n Stool:\n Drains:\n Balance:\n -671 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 430 (345 - 537) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n : 89\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.31/33/163/18/-8\n Ve: 10.2 L/min\n PaO2 / FiO2: 408\n Physical Examination\n General: NAD, unable to follow commands, not withdrawing upper\n extremities to pain\n Lungs: soft coarse BS bilateral\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, CR < 2s, ext. PE\n RUE > LUE\n Labs / Radiology\n 312 K/uL\n 10.2 g/dL\n 180 mg/dL\n 12.5 mg/dL\n 18 mEq/L\n 4.2 mEq/L\n 66 mg/dL\n 102 mEq/L\n 139 mEq/L\n 32.8 %\n 11.9 K/uL\n [image002.jpg]\n 03:17 AM\n 10:02 PM\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n WBC\n 11.7\n 14.7\n 13.4\n 11.9\n Hct\n 38.8\n 38.5\n 35.3\n 33.7\n 32.8\n Plt\n 12\n Cr\n 8.2\n 10.4\n 11.4\n 12.1\n 12.6\n 12.5\n TCO2\n 22\n 23\n 23\n 17\n Glucose\n 75\n 177\n 180\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:8.7 mg/dL, Mg++:2.3\n mg/dL, PO4:4.0 mg/dL\n Microbiology\n - blood Cx : pending\n - blood Cx : pending\n - sputum Cx : contamination\n - sputum Cx : 2+ GNR, 1+ GPC in pairs\n - MRSA : pending\n - C. Diff : pending\n Imaging\n - CXR : slight improvement in overall pulmonary edema, unchaged\n bibasilar atelectasis, low lung volumes\n - CXR :\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: replaced temporary dialysis catheter with tunneled\n line vs. additional temporary catheter via IR, pressures have been\n stable and may be suitable for HD vs. CVVH today\n - pneumonia: continue vanomycin (day 8) and cefepime () for GP and\n GN coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status\n # Hypotension / Fevers: s/p axillary a-line placement with adequate\n pressures off pressors since line placed. This suggests that\n non-invassive pressures may have been inaccurate. Patient has remained\n afebrile since .\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n # High Bilious Output: continued high output now 1500 cc per day in\n setting of BM suggesting now obstruction or ileus. This may represent\n inflammatory process without outflow obstruction.\n - continue PPI with daily guiacs to evaluate for continued bleeding\n - consider replacing NGT as may have migrated to inappropriate position\n # ESRD: patient attempted CVVH yesterday but line problems prevented\n full session. Patient remains clinically volume overloaded with\n negative fluid balance while in ICU do to elevated NG output.\n - replaced temporary dialysis catheter today vs. tunneled catheter\n today\n - consult renal re: CVVH vs. HD now with adequate pressures\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right (not functioning); axillary A-line\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Generic Note",
"row_id": 598526,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during morning\n rounds. Problems with HD catheter clotting. R arm swollen. Weaned off\n levophed\n 100.2 84 118/44\n Unresponsive, grimaces to painful stim\n Chest few mid insp crackles\n CV 2/6 SEM\n Abd\n obese, w/o apparent tenderness\n WBC 11.9\n Hct 33\n Fever curve seems to be trending up again and he is now culturing GNR\n from sputum. We are covering for GPC and for GNR in sputum. No signif\n change in WBC so possible this is non-infectious. No other apparent\n sources but his mental status remains poor. Nothing to suggest he has a\n CNS infection. problem now is venous access for HD. With\n swollen R arm may well have clot. Have tried to TPA HD line but likely\n will need a replacement catheter.\n Time spent 40 min\n Critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598589,
"text": "Chief Complaint: 73 yom with anuric ESRD HD-dependent intially admitted\n s/p fall suffering an acute on chronic subdural hematoma c/b seizure,\n transferred to the MICU for respiratory distress, hypoxia, fever and\n hypotension. Patient's HD line was pulled out of concern for\n bacteremia in setting of persistent fevers and most recent sputum\n cultures show GNR and GPC on GS.\n 24 Hour Events:\n - axillary a-line placed showing pressures higher than measured by\n non-invasive\n - CVVH started but stopped prematurely because of line difficulties\n clots\n - Pharmacy: Vancomycin 1gm q 24 and cefepime 1 gm q 12\n - Neuro:: fosphenytoin dosing 200 AM/100 PM/100 HS\n - Neuro consulted re: prognosis and could not elaborate do to co-morbid\n illnesses\n - Total CVVH output 60 cc\n - NG aspirate now green again\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:11 PM\n Cefipime - 02:15 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:10 PM\n Fosphenytoin - 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 06:12 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: 90 (78 - 93) bpm\n BP: 95/42(60) {94/41(60) - 135/59(89)} mmHg\n RR: 29 (13 - 32) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 789 mL\n 80 mL\n PO:\n TF:\n IVF:\n 789 mL\n 80 mL\n Blood products:\n Total out:\n 1,460 mL\n 400 mL\n Urine:\n NG:\n 1,400 mL\n 400 mL\n Stool:\n Drains:\n Balance:\n -671 mL\n -320 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 430 (345 - 537) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 40%\n : 89\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.31/33/163/18/-8\n Ve: 10.2 L/min\n PaO2 / FiO2: 408\n Physical Examination\n General: NAD, unable to follow commands, not withdrawing upper\n extremities to pain\n Lungs: soft coarse BS bilateral\n Heart: RRR, no MRG\n Abdomen: soft, NTND\n Extremities: WWP, CR < 2s, ext. PE\n RUE > LUE\n Labs / Radiology\n 312 K/uL\n 10.2 g/dL\n 180 mg/dL\n 12.5 mg/dL\n 18 mEq/L\n 4.2 mEq/L\n 66 mg/dL\n 102 mEq/L\n 139 mEq/L\n 32.8 %\n 11.9 K/uL\n [image002.jpg]\n 03:17 AM\n 10:02 PM\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n WBC\n 11.7\n 14.7\n 13.4\n 11.9\n Hct\n 38.8\n 38.5\n 35.3\n 33.7\n 32.8\n Plt\n 12\n Cr\n 8.2\n 10.4\n 11.4\n 12.1\n 12.6\n 12.5\n TCO2\n 22\n 23\n 23\n 17\n Glucose\n 75\n 177\n 180\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:8.7 mg/dL, Mg++:2.3\n mg/dL, PO4:4.0 mg/dL\n Microbiology\n - blood Cx : pending\n - blood Cx : pending\n - sputum Cx : contamination\n - sputum Cx : 2+ GNR, 1+ GPC in pairs\n - MRSA : pending\n - C. Diff : pending\n Imaging\n - CXR : slight improvement in overall pulmonary edema, unchaged\n bibasilar atelectasis, low lung volumes\n - CXR :\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: replaced temporary dialysis catheter with tunneled\n line vs. additional temporary catheter via IR, pressures have been\n stable and may be suitable for HD vs. CVVH today\n - pneumonia: continue vanomycin (day 8) and cefepime (8) for GP and GN\n coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status\n # Hypotension / Fevers: s/p axillary a-line placement with adequate\n pressures off pressors since line placed. This suggests that\n non-invassive pressures may have been inaccurate. Patient has remained\n afebrile since .\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n # High Bilious Output: continued high output now 1500 cc per day in\n setting of BM suggesting now obstruction or ileus. This may represent\n inflammatory process without outflow obstruction.\n - continue PPI with daily guiacs to evaluate for continued bleeding\n - curbside GI regarding etiologies of high NG output\n # ESRD: patient attempted CVVH yesterday but line problems prevented\n full session. Patient remains clinically volume overloaded with\n negative fluid balance while in ICU do to elevated NG output.\n - replaced temporary dialysis catheter today vs. tunneled catheter\n today\n - consult renal re: CVVH vs. HD now with adequate pressures\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: f/u duplex ultrasound to evaluate for\n DVT\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right (not functioning); axillary A-line\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 598642,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n 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: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Frothy\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: RSBI 89\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: continue to follow pt and assess WOB\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Social Work",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 599560,
"text": "Social Work Initial Note:\n Received referral from MICU team to assess and support pt/family\n coping. Reviewed chart and discussed with RN. Pt is a 73 y.o. married\n man admitted to on with dx of subdural hemorrhage. Per\n medical record, PMH includes epilepsy, CAD s/p CABG (), ESRD on HD\n (M, W, F), and DM2.\n SW unable to interview pt due to current medical condition. Spoke by\n phone with his wife/HCP, (w: , c:\n ), to reach out to family in context of pt\ns prolonged\n hospitalization and to assess and support coping. Wife states she\n feels she is coping well and in good communication with MICU team re\n pt\ns condition and plan of care. She states she is hopeful that pt\n might be extubated today and that he is making some progress.\n Discussed events leading to hospitalization: wife speaks of how she\n suspects pt fell at home (unwitnessed) and then forgot to tell her\n about this due to his struggles with short-term memory that she states\n has been present for the past three years. She states pt told her\n about the fall likely about three days after it happened, and he was\n subsequently hospitalized. She states she and pt live at their home in\n and that she assists with his medication monitoring. She\n states pt has a daughter, , who works at and is therefore able\n to visit him several times a day. Wife reports she comes in on the\n weekends. SW provided her with parking stickers. Informed her of SW\n role for emotional and resource support as well as facilitation with\n team communication as needed, and encouraged her to call if she would\n like to talk further.\n SW will remain available to pt/family for additional support as needed\n during hospitalization. Please page with any questions or concerns.\n , LICSW, #\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598935,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.4\nF - 04:00 PM\n -No bands in diff, but given hypotension, fever and elevated white\n count, recultured and broadened coverage to meropenem, Gentamycin and\n Vanco.\n - CT head - results pending\n - Hold off on LP, neuro doesn't think this is neurological as symptoms\n are improving\n - spoke with daughter: she's seen him like this before when he's\n azotemic. waiting for a few more cycles of dialysis to see if he\n improves.\n - HD or CVVH tomorrow as pt can tolerate.\n - neurology thinks he will improve with tx of infection\n - TPN started\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 AM\n Vancomycin - 07:00 PM\n Gentamicin - 08:45 PM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:28 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: 38\nC (100.4\n HR: 96 (91 - 105) bpm\n BP: 139/56(87) {93/38(59) - 151/61(94)} mmHg\n RR: 29 (22 - 40) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,477 mL\n 452 mL\n PO:\n TF:\n IVF:\n 1,222 mL\n 103 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,477 mL\n 452 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 395 (380 - 440) mL\n PS : 10 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n : 76\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: 7.36/37/86./20/-3\n Ve: 5 L/min\n PaO2 / FiO2: 218\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 314 K/uL\n 10.2 g/dL\n 392 mg/dL\n 8.0 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.8 %\n 14.3 K/uL\n [image002.jpg]\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n 03:21 AM\n 03:44 AM\n WBC\n 11.9\n 11.2\n 13.7\n 14.3\n Hct\n 32.8\n 33.5\n 34.6\n 32.4\n 32.8\n Plt\n 14\n Cr\n 12.5\n 7.9\n 5.8\n 8.0\n TCO2\n 17\n 24\n 18\n 17\n 22\n Glucose\n 180\n 172\n 213\n 392\n Other labs: PT / PTT / INR:18.1/35.0/1.6, Differential-Neuts:77.0 %,\n Band:2.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Ca++:8.8 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR - RLL Opacity, increased haziness consistent with\n pulmonary edema\n Microbiology: Gram stain - Gram pos cocci in pairs and clusters\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - pneumonia, completed 10 day course\n - continue vanomycin (day 10)\n - Pt respiked, possible new VAP (fever in setting of hypotension) -\n Gentamycin day 1, Meropenem day 1, Vancomycin Day 11 for GP and GN\n coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status, correct electrolyte disturbances, treat infection\n # Hypotension / Fevers: Spiked temperatures overnight. Pt was pan\n cultured. Pt has known MRSA pneumonia. Has completed a course of\n vanco today. Hypotension as also noted and pt was restarted on\n levophed\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n - f/u cultures\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - CT head\n # Sinus tachy with aberrancy\n continue strict monitoring of\n electrolytes. Called renal to discuss HD or CVVH. Recommended\n starting it tomorrow. Continue monitoring on tele.\n # High Bilious Output: continued output, reduced to about 300cc over\n last 24 hrs (down from 1500 - 2000cc). He is having BM and Xray\n confirmed no obstruction or ileus. This may represent inflammatory\n process without outflow obstruction. However, liver enzymes do not\n support inflammatory process of gallbladder or pancreas. Hct trending\n down. Hct 32.4 today. Transfuse if < 21.\n - continue PPI\n # ESRD: Continue HD or CVVH as tolerated by BP\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will not pull out PICC as non-occlusive\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:05 PM 41. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 598940,
"text": "Chief Complaint: Altered mental status, respiratory failure, septic\n 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 Temp spike yest with hotn -- abx expanded to /gent/vanc\n 24 Hour Events:\n FEVER - 101.4\nF - 04:00 PM\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 AM\n Vancomycin - 07:00 PM\n Gentamicin - 08:45 PM\n Meropenem - 08:01 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:48 AM\n Other medications:\n per ICU resident\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: Tube feeds\n Respiratory: mechanical ventilation\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:21 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: 38\nC (100.4\n HR: 100 (91 - 105) bpm\n BP: 105/52(70) {93/38(59) - 151/62(94)} mmHg\n RR: 28 (22 - 40) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 92 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,477 mL\n 669 mL\n PO:\n TF:\n IVF:\n 1,222 mL\n 222 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,477 mL\n 669 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 420 (380 - 438) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 76\n PIP: 16 cmH2O\n SpO2: 92%\n ABG: 7.36/37/86./20/-3\n Ve: 11.8 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress, intubated\n Head, Ears, Nose, Throat: Normocephalic, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\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 10.2 g/dL\n 314 K/uL\n 392 mg/dL\n 8.0 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.8 %\n 14.3 K/uL\n [image002.jpg]\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n 03:21 AM\n 03:44 AM\n WBC\n 11.9\n 11.2\n 13.7\n 14.3\n Hct\n 32.8\n 33.5\n 34.6\n 32.4\n 32.8\n Plt\n 14\n Cr\n 12.5\n 7.9\n 5.8\n 8.0\n TCO2\n 17\n 24\n 18\n 17\n 22\n Glucose\n 180\n 172\n 213\n 392\n Other labs: PT / PTT / INR:18.1/35.0/1.6, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:28/54, Alk Phos / T Bili:176/0.8,\n Amylase / Lipase:55/88, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:0.8 mmol/L,\n Albumin:2.6 g/dL, LDH:240 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.1\n mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently who now has persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Sepsis-\n Off pressors - cont vanc//gent. Follow fever curve\n 2)Respiratory Failure-\n Cont PSV --> will intiate CVVH and hope that improvement in fluid\n status and mental status bring us closer to extubation\n 3)Renal Failure-\n CVVH today\n 4)Sub-Dural Hematoma/Altered Mental Status- Holding sedation\n 5)Seizure Disorder-\n -Neurontin\n -Dilantin\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:05 PM 20 mL/hour\n Comments: start TFs today\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Comments: non-occlusive thrombus on PICC --> monitoring closely\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598941,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.4\nF - 04:00 PM\n -No bands in diff, but given hypotension, fever and elevated white\n count, recultured and broadened coverage to meropenem, Gentamycin and\n Vanco.\n - CT head - results pending\n - Hold off on LP, neuro doesn't think this is neurological as symptoms\n are improving\n - spoke with daughter: she's seen him like this before when he's\n azotemic. waiting for a few more cycles of dialysis to see if he\n improves.\n - HD or CVVH tomorrow as pt can tolerate.\n - neurology thinks he will improve with tx of infection\n - TPN started\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 AM\n Vancomycin - 07:00 PM\n Gentamicin - 08:45 PM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 11:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:28 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: 38\nC (100.4\n HR: 96 (91 - 105) bpm\n BP: 139/56(87) {93/38(59) - 151/61(94)} mmHg\n RR: 29 (22 - 40) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,477 mL\n 452 mL\n PO:\n TF:\n IVF:\n 1,222 mL\n 103 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,477 mL\n 452 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 395 (380 - 440) mL\n PS : 10 cmH2O\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n : 76\n PIP: 15 cmH2O\n SpO2: 96%\n ABG: 7.36/37/86./20/-3\n Ve: 5 L/min\n PaO2 / FiO2: 218\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 314 K/uL\n 10.2 g/dL\n 392 mg/dL\n 8.0 mg/dL\n 20 mEq/L\n 3.6 mEq/L\n 30 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.8 %\n 14.3 K/uL\n [image002.jpg]\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n 03:21 AM\n 03:44 AM\n WBC\n 11.9\n 11.2\n 13.7\n 14.3\n Hct\n 32.8\n 33.5\n 34.6\n 32.4\n 32.8\n Plt\n 14\n Cr\n 12.5\n 7.9\n 5.8\n 8.0\n TCO2\n 17\n 24\n 18\n 17\n 22\n Glucose\n 180\n 172\n 213\n 392\n Other labs: PT / PTT / INR:18.1/35.0/1.6, Differential-Neuts:77.0 %,\n Band:2.0 %, Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Ca++:8.8 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR - RLL Opacity, increased haziness consistent with\n pulmonary edema\n Microbiology: Gram stain - Gram pos cocci in pairs and clusters\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - pneumonia, completed 10 day course\n - continue vanomycin (day 10)\n - treating for VAP (fever in setting of hypotension) - Gentamycin day\n 1, Meropenem day 1, Vancomycin Day 11 for GP and GN coverage\n will\n adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status, correct electrolyte disturbances, treat infection\n # Hypotension / Fevers: Spiked temperatures overnight. Pt was pan\n cultured. Pt has known MRSA pneumonia. Has completed a course of\n vanco today. Hypotension as also noted and pt was restarted on\n levophed\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n - f/u cultures\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - CT head\n # Sinus tachy with aberrancy\n continue strict monitoring of\n electrolytes. Called renal to discuss HD or CVVH. Recommended\n starting it tomorrow. Continue monitoring on tele.\n # High Bilious Output: continued output, reduced to about 300cc over\n last 24 hrs (down from 1500 - 2000cc). He is having BM and Xray\n confirmed no obstruction or ileus. This may represent inflammatory\n process without outflow obstruction. However, liver enzymes do not\n support inflammatory process of gallbladder or pancreas. Hct stable.\n Transfuse if < 21.\n - improved significantly,\n - attempt NG\n - continue PPI\n # ESRD: CVVH today\n - touch base with renal regarding when dialysis can restart, now that\n he is off pressors\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will not pull out PICC as non-occlusive\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n TPN w/ Lipids - 07:05 PM 41. mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 598864,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 213 mg/dL\n 02:26 AM\n Glucose Finger Stick\n 233\n 10:00 AM\n BUN\n 18 mg/dL\n 02:26 AM\n Creatinine\n 5.8 mg/dL\n 02:26 AM\n Sodium\n 142 mEq/L\n 02:26 AM\n Potassium\n 3.6 mEq/L\n 02:26 AM\n Chloride\n 109 mEq/L\n 02:26 AM\n TCO2\n 17 mEq/L\n 02:26 AM\n PO2 (arterial)\n 96. mm Hg\n 06:10 AM\n PCO2 (arterial)\n 34 mm Hg\n 06:10 AM\n pH (arterial)\n 7.28 units\n 06:10 AM\n CO2 (Calc) arterial\n 17 mEq/L\n 06:10 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:26 AM\n Phosphorus\n 2.3 mg/dL\n 02:26 AM\n Ionized Calcium\n 1.20 mmol/L\n 02:44 AM\n Magnesium\n 1.8 mg/dL\n 02:26 AM\n ALT\n 21 IU/L\n 02:26 AM\n Alkaline Phosphate\n 162 IU/L\n 02:26 AM\n AST\n 49 IU/L\n 02:26 AM\n Total Bilirubin\n 0.8 mg/dL\n 02:26 AM\n Phenytoin (Dilantin)\n 5.1 ug/mL\n 03:35 AM\n WBC\n 13.7 K/uL\n 02:26 AM\n Hgb\n 9.9 g/dL\n 02:26 AM\n Hematocrit\n 32.4 %\n 02:26 AM\n Current diet order / nutrition support: NPO; Day 1 TPN c/ non-standard\n lytes and 12 units insulin\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Specifics:\n Patient NPO x5 days today c/ TPN to begin tonight. Lytes in TPN\n conservative despite low levels given renal failure on HD.\n FSBG\ns elevated. Insulin added to TPN. Would also consider tighter\n SS.\n *Please note TPN consult was initially answered . TPN\n recommendations entered for signature and and team paged to\n notify them*\n Medical Nutrition Therapy Plan - Recommend the Following\n Will advance TPN pending glycemic control to goal of 1750\n mL(330 dextrose/95 gr protien/50 lipids) kcals- will enter\n recommendations for MD signature daily\n Lyte management as you are\n Consider tighter sliding scale for optimal glucose control\n Following #\n"
},
{
"category": "Nutrition",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 598955,
"text": "Subjective: patient intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 94.2 kg\n 92 kg ( 12:00 AM)\n 30.4\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.3 kg\n 125%\n 80kg\n 94kg\n 100%\n Pertinent medications: Norepinephrine, HISS, protonix, cyanocobalimin,\n folic acid, fish oil, others noted\n Labs:\n Value\n Date\n Glucose\n 392 mg/dL\n 03:21 AM\n Glucose Finger Stick\n 459\n 10:00 AM\n BUN\n 30 mg/dL\n 03:21 AM\n Creatinine\n 8.0 mg/dL\n 03:21 AM\n Sodium\n 138 mEq/L\n 03:21 AM\n Potassium\n 3.6 mEq/L\n 03:21 AM\n Chloride\n 105 mEq/L\n 03:21 AM\n TCO2\n 20 mEq/L\n 03:21 AM\n PO2 (arterial)\n 95. mm Hg\n 02:14 PM\n PO2 (venous)\n 76. mm Hg\n 04:56 AM\n PCO2 (arterial)\n 42 mm Hg\n 02:14 PM\n PCO2 (venous)\n 43 mm Hg\n 04:56 AM\n pH (arterial)\n 7.30 units\n 02:14 PM\n pH (venous)\n 7.31 units\n 04:56 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 02:14 PM\n CO2 (Calc) venous\n 23 mEq/L\n 04:56 AM\n Albumin\n 2.6 g/dL\n 03:35 AM\n Calcium non-ionized\n 8.8 mg/dL\n 03:21 AM\n Phosphorus\n 3.1 mg/dL\n 03:21 AM\n Ionized Calcium\n 1.24 mmol/L\n 02:14 PM\n Magnesium\n 1.9 mg/dL\n 03:21 AM\n ALT\n 28 IU/L\n 03:21 AM\n Alkaline Phosphate\n 176 IU/L\n 03:21 AM\n AST\n 54 IU/L\n 03:21 AM\n Amylase\n 55 IU/L\n 09:35 AM\n Total Bilirubin\n 0.8 mg/dL\n 03:21 AM\n Triglyceride\n 205 mg/dL\n 02:26 AM\n Phenytoin (Free)\n 3.0 ug/mL\n 04:51 AM\n Phenytoin (Dilantin)\n 5.1 ug/mL\n 03:35 AM\n Current diet order / nutrition support: Tube Feed order: Novasource\n Renal @ 40mL/hr (1920kcals, 71g protein)\n GI: abd soft, obese, bowel sounds present, + loose brown stool.\n Assessment of Nutritional Status\n Estimated Nutritional Needs\n Calories: -2400 ( 25-30 cal/kg)\n Protein: 96-120 (1.2-1.5 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Specifics:\n 73 yo man adm for SDH complicated by seizures, persistent renal\n failure, hyperglycemia and recurrent fever in the setting of sepsis.\n Patient continues on/off pressor support and is receiving HD or CVVH.\n Patient received TPN x1day () due to prolonged NPO due to high\n gastric residuals. This is now resolved and team would like to start\n tube feedings. Recommend a low carbohydrate, concentrated formula\n given hyperglycemia and poor renal function.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend tube feeding goal of Nutren Pulmonary @ 60mL/hr\n (2160kcals, 98g protein)\n Start at 10ml/hr and advance 10 mL q4-6hrs as tolerated to\n goal.\n Monitor abd exam and residuals.\n Following - #\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599297,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23cm at teeth\n Route: po\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Plan\n Pt remains intubated, vent supported. No changes made overnight.\n Administering MDI\ns as ordered. See flowsheet for further pt data.\n Will follow.\n 03:40\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599390,
"text": "Chief Complaint:\n 24 Hour Events:\n - RUE u/s - Prelim read - Stable appearance since with non\n occlusive thrombus in nid axillary vein.\n - HD after CVVH filter clotted\n - Trial of PSV to 5, but was tachypneic.\n - Spiking fevers 101.3 at 4pm , again at 8pm\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:06 PM\n Meropenem - 09:30 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 PM\n Fosphenytoin - 12:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 109) bpm\n BP: 114/47(71) {84/40(56) - 151/61(94)} mmHg\n RR: 27 (15 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,154 mL\n 558 mL\n PO:\n TF:\n 970 mL\n 165 mL\n IVF:\n 864 mL\n 333 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,154 mL\n 558 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 302 (302 - 540) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n : 64\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///27/\n Ve: 10.2 L/min\n Physical Examination\n Intubated, follows simple commands\n RRR, cta b/l, abd soft NT/ND\n RUE edema stable, 2+ pulses\n Labs / Radiology\n 256 K/uL\n 10.2 g/dL\n 152 mg/dL\n 5.1 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 22 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.2 %\n 14.8 K/uL\n [image002.jpg]\n 06:10 AM\n 03:21 AM\n 03:44 AM\n 02:14 PM\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n 10:57 PM\n WBC\n 14.3\n 16.5\n 20.4\n 18.1\n 14.8\n Hct\n 32.8\n 33.1\n 35.1\n 29.0\n 32.2\n Plt\n 31\n 256\n Cr\n 8.0\n 8.6\n 5.8\n 6.0\n 6.5\n 5.1\n TropT\n 0.28\n TCO2\n 17\n 22\n 21\n 21\n Glucose\n 392\n 504\n 301\n 233\n 81\n 152\n Other labs: PT / PTT / INR:15.1/30.6/1.3, CK / CKMB /\n Troponin-T:86/2/0.28, ALT / AST:29/75, Alk Phos / T Bili:190/0.4,\n Amylase / Lipase:44/123, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL, LDH:266 IU/L, Ca++:8.5 mg/dL, Mg++:1.8 mg/dL, PO4:1.7\n mg/dL\n Imaging: RUE u/s - Prelim read - Stable appearance since with non\n occlusive thrombus in nid axillary vein.\n CXR\n unchanged from prior, L pleural effusion\n Microbiology: SPUTUM:\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND\n CLUSTERS.\n BLOOD CX:\n Pending\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed restarted yesterday and has required levophed\n off and on, now on. Were concerned for VAP given sputum GS with GPR.\n However no growth.\n - on vancomycin / meropenem (day 4), Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for residual GPCs\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - is there an infection somewhere else? - line infection, sinusitis,\n intrabdominal process --> LFTs in am, RUQ u/s today\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum GS significant for GNR and\n GPC; Barriers to extubation include mental status, fluid overload and\n underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 4, - Vancomycin Day 4 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters, cultures\n pending.\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will pull out PICC given fevers, unclear source and send tip for\n cultures\n - repeat RUE u/S: shows same as prior\n # ESRD:\n - HD successful yesterday\n - f/u renal recs re continued HD\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:24 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598721,
"text": "Chief Complaint:\n 24 Hour Events:\n - duplex US of RUEx: non-occlusive thrombus along PICC in the right\n axillary vein, with peripheral flow noted, does not propagate centrally\n into SCV, brachial veins are patent\n - temporary line replaced by IR and HD initiated with 2L taken off\n - sedation discontinued but patient remains unresponsive, no withdrawal\n of upper extremities\n - neuro: SDH alone likely not sole cause of altered MS, likely\n multifactorial secondary to infection, uremia, seizures - check daily\n dilantin levels\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:11 PM\n Cefipime - 03:14 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 02:00 PM\n Fentanyl - 02:45 PM\n Pantoprazole (Protonix) - 08:17 PM\n Fosphenytoin - 01:22 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 07:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.4\nC (99.3\n HR: 92 (80 - 99) bpm\n BP: 97/43(62) {84/31(47) - 151/62(95)} mmHg\n RR: 22 (18 - 36) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 290 mL\n 136 mL\n PO:\n TF:\n IVF:\n 290 mL\n 136 mL\n Blood products:\n Total out:\n 2,450 mL\n 0 mL\n Urine:\n NG:\n 450 mL\n Stool:\n Drains:\n Balance:\n -2,160 mL\n 136 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 448 (331 - 448) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n : 89\n PIP: 15 cmH2O\n SpO2: 94%\n ABG: 7.36/41/118/23/-1\n Ve: 9.1 L/min\n PaO2 / FiO2: 295\n Physical Examination\n Cardiovascular: Gen: NAD, sedated\n CV: RRR, no r/g/m\n Lungs: CTAB\n Abd: soft, distended, not tense, ABS. light green fluid suctioned from\n OG tube\n Ext: no c/c/e\n Sacral edema\n Labs / Radiology\n 322 K/uL\n 10.2 g/dL\n 172 mg/dL\n 7.9 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 32 mg/dL\n 102 mEq/L\n 142 mEq/L\n 33.5 %\n 11.2 K/uL\n [image002.jpg]\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n WBC\n 14.7\n 13.4\n 11.9\n 11.2\n Hct\n 38.5\n 35.3\n 33.7\n 32.8\n 33.5\n Plt\n 22\n Cr\n 10.4\n 11.4\n 12.1\n 12.6\n 12.5\n 7.9\n TCO2\n 23\n 23\n 17\n 24\n Glucose\n 178\n 222\n 175\n 177\n 180\n 172\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:2.8 mg/dL\n Fluid analysis / Other labs: Phenytoin 5.1\n Imaging: RUE U/S : (Prelim) Nonocclusive thrombus along the PICC in the\n right axillary vein, with peripheral flow noted. Does not propagate\n centrally into the subclavian vein at this time. No thrombus noted more\n distally, brachial veins are patent.\n Microbiology: All Blood Cx negative to date.\n Sputum - + (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS.\n Growth - sparse Coag+ Staph\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Respiratory Distress: etiology includes volume overload given\n resuscitation with anuric renal failure and likely PNA supported by\n sputum GS significant for GNR and GPC. Barriers to intubation include\n mental status, fluid overload and underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: replaced temporary dialysis catheter another\n temporary catheter via IR, pressures have been stable, went for HD\n yesterday\n - pneumonia: continue vanomycin (day 9) and cefepime (9) for GP and GN\n coverage\n will adjust as cultures and sensitivies return\n - mental status: continue no sedation for further evaluation of mental\n status\n # Hypotension / Fevers: s/p axillary a-line placement with adequate\n pressures off pressors since line placed. This suggests that\n non-invassive pressures may have been inaccurate. Patient has remained\n afebrile since . Low grade to 100.2 overnight.\n - continue vancomycin / cefepime for concern of pneumosepsis pending\n cultures and sensitivities\n - repeat sputum cx\n - CXR\n # High Bilious Output: continued high output now 450cc per day(down\n from 1500 - 2000cc) in setting of BM suggesting now obstruction or\n ileus. This may represent inflammatory process without outflow\n obstruction. Livern enzymes do not support inflammatory process of\n gallbladder or pancreas. Hct trending down. Hct 33.5 today.\n Transfuse if < 21.\n - continue PPI with daily guiacs to evaluate for continued bleeding\n # ESRD: patient attempted CVVH yesterday but line problems prevented\n full session. Patient remains clinically volume overloaded with\n negative fluid balance while in ICU do to elevated NG output.\n - replaced temporary dialysis catheter yesterday\n - HD now with adequate pressures, dialysis again today\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - f/u with IV team regarding need to d/c PICC\n - pt has poor access\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: consult regarding TPN\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600282,
"text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\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 Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Able to wean Pt to PSV, tolerated well through the night.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, underlying illness not resolved\n ------ Protected Section------\n Above note is for wrong patient.\n ------ Protected Section Error Entered By: , RN\n on: 04:59 ------\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599120,
"text": "TITLE: 73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted\n to the neurology service after being transferred from for further management of a traumatic L SDH sustained 3 days\n prior to admission.\n UPDATE: Pt spiked ax temp to 101.1 today, pan C&S drawn/sent for\n analysis. CRRT re-started on old machine with IV Calcium Citrate,\n unfortunately circuit lasted less than two hours with significant\n access and machine issues. Pt now to start HD 10/12 per Renal recs.\n IV Levophed & IV Insulin gtts maintained in place today. High\n residuals per OGT, tube feeds now on hold. Supportive family cont to\n visit daily and kept up to date with POC/pt status. MRSA+ Precautions\n remain in place. The pt is a Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on CPAP/PS 10/5 with 40% FiO2 in place. LS have\n varied from coarse rhonchi to fairly clear today. Afternoon CXR looks\ngood\n per HO. Mod amounts of thick tan sec per ETT today, slightly\n more than on . Resting AM ABG values c/w met acidosis;\n 7.35-37-95. AM RSBI value of 61. The pt has a weak cough and poor\n gag reflex.\n Action:\n Sputum C&S to be sent with next suitable specimen. Pt OOB to chair\n for three hours to optimize resp fxn. Anti-bx cov provided on timed\n basis.\n Response:\n Pt remains stable on currently MV settings. No MV setting changes in\n light of no changes in MS and question of whether pt can protect\n airway.\n Plan:\n The pt will need a random Vanco level drawn with AM labs .\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt received this AM off 2^nd CRRT circuit in under 16 hours with an AM\n Cr value down to 5.8. RSC HD line with good flow noted with 30ml of\n blood drawn back in less than 3 seconds from both lines (arterial\n slightly better than venous).\n Action:\n Pt started on 3^rd CRRT circuit utilizing old CRRT machine and using IV\n Citrate. Arterial/Venous lines switched to ameliorate alarms.\n Multiple flow setting changes to ameliorate alarms.\n Response:\n Unfortunately the circuit clotted off within two hours of initiation\n with significantly abnormal access & filter pressures.\n Plan:\n CRRT now d/c\ned. Standard HD to be attempted .\n Hypotension (not Shock)\n Assessment:\n Pt received/maintained on IV Levophed gtt infusing @ 0.02mcg/kg/min\n titrated to keep MAP > 65. Pt spiked ax temp to 101.1 with rising AM\n WBCC to 20\n new/ongoing sepsis?\n Action:\n Freq Levophed gtt rate adjustments 2^nd labile SABP values.\n Response:\n IV Levophed currently infusing @ 0.08mccg/kg/min.\n Plan:\n Cont to follow ABP Map values closely and adjust IV Levophed gtt rate\n accordingly.\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert this AM, opening eyes to verbal stimuli but not following\n commands or appearing purposeful. Pt has become more lethargic as the\n day has gone by likely 2^nd spiking an ax temp to 101.1.\n Action:\n Pt freq re-oriented to person/place/time/care rationale. No\n psychoactive agents required today with minimal agitation issues or\n obvious discomfort.\n Response:\n Pt now less alert compared with this AM.\n Plan:\n Cont to follow MS exam closely, freq re-orient, minimize exposure to\n psycho-active agents if poss.\n Alteration in Nutrition\n Assessment:\n Pt received on Full strength Novasource Renal infusing @ target goal of\n 40ml/hr via OGT.\n Action:\n Pt developed a residual of 270ml this afternoon.\n Response:\n Tube feeds now on hold.\n Plan:\n Will re-start tube feeds when residuals drop < 100ml and will cont to\n follow tube feed tol on an ongoing basis.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with tmax of 101.1 axillary today. Pt with slightly more sec per\n ETT today\n tan thick tenacious.\n Action:\n Blood C&S times two drawn/sent for analysis. Will send sputum C&S\n with next suitable specimen. Repeat afternoon CXR looked\ngood\n per\n HO. Random AM Gent value of 3.1, dose subsequently held. QD IV Vanco\n dose given @ 16:00 per team after discussion with ID.\n Response:\n Pt remains febrile @ this time.\n Plan:\n Await culture data, await ID recs concerning fever/increased sputum\n prod/increased WBCC.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Pt received/maintained on Insulin gtt infusing @ 8units/hr with\n normoglycemic FS values.\n Action:\n Q1 to 2 hr FS checks with Insulin gtt dose changes made accordingly.\n Response:\n Insulin gtt currently infusing @ 10units/hr with slightly higher FS\n values.\n Plan:\n Will cont to follow FS values and adjust Insulin gtt accordingly.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599121,
"text": "Demographics\n Day of intubation: 8\n Day of mechanical ventilation: 8\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n 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: 28 cmH2O\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 / Thick\n Sputum source/amount: Suctioned / Small\n Comments: Pt data as above/ per Meta-V. Pt remains on PSV of 10/ 5 PEEP\n FIO2 .40. Appears comfortable\n RSBI 61 this AM. No changes due to\n febrile/ increased WBC today. Will c/w PSV 10 as tolerated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599458,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n 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: 25 cmH2O\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 / Thin\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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI-77\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599554,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n ABP 70-140\ns, systolic with maps 55-80. Generally, blood pressure is\n more elevated when the pt is more awake and stimulated.\n Action:\n Arterial bp continues to be quite labile requiring frequent titration\n of the levophed drip.\n Response:\n Maintaining sbp >90, maps >60 with low dose levophed.\n Plan:\n Monitor hemodynamic status closely, titrate levophed drip as pt\n tolerates.\n Seizure, without status epilepticus\n Assessment:\n Pt is more alert, opening his eyes when his name is called and +/- his\n ability to squeeze his left hand to command. He has been consistently\n unable to blink or shake his head from side to side on command. He is\n grimacing and continues to be resistant to mouth care. Pt continues to\n have transient left hand tremors. MICU ream called neurology to see the\n pt.\n Action:\n Neurology called re: hand tremor and ?seizure activity. 24hr EEG\n w/video set up at bedside.\n Response:\n Transient hand tremor w/?sz activity. No other change in neuro exam\n noted.\n Plan:\n Continue to monitor neuro/mental status exam, eeg to r/o seizure\n activity.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Hemodialysis treatment lasted 3.5 hours and 2.4 liters was removed. The\n line clotted off when the pt was repositioned and the dialysis rn was\n unable to return the blood. Also of note, dialysis was interrupted for\n approx 1 hour to instill tpa for a poorly functioning catheter.\n Action:\n Repeat hct sent this afternoon. Pt is ~1 liter fluid balance negative\n today s/p dialysis.\n Response:\n Repeat hct stable @29. Renal team has requested either a ct w/contrast\n or mrv to look at the pt\ns left arm/svc for ?clot formation.\n Plan:\n Continue qod hd but ?long term plan for hd line placement.\n"
},
{
"category": "Nutrition",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 599556,
"text": "Subjective\n Patient having EKG leads put on\n Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 287 mg/dL\n 03:34 AM\n Glucose Finger Stick\n 226\n 10:00 AM\n BUN\n 40 mg/dL\n 03:34 AM\n Creatinine\n 7.4 mg/dL\n 03:34 AM\n Sodium\n 138 mEq/L\n 03:34 AM\n Potassium\n 4.0 mEq/L\n 03:34 AM\n Chloride\n 102 mEq/L\n 03:34 AM\n TCO2\n 28 mEq/L\n 03:34 AM\n PO2 (arterial)\n 126 mm Hg\n 03:56 AM\n PCO2 (arterial)\n 49 mm Hg\n 03:56 AM\n pH (arterial)\n 7.36 units\n 03:56 AM\n CO2 (Calc) arterial\n 29 mEq/L\n 03:56 AM\n Calcium non-ionized\n 8.6 mg/dL\n 03:34 AM\n Phosphorus\n 2.3 mg/dL\n 03:34 AM\n Magnesium\n 2.2 mg/dL\n 03:34 AM\n ALT\n 23 IU/L\n 03:34 AM\n Alkaline Phosphate\n 168 IU/L\n 03:34 AM\n AST\n 44 IU/L\n 03:34 AM\n Total Bilirubin\n 0.4 mg/dL\n 03:34 AM\n WBC\n 12.7 K/uL\n 03:34 AM\n Hgb\n 9.1 g/dL\n 03:34 AM\n Hematocrit\n 29.8 %\n 02:20 PM\n Current diet order / nutrition support: Novasource renal @ 40mL/hr\n ( kcals 67 gr protein) on hold\n GI: Abd: soft/distended/+bs\n Assessment of Nutritional Status\n Specifics:\n Patient transitioned back to tube feeds which have been well\n tolerated since. Currently on hold for ? extubation. If unable to\n extubated or patient needs feeds p/ extubation, will need to change\n tube feed and goal rate as patient does not appear to need renal\n formula at this time as patient being dialyzed regularly. Low PO4\n noted.\n Insulin drip transitioned to glargine and ISS, will likely need\n additional adjustments for optimal control.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeds\n Tube feeding recommendations: If tube feeds resume, please\n change Rx to Nutren 2.0 @45mL/hr (2160 kcals/86 grams protein) Will\n need to add 30 grams beneprotein to feed once tolerance established @\n goal-new kcals/protein will = 2267 and 112 respectively\n Residual checks q4, hold if >200ml\n Swallow eval once extubated-diet per SLP\n Adjust insulin regimen prn for optimal glycemic control\n Lyte management per renal\n Following #\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598578,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Events Today: Right arm diameter notably larger than the left. US study\n obtained to r/o dvt this afternoon.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5 and o2 40%. SRR\n high 20\ns with TV ~300cc. Suctioned q2-4 hours for moderate amounts of\n thick, rust colored secretions requiring ns lavage.\n Action:\n Pt remains intubated d/t volume overload and no change in his mental\n status despite being off of sedation >24 hours now.\n Response:\n Unchanged.\n Plan:\n Monitor lung exam, saturations, serial abg\ns, continue pulmonary\n toilet. ?extubation within the next several days following dialysis\n treatments.\n Hypotension (not Shock)\n Assessment:\n ABP ranging 90-130\ns depending on the level of stimulation.\n Action:\n None; pt normotensive.\n Response:\n Plan:\n Follow hemodynamic status closely. Levophed at the bedside.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 190-200\ns. Pt received humalog insulin per sliding scale.\n Abd remains soft but distended w/+bs. Pt continues to pass gastric\n fluid from ogt. Nutrition has made recommendations for tpn.\n Action:\n Pt continues to be hyperglycemic despite npo status x several days. Pt\n to start tpn tomarrow.\n Response:\n Pt receiving insulin as per sliding scale.\n Plan:\n Intern to\ntighten\n hiss given relative hyperglycemia while npo.\n Continue to place ogt to lis. TPN to start tomorrow.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Dialysis RN unable to initiate hd with previous line. Another Quinton\n catheter with a vip port was placed in angio this afternoon. Pt\n currently being dialyzed with fluid removal.\n Action:\n New dialysis line placed in angio.\n Response:\n Pt currently undergoing dialysis with uf.\n Plan:\n Per renal attending, pt to be dialyzed again tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt has been off of continuous sedation x24 hours with no change in his\n mental status or motor exam.\n Action:\n Pt currently receiving dialysis with uremia being a possible cause of\n his decreased mental status.\n Response:\n Exam unchanged so far today.\n Plan:\n Follow mental status, neuro exam. Will repeat dialysis treatment\n tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 598841,
"text": "Chief Complaint: Sub-Dural Hematoma\n respiratory Failure\n 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 FEVER - 102.3\nF - 08:00 PM\n History obtained from Patient\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 02:00 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 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 Genitourinary: Dialysis\n Flowsheet Data as of 11:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 38.4\nC (101.2\n HR: 105 (89 - 108) bpm\n BP: 103/42(63) {70/30(43) - 175/70(109)} mmHg\n RR: 28 (22 - 53) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 91 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 386 mL\n 633 mL\n PO:\n 60 mL\n TF:\n IVF:\n 276 mL\n 633 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 386 mL\n 633 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 440 (330 - 455) mL\n PS : 10 cmH2O\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 82\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: 7.28/34/96./17/-9\n Ve: 9.2 L/min\n PaO2 / FiO2: 242\n Physical Examination\n General Appearance: Overweight / Obese\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, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Unresponsive, He will move his lower\n extremities to stimulation but without reliable withdrawl to pain which\n is a paradox. He does grimace with stimulation but no organized\n responses seen. He is without obvious clonus but this exam is without\n change despite 3 days off of sedation.\n Labs / Radiology\n 9.9 g/dL\n 299 K/uL\n 213 mg/dL\n 5.8 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 109 mEq/L\n 142 mEq/L\n 32.4 %\n 13.7 K/uL\n [image002.jpg]\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n 05:40 PM\n 02:26 AM\n 02:44 AM\n 06:10 AM\n WBC\n 11.9\n 11.2\n 13.7\n Hct\n 33.7\n 32.8\n 33.5\n 34.6\n 32.4\n Plt\n \n Cr\n 12.6\n 12.5\n 7.9\n 5.8\n TCO2\n 23\n 17\n 24\n 18\n 17\n Glucose\n 177\n 180\n 172\n 213\n Other labs: PT / PTT / INR:23.7/40.6/2.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:21/49, Alk Phos / T Bili:162/0.8,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:0.8 mmol/L, Albumin:2.6 g/dL,\n Ca++:8.4 mg/dL, Mg++:1.8 mg/dL, PO4:2.3 mg/dL\n Fluid analysis / Other labs: Vanco-Pending\n Imaging: CXR-ETT at 2cm HD catheter in place, RLL opacity\n Sputum\n==MRSA\n Assessment and Plan\n Patient with initial history notable for sub-dural hematoma complicated\n by seizures subsequently who now has persistent renal failure and\n recurrent fever in the setting of sepsis. Of concern is that patient\n has had evidence of significant fever in the setting of a mild rise in\n WBC count. This is without localizing laboratory findings.\n 1)Sepsis-\n -Levophed\n -Vanco/Cefepime\n -Will resend cultures from blood, sputum and urine\n -Will continue Vanco at this time\n -Follow cultures\n -Will go to broad spectrum antibiotics in the setting of increased\n pressor requirements\n -Will have to expand to coverage to focus on VAP with Vanco/Meropenem\n 2)Respiratory Failure-\n -Atrovent/Albuterol\n -Continue with PSV support\n -Maintain O2\n 3)Renal Failure-\n -Will move to CVVH in the setting of hypotension if unable to tolerate\n HD over next 24 hours\n 4)Sub-Dural Hematoma/Altered Mental Status-He has persistent deficit as\n described above\n -Will repeat head CT to evaluate stability of bleed or new obvious\n insult\n -Will follow neuro exam\n -Will continue hold of sedation and follow exam\n -Without trend to improvement will have to raise concern for persistent\n neurologic deficit\n 5)Seizure Disorder-\n -Neurontin\n -Dilantin\n ICU Care\n Nutrition: TPN to start\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 44 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598917,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Hypotension (not Shock)\n Assessment:\n Pt received on levophed at 0.03 mics/hr.\n Action:\n Tried to turned off Levo,but BP dropped down to low 80\ns to high 70\n within 10 minutes. Restartd Levo at 0.01 mics and titrated upto 0.02\n mics.\n Response:\n BP stable. Cont Levo at 0.02 mics.\n Plan:\n Cont pressor support and wean Levo as tolerated.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp Max 100.6,\n Action:\n Pt pan cultured yesterday, given abx as ordered..\n Response:\n Pt current temp is 99.5 axillary.\n Plan:\n Closely monitor temp curve.Cont abx and follow cx data.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt had HD day before yesterday..\n Action:\n BUN and Cr Increasing.\n Response:\n Pt chronically anuric,K is 3.6\n Plan:\n Closely monitor renal function, follow up with renal team. CRRT today?\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on PS 40% 10/5, BLS clear to diminish at the bases.RR in\n 20\ns, SPO2 96-97%.\n Action:\n Suctioned for small amount of clear secretions from ETT,Given abx as\n ordered. Pt moves all extremities except RUE. Does not open eyes,\n Corneal reflex intact, Impaired Gag. Pt grimaces with Care and turning.\n Cont TPN, OGT with Minimal residuals.\n Response:\n No changes made on the vent,ABG this morningis 7.42/37/82.\n Plan:\n Cont pulm toileting,Trend ABG,Cont ABG,follow up with culture.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599021,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 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: 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: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved;\n Comments: Pt still remains with a questionable mental status. Pt was\n sucitoned for moderate amount of secretions this shift. Pt does bite\n down when being suctioned. Pt has clear to rhonchi lung sounds.\n Albuterol given at appropriate times. Pt to be assessed by MD team and\n continue current support\n BEDSIDE RSBI- 61\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599022,
"text": "73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted to the\n neurology service after being transferred from for\n further management of a traumatic L SDH sustained 3 days prior to\n admission.\n Shift Events:\n Initiated insulin gtt\n Filter change crrt\n Titrating levophed to off\n Alteration in Nutrition\n Assessment:\n Tpn stopped , restart tf, abd firm, stool brown in flexiseal, bt\n present,\n Action:\n Tf to goal rate of 40cc hr with 50 cc flush q 6 hrs, check residual q\n \n Response:\n Tol. TF at goal rate with 20-30 cc residual\n Plan:\n Cont. TF, check residual q 4 hr\n Altered mental status (not Delirium)\n Assessment:\n Grimace to movement, mouth care, bath, not following commands, resist\n mouth care, cataracts bil. , withdraws to pain\n Action:\n Neuro checks with assessment, fentanyl x 1 for pain with bath\n Response:\n Tol. Movement, agitated with oral care, turning\n Plan:\n Medicate for pain as needed\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Cont. CVVHD, line site wnl, high filter pressures with reinitiation of\n new filter/treatment, K 3.4, ICA 1.18, .\n Action:\n Line flushed easily, drsg . Goal 100 cc neg, rescue flush q 4hr\n and prn\n Response:\n Immediate high filter pressures, rescue flush done without problem,\n bun creat declining\n Plan:\n Cont. cvvh, lab monitoring as ordered, titrate lab results to protocol\n Hypotension (not Shock)\n Assessment:\n Map 55-75, cont. to titrate levophed, pp difficult to palpate\n Action:\n Able to temp. turn off levo. Then increased ectopy decreased bp\n restarted\n Response:\n Variable bp\n Plan:\n Titrate to off maintaining maps 65 or above\n Diabetes Mellitus (DM), Type II\n Assessment:\n Bs 300\ns initiated insulin gtt, tpn stopped recent, restart tube\n feedings\n Action:\n Titrating insulin in increasing amts to obtain goal 150-200\n Response:\n At this writing insulin at 8 units hr., bs 204\n Plan:\n Cont. to titrate to goal , hrly blood sugars\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 40% cpap, appears comfortable ,rr 22-30 with agitating, biting down on\n tube, resistive to suction, suctioning thick tenacious light yellow\n sputum mod amt, oral large secretions clear, sats 100%\n Action:\n Remains on cpap, rsbi 61 , suction prn, mouth care, repositioned tube\n Response:\n Stable\n Plan:\n Wean to extubate, pulm care\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599274,
"text": "73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted to the\n neurology service after being transferred from for\n further management of a traumatic L SDH sustained 3 days prior to\n admission.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp today and then fever spike to 101.3 F oral this\n afternoon. WBC elevated.\n Action:\n Cont abx tx w/ vanc and meropenum, admin Tylenol. Mult cx\ns pending.\n Response:\n Pt remains consistently febrile. Stool cx neg for cdiff, no pos blood\n cx\ns to date, MRSA in sputum.\n Plan:\n Cont abx tx, assess CXRs, follow cx data, search for other source if\n fever persists: CNS, abd.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt has temp HD line R SC, anuric, elevated BUN / Cre 30 / 6.5.\n Action:\n HD today x 4 h.\n Response:\n Pt able to tol 2 L fluid off w/ vasopressor support.\n Plan:\n Cont HD tx\ns tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on 40% PS 10/5, sp02 96-98%. LS rhonchorous throughout,\n mod ETT suction, mod oral secretions.\n Action:\n Attempt to wean vent to , suction PRN, pulm toilet.\n Response:\n Pt becoming tachypnic w/ labored breathing w/ , vent back to .\n Plan:\n Wean vent support as tol.\n Diabetes Mellitus (DM), Type II\n Assessment:\n BG consistently elevated this admission, pt on insulin gtt.\n Action:\n Q 2 h BG checks, titrate gtt according to chart.\n Response:\n BG 128-196 today.\n Plan:\n Cont insulin gtt\n Hypotension (not Shock)\n Assessment:\n Pt requires levophed to maintain ABPs w/ MAP > 60. Pt very sensitive\n to levo, received pt on 0.06 mcg/kg/min.\n Action:\n Titrate to 0.08 mcgs during HD.\n Response:\n Pt tol procedure well, able to titrate levo down to 0.04 mcgs this\n afternoon.\n Plan:\n Wean pressor as tol.\n Alteration in Nutrition\n Assessment:\n TF running at goal.\n Action:\n Check residual q 4 h.\n Response:\n Pt tol TF w/ < 40-50 cc residual.\n Plan:\n Cont TF.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599536,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:14 AM\n abd CT to search for infection\n PICC LINE - STOP 04:53 PM\n - Renal recs: concern for SVC syndrome given UE>LE edema, recommend\n MRV, however, not urgent because it won't change management\n - PICC pulled, catheter tip sent for cultures\n - Abdominal u/s done\n - HD planned for today\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:06 PM\n Meropenem - 09:30 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:48 AM\n Fosphenytoin - 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 07:50 AM\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: 37.3\nC (99.2\n HR: 81 (81 - 105) bpm\n BP: 113/44(68) {76/34(48) - 147/67(98)} mmHg\n RR: 20 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,833 mL\n 167 mL\n PO:\n TF:\n 850 mL\n 43 mL\n IVF:\n 713 mL\n 74 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,833 mL\n 167 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 419 (343 - 449) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 77\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.36/49/126/28/1\n Ve: 6.5 L/min\n PaO2 / FiO2: 315\n Physical Examination\n Cardiovascular: Gen: NAD,\n CV: RRR\n Lungs: CTAB\n Abd: mildly distended, non tender\n Neuro: opens eyes to voice, shakes and nods head in response to\n questions. Squeezes hand. Will not move LE on command.\n Labs / Radiology\n 251 K/uL\n 9.1 g/dL\n 287 mg/dL\n 7.4 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 40 mg/dL\n 102 mEq/L\n 138 mEq/L\n 30.1 %\n 12.7 K/uL\n [image002.jpg]\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n 10:57 PM\n 06:27 AM\n 12:45 PM\n 03:34 AM\n 03:56 AM\n WBC\n 16.5\n 20.4\n 18.1\n 14.8\n 17.4\n 12.7\n Hct\n 33.1\n 35.1\n 29.0\n 32.2\n 31.7\n 30.1\n Plt\n \n Cr\n 8.6\n 5.8\n 6.0\n 6.5\n 5.1\n 5.8\n 7.4\n TropT\n 0.28\n TCO2\n 21\n 29\n 29\n Glucose\n 1\n 152\n 181\n 287\n Other labs: PT / PTT / INR:13.9/28.7/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:44/131, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.6\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.3 mg/dL\n Imaging: Abd U/S: 1. The patient is status post cholecystectomy. No\n biliary dilatation.\n 2. No focal liver lesion.\n 3. Complex right renal cyst and simple right renal cyst. Followup of\n right\n renal cyst recommended in 12 months.\n Microbiology: Sputum - minimal growth of staph aureus\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed restarted yesterday and has required levophed\n off and on, now on. Were concerned for VAP given sputum GS with GPR.\n However no growth.\n - on vancomycin / meropenem (day 4), Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for residual GPCs\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum GS significant for GNR and\n GPC; Barriers to extubation include mental status, fluid overload and\n underlying infection.\n - respiratory failure: SBT today, attempt extubation today\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 5, - Vancomycin Day 5 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters, cultures\n pending.\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n - appears much improved today\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will pull out PICC given fevers, unclear source and send tip for\n cultures\n - repeat RUE u/S: shows same as prior\n - no rush for MRV, renal will require for anatomy for long term HD line\n # ESRD:\n - HD today\n - f/u renal recs\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF, on hol dfor potential extubation, speech\n and swallow pending extubation\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 03:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599548,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599549,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598482,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5, o2 40%. RR\n teens\ns-20\ns with TV ~400cc. Pt suctioned q2-3hrs with saline lavage\n for moderate amounts of thick, rust colored sputum. CXR c/w worsening\n pulmonary edema this morning.\n Action:\n No change in ventilatory status.\n Response:\n Pt not ready for extubation d/t fluid overload and reduced mental\n status.\n Plan:\n Follow lung exam, serial abg\ns, pulmonary toilet.\n Altered mental status (not Delirium)\n Assessment:\n Sedation turned off yesterday at 1030. He is grimacing and down\n during mouth care. He is opening his eyes only when stimulated. He is\n moving his leg laterally on the bed and his left arm off the bed. His\n right arm moves only reflexively to noxious stimulation. No purposeful\n movement noted.\n Action:\n Sedation turned off to assess mental status/neuro exam.\n Response:\n Neither mental status nor motor exam has changed or improved despite\n the sedation having been off for since 1030 yesterday.\n Plan:\n Would continue to hold sedation as long as behavior does not interfere\n with treatments. Continue to monitor neuro/mental status for changes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 160-190\ns. Pt received sliding scale coverage per hiss. Abd\n exam unchanged. He continues to pass moderate amounts of bilious\n drainage from his ogt.\n Action:\n Continue ogt to LIS. Nutrition consult placed for TPN recs.\n Response:\n Unchanged.\n Plan:\n Continue to monitor gastric output. Cover q6hr fs with hiss. Anticipate\n TPN recs from nutrition.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n CRRT initiated @1830 yesterday for worsening uremia and volume\n overload.\n Action:\n CRRT stopped due to excess line pressures. Ports were switched and\n lines tested. Nurse was unable to draw off the blue port, MD made\n aware..\n Response:\n CRRT off.\n Plan:\n Since pt. has been off pressors and SBP has ranged 117-130\ns pt. will\n stay off CRRT and once line is changed or manipulated down in IR pt.\n may have HD, today.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598922,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Hypotension (not Shock)\n Assessment:\n Pt received on levophed at 0.03 mics/hr.\n Action:\n Tried to turned off Levo,but BP dropped down to low 80\ns to high 70\n within 10 minutes. Restartd Levo at 0.01 mics and titrated upto 0.02\n mics.\n Response:\n BP stable. Cont Levo at 0.02 mics.\n Plan:\n Cont pressor support and wean Levo as tolerated.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp Max 100.6,\n Action:\n Pt pan cultured yesterday, given abx as ordered..\n Response:\n Pt current temp is 99.5 axillary.\n Plan:\n Closely monitor temp curve.Cont abx and follow cx data.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt had HD day before yesterday..\n Action:\n BUN and Cr Increasing.\n Response:\n Pt chronically anuric,K is 3.6\n Plan:\n Closely monitor renal function, follow up with renal team. CRRT today?\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on PS 40% 10/5, BLS clear to diminish at the bases.RR in\n 20\ns, SPO2 96-97%.\n Action:\n Suctioned for small amount of clear secretions from ETT,Given abx as\n ordered. Pt moves all extremities except RUE. Does not open eyes,\n Corneal reflex intact, Impaired Gag. Pt grimaces with Care and turning.\n Cont TPN, OGT with Minimal residuals.\n Response:\n No changes made on the vent,ABG this morningis 7.42/37/82.\n Plan:\n Cont pulm toileting,Trend ABG,Cont ABG,follow up with culture.\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599269,
"text": "73M with CAD s/p CABG, DM, ESRD on HD, Afib on coumadin admitted to the\n neurology service after being transferred from for\n further management of a traumatic L SDH sustained 3 days prior to\n admission.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp and fever spike to\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Rehab Services",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Swallowing Consult",
"row_id": 599511,
"text": "TITLE: SWALLOWING CONSULT\nWe received consult for bedside swallowing evaluation. Arrived to\nfloor. Patient remains intubated and is not appropriate for POs.\nPlease reconsult once patient is stable and appropriate following\nextubation and we will be happy to return.\n_______________________________\n , MS, CCC-SLP\nPager #\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 599512,
"text": "Chief Complaint: Respiratory Failure, Subdural hematoma, Septic sjhock\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 Currently getting HD.\n More awake and interactive\n 24 Hour Events:\n ULTRASOUND - At 11:14 AM\n abd CT to search for infection\n PICC LINE - STOP 04:53 PM\n History obtained from Medical records, icu team\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:06 PM\n Meropenem - 09:30 PM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Fosphenytoin - 08:12 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: mechanical ventilation\n Genitourinary: Dialysis\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:15 AM\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: 37.3\nC (99.1\n HR: 85 (81 - 105) bpm\n BP: 105/44(82) {76/34(48) - 147/67(98)} mmHg\n RR: 16 (13 - 32) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,833 mL\n 240 mL\n PO:\n TF:\n 850 mL\n 43 mL\n IVF:\n 713 mL\n 107 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,833 mL\n 240 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 471 (343 - 471) mL\n PS : 10 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 77\n PIP: 6 cmH2O\n SpO2: 95%\n ABG: 7.36/49/126/28/1\n Ve: 10.7 L/min\n PaO2 / FiO2: 315\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n scattered)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.1 g/dL\n 251 K/uL\n 287 mg/dL\n 7.4 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 40 mg/dL\n 102 mEq/L\n 138 mEq/L\n 30.1 %\n 12.7 K/uL\n [image002.jpg]\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n 10:57 PM\n 06:27 AM\n 12:45 PM\n 03:34 AM\n 03:56 AM\n WBC\n 16.5\n 20.4\n 18.1\n 14.8\n 17.4\n 12.7\n Hct\n 33.1\n 35.1\n 29.0\n 32.2\n 31.7\n 30.1\n Plt\n \n Cr\n 8.6\n 5.8\n 6.0\n 6.5\n 5.1\n 5.8\n 7.4\n TropT\n 0.28\n TCO2\n 21\n 29\n 29\n Glucose\n 1\n 152\n 181\n 287\n Other labs: PT / PTT / INR:13.9/28.7/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:44/131, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.6\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently who now has persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Septic shock-\n Fever curve trending down but still with low grade fever. WBC trending\n down. Cont vanc/. Cont to culture with fever spikes. Check stool\n for c.diff. Cont levophed\n 2)Respiratory Failure- SBT after HD session this AM\n 3)Renal Failure- HD today\n 4)Sub-Dural Hematoma/Altered Mental Status- Mental status continues to\n improve\n 5)Seizure Disorder-\n -Neurontin\n -Dilantin\n 6)PICC line clot: PICC now pulled. Follow up PICC culture. Will hold\n off on MRI without contrast - will need to get done at some point.\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 03:10 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 598435,
"text": "Chief Complaint: 73 yoM admitted with left SDH c/b seizure, on HD w/o\n residual UOP, and possible line infection on gent/vanco. Being\n transferred for respiratory distress, hypotension & hypoxia.\n 24 Hour Events:\n SPUTUM CULTURE - At 12:00 PM\n culture repeated\n ANGIOGRAPHY - At 03:00 PM\n temporary dialysis line placement.\n DIALYSIS CATHETER - START 04:10 PM\n sideport\n -Renal: tunneled line okay, check vanco trough daily, if trough between\n 15-20 give 500mg IV Vanco, if < 15 give 1gm.\n -lipase mildly elevated, AST, alk phos very mildly elevated; holding\n off on RUQ US\n -prelim read of KUB does not show any obstruction\n - sputum cultures - positive for GNR and G+ Cocci in Pairs\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 01:06 PM\n Vancomycin - 02:11 PM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 0.5 mg/hour\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:05 AM\n Midazolam (Versed) - 03:35 PM\n Fentanyl - 03:36 PM\n Fosphenytoin - 12:05 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 07:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.9\nC (98.4\n HR: 80 (77 - 89) bpm\n BP: 108/42(56) {86/22(39) - 128/87(91)} mmHg\n RR: 19 (14 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,028 mL\n 71 mL\n PO:\n TF:\n IVF:\n 983 mL\n 71 mL\n Blood products:\n Total out:\n 450 mL\n 950 mL\n Urine:\n NG:\n 450 mL\n 950 mL\n Stool:\n Drains:\n Balance:\n 578 mL\n -879 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 602 (402 - 602) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: ///23/\n Ve: 10 L/min\n Physical Examination\n Cardiovascular: Gen: NAD, intubated, sedated\n CV: RRR, no r/g/m\n Lungs: CTAB\n Abd: soft, distended, less tense, + BS\n Ext: trace edema, 2+ DP, sacral 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 317 K/uL\n 11.2 g/dL\n 175 mg/dL\n 12.1 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 62 mg/dL\n 100 mEq/L\n 137 mEq/L\n 35.3 %\n 13.4 K/uL\n [image002.jpg]\n 01:04 PM\n 04:15 AM\n 02:49 AM\n 03:17 AM\n 10:02 PM\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n WBC\n 14.0\n 13.3\n 11.7\n 14.7\n 13.4\n Hct\n 37.8\n 40.3\n 38.8\n 38.5\n 35.3\n Plt\n 174\n 193\n 254\n 269\n 317\n Cr\n 11.9\n 12.9\n 8.2\n 10.4\n 11.4\n 12.1\n TropT\n 0.35\n TCO2\n 25\n 22\n 23\n Glucose\n 164\n 94\n \n 175\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:9.0 mg/dL, Mg++:2.5\n mg/dL, PO4:3.7 mg/dL\n Imaging: CXR -\n Microbiology: All blood cultures negative to date.\n Sputum Culture - positive for GNR and G+ Cocci in Pairs\n Assessment and Plan\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yoM admitted with left SDH c/b seizure, on HD w/o residual UOP, and\n possible line infection on gent/vanco. Being transferred for\n respiratory distress, hypotension & hypoxia.\n (#) RESPIRATORY DISTRESS: pt has been intubated for respiratory\n distress; likely some element of volume overload given anuric state &\n IVF boluses given for hypotension. There is some question as to\n whether he also had an aspiration event given his poor mental status.\n He may have also has a PE given he is not currently anticoagulated,\n unable to tolerate CTA, ? intervention possible if bleed.\n -- patient intubated for respiratory distress; appears to be\n oxygenating well now.\n -- volume overload - w/out HD yesterday, negative since ICU\n admission, but has been receiving IVF boluses prior and again this AM,\n pending possible dialysis today\n -- PNA - Gram stain with GNR and G+ Cocci in pairs , cultures\n pending. On Vanco and Cefepime. (Had been on Vanco and Gent since\n , changed to Vanc/Cefepime on ). He will need daily Vanco and\n Gent troughs for dosing.\n -- f/u sputum culture\n -- d/c versed/fentanyl for sedation\n (#) HYPOTENSION, FEVERS: has been problem throughout\n this admission; Sepsis high on differential from pneumonia. He has\n been treated for line infection since for fever. Central\n hypotension also possible given recent SDH. Continues to be on\n levophed, despite trying to wean. He responds only briefly to fluids.\n Other concern is lack of good measurement. Currently obtaining calf\n pressure, questionable accuracy. Has PICC in one arm, for periods.\n Episodes seem to be transient. Does have known CAD & CHF, though no\n echo in system.\n -- cont vanco/cefepime\n -- f/u blood cultures, sputum cultures\n -- wean levo as tolerated\n -- volume challenge this AM\n (#) High bilious output via NG tube - ? ilius vs SBO. Also concerned\n for inflammatory process in the abdomen. 950cc out over 25 hrs, half\n the amount yesterday. KUB benign, and pt had BM yesterday. Liver\n enzymes unimpressive.\n - improving, continue to follow.\n - recheck liver enzymes for trend\n - guaic pos aspirate, PPI\n (#) ESRD, HD: had a temp line he was supposed to have a tunneled line\n on ; volume overloaded, but about .5 L positive since ICU due to NG\n output.\n -- cont vanco/cefepime\n -- CVVH vs dialysis today\n (#) AFib: rate controlled now; seems to be in sinus rhyhm; not on\n coumadin currently with recent SDH.\n -- cont to follow\n -- not on rate meds currently\n (#) Seizure: no evidence of seziure activity now while in the ICU\n -- cont fosphenytoin\n (#) SDH:\n - - touch base with neurology regarding prognosis\n -- neurology following\n -- holding anticoagulation now, including SQH\n (#) h/o glaucoma, cataracts:\n -- cont home meds\n .\n (#) ASTHMA: does not appear to be acive as no wheezing on exam & pt\n doesn't appear super tight, thoguh may be contributing.\n -- will place on standing inhalers overnight; consider decreasing to\n PRN in am\n (#) DM:\n -- cont SSI + lantus 20/10, blood sugars increasing in setting of\n infection. will tighten sliding scale rather than basal\n (#) ACCESS: double lumen PICC on right; no HD catheter currently\n (#) Nutrition: NPO currently; no IVF maintenance given c/f volume\n overload\n (#) PPX: pneumoboots (no SQH with recent SDH); on PPI; bowel reg\n (#) CODE: full; confirmed with wife on admission via phone\n (#) DISPO: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 598708,
"text": "Chief Complaint: Altered Mental Status\n SDH\n Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n patient with non-occlusive thrombus noted in upper extremity and PICC\n line pulled.\n HD--2 liters negative completed without incident\n Sedation off and patient with persistent decrease in mental status.\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:11 PM\n Cefipime - 03:14 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 02:00 PM\n Fentanyl - 02:45 PM\n Pantoprazole (Protonix) - 08:17 PM\n Fosphenytoin - 08:26 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 10:50 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: 100 (80 - 100) bpm\n BP: 89/41(57) {84/31(47) - 151/62(95)} mmHg\n RR: 18 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 290 mL\n 204 mL\n PO:\n TF:\n IVF:\n 290 mL\n 154 mL\n Blood products:\n Total out:\n 2,600 mL\n 0 mL\n Urine:\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -2,310 mL\n 204 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 448 (331 - 448) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 89\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.36/41/118/23/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 295\n Physical Examination\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), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed, Minimal Grimace\nhe will withdraw lower extremities to\n simulation. Very decreased pain sensation.\n Labs / Radiology\n 10.2 g/dL\n 322 K/uL\n 172 mg/dL\n 7.9 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 32 mg/dL\n 102 mEq/L\n 142 mEq/L\n 33.5 %\n 11.2 K/uL\n [image002.jpg]\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n WBC\n 14.7\n 13.4\n 11.9\n 11.2\n Hct\n 38.5\n 35.3\n 33.7\n 32.8\n 33.5\n Plt\n 22\n Cr\n 10.4\n 11.4\n 12.1\n 12.6\n 12.5\n 7.9\n TCO2\n 23\n 23\n 17\n 24\n Glucose\n 178\n 222\n 175\n 177\n 180\n 172\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:2.8 mg/dL\n Imaging: CXR-no new\n Microbiology: Blood Cultures--negative\n Sputum--1+ GPC, 2+ GNR and growth of sparse GPC--from \n Assessment and Plan\n 73 yo male with h/o Chronic Renal Failure and now has SDH complicated\n by seizure, altered mental status and now with fevers and concern for\n sepsis and now with patient showing persistent and concerning\n alteration in mental status even with sedation discontinued.\n 1)Respiratory Failure-Patient with persistent volume overload and\n concern for pneumonia at this time. In the setting of persistent\n alteration of mental status will need to continue invasive support.\n -Continue with broad antibiotic support\n -Suction as needed\n -Wean in PSV mode going forward\n 2)Altered Mental Status-In setting of Sub-Dural Hematoma, seizure and\n signficant toxic/metabolic insult but with very slow to improve\n responsiveness with sedation discontinued\n -Dliantin\n -Hold sedation\n -Follow exam\n -EEG and repeat head imaging if not able to see trend to improved\n alertness\n 3)Pneumonia-\n -Cefepime/Vanco to continue\n -High stool output to be followed\nwe see suggestion of ileus and\n continued drainge leading to decompression\n 4)Renal Failure-\n _Continue with HD\n -Will continue to maintain negative fluid balance.\n ICU Care\n Nutrition: npo\nwill need TPN to be considered\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:07 AM\nwill pull PICC with thrombus seen\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598914,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Also has h/o iddm and afib,\n not on coumadin due to recent SDH.\n Pt had USG to rt arm on ( Rt arm swollen) which shows non-occluding\n thrombus, PICC line remains in place and is being used, team aware.\n Hypotension (not Shock)\n Assessment:\n Pt received on levophed at 0.03 mics/hr.\n Action:\n Tried to turned off Levo,bue BP dropped down to low 80\ns to high 70\n within 10 minutes. Restartd Levo at 0.01 mics and titrated upto 0.02\n mics.\n Response:\n BP stable. Cont Levo at 0.02 mics.\n Plan:\n Cont pressor support, tx infex / sepsis w/ ABX, follow cx data.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp Max 100.6,\n Action:\n Pt pan cultured yesterday, given abx as ordered..\n Response:\n Pt current temp is 99.5 axillary.\n Plan:\n Closely monitor temp curve.Cont abx and follow cx data.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt had HD day before yesterday..\n Action:\n BUN and Cr Increasing.\n Response:\n Pt chronically anuric,K is 3.6\n Plan:\n Closely monitor renal function, follow up with renal team. CRRT today?\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on PS 40% 10/5, BLS clear to diminish at the bases.RR in\n 20\ns, SPO2 96-97%.\n Action:\n Suctioned for small amount of clear secretions from ETT,Given abx as\n ordered. Pt moves all extremities except RUE., Does not open eyes,\n Corneal reflex intact, Impaired Gag. Pt grimaces with Care and turning.\n Cont TPN,OGT with Minimal residuals.\n Response:\n No changes made on the vent,ABG this morningis 7.42/37/82.\n Plan:\n Cont pulm toileting,Trend ABG,Cont ABG,follow up with culture.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599259,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.1\nF - 04:00 PM\n -CVVH filter clotted for unclear reasons; re-ordered repeat Rt upper\n extremity US (initially had clot in PICC on rt) to ensure no further\n extension however by evening still not done/no read on it\n -pressures in the AM initially low in the 80s; has not required\n levophed however as pressures rose spontaneously to 110s - 120s\n -tolerating tube feeds with normal residuals/ no biliary output\n anylonger\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 08:00 AM\n Gentamicin - 08:45 PM\n Vancomycin - 04:06 PM\n Meropenem - 08:23 PM\n Infusions:\n Norepinephrine - 0.06 mcg/Kg/min\n Insulin - Regular - 5 units/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 07:49 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 07:57 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: 37.4\nC (99.4\n HR: 93 (88 - 106) bpm\n BP: 137/48(82) {89/34(52) - 142/57(295)} mmHg\n RR: 21 (20 - 60) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,641 mL\n 649 mL\n PO:\n 60 mL\n TF:\n 793 mL\n 307 mL\n IVF:\n 1,538 mL\n 242 mL\n Blood products:\n Total out:\n 762 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,879 mL\n 649 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 361 (361 - 458) mL\n PS : 10 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n : 102\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///22/\n Ve: 9.8 L/min\n Physical Examination\n Cardiovascular: Gen: sedated, will open eyes to touch.\n CV: RRR\n Lungs: CTAB\n Abd: distended ABS\n Ext: no c/c/e\n Neuro: does not respond to command\n Peripheral 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 231 K/uL\n 9.3 g/dL\n 81 mg/dL\n 6.5 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 30 mg/dL\n 108 mEq/L\n 140 mEq/L\n 29.0 %\n 18.1 K/uL\n [image002.jpg]\n 02:44 AM\n 06:10 AM\n 03:21 AM\n 03:44 AM\n 02:14 PM\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n WBC\n 14.3\n 16.5\n 20.4\n 18.1\n Hct\n 32.8\n 33.1\n 35.1\n 29.0\n Plt\n 31\n Cr\n 8.0\n 8.6\n 5.8\n 6.0\n 6.5\n TCO2\n 18\n 17\n 22\n 21\n 21\n Glucose\n 392\n 504\n 301\n 233\n 81\n Other labs: PT / PTT / INR:15.1/30.6/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:28/54, Alk Phos / T Bili:176/0.8,\n Amylase / Lipase:55/88, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL, LDH:240 IU/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:2.1\n mg/dL\n Imaging: CXR - Mild congestive failure. There are small bilateral\n pleural effusions\n and mild bibasilar atelectasis.\n Microbiology: Sputum - MRSA - sparse growth\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: New fever overnight. Pt was pan\n cultured. Hypotension as also noted and pt was restarted on levophed\n yesterday and has required levophed off and on. Were concerned for VAP\n given sputum GS with GPR. However no growth.\n - on vancomycin / meropenem, Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for residual GPCs\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - is there an infection somewhere else? - line infection, sinusitis,\n intrabdominal process --> liver enzymes, amylase/lipase\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum GS significant for GNR and\n GPC; Barriers to intubation include mental status, fluid overload and\n underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 3, - Vancomycin Day 3 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters.\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # ESRD:\n - CVVH filter clotted\n - trial of HD today\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will not pull out PICC as non-occlusive\n - repeat RUE u/S\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:47 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599343,
"text": "Chief Complaint:\n 24 Hour Events:\n - RUQ u/s - Prelim read - Stable appearance since with non\n occlusive thrombus in nid axillary vein.\n - HD after CVVH filter clotted\n - Trial of PSV to 5, but was tachypneic.\n - Spiking fevers 101.3 at 4pm , again at 8pm\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:06 PM\n Meropenem - 09:30 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:30 PM\n Fosphenytoin - 12:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 109) bpm\n BP: 114/47(71) {84/40(56) - 151/61(94)} mmHg\n RR: 27 (15 - 33) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,154 mL\n 558 mL\n PO:\n TF:\n 970 mL\n 165 mL\n IVF:\n 864 mL\n 333 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,154 mL\n 558 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 302 (302 - 540) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n : 64\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///27/\n Ve: 10.2 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 256 K/uL\n 10.2 g/dL\n 152 mg/dL\n 5.1 mg/dL\n 27 mEq/L\n 3.2 mEq/L\n 22 mg/dL\n 105 mEq/L\n 141 mEq/L\n 32.2 %\n 14.8 K/uL\n [image002.jpg]\n 06:10 AM\n 03:21 AM\n 03:44 AM\n 02:14 PM\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n 10:57 PM\n WBC\n 14.3\n 16.5\n 20.4\n 18.1\n 14.8\n Hct\n 32.8\n 33.1\n 35.1\n 29.0\n 32.2\n Plt\n 31\n 256\n Cr\n 8.0\n 8.6\n 5.8\n 6.0\n 6.5\n 5.1\n TropT\n 0.28\n TCO2\n 17\n 22\n 21\n 21\n Glucose\n 392\n 504\n 301\n 233\n 81\n 152\n Other labs: PT / PTT / INR:15.1/30.6/1.3, CK / CKMB /\n Troponin-T:86/2/0.28, ALT / AST:29/75, Alk Phos / T Bili:190/0.4,\n Amylase / Lipase:44/123, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL, LDH:266 IU/L, Ca++:8.5 mg/dL, Mg++:1.8 mg/dL, PO4:1.7\n mg/dL\n Imaging: RUQ u/s - Prelim read - Stable appearance since with non\n occlusive thrombus in nid axillary vein.\n CXR -\n Microbiology: SPUTUM:\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND\n CLUSTERS.\n BLOOD CX:\n Pending\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed restarted yesterday and has required levophed\n off and on, now on. Were concerned for VAP given sputum GS with GPR.\n However no growth.\n - on vancomycin / meropenem, Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for residual GPCs\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - is there an infection somewhere else? - line infection, sinusitis,\n intrabdominal process --> liver enzymes, amylase/lipase?\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum GS significant for GNR and\n GPC; Barriers to extubation include mental status, fluid overload and\n underlying infection.\n - respiratory failure: continue PSV with daily , attempt to\n wean once HD re-initiated\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 4, - Vancomycin Day 4 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters, cultures\n pending.\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will not pull out PICC as non-occlusive\n - repeat RUE u/S: shows same as prior\n # ESRD:\n - HD successful yesterday\n - f/u renal recs re continued HD\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: continue SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated; may attempt extubation s/p\n HD\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:24 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 599364,
"text": "Chief Complaint: Subdural hematoma, Respiratory Failure, 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 Tolerated HD yesterday\n Did not tolerate PSV due to tachypnea yesterday\n 24 Hour Events:\n ULTRASOUND - At 02:00 PM\n RUE US to eval known semi-occlusive thrombis\n FEVER - 101.3\nF - 04:00 PM\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:06 PM\n Meropenem - 09:30 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Insulin - Regular - 2 units/hour\n Other ICU medications:\n Fosphenytoin - 08:00 AM\n Pantoprazole (Protonix) - 08:48 AM\n Other medications:\n per ICU resdient note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: Tachycardia\n Nutritional Support: Tube feeds\n Respiratory: mechanical ventilation\n Genitourinary: Dialysis\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.5\nC (101.3\n Tcurrent: 37.4\nC (99.4\n HR: 105 (86 - 109) bpm\n BP: 118/44(73) {84/41(56) - 143/61(90)} mmHg\n RR: 15 (15 - 32) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,154 mL\n 824 mL\n PO:\n TF:\n 970 mL\n 289 mL\n IVF:\n 864 mL\n 415 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,154 mL\n 824 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 402 (302 - 540) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 64\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: ///28/\n Ve: 9.7 L/min\n Physical Examination\n General Appearance: No acute distress\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 Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, more attentive\n today and tracking\n Labs / Radiology\n 9.9 g/dL\n 236 K/uL\n 181 mg/dL\n 5.8 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 103 mEq/L\n 141 mEq/L\n 31.7 %\n 17.4 K/uL\n [image002.jpg]\n 03:21 AM\n 03:44 AM\n 02:14 PM\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n 10:57 PM\n 06:27 AM\n WBC\n 14.3\n 16.5\n 20.4\n 18.1\n 14.8\n 17.4\n Hct\n 32.8\n 33.1\n 35.1\n 29.0\n 32.2\n 31.7\n Plt\n \n Cr\n 8.0\n 8.6\n 5.8\n 6.0\n 6.5\n 5.1\n 5.8\n TropT\n 0.28\n TCO2\n 22\n 21\n 21\n Glucose\n 392\n 504\n 301\n 233\n 81\n 152\n 181\n Other labs: PT / PTT / INR:13.9/28.7/1.2, CK / CKMB /\n Troponin-T:90/2/0.28, ALT / AST:29/75, Alk Phos / T Bili:190/0.4,\n Amylase / Lipase:44/123, Differential-Neuts:77.0 %, Band:2.0 %,\n Lymph:4.0 %, Mono:12.0 %, Eos:3.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.6 g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:2.2\n mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently who now has persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Sepsis-\n Cont vanc/ - still spiking temps and has elevated WBC. No new\n culture data. Continues on pressors. Will get RUQ ultrasound. Will\n pull PICC line\n 2)Respiratory Failure- Currently on PSV - will aim for one more HD\n session and try to move toward extubation.\n 3)Renal Failure- further HD per renal\n 4)Sub-Dural Hematoma/Altered Mental Status- Mental status improving\n 5)Seizure Disorder-\n -Neurontin\n -Dilantin\n 6)PICC line clot: Stable by prelim read of RUE u/s. Planning to pull\n PICC\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:24 AM 40 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599623,
"text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 10:43 AM\n c. diff\n INVASIVE VENTILATION - STOP 04:33 PM\n INVASIVE VENTILATION - START 10:20 PM\n - readjusted sliding scale (cut in half) b/c now NPO after OG tube\n removed following extubation; continued on 40 of lantus standing\n -extubated post HD; was respirating on shovel mask at 35 - 40 / min,\n abdominal breathing persistent, tiring out, respiratory distress, was\n reintubated and repeat ABG was: 124* 58* 7.35\n -Neuro suggested starting EEG given tremors; checking daily dilantin\n levels starting tomorrow AM; also they suggested can repeat head CT for\n prognostic purposes especially if worsening MS\n status continues to fluctuate: stopped gabapentin as this can\n accumulate w/ renal failure (was taking for neuropathic pain) and\n checked Vit B12, folate, TSH\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:37 PM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Dextrose 50% - 09:40 PM\n Fosphenytoin - 12:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.5\nC (99.5\n HR: 84 (81 - 100) bpm\n BP: 128/49(77) {86/37(53) - 162/64(101)} mmHg\n RR: 22 (12 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 545 mL\n 239 mL\n PO:\n TF:\n 43 mL\n 48 mL\n IVF:\n 363 mL\n 71 mL\n Blood products:\n Total out:\n 2,400 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,855 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (400 - 450) mL\n Vt (Spontaneous): 486 (471 - 486) 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: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.43/47/98./31/5\n Ve: 9.2 L/min\n PaO2 / FiO2: 196\n Physical Examination\n Cardiovascular: Gen: NAD, intubated, sedated\n CV: RRR. Nl S1 and S2\n Lungs: CTAB\n Abd: soft ND NT ABS\n Ext: no c/c/e\n Peripheral 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 185 K/uL\n 9.3 g/dL\n 77 mg/dL\n 6.0 mg/dL\n 31 mEq/L\n 3.2 mEq/L\n 25 mg/dL\n 104 mEq/L\n 141 mEq/L\n 29.4 %\n 10.4 K/uL\n [image002.jpg]\n 03:56 AM\n 02:20 PM\n 05:59 PM\n 09:34 PM\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n WBC\n 10.4\n Hct\n 29.8\n 29.4\n Plt\n 185\n Cr\n 6.0\n TCO2\n 29\n 34\n 33\n 32\n Glucose\n 50\n 147\n 95\n 88\n 88\n 75\n 77\n Other labs: Amylase / Lipase:41/64, Albumin:2.5 g/dL, Ca++:8.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Fluid analysis / Other labs: Phenytoin = 2.6\n Imaging: CXR - low lung volumes, appears well\n Microbiology: Sputum - - STAPH AUREUS COAG +.\n Sputum GS - Gram positve cocci in pairs and clusters\n Catheter tip - no significant growth\n Cdiff - negative\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed on and off for labile BP.\n - on vancomycin / meropenem (day 6), Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for minimal Staph aureus\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - ? central etiology of fever/autonomic dysfunction such as seizure\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum positive for minimal Staph\n aureus. CXR cleared, mental status improved. Attempted trial of\n extubation. Pt failed and is reintubated. Per his lack of\n significant growth in sputum, appears more euvolemic on exam (despite\n 3.5 L + LOS), and clarity of chest Xray, would not expect pt to have\n this degree of respiratory failure. Pt may not be strong enough to\n ventilate on his own.\n - respiratory failure: pt likely will require trach, and long term\n ventilation\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 6, - Vancomycin Day 6 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters, cultures\n pending.\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n - appears much improved today\n - Vit B12, folate, TSH all normal\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n - f/u EEG\n - most recent CT scan showed stabilization of SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will pull out PICC given fevers, unclear source and send tip for\n cultures\n - repeat RUE u/S: shows same as prior\n - will need to do MRV eventually\n # ESRD:\n - HD line clotted again yesterday. Address placement of a new line.\n - need MRV first, will d/w Renal\n - f/u renal recs\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF, on hold for potential extubation, speech\n and swallow pending extubation\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 12:25 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599624,
"text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 10:43 AM\n c. diff\n INVASIVE VENTILATION - STOP 04:33 PM\n INVASIVE VENTILATION - START 10:20 PM\n - readjusted sliding scale (cut in half) b/c now NPO after OG tube\n removed following extubation; continued on 40 of lantus standing\n -extubated post HD; was respirating on shovel mask at 35 - 40 / min,\n abdominal breathing persistent, tiring out, respiratory distress, was\n reintubated and repeat ABG was: 124* 58* 7.35\n -Neuro suggested starting EEG given tremors; checking daily dilantin\n levels starting tomorrow AM; also they suggested can repeat head CT for\n prognostic purposes especially if worsening MS\n status continues to fluctuate: stopped gabapentin as this can\n accumulate w/ renal failure (was taking for neuropathic pain) and\n checked Vit B12, folate, TSH\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:37 PM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Dextrose 50% - 09:40 PM\n Fosphenytoin - 12:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.5\nC (99.5\n HR: 84 (81 - 100) bpm\n BP: 128/49(77) {86/37(53) - 162/64(101)} mmHg\n RR: 22 (12 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 545 mL\n 239 mL\n PO:\n TF:\n 43 mL\n 48 mL\n IVF:\n 363 mL\n 71 mL\n Blood products:\n Total out:\n 2,400 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,855 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (400 - 450) mL\n Vt (Spontaneous): 486 (471 - 486) 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: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.43/47/98./31/5\n Ve: 9.2 L/min\n PaO2 / FiO2: 196\n Physical Examination\n Cardiovascular: Gen: NAD, intubated, sedated\n CV: RRR. Nl S1 and S2\n Lungs: CTAB\n Abd: soft ND NT ABS\n Ext: no c/c/e\n Peripheral 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 185 K/uL\n 9.3 g/dL\n 77 mg/dL\n 6.0 mg/dL\n 31 mEq/L\n 3.2 mEq/L\n 25 mg/dL\n 104 mEq/L\n 141 mEq/L\n 29.4 %\n 10.4 K/uL\n [image002.jpg]\n 03:56 AM\n 02:20 PM\n 05:59 PM\n 09:34 PM\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n WBC\n 10.4\n Hct\n 29.8\n 29.4\n Plt\n 185\n Cr\n 6.0\n TCO2\n 29\n 34\n 33\n 32\n Glucose\n 50\n 147\n 95\n 88\n 88\n 75\n 77\n Other labs: Amylase / Lipase:41/64, Albumin:2.5 g/dL, Ca++:8.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Fluid analysis / Other labs: Phenytoin = 2.6\n Imaging: CXR - low lung volumes, appears well\n Microbiology: Sputum - - STAPH AUREUS COAG +.\n Sputum GS - Gram positve cocci in pairs and clusters\n Catheter tip - no significant growth\n Cdiff - negative\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed on and off for labile BP.\n - on vancomycin / meropenem (day 6), Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for minimal Staph aureus\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n - ? central etiology of fever/autonomic dysfunction such as seizure\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum positive for minimal Staph\n aureus. CXR cleared, mental status improved. Attempted trial of\n extubation. Pt failed and is reintubated. Per his lack of\n significant growth in sputum, appears more euvolemic on exam (despite\n 3.5 L + LOS), and clarity of chest Xray, would not expect pt to have\n this degree of respiratory failure. Pt may not be strong enough to\n ventilate on his own.\n - respiratory failure: pt likely will require trach, and long term\n ventilation\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 6, - Vancomycin Day 6 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters, cultures\n pending.\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n - appears much improved today\n - Vit B12, folate, TSH all normal\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n - f/u EEG\n - most recent CT scan showed stabilization of SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will pull out PICC given fevers, unclear source and send tip for\n cultures\n - repeat RUE u/S: shows same as prior\n - will need to do MRV eventually\n # ESRD:\n - HD line clotted again yesterday. Address placement of a new line.\n - need MRV first, will d/w Renal\n - f/u renal recs\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # R renal cyst\n one complex cyst and one simple cyst on right kidney.\n Radiology rec 12 month follow up.\n - possible malignancy\n - possible abscess seems unlikely\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF, on hold for potential extubation, speech\n and swallow pending extubation\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 12:25 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2191-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 598477,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5, o2 40%. RR\n teens\ns-20\ns with TV ~400cc. Pt suctioned q3-4hrs with saline lavage\n for moderate amounts of thick, rust colored sputum. CXR c/w worsening\n pulmonary edema this morning.\n Action:\n No change in ventilatory status.\n Response:\n Pt not ready for extubation d/t fluid overload and reduced mental\n status.\n Plan:\n Follow lung exam, serial abg\ns, pulmonary toilet.\n Altered mental status (not Delirium)\n Assessment:\n Sedation turned off for\nwake up\n earlier this morning. He is grimacing\n and down during mouth care. He is opening his eyes only when\n stimulated. He is moving his legs laterally on the bed and his left arm\n off the bed. His right arm moves only reflexively to noxious\n stimulation. No purposeful movement noted.\n Action:\n Sedation turned off to assess mental status/neuro exam.\n Response:\n Neither mental status nor motor exam has changed or improved despite\n the sedation having been off for several hours now.\n Plan:\n Would continue to hold sedation as long as behavior does not interfere\n with treatments. Continue to monitor neuro/mental status for changes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 170-190\ns. Pt received sliding scale coverage per hiss. Abd\n exam unchanged. He continues to pass moderate amounts of\n bilious/coffee grounds drainage from his ogt.\n Action:\n Continue ogt to LIS. Nutrition consult placed for TPN recs.\n Response:\n Unchanged.\n Plan:\n Continue to monitor gastric output. Cover q6hr fs with hiss. Anticipate\n TPN recs from nutrition.\n Hypotension (not Shock)\n Assessment:\n A right axillary arterial line was placed this morning and found to be\n significantly higher than the noninvasive.\n Action:\n Low dose levophed drip turned off ~1300.\n Response:\n ABP continues to improve as the day has progressed.\n Plan:\n Follow hemodynamic status closely; restart levophed drip if necessary.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n CRRT initiated @1830 for worsening uremia and volume overload.\n Action:\n Although initially there was good blood return from both of the\n dialysis line ports, the blue port continues to flush well but unable\n to draw blood: dialysis lines reversed.\n Response:\n CRRT system running at the present time although access and filter\n pressures are rising.\n Plan:\n Con\nt CRRT overnoc with the goal of removing 150cc from pt hourly.\n ?transition to dialysis in the am if blood pressure continues to\n improve.\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 598704,
"text": "Chief Complaint: Altered Mental Status\n SDH\n Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n patient with non-occlusive thrombus noted in upper extremity and PICC\n line pulled.\n HD--2 liters negative completed without incident\n Sedation off and patient with persistent decrease in mental status.\n History obtained from Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 02:11 PM\n Cefipime - 03:14 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 02:00 PM\n Fentanyl - 02:45 PM\n Pantoprazole (Protonix) - 08:17 PM\n Fosphenytoin - 08:26 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 10:50 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: 100 (80 - 100) bpm\n BP: 89/41(57) {84/31(47) - 151/62(95)} mmHg\n RR: 18 (12 - 36) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 91.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 290 mL\n 204 mL\n PO:\n TF:\n IVF:\n 290 mL\n 154 mL\n Blood products:\n Total out:\n 2,600 mL\n 0 mL\n Urine:\n NG:\n 600 mL\n Stool:\n Drains:\n Balance:\n -2,310 mL\n 204 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 448 (331 - 448) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 89\n PIP: 16 cmH2O\n SpO2: 95%\n ABG: 7.36/41/118/23/-1\n Ve: 10.6 L/min\n PaO2 / FiO2: 295\n Physical Examination\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), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed, Tone:\n Not assessed, Minimal Grimace\n Labs / Radiology\n 10.2 g/dL\n 322 K/uL\n 172 mg/dL\n 7.9 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 32 mg/dL\n 102 mEq/L\n 142 mEq/L\n 33.5 %\n 11.2 K/uL\n [image002.jpg]\n 04:12 AM\n 05:04 AM\n 04:34 PM\n 02:53 AM\n 02:26 PM\n 02:28 PM\n 04:51 AM\n 05:04 AM\n 03:35 AM\n 04:35 AM\n WBC\n 14.7\n 13.4\n 11.9\n 11.2\n Hct\n 38.5\n 35.3\n 33.7\n 32.8\n 33.5\n Plt\n 22\n Cr\n 10.4\n 11.4\n 12.1\n 12.6\n 12.5\n 7.9\n TCO2\n 23\n 23\n 17\n 24\n Glucose\n 178\n 222\n 175\n 177\n 180\n 172\n Other labs: PT / PTT / INR:14.8/28.2/1.3, CK / CKMB /\n Troponin-T:147/4/0.35, ALT / AST:16/52, Alk Phos / T Bili:122/1.0,\n Amylase / Lipase:55/88, Differential-Neuts:83.3 %, Lymph:8.0 %,\n Mono:5.6 %, Eos:2.8 %, Lactic Acid:1.0 mmol/L, Ca++:8.1 mg/dL, Mg++:1.8\n mg/dL, PO4:2.8 mg/dL\n Imaging: CXR-no new\n Microbiology: Blood Cultures--negative\n Sputum--1+ GPC, 2+ GNR and growth of sparse GPC--from \n Assessment and Plan\n 73 yo male with h/o Chronic Renal Failure and now has SDH complicated\n by seizure, altered mental status and now with fevers and concern for\n sepsis and now with patient showing persistent and concerning\n alteration in mental status even with sedation discontinued.\n 1)Respiratory Failure-Patient with persistent\n 2)Altered Mental Status-In setting of Sub-Dural Hematoma, seizure and\n signficant toxic/metabolic insult but with very slow to improve\n responsiveness with sedation discontinued\n -Dliantin\n 3)\n -Cefepime/Vanco\n ALTERATION IN NUTRITION\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPERTENSION, BENIGN\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:07 AM\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-08-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599176,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 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: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved;\n Comments: Pt had no acute issues this shift, with moderate secretions,\n stable vital signs and RR within normal range. Pt has RSBI trial which\n showed good tidal volumes, but RR was elevated to 25-30 bpm range. Pt\n was given albuterol at appropriate times. Pt to continue current\n support\n BEDSIDE RSBI- 102\n"
},
{
"category": "Physician ",
"chartdate": "2191-08-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599493,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:14 AM\n abd CT to search for infection\n PICC LINE - STOP 04:53 PM\n - Renal recs: concern for SVC syndrome given UE>LE edema, recommend\n MRV, however, not urgent because it won't change management\n - PICC pulled, catheter tip sent for cultures\n - Abdominal u/s done, pending.\n - HD tomorrow, none today\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 04:06 PM\n Meropenem - 09:30 PM\n Infusions:\n Norepinephrine - 0.02 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:48 AM\n Fosphenytoin - 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 07:50 AM\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: 37.3\nC (99.2\n HR: 81 (81 - 105) bpm\n BP: 113/44(68) {76/34(48) - 147/67(98)} mmHg\n RR: 20 (15 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,833 mL\n 167 mL\n PO:\n TF:\n 850 mL\n 43 mL\n IVF:\n 713 mL\n 74 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,833 mL\n 167 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 419 (343 - 449) mL\n PS : 10 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 77\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: 7.36/49/126/28/1\n Ve: 6.5 L/min\n PaO2 / FiO2: 315\n Physical Examination\n Cardiovascular: Gen: NAD,\n CV: RRR\n Lungs: CTAB\n Abd: mildly distended, non tender\n Neuro: opens eyes to voice, shakes and nods head in response to\n questions. Squeezes hand. Will not move LE on command.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 251 K/uL\n 9.1 g/dL\n 287 mg/dL\n 7.4 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 40 mg/dL\n 102 mEq/L\n 138 mEq/L\n 30.1 %\n 12.7 K/uL\n [image002.jpg]\n 02:15 PM\n 08:28 PM\n 01:43 AM\n 07:04 PM\n 01:42 AM\n 10:57 PM\n 06:27 AM\n 12:45 PM\n 03:34 AM\n 03:56 AM\n WBC\n 16.5\n 20.4\n 18.1\n 14.8\n 17.4\n 12.7\n Hct\n 33.1\n 35.1\n 29.0\n 32.2\n 31.7\n 30.1\n Plt\n \n Cr\n 8.6\n 5.8\n 6.0\n 6.5\n 5.1\n 5.8\n 7.4\n TropT\n 0.28\n TCO2\n 21\n 29\n 29\n Glucose\n 1\n 152\n 181\n 287\n Other labs: PT / PTT / INR:13.9/28.7/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:44/131, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.6\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:2.3 mg/dL\n Imaging: Abd U/S: 1. The patient is status post cholecystectomy. No\n biliary dilatation.\n 2. No focal liver lesion.\n 3. Complex right renal cyst and simple right renal cyst. Followup of\n right\n renal cyst recommended in 12 months.\n Microbiology: Sputum - minimal growth of staph aureus\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed restarted yesterday and has required levophed\n off and on, now on. Were concerned for VAP given sputum GS with GPR.\n However no growth.\n - on vancomycin / meropenem (day 4), Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for residual GPCs\n - CXR\n - continue levophed for hypotension, avoid aggressive volume\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum GS significant for GNR and\n GPC; Barriers to extubation include mental status, fluid overload and\n underlying infection.\n - respiratory failure: SBT today, attempt extubation today\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 4, - Vancomycin Day 4 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters, cultures\n pending.\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n - appears much improved today\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will pull out PICC given fevers, unclear source and send tip for\n cultures\n - repeat RUE u/S: shows same as prior\n # ESRD:\n - HD today\n - f/u renal recs\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: double lumen PICC on right; axillary A-line, temp line for HD\n # Nutrition: tolerating TF, on hol dfor potential extubation, speech\n and swallow pending extubation\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 03:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600340,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 09:57 PM\n C&S drawn/sent from RUE & RSC HD side ports.\n SPUTUM CULTURE - At 09:58 PM\n FEVER - 102.4\nF - 01:00 AM\n - Off pressors for most of the day, restarted briefly for BP in 80s.\n - Spiked temp to 101.3 Blood and urine cultured\n - Continued to have hiccoughs.\n - Contact IR re: placing a temp line. NPO after MN for placement of\n femoral temp line with side port for access. Infected HD line should\n be pulled afterward.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:45 PM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 02:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.9\nC (100.3\n HR: 80 (76 - 95) bpm\n BP: 109/40(65) {92/32(54) - 167/66(105)} mmHg\n RR: 26 (20 - 45) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n CO/CI (Fick): (6.1 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 62 - 62\n Total In:\n 1,203 mL\n 284 mL\n PO:\n TF:\n 1,072 mL\n 121 mL\n IVF:\n 6 mL\n 14 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 284 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 343 (255 - 637) mL\n PS : 5 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 167\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///24/\n Ve: 8 L/min\n Physical Examination\n Cardiovascular: GEN: nad\n cv: RRR\n Lungs: CTAB anteriorly\n Ext: RUE edema\n Neuro: eyes open, does not respond to commands.\n Peripheral 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 280 K/uL\n 8.6 g/dL\n 114 mg/dL\n 9.9 mg/dL\n 24 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 101 mEq/L\n 138 mEq/L\n 26.7 %\n 9.6 K/uL\n [image002.jpg]\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n 9.6\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n 26.7\n Plt\n 185\n 234\n 196\n 241\n 280\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n TCO2\n 32\n 31\n 31\n Glucose\n 88\n 75\n 77\n 135\n 183\n 116\n 155\n 114\n Other labs: PT / PTT / INR:14.0/25.4/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:7.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Fluid analysis / Other labs: Vanco\n Imaging: CXR - no parenchymal process.\n Microbiology: Sputum - gram stain GPCs in pairs and clusters\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers most likely source is line infection.\n On day 9 vancomycin. On and off pressors overnight with addition of\n midodren and florinef. More likely due to abnormal autonomic\n dysfunction to renal failure, but ddx includes infectious etiology\n given recent h/o sepsis.\n - Continue midodrine and florinef and reduce levophed as tolerated\n -keep MAP > 65\n -continue vancomycin given skin infection.\n - now febrile, may be bacteremic, surveillance cultures\n - d/c line in RIJ after placement of temporary femoral line\n - touch base with renal regarding posponing dialysis until new line\n placement\n # Respiratory Distress: Problem of inability to maintain secretions,\n based on failure of attempted trial of extubation.\n - On pressure support . attempt extubation after d/w family re:\n reintubation and trach placement for long term ventilation\n - continue HD for volume overload\n - f/u sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA - pending\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: Bolused IV phenytoin 300mg and f/u dilantin level in AM\n - touch base re: anti-seizure regimen given -EEG\n # ESRD:\n - HD on monday\n - femoral temp line placement today\n - d/c of infected HD line\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, temp line for HD (infected); weaning\n pressors in attempt to pull HD line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 22 Gauge - 03:00 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": "2191-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601591,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:31 PM\n BLOOD CULTURED - At 04:31 PM\n SPUTUM CULTURE - At 04:31 PM\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 06:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.7\nC (98.1\n HR: 84 (76 - 98) bpm\n BP: 139/53(75) {125/39(65) - 181/78(95)} mmHg\n RR: 24 (17 - 50) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,520 mL\n 272 mL\n PO:\n TF:\n 1,440 mL\n 239 mL\n IVF:\n 120 mL\n 33 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 1,820 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (293 - 414) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 98\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8.6 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 437 K/uL\n 8.4 g/dL\n 254 mg/dL\n 8.8 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 56 mg/dL\n 98 mEq/L\n 139 mEq/L\n 28.3 %\n 13.9 K/uL\n [image002.jpg]\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n WBC\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n Hct\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n Plt\n 220\n 284\n 267\n 338\n 307\n 376\n 437\n Cr\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n TCO2\n 29\n 34\n Glucose\n 300\n 66\n 174\n 219\n 107\n 272\n 254\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 73yoM h/o ESRD admitted with subdural hematomas after fall, now w/ poor\n mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Low grade fever to 100.1 yesterday afternoon, pt\n was recultured with 2 BCx's and sputum Cx showing 2+ GPC's in pairs and\n 2+ GNR's which do not appear to be new, and pt has received long course\n of ABx for MRSA PNA, so Cx's likely represent continued colonization.\n Workup to date has included removal of all nonessential meds to\n eliminate sources of drug fever, repeated panCx's, LE u/s which was\n negative and CT thorax which recommended MRI Lspine for evaluation of\n infectious etiology vs Schmorl's nods, and subsequent MRI Lspine which\n did not show infectious osteo or discitis. WBC count continues to trend\n down,and pt was not hypotensive through yesterday, pressors now being\n held. Pt currently off ABx.\n 2. Persistent hypotension - poor autonomic function given renal\n failure, vs sepsis vs adrenal insufficiency. stim test adequate.\n - Midodrine held yesterday as sbp's ranging 125-181, now off pressors\n - No underlying infection has been discovered despite requirement of\n pressors\n 3. Respiratory Distress: On PSV with trach. Attempt to trach mask.\n 4. Mental Status change: Following some instructions and moving L arm\n to command.\n Continues to be non-responsive to instructions. Slight improvement in\n that he does make intermittent purposeful movements, including trying\n to remove trach. Unclear underlying etiology: could be secondary to\n slow clearance of sedation or delirium of underlying infection versus\n effect of subdural hematomas.\n -Continue to hold sedation\n #Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: 100 mg starting on for 2 days,\n then can discontinue\n - uptitrating keppra to 250 mg X 2 days, then increase to 500 mg\n qAM and 250 qPM on ; will also get 500 mg boluses after each HD\n session\n # ESRD:\n - cont HD w/ femoral temp line\n - tunneled HD line per renal recs now that his is afebrile\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n -\n # Access: femoral line\n # FEN: tolerating TF, replate lytes prn\n - IR to evaluate today for placement of PEG tube\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601594,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:31 PM\n BLOOD CULTURED - At 04:31 PM\n SPUTUM CULTURE - At 04:31 PM\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 06:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.7\nC (98.1\n HR: 84 (76 - 98) bpm\n BP: 139/53(75) {125/39(65) - 181/78(95)} mmHg\n RR: 24 (17 - 50) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,520 mL\n 272 mL\n PO:\n TF:\n 1,440 mL\n 239 mL\n IVF:\n 120 mL\n 33 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 1,820 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (293 - 414) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 98\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8.6 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 437 K/uL\n 8.4 g/dL\n 254 mg/dL\n 8.8 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 56 mg/dL\n 98 mEq/L\n 139 mEq/L\n 28.3 %\n 13.9 K/uL\n [image002.jpg]\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n WBC\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n Hct\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n Plt\n 220\n 284\n 267\n 338\n 307\n 376\n 437\n Cr\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n TCO2\n 29\n 34\n Glucose\n 300\n 66\n 174\n 219\n 107\n 272\n 254\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 73yoM h/o ESRD admitted with subdural hematomas after fall, now w/ poor\n mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Low grade fever to 100.1 yesterday afternoon, pt\n was recultured with 2 BCx's and sputum Cx showing 2+ GPC's in pairs and\n 2+ GNR's which do not appear to be new, and pt has received long course\n of ABx for MRSA PNA, so Cx's likely represent continued colonization.\n Workup to date has included removal of all nonessential meds to\n eliminate sources of drug fever, repeated panCx's, LE u/s which was\n negative and CT thorax which recommended MRI Lspine for evaluation of\n infectious etiology vs Schmorl's nods, and subsequent MRI Lspine which\n did not show infectious osteo or discitis. WBC count continues to trend\n down,and pt was not hypotensive through yesterday, pressors now being\n held. Pt currently off ABx.\n 2. Persistent hypotension - poor autonomic function given renal\n failure, vs sepsis vs adrenal insufficiency. stim test adequate.\n - Midodrine held yesterday as sbp's ranging 125-181, now off pressors\n - No underlying infection has been discovered despite requirement of\n pressors\n 3. Respiratory Distress: On PSV with trach. Attempt to trach mask.\n 4. Mental Status change: Following some instructions and moving L arm\n to command.\n Continues to be non-responsive to instructions. Slight improvement in\n that he does make intermittent purposeful movements, including trying\n to remove trach. Unclear underlying etiology: could be secondary to\n slow clearance of sedation or delirium of underlying infection versus\n effect of subdural hematomas.\n -Continue to hold sedation\n #Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs Dilantin taper, started 100mg daily yesterday and will get\n 100mg today, then stop tomorrow.\n - Uptitrating Keppra, today to receive 500mg in am and 250mg in pm.\n Continue 500mg boluses after HD.\n # ESRD:\n - cont HD w/ femoral temp line, to go to HD today\n - will need to discuss placement of more permanent/tunneled line with\n renal, and whether low grade 100.1 temps will contraindicate.\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n - Blood sugars in 300\ns yesterday, will need adjustment of SSI\n # Access: femoral line, currently temporary and will need placement of\n more permanent line.\n # FEN: tolerating TF, replate lytes prn\n - IR to evaluate today for placement of PEG tube\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601601,
"text": "Chief Complaint:\n 24 Hour Events:\n Low grade fever to 100.1 at 3pm and 6pm, was BCx\nd x2 and sputum Cx\n with 2+ GPC\ns and 2+ GNR\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 06:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.7\nC (98.1\n HR: 84 (76 - 98) bpm\n BP: 139/53(75) {125/39(65) - 181/78(95)} mmHg\n RR: 24 (17 - 50) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,520 mL\n 272 mL\n PO:\n TF:\n 1,440 mL\n 239 mL\n IVF:\n 120 mL\n 33 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 1,820 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (293 - 414) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 98\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8.6 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 437 K/uL\n 8.4 g/dL\n 254 mg/dL\n 8.8 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 56 mg/dL\n 98 mEq/L\n 139 mEq/L\n 28.3 %\n 13.9 K/uL\n [image002.jpg]\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n WBC\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n Hct\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n Plt\n 220\n 284\n 267\n 338\n 307\n 376\n 437\n Cr\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n TCO2\n 29\n 34\n Glucose\n 300\n 66\n 174\n 219\n 107\n 272\n 254\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 73yoM h/o ESRD admitted with subdural hematomas after fall, now w/ poor\n mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Low grade fever to 100.1 yesterday afternoon, pt\n was recultured with 2 BCx's and sputum Cx showing 2+ GPC's in pairs and\n 2+ GNR's which do not appear to be new, and pt has received long course\n of ABx for MRSA PNA, so Cx's likely represent continued colonization.\n Workup to date has included removal of all nonessential meds to\n eliminate sources of drug fever, repeated panCx's, LE u/s which was\n negative and CT thorax which recommended MRI Lspine for evaluation of\n infectious etiology vs Schmorl's nods, and subsequent MRI Lspine which\n did not show infectious osteo or discitis. WBC count continues to trend\n down,and pt was not hypotensive through yesterday, pressors now being\n held. Pt currently off ABx.\n 2. Persistent hypotension - poor autonomic function given renal\n failure, vs sepsis vs adrenal insufficiency. stim test adequate.\n - Midodrine held yesterday as sbp's ranging 125-181, now off pressors\n - No underlying infection has been discovered despite requirement of\n pressors\n 3. Respiratory Distress: On PSV with trach, currently with FiO2\n 50%\n - Attempt to trach mask.\n 4. Mental Status change: Per nursing was moving L arm to commands,\n however unable to follow commands this am. Does have spontaneous\n movement of 4 extrems. Unclear underlying etiology: could be secondary\n to slow clearance of sedation or delirium of underlying infection\n versus effect of subdural hematomas.\n -Continue to hold sedation\n 5. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n 6. Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs Dilantin taper, started 100mg daily yesterday and will get\n 100mg today, then stop tomorrow.\n - Uptitrating Keppra, today to receive 500mg in am and 250mg in pm.\n Continue 500mg boluses after HD.\n 7. ESRD:\n - Cont HD w/ femoral temp line, to get HD today\n - Will need to discuss placement of more permanent/tunneled line with\n renal, and whether low grade 100.1 temps will contraindicate.\n 8. SDH: continue to hold anticoagulation, will follow neurology recs\n 9. Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n 10. DM: On SSI + lantus 40 daily; maintain BG < 250\n - Blood sugars in 300\ns yesterday, will need adjustment of SSI\n 11. Access: femoral line, currently temporary and will need placement\n of more permanent line.\n # FEN: tolerating TF, replate lytes prn\n - IR to evaluate today for placement of PEG tube\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 601428,
"text": "TITLE:\n Chief Complaint: Resp failure, persistent fever\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 - Trial on vent mask, required return to mech vent after 2.5 hrs\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 04:52 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 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37\nC (98.6\n HR: 83 (75 - 93) bpm\n BP: 147/54(79) {97/41(63) - 162/119(125)} mmHg\n RR: 37 (16 - 37) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,978 mL\n 1,230 mL\n PO:\n TF:\n 1,201 mL\n 646 mL\n IVF:\n 127 mL\n 54 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,978 mL\n 1,230 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 293 (293 - 378) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 103\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: 7.38/56/80./29/5\n Ve: 7.9 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, NG tube, trached\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender, Obese\n Skin: Not assessed\n Neurologic: No(t) Follows simple commands, Responds to: Not assessed,\n Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 376 K/uL\n 272 mg/dL\n 7.5 mg/dL\n 29 mEq/L\n 5.2 mEq/L\n 40 mg/dL\n 99 mEq/L\n 142 mEq/L\n 30.0 %\n 14.9 K/uL\n [image002.jpg]\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n WBC\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n Hct\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n Plt\n 280\n 220\n 284\n \n 376\n Cr\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n TCO2\n 29\n 34\n Glucose\n 114\n 300\n 66\n 174\n 219\n 107\n 272\n Other labs: PT / PTT / INR:12.0/22.3/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.0 %, Band:1.0 %,\n Lymph:7.3 %, Mono:6.2 %, Eos:4.2 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 73M ESRD admitted with subdural hematomas after fall, admitted with\n altered mental status and persistent fevers.\nFevers:\n -negative w/u to date - did have GNR in sputum but trached so likely\n colonizer\n -leading dx drug fever\n -? Fosphenytoin though did have a spike post d/c\n -d/c nonessential drugs\n -cont to cx and imaging to assess for source\n\nAltered mental status\n -remains unresponsive\n -is doing some purposeful movement which is improvement\n -etiology felt slow clearance of drugs/metabolites vs. residual effect\n from SDH\n -cont to hold sedating drugs\n\nPersistent hypotension\n - etiology: autonomic dysfxn related to renal failure vs. adrenal\n insufficiency vs. sepsis\n - stim test performed/pending\n Respiratory failure:\n -trached\n -trial PSV today\n\nSeizure:\n -EEG neg. no evidence of ongoing seizure activity\n -management of meds per neuro recs\n\n ESRD:\n - stable, cont HD\n\nAccess\n -extremely challenging with Mr. \n -needs more permanent access- d/w renal\n\nGlycemic control\n titrate SSRI\n SDH\n -holding anticoagulation\n -neurology following\n For remainder of plan, please see resident note above.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 03:59 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 601436,
"text": "TITLE:\n Chief Complaint: Resp failure, persistent fever\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 - Trial on vent mask, required return to mech vent after 2.5 hrs\n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 04:52 AM\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 11:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37\nC (98.6\n HR: 83 (75 - 93) bpm\n BP: 147/54(79) {97/41(63) - 162/119(125)} mmHg\n RR: 37 (16 - 37) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,978 mL\n 1,230 mL\n PO:\n TF:\n 1,201 mL\n 646 mL\n IVF:\n 127 mL\n 54 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,978 mL\n 1,230 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 293 (293 - 378) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI: 103\n PIP: 15 cmH2O\n SpO2: 95%\n ABG: 7.38/56/80./29/5\n Ve: 7.9 L/min\n PaO2 / FiO2: 160\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, NG tube, trached\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: )\n Abdominal: Soft, Non-tender, Obese\n Skin: Not assessed\n Neurologic: No(t) Follows simple commands, Responds to: Not assessed,\n Movement: Purposeful, Sedated, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 376 K/uL\n 272 mg/dL\n 7.5 mg/dL\n 29 mEq/L\n 5.2 mEq/L\n 40 mg/dL\n 99 mEq/L\n 142 mEq/L\n 30.0 %\n 14.9 K/uL\n [image002.jpg]\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n WBC\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n Hct\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n Plt\n 280\n 220\n 284\n \n 376\n Cr\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n TCO2\n 29\n 34\n Glucose\n 114\n 300\n 66\n 174\n 219\n 107\n 272\n Other labs: PT / PTT / INR:12.0/22.3/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.0 %, Band:1.0 %,\n Lymph:7.3 %, Mono:6.2 %, Eos:4.2 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n 73M ESRD admitted with subdural hematomas after fall, admitted with\n altered mental status and persistent fevers.\nFevers:\n -negative w/u to date - did have GNR in sputum but trached so likely\n colonizer\n -leading dx drug fever\n -? Fosphenytoin though did have a spike post d/c\n -d/c nonessential drugs\n -cont to cx and imaging to assess for source\n\nAltered mental status\n -remains unresponsive\n -is doing some purposeful movement which is improvement\n -etiology felt slow clearance of drugs/metabolites vs. residual effect\n from SDH\n -cont to hold sedating drugs\n\nPersistent hypotension\n - etiology: autonomic dysfxn related to renal failure vs. adrenal\n insufficiency vs. sepsis\n - stim response adequate\n Respiratory failure:\n -trached\n -trial PSV today\n\nSeizure:\n -EEG neg. no evidence of ongoing seizure activity\n -management of meds per neuro recs\n\n ESRD:\n - stable, cont HD\n\nAccess\n -extremely challenging with Mr. \n -needs more permanent access- d/w renal\n\nGlycemic control\n titrate SSRI\n SDH\n -holding anticoagulation\n -neurology following\n For remainder of plan, please see resident note above.\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 03:59 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601662,
"text": "Chief Complaint:\n 24 Hour Events:\n Low grade fever to 100.1 at 3pm and 6pm, was BCx\nd x2 and sputum Cx\n with 2+ GPC\ns and 2+ GNR\ns. Then febrile this am while on rounds up to\n 102.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 06:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.7\nC (98.1\n HR: 84 (76 - 98) bpm\n BP: 139/53(75) {125/39(65) - 181/78(95)} mmHg\n RR: 24 (17 - 50) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,520 mL\n 272 mL\n PO:\n TF:\n 1,440 mL\n 239 mL\n IVF:\n 120 mL\n 33 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 1,820 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (293 - 414) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 98\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8.6 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 437 K/uL\n 8.4 g/dL\n 254 mg/dL\n 8.8 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 56 mg/dL\n 98 mEq/L\n 139 mEq/L\n 28.3 %\n 13.9 K/uL\n [image002.jpg]\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n WBC\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n Hct\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n Plt\n 220\n 284\n 267\n 338\n 307\n 376\n 437\n Cr\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n TCO2\n 29\n 34\n Glucose\n 300\n 66\n 174\n 219\n 107\n 272\n 254\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b seizures after a\n fall, now with unresponsive mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Low grade fever to 100.1 yesterday afternoon, pt\n was recultured with 2 BCx's and sputum Cx showing 2+ GPC's in pairs and\n 2+ GNR's which do not appear to be new, and pt has received long course\n of ABx for MRSA PNA, so Cx's likely represent continued colonization.\n Workup to date has included removal of all nonessential meds to\n eliminate sources of drug fever, repeated panCx's, LE u/s which was\n negative and CT thorax which recommended MRI Lspine for evaluation of\n infectious etiology vs Schmorl's nods, and subsequent MRI Lspine which\n did not show infectious osteo or discitis. WBC count continues to trend\n down,and pt was not hypotensive through yesterday, pressors now being\n held. Pt currently off ABx.\n --Will not restart ABx\n --Check culture every other day\n --Head CT with sinus protocol to eval for sinus infection\n 2. Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n --Neuro recs Dilantin taper\n will d/c today.\n --Uptitrating Keppra, today to receive 500mg in am and 250mg in pm.\n Continue 500mg boluses after HD.\n 3. DM: On SSI + lantus 40 daily; maintain BG < 250\n - Blood sugars in 300\ns yesterday, will need adjustment of SSI\n 4. Hypotension\nResolving, as not currently hypotense > 24hrs. Poor\n autonomic function given renal failure, vs sepsis vs adrenal\n insufficiency. stim test adequate.\n --Midodrine held yesterday as sbp's ranging 125-181, now off pressors\n --No infections found to date to explain previous hypotension\n 5. Respiratory Distress: On PSV with trach, currently with FiO2\n 50%\n --Attempt to trach mask.\n 6. Mental Status change: Per nursing was moving L arm to commands,\n however unable to follow commands this am. Does have spontaneous\n movement of 4 extrems. Unclear underlying etiology: could be secondary\n to slow clearance of sedation or delirium of underlying infection\n versus effect of subdural hematomas.\n --Continue to hold sedation\n --Will get EEG today\n 7. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n --continue wound care\n 8. ESRD:\n - Cont HD w/ femoral temp line, to get HD today with Epo\n - Will need to discuss placement of more permanent/tunneled line with\n renal, and whether low grade 100.1 temps will contraindicate.\n - Access still L femoral line placed .\n 8. SDH\nHold anticoagulation.\n --Will get repeat EEG to see if having subclinical seizures.\n 9. Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n 11. Access: femoral line, currently temporary and will need placement\n of more permanent line.\n # FEN: tolerating TF, replate lytes prn\n --IP to evaluate today for placement of PEG tube, currently NPO\n --If PEG tube placed will remove NG tube\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601160,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions; Comments: Pt remain on CPAP/PSV with\n Tv in the 275-425ml range and RR in 20-30bpm. Pt was suctioned for\n moderate amount of yellow and given MDIs. Pt continues on normal\n course and to be assessed by MD team.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601494,
"text": "TITLE 73 year ole man with esrd on hemodialysis admitted with left\n acute on chronic SDH c/b seizure, transferred to MICU for concern of\n sepsis with hypoxia and hypotension. Extubated x3 this admission but\n requiring reintubation within 24 hours. Failure to extubate thought to\n be r/t volume overload and altered mental status.\n UPDATE: Pt tol nearly seven hours on 50% trach mask today, now resting\n back on CPAP/PS mode. Axillary temp spike to 100.1 today, blood &\n sputum C&S sent for analysis\n no antibx cov ordered @ this time. PEG\n to be placed tomorrow by IP. Supportive wife visited today/met\n with MICU MD\ns/kept up to date with POC/pt status. +MRSA Contact\n Isolation precautions remain in place. The pt remains a Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP/PS 10/5 with 50% FiO2 with nl sats, RR and resp\n effort. LS have varied today from coarse rhonchi to fairly clear.\n Medium amounts of thick tan/blood tinged sec per trach today. Pt noted\n to desat to the low 80\ns fairly rapidly when on RA.\n Action:\n Pt placed on trach mask trial with 50% FiO2 @ 10:00 today.\n Response:\n Pt with good tol of trach mask lasting until 17:00 before becoming\n tachypneic (in assoc with temp spike) and now back on CPAP/PS resting\n settings.\n Plan:\n Will rest pt overnight on CPAP/PS settings and hope to switch back to\n trach mask early in shift.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Axillary temp up to 100.1 this afternoon.\n Action:\n Blood C&S times two drawn/sent from b/l UE\ns, sputum C&S sent as well.\n Response:\n Plan:\n Will cont to follow temp trend.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n AM BUN/Cr up to 40 & 7.5 respectively. Serum sodium dropped to 142\n today s/p increased FWB started on .\n Action:\n Following daily labs.\n Response:\n Stable ESRD, HD treatment schedule is M-W-F.\n Plan:\n Next HD treatment slated for Monday. Pt will need a permanent HD line\n prior to d/c to rehab.\n Altered mental status (not Delirium)\n Assessment:\n No overt changes in MS noted today with pt not following commands nor\n appearing purposeful. Pt does not track. Pt is very strong, becomes\n quite agitated with direct pt care/turns. With most direct pt care\n delivered the pt becomes agitated, thrashes in bed, grimaces. Pt does\n not move his RUE.\n Action:\n Pt freq re-oriented to person/time/place/care rationale to facilitate\n nl cognition. Family encouraged to interact with pt. No analgesic nor\n anti-anxiety meds admin today.\n Response:\n No apparent change in MS noted today.\n Plan:\n Cont to freq re-orient pt. Attempt to minimize use of opiate and/or\n anti-anxiety agents as able. Encourage family to visit/interact with\n pt. Provide verbal/non-verbal support.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Resident / Attending Notes",
"row_id": 601090,
"text": "Chief Complaint:\n 24 Hour Events:\n - spoke with daughter about current situation, did not seem to be ready\n for backing off care, wants to reeval mental status after HD\n - Dilatin d/c'd, neuro to make recs tomorrow re different antiepileptic\n - renal recs: d/c dilantin\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 08:15 AM\n Lansoprazole (Prevacid) - 08:02 PM\n Morphine Sulfate - 04:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.6\nC (99.6\n HR: 79 (73 - 92) bpm\n BP: 97/41(54) {74/38(50) - 172/103(159)} mmHg\n RR: 12 (12 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,670 mL\n 495 mL\n PO:\n TF:\n 1,260 mL\n 457 mL\n IVF:\n 120 mL\n 38 mL\n Blood products:\n Total out:\n 120 mL\n 0 mL\n Urine:\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 1,550 mL\n 495 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 80 (80 - 466) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 97%\n ABG: ///26/\n Ve: 9.4 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 338 K/uL\n 8.9 g/dL\n 219 mg/dL\n 7.6 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 35 mg/dL\n 100 mEq/L\n 142 mEq/L\n 29.2 %\n 9.4 K/uL\n [image002.jpg]\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n WBC\n 8.6\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n Hct\n 30.2\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n Plt\n 196\n 241\n 280\n 220\n 284\n 267\n 338\n Cr\n 5.7\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n TCO2\n 31\n 31\n 29\n Glucose\n 116\n 155\n 114\n 300\n 66\n 174\n 219\n Other labs: PT / PTT / INR:13.9/25.6/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.3 %, Band:0.0 %,\n Lymph:8.1 %, Mono:5.5 %, Eos:3.7 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ESRD admitted with subdural hematomas after fall, now w/ poor mental\n status and persistent fevers.\n .\n # Fevers: Some improvement after d/c of fosphenytoin although one fever\n spike O/N to 101. Has not required pressors for last 24 hrs although\n still on midodrine and florinef. Have extensively searched for\n underlying source of fevers, including re-peated pancultures, CT of\n chest, abdomen, pelvis. The only findings have been enlarged\n mediastinal lymph nodes: (1.5 x 2.1 cm prevascular lymph node and a\n precarinal lymph node measuring 2.2 x 0.7 cm). Repeated sputum\n cultures show gram + cocci, however has already received long abx\n course for MRSA PNA and likely represents continued colonization. Have\n D/c'd nonessential meds to eliminate possible sources of drug fever,\n including fosphenytoin yesterday. Other tests not yet done for fever\n of unknown origin workup include: lower extremity US.\n -Can consider lower extremity US to search for DVT\n - Continue midodrine and florinef and reduce levophed as tolerated\n (hasn't required over last 24 hours): if no pressor requirement today,\n consider tapering off florinef and midodrine tomorrow\n - d/c all nonessential meds, vanc, dilantin\n - keep MAP > 65\n .\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n .\n # Respiratory Distress: Trach placed. Had some oozing but improved.\n Attempt switch to pressure support today.\n - monitor trach site\n - continue HD for volume overload\n .\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n .\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: went back up to 200 mg dilantin X 2\n days, then 100 mg starting on for 2 days, then can discontinue\n -uptitrating keppra to 250 mg X 3 days, then increase to 500 mg qAM\n and 250 qPM on day 4; will also get 500 mg boluses after each HD\n session\n .\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n .\n # SDH: continue to hold anticoagulation, will follow neurology recs\n .\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n .\n # DM: On SSI + lantus 40 daily; elevated sugars in am\n - adjust SSI\n .\n # Access: femoral line\n .\n # FEN: tolerating TF, give phos\n .\n # PPX: pneumoboots, PPI; bowel reg\n .\n # Code: full (confirmed with wife on admission via phone)\n .\n # Dispo: to remain in ICU while intubated\n - family meeting to discuss goals of care\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:42 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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 CRITICAL CARE STAFF ADDENDUM\n I saw and examined the Mr. with the ICU team; Dr. \ns note\n reflects my input. Family discussion by ICU team by phone. Dilantin\n weaning and changeover to Keppra underway. Febrile to 101.7.\n Tolerating dialysis but on a bit of vasopressor. Sedated but opens\n eyes to voice. Heart regular, abdomen soft. Labs, meds, and imaging\n reviewed.\n A/P\n 73 y/o man with ESRD on HD admitted with SDH after fall. Has ongoing\n persistent encephalopathy and fevers. Evaluation of fevers has not\n revealed clear source, and there has been concern for drug-related\n fevers. We will change phenytoin to keppra as suggested by neurology.\n Would culture with each spike, since he is at risk for nosocomial\n infection. We are treating Staph in sputum as colonizer at present,\n but if decompensates would need rx. For , check cortisol and\n continue midodrine/florinef. For respiratory failure\n on PSV now but\n did not tolerate SBT today. Try to avoid standing sedation given\n encephalopathy/altered mental status. Venous access is a challenge,\n and we will discuss with renal future possible options for access.\n He is critically ill. 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 15:59 ------\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601312,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 05:30 PM\n -obtained lower extremity US to assess for DVT given persistent fevers:\n none seen\n -dilantin on 200 X 2 days, will taper down to 100 X 2 days\n thereafter, then D/c\n -on keppra 250 X 3 days, then keppra 500 qam 250 qpm\n - stim test in PM given hypotension , results pending\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:04 AM\n Fosphenytoin - 06:00 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 06:49 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: 37.3\nC (99.2\n HR: 84 (79 - 98) bpm\n BP: 138/76(93) {76/38(52) - 138/76(93)} mmHg\n RR: 28 (15 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,608 mL\n 176 mL\n PO:\n TF:\n 1,319 mL\n 144 mL\n IVF:\n 129 mL\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,608 mL\n 176 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 548 (291 - 548) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n SpO2: 95%\n ABG: ///33/\n Ve: 9.7 L/min\n Physical Examination\n Cardiovascular: Gen: intubated sedated\n Peripheral 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 307 K/uL\n 8.6 g/dL\n 107 mg/dL\n 5.4 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 101 mEq/L\n 144 mEq/L\n 28.4 %\n 16.6 K/uL\n [image002.jpg]\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n WBC\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n Hct\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n Plt\n 241\n 280\n 220\n \n 307\n Cr\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n TCO2\n 31\n 29\n Glucose\n 155\n 114\n 300\n 66\n 174\n 219\n 107\n Other labs: PT / PTT / INR:12.7/18.9/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.3 %, Band:0.0 %,\n Lymph:8.1 %, Mono:5.5 %, Eos:3.7 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Imaging: BLE US - negative for DVT\n Microbiology: STAPH AUREUS COAG + - sparse growth\n |\n ERYTHROMYCIN---------- =>8 R\n GENTAMICIN------------ <=0.5 S\n LEVOFLOXACIN---------- =>8 R\n OXACILLIN------------- =>4 R\n RIFAMPIN-------------- <=0.5 S\n TETRACYCLINE---------- <=1 S\n TRIMETHOPRIM/SULFA---- <=0.5 S\n VANCOMYCIN------------ <=1 S\n NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA - sparse growth\n |\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- 2 S\n CEFTRIAXONE----------- 8 S\n CIPROFLOXACIN---------<=0.25 S\n GENTAMICIN------------ <=1 S\n IMIPENEM-------------- <=1 S\n LEVOFLOXACIN---------- 1 S\n MEROPENEM------------- 1 S\n PIPERACILLIN---------- 16 S\n PIPERACILLIN/TAZO----- 8 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- 4 R\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ESRD admitted with subdural hematomas after fall, now w/ poor mental\n status and persistent fevers.\n # Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. However, also has a leukocytosis today which he has\n intermittently had, in this case may be due to coritsol stim test.\n Some improvement after d/c of fosphenytoin although one fever spike O/N\n to 101. Has not required pressors for last 48 hrs (one hrs duration\n last night) although still on midodrine and florinef. Have\n extensively searched for underlying source of fevers, including\n repeated pancultures, CT of chest, abdomen, pelvis. The only findings\n have been enlarged mediastinal lymph nodes: (1.5 x 2.1 cm prevascular\n lymph node and a precarinal lymph node measuring 2.2 x 0.7 cm).\n Repeated sputum cultures show gram + cocci, however has already\n received long abx course for MRSA PNA and likely represents continued\n colonization. Also has non-fermenter bacteria (not pseudomonas).\n Have D/c'd nonessential meds to eliminate possible sources of drug\n fever, including fosphenytoin yesterday. Lower extremity US\n negative.\n - f/u diff for bandemia - if positive consider starting tx for non\n fermenter bacteria\n - CXR\n - Continue midodrine and florinef and reduce levophed as tolerated\n (brief requirement over last 24 hours): if no pressor requirement\n today, consider tapering off florinef and midodrine tomorrow\n - d/c all nonessential meds, vanc, dilantin\n - keep sbp> 90\n #Persistent hypotension - poor autonomic function given renal failure,\n vs sepsis vs adrenal insufficiency\n - stim test pending\n - higher threshold to start pressors, sbp> 90\n - no underlying infection has been discovered despite requirement of\n pressors\n #Metabolic alkylosis - Worsening in the state of persistently elevated\n minute ventilation. Overbreathing vent (set at MV of 8.8L/min).\n - avoiding sedation\n - switch to pressure control for improved comfort.\n # Respiratory Distress: On AC with trach. Attempt switch to pressure\n support today.\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: 200 mg dilantin today, then 100 mg\n starting on for 2 days, then can discontinue\n - uptitrating keppra to 250 mg X 2 days, then increase to 500 mg\n qAM and 250 qPM on ; will also get 500 mg boluses after each HD\n session\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n # Access: femoral line\n # FEN: tolerating TF, replate lytes prn\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n - family meeting to discuss goals of care\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:00 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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 PE (not included above)\n Appears agitated, responsive to some commands\n RRR, Nl S1 and S2, no murmur\n Lungs rhonchorous\n Abd non distended non tender\n Femoral line clean, examination causes patient discomfort\n No peripheral edema, extremeities warm and well perfused\n Pupils minimally responsive, able to move all extremeties except RUE.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:17 ------\n Chart reviewed, pt examined, case discussed in detail. I was with Dr.\n and team for delivery of all key services. Her note above\n reflects my thoughts. In addition, I would add/emphasize:\n -LENIs neg for DVT\n 73M ESRD admitted with subdural hematomas after fall, admitted with\n altered mental status and persistent fevers.\nFevers:\n -negative w/u to date\n -leading dx drug fever\n -? Fosphenytoin though did have a spike post d/c\n -d/c nonessential drugs\n -cont to cx and imaging to assess for source\nAltered mental status\n -remains unresponsive\n -is doing some purposeful movement which is improvement\n -etiology felt slow clearance of drugs/metabolites vs. residual effect\n from SDH\n -cont to hold sedating drugs\nPersistent hypotension\n - etiology: autonomic dysfxn related to renal failure vs. adrenal\n insufficiency vs. sepsis\n - stim test performed/pending\n Respiratory failure:\n -trached\n -trial PSV today\nSeizure:\n -EEG neg. no evidence of ongoing seizure activity\n -management of meds per neuro recs\n ESRD:\n - stable, cont HD\nAccess\n -extremely challenging with Mr. \n -needs more permanent access- d/w renal\n SDH\n -holding anticoagulation\n -neurology following\n For remainder of plan, please see resident note above.\n Patient is critically ill.\n Time spent on care: 35min.\n ------ Protected Section Addendum Entered By: , MD\n on: 19:41 ------\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601397,
"text": "Chief Complaint:\n 24 Hour Events:\n - Stim 16.9 --> 31.7 --> 36.5, adequate\n - increased free water flushes\n - trial on vent mask, unsuccessful after 2.5 hrs, back on PS 10/5.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 04:52 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 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.6\nC (97.9\n HR: 79 (75 - 96) bpm\n BP: 128/61(76) {97/41(61) - 162/119(125)} mmHg\n RR: 26 (16 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,977 mL\n 678 mL\n PO:\n TF:\n 1,200 mL\n 240 mL\n IVF:\n 127 mL\n 38 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,977 mL\n 678 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 324 (319 - 378) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 103\n PIP: 16 cmH2O\n SpO2: 94%\n ABG: 7.38/56/80./29/5\n Ve: 7.7 L/min\n PaO2 / FiO2: 160\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 376 K/uL\n 9.0 g/dL\n 272 mg/dL\n 7.5 mg/dL\n 29 mEq/L\n 5.2 mEq/L\n 40 mg/dL\n 99 mEq/L\n 142 mEq/L\n 30.0 %\n 14.9 K/uL\n [image002.jpg]\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n WBC\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n Hct\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n Plt\n 280\n 220\n 284\n \n 376\n Cr\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n TCO2\n 29\n 34\n Glucose\n 114\n 300\n 66\n 174\n 219\n 107\n 272\n Other labs: PT / PTT / INR:12.0/22.3/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.0 %, Band:1.0 %,\n Lymph:7.3 %, Mono:6.2 %, Eos:4.2 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR\n Microbiology: SPUTUM GRAM STAIN:\n 3+: GRAM NEGATIVE ROD(S).\n 1+: GRAM POSITIVE COCCI IN PAIRS.\n Blood Cx: negative from , pending\n Urine Cx: pending\n Assessment and Plan\n 73yoM h/o ESRD admitted with subdural hematomas after fall, now w/ poor\n mental status and persistent fevers.\n # Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. No fever x24hrs. Have D/c'd nonessential meds to\n eliminate possible sources of drug fever, including fosphenytoin.\n Leukocytosis trending down. On midodrine and florinef, few hours on\n very low dose levo. Have extensively searched for underlying source of\n fevers, including repeated pancultures, Lower extremity US negative,\n CT of chest, abdomen, pelvis. Repeated sputum cultures show gram +\n cocci, however has already received long abx course for MRSA PNA and\n likely represents continued colonization.\n #Persistent hypotension - poor autonomic function given renal failure,\n vs sepsis vs adrenal insufficiency. stim test adequate.\n - Continue midodrine and florinef and reduce levophed as tolerated\n (brief requirement over last 24 hours): if no pressor requirement\n today, consider tapering off florinef and midodrine tomorrow\n - higher threshold to start pressors, sbp> 90\n - no underlying infection has been discovered despite requirement of\n pressors\n #Metabolic alkylosis - Worsening in the state of persistently elevated\n minute ventilation. Overbreathing vent (set at MV of 8.8L/min).\n - avoiding sedation\n - switch to pressure control for improved comfort.\n # Respiratory Distress: On AC with trach. Attempt switch to pressure\n support today.\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: 100 mg starting on for 2 days,\n then can discontinue\n - uptitrating keppra to 250 mg X 2 days, then increase to 500 mg\n qAM and 250 qPM on ; will also get 500 mg boluses after each HD\n session\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n # Access: femoral line, now afebrile -> PICC tomorrow\n # FEN: tolerating TF, replate lytes prn\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601398,
"text": "Chief Complaint:\n 24 Hour Events:\n - Stim 16.9 --> 31.7 --> 36.5, adequate\n - increased free water flushes\n - trial on vent mask, unsuccessful after 2.5 hrs, back on PS 10/5.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 04:52 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 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.6\nC (97.9\n HR: 79 (75 - 96) bpm\n BP: 128/61(76) {97/41(61) - 162/119(125)} mmHg\n RR: 26 (16 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,977 mL\n 678 mL\n PO:\n TF:\n 1,200 mL\n 240 mL\n IVF:\n 127 mL\n 38 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,977 mL\n 678 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 324 (319 - 378) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 103\n PIP: 16 cmH2O\n SpO2: 94%\n ABG: 7.38/56/80./29/5\n Ve: 7.7 L/min\n PaO2 / FiO2: 160\n Physical Examination\n Gen: NAD, opens eyes\n CV: RRR, Lungs: CTAB\n Abd: ND NT ABS\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 272 mg/dL\n 7.5 mg/dL\n 29 mEq/L\n 5.2 mEq/L\n 40 mg/dL\n 99 mEq/L\n 142 mEq/L\n 30.0 %\n 14.9 K/uL\n [image002.jpg]\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n WBC\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n Hct\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n Plt\n 280\n 220\n 284\n \n 376\n Cr\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n TCO2\n 29\n 34\n Glucose\n 114\n 300\n 66\n 174\n 219\n 107\n 272\n Other labs: PT / PTT / INR:12.0/22.3/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.0 %, Band:1.0 %,\n Lymph:7.3 %, Mono:6.2 %, Eos:4.2 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR\n Microbiology: SPUTUM GRAM STAIN:\n 3+: GRAM NEGATIVE ROD(S).\n 1+: GRAM POSITIVE COCCI IN PAIRS.\n Blood Cx: negative from , pending\n Urine Cx: pending\n Assessment and Plan\n 73yoM h/o ESRD admitted with subdural hematomas after fall, now w/ poor\n mental status and persistent fevers.\n # Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. No fever x24hrs. Have D/c'd nonessential meds to\n eliminate possible sources of drug fever, including fosphenytoin.\n Leukocytosis trending down. On midodrine and florinef, few hours on\n very low dose levo. Have extensively searched for underlying source of\n fevers, including repeated pancultures, Lower extremity US negative,\n CT of chest, abdomen, pelvis. Repeated sputum cultures show gram +\n cocci, however has already received long abx course for MRSA PNA and\n likely represents continued colonization.\n #Persistent hypotension - poor autonomic function given renal failure,\n vs sepsis vs adrenal insufficiency. stim test adequate.\n - Continue midodrine and florinef and reduce levophed as tolerated\n (brief requirement over last 24 hours): if no pressor requirement\n today, consider tapering off florinef and midodrine tomorrow\n - higher threshold to start pressors, sbp> 90\n - no underlying infection has been discovered despite requirement of\n pressors\n #Metabolic alkylosis - Worsening in the state of persistently elevated\n minute ventilation. Overbreathing vent (set at MV of 8.8L/min).\n - avoiding sedation\n - switch to pressure control for improved comfort.\n # Respiratory Distress: On AC with trach. Attempt switch to pressure\n support today.\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: 100 mg starting on for 2 days,\n then can discontinue\n - uptitrating keppra to 250 mg X 2 days, then increase to 500 mg\n qAM and 250 qPM on ; will also get 500 mg boluses after each HD\n session\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n # Access: femoral line, now afebrile -> PICC tomorrow\n # FEN: tolerating TF, replate lytes prn\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601484,
"text": "TITLE\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 renal failure, End stage (End stage renal disease, ESRD)\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": "2191-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601486,
"text": "TITLE\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 renal failure, End stage (End stage renal disease, ESRD)\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": "2191-09-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601779,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt afebrile overnight.WCC 13.6.No clear source of infection.\n Action:\n CT head showed sinusitis.NGT d/ced.\n Response:\n Remains afebrile.\n Plan:\n ENT consult.IR to place tunneled HD line todayt/tomorrow.IR toplace PEG\n at bed side ?today/tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt responds to stimulus.moves head and lt hand.Occassionally obeys\n command.\n Action:\n EEG yesterday with results pending.\n Response:\n Conts the same.\n Plan:\n Continue to monitor MS.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601780,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt afebrile overnight.WCC 13.6.No clear source of infection.\n Action:\n CT head showed sinusitis.NGT d/ced.\n Response:\n Remains afebrile.\n Plan:\n ENT consult.IR to place tunneled HD line todayt/tomorrow.IR toplace PEG\n at bed side ?today/tomorrow.\n Altered mental status (not Delirium)\n Assessment:\n Pt responds to stimulus.moves head and lt hand.Occassionally obeys\n command.\n Action:\n EEG yesterday with results pending.\n Response:\n Conts the same.\n Plan:\n Continue to monitor MS.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601370,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Right femoral HD with VIP port; site unremarkable. HD scheduled for MWF\n Action:\n 30 gm kayexalate given via flexiseal irrigation port for elevated K 5.2\n Response:\n Continues with large amt of loose stool, golden in color\n Plan:\n HD tomorrow. Recheck lytes in am.\n Hypotension (not Shock)\n Assessment:\n NIBP taken from left thigh; off pressor; HR 80\ns, SR\n Action:\n Bp closely monitored\n Response:\n Adequate SBP >90. Temperature wnl. Tolerating tubefeeds at goal with\n water boluses.\n Plan:\n Levophed if Bp <90.\n Impaired Skin Integrity\n Assessment:\n Excoriated area to rectal/buttocks and scrotal area; prolonged bedrest\n Action:\n Freq position changes; kinair bed; freq application of barrier\n cream/aloe vesta\n Response:\n Areas healing well; presently pink, and tender\n Plan:\n Cont with kinair, freq position changes, nutrition, monitor excoriated\n areas\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601540,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 13\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\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: Yellow / 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 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: Intolerant of\n weaning attempts\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601650,
"text": "Chief Complaint:\n 24 Hour Events:\n Low grade fever to 100.1 at 3pm and 6pm, was BCx\nd x2 and sputum Cx\n with 2+ GPC\ns and 2+ GNR\ns. Then febrile this am while on rounds up to\n 102.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 06:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.7\nC (98.1\n HR: 84 (76 - 98) bpm\n BP: 139/53(75) {125/39(65) - 181/78(95)} mmHg\n RR: 24 (17 - 50) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,520 mL\n 272 mL\n PO:\n TF:\n 1,440 mL\n 239 mL\n IVF:\n 120 mL\n 33 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 1,820 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (293 - 414) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 98\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8.6 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 437 K/uL\n 8.4 g/dL\n 254 mg/dL\n 8.8 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 56 mg/dL\n 98 mEq/L\n 139 mEq/L\n 28.3 %\n 13.9 K/uL\n [image002.jpg]\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n WBC\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n Hct\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n Plt\n 220\n 284\n 267\n 338\n 307\n 376\n 437\n Cr\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n TCO2\n 29\n 34\n Glucose\n 300\n 66\n 174\n 219\n 107\n 272\n 254\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b seizures after a\n fall, now with unresponsive mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Low grade fever to 100.1 yesterday afternoon, pt\n was recultured with 2 BCx's and sputum Cx showing 2+ GPC's in pairs and\n 2+ GNR's which do not appear to be new, and pt has received long course\n of ABx for MRSA PNA, so Cx's likely represent continued colonization.\n Workup to date has included removal of all nonessential meds to\n eliminate sources of drug fever, repeated panCx's, LE u/s which was\n negative and CT thorax which recommended MRI Lspine for evaluation of\n infectious etiology vs Schmorl's nods, and subsequent MRI Lspine which\n did not show infectious osteo or discitis. WBC count continues to trend\n down,and pt was not hypotensive through yesterday, pressors now being\n held. Pt currently off ABx.\n --Will not restart ABx\n 2. Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n --Neuro recs Dilantin taper\n will d/c today.\n - Uptitrating Keppra, today to receive 500mg in am and 250mg in pm.\n Continue 500mg boluses after HD.\n 3. Persistent hypotension - poor autonomic function given renal\n failure, vs sepsis vs adrenal insufficiency. stim test adequate.\n - Midodrine held yesterday as sbp's ranging 125-181, now off pressors\n - No underlying infection has been discovered despite requirement of\n pressors\n 3. Respiratory Distress: On PSV with trach, currently with FiO2\n 50%\n - Attempt to trach mask.\n 4. Mental Status change: Per nursing was moving L arm to commands,\n however unable to follow commands this am. Does have spontaneous\n movement of 4 extrems. Unclear underlying etiology: could be secondary\n to slow clearance of sedation or delirium of underlying infection\n versus effect of subdural hematomas.\n --Continue to hold sedation\n 5. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n --continue wound care\n 7. ESRD:\n - Cont HD w/ femoral temp line, to get HD today with Epo\n - Will need to discuss placement of more permanent/tunneled line with\n renal, and whether low grade 100.1 temps will contraindicate.\n - Access still L femoral line placed .\n 8. SDH: continue to hold anticoagulation, will follow neurology recs\n 9. Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n 10. DM: On SSI + lantus 40 daily; maintain BG < 250\n - Blood sugars in 300\ns yesterday, will need adjustment of SSI\n 11. Access: femoral line, currently temporary and will need placement\n of more permanent line.\n # FEN: tolerating TF, replate lytes prn\n - IR to evaluate today for placement of PEG tube\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601475,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff pressure: 28 cmH2O\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 / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Accessory muscle use, Tachypneic (RR> 35 b/min)\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: Periodic SBT's for conditioning; Comments: trach mask\n as tolerates\n :\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601580,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Rd the pt on CPAP 50%/peep 5/PS 10.Sating 96-98%.LS rhonchorous.\n Action:\n No vent changes overnight.Tolerated trach collar yesterday for 7hrs.\n Response:\n No changes.\n Plan:\n Trach collar today as pt tolerates.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 99.5.\n Action:\n Last BC yesterday.\n Response:\n Afebrile.\n Plan:\n Cont to follow BC.IR to come and evaluate for PEG.TF on hold since 4am.\n"
},
{
"category": "General",
"chartdate": "2191-09-12 00:00:00.000",
"description": "Generic Note",
"row_id": 601631,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. Continues febrile\n 102 this\n am.\n 100.1 93 147/68\n Unresponsive\n Chest\n few crackles\n CV\n 2/6 SEM\n Abd\n soft\n WBC 13.9\n His mental status has declined over last several days. Got sedating\n meds last week but nothing since . Will recheck EEG for\n non-convulsive status, d/c phenytoin, reimage head. Reculturing,\n checking LFTs, lipase, stopping phenytoin for fever. WBC bumped over\n weekend but no clinical change. Sinuses seem tended\n will check with\n head CT. BP is actually increasing and we are weaning Fluorinef and\n Midodrine.\n Time spent 40 min\n Critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601299,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 05:30 PM\n -obtained lower extremity US to assess for DVT given persistent fevers:\n none seen\n -dilantin on 200 X 2 days, will taper down to 100 X 2 days\n thereafter, then D/c\n -on keppra 250 X 3 days, then keppra 500 qam 250 qpm\n - stim test in PM given hypotension , results pending\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:04 AM\n Fosphenytoin - 06:00 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 06:49 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: 37.3\nC (99.2\n HR: 84 (79 - 98) bpm\n BP: 138/76(93) {76/38(52) - 138/76(93)} mmHg\n RR: 28 (15 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,608 mL\n 176 mL\n PO:\n TF:\n 1,319 mL\n 144 mL\n IVF:\n 129 mL\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,608 mL\n 176 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 548 (291 - 548) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n SpO2: 95%\n ABG: ///33/\n Ve: 9.7 L/min\n Physical Examination\n Cardiovascular: Gen: intubated sedated\n Peripheral 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 307 K/uL\n 8.6 g/dL\n 107 mg/dL\n 5.4 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 101 mEq/L\n 144 mEq/L\n 28.4 %\n 16.6 K/uL\n [image002.jpg]\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n WBC\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n Hct\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n Plt\n 241\n 280\n 220\n \n 307\n Cr\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n TCO2\n 31\n 29\n Glucose\n 155\n 114\n 300\n 66\n 174\n 219\n 107\n Other labs: PT / PTT / INR:12.7/18.9/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.3 %, Band:0.0 %,\n Lymph:8.1 %, Mono:5.5 %, Eos:3.7 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Imaging: BLE US - negative for DVT\n Microbiology: STAPH AUREUS COAG + - sparse growth\n |\n ERYTHROMYCIN---------- =>8 R\n GENTAMICIN------------ <=0.5 S\n LEVOFLOXACIN---------- =>8 R\n OXACILLIN------------- =>4 R\n RIFAMPIN-------------- <=0.5 S\n TETRACYCLINE---------- <=1 S\n TRIMETHOPRIM/SULFA---- <=0.5 S\n VANCOMYCIN------------ <=1 S\n NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA - sparse growth\n |\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- 2 S\n CEFTRIAXONE----------- 8 S\n CIPROFLOXACIN---------<=0.25 S\n GENTAMICIN------------ <=1 S\n IMIPENEM-------------- <=1 S\n LEVOFLOXACIN---------- 1 S\n MEROPENEM------------- 1 S\n PIPERACILLIN---------- 16 S\n PIPERACILLIN/TAZO----- 8 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- 4 R\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ESRD admitted with subdural hematomas after fall, now w/ poor mental\n status and persistent fevers.\n # Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. However, also has a leukocytosis today which he has\n intermittently had, in this case may be due to coritsol stim test.\n Some improvement after d/c of fosphenytoin although one fever spike O/N\n to 101. Has not required pressors for last 48 hrs (one hrs duration\n last night) although still on midodrine and florinef. Have\n extensively searched for underlying source of fevers, including\n repeated pancultures, CT of chest, abdomen, pelvis. The only findings\n have been enlarged mediastinal lymph nodes: (1.5 x 2.1 cm prevascular\n lymph node and a precarinal lymph node measuring 2.2 x 0.7 cm).\n Repeated sputum cultures show gram + cocci, however has already\n received long abx course for MRSA PNA and likely represents continued\n colonization. Also has non-fermenter bacteria (not pseudomonas).\n Have D/c'd nonessential meds to eliminate possible sources of drug\n fever, including fosphenytoin yesterday. Lower extremity US\n negative.\n - f/u diff for bandemia - if positive consider starting tx for non\n fermenter bacteria\n - CXR\n - Continue midodrine and florinef and reduce levophed as tolerated\n (brief requirement over last 24 hours): if no pressor requirement\n today, consider tapering off florinef and midodrine tomorrow\n - d/c all nonessential meds, vanc, dilantin\n - keep sbp> 90\n #Persistent hypotension - poor autonomic function given renal failure,\n vs sepsis vs adrenal insufficiency\n - stim test pending\n - higher threshold to start pressors, sbp> 90\n - no underlying infection has been discovered despite requirement of\n pressors\n #Metabolic alkylosis - Worsening in the state of persistently elevated\n minute ventilation. Overbreathing vent (set at MV of 8.8L/min).\n - avoiding sedation\n - switch to pressure control for improved comfort.\n # Respiratory Distress: On AC with trach. Attempt switch to pressure\n support today.\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: 200 mg dilantin today, then 100 mg\n starting on for 2 days, then can discontinue\n - uptitrating keppra to 250 mg X 2 days, then increase to 500 mg\n qAM and 250 qPM on ; will also get 500 mg boluses after each HD\n session\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n # Access: femoral line\n # FEN: tolerating TF, replate lytes prn\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n - family meeting to discuss goals of care\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:00 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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 PE (not included above)\n Appears agitated, responsive to some commands\n RRR, Nl S1 and S2, no murmur\n Lungs rhonchorous\n Abd non distended non tender\n Femoral line clean, examination causes patient discomfort\n No peripheral edema, extremeities warm and well perfused\n Pupils minimally responsive, able to move all extremeties except RUE.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:17 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601365,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 12\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\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: Yellow / 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 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: Intolerant of\n weaning attempts\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601600,
"text": "Chief Complaint:\n 24 Hour Events:\n Low grade fever to 100.1 at 3pm and 6pm, was BCx\nd x2 and sputum Cx\n with 2+ GPC\ns and 2+ GNR\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 06:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.7\nC (98.1\n HR: 84 (76 - 98) bpm\n BP: 139/53(75) {125/39(65) - 181/78(95)} mmHg\n RR: 24 (17 - 50) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 2,520 mL\n 272 mL\n PO:\n TF:\n 1,440 mL\n 239 mL\n IVF:\n 120 mL\n 33 mL\n Blood products:\n Total out:\n 700 mL\n 0 mL\n Urine:\n NG:\n Stool:\n 700 mL\n Drains:\n Balance:\n 1,820 mL\n 272 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (293 - 414) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 98\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8.6 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 437 K/uL\n 8.4 g/dL\n 254 mg/dL\n 8.8 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 56 mg/dL\n 98 mEq/L\n 139 mEq/L\n 28.3 %\n 13.9 K/uL\n [image002.jpg]\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n WBC\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n Hct\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n Plt\n 220\n 284\n 267\n 338\n 307\n 376\n 437\n Cr\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n TCO2\n 29\n 34\n Glucose\n 300\n 66\n 174\n 219\n 107\n 272\n 254\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.4 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 73yoM h/o ESRD admitted with subdural hematomas after fall, now w/ poor\n mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Low grade fever to 100.1 yesterday afternoon, pt\n was recultured with 2 BCx's and sputum Cx showing 2+ GPC's in pairs and\n 2+ GNR's which do not appear to be new, and pt has received long course\n of ABx for MRSA PNA, so Cx's likely represent continued colonization.\n Workup to date has included removal of all nonessential meds to\n eliminate sources of drug fever, repeated panCx's, LE u/s which was\n negative and CT thorax which recommended MRI Lspine for evaluation of\n infectious etiology vs Schmorl's nods, and subsequent MRI Lspine which\n did not show infectious osteo or discitis. WBC count continues to trend\n down,and pt was not hypotensive through yesterday, pressors now being\n held. Pt currently off ABx.\n 2. Persistent hypotension - poor autonomic function given renal\n failure, vs sepsis vs adrenal insufficiency. stim test adequate.\n - Midodrine held yesterday as sbp's ranging 125-181, now off pressors\n - No underlying infection has been discovered despite requirement of\n pressors\n 3. Respiratory Distress: On PSV with trach, currently with FiO2\n 50%\n - Attempt to trach mask.\n 4. Mental Status change: Per nursing was moving L arm to commands,\n however unable to follow commands this am. Does have spontaneous\n movement of 4 extrems. Unclear underlying etiology: could be secondary\n to slow clearance of sedation or delirium of underlying infection\n versus effect of subdural hematomas.\n -Continue to hold sedation\n 5. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n 6. Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs Dilantin taper, started 100mg daily yesterday and will get\n 100mg today, then stop tomorrow.\n - Uptitrating Keppra, today to receive 500mg in am and 250mg in pm.\n Continue 500mg boluses after HD.\n 7. ESRD:\n - Cont HD w/ femoral temp line, to get HD today\n - Will need to discuss placement of more permanent/tunneled line with\n renal, and whether low grade 100.1 temps will contraindicate.\n 8. SDH: continue to hold anticoagulation, will follow neurology recs\n 9. Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n - Blood sugars in 300\ns yesterday, will need adjustment of SSI\n # Access: femoral line, currently temporary and will need placement of\n more permanent line.\n # FEN: tolerating TF, replate lytes prn\n - IR to evaluate today for placement of PEG tube\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601710,
"text": "Impaired Skin Integrity\n Assessment:\n Pt with stage 2 pressure ulcer to perianal area.\n Action:\n Wound care in to assess and state that ulcer has improved in past\n week. Pt turned and repositioned q 2 hours. Flexiseal in place.\n Response:\n Pt with improvement in pressure ulcer\n Plan:\n Cont with current regimen\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with fever spike this morning to 102, still without source for\n fever.\n Action:\n Fosphenytoin d/c\nd for possible cause of drug fever.\n Head/sinus CT done to r/o sinusitis.\n HD line possibly to be changed to tunneled line tomorrow in IR.\n Blood culture and mycolytic culture sent from HD line today\n Response:\n Results pending\n Plan:\n Cont to monitor for possible causes of fever. Pt supposed to have PEG\n placed tomorrow. If not, may need to change NGT to OGT.\n Altered mental status (not Delirium)\n Assessment:\n Pt continue with depressed mental status from the weekend MD team.\n Pt does open eyes to stimulus and moves spontaneously but does not\n follow commands. When not stimulated, pt is continuously sleeping.\n Action:\n Head CT done\n EEG done\n Response:\n Results pending.\n Plan:\n Continue to monitor MS.\n"
},
{
"category": "Case Management ",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Discharge Plan Note",
"row_id": 602016,
"text": "Case Management Discharge Plan Note\n The patient is a 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b\n seizures after a fall, was ventilated, unresponsive, and having\n persistent fevers thought to be due to drugs, but now waking up a\n little more, weaning from vent, and hasn't now had fevers since \n 8am. Also seen to have sinusitis and mucosal thickenings on CT sinuses.\n This nurse case manager spoke with the patient\ns wife \n this morning. Mrs. has accepted a bed offer from Northeast with discharge likely this afternoon.\n This NCM has also spoken with the MICU resident as well as the\n patient\ns nurse so that all are aware of the discharge plan.\n This NCM has also informed the case manager who is based at\n the practice of the patient\ns PCP of the plan to transfer the patient\n to today. This facility was previously identified by\n as preferred by the practice.\n Please page for any questions or changes in this discharge plan.\n , RN, BSN\n MICU service Case Manager\n Phone: 7-0306 Pager: \n"
},
{
"category": "Physician ",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 602007,
"text": "Chief Complaint: Respiratory failure, fever\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 12:15 PM\n ANGIOGRAPHY - At 12:30 PM\n to IR for picc line and tunneled dialysis line\n TUNNELED (HICKMAN) LINE - START 03:00 PM\n placed in ir\n PICC LINE - START 03:00 PM\n PEG INSERTION - At 04:49 PM\n per ip at the bedside\n DIALYSIS CATHETER - STOP 07:00 PM\n BLOOD CULTURED - At 05:25 AM\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefazolin - 04:30 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 04:45 PM\n Propofol - 05:35 PM\n Fentanyl - 06:00 PM\n Lansoprazole (Prevacid) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) OG / NG tube\n Cardiovascular: Edema, Tachycardia\n Nutritional Support: Tube feeds\n Respiratory: tracheostomy\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, Seizure\n Psychiatric / Sleep: minimally responsive\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.4\nC (97.5\n HR: 87 (74 - 93) bpm\n BP: 141/64(81) {73/33(42) - 172/80(92)} mmHg\n RR: 24 (10 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.1 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,000 mL\n 111 mL\n PO:\n TF:\n IVF:\n 790 mL\n 111 mL\n Blood products:\n Total out:\n 0 mL\n 850 mL\n Urine:\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,000 mL\n -739 mL\n Respiratory support\n O2 Delivery Device: Trach mask , Tracheostomy tube\n Ventilator mode: Standby\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 447 (367 - 447) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 69\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 8.5 L/min\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, Poor dentition, Trache\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), 2/6 SEM\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not\n assessed), failed fistula R\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: No(t) Resonant : , No(t) Hyperresonant: , No(t) Dullness :\n ), (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, No(t) Tender:\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed,\n Tone: Not assessed\n Labs / Radiology\n 7.7 g/dL\n 373 K/uL\n 116 mg/dL\n 9.0 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 50 mg/dL\n 99 mEq/L\n 141 mEq/L\n 24.9 %\n 10.9 K/uL\n [image002.jpg]\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n 04:03 AM\n 10:59 AM\n 05:10 AM\n WBC\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n 13.8\n 10.9\n Hct\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n 28.6\n 24.9\n Plt\n 76\n 437\n 387\n 373\n Cr\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n 7.6\n 9.0\n TCO2\n 34\n 31\n Glucose\n 174\n 219\n 107\n 272\n 254\n 82\n 116\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:38/87, Alk Phos / T Bili:270/0.7,\n Amylase / Lipase:41/42, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.3 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n He has improved his mental status but is still intermittently\n interactive. Does follow simple commands. Hopefully will regain\n additional function as SDH decreases in size. Now again off ventilator\n but cough remains poor and I doubt he can be decannulated without\n signifficant improvement in neurological fxn. Catheters placed\n yesterday - PICC and tunnelled HD line. Has become afebrile - suspect\n this was phenytoin exascerbated this weekend by sinusitis. Plan for\n transfer to today.\n ICU Care\n Nutrition:\n Comments: Tube feeds per PEG\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Tunneled (Hickman) Line - 03:00 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to rehab / long term care facility\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601296,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 05:30 PM\n -obtained lower extremity US to assess for DVT given persistent fevers:\n none seen\n -dilantin on 200 X 2 days, will taper down to 100 X 2 days\n thereafter, then D/c\n -on keppra 250 X 3 days, then keppra 500 qam 250 qpm\n - stim test in PM given hypotension , results pending\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:04 AM\n Fosphenytoin - 06:00 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 06:49 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: 37.3\nC (99.2\n HR: 84 (79 - 98) bpm\n BP: 138/76(93) {76/38(52) - 138/76(93)} mmHg\n RR: 28 (15 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,608 mL\n 176 mL\n PO:\n TF:\n 1,319 mL\n 144 mL\n IVF:\n 129 mL\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,608 mL\n 176 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 548 (291 - 548) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n SpO2: 95%\n ABG: ///33/\n Ve: 9.7 L/min\n Physical Examination\n Cardiovascular: Gen: intubated sedated\n Peripheral 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 307 K/uL\n 8.6 g/dL\n 107 mg/dL\n 5.4 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 101 mEq/L\n 144 mEq/L\n 28.4 %\n 16.6 K/uL\n [image002.jpg]\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n WBC\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n Hct\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n Plt\n 241\n 280\n 220\n \n 307\n Cr\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n TCO2\n 31\n 29\n Glucose\n 155\n 114\n 300\n 66\n 174\n 219\n 107\n Other labs: PT / PTT / INR:12.7/18.9/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.3 %, Band:0.0 %,\n Lymph:8.1 %, Mono:5.5 %, Eos:3.7 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Imaging: BLE US - negative for DVT\n Microbiology: STAPH AUREUS COAG + - sparse growth\n |\n ERYTHROMYCIN---------- =>8 R\n GENTAMICIN------------ <=0.5 S\n LEVOFLOXACIN---------- =>8 R\n OXACILLIN------------- =>4 R\n RIFAMPIN-------------- <=0.5 S\n TETRACYCLINE---------- <=1 S\n TRIMETHOPRIM/SULFA---- <=0.5 S\n VANCOMYCIN------------ <=1 S\n NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA - sparse growth\n |\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- 2 S\n CEFTRIAXONE----------- 8 S\n CIPROFLOXACIN---------<=0.25 S\n GENTAMICIN------------ <=1 S\n IMIPENEM-------------- <=1 S\n LEVOFLOXACIN---------- 1 S\n MEROPENEM------------- 1 S\n PIPERACILLIN---------- 16 S\n PIPERACILLIN/TAZO----- 8 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- 4 R\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ESRD admitted with subdural hematomas after fall, now w/ poor mental\n status and persistent fevers.\n # Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. However, also has a leukocytosis today which he has\n intermittently had, in this case may be due to coritsol stim test.\n Some improvement after d/c of fosphenytoin although one fever spike O/N\n to 101. Has not required pressors for last 48 hrs (one hrs duration\n last night) although still on midodrine and florinef. Have\n extensively searched for underlying source of fevers, including\n repeated pancultures, CT of chest, abdomen, pelvis. The only findings\n have been enlarged mediastinal lymph nodes: (1.5 x 2.1 cm prevascular\n lymph node and a precarinal lymph node measuring 2.2 x 0.7 cm).\n Repeated sputum cultures show gram + cocci, however has already\n received long abx course for MRSA PNA and likely represents continued\n colonization. Also has non-fermenter bacteria (not pseudomonas).\n Have D/c'd nonessential meds to eliminate possible sources of drug\n fever, including fosphenytoin yesterday. Lower extremity US\n negative.\n - f/u diff for bandemia - if positive consider starting tx for non\n fermenter bacteria\n - CXR\n - Continue midodrine and florinef and reduce levophed as tolerated\n (brief requirement over last 24 hours): if no pressor requirement\n today, consider tapering off florinef and midodrine tomorrow\n - d/c all nonessential meds, vanc, dilantin\n - keep sbp> 90\n #Persistent hypotension - poor autonomic function given renal failure,\n vs sepsis vs adrenal insufficiency\n - stim test pending\n - higher threshold to start pressors, sbp> 90\n - no underlying infection has been discovered despite requirement of\n pressors\n #Metabolic alkylosis - Worsening in the state of persistently elevated\n minute ventilation. Overbreathing vent (set at MV of 8.8L/min).\n - avoiding sedation\n - switch to pressure control for improved comfort.\n # Respiratory Distress: On AC with trach. Attempt switch to pressure\n support today.\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: 200 mg dilantin today, then 100 mg\n starting on for 2 days, then can discontinue\n - uptitrating keppra to 250 mg X 2 days, then increase to 500 mg\n qAM and 250 qPM on ; will also get 500 mg boluses after each HD\n session\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n # Access: femoral line\n # FEN: tolerating TF, replate lytes prn\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n - family meeting to discuss goals of care\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:00 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601844,
"text": "Chief Complaint:\n 24 Hour Events:\n --Febrile to 102 this am, re-BCx and Myco/lytic Cx\n --HD yesterday\n --EEG\n --BP's increasing and Fluoronef and Midodrine tapered\n --Head CT with opacification of mastoids, sinus mucosal thickening;\n ethmoidal, L maxillary, and sphenoidal sinuses with hyperdense material\n in L sphenoid sinus, could be inspissated mucus vs fungal infection in\n sphenoid sinus --> NGT removed\n --Held all sedating/pain meds\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.2\nC (97.1\n HR: 81 (73 - 93) bpm\n BP: 150/55(75) {94/22(42) - 159/85(94)} mmHg\n RR: 27 (20 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 283 mL\n PO:\n TF:\n 239 mL\n IVF:\n 44 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -217 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: T-piece, Tracheostomy tube\n Ventilator mode: Standby\n Vt (Spontaneous): 556 (556 - 556) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///28/\n Ve: 12 L/min\n Physical Examination\n Gen: NAD, opens eyes\n CV: RRR\n Lungs: CTA anteriorly\n Abd: ND NT\n Ext: 2+ pulses\n Labs / Radiology\n 387 K/uL\n 8.5 g/dL\n 82 mg/dL\n 7.6 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 42 mg/dL\n 99 mEq/L\n 142 mEq/L\n 28.6 %\n 13.8 K/uL\n [image002.jpg]\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n 04:03 AM\n WBC\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n 13.8\n Hct\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n 28.6\n Plt\n \n 387\n Cr\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n 7.6\n TCO2\n 29\n 34\n Glucose\n 66\n 174\n 219\n 107\n 272\n 254\n 82\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:38/87, Alk Phos / T Bili:270/0.7,\n Amylase / Lipase:41/42, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:3.5 mg/dL\n Imaging: CT HEAD: opacification of mastoids, sinus mucosal thickening;\n ethmoidal, L maxillary, and sphenoidal sinuses with hyperdense material\n in L sphenoid sinus, could be inspissated mucus vs fungal infection in\n sphenoid sinus\n Microbiology: Sputum Gram Stain:\n 2+ GRAM POSITIVE COCCI IN PAIRS.\n 2+ GRAM NEGATIVE ROD(S).\n Assessment and Plan\n 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b seizures after a\n fall, now with unresponsive mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Febrile to 102 this am , pt was recultured re-BCx\n and Myco/lytic Cx. Head CT with opacification of mastoids, sinus\n mucosal thickening; ethmoidal, L maxillary, and sphenoidal sinuses with\n hyperdense material in L sphenoid sinus, could be inspissated mucus vs\n fungal infection in sphenoid sinus --> NGT removedWith 2 BCx's and\n sputum Cx showing 2+ GPC's in pairs and 2+ GNR's which do not appear to\n be new, and pt has received long course of ABx for MRSA PNA, so Cx's\n likely represent continued colonization. Workup to date has included\n removal of all nonessential meds to eliminate sources of drug fever,\n repeated panCx's, LE u/s which was negative and CT thorax which\n recommended MRI Lspine for evaluation of infectious etiology vs\n Schmorl's nods, and subsequent MRI Lspine which did not show infectious\n osteo or discitis. WBC count continues to trend down,and pt was not\n hypotensive through yesterday, pressors now being held. Pt currently\n off ABx.\n - Consult ENT for nasopharyngeal culture or aspirate given concern for\n fungal sinusitis\n - Nasal steroids and afrin\n - Augmentin for bacterial sinusitis\n - Check culture every other day\n 2. Seizure: no gross evidence of ongoing seizure activity; however\n mental status poor, EEG repeated and pending. Dilantin stopped. Keppra\n 500mg in am and 250mg in pm. Continue 500mg boluses after HD.\n 3. DM: On SSI + lantus 40 daily; maintain BG < 250\n - Blood sugars in 300\ns yesterday, will need adjustment of SSI\n 4. Hypotension\nResolving, no pressors> 24hrs. Fluoronef and Midodrine\n tapered. Poor autonomic function given renal failure vs sepsis. \n stim test adequate.\n - Continue to wean Fluoronef and Midodrine as tolerated\n 5. Respiratory Distress: tolerating t-piece\n - recheck ABG\n - vent support as needed\n 6. Mental Status change: Per nursing was moving L arm to commands,\n however unable to follow commands this am. Does have spontaneous\n movement of 4 extrems. Unclear underlying etiology: could be secondary\n to slow clearance of sedation or delirium of underlying infection\n versus effect of subdural hematomas.\n --Continue to hold sedation\n 7. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n --continue wound care\n 8. ESRD: HD yesterday with EPO\n - Cont HD w/ femoral temp line\n - Access still L femoral line placed .\n 8. SDH\nHold anticoagulation.\n --Will get repeat EEG to see if having subclinical seizures.\n 9. Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # Access: femoral line\n - IR evaluated for tunneled HD line to be done tomorrow\n - PICC line to be placed\n # FEN: tolerating TF, replate lytes prn\n - NG pulled yesterday, PEG today, currently NPO\n # PPX: pneumoboots, PPI, bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n - case management for transfer to rehab facility\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601897,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\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: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent non-invasive ventilation\n Visual assessment of breathing pattern: placed on vent due to sedation\n given for procedures.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment: AC 500 x 14 x peep 5 and 100%\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: return to trache mask after procedures\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 Radiology\n 12:15\n Bedside Procedures:\n ABG puncture (10:00)\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601965,
"text": "Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of skin impairment, please refer to metavision\n for specifics.\n Action:\n Pt on kinair bed. Turned and repositioned frequently. Skin care\n provided per wound care recommendations.\n Response:\n Pt\ns skin greatly improved since last week.\n Plan:\n Continue to assess skin, provide skin care per recs, reposition\n frequently, maintain kinair.\n Alteration in Nutrition\n Assessment:\n Pt received with newly placed PEG to low intermittent suction draining\n bilious fluid. Abd soft with bowel sounds. Pt does not grimace with\n abdominal palpation\n Action:\n Meds given via PEG and clamped x3 hours. Then PEG connected to\n drainage bag to gravity.\n Response:\n Drainage bag draining dark bilious fluid.\n Plan:\n PEG to gravity. Can use for meds and then clamp. Tube feeds can be\n restarted at 1800 .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt afebrile throughout shift.\n Action:\n Surveillance blood cultures sent with AM labs. Temp checked.\n Response:\n Afebrile. All blood culture data still pending.\n Plan:\n Continue to monitor temp curve, f/u culture data.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601966,
"text": "Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of skin impairment, please refer to metavision\n for specifics.\n Action:\n Pt on kinair bed. Turned and repositioned frequently. Skin care\n provided per wound care recommendations.\n Response:\n Pt\ns skin greatly improved since last week.\n Plan:\n Continue to assess skin, provide skin care per recs, reposition\n frequently, maintain kinair.\n Alteration in Nutrition\n Assessment:\n Pt received with newly placed PEG to low intermittent suction draining\n bilious fluid. Abd soft with bowel sounds. Pt does not grimace with\n abdominal palpation\n Action:\n Meds given via PEG and clamped x3 hours. Then PEG connected to\n drainage bag to gravity.\n Response:\n Drainage bag draining dark bilious fluid.\n Plan:\n PEG to gravity. Can use for meds and then clamp. Tube feeds can be\n restarted at 1800 .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt afebrile throughout shift.\n Action:\n Surveillance blood cultures sent with AM labs. Temp checked.\n Response:\n Afebrile. All blood culture data still pending.\n Plan:\n Continue to monitor temp curve, f/u culture data.\n ------ Protected Section------\n Note erroneously signed.\n ------ Protected Section Error Entered By: , RN\n on: 06:38 ------\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601988,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt received tunneled HD line, PICC line, and PEG tube all yesterday.\n PEG tube draining dark bilious material when set to drainage\n ENT consulted for sinusitis seen on CT scan, nasal steroids,\n neosynephrine spray, and ABx started.\n Continues only on Keppra, no Dilantin\n Afebrile through yesterday\n RSBI 69 this am\n Transiently hypotense when PEG tube placed, received fluid bolus, but\n otherwise normotensive through day and Midodrine set to lower\n parameters\n 7.38/50/70 on T piece 12L and FiO2 50% but put back on vent overnight\n due to sedation from procedures yesterday, but back to T piece this am\n ENT feels that sinusitis on CT scan is due to obstruction by chronic NG\n tube and that this will clear once NG tube is out. They recommended\n saline wash, nasal steroids, augmentin and re-image in 4 to 7 days.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefazolin - 04:30 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 04:45 PM\n Propofol - 05:35 PM\n Fentanyl - 06:00 PM\n Lansoprazole (Prevacid) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 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: 36.5\nC (97.7\n HR: 86 (74 - 93) bpm\n BP: 172/62(81) {73/33(42) - 172/80(92)} mmHg\n RR: 16 (10 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.1 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,000 mL\n 68 mL\n PO:\n TF:\n IVF:\n 790 mL\n 68 mL\n Blood products:\n Total out:\n 0 mL\n 850 mL\n Urine:\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,000 mL\n -782 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 447 (367 - 447) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 69\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.38/50/70/25/2\n Ve: 8.5 L/min\n PaO2 / FiO2: 175\n Physical Examination\n Opens eyes to voice, squeezed hand on the L but not on the R. Doesn\n track across room. On T piece.\n Rhonchorous BS\n S1 S2 soft, difficult to hear over breath sounds\n Abd protruberant, with new PEG tube placed\n New PICC on L and HD line on R\n Pneumoboots on\n Labs / Radiology\n 373 K/uL\n 7.7 g/dL\n 116 mg/dL\n 9.0 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 50 mg/dL\n 99 mEq/L\n 141 mEq/L\n 24.9 %\n 10.9 K/uL\n [image002.jpg]\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n 04:03 AM\n 10:59 AM\n 05:10 AM\n WBC\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n 13.8\n 10.9\n Hct\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n 28.6\n 24.9\n Plt\n 76\n 437\n 387\n 373\n Cr\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n 7.6\n 9.0\n TCO2\n 34\n 31\n Glucose\n 174\n 219\n 107\n 272\n 254\n 82\n 116\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:38/87, Alk Phos / T Bili:270/0.7,\n Amylase / Lipase:41/42, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.3 mg/dL, PO4:5.0 mg/dL\n Microbiology: Aspergillus still pending\n BCx x4 pending from to \n Catheter tip still pending\n Sputum Cx x3 with GPC coag + Staph and GNR not pseudomonas\n Assessment and Plan\n 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b seizures after a\n fall, was ventilated, unresponsive, and having persistent fevers\n thought to be due to drugs, but now waking up a little more, weaning\n from vent, and hasn't now had fevers since 8am. Also seen to\n have sinusitis and mucosal thickenings on CT sinuses.\n 1. Fevers--Has had negative workup for FUO and leading thought is that\n these were drug fevers, and so all unnecessary drugs were stopped and\n Dilantin has now been tapered. WBC's were 13-14 but going down this am.\n Now with concerning CT scan, and we are treating presumed sinus\n infections.\n --F/u with ENT\n --Continue Augmentin for bacterial sinusitis\n --Continue nasal sprays\n --Plan for re-imaging in a few more days\n --Checking Cx's qod, last one collected today\n 2. ESRD--To get HD today\n --Will try to hold Midodrine before/after HD today and watch bp.\n --If fails that, then Midodrine before HD on Friday\n 3. Drop in Hct over last 24 hrs\n --Will repeat Hct later this afternoon\n --Increase Epo to 5000U with HD today per renal.\n --Consider transfusing with HD today but can likely f/u pm Hct and\n watch\n --Has PICC and HD line\n --Get new T&S this am\n 4. Seizure: Still no e/o ongoing seizure activity. Repeat EEG \n still pending. Continues on Keppra 500mg in am and 250mg in pm.\n Continue 500mg boluses after HD.\n 5. DM: On SSI + lantus 40 daily. BS's well controlled yesterday 100-140\n --Continue insulin regimen as is\n 6. Hypotension--Not requiring pressors. Off Fluoronef and Midodrine\n parameters now decreased to sbp >100. Poor autonomic function given\n renal failure vs sepsis. stim test adequate.\n --Watch bp's through today and if continued good pressures can d/c\n Midodrine\n 7. Respiratory Distress: Tolerated t-piece well and had decent ABG\n yesterday am.\n --Continue weaning vent, currently on T piece this am\n 8. Mental Status change: Appears to be a little more responsive to\n stimuli but still not following commands.\n --Hold sedation\n --Keppra for seizures\n --Continue to treat underlying conditions--sinus infxn?\n 9. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n --continue wound care\n 10. SDH\nHold anticoagulation.\n --Repeat EEG pending\n 11. Glaucoma / Cataracts: continue home eye drops.\n # Access: R sided HD line, L PICC, and PEG tube\n # FEN: TF's through PEG\n # PPX: pneumoboots, PPI, bowel regimen, no subQ heparin due to SDH's\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: f/u with case management for transfer to rehab facility\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 03:00 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601032,
"text": "Chief Complaint:\n 24 Hour Events:\n - spoke with daughter about current situation, did not seem to be ready\n for backing off care, wants to reeval mental status after HD\n - Dilatin d/c'd, neuro to make recs tomorrow re different antiepileptic\n - renal recs: d/c dilantin\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 08:15 AM\n Lansoprazole (Prevacid) - 08:02 PM\n Morphine Sulfate - 04:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.6\nC (99.6\n HR: 79 (73 - 92) bpm\n BP: 97/41(54) {74/38(50) - 172/103(159)} mmHg\n RR: 12 (12 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,670 mL\n 495 mL\n PO:\n TF:\n 1,260 mL\n 457 mL\n IVF:\n 120 mL\n 38 mL\n Blood products:\n Total out:\n 120 mL\n 0 mL\n Urine:\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 1,550 mL\n 495 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 80 (80 - 466) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 97%\n ABG: ///26/\n Ve: 9.4 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 338 K/uL\n 8.9 g/dL\n 219 mg/dL\n 7.6 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 35 mg/dL\n 100 mEq/L\n 142 mEq/L\n 29.2 %\n 9.4 K/uL\n [image002.jpg]\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n WBC\n 8.6\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n Hct\n 30.2\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n Plt\n 196\n 241\n 280\n 220\n 284\n 267\n 338\n Cr\n 5.7\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n TCO2\n 31\n 31\n 29\n Glucose\n 116\n 155\n 114\n 300\n 66\n 174\n 219\n Other labs: PT / PTT / INR:13.9/25.6/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.3 %, Band:0.0 %,\n Lymph:8.1 %, Mono:5.5 %, Eos:3.7 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ESRD admitted with subdural hematomas after fall, now w/ poor mental\n status and persistent fevers.\n .\n # Fevers: Some improvement after d/c of fosphenytoin although one fever\n spike O/N to 101. Has not required pressors for last 24 hrs although\n still on midodrine and florinef. Have extensively searched for\n underlying source of fevers, including re-peated pancultures, CT of\n chest, abdomen, pelvis. The only findings have been enlarged\n mediastinal lymph nodes: (1.5 x 2.1 cm prevascular lymph node and a\n precarinal lymph node measuring 2.2 x 0.7 cm). Repeated sputum\n cultures show gram + cocci, however has already received long abx\n course for MRSA PNA and likely represents continued colonization. Have\n D/c'd nonessential meds to eliminate possible sources of drug fever,\n including fosphenytoin yesterday. Other tests not yet done for fever\n of unknown origin workup include: lower extremity US.\n -Can consider lower extremity US to search for DVT\n - Continue midodrine and florinef and reduce levophed as tolerated\n (hasn't required over last 24 hours): if no pressor requirement today,\n consider tapering off florinef and midodrine tomorrow\n - d/c all nonessential meds, vanc, dilantin\n - keep MAP > 65\n .\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n .\n # Respiratory Distress: Trach placed. Had some oozing but improved.\n Attempt switch to pressure support today.\n - monitor trach site\n - continue HD for volume overload\n .\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n .\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: D/c dilantin yesterday (could be causing clotting in HD);\n will suggest another anti-seizure regimen today; f/u neuro recs\n .\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n .\n # SDH: continue to hold anticoagulation, will follow neurology recs\n .\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n .\n # DM: On SSI + lantus 40 daily; elevated sugars in am\n - adjust SSI\n .\n # Access: femoral line\n .\n # FEN: tolerating TF, give phos\n .\n # PPX: pneumoboots, PPI; bowel reg\n .\n # Code: full (confirmed with wife on admission via phone)\n .\n # Dispo: to remain in ICU while intubated\n - family meeting to discuss goals of care\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:42 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601563,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Rd the pt on CPAP 50%/peep 5/PS 10.Sating 96-98%.LS rhonchorous.\n Action:\n No vent changes overnight.Tolerated trach collar yesterday for 7hrs.\n Response:\n No changes.\n Plan:\n Trach collar today as pt tolerates.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 99.5.\n Action:\n Last BC yesterday.\n Response:\n Afebrile.\n Plan:\n Cont to follow BC.IR to come and evaluate for PEG.TF on hold since 4am.\n"
},
{
"category": "General",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Generic Note",
"row_id": 601828,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. Remains lethargic but following\n commands.\n 98.3 85 159/62\n Responds to commands\n Chest\n mid insp crackles\n CV 2/6 SEM\n Abd\n soft\n WBC 13.8\n Weaned completely off vent. CT showed substantial sinusitis, possibly\n fungal. We are consulting ENT, starting nasal steroids and\n neosyenephrine spray, abx. Plan for access changes today\n IR to place\n tunneled line and PICC if possible today. IV access remains major\n issue going forward. Now off phenytoin and switched to Kepra\n visible sz since switch and mental status seems sl better. Too early\n to see resolution of drug fever. Family mtg later today to rediscuss\n goals of care.\n Time spent 35 min\n Critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601960,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on a T-piece @ 50% cool neb with RR 20-30\ns while\n maintaining sats >97%. ABG repeated on those settings. Pt went later\n to IR for a picc line and tunneled hd catheter placement and was placed\n back on a ventilator for those procedures.\n Action:\n Repeat abg on a T-piece this morning was c/w previous abg results. Lung\n exam notable for diminished breath sounds at the bases. Pt remains on\n ventilatory support during a g-tube placement after receiving iv\n sedation.\n Response:\n Pt doing well off ventilatory support for more than 24 hours. He\n remains on ventilatory support at the present time as a result of\n multiple procedures today requiring iv sedation.\n Plan:\n Continue ventilatory support until pt more alert.\n Hypotension (not Shock)\n Assessment:\n Pt has been normotensive today without receiving any mitodrine.\n Transient hypotension noted in the setting of sedation.\n Action:\n Pt received a fluid bolus x1 for hypotension during the g-tube\n placement.\n Response:\n Transient hypotension was fluid responsive.\n Plan:\n Monitor hemodynamic status closely.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 100-140\n Action:\n Pt received half doses of lantus this morning as well as half doses of\n the riss coverage.\n Response:\n Fingersticks have been within an acceptable range today.\n Plan:\n Monitor fs qid with half doses as long as the pt remains npo.\n Alteration in Nutrition\n Assessment:\n Pt has remained npo without an oral access since his ngt was removed\n earlier this morning.\n Action:\n G-tube placement this evening with the ip service.\n Response:\n Plan:\n give meds tonight although enteral feedings may not be resumed for\n 24 hours.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601962,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on a T-piece @ 50% cool neb with RR 20-30\ns while\n maintaining sats >97%. ABG repeated on those settings. Pt went later\n to IR for a picc line and tunneled hd catheter placement and was placed\n back on a ventilator for those procedures.\n Action:\n Repeat abg on a T-piece this morning was c/w previous abg results. Lung\n exam notable for diminished breath sounds at the bases. Pt remains on\n ventilatory support during a g-tube placement after receiving iv\n sedation.\n Response:\n Pt doing well off ventilatory support for more than 24 hours. He\n remains on ventilatory support at the present time as a result of\n multiple procedures today requiring iv sedation.\n Plan:\n Continue ventilatory support until pt more alert.\n Hypotension (not Shock)\n Assessment:\n Pt has been normotensive today without receiving any mitodrine.\n Transient hypotension noted in the setting of sedation.\n Action:\n Pt received a fluid bolus x1 for hypotension during the g-tube\n placement.\n Response:\n Transient hypotension was fluid responsive.\n Plan:\n Monitor hemodynamic status closely.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 100-140\n Action:\n Pt received half doses of lantus this morning as well as half doses of\n the riss coverage.\n Response:\n Fingersticks have been within an acceptable range today.\n Plan:\n Monitor fs qid with half doses as long as the pt remains npo.\n Alteration in Nutrition\n Assessment:\n Pt has remained npo without an oral access since his ngt was removed\n earlier this morning.\n Action:\n G-tube placement this evening with the ip service.\n Response:\n Plan:\n give meds tonight although enteral feedings may not be resumed for\n 24 hours.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601674,
"text": "Demographics\n Day of mechanical ventilation: 13\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Plan\n Pt. weaned to 50% TM tol ok at this time.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601896,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on a T-piece @ 50% cool neb with RR 20-30\ns while\n maintaining sats >97%. ABG repeated on those settings. Pt went later\n to IR for a picc line and tunneled hd catheter placement and was placed\n back on a ventilator for those procedures.\n Action:\n Repeat abg on a T-piece this morning was c/w previous abg results. Lung\n exam notable for diminished breath sounds at the bases. Pt remains on\n ventilatory support during a g-tube placement after receiving iv\n sedation.\n Response:\n Pt doing well off ventilatory support for more than 24 hours. He\n remains on ventilatory support at the present time as a result of\n multiple procedures today requiring iv sedation.\n Plan:\n Continue ventilatory support until pt more alert.\n Hypotension (not Shock)\n Assessment:\n Pt has been normotensive today without receiving any mitodrine.\n Transient hypotension noted in the setting of sedation.\n Action:\n Pt received a fluid bolus x1 for hypotension during the g-tube\n placement.\n Response:\n Transient hypotension was fluid responsive.\n Plan:\n Monitor hemodynamic status closely.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 100-140\n Action:\n Pt received half doses of lantus this morning as well as half doses of\n the riss coverage.\n Response:\n Fingersticks have been within an acceptable range today.\n Plan:\n Monitor fs qid with half doses as long as the pt remains npo.\n Alteration in Nutrition\n Assessment:\n Pt has remained npo without an oral access since his ngt was removed\n earlier this morning.\n Action:\n G-tube placement this evening with the ip service.\n Response:\n Plan:\n give meds tonight although enteral feedings may not be resumed for\n 24 hours.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601961,
"text": "Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of skin impairment, please refer to metavision\n for specifics.\n Action:\n Pt on kinair bed. Turned and repositioned frequently. Skin care\n provided per wound care recommendations.\n Response:\n Pt\ns skin greatly improved since last week.\n Plan:\n Continue to assess skin, provide skin care per recs, reposition\n frequently, maintain kinair.\n Alteration in Nutrition\n Assessment:\n Pt received with newly placed PEG to low intermittent suction draining\n bilious fluid. Abd soft with bowel sounds. Pt does not grimace with\n abdominal palpation\n Action:\n Meds given via PEG and clamped x3 hours. Then PEG connected to\n drainage bag to gravity.\n Response:\n Drainage bag draining dark bilious fluid.\n Plan:\n PEG to gravity. Can use for meds and then clamp. Tube feeds can be\n restarted at 1800 .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt afebrile throughout shift.\n Action:\n Surveillance blood cultures sent with AM labs. Temp checked.\n Response:\n Afebrile. All blood culture data still pending.\n Plan:\n Continue to monitor temp curve, f/u culture data.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600936,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600942,
"text": "73 year ole man with esrd on hemodialysis admitted with left acute on\n chronic SDH c/b seizure, transferred to MICU for concern of sepsis with\n hypoxia and hypotension. Extubated x3 this admission but requiring\n reintubation within 24 hours. Failure to extubate thought to be r/t\n volume overload and altered mental status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains trached and vented on ac 15x550 w/peep5 and o2 50%. He\n received ivp morphine x2 and appears more comfortable at rest, rarely\n breathing over the set rate. He was suctioned q3-4hrs for small amounts\n of thick, yellow sputum. Of note, pt changed to psv this morning in\n hope of weaning.\n Action:\n Unsuccessful attempt to wean to psv when the pt became acutely sob\n w/respiratory rate ^40\n Response:\n Pt comfortable on ac mode of ventilation with small amounts of morphine\n for comfort.\n Plan:\n Monitor lung exam, wean ventilatory support as pt tolerates, follow\n serial abg\ns, continue pulmonary toilet.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 200-240\ns today.\n Action:\n Pt received insulin per riss parameters. Received lantus @noon.\n Response:\n No improvement noted in fingerstick values following repeat check.\n Plan:\n Slight change made to riss this morning. Continue to monitor serial\n fingersticks with riss coverage.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.7 axillary. Pt received Tylenol @noon. Vancomycin renally\n dosed was discontinued today.\n Action:\n Pt responding to Tylenol dosing with subsequent temperature curve\n trending downward to 98.9 axillary. MICU team to review medication list\n and remove potential causes for a drug fever. Cultures were not\n repeated today.\n Response:\n Currently afebrile s/p Tylenol dosing.\n Plan:\n Follow temperature curve and give Tylenol prn. Follow up with the team\n re: potential drug sources for fever.\n Alteration in Nutrition\n Assessment:\n Abd is soft, distended w/+bs. Although ngt aspirates were elevated this\n morning and tube feedings were held for ~2 hours this morning, feedings\n were resumed w/o incident this afternoon. Pt continues to pass small\n amounts of stool frequently.\n Action:\n Tube feedings held this morning d/t high residuals.\n Response:\n Tube feedings resumed w/o incident this afternoon.\n Plan:\n Follow ngt residuals, continue enteral feedings\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601008,
"text": "Morphine 2mg x1 given for discomfort and pain prior moving and turning\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient trached and vented on A/C 15x550 w/peep 5 and O2 50%.\n He appears more comfortable at rest after morphine IV push this\n afternoon. Bilateral lung sounds rhonchorous and diminished bases. He\n was suctioned q3-4hrs for small amounts of thick, yellow sputum. O2\n sats 99-100%\n Action:\n No change in vent settings, pul toilet and MDI\ns as ordered\n Response:\n Stable overnight, no vent changes\n Plan:\n Wean vent as tolerated, continue pulmonary toilet and MDI\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS >230 . On TF at goal rate\n Action:\n Pt received insulin per riss parameters and lantus fixed dose\n Response:\n Fingersticks 230-246\n Plan:\n Continue to monitor serial fingersticks with riss coverage and fixed\n dose.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spike yesterday AM, afebrile at the beginning of shift,\n Action:\n Fosphenytoin d/ced ? potential drug sources for fever\n Response:\n Low grade temp 99.6\n Plan:\n Follow temperature curve and give Tylenol prn. Follow up culture\n results\n Alteration in Nutrition\n Assessment:\n Abd is soft, distended w/+bs. Tube feed at goal rate, Pt continues to\n pass small amounts of stool frequently.\n Action:\n Tube feeding continued\n Response:\n TF residual <30mls, TF continued at goal\n Plan:\n Follow ngt residuals, continue enteral feedings\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skin issues (see metavision for specifics). On \n air bed, TF continued and patient continues to have incontinence with\n stool\n Action:\n Pt turned and repositioned frequently, Skin kept clean and dry.\n Acyclovir ointment and lidocaine applied to excoriated gluteals and\n scrotum. Wound care as per wound care recommendations\n Response:\n Wounds are healing, No further breakdown in skin\n Plan:\n Continue to turn patient frequently, provide skin care as needed,\n maintain Kinair, treat wounds per wound care recommendations.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600957,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains trached and vented on ac 15x550 w/peep5 and o2 50%. He\n received ivp morphine x2 and appears more comfortable at rest, rarely\n breathing over the set rate. He was suctioned q3-4hrs for small amounts\n of thick, yellow sputum. Of note, pt changed to psv this morning in\n hope of weaning.\n Action:\n Unsuccessful attempt to wean to psv when the pt became acutely sob\n w/respiratory rate ^40\n Response:\n Pt comfortable on ac mode of ventilation with small amounts of morphine\n for comfort.\n Plan:\n Monitor lung exam, wean ventilatory support as pt tolerates, follow\n serial abg\ns, continue pulmonary toilet.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 200-240\ns today.\n Action:\n Pt received insulin per riss parameters. Received lantus @noon.\n Response:\n No improvement noted in fingerstick values following repeat check.\n Plan:\n Slight change made to riss this morning. Continue to monitor serial\n fingersticks with riss coverage.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.7 axillary. Pt received Tylenol @noon. Vancomycin renally\n dosed was discontinued today.\n Action:\n Pt responding to Tylenol dosing with subsequent temperature curve\n trending downward to 98.9 axillary. MICU team to review medication list\n and remove potential causes for a drug fever. Cultures were not\n repeated today.\n Response:\n Currently afebrile s/p Tylenol dosing.\n Plan:\n Follow temperature curve and give Tylenol prn. Follow up with the team\n re: potential drug sources for fever.\n Alteration in Nutrition\n Assessment:\n Abd is soft, distended w/+bs. Although ngt aspirates were elevated this\n morning and tube feedings were held for ~2 hours this morning, feedings\n were resumed w/o incident this afternoon. Pt continues to pass small\n amounts of stool frequently.\n Action:\n Tube feedings held this morning d/t high residuals.\n Response:\n Tube feedings resumed w/o incident this afternoon.\n Plan:\n Follow ngt residuals, continue enteral feedings\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600958,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient trached and vented on A/C 15x550 w/peep 5 and O2 50%.\n He appears more comfortable at rest after morphine IV push this\n afternoon. Bilateral lung sounds rhonchorous and diminished bases. He\n was suctioned q3-4hrs for small amounts of thick, yellow sputum. O2\n sats 99-100%\n Action:\n No change in vent settings, pul toilet and MDI\ns as ordered\n Response:\n Stable overnight,\n Plan:\n Wean vent as tolerated, continue pulmonary toilet and MDI\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS >230 . On TF at goal rate\n Action:\n Pt received insulin per riss parameters and lantus fixed dose\n Response:\n Plan:\n Continue to monitor serial fingersticks with riss coverage and fixed\n dose.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spike yesterday AM, afebrile at the beginning of shift,\n Action:\n Fosphenytoin d/ced ? potential drug sources for fever\n Response:\n Plan:\n Follow temperature curve and give Tylenol prn. Follow up culture\n results\n Alteration in Nutrition\n Assessment:\n Abd is soft, distended w/+bs. Tube feed at goal rate, Pt continues to\n pass small amounts of stool frequently.\n Action:\n Tube feeding continued\n Response:\n Plan:\n Follow ngt residuals, continue enteral feedings\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600959,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient trached and vented on A/C 15x550 w/peep 5 and O2 50%.\n He appears more comfortable at rest after morphine IV push this\n afternoon. Bilateral lung sounds rhonchorous and diminished bases. He\n was suctioned q3-4hrs for small amounts of thick, yellow sputum. O2\n sats 99-100%\n Action:\n No change in vent settings, pul toilet and MDI\ns as ordered\n Response:\n Stable overnight,\n Plan:\n Wean vent as tolerated, continue pulmonary toilet and MDI\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS >230 . On TF at goal rate\n Action:\n Pt received insulin per riss parameters and lantus fixed dose\n Response:\n Plan:\n Continue to monitor serial fingersticks with riss coverage and fixed\n dose.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spike yesterday AM, afebrile at the beginning of shift,\n Action:\n Fosphenytoin d/ced ? potential drug sources for fever\n Response:\n Plan:\n Follow temperature curve and give Tylenol prn. Follow up culture\n results\n Alteration in Nutrition\n Assessment:\n Abd is soft, distended w/+bs. Tube feed at goal rate, Pt continues to\n pass small amounts of stool frequently.\n Action:\n Tube feeding continued\n Response:\n Plan:\n Follow ngt residuals, continue enteral feedings\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skin issues (see metavision for specifics). On \n air bed, TF continued and patient continues to have incontinence with\n stool\n Action:\n Pt turned and repositioned frequently, Skin kept clean and dry.\n Acyclovir ointment and lidocaine applied to excoriated gluteals and\n scrotum. Wound care as per wound care recommendations\n Response:\n Wounds are healing, No further breakdown in skin\n Plan:\n Continue to turn patient frequently, provide skin care as needed,\n maintain Kinair, treat wounds per wound care recommendations.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601119,
"text": "TITLE: 73 year ole man with esrd on hemodialysis admitted with left\n acute on chronic SDH c/b seizure, transferred to MICU for concern of\n sepsis with hypoxia and hypotension. Extubated x3 this admission but\n requiring reintubation within 24 hours. Failure to extubate thought to\n be r/t volume overload and altered mental status.\n UPDATE: Pt required IV Levophed gtt while on HD today to maintain MAP\n > 65, now weaned off s/p completion of HD treatment. MV AC mode\n switched to CPAP/PS 12/5 with 50% FiO2 in place and tolerating well\n with no significant changes in RR, sats, VS, resp pattern. Afebrile\n thus far today. Anti-sz meds added back on today per neuro recs with\n no clinically obvious seizure activity evident @ BS. Family cont to\n visit daily and kept up to date with POC/pt status, still awaiting\n official family meeting to discuss goals of care. The pt may receive a\n PEG once afebrile for > 48 hrs, last fever recorded on @ 08:00.\n +MRSA Contact precautions remain in place. The pt remains a Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on MV support. LS with occ coarse rhonchi,\n sxn\ned for sm to mod amounts of thick tan/ greenish sputum. LS clear\n with effective sxn\ning. Of note, pt failed early AM RSBI with\n increased RR/ decreased sats. #8 Portex trach site appearance is\n benign.\n Action:\n Pt switched to CPAP/PS 12/5 with 50% FiO2 this AM. Sxn\ning provided\n PRN. Pt sat upright 30 degrees to optimize resp fxn.\n Response:\n Pt appears to tol CPAP/PS MV setting well today with no significant\n change in RR, resp pattern, sats, VS.\n Plan:\n Cont to calibrate MV settings to optimize gas exchange/pt comfort.\n Hypotension (not Shock)\n Assessment:\n Pt MAP\ns dropped below 60 with initiation of HD this AM. Team MAP goal\n of 65 noted.\n Action:\n IV Levophed gtt initiated and titrated to keep MAP > 65, pt never\n required the rate above 0.03mcg/kg/min. IV Levophed gtt weaned off\n approx two hours after completion of HD.\n Response:\n Pt responded well to transient IV Levophed gtt.\n Plan:\n Cont to closely follow MAP\ns to ensure MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt is an ESRD pt.\n Action:\n Pt received a four hour HD treatment today. No UF 2^nd need to\n initiate IV Levophed gtt to maintain MAP\ns > 65. Pt received both\n Zemplar & Epogen by HD RN today.\n Response:\n Pt had no issues surrounding HD treatment, HD catheter. Unable to\n remove fluids 2^nd IV Levophed gtt for hypotension.\n Plan:\n Pt will cont to receive HD on M-W-F per HD schedule.\n Altered mental status (not Delirium)\n Assessment:\n The pt does not follow commands nor appear purposeful. The pt will not\n nod his head appropriately to simple yes/no questions. Pt thrashes,\n becomes tachypneic and grimaces in bed in response to direct pt care,\n reaches for trach consistently when LUE is untied.\n Action:\n Pt freq re-oriented to person/place/time/care rationale. 2mg IV\n Morphine provided this AM for grimacing and to facilitate HD\n treatment. Family members cont to visit and are encouraged to interact\n with pt to nl cognition.\n Response:\n Pt appears comfortable for the most part when left alone or in response\n to low dose Morphine SO4. However, pt exhibits agitation/grimacing\n when receiving direct pt care.\n Plan:\n Cont to freq re-orient pt to person/place/time/care rationale. Cont to\n utilize low dose Morphine SO4 for discomfort/agitation.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple open wounds noted in Metavision. Worst lesions are in\n the peri-rectal area. All wounds appear far improved from this past\n weekend.\n Action:\n All sites cleansed with warm water and kept clean. Flexiseal FCS\n placed today and seems to be working well at this time with minimal\n leakage and viscous golden stool output in tubing/drainage bag.\n Response:\n All altered skin areas appear to be improving when last seen on Monday\n AM.\n Plan:\n Cont to follow skin care RN recs. Maintain pt on First Step mattress.\n Cont to turn/re-position pt Q1-2 hrs to ensure optimal skin care/pt\n comfort.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601195,
"text": "EVENTS: high TF residual, 220mls, TF held for 4hrs and restarted in AM\n Continue to have low grade temp\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received, trached, vented, CPAP/PSV 12/5 and 50%. Lung sounds with\n occ rhonchorous, sxn\ned for sm to mod amounts of thick tan/ greenish\n sputum.\n Action:\n Continued CPAP unitil 5am and then patient became tachypneic, RR 40\n and switched to CMV 550/16/5 and 50%, pul toilet and MDI\ns as tolerated\n Response:\n O2 sats 95-100%, thick yellow/greenish secretion with suction. Switched\n to CMV ventilation as he was tachypneic\n Plan:\n Wean vent as tolerated, pul toilet and MDI\n Hypotension (not Shock)\n Assessment:\n SBP 90-120\ns MAP>65, off levophed all through out the shift\n Action:\n Off levophed\n Response:\n MAP> 60-65\n Plan:\n Cont to closely follow MAP\ns to ensure MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt is an ESRD pt.\n Action:\n Pt received a four hour HD treatment yesterday.\n Response:\n AM labs BUN 24/creat 5.4\n Plan:\n Pt will cont to receive HD on M-W-F per HD schedule.\n Altered mental status (not Delirium)\n Assessment:\n The pt does not follow commands nor appear purposeful. Pt thrashes,\n becomes tachypneic and grimaces in bed in response to direct pt care.\n Lt arm restraint in place for safety\n Action:\n Continue to reorient the patient,\n Response:\n No morphine sulphate overnoc\n Plan:\n Cont to freq re-orient pt to person/place/time/care rationale. Cont to\n utilize low dose Morphine SO4 for discomfort/agitation.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skin issues (see metavision for specifics). On \n air bed, flexy seal in place\n Action:\n Pt turned and repositioned frequently, Skin kept clean and dry. Wound\n care as per wound care recommendations\n Response:\n Wounds are healing, No further breakdown in skin\n Plan:\n Continue to turn patient frequently, provide skin care as needed,\n maintain Kinair, treat wounds per wound care recommendations.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601284,
"text": "TITLE: 73 year ole man with esrd on hemodialysis admitted with left\n acute on chronic SDH c/b seizure, transferred to MICU for concern of\n sepsis with hypoxia and hypotension. Extubated x3 this admission but\n requiring reintubation within 24 hours. Failure to extubate thought to\n be r/t volume overload and altered mental status.\n UPDATE: Pt more alert today but does not follow commands nor appear\n purposeful. Pt cont to grimace, thrash and resist direct pt care. Pt\n switched from AC to CPAP/PS this AM with good tol, now on first trach\n mask trial since tracheostomy placement on 10/ . Family cont to visit\n pt (son, , wife), all kept up to date with /pt status. 200ml Q6\n hr FWB initiated today for hypernatremia of 144. Blood C&S & sputum\n C&S sent today for +bandemia on AM WBCC diff & for ax max of 99.7.\n Before transfer to rehab facility the pt will need PEG & new HD cath\n placement. MRSA+ Contact isolation precautions remain in place. The\n pt remains a Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on AC-16-50-550-5 this AM with nl sats, RR in the high\n 20\ns/30\ns, with generally shallow resp. LS have varied from coarse to\n clear today, sxn\ning sm to mod amounts of thick tan sec.\n Action:\n Pt sat upright 30 degrees to optimize resp fxn. MV settings changed to\n CPAP/PS 12/5 with 50% then to with 50% in the afternoon. Pt\n currently on a trach mask trial (TMT) with fair tolerance (RR, HR & BP\n all slightly up). Pt sxn\ned PRN. Awaiting blood & sputum C&S\n results.\n Response:\n HO to obtain ABG shortly to ensure pt tol of TMT.\n Plan:\n F/U ABG drawn/sent for analysis, currently pending. Cont to follow\n resp fxn closely, sxn PRN, adjust resp support accordingly.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt is ESRD receiving HD on M-W-F.\n Action:\n No HD today.\n Response:\n Plan:\n Next HD treatment due on Monday.\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert today when compared with 10/23 but does not follow\n commands nor appear purposeful. The pt does not nod head appropriately\n to simple yes/no questions. Pt conts to resist direct pt care with\n thrashing, restlessness, grimacing. LUE wrist restraint in place to\n protect trach/pt safety. No analgesic or antianxiety meds admin\n today.\n Action:\n Family visitors encouraged to interact with pt, offered stool in order\n to talk directly to pts face. Pt freq re-oriented to\n person/place/time/care rationale to facilitate nl cognition. No\n analgesic or anti-anxiety meds admin today.\n Response:\n MS exam remains marginal at this time.\n Plan:\n Cont to re-orient pt throughout shift to facilitate nl cognition. Hold\n psycho-active agents if able. Cont to promote family/pt interactions.\n Maintain LUE soft wrist restraint for pt safety.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601797,
"text": "Chief Complaint:\n 24 Hour Events:\n --Febrile to 102 this am, re-BCx and Myco/lytic Cx\n --HD yesterday\n --EEG\n --BP's increasing and Fluoronef and Midodrine tapered\n --Head CT with opacification of mastoids, sinus mucosal thickening;\n ethmoidal, L maxillary, and sphenoidal sinuses with hyperdense material\n in L sphenoid sinus, could be inspissated mucus vs fungal infection in\n sphenoid sinus --> NGT removed\n --Held all sedating/pain meds\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.2\nC (97.1\n HR: 81 (73 - 93) bpm\n BP: 150/55(75) {94/22(42) - 159/85(94)} mmHg\n RR: 27 (20 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 283 mL\n PO:\n TF:\n 239 mL\n IVF:\n 44 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -217 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: T-piece, Tracheostomy tube\n Ventilator mode: Standby\n Vt (Spontaneous): 556 (556 - 556) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///28/\n Ve: 12 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 387 K/uL\n 8.5 g/dL\n 82 mg/dL\n 7.6 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 42 mg/dL\n 99 mEq/L\n 142 mEq/L\n 28.6 %\n 13.8 K/uL\n [image002.jpg]\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n 04:03 AM\n WBC\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n 13.8\n Hct\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n 28.6\n Plt\n \n 387\n Cr\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n 7.6\n TCO2\n 29\n 34\n Glucose\n 66\n 174\n 219\n 107\n 272\n 254\n 82\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:38/87, Alk Phos / T Bili:270/0.7,\n Amylase / Lipase:41/42, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:3.5 mg/dL\n Imaging: CT HEAD: opacification of mastoids, sinus mucosal thickening;\n ethmoidal, L maxillary, and sphenoidal sinuses with hyperdense material\n in L sphenoid sinus, could be inspissated mucus vs fungal infection in\n sphenoid sinus\n Microbiology: Sputum Gram Stain:\n 2+ GRAM POSITIVE COCCI IN PAIRS.\n 2+ GRAM NEGATIVE ROD(S).\n Assessment and Plan\n 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b seizures after a\n fall, now with unresponsive mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Febrile to 102 this am , pt was recultured re-BCx\n and Myco/lytic Cx. Head CT with opacification of mastoids, sinus\n mucosal thickening; ethmoidal, L maxillary, and sphenoidal sinuses with\n hyperdense material in L sphenoid sinus, could be inspissated mucus vs\n fungal infection in sphenoid sinus --> NGT removedWith 2 BCx's and\n sputum Cx showing 2+ GPC's in pairs and 2+ GNR's which do not appear to\n be new, and pt has received long course of ABx for MRSA PNA, so Cx's\n likely represent continued colonization. Workup to date has included\n removal of all nonessential meds to eliminate sources of drug fever,\n repeated panCx's, LE u/s which was negative and CT thorax which\n recommended MRI Lspine for evaluation of infectious etiology vs\n Schmorl's nods, and subsequent MRI Lspine which did not show infectious\n osteo or discitis. WBC count continues to trend down,and pt was not\n hypotensive through yesterday, pressors now being held. Pt currently\n off ABx.\n - Nasopharyngeal culture?\n - Will not restart ABx\n - Check culture every other day\n 2. Seizure: no gross evidence of ongoing seizure activity; however\n mental status poor, EEG repeated and pending. Dilantin stopped. Keppra\n 500mg in am and 250mg in pm. Continue 500mg boluses after HD.\n 3. DM: On SSI + lantus 40 daily; maintain BG < 250\n - Blood sugars in 300\ns yesterday, will need adjustment of SSI\n 4. Hypotension\nResolving, no pressors> 24hrs. Fluoronef and Midodrine\n tapered. Poor autonomic function given renal failure vs sepsis. \n stim test adequate.\n - Continue to wean Fluoronef and Midodrine as tolerated\n 5. Respiratory Distress: On PSV with trach, currently with FiO2\n 50%\n --Attempt to trach mask.\n 6. Mental Status change: Per nursing was moving L arm to commands,\n however unable to follow commands this am. Does have spontaneous\n movement of 4 extrems. Unclear underlying etiology: could be secondary\n to slow clearance of sedation or delirium of underlying infection\n versus effect of subdural hematomas.\n --Continue to hold sedation\n 7. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n --continue wound care\n 8. ESRD: HD yesterday with EPO\n - Cont HD w/ femoral temp line\n - Access still L femoral line placed .\n 8. SDH\nHold anticoagulation.\n --Will get repeat EEG to see if having subclinical seizures.\n 9. Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # Access: femoral line\n - IR evaluated for tunneled line to be done tomorrow\n # FEN: tolerating TF, replate lytes prn\n - NG pulled yesterday, PEG today, currently NPO\n # PPX: pneumoboots, PPI, bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601800,
"text": "Chief Complaint:\n 24 Hour Events:\n --Febrile to 102 this am, re-BCx and Myco/lytic Cx\n --HD yesterday\n --EEG\n --BP's increasing and Fluoronef and Midodrine tapered\n --Head CT with opacification of mastoids, sinus mucosal thickening;\n ethmoidal, L maxillary, and sphenoidal sinuses with hyperdense material\n in L sphenoid sinus, could be inspissated mucus vs fungal infection in\n sphenoid sinus --> NGT removed\n --Held all sedating/pain meds\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.2\nC (97.1\n HR: 81 (73 - 93) bpm\n BP: 150/55(75) {94/22(42) - 159/85(94)} mmHg\n RR: 27 (20 - 37) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.7 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 283 mL\n PO:\n TF:\n 239 mL\n IVF:\n 44 mL\n Blood products:\n Total out:\n 500 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -217 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: T-piece, Tracheostomy tube\n Ventilator mode: Standby\n Vt (Spontaneous): 556 (556 - 556) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///28/\n Ve: 12 L/min\n Physical Examination\n Gen: NAD, opens eyes\n CV: RRR\n Lungs: CTA anteriorly\n Abd: ND NT\n Ext: 2+ pulses\n Labs / Radiology\n 387 K/uL\n 8.5 g/dL\n 82 mg/dL\n 7.6 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 42 mg/dL\n 99 mEq/L\n 142 mEq/L\n 28.6 %\n 13.8 K/uL\n [image002.jpg]\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n 04:03 AM\n WBC\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n 13.8\n Hct\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n 28.6\n Plt\n \n 387\n Cr\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n 7.6\n TCO2\n 29\n 34\n Glucose\n 66\n 174\n 219\n 107\n 272\n 254\n 82\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:38/87, Alk Phos / T Bili:270/0.7,\n Amylase / Lipase:41/42, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.3 mg/dL, PO4:3.5 mg/dL\n Imaging: CT HEAD: opacification of mastoids, sinus mucosal thickening;\n ethmoidal, L maxillary, and sphenoidal sinuses with hyperdense material\n in L sphenoid sinus, could be inspissated mucus vs fungal infection in\n sphenoid sinus\n Microbiology: Sputum Gram Stain:\n 2+ GRAM POSITIVE COCCI IN PAIRS.\n 2+ GRAM NEGATIVE ROD(S).\n Assessment and Plan\n 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b seizures after a\n fall, now with unresponsive mental status and persistent fevers.\n 1. Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. Febrile to 102 this am , pt was recultured re-BCx\n and Myco/lytic Cx. Head CT with opacification of mastoids, sinus\n mucosal thickening; ethmoidal, L maxillary, and sphenoidal sinuses with\n hyperdense material in L sphenoid sinus, could be inspissated mucus vs\n fungal infection in sphenoid sinus --> NGT removedWith 2 BCx's and\n sputum Cx showing 2+ GPC's in pairs and 2+ GNR's which do not appear to\n be new, and pt has received long course of ABx for MRSA PNA, so Cx's\n likely represent continued colonization. Workup to date has included\n removal of all nonessential meds to eliminate sources of drug fever,\n repeated panCx's, LE u/s which was negative and CT thorax which\n recommended MRI Lspine for evaluation of infectious etiology vs\n Schmorl's nods, and subsequent MRI Lspine which did not show infectious\n osteo or discitis. WBC count continues to trend down,and pt was not\n hypotensive through yesterday, pressors now being held. Pt currently\n off ABx.\n - Nasopharyngeal culture?\n - Will not restart ABx\n - Check culture every other day\n 2. Seizure: no gross evidence of ongoing seizure activity; however\n mental status poor, EEG repeated and pending. Dilantin stopped. Keppra\n 500mg in am and 250mg in pm. Continue 500mg boluses after HD.\n 3. DM: On SSI + lantus 40 daily; maintain BG < 250\n - Blood sugars in 300\ns yesterday, will need adjustment of SSI\n 4. Hypotension\nResolving, no pressors> 24hrs. Fluoronef and Midodrine\n tapered. Poor autonomic function given renal failure vs sepsis. \n stim test adequate.\n - Continue to wean Fluoronef and Midodrine as tolerated\n 5. Respiratory Distress: On PSV with trach, currently with FiO2\n 50%\n --Attempt to trach mask.\n 6. Mental Status change: Per nursing was moving L arm to commands,\n however unable to follow commands this am. Does have spontaneous\n movement of 4 extrems. Unclear underlying etiology: could be secondary\n to slow clearance of sedation or delirium of underlying infection\n versus effect of subdural hematomas.\n --Continue to hold sedation\n 7. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n --continue wound care\n 8. ESRD: HD yesterday with EPO\n - Cont HD w/ femoral temp line\n - Access still L femoral line placed .\n 8. SDH\nHold anticoagulation.\n --Will get repeat EEG to see if having subclinical seizures.\n 9. Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # Access: femoral line\n - IR evaluated for tunneled line to be done tomorrow\n # FEN: tolerating TF, replate lytes prn\n - NG pulled yesterday, PEG today, currently NPO\n # PPX: pneumoboots, PPI, bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601202,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 05:30 PM\n -obtained lower extremity US to assess for DVT given persistent fevers:\n none seen\n -dilantin on 200 X 2 days, will taper down to 100 X 2 days\n thereafter, then D/c\n -on keppra 250 X 3 days, then keppra 500 qam 250 qpm\n - stim test in PM given hypotension , results pending\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 09:04 AM\n Fosphenytoin - 06:00 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 06:49 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: 37.3\nC (99.2\n HR: 84 (79 - 98) bpm\n BP: 138/76(93) {76/38(52) - 138/76(93)} mmHg\n RR: 28 (15 - 30) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,608 mL\n 176 mL\n PO:\n TF:\n 1,319 mL\n 144 mL\n IVF:\n 129 mL\n 32 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,608 mL\n 176 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 548 (291 - 548) mL\n PS : 12 cmH2O\n RR (Set): 16\n RR (Spontaneous): 30\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n SpO2: 95%\n ABG: ///33/\n Ve: 9.7 L/min\n Physical Examination\n Cardiovascular: Gen: intubated sedated\n Peripheral 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 307 K/uL\n 8.6 g/dL\n 107 mg/dL\n 5.4 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 101 mEq/L\n 144 mEq/L\n 28.4 %\n 16.6 K/uL\n [image002.jpg]\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n WBC\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n Hct\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n Plt\n 241\n 280\n 220\n \n 307\n Cr\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n TCO2\n 31\n 29\n Glucose\n 155\n 114\n 300\n 66\n 174\n 219\n 107\n Other labs: PT / PTT / INR:12.7/18.9/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.3 %, Band:0.0 %,\n Lymph:8.1 %, Mono:5.5 %, Eos:3.7 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Imaging: BLE US - negative for DVT\n Microbiology: STAPH AUREUS COAG + - sparse growth\n |\n ERYTHROMYCIN---------- =>8 R\n GENTAMICIN------------ <=0.5 S\n LEVOFLOXACIN---------- =>8 R\n OXACILLIN------------- =>4 R\n RIFAMPIN-------------- <=0.5 S\n TETRACYCLINE---------- <=1 S\n TRIMETHOPRIM/SULFA---- <=0.5 S\n VANCOMYCIN------------ <=1 S\n NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA - sparse growth\n |\n CEFEPIME-------------- <=1 S\n CEFTAZIDIME----------- 2 S\n CEFTRIAXONE----------- 8 S\n CIPROFLOXACIN---------<=0.25 S\n GENTAMICIN------------ <=1 S\n IMIPENEM-------------- <=1 S\n LEVOFLOXACIN---------- 1 S\n MEROPENEM------------- 1 S\n PIPERACILLIN---------- 16 S\n PIPERACILLIN/TAZO----- 8 S\n TOBRAMYCIN------------ <=1 S\n TRIMETHOPRIM/SULFA---- 4 R\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n ESRD admitted with subdural hematomas after fall, now w/ poor mental\n status and persistent fevers.\n # Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. However, also has a leukocytosis today which he has\n intermittently had, in this case may be due to coritsol stim test.\n Some improvement after d/c of fosphenytoin although one fever spike O/N\n to 101. Has not required pressors for last 48 hrs (one hrs duration\n last night) although still on midodrine and florinef. Have\n extensively searched for underlying source of fevers, including\n repeated pancultures, CT of chest, abdomen, pelvis. The only findings\n have been enlarged mediastinal lymph nodes: (1.5 x 2.1 cm prevascular\n lymph node and a precarinal lymph node measuring 2.2 x 0.7 cm).\n Repeated sputum cultures show gram + cocci, however has already\n received long abx course for MRSA PNA and likely represents continued\n colonization. Also has non-fermenter bacteria (not pseudomonas).\n Have D/c'd nonessential meds to eliminate possible sources of drug\n fever, including fosphenytoin yesterday. Lower extremity US\n negative.\n - f/u diff for bandemia - if positive consider starting tx for non\n fermenter bacteria\n - CXR\n - RUE US to search for DVT\n - Continue midodrine and florinef and reduce levophed as tolerated\n (brief requirement over last 24 hours): if no pressor requirement\n today, consider tapering off florinef and midodrine tomorrow\n - d/c all nonessential meds, vanc, dilantin\n - keep MAP > 60\n #Persistent hypotension - poor autonomic function given renal failure,\n vs sepsis vs adrenal insufficiency\n - stim test pending\n - higher threshold to start pressors\n - no underlying infection has been discovered despite requirement of\n pressors\n #Metabolic alkylosis - Worsening in the state of persistently elevated\n minute ventilation. Overbreathing vent (set at MV of 8.8L/min).\n - avoiding sedation\n - switch to pressure control for improved comfort.\n # Respiratory Distress: On AC with trach. Attempt switch to pressure\n support today.\n - monitor trach site\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: 200 mg dilantin today, then 100 mg\n starting on for 2 days, then can discontinue\n - uptitrating keppra to 250 mg X 2 days, then increase to 500 mg\n qAM and 250 qPM on ; will also get 500 mg boluses after each HD\n session\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n # Access: femoral line\n # FEN: tolerating TF, replate lytes prn\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n - family meeting to discuss goals of care\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 04:00 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601282,
"text": "TITLE: 73 year ole man with esrd on hemodialysis admitted with left\n acute on chronic SDH c/b seizure, transferred to MICU for concern of\n sepsis with hypoxia and hypotension. Extubated x3 this admission but\n requiring reintubation within 24 hours. Failure to extubate thought to\n be r/t volume overload and altered mental status.\n UPDATE: Pt more alert today but does not follow commands nor appear\n purposeful. Pt cont to grimace, thrash and resist direct pt care. Pt\n switched from AC to CPAP/PS this AM with good tol, now on first trach\n mask trial since tracheostomy placement on 10/ . Family cont to visit\n pt (son, , wife), all kept up to date with /pt status. Before\n transfer to rehab facility the pt will need PEG & new HD cath\n placement. MRSA+ Contact isolation precautions remain in place. The\n pt remains a Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on AC-16-50-550-5 this AM with nl sats, RR in the high\n 20\ns/30\ns, with generally shallow resp. LS have varied from coarse to\n clear today, sxn\ning sm to mod amounts of thick tan sec.\n Action:\n Pt sat upright 30 degrees to optimize resp fxn. MV settings changed to\n CPAP/PS 12/5 with 50% then to with 50% in the afternoon. Pt\n currently on a trach mask trial (TMT) with fair tolerance (RR, HR & BP\n all slightly up). Pt sxn\ned PRN. Awaiting blood & sputum C&S\n results.\n Response:\n HO to obtain ABG shortly to ensure pt tol of TMT.\n Plan:\n Cont to follow resp fxn closely, sxn PRN, adjust resp support\n accordingly.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt is ESRD receiving HD on M-W-F.\n Action:\n No HD today.\n Response:\n Plan:\n Next HD treatment due on Monday.\n Altered mental status (not Delirium)\n Assessment:\n Pt more alert today when compared with 10/23 but does not follow\n commands nor appear purposeful. The pt does not nod head appropriately\n to simple yes/no questions. Pt conts to resist direct pt care with\n thrashing, restlessness, grimacing. LUE wrist restraint in place to\n protect trach/pt safety. No analgesic or antianxiety meds admin\n today.\n Action:\n Family visitors encouraged to interact with pt, offered stool in order\n to talk directly to pts face. Pt freq re-oriented to\n person/place/time/care rationale to facilitate nl cognition. No\n analgesic or anti-anxiety meds admin today.\n Response:\n MS exam remains marginal at this time.\n Plan:\n Cont to re-orient pt throughout shift to facilitate nl cognition. Hold\n psycho-active agents if able. Cont to promote family/pt interactions.\n Maintain LUE soft wrist restraint for pt safety.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600986,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 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 / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved; Comments: Pt remained stable this shift with vent outcomes\n all within normal range. Pt had minimal secretion suctioned, with no\n improvements in lung sounds. Pt is still unresponsive but awake. RSBI\n trial was stopped due to pt having tidal volumes lower than 100cc and\n RR reaching high 30s. Pt to be followed up by MD team and to remain on\n current support\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601109,
"text": "TITLE: 73 year ole man with esrd on hemodialysis admitted with left\n acute on chronic SDH c/b seizure, transferred to MICU for concern of\n sepsis with hypoxia and hypotension. Extubated x3 this admission but\n requiring reintubation within 24 hours. Failure to extubate thought to\n be r/t volume overload and altered mental status.\n UPDATE: Pt required IV Levophed gtt while on HD today to maintain MAP\n > 65, now weaned off s/p completion of HD treatment. MV AC mode\n switched to CPAP/PS 12/5 with 50% FiO2 in place and tolerating well\n with no significant changes in RR, sats, VS, resp pattern. Afebrile\n thus far today. Anti-sz meds added back on today per neuro recs with\n no clinically obvious seizure activity evident @ BS. Family cont to\n visit daily and kept up to date with POC/pt status. +MRSA Contact\n precautions remain in place. The pt remains a Full Code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on MV support. LS with occ coarse rhonchi,\n sxn\ned for sm to mod amounts of thick tan/ greenish sputum. LS clear\n with effective sxn\ning. Of note, pt failed early AM RSBI with\n increased RR/ decreased sats. #8 Portex trach site appearance is\n benign.\n Action:\n Pt switched to CPAP/PS 12/5 with 50% FiO2 this AM. Sxn\ning provided\n PRN. Pt sat upright 30 degrees to optimize resp fxn.\n Response:\n Pt appears to tol CPAP/PS MV setting well today with no significant\n change in RR, resp pattern, sats, VS.\n Plan:\n Cont to calibrate MV settings to optimize gas exchange/pt comfort.\n Hypotension (not Shock)\n Assessment:\n Pt MAP\ns dropped below 60 with initiation of HD this AM. Team MAP goal\n of 65 noted.\n Action:\n IV Levophed gtt initiated and titrated to keep MAP > 65, pt never\n required the rate above 0.03mcg/kg/min. IV Levophed gtt weaned off\n approx two hours after completion of HD.\n Response:\n Pt responded well to transient IV Levophed gtt.\n Plan:\n Cont to closely follow MAP\ns to ensure MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601110,
"text": "Demographics\n Day of mechanical ventilation: 10\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\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: Green / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: weaned from AC to PS tolerating well.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: trach collar when tolerated.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601881,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601883,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n -\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601952,
"text": "Impaired Skin Integrity\n Assessment:\n Pt with multiple areas of skin impairment, please refer to metavision\n for specifics.\n Action:\n Pt on kinair bed. Turned and repositioned frequently. Skin care\n provided per wound care recommendations.\n Response:\n Pt\ns skin greatly improved since last week.\n Plan:\n Continue to assess skin, provide skin care per recs, reposition\n frequently, maintain kinair.\n Alteration in Nutrition\n Assessment:\n Pt received with newly placed PEG to low intermittent suction draining\n bilious fluid. Abd soft with bowel sounds. Pt does not grimace with\n abdominal palpation\n Action:\n Meds given via PEG and clamped x3 hours. Then PEG connected to\n drainage bag to gravity.\n Response:\n Drainage bag draining dark bilious fluid.\n Plan:\n PEG to gravity. Can use for meds and then clamp. Tube feeds can be\n restarted at 1800 .\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt afebrile throughout shift.\n Action:\n Surveillance blood cultures sent with AM labs. Temp checked.\n Response:\n Afebrile. All blood culture data still pending.\n Plan:\n Continue to monitor temp curve, f/u culture data.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600985,
"text": "Morphine 2mg x1 given for discomfort and pain before turning\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient trached and vented on A/C 15x550 w/peep 5 and O2 50%.\n He appears more comfortable at rest after morphine IV push this\n afternoon. Bilateral lung sounds rhonchorous and diminished bases. He\n was suctioned q3-4hrs for small amounts of thick, yellow sputum. O2\n sats 99-100%\n Action:\n No change in vent settings, pul toilet and MDI\ns as ordered\n Response:\n Stable overnight, no vent changes\n Plan:\n Wean vent as tolerated, continue pulmonary toilet and MDI\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS >230 . On TF at goal rate\n Action:\n Pt received insulin per riss parameters and lantus fixed dose\n Response:\n Fingersticks 230-246\n Plan:\n Continue to monitor serial fingersticks with riss coverage and fixed\n dose.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spike yesterday AM, afebrile at the beginning of shift,\n Action:\n Fosphenytoin d/ced ? potential drug sources for fever\n Response:\n Low grade temp 99.6\n Plan:\n Follow temperature curve and give Tylenol prn. Follow up culture\n results\n Alteration in Nutrition\n Assessment:\n Abd is soft, distended w/+bs. Tube feed at goal rate, Pt continues to\n pass small amounts of stool frequently.\n Action:\n Tube feeding continued\n Response:\n TF residual <30mls, TF continued at goal\n Plan:\n Follow ngt residuals, continue enteral feedings\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skin issues (see metavision for specifics). On \n air bed, TF continued and patient continues to have incontinence with\n stool\n Action:\n Pt turned and repositioned frequently, Skin kept clean and dry.\n Acyclovir ointment and lidocaine applied to excoriated gluteals and\n scrotum. Wound care as per wound care recommendations\n Response:\n Wounds are healing, No further breakdown in skin\n Plan:\n Continue to turn patient frequently, provide skin care as needed,\n maintain Kinair, treat wounds per wound care recommendations.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601184,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received, trached, vented, CPAP/PSV 12/5 and 50%. Lung sounds with\n occ rhonchorous, sxn\ned for sm to mod amounts of thick tan/ greenish\n sputum.\n Action:\n Continued CPAP unitil 5am and then patient became tachypneic, RR 40\n and switched to CMV 550/16/5 and 50%, pul toilet and MDI\ns as tolerated\n Response:\n O2 sats 95-100%, thick yellow/greenish secretion with suction. Switched\n to CMV ventilation as he was tachypneic\n Plan:\n Wean vent as tolerated, pul toilet and MDI\n Hypotension (not Shock)\n Assessment:\n SBP 90-120\ns MAP>65, off levophed all through out the shift\n Action:\n Off levophed\n Response:\n MAP> 60-65\n Plan:\n Cont to closely follow MAP\ns to ensure MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt is an ESRD pt.\n Action:\n Pt received a four hour HD treatment yesterday.\n Response:\n Plan:\n Pt will cont to receive HD on M-W-F per HD schedule.\n Altered mental status (not Delirium)\n Assessment:\n The pt does not follow commands nor appear purposeful. The pt will not\n nod his head appropriately to simple yes/no questions. Pt thrashes,\n becomes tachypneic and grimaces in bed in response to direct pt care,\n reaches for trach consistently when LUE is untied.\n Action:\n Pt freq re-oriented to person/place/time/care rationale. 2mg IV\n Morphine provided this AM for grimacing and to facilitate HD\n treatment. Family members cont to visit and are encouraged to interact\n with pt to nl cognition.\n Response:\n Pt appears comfortable for the most part when left alone or in response\n to low dose Morphine SO4. However, pt exhibits agitation/grimacing\n when receiving direct pt care.\n Plan:\n Cont to freq re-orient pt to person/place/time/care rationale. Cont to\n utilize low dose Morphine SO4 for discomfort/agitation.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple open wounds noted in Metavision. Worst lesions are in\n the peri-rectal area. All wounds appear far improved from this past\n weekend.\n Action:\n All sites cleansed with warm water and kept clean. Flexiseal FCS\n placed today and seems to be working well at this time with minimal\n leakage and viscous golden stool output in tubing/drainage bag.\n Response:\n All altered skin areas appear to be improving when last seen on Monday\n AM.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601186,
"text": "EVENTS: high TF residual, 220mls, TF held for 4hrs and restarted in AM\n Continue to have low grade temp\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received, trached, vented, CPAP/PSV 12/5 and 50%. Lung sounds with\n occ rhonchorous, sxn\ned for sm to mod amounts of thick tan/ greenish\n sputum.\n Action:\n Continued CPAP unitil 5am and then patient became tachypneic, RR 40\n and switched to CMV 550/16/5 and 50%, pul toilet and MDI\ns as tolerated\n Response:\n O2 sats 95-100%, thick yellow/greenish secretion with suction. Switched\n to CMV ventilation as he was tachypneic\n Plan:\n Wean vent as tolerated, pul toilet and MDI\n Hypotension (not Shock)\n Assessment:\n SBP 90-120\ns MAP>65, off levophed all through out the shift\n Action:\n Off levophed\n Response:\n MAP> 60-65\n Plan:\n Cont to closely follow MAP\ns to ensure MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt is an ESRD pt.\n Action:\n Pt received a four hour HD treatment yesterday.\n Response:\n Plan:\n Pt will cont to receive HD on M-W-F per HD schedule.\n Altered mental status (not Delirium)\n Assessment:\n The pt does not follow commands nor appear purposeful. Pt thrashes,\n becomes tachypneic and grimaces in bed in response to direct pt care.\n Lt arm restraint in place for safety\n Action:\n Continue to reorient the patient,\n Response:\n No morphine sulphate overnoc\n Plan:\n Cont to freq re-orient pt to person/place/time/care rationale. Cont to\n utilize low dose Morphine SO4 for discomfort/agitation.\n Impaired Skin Integrity\n Assessment:\n Pt with multiple skin issues (see metavision for specifics). On \n air bed, flexy seal in place\n Action:\n Pt turned and repositioned frequently, Skin kept clean and dry. Wound\n care as per wound care recommendations\n Response:\n Wounds are healing, No further breakdown in skin\n Plan:\n Continue to turn patient frequently, provide skin care as needed,\n maintain Kinair, treat wounds per wound care recommendations.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601441,
"text": "Chief Complaint:\n 24 Hour Events:\n - Stim 16.9 --> 31.7 --> 36.5, adequate\n - increased free water flushes\n - trial on vent mask, unsuccessful after 2.5 hrs, back on PS 10/5.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fosphenytoin - 04:52 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 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.6\nC (97.9\n HR: 79 (75 - 96) bpm\n BP: 128/61(76) {97/41(61) - 162/119(125)} mmHg\n RR: 26 (16 - 35) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.5 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,977 mL\n 678 mL\n PO:\n TF:\n 1,200 mL\n 240 mL\n IVF:\n 127 mL\n 38 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,977 mL\n 678 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 324 (319 - 378) mL\n PS : 10 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 103\n PIP: 16 cmH2O\n SpO2: 94%\n ABG: 7.38/56/80./29/5\n Ve: 7.7 L/min\n PaO2 / FiO2: 160\n Physical Examination\n Gen: NAD, opens eyes\n CV: RRR, Lungs: CTAB\n Abd: ND NT ABS\n Labs / Radiology\n 376 K/uL\n 9.0 g/dL\n 272 mg/dL\n 7.5 mg/dL\n 29 mEq/L\n 5.2 mEq/L\n 40 mg/dL\n 99 mEq/L\n 142 mEq/L\n 30.0 %\n 14.9 K/uL\n [image002.jpg]\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n WBC\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n 16.6\n 14.9\n Hct\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n 28.4\n 30.0\n Plt\n 280\n 220\n 284\n \n 376\n Cr\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n 5.4\n 7.5\n TCO2\n 29\n 34\n Glucose\n 114\n 300\n 66\n 174\n 219\n 107\n 272\n Other labs: PT / PTT / INR:12.0/22.3/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.0 %, Band:1.0 %,\n Lymph:7.3 %, Mono:6.2 %, Eos:4.2 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Imaging: CXR\n Microbiology: SPUTUM GRAM STAIN:\n 3+: GRAM NEGATIVE ROD(S).\n 1+: GRAM POSITIVE COCCI IN PAIRS.\n Blood Cx: negative from , pending\n Urine Cx: pending\n Assessment and Plan\n 73yoM h/o ESRD admitted with subdural hematomas after fall, now w/ poor\n mental status and persistent fevers.\n # Fevers: Given negative workup for FUO, considering drug fever as\n underlying source. No fever x24hrs. Have D/c'd nonessential meds to\n eliminate possible sources of drug fever, including fosphenytoin.\n Leukocytosis trending down. On midodrine and florinef, few hours on\n very low dose levo. Have extensively searched for underlying source of\n fevers, including repeated pancultures, Lower extremity US negative,\n CT of chest, abdomen, pelvis. Repeated sputum cultures show gram +\n cocci, however has already received long abx course for MRSA PNA and\n likely represents continued colonization.\n #Persistent hypotension - poor autonomic function given renal failure,\n vs sepsis vs adrenal insufficiency. stim test adequate.\n - Continue midodrine and florinef and reduce levophed as tolerated\n (brief requirement over last 24 hours): if no pressor requirement\n today, consider tapering off florinef and midodrine tomorrow\n - higher threshold to start pressors, sbp> 90\n - no underlying infection has been discovered despite requirement of\n pressors\n # Respiratory Distress: On PSV with trach. Attempt to trach mask.\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n #Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: 100 mg starting on for 2 days,\n then can discontinue\n - uptitrating keppra to 250 mg X 2 days, then increase to 500 mg\n qAM and 250 qPM on ; will also get 500 mg boluses after each HD\n session\n # ESRD:\n - cont HD w/ femoral temp line\n - tunneled HD line per renal recs now that his is afebrile\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; maintain BG < 250\n # Access: femoral line\n # FEN: tolerating TF, replate lytes prn\n - consult IP for PEG\n # PPX: pneumoboots, PPI; bowel regimen\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601949,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\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: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Placed on ventilator for elective procedre. Received on PSV,\n weaned IPS o/n.\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 RSBI doe ~69. TC later as tolerated!!!\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 601879,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 600913,
"text": "Objective\n Pertinent medications: glargine, RISS, Abx, B12, folate, others noted\n Labs:\n Value\n Date\n Glucose\n 174 mg/dL\n 02:26 AM\n Glucose Finger Stick\n 193\n 10:00 AM\n BUN\n 20 mg/dL\n 02:26 AM\n Creatinine\n 5.3 mg/dL\n 02:26 AM\n Sodium\n 140 mEq/L\n 02:26 AM\n Potassium\n 3.9 mEq/L\n 02:26 AM\n Chloride\n 103 mEq/L\n 02:26 AM\n TCO2\n 24 mEq/L\n 02:26 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:26 AM\n Phosphorus\n 1.5 mg/dL\n 02:26 AM\n Magnesium\n 1.6 mg/dL\n 02:26 AM\n WBC\n 8.1 K/uL\n 02:26 AM\n Hgb\n 8.8 g/dL\n 02:26 AM\n Hematocrit\n 28.7 %\n 02:26 AM\n Current diet order / nutrition support: Isosource 1.5@ 60 mL/hr c/ 15\n grams beneprotein (2213 kcals/111 gr protein)\n GI: Abd: soft/distended/+bs/+bm\n Assessment of Nutritional Status\n Specifics:\n 73 year old male c/ SDH, ESRD on HD, s/p trach placement yesterday, to\n receive PEG when afebrile. Tube feeds now nfusing via NGT. Formula\n changed to increase fiber in attempt to decrease stool output.\n Per discussion c/ RN, output is decreased. Tube feeds currently\n infusing @ goal but were held for a short time earlier today d/t\n residuals of 120mL. Per current policy, feeds do not need to be held\n unless residuals are >200mL. At goal, feeds meet 100% estimated\n nutrition needs. FSBG\ns elevated, RISS tightened today. Low PO4-1\n packet neutrphos given-will likely need additional repletion.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeds\n Tube feeding recommendations: Continue c/ tube feeds at\n goal, do not hold feeds unless residuals >200mL\n If stool output increases, can trial banana flakes tid\n Continue to adjust insulin regimen prn\n Lyte management as you are, patient may need more Phos\n Following #\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599716,
"text": "Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\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 Comments:\n Remains vented and somnolent. Attempt to wean but in light of previous\n day\ns failed extubation, probably headed for trach. MRV today to assess\n condition of access vessels for dialysis cath.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599717,
"text": "Chief Complaint:\n 24 Hour Events:\n STOOL CULTURE - At 10:43 AM\n c. diff\n INVASIVE VENTILATION - STOP 04:33 PM\n INVASIVE VENTILATION - START 10:20 PM\n - readjusted sliding scale (cut in half) b/c now NPO after OG tube\n removed following extubation; continued on 40 of lantus standing\n -extubated post HD; was respirating on shovel mask at 35 - 40 / min,\n abdominal breathing persistent, tiring out, respiratory distress, was\n reintubated and repeat ABG was: 124* 58* 7.35\n -Neuro suggested starting EEG given tremors; checking daily dilantin\n levels starting tomorrow AM; also they suggested can repeat head CT for\n prognostic purposes especially if worsening MS\n status continues to fluctuate: stopped gabapentin as this can\n accumulate w/ renal failure (was taking for neuropathic pain) and\n checked Vit B12, folate, TSH\n - HD line clotted. No drop in Hct. Has been only receiving half tx of\n HD given slow flow rate.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:37 PM\n Infusions:\n Norepinephrine - 0.03 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Dextrose 50% - 09:40 PM\n Fosphenytoin - 12:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.5\nC (99.5\n HR: 84 (81 - 100) bpm\n BP: 128/49(77) {86/37(53) - 162/64(101)} mmHg\n RR: 22 (12 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 545 mL\n 239 mL\n PO:\n TF:\n 43 mL\n 48 mL\n IVF:\n 363 mL\n 71 mL\n Blood products:\n Total out:\n 2,400 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,855 mL\n 239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (400 - 450) mL\n Vt (Spontaneous): 486 (471 - 486) 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: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 100%\n ABG: 7.43/47/98./31/5\n Ve: 9.2 L/min\n PaO2 / FiO2: 196\n Physical Examination\n Gen: NAD, intubated, sedated\n Neck: Pustular fluid from RIJ\n CV: RRR. Nl S1 and S2\n Lungs: CTAB\n Abd: soft ND NT ABS\n Ext: no c/c/e\n Neuro: responds to commands, can squeeze left hand. Lifts right leg\n off of bed against gravity. Attempts to lift left leg up. No movement\n of RUE. Nods and shakes head in response to questions.\n Labs / Radiology\n 185 K/uL\n 9.3 g/dL\n 77 mg/dL\n 6.0 mg/dL\n 31 mEq/L\n 3.2 mEq/L\n 25 mg/dL\n 104 mEq/L\n 141 mEq/L\n 29.4 %\n 10.4 K/uL\n [image002.jpg]\n 03:56 AM\n 02:20 PM\n 05:59 PM\n 09:34 PM\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n WBC\n 10.4\n Hct\n 29.8\n 29.4\n Plt\n 185\n Cr\n 6.0\n TCO2\n 29\n 34\n 33\n 32\n Glucose\n 50\n 147\n 95\n 88\n 88\n 75\n 77\n Other labs: Amylase / Lipase:41/64, Albumin:2.5 g/dL, Ca++:8.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Fluid analysis / Other labs: Phenytoin = 2.6\n Imaging: CXR - low lung volumes, appears well\n Microbiology: Sputum - - STAPH AUREUS COAG +.\n Sputum GS - Gram positve cocci in pairs and clusters\n Catheter tip - no significant growth\n Cdiff - negative\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed on and off for labile BP.\n - on vancomycin / meropenem (day 6), Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for minimal Staph aureus\n - do not d/c line given lack of access for pressors. Anatomy is poor\n and new line will likely be difficult, continue tx w/ vancomycin\n - Start midodrine to wean levophed\n - ? central etiology of fever/autonomic dysfunction such as seizure\n - daily surveillance cultures.\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum positive for minimal Staph\n aureus. CXR cleared, mental status improved. Attempted trial of\n extubation. Pt failed and is reintubated. Per his lack of\n significant growth in sputum, appears more euvolemic on exam (despite\n 3.5 L + LOS), and clarity of chest Xray, would not expect pt to have\n this degree of respiratory failure. Pt may not be strong enough to\n ventilate on his own.\n - respiratory failure: pt likely will require trach, and long term\n ventilation\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 6, - Vancomycin Day 6 (after completion of 10 day course) for GP and\n GN coverage . Gram stain + GPC in pairs and clusters, cultures\n pending.\n #Scrotal and buttock lesions\n most likely dependent skin ulcers,\n however given location\n - check RPR\n - continue wound care\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n - appears much improved today\n - Vit B12, folate, TSH all normal\n # Seizure: no gross evidence of ongoing seizure activity\n - c/w neuro regarding fosphenytoin dosing considering possible HD\n - f/u EEG\n - most recent CT scan showed stabilization of SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot\n - will pull out PICC given fevers, unclear source and send tip for\n cultures\n - repeat RUE u/S: shows same as prior\n - will need to do MRV eventually\n # ESRD:\n - HD line clotted again yesterday. Address placement of a new line.\n - need MRV first, will d/w Renal\n - f/u renal recs\n - address goals of care\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # R renal cyst\n one complex cyst and one simple cyst on right kidney.\n Radiology rec 12 month follow up.\n - possible malignancy\n - possible abscess seems unlikely\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: axillary A-line, temp line for HD (infected)\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 12:25 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 599817,
"text": "Chief Complaint: Respiratory Failure, Delirium, subdural hematoma\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 Started on midodrine yesterday\n Getting HD this AM\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 03:54 PM\n MRV to eval for SVC syndrome - no SVC occlusion but extensive narrowing\n through neck veins - L IJ, L SC, R SC, R brachiocephalic\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:07 PM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:00 PM\n Fentanyl - 12:24 AM\n Fosphenytoin - 12:35 AM\n Insulin - Regular - 06:27 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Nutritional Support: Tube feeds\n Respiratory: mechanical ventilation\n Genitourinary: Dialysis\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.3\nC (99.1\n HR: 86 (81 - 93) bpm\n BP: 103/39(57) {86/34(51) - 153/61(94)} mmHg\n RR: 18 (13 - 77) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 945 mL\n 823 mL\n PO:\n TF:\n 390 mL\n 435 mL\n IVF:\n 375 mL\n 128 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 945 mL\n 823 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 233 (233 - 233) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 22 cmH2O\n Plateau: 20 cmH2O\n Compliance: 30 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n Ve: 8.4 L/min\n Physical Examination\n General Appearance: No acute distress\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\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, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 234 K/uL\n 183 mg/dL\n 7.7 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 31 mg/dL\n 104 mEq/L\n 141 mEq/L\n 28.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:59 PM\n 09:34 PM\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n WBC\n 10.4\n 10.0\n Hct\n 29.4\n 28.4\n Plt\n 185\n 234\n Cr\n 6.0\n 7.4\n 7.7\n TCO2\n 34\n 33\n 32\n Glucose\n 50\n 147\n 95\n 88\n 88\n 75\n 77\n 135\n 183\n Other labs: PT / PTT / INR:14.4/25.4/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently who now has persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Septic shock-\n Still having low grade fevers and pressor requirment. Cont vanc/.\n Ongoing pressor requirement. Unfortunately, ongoing pressor need along\n with extremely limited access sites make line holiday difficult to\n achieve. Have added midodrine and will try to wean pressors after HD.\n 2)Respiratory Failure- Mental status better today. be able to try\n one more attempt to extubate over weekend if mental status continues to\n improve - but trch remains a distinct possibility if his family agrees\n based on goals of care\n 3)Renal Failure- HD today\n 4)Sub-Dural Hematoma/Altered Mental Status- Mental status today better\n thanb\n 5)Seizure Disorder- Neurontin, Dilantin\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 10:09 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 12:25 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599828,
"text": "Chief Complaint:\n 24 Hour Events:\n - Bolused IV phenytoin 300mg and check free dilantin in AM\n - Pt started on midodrine\n - MRV - narrowing of R Subclav and R Brachiocephalic. Narrowing of L\n subclavian and L IJ. Patent SVC and RIJ. Enlarged mediastinal LN\n unchanged from prior.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:07 PM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:00 PM\n Fentanyl - 12:24 AM\n Fosphenytoin - 12:35 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 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.1\nC (98.8\n HR: 85 (81 - 93) bpm\n BP: 131/48(79) {96/40(59) - 149/61(94)} mmHg\n RR: 77 (13 - 77) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 945 mL\n 295 mL\n PO:\n TF:\n 390 mL\n 210 mL\n IVF:\n 375 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 945 mL\n 295 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 233 (233 - 233) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n Ve: 7.9 L/min\n Physical Examination\n Labs / Radiology\n 234 K/uL\n 9.0 g/dL\n 183 mg/dL\n 7.7 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 31 mg/dL\n 104 mEq/L\n 141 mEq/L\n 28.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:59 PM\n 09:34 PM\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n WBC\n 10.4\n 10.0\n Hct\n 29.4\n 28.4\n Plt\n 185\n 234\n Cr\n 6.0\n 7.4\n 7.7\n TCO2\n 34\n 33\n 32\n Glucose\n 50\n 147\n 95\n 88\n 88\n 75\n 77\n 135\n 183\n Other labs: PT / PTT / INR:14.4/25.4/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Fluid analysis / Other labs: RPR negative\n Imaging: - MRV: narrowing of R Subclav and R Brachiocephalic.\n Narrowing of L subclavian and L IJ. Patent SVC and RIJ. Enlarged\n mediastinal LN unchanged from prior.\n Microbiology: SPUTUM\n -GRAM STAIN: 1+ GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS.\n -RESPIRATORY CULTURE (Preliminary): STAPH AUREUS COAG +. SPARSE\n GROWTH.\n CATHETER TIP: No significant growth.\n Stool: C. diff negative\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Hypotension / Fevers/White count: Continues with fevers, pan cultured\n . Levophed on and off for labile BP.\n - on vancomycin / meropenem (day 7), Meropenem is empiric for GNR\n - All Bcx negative/NGTD, sputum + for minimal Staph aureus\n - do not d/c line given lack of access for pressors, catheter tip\n culture negative. Anatomy is poor and new line will likely be\n difficult, continue tx w/ vancomycin\n - Start midodrine to wean levophed\n - ? central etiology of fever/autonomic dysfunction such as seizure\n - daily surveillance cultures.\n # Respiratory Distress: volume overload (resuscitation with anuric\n renal failure); PNA supported by sputum positive for minimal Staph\n aureus. CXR cleared, mental status improved. Attempted trial of\n extubation. Pt failed and is reintubated. Per his lack of\n significant growth in sputum, appears more euvolemic on exam (despite\n 3.5 L + LOS), and clarity of chest Xray, would not expect pt to have\n this degree of respiratory failure. Pt may not be strong enough to\n ventilate on his own.\n - respiratory failure: pt likely will require trach, and long term\n ventilation\n - volume overload: continue HD\n - pneumonia, completed 10 day course for MRSA pneumonia\n - treating for VAP (fever in setting of hypotension) - Meropenem day\n 7, - Vancomycin Day 7 (after completion of 10 day course) for GP and\n GN coverage .\n #Scrotal and buttock lesions\n most likely dependent skin ulcers, RPR\n negative\n - continue wound care\n # Mental status: - CT head showed no worsening of SDH; no sedation for\n further evaluation of mental status, correct electrolyte disturbances,\n treat infection\n - appears much improved today\n - Vit B12, folate, TSH all normal\n # Seizure: no gross evidence of ongoing seizure activity\n - Bolused IV phenytoin 300mg and check free dilantin in AM\n - f/u EEG\n - most recent CT scan showed stabilization of SDH\n # Right Upper Extremity Swelling: u/s shows non occlusive clot, MRV\n shows narrowing of R Subclav and R Brachiocephalic. Narrowing of L\n subclavian and L IJ. Patent SVC and RIJ. Enlarged mediastinal LN\n unchanged from prior. PICC tip cultures negative. Likely clot.\n -continue to monitor\n # ESRD:\n - HD line clotting with HD, only central access, needs a new line\n - f/u renal recs\n - address goals of care\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. Did have h/o Guaic posive output.\n - continue PPI\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # R renal cyst\n one complex cyst and one simple cyst on right kidney.\n Radiology rec 12 month follow up.\n - possible malignancy\n - possible abscess seems unlikely\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: axillary A-line, temp line for HD (infected)\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n - Family Meeting\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 12:25 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": "2191-09-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600046,
"text": "73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n Altered mental status (not Delirium)\n Assessment:\n Patient alert, not following commands. L arm with normal strength,\n continuously trying to pull out ETT. R arm with no movement. Moves\n bilat legs on bed. L pupil dilated, non reactive. R pupil surgical, non\n reactive. No seizure activity noted this shift.\n Action:\n Patient remains off all sedation. Continues on Dilantin. Level checked\n this afternoon prior to 1600 dose.\n Response:\n Mental status unchanged. No seizure activity noted this shift.\n Plan:\n need Dilantin bolus; follow up on levels drawn at 1600. Continue to\n monitor mental status. Maintain safety with lines and tubes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on CMV 450 /RR 16/ 5 peep/ 50%. SAT 100%. Suctioning\n for large amounts thick white sputum. Lung sounds rhonchorous.\n Action:\n Weaned vent to PSV 10 PS/ % peep/ 50%.\n Response:\n SAT remains 100% ABG sent at 1600 7.41 / 47 / 127 / 4 / 31.\n Plan:\n To remain on PSV as tolerated. This is 3^rd intubation for this\n admission, may require trach placement.\n Hypotension (not Shock)\n Assessment:\n Received patient on Levophed 0.01mcg/kg/min. BP 140\ns/50\ns (70-80\n HR 80-90\ns NSR.\n Action:\n Attempted to wean off pressor. Fludrocortisone Acetate added 0.1mg\n daily.\n Response:\n BP dropped to 70 systolic within 5 minutes of drip shut off.\n Plan:\n Continue Midodrine, Fludrocortisone. Continue to attempt to wean\n pressor.\n Access: #22 G L wrist, VIP port of HD cath.\n Spouse in to visit, updated by RN, MD.\n Patient frequently incontinent of stool.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600105,
"text": "73 yo man admitted , with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the MICU for respiratory\n distress, hypotension & hypoxia. Now intubated, (2 failed\n extubations). Has h/o IDDM and AFIB, not on coumadin due to recent\n SDH.\n Altered mental status (not Delirium)\n Assessment:\n Patient alert, not following commands. L arm with normal strength,\n continuously trying to pull out ETT. R arm with no movement. Moves\n bilat legs on bed. L pupil dilated, non reactive. R pupil surgical, non\n reactive. No seizure activity noted this shift. Received additional\n 300mg dose of Fosphenytoin times one at .\n Action:\n Patient remains off all sedation. Continues on Dilantin.\n Response:\n Mental status unchanged. No seizure activity noted this shift.\n Plan:\n Will need to follow dialntin level. Continue to monitor mental status.\n Maintain safety with lines and tubes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioning for moderate amounts thick white sputum. Lung sounds\n rhonchorous.\n Action:\n PSV 10, peep 5, 50% FiO2\n Response:\n SAT remains mid 90\ns-100%\n Plan:\n Tolerating current vent settings. This is 3^rd intubation for this\n admission, may require trach placement.\n Hypotension (not Shock)\n Assessment:\n Received patient on Levophed 0.01mcg/kg/min. BP 110\ns to 150(70-80\n HR 80-90\ns NSR.\n Action:\n Attempted to wean off pressor. Fludrocortisone Acetate added 0.1mg\n daily.\n Response:\n BP dropped to 70 systolic within 5 minutes of drip shut off.\n Plan:\n Continue Midodrine, Fludrocortisone. Continue to attempt to wean\n pressor.\n Access: #22 G L wrist, VIP port of HD cath.\n Spouse in to visit, updated by RN, MD.\n Patient frequently incontinent of stool.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5, o2 40%. RR\n teens\ns-20\ns with TV ~400cc. Pt suctioned q3-4hrs with saline lavage\n for moderate amounts of thick, rust colored sputum. CXR c/w worsening\n pulmonary edema this morning.\n Action:\n No change in ventilatory status.\n Response:\n Pt not ready for extubation d/t fluid overload and reduced mental\n status.\n Plan:\n Follow lung exam, serial abg\ns, pulmonary toilet.\n Altered mental status (not Delirium)\n Assessment:\n Sedation turned off for\nwake up\n earlier this morning. He is grimacing\n and down during mouth care. He is opening his eyes only when\n stimulated. He is moving his legs laterally on the bed and his left arm\n off the bed. His right arm moves only reflexively to noxious\n stimulation. No purposeful movement noted.\n Action:\n Sedation turned off to assess mental status/neuro exam.\n Response:\n Neither mental status nor motor exam has changed or improved despite\n the sedation having been off for several hours now.\n Plan:\n Would continue to hold sedation as long as behavior does not interfere\n with treatments. Continue to monitor neuro/mental status for changes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 170-190\ns. Pt received sliding scale coverage per hiss. Abd\n exam unchanged. He continues to pass moderate amounts of\n bilious/coffee grounds drainage from his ogt.\n Action:\n Continue ogt to LIS. Nutrition consult placed for TPN recs.\n Response:\n Unchanged.\n Plan:\n Continue to monitor gastric output. Cover q6hr fs with hiss. Anticipate\n TPN recs from nutrition.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 602025,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Pt received tunneled HD line, PICC line, and PEG tube all yesterday.\n PEG tube draining dark bilious material when set to drainage\n ENT consulted for sinusitis seen on CT scan, nasal steroids,\n neosynephrine spray, and ABx started.\n Continues only on Keppra, no Dilantin\n Afebrile through yesterday\n RSBI 69 this am\n Transiently hypotense when PEG tube placed, received fluid bolus, but\n otherwise normotensive through day and Midodrine set to lower\n parameters\n 7.38/50/70 on T piece 12L and FiO2 50% but put back on vent overnight\n due to sedation from procedures yesterday, but back to T piece this am\n ENT feels that sinusitis on CT scan is due to obstruction by chronic NG\n tube and that this will clear once NG tube is out. They recommended\n saline wash, nasal steroids, augmentin and re-image in 4 to 7 days.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Cefazolin - 04:30 PM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 04:45 PM\n Propofol - 05:35 PM\n Fentanyl - 06:00 PM\n Lansoprazole (Prevacid) - 10:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:32 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: 36.5\nC (97.7\n HR: 86 (74 - 93) bpm\n BP: 172/62(81) {73/33(42) - 172/80(92)} mmHg\n RR: 16 (10 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 88.1 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,000 mL\n 68 mL\n PO:\n TF:\n IVF:\n 790 mL\n 68 mL\n Blood products:\n Total out:\n 0 mL\n 850 mL\n Urine:\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 1,000 mL\n -782 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 0 (0 - 500) mL\n Vt (Spontaneous): 447 (367 - 447) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 69\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.38/50/70/25/2\n Ve: 8.5 L/min\n PaO2 / FiO2: 175\n Physical Examination\n Opens eyes to voice, squeezed hand on the L but not on the R. Doesn\n track across room. On T piece.\n Rhonchorous BS\n S1 S2 soft, difficult to hear over breath sounds\n Abd protruberant, with new PEG tube placed\n New PICC on L and HD line on R\n Pneumoboots on\n Labs / Radiology\n 373 K/uL\n 7.7 g/dL\n 116 mg/dL\n 9.0 mg/dL\n 25 mEq/L\n 4.6 mEq/L\n 50 mg/dL\n 99 mEq/L\n 141 mEq/L\n 24.9 %\n 10.9 K/uL\n [image002.jpg]\n 02:26 AM\n 03:20 AM\n 02:30 AM\n 03:44 AM\n 05:18 PM\n 02:55 AM\n 03:36 AM\n 04:03 AM\n 10:59 AM\n 05:10 AM\n WBC\n 8.1\n 9.4\n 16.6\n 14.9\n 13.9\n 13.8\n 10.9\n Hct\n 28.7\n 29.2\n 28.4\n 30.0\n 28.3\n 28.6\n 24.9\n Plt\n 76\n 437\n 387\n 373\n Cr\n 5.3\n 7.6\n 5.4\n 7.5\n 8.8\n 7.6\n 9.0\n TCO2\n 34\n 31\n Glucose\n 174\n 219\n 107\n 272\n 254\n 82\n 116\n Other labs: PT / PTT / INR:11.9/22.0/1.0, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:38/87, Alk Phos / T Bili:270/0.7,\n Amylase / Lipase:41/42, Differential-Neuts:82.4 %, Band:1.0 %,\n Lymph:6.0 %, Mono:6.5 %, Eos:4.4 %, Lactic Acid:1.2 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:2.3 mg/dL, PO4:5.0 mg/dL\n Microbiology: Aspergillus still pending\n BCx x4 pending from to \n Catheter tip still pending\n Sputum Cx x3 with GPC coag + Staph and GNR not pseudomonas\n Assessment and Plan\n 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b seizures after a\n fall, was ventilated, unresponsive, and having persistent fevers\n thought to be due to drugs, but now waking up a little more, weaning\n from vent, and hasn't now had fevers since 8am. Also seen to\n have sinusitis and mucosal thickenings on CT sinuses.\n 1. Fevers--Has had negative workup for FUO and leading thought is that\n these were drug fevers, and so all unnecessary drugs were stopped and\n Dilantin has now been tapered. WBC's were 13-14 but going down this am.\n Now with concerning CT scan, and we are treating presumed sinus\n infections.\n --F/u with ENT\n --Continue Augmentin for bacterial sinusitis\n --Continue nasal sprays\n --Plan for re-imaging in a few more days\n --Checking Cx's qod, last one collected today\n 2. ESRD--To get HD today\n --Will try to hold Midodrine before/after HD today and watch bp.\n --If fails that, then Midodrine before HD on Friday\n 3. Drop in Hct over last 24 hrs\n --Will repeat Hct later this afternoon\n --Increase Epo to 5000U with HD today per renal.\n --Consider transfusing with HD today but can likely f/u pm Hct and\n watch\n --Has PICC and HD line\n --Get new T&S this am\n 4. Seizure: Still no e/o ongoing seizure activity. Repeat EEG \n still pending. Continues on Keppra 500mg in am and 250mg in pm.\n Continue 500mg boluses after HD.\n 5. DM: On SSI + lantus 40 daily. BS's well controlled yesterday 100-140\n --Continue insulin regimen as is\n 6. Hypotension--Not requiring pressors. Off Fluoronef and Midodrine\n parameters now decreased to sbp >100. Poor autonomic function given\n renal failure vs sepsis. stim test adequate.\n --Watch bp's through today and if continued good pressures can d/c\n Midodrine\n 7. Respiratory Distress: Tolerated t-piece well and had decent ABG\n yesterday am.\n --Continue weaning vent, currently on T piece this am\n 8. Mental Status change: Appears to be a little more responsive to\n stimuli but still not following commands.\n --Hold sedation\n --Keppra for seizures\n --Continue to treat underlying conditions--sinus infxn?\n 9. Scrotal and buttock ulcers\n most likely dependent skin ulcers.\n Herpes DFA - negative\n --continue wound care\n 10. SDH\nHold anticoagulation.\n --Repeat EEG pending\n 11. Glaucoma / Cataracts: continue home eye drops.\n # Access: R sided HD line, L PICC, and PEG tube\n # FEN: TF's through PEG\n # PPX: pneumoboots, PPI, bowel regimen, no subQ heparin due to SDH's\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: f/u with case management for transfer to rehab facility\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Tunneled (Hickman) Line - 03:00 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Stable for d/c today to . Will not get HD today, but tomorrow at\n rehab facility, will give appropriate instructions to accepting\n facility as pt may need 10 mg Midodrine before HD. Also may need 1U\n PRBC\ns during HD tomorrow.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:18 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600919,
"text": "Demographics\n Day of mechanical ventilation: 9\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt weaned on PSV settings as charted for 1 hour today; became\n tachypneic & placed back on A/C settings as ordered.\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: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600383,
"text": ": 73 yo man admitted , with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with an oral temp max of 102.4, team notified -- blood and sputum\n C&S subsequently sent for analysis. Pt thought to have infected\n infected RSC HD line which is slatted to be d/c\ned in IR later today.\n Action:\n Following serial oral temp values. Pt med with 650mg PO Acetaminophen\n for comfort.\n Response:\n Pt remains febrile @ this time.\n Plan:\n Cont to follow fever curve, culture data, provide antibx on timed\n schedule, await AM CXR results, send random Vanco level today @ 06:00.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on CPAP/PS 5/5 with 50% FiO2 in place. Sxn\n ETT for sm to mod amounts of thick tan sec with plugs noted on\n occasion. LS have varied from diffuse coarse rhonchi to fairly clear\n s/p effective sxn\ning. RR noted to be in the high 30\ns when pt is\n rhonchorous, improving to the 20\ns with clearance of sec. RT to obtain\n AM RSBI prior to start of AM shift. Nl sat values all shift. Mixed\n venous O2 sat of 61% noted when pts SBP values dropped to 80\n Action:\n Pt sat upright 30 to 45 degrees to optimize resp fxn. Sputum C&S sent\n for analysis. Pt sxn\ned Q2-3 hrs PRN. AM CXR obtained, results\n currently pending.\n Response:\n Pts mixed venous O2 sat was low when pt was in a low flow cardiac\n state.\n Plan:\n Cont to follow lung exam closely, provide sxn\ning as needed for sec\n clearance, provide IV Vanco with HD treatments/follow Vanco serum\n levels. Adjust MV settings to ensure optimal gas exchange. Move pt\n OOB to chair during day shift to maximize resp fxn. Team hopes to\n possibly extubate pt s/p new HD line placement followed by HD treatment\n later today.\n Hypotension (not Shock)\n Assessment:\n Pt became transiently hypotensive on two occasions thus far tonight\n with SBP values dropping/staying in the 80\ns. Both episodes were assoc\n with pt turns. RUE Ax a-line remains positional. Pt is likely\n septic.\n Action:\n IV Levophed briefly started/stopped to maintain MAP values > 60 earlier\n in shift. IV Levophed gtt is currently infusing @ 0.02mcg/kg/min.\n Response:\n Pt is currently normotensive on 0.02mcg/kg/min IV Levophed gtt.\n Plan:\n Cont to closely follow SBP values, calibrate IV Levophed gtt to\n maintain MAP\ns > 65, follow C&S/CXR data.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Ptwith ESRD on HD, Pt had RSC for hD looked infected. TF was held\n since 0300 for new HD line.\n Action:\n Pt went to IR for new HD line this morning, put a new Right fem line\n and pulled out old infected line and tip sent for culture. Pt started\n on HD at 1230 for 1L\n Response:\n Restarted on TF.\n Plan\n Closely monitoring renal function, Follow up with renal team.\n Altered mental status (not Delirium)\n Assessment:\n Pt appears confused/lethargic, inconsistently follows simple commands.\n Pt noted to have hiccoughs all shift. LUE soft wrist restraints in\n place to protect airway. Pt unable/unwilling to nod head\n appropriately to simple yes/no questions.\n Action:\n No psycho-active agents provided to pt. Pt freq re-oriented to\n person/place/time/care rationale to facilitate nl cognition. Verbal\n reassurance provided.\n Response:\n Pt MS with waxing/ delirium.\n Plan:\n Cont to freq re-orient pt, encourage family members to visit pt/engage\n pt psychologically, avoid use of sedatives when possible.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 600689,
"text": "Chief Complaint: Subdural hematoma, Encephalopathy/Delirium,\n Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n MRI of spine last PM to follow up on CT findings of ?osteo in L3-L5\n vertebrae\n Off levophed this this AM\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:05 AM\n MAGNETIC RESONANCE IMAGING - At 10:30 PM\n spine\n FEVER - 102.0\nF - 12:00 PM\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 10:00 PM\n Fentanyl - 10:00 PM\n Fosphenytoin - 08:55 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: mechanical ventilation\n Genitourinary: Foley, Dialysis\n Heme / Lymph: Anemia\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 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 36.4\nC (97.5\n HR: 86 (76 - 93) bpm\n BP: 92/30(46) {57/27(43) - 193/96(122)} mmHg\n RR: 28 (14 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,164 mL\n 57 mL\n PO:\n TF:\n 948 mL\n 2 mL\n IVF:\n 186 mL\n 55 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,164 mL\n 57 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 334 (301 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 29\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 210\n PIP: 16 cmH2O\n SpO2: 98%\n ABG: ///26/\n Ve: 10 L/min\n Physical Examination\n General Appearance: No acute distress\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\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, R arm swelling\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, more\n sleepy this AM\n Labs / Radiology\n 9.2 g/dL\n 284 K/uL\n 66 mg/dL\n 8.1 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 102 mEq/L\n 142 mEq/L\n 30.1 %\n 9.6 K/uL\n [image002.jpg]\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n WBC\n 10.0\n 8.6\n 8.6\n 9.6\n 7.7\n 9.6\n Hct\n 28.4\n 30.2\n 27.7\n 26.7\n 28.4\n 30.1\n Plt\n 80\n 220\n 284\n Cr\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n 6.0\n 8.1\n TCO2\n 32\n 31\n 31\n Glucose\n 77\n 135\n 183\n 116\n 155\n 114\n 300\n 66\n Other labs: PT / PTT / INR:13.3/24.6/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:72.2 %, Band:0.0 %,\n Lymph:12.3 %, Mono:8.8 %, Eos:6.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.5 g/dL, LDH:266 IU/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\n mg/dL\n Fluid analysis / Other labs: ESR: 80\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently - now with persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Septic shock-\n Still spiking fevers - there is a possibility of lumbar osteo on\n abdominal CT. Awaiting read of f/u spine MRI. Cont vanc and continue\n to culture with spikes. Cont midodrine. Femoral HD line.\n 2)Respiratory Failure- Trach today. Holding off on PEG given fevers.\n Appreciate IP's input.\n 3)Renal Failure- Having problem this AM with HD catheter -- TPA being\n administered. If this catheter proves inoperative, will need to\n discuss difficult access isue with renal team\n 4)Sub-Dural Hematoma/Altered Mental Status- Mental status has palteuaed\n - more sleepy today\n 5)Seizure Disorder- Neurontin, Dilantin\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 AM\n Dialysis Catheter - 10:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600692,
"text": "Chief Complaint:\n 24 Hour Events:\n -IP consulted for trach/PEG placement; they will place him tomorrow; is\n NPO after midnight and will receive ddAVP 30 min prior to procedure\n given low platelets\n -optho consulted: felt that no acute management was necessary, that if\n his hospital course is only days more, then he could see an optho as\n outpatient. If going to have continued prolonged hospital course, can\n consult optho formally.\n -CT abd/pelvis: lumbar spine at level of L2-L4 suggestive of\n osteomyelitis, although findings are nonspecific, MRI lumbar obtained\n tonight for further evaluation; final read of CT is still pending\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 10:00 PM\n Fentanyl - 10:00 PM\n Fosphenytoin - 12:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.1\nC (100.5\n HR: 79 (76 - 93) bpm\n BP: 104/34(49) {57/17(34) - 193/96(122)} mmHg\n RR: 23 (14 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,164 mL\n 50 mL\n PO:\n TF:\n 948 mL\n 2 mL\n IVF:\n 186 mL\n 47 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,164 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 301 (301 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 210\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 9.6 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 284 K/uL\n 9.2 g/dL\n 66 mg/dL\n 8.1 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 102 mEq/L\n 142 mEq/L\n 30.1 %\n 9.6 K/uL\n [image002.jpg]\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n WBC\n 10.0\n 8.6\n 8.6\n 9.6\n 7.7\n 9.6\n Hct\n 28.4\n 30.2\n 27.7\n 26.7\n 28.4\n 30.1\n Plt\n 80\n 220\n 284\n Cr\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n 6.0\n 8.1\n TCO2\n 32\n 31\n 31\n Glucose\n 77\n 135\n 183\n 116\n 155\n 114\n 300\n 66\n Other labs: PT / PTT / INR:13.3/24.6/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:72.2 %, Band:0.0 %,\n Lymph:12.3 %, Mono:8.8 %, Eos:6.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.5 g/dL, LDH:266 IU/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers, source still unclear but CT suggests\n possibility of osteomyelitis. ESR is 80, which is lower than what you\n would expect. On vancomycin. On and off pressors despite addition of\n midodrine and florinef. More likely due to abnormal autonomic\n dysfunction to renal failure, but ddx includes infectious etiology\n given recent h/o sepsis.\n - Continue midodrine and florinef and reduce levophed as tolerated\n -keep MAP > 65\n -continue vancomycin which he has been on for coverage of ?line\n infection, would continue this for ? osteomyelitis and it should cover\n the most likely organisms (strep+staph)\n -F/u MRI findings today for osteo; if continued suspicion, can call IR\n for drainage.\n -F/u final read of CT abd\n .\n # Respiratory Distress: Problem of inability to maintain secretions,\n based on failure of attempted trial of extubation. Going for trach\n today\n -IP placing trach today\n -ddAVP 30 minutes prior to procedure\n - continue HD for volume overload\n - f/u sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: continue on fosphenytoin, q4d free phenytoin level\n checks.\n - touch base re: anti-seizure regimen given\n # ESRD:\n - cont HD w/ femoral temp line\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops. Call optho re: eval.\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, femoral line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 AM\n Dialysis Catheter - 10:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Case Management ",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Discharge Plan Note",
"row_id": 602017,
"text": "Case Management Discharge Plan Note\n The patient is a 73yoM h/o ESRD anuric on HD, admitted for SDHs c/b\n seizures after a fall, was ventilated, unresponsive, and having\n persistent fevers thought to be due to drugs, but now waking up a\n little more, weaning from vent, and hasn't now had fevers since \n 8am. Also seen to have sinusitis and mucosal thickenings on CT sinuses.\n This nurse case manager spoke with the patient\ns wife \n this morning. Mrs. has accepted a bed offer from Northeast with discharge likely this afternoon.\n This NCM has also spoken with the MICU resident as well as the\n patient\ns nurse so that all are aware of the discharge plan.\n This NCM has also informed the case manager who is based at\n the practice of the patient\ns PCP of the plan to transfer the patient\n to today. This facility was previously identified by\n as preferred by the practice.\n Please page for any questions or changes in this discharge plan.\n , RN, BSN\n MICU service Case Manager\n Phone: 7-0306 Pager: \n ------ Protected Section ------\n This NCM just spoke with Mrs. and confirmed that the plan is\n to transfer the patient to sometime this afternoon.\n This NCM also provided Mrs. with the address and phone number\n for the facility.\n ------ Protected Section Addendum Entered By: , RN\n on: 12:11 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599771,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Alteration in Nutrition\n Assessment:\n Tube feedings with 50cc residual. Stooling gold brwn stool\n Action:\n Increase tf to goal of 40 cc hr, with flush q 6 hr, following\n residuals, held stool softner this night for multiple stools\n Response:\n Min. residual tf at goal residual 20cc at 0600\n Plan:\n Tf to goal, residual checks freq.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 99.8, no Tylenol given\n Action:\n Supportive care\n Response:\n Stable temp\n Plan:\n Follow temps.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 40%, cmv for night. No distress, suction for mod amt light\n color\n Action:\n No changes in vent sets this night, pulm. Care and support\n Response:\n Sats 100%\n Plan:\n Consideration of trach.\n Hypotension (not Shock)\n Assessment:\n Cont. on levo gtt at .04, started on midodrine today\n Action:\n Increased dose of 10 mgm midodrine tonight given\n Response:\n Cont. need for levo support\n Plan:\n Cont. midodrine, wean levo. As able\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600097,
"text": "Altered mental status (not Delirium)\n Assessment:\n Patient alert, not following commands. L arm with normal strength,\n continuously trying to pull out ETT. R arm with no movement. Moves\n bilat legs on bed. L pupil dilated, non reactive. R pupil surgical, non\n reactive. No seizure activity noted this shift.\n Action:\n Patient remains off all sedation. Continues on Dilantin. Level checked\n this afternoon prior to 1600 dose.\n Response:\n Mental status unchanged. No seizure activity noted this shift.\n Plan:\n need Dilantin bolus; follow up on levels drawn at 1600. Continue to\n monitor mental status. Maintain safety with lines and tubes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on CMV 450 /RR 16/ 5 peep/ 50%. SAT 100%. Suctioning\n for large amounts thick white sputum. Lung sounds rhonchorous.\n Action:\n Weaned vent to PSV 10 PS/ % peep/ 50%.\n Response:\n SAT remains 100% ABG sent at 1600 7.41 / 47 / 127 / 4 / 31.\n Plan:\n To remain on PSV as tolerated. This is 3^rd intubation for this\n admission, may require trach placement.\n Hypotension (not Shock)\n Assessment:\n Received patient on Levophed 0.01mcg/kg/min. BP 140\ns/50\ns (70-80\n HR 80-90\ns NSR.\n Action:\n Attempted to wean off pressor. Fludrocortisone Acetate added 0.1mg\n daily.\n Response:\n BP dropped to 70 systolic within 5 minutes of drip shut off.\n Plan:\n Continue Midodrine, Fludrocortisone. Continue to attempt to wean\n pressor.\n Access: #22 G L wrist, VIP port of HD cath.\n Spouse in to visit, updated by RN, MD.\n Patient frequently incontinent of stool.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600102,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Altered mental status (not Delirium)\n Assessment:\n Patient alert, not following commands. L arm with normal strength,\n continuously trying to pull out ETT. R arm with no movement. Moves\n bilat legs on bed. L pupil dilated, non reactive. R pupil surgical, non\n reactive. No seizure activity noted this shift.\n Action:\n Patient remains off all sedation. Continues on Dilantin.\n Response:\n Mental status unchanged. No seizure activity noted this shift.\n Plan:\n need Dilantin bolus; follow up on levels drawn at 1600. Continue to\n monitor mental status. Maintain safety with lines and tubes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioning for large amounts thick white sputum. Lung sounds\n rhonchorous.\n Action:\n Weaned vent to PSV 10 PS/ % peep/ 50%.\n Response:\n SAT remains 100% ABG sent at 1600 7.41 / 47 / 127 / 4 / 31.\n Plan:\n To remain on PSV as tolerated. This is 3^rd intubation for this\n admission, may require trach placement.\n Hypotension (not Shock)\n Assessment:\n Received patient on Levophed 0.01mcg/kg/min. BP 110\ns to 150(70-80\n HR 80-90\ns NSR.\n Action:\n Attempted to wean off pressor. Fludrocortisone Acetate added 0.1mg\n daily.\n Response:\n BP dropped to 70 systolic within 5 minutes of drip shut off.\n Plan:\n Continue Midodrine, Fludrocortisone. Continue to attempt to wean\n pressor.\n Access: #22 G L wrist, VIP port of HD cath.\n Spouse in to visit, updated by RN, MD.\n Patient frequently incontinent of stool.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains orally intubated and vented on psv10/peep5, o2 40%. RR\n teens\ns-20\ns with TV ~400cc. Pt suctioned q3-4hrs with saline lavage\n for moderate amounts of thick, rust colored sputum. CXR c/w worsening\n pulmonary edema this morning.\n Action:\n No change in ventilatory status.\n Response:\n Pt not ready for extubation d/t fluid overload and reduced mental\n status.\n Plan:\n Follow lung exam, serial abg\ns, pulmonary toilet.\n Altered mental status (not Delirium)\n Assessment:\n Sedation turned off for\nwake up\n earlier this morning. He is grimacing\n and down during mouth care. He is opening his eyes only when\n stimulated. He is moving his legs laterally on the bed and his left arm\n off the bed. His right arm moves only reflexively to noxious\n stimulation. No purposeful movement noted.\n Action:\n Sedation turned off to assess mental status/neuro exam.\n Response:\n Neither mental status nor motor exam has changed or improved despite\n the sedation having been off for several hours now.\n Plan:\n Would continue to hold sedation as long as behavior does not interfere\n with treatments. Continue to monitor neuro/mental status for changes.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS ranging 170-190\ns. Pt received sliding scale coverage per hiss. Abd\n exam unchanged. He continues to pass moderate amounts of\n bilious/coffee grounds drainage from his ogt.\n Action:\n Continue ogt to LIS. Nutrition consult placed for TPN recs.\n Response:\n Unchanged.\n Plan:\n Continue to monitor gastric output. Cover q6hr fs with hiss. Anticipate\n TPN recs from nutrition.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 600366,
"text": "Chief Complaint: Renal Failure, Respiratory Failure, subdural hematoma\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 IR this AM to get R IJ HD line pulled and new line placed in femoral\n vein\n Still on low dose of levophed\n 24 Hour Events:\n BLOOD CULTURED - At 09:57 PM\n C&S drawn/sent from RUE & RSC HD side ports.\n SPUTUM CULTURE - At 09:58 PM\n FEVER - 102.4\nF - 01:00 AM\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:45 PM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 02:07 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: mechanical ventilation\n Genitourinary: Dialysis\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.4\nC (99.3\n HR: 91 (76 - 95) bpm\n BP: 137/55(86) {92/32(54) - 150/55(89)} mmHg\n RR: 26 (20 - 45) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n CO/CI (Fick): (6.1 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 62 - 62\n Total In:\n 1,203 mL\n 290 mL\n PO:\n TF:\n 1,072 mL\n 121 mL\n IVF:\n 6 mL\n 19 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 532 (255 - 532) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 167\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///24/\n Ve: 11.8 L/min\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: scattered)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: none, Left lower extremity\n edema: Trace, R arm swelling\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 280 K/uL\n 114 mg/dL\n 9.9 mg/dL\n 24 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 101 mEq/L\n 138 mEq/L\n 26.7 %\n 9.6 K/uL\n [image002.jpg]\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n 9.6\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n 26.7\n Plt\n 185\n 234\n 196\n 241\n 280\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n TCO2\n 32\n 31\n 31\n Glucose\n 88\n 75\n 77\n 135\n 183\n 116\n 155\n 114\n Other labs: PT / PTT / INR:14.0/25.4/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:7.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently - now with persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Septic shock-\n Continues to have low grade fevers and low dose pressor requirment.\n Cont vanc for MRSA in sputum. Cont midodrine. Getting R IJ line\n pulled today and replaced with femoral HD line\n 2)Respiratory Failure- Mental status has plateaued - pt dooing well on\n PSV 5/5. Need to establish reintubation plan with family prior to\n proceeding with extubation - likely tomorrow given IR\n procedure/sedation today. Need to establish if they would want to\n proceed with trach if he fails extubation.\n 3)Renal Failure- next HD this afternoon per renal\n 4)Sub-Dural Hematoma/Altered Mental Status- Improved mental status from\n last week but has plateued somewhat\n 5)Seizure Disorder- Neurontin, Dilantin\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 22 Gauge - 03:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "General",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Generic Note",
"row_id": 600370,
"text": "TITLE: Rehab \n Pt. continues to be medically inappropriate for PT treatment. Will sign\n off as have not been able to see patient for 2 weeks. Please re-consult\n when status improves. Page with questions.\n Pager \n"
},
{
"category": "Nursing",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600465,
"text": "HPI: 73 yo man admitted , with left SDH c/b seizure and possible\n line infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Diabetes Mellitus (DM), Type II\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600470,
"text": "HPI: 73 yo man admitted , with left SDH c/b seizure and possible\n line infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation.\n Of note MS \n . Aline removed (see\n below).\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101 F oral tonight. Mult cx\ns already pending.\n Action:\n Admin Tylenol, tepid bath, cool cloth to forehead.\n Response:\n Temp decreased this AM to 98.8 F.\n Plan:\n Offer supportive care, follow cx data.\n Hypotension (not Shock)\n Assessment:\n Received pt on 0.02 mcg/kg/min levophed. A line dislodged, then lost\n waveform.\n Action:\n Remove a line, place NBP on RLE. Titrate levo as tol. Admin midodrine\n asdir.\n Response:\n This AM levo at 0.03 mcg/kg/min.\n Plan:\n Wean levo as able.\n Diabetes Mellitus (DM), Type II\n Assessment:\n BG elevated . TF running at goal.\n Action:\n Admin RISS asdir.\n Response:\n BG remains elevated.\n Plan:\n Cont to check BG q 6 hr or more prn, re-address long acting / SS if\n needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated 50% PS 5/5. Sp02 100%, Tv 250. LS rhonchi bilat\n , mod thick tan secretions via ETT. SRR 25-31.\n Action:\n Suction PRN, pulm toilet, MDIs, freq reposition.\n Response:\n this AM 65.\n Plan:\n Consider trach despite adequate pt has weak cough, thick\n secretions, and AMS.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600676,
"text": "Chief Complaint:\n 24 Hour Events:\n -IP consulted for trach/PEG placement; they will place him tomorrow; is\n NPO after midnight and will receive ddAVP 30 min prior to procedure\n given low platelets\n -optho consulted: felt that no acute management was necessary, that if\n his hospital course is only days more, then he could see an optho as\n outpatient. If going to have continued prolonged hospital course, can\n consult optho formally.\n -CT abd/pelvis: lumbar spine at level of L2-L4 suggestive of\n osteomyelitis, although findings are nonspecific, MRI lumbar obtained\n tonight for further evaluation; final read of CT is still pending\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 10:00 PM\n Fentanyl - 10:00 PM\n Fosphenytoin - 12:03 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.1\nC (100.5\n HR: 79 (76 - 93) bpm\n BP: 104/34(49) {57/17(34) - 193/96(122)} mmHg\n RR: 23 (14 - 31) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,164 mL\n 50 mL\n PO:\n TF:\n 948 mL\n 2 mL\n IVF:\n 186 mL\n 47 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,164 mL\n 50 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 301 (301 - 475) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 210\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///26/\n Ve: 9.6 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 284 K/uL\n 9.2 g/dL\n 66 mg/dL\n 8.1 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 102 mEq/L\n 142 mEq/L\n 30.1 %\n 9.6 K/uL\n [image002.jpg]\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n WBC\n 10.0\n 8.6\n 8.6\n 9.6\n 7.7\n 9.6\n Hct\n 28.4\n 30.2\n 27.7\n 26.7\n 28.4\n 30.1\n Plt\n 80\n 220\n 284\n Cr\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n 6.0\n 8.1\n TCO2\n 32\n 31\n 31\n Glucose\n 77\n 135\n 183\n 116\n 155\n 114\n 300\n 66\n Other labs: PT / PTT / INR:13.3/24.6/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:72.2 %, Band:0.0 %,\n Lymph:12.3 %, Mono:8.8 %, Eos:6.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.5 g/dL, LDH:266 IU/L, Ca++:8.7 mg/dL, Mg++:1.9 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers, source still unclear but CT suggests\n possibility of osteomyelitis. ESR is 80, which is lower than what you\n would expect. On vancomycin. On and off pressors despite addition of\n midodrine and florinef. More likely due to abnormal autonomic\n dysfunction to renal failure, but ddx includes infectious etiology\n given recent h/o sepsis.\n - Continue midodrine and florinef and reduce levophed as tolerated\n -keep MAP > 65\n -continue vancomycin which he has been on for coverage of ?line\n infection, would continue this for ? osteomyelitis and it should cover\n the most likely organisms (strep+staph)\n -F/u MRI findings today for osteo; if continued suspicion, can call IR\n for drainage.\n -F/u final read of CT abd\n .\n # Respiratory Distress: Problem of inability to maintain secretions,\n based on failure of attempted trial of extubation. Going for trach\n today\n -IP placing trach today\n -ddAVP 30 minutes prior to procedure\n - continue HD for volume overload\n - f/u sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: continue on fosphenytoin, q4d free phenytoin level\n checks.\n - touch base re: anti-seizure regimen given\n # ESRD:\n - cont HD w/ femoral temp line\n - replace RIJ HD line when infection heals.\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops. Call optho re: eval.\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, femoral line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 AM\n Dialysis Catheter - 10:30 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": "2191-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600807,
"text": "Impaired Skin Integrity\n Assessment:\n Pt with multiple skin issues (see metavision for specifics).\n Action:\n On Kinair bed, pt turned and repositioned frequently when dialysis was\n completed. Skin kept clean and dry. Acyclovir ointment and lidocaine\n applied to excoriated gluteals and scrotum. Evaluated today with MICU\n CNS.\n Response:\n No further breakdown in skin. MICU CNS stated the area looks improved.\n Plan:\n Continue to turn patient frequently, provide skin care as needed,\n maintain Kinair, treat wounds per wound care recommendations.\n Alteration in Nutrition\n Assessment:\n Pt received NPO for trach placement today.\n Action:\n Pt trached today and OGT was pulled with ETT. NGT placed in left nare.\n Pt given\n dose of lantus this afternoon because NPO.\n Response:\n NGT confirmed by CXR. Tube feeds not restarted today due to likely\n placement of PEG tomorrow. PEG not placed today because pt was febrile\n overnight.\n Plan:\n If pt spikes temp then can restart tube feeds because PEG won\nt be\n placed until 24hours afebrile. Q6hour finger sticks.\n Altered mental status (not Delirium)\n Assessment:\n Pt is alert with eyes open, does not follow commands, makes purposeful\n movement with left arm only (eg trying to pull at NGT and trach), does\n not move right arm, BLE moving on the bed.\n Action:\n Neuros assessed.\n Response:\n Neuro assessment back to baseline after pt recovered from anesthesia.\n Plan:\n Continue to assess neuro status.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received intubated CPAP + PS 10/5 50% with sats 100%.\n Action:\n Trach placed at bedside by IP.\n Response:\n Pt tolerated anesthesia and is not back on original settings continuing\n with sats 100% and no tachypnea, bloody sputum suctioned and blood\n around trach insertion site that has now clotted off.\n Plan:\n Maintain current settings. IP aware of bleeding, no intervention at\n this time.\n"
},
{
"category": "General",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Generic Note",
"row_id": 600887,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. More sedated\n got lorazepam\n and morphine overnight.\n 101.7 (ax) 89 118/81\n Chest\n few mid insp crackles\n CV 2/6 SEM\n Abd\n soft obese\n Extrem\n 2+ edema\n WBC 8.1\n 6% Eos\n Glu 174\n Sedated overnight due to apparent discomfort with nursing care. Remains\n febrile with multiple neg cx. Drug fever seems likely to be\n contributing particularly with eosinbophilia. Phenytoin may be first\n thing to stop. Would d/c all meds we can given persistent fever.\n Remains on vent in AC\n will switch to PSV and hopefully try trache\n collar today. BP holding on Midodrine.\n Trying to arrange family mtg for discussion of goals of care.\n Time spent 40 min\n Critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599890,
"text": "Day of mechanical ventilation: 3\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\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 / Moderate\n Comments:\n Pt remains on same vent settings with no ABG\ns. Still with pressor\n requirement. Slow improvement in mental status. Will probably try to\n trach over weekend. If failed, he will need trach.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599891,
"text": "Altered mental status (not Delirium)\n Assessment:\n Pt. intermittently alert, responsive to voice. Pupils surgical\n bilaterally and do not react. Pt. able to follow commands with LE\n (\nthumbs up\n/squeeze) and BLE\ns (wiggle toes, bend at knees). RUE does\n respond to pain with very brisk withdrawal. Pt. nodding to\n communicate, sometimes inconsistenly.\n Action:\n Neuro checks as ordered. Fosphenytoin change/administered.\n Response:\n No significant change in MS today. No seizure activity noted.\n Plan:\n Continue to monitor and treat as indicated.\n Hypotension (not Shock)\n Assessment:\n BP extremely labile. Please note all validated entries. Pt. cont\ns to\n require low dose levophed gtt. Skin warm, dry, RUE edematous due to\n thrombus. HD today, removed 3 Liters. Anuric.\n Action:\n Levophed titrated frequently as documented, required greatest dose\n during HD. Midodrine 10mg given tid today.\n Response:\n See vital signs/titration. .02mcg/kg/min will drop BP into\n 80\ns/30-40\ns if weaned regardless of situation. Pt. presently stable\n on .03mcg with MAP 67.\n Plan:\n Continue attempts to wean off levophed. Ultimate goal is line holiday\n when pressor off due to known abcess to HD cath. Continue midodrine,\n team to consider increasing to 15mg tid.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with presumed VAP remains on CMV with history failing extubation\n trials x 2 and tiring on PSV. Minimal/ineffective spontaneous cough.\n Action:\n No vent changes made today. Vanco dosed renally and given this\n afternoon. Suctioned Q3hr for small to moderate amt. white thick\n secretions.\n Response:\n Sats 100% with no resp. distress noted.\n Plan:\n Continue antibiotic therapy, pulmonary hygiene, get OOB on non HD\n days. Possible trach vs. extubation over weekend or early next week.\n *Please note metavision for altered skin integrity A A R P. Pain\n medication helpful prior to incontinence/skin/wound/peri care.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599963,
"text": "Events: BP remains labile w/ any attempt to wean SBP 77- 180\ns/ MAP\n 40-70\ns and remains on low dose Levo gtt @ .01mcg/kg/hr. Pt alert all\n night and will intermittently approp respond to questioning- cont to be\n agitated with nursing care, oral care, turning, wound care,? pt is back\n pain/wound. Pt s/p fall with known SDH medically treated since\n admission for ? seizure activity since admission. Neuro following but\n medical plan to optimize Dilanin therapy. Pt with intermittent left\n hand rhythmic twitch, noted x1 to have left facial and left leq\n twitch- all less than 20 sec and resolving on own- pt the agitated and\n given 1mg IVP Midaz. Pt will actively reach at pull at ETT. Increased\n anxiety and audibly rhonchi x 1 overnight, pt coughing- suction for\n thick white secretions and sm mucus plug. T max 100.8 ax. Cont to have\n continuous loose green stool.\n Alteration in Nutrition\n Assessment:\n Changed to Nutren 2.0 FS with 30 mg beneprotein\n Action:\n 20 cc residuals, TF @ goal 40cc/hr with 50cc free water flush Q6\n Response:\n Tolerating\n Plan:\n Cont TF @ goal, monitor residuals\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt bites with oral care/temps- T max 100.8 ax, not diaphoretic,\n Action:\n Not re-cultured,\n Response:\n Cont temp 100 ax\n Plan:\n On Vanco IV with HD, monitor temp curve, re-cultures if spikes\n Seizure, without status epilepticus\n Assessment:\n Pt intermittently follows commands, known short term memory loss, moves\n left hand away from/to painful stimuli aprrop, noted left hand twitch,\n left facial twitch, left leg twitch\n Action:\n 1mg IVP Midaz, no further testing\n Response:\n Pt stopped facial and leg twitching with 1 min Versed dose,\n intermittent left hand twitching\n Plan:\n Cont to monitor, follow Dilantin levels, PRN Lorazepam and Midaz\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 600351,
"text": "Chief Complaint: Renal Failure, Respiratory Failure, subdural hematoma\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 IR this AM to get R IJ HD line pulled and new line placed in femoral\n vein\n Still on low dose of levophed\n 24 Hour Events:\n BLOOD CULTURED - At 09:57 PM\n C&S drawn/sent from RUE & RSC HD side ports.\n SPUTUM CULTURE - At 09:58 PM\n FEVER - 102.4\nF - 01:00 AM\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:45 PM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 02:07 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: mechanical ventilation\n Genitourinary: Dialysis\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.4\nC (99.3\n HR: 91 (76 - 95) bpm\n BP: 137/55(86) {92/32(54) - 150/55(89)} mmHg\n RR: 26 (20 - 45) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n CO/CI (Fick): (6.1 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 62 - 62\n Total In:\n 1,203 mL\n 290 mL\n PO:\n TF:\n 1,072 mL\n 121 mL\n IVF:\n 6 mL\n 19 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 532 (255 - 532) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 167\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///24/\n Ve: 11.8 L/min\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: scattered)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, R arm swelling\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.6 g/dL\n 280 K/uL\n 114 mg/dL\n 9.9 mg/dL\n 24 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 101 mEq/L\n 138 mEq/L\n 26.7 %\n 9.6 K/uL\n [image002.jpg]\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n 9.6\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n 26.7\n Plt\n 185\n 234\n 196\n 241\n 280\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n TCO2\n 32\n 31\n 31\n Glucose\n 88\n 75\n 77\n 135\n 183\n 116\n 155\n 114\n Other labs: PT / PTT / INR:14.0/25.4/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:7.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently - now with persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Septic shock-\n Continues to have low grade fevers and low dose pressor requirment.\n Cont vanc for MRSA in sputum. Cont midodrine. Getting R IJ line\n pulled today and replaced with femoral HD line\n 2)Respiratory Failure- Mental status has plateaued - pt dooing well on\n PSV 5/5. Need to establish reintubation plan with family prior to\n proceeding with extubation - likely tomorrow given IR\n procedure/sedation today. Need to establish if they would want to\n proceed with trach if he fails extubation.\n 3)Renal Failure- next HD per renal\n 4)Sub-Dural Hematoma/Altered Mental Status- Improved mental status from\n last week but has plateued somewhat\n 5)Seizure Disorder- Neurontin, Dilantin\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 22 Gauge - 03:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599957,
"text": "Events: BP remains labile w/ any attempt to wean SBP 77- 180\ns/ MAP\n 40-70\ns and remains on low dose Levo gtt @ .01mcg/kg/hr. Pt alert all\n night and will intermittently approp respond to questioning- cont to be\n agitated with nursing care, oral care, turning, wound care,? pt is back\n pain/wound. Pt s/p fall with known SDH medically treated since\n admission for ? seizure activity since admission. Neuro following but\n medical plan to optimize Dilanin therapy. Pt with intermittent left\n hand rhythmic twitch, noted x1 to have left facial and left leq\n twitch- all less than 20 sec and resolving on own- pt the agitated and\n given 1mg IVP Midaz. Increased anxiety and audibly rhonchi x 1\n overnight, pt coughing- suction for thick white secretions and sm mucus\n plug. T max 100.8 ax. Cont to have continuous loose green stool.\n Alteration in Nutrition\n Assessment:\n Changed to Nutren 2.0 FS with 30 mg beneprotein\n Action:\n 20 cc residuals, TF @ goal 40cc/hr with 50cc free water flush Q6\n Response:\n Tolerating\n Plan:\n Cont TF @ goal, monitor residuals\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt bites with oral care/temps- T max 100.8 ax, not diaphoretic,\n Action:\n Not re-cultured,\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599959,
"text": "Events: BP remains labile w/ any attempt to wean SBP 77- 180\ns/ MAP\n 40-70\ns and remains on low dose Levo gtt @ .01mcg/kg/hr. Pt alert all\n night and will intermittently approp respond to questioning- cont to be\n agitated with nursing care, oral care, turning, wound care,? pt is back\n pain/wound. Pt s/p fall with known SDH medically treated since\n admission for ? seizure activity since admission. Neuro following but\n medical plan to optimize Dilanin therapy. Pt with intermittent left\n hand rhythmic twitch, noted x1 to have left facial and left leq\n twitch- all less than 20 sec and resolving on own- pt the agitated and\n given 1mg IVP Midaz. Increased anxiety and audibly rhonchi x 1\n overnight, pt coughing- suction for thick white secretions and sm mucus\n plug. T max 100.8 ax. Cont to have continuous loose green stool.\n Alteration in Nutrition\n Assessment:\n Changed to Nutren 2.0 FS with 30 mg beneprotein\n Action:\n 20 cc residuals, TF @ goal 40cc/hr with 50cc free water flush Q6\n Response:\n Tolerating\n Plan:\n Cont TF @ goal, monitor residuals\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt bites with oral care/temps- T max 100.8 ax, not diaphoretic,\n Action:\n Not re-cultured,\n Response:\n Cont temp 100 ax\n Plan:\n On Vanco IV with HD, monitor temp curve, re-cultures if spikes\n Seizure, without status epilepticus\n Assessment:\n Pt intermittently follows commands, known short term memory loss, moves\n left hand away from/to painful stimuli aprrop, noted left hand twitch,\n left facial twitch, left leg twitch\n Action:\n 1mg IVP Midaz\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600461,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\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: Yellow / 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 Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n maintain secretions and monitor WOB\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600865,
"text": "Chief Complaint:\n 24 Hour Events:\n - trach from IP - a little bit of oozing at the site, which improved.\n He became agitated afterwards and tachypneic. Confirmed trach\n placement, and no PNX with radiology. Concerned about pain, increased\n his sedation. Still tachypneic, switched to AC to further increase\n sedation. Stopped overbreathing, pH improved. He continued to remain\n agitated throughout the night.\n - MRI spine: no osteo\n - CT abd: Schmorl's nodes/?osteo. Prominent mediastinal LN\n - sputum cx : sparse MRSA, sparse GNR.\n - Renal believes clotting of lines may be dilantin, don't have a\n lot of other suggestions regarding HD access at this time\n - fever 101.5F\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Vecuronium - 11:40 AM\n Fosphenytoin - 04:20 PM\n Midazolam (Versed) - 04:35 AM\n Fentanyl - 04:35 AM\n Morphine Sulfate - 06:20 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 38.1\nC (100.5\n HR: 93 (76 - 94) bpm\n BP: 167/73(97) {80/30(46) - 200/165(175)} mmHg\n RR: 27 (12 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 865 mL\n 550 mL\n PO:\n TF:\n 77 mL\n 452 mL\n IVF:\n 418 mL\n 38 mL\n Blood products:\n Total out:\n 1,000 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -135 mL\n 550 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): 591 (334 - 591) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 5\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 67\n PIP: 16 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.58/30/133/24/7\n Ve: 14.1 L/min\n PaO2 / FiO2: 266\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 267 K/uL\n 8.8 g/dL\n 174 mg/dL\n 5.3 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 103 mEq/L\n 140 mEq/L\n 28.7 %\n 8.1 K/uL\n [image002.jpg]\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n WBC\n 10.0\n 8.6\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n Hct\n 28.4\n 30.2\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n Plt\n 80\n 220\n 284\n 267\n Cr\n 7.7\n 5.7\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n TCO2\n 31\n 31\n 29\n Glucose\n 183\n 116\n 155\n 114\n 300\n 66\n 174\n Other labs: PT / PTT / INR:13.3/24.6/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:72.2 %, Band:0.0 %,\n Lymph:12.3 %, Mono:8.8 %, Eos:6.0 %, Lactic Acid:1.0 mmol/L,\n Albumin:2.5 g/dL, LDH:266 IU/L, Ca++:8.4 mg/dL, Mg++:1.6 mg/dL, PO4:1.5\n mg/dL\n Imaging: CXR:\n Microbiology: Preliminary Sputum Cx: Spare growth Staph aureus coag +\n and GNR\n Catheter tip negative\n Blood cx pending, last negative \n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers, not osteomyelitis by MRI. On\n vancomycin (day 7) for ?line infection although negative cultures. On\n and off pressors despite addition of midodrine and florinef. More\n likely due to abnormal autonomic dysfunction to renal failure, but\n ddx includes infectious etiology given recent h/o sepsis.\n - Continue midodrine and florinef and reduce levophed as tolerated\n -keep MAP > 65\n .\n # Respiratory Distress: Trach yesterday. Had some oozing but improved.\n Episodic aggitation and tachypnia, improved with increased sedation and\n AC.\n - monitor trach site\n - wean vent as tolerated\n - continue HD for volume overload\n - f/u sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: continue on fosphenytoin, q4d free phenytoin level\n checks.\n - touch base re: anti-seizure regimen given dilantin could be causing\n clotting in HD\n # ESRD:\n - cont HD w/ femoral temp line\n - need more permanent access: touch base w: renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200s\n # Access: femoral line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full (confirmed with wife on admission via phone)\n # Dispo: to remain in ICU while intubated\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 10:45 PM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 601069,
"text": "Chief Complaint:\n 24 Hour Events:\n - spoke with daughter about current situation, did not seem to be ready\n for backing off care, wants to reeval mental status after HD\n - Dilatin d/c'd, neuro to make recs tomorrow re different antiepileptic\n - renal recs: d/c dilantin\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:54 PM\n Infusions:\n Other ICU medications:\n Fosphenytoin - 08:15 AM\n Lansoprazole (Prevacid) - 08:02 PM\n Morphine Sulfate - 04:08 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.6\nC (99.6\n HR: 79 (73 - 92) bpm\n BP: 97/41(54) {74/38(50) - 172/103(159)} mmHg\n RR: 12 (12 - 31) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 87.6 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,670 mL\n 495 mL\n PO:\n TF:\n 1,260 mL\n 457 mL\n IVF:\n 120 mL\n 38 mL\n Blood products:\n Total out:\n 120 mL\n 0 mL\n Urine:\n NG:\n 120 mL\n Stool:\n Drains:\n Balance:\n 1,550 mL\n 495 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 80 (80 - 466) mL\n PS : 8 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 27 cmH2O\n Plateau: 23 cmH2O\n SpO2: 97%\n ABG: ///26/\n Ve: 9.4 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 338 K/uL\n 8.9 g/dL\n 219 mg/dL\n 7.6 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 35 mg/dL\n 100 mEq/L\n 142 mEq/L\n 29.2 %\n 9.4 K/uL\n [image002.jpg]\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n 04:19 AM\n 09:21 PM\n 02:26 AM\n 03:20 AM\n WBC\n 8.6\n 8.6\n 9.6\n 7.7\n 9.6\n 8.1\n 9.4\n Hct\n 30.2\n 27.7\n 26.7\n 28.4\n 30.1\n 28.7\n 29.2\n Plt\n 196\n 241\n 280\n 220\n 284\n 267\n 338\n Cr\n 5.7\n 8.0\n 9.9\n 6.0\n 8.1\n 5.3\n 7.6\n TCO2\n 31\n 31\n 29\n Glucose\n 116\n 155\n 114\n 300\n 66\n 174\n 219\n Other labs: PT / PTT / INR:13.9/25.6/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:82.3 %, Band:0.0 %,\n Lymph:8.1 %, Mono:5.5 %, Eos:3.7 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ESRD admitted with subdural hematomas after fall, now w/ poor mental\n status and persistent fevers.\n .\n # Fevers: Some improvement after d/c of fosphenytoin although one fever\n spike O/N to 101. Has not required pressors for last 24 hrs although\n still on midodrine and florinef. Have extensively searched for\n underlying source of fevers, including re-peated pancultures, CT of\n chest, abdomen, pelvis. The only findings have been enlarged\n mediastinal lymph nodes: (1.5 x 2.1 cm prevascular lymph node and a\n precarinal lymph node measuring 2.2 x 0.7 cm). Repeated sputum\n cultures show gram + cocci, however has already received long abx\n course for MRSA PNA and likely represents continued colonization. Have\n D/c'd nonessential meds to eliminate possible sources of drug fever,\n including fosphenytoin yesterday. Other tests not yet done for fever\n of unknown origin workup include: lower extremity US.\n -Can consider lower extremity US to search for DVT\n - Continue midodrine and florinef and reduce levophed as tolerated\n (hasn't required over last 24 hours): if no pressor requirement today,\n consider tapering off florinef and midodrine tomorrow\n - d/c all nonessential meds, vanc, dilantin\n - keep MAP > 65\n .\n #Mental Status change - Continues to be non-responsive to\n instructions. Slight improvement in that he does make intermittent\n purposeful movements, including trying to remove trach. Unclear\n underlying etiology: could be secondary to slow clearance of sedation\n or delirium of underlying infection versus effect of subdural\n hematomas.\n -Continue to hold sedation\n .\n # Respiratory Distress: Trach placed. Had some oozing but improved.\n Attempt switch to pressure support today.\n - monitor trach site\n - continue HD for volume overload\n .\n #Scrotal and buttock lesions\n most likely dependent skin ulcers.\n Herpes DFA - negative\n - continue wound care\n .\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: to taper dilantin: went back up to 200 mg dilantin X 2\n days, then 100 mg starting on for 2 days, then can discontinue\n -uptitrating keppra to 250 mg X 3 days, then increase to 500 mg qAM\n and 250 qPM on day 4; will also get 500 mg boluses after each HD\n session\n .\n # ESRD:\n - cont HD w/ femoral temp line today\n - need more permanent access: touch base w: renal\n .\n # SDH: continue to hold anticoagulation, will follow neurology recs\n .\n # Glaucoma / Cataracts: continue home eye drops.\n -Consider inpt optho c/s if continued prolonged hospitalization.\n .\n # DM: On SSI + lantus 40 daily; elevated sugars in am\n - adjust SSI\n .\n # Access: femoral line\n .\n # FEN: tolerating TF, give phos\n .\n # PPX: pneumoboots, PPI; bowel reg\n .\n # Code: full (confirmed with wife on admission via phone)\n .\n # Dispo: to remain in ICU while intubated\n - family meeting to discuss goals of care\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 01:42 AM 60 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 10:30 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": "2191-09-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600026,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 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: 28 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: Crackles\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: 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: Intolerant of\n weaning attempts, Cannot manage secretions; Comments: some weaning\n tolerated this shift.... plan to revaluate in AM rounds\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "General",
"chartdate": "2191-09-04 00:00:00.000",
"description": "Generic Note",
"row_id": 600155,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined during\n multidisciplinary rounds this morning. Briefly on norepi overnight but\n off most of day. RSBI 76 PSV now \n 99.8 94 141/57\n Alert but not interacting\n Chest\n few crackles\n CV 2/6 sem\n Not moving R arm clonus both LE\n WBC 8.6\n Resp Failure\n CRF on HD\n Fever\n SDH\n altered MS\n BP remains labile but we seem to have made some progress with Midodrine\n and Fluorinef. Will check MVO2 this am and recheck if BP falls to see\n if we can get some gauge of his CO. His weaning parameters suggest he\n is extubatable but he failed last time with similar numbers\n presumably due to secretions. Since he will need to go to IR for a new\n HD catheter will hold on extubation until after that is done (hopefully\n tomorrow). Have spoken with son today about likely need for trache if\n he fails extubation again\n family needs to discuss wheter Mr. \n would want a trache. Last diff had 8 eos and immature forms\n we are\n repeating today\n may be that his fever is due to drug rxn rather than\n due to persistent infection\n Time spent 40 min\n Critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600325,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:00 PM\n 1st of 2 blood cultures\n BLOOD CULTURED - At 12:30 AM\n 2nd of 2 blood cultures\n -phenytoin level was 3.4 this AM; free phenyotin/phenytoin level was\n checked this PM prior to afternoon dose; given low total phenytoin, he\n got 300 mg IV X 1 of phenytoin this evening at 8 PM in addition to his\n usual TID phenytoin\n -starting fluorinef for pressure support\n -changed ventilator settings to PSV and repeat blood gas was 7.4 47\n 127\n -attempted to pull off pressors... No overnight pressor requirement.\n -renal recs: next HD will be on Monday; would use free phenytoin as a\n guide to dose (2.7 - 3 per neurology)\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:07 PM\n Vancomycin - 01:45 PM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.5\nC (99.5\n HR: 84 (74 - 99) bpm\n BP: 139/53(85) {84/29(49) - 171/64(104)} mmHg\n RR: 20 (15 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,390 mL\n 326 mL\n PO:\n TF:\n 959 mL\n 273 mL\n IVF:\n 51 mL\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,390 mL\n 326 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 271 (262 - 783) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: 7.41/47/127/27/4\n Ve: 10.8 L/min\n PaO2 / FiO2: 254\n Physical Examination\n Cardiovascular: Gen: NAD, sedated, intubated\n CV: RRR, nl S1 and S2\n Lungs: clear anteriorly\n Abd: soft, NT, ND, ABS\n Ext: no c/c/e\n Neuro: , , opens eyes\n Peripheral 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 241 K/uL\n 8.8 g/dL\n 155 mg/dL\n 8.0 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 100 mEq/L\n 139 mEq/L\n 27.7 %\n 8.6 K/uL\n [image002.jpg]\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n Plt\n 185\n 234\n 196\n 241\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n TCO2\n 32\n 31\n 31\n Glucose\n 88\n 88\n 75\n 77\n 135\n 183\n 116\n 155\n Other labs: PT / PTT / INR:14.4/26.8/1.2, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: Phenytoin 6.8\n Imaging: CXR: low lung volumes, no opacities,\n Microbiology: - sputum pos MRSA\n PICC catheter tip - no growth\n Blood, stool, RPR - negative\n HSV pending\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers concerning for VAP with sputum + for\n minimal Staph aureus () also gross pus from R HD line could be\n source. On day 8 vancomycin, pan cultured . Off pressors\n overnight with addition of midodren and florinef.\n - Continue midodrine and reduce levophed as tolerated\n -Can try adding florinef for further BP support\n -keep MAP > 65\n -continue vancomycin given recent positive cx for MRSA to complete 10 d\n course\n # Respiratory Distress: likely secondary to PNA vs pulmonary edema.\n Attempted trial of extubation 2d ago, pt failed and is reintubated.\n - attempt switch to pressure support today; consider possibility of\n trach placement for long term ventilation\n - continue HD for volume overload\n - on day 8 of vanc for pneumonia, s/p 10d tx for MRSA pna\n - repeat sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: Bolused IV phenytoin 300mg and f/u dilantin level in AM\n - touch base re: anti-seizure regimen given -EEG\n # ESRD:\n - HD on monday\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, temp line for HD (infected); weaning\n pressors in attempt to pull HD line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 22 Gauge - 03:00 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": "2191-09-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600329,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 09:57 PM\n C&S drawn/sent from RUE & RSC HD side ports.\n SPUTUM CULTURE - At 09:58 PM\n FEVER - 102.4\nF - 01:00 AM\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 01:45 PM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 02:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 37.9\nC (100.3\n HR: 80 (76 - 95) bpm\n BP: 109/40(65) {92/32(54) - 167/66(105)} mmHg\n RR: 26 (20 - 45) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n CO/CI (Fick): (6.1 L/min) / (2.9 L/min/m2)\n Mixed Venous O2% Sat: 62 - 62\n Total In:\n 1,203 mL\n 284 mL\n PO:\n TF:\n 1,072 mL\n 121 mL\n IVF:\n 6 mL\n 14 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,203 mL\n 284 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 343 (255 - 637) mL\n PS : 5 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 167\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///24/\n Ve: 8 L/min\n Physical Examination\n Cardiovascular: GEN: nad\n cv: RRR\n Lungs: CTAB anteriorly\n Ext: RUE edema\n Neuro: eyes open, does not respond to commands.\n Peripheral 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 280 K/uL\n 8.6 g/dL\n 114 mg/dL\n 9.9 mg/dL\n 24 mEq/L\n 5.1 mEq/L\n 49 mg/dL\n 101 mEq/L\n 138 mEq/L\n 26.7 %\n 9.6 K/uL\n [image002.jpg]\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n 9.6\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n 26.7\n Plt\n 185\n 234\n 196\n 241\n 280\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n TCO2\n 32\n 31\n 31\n Glucose\n 88\n 75\n 77\n 135\n 183\n 116\n 155\n 114\n Other labs: PT / PTT / INR:14.0/25.4/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:7.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Fluid analysis / Other labs: Vanco\n Imaging: CXR - no parenchymal process.\n Microbiology: Sputum - gram stain GPCs in pairs and clusters\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers most likely source is line infection.\n On day 9 vancomycin. On and off pressors overnight with addition of\n midodren and florinef.\n - Continue midodrine and florinef and reduce levophed as tolerated\n -keep MAP > 65\n -continue vancomycin given skin infection.\n - now febrile, may be bacteremic, surveillance cultures\n - d/c line in RIJ after placement of temporary femoral line\n - touch base with renal regarding posponing dialysis until new line\n placement\n # Respiratory Distress: Problem of inability to maintain secretions,\n based on failure of attempted trial of extubation.\n - On pressure support . attempt extubation after d/w family re:\n reintubation and trach placement for long term ventilation\n - continue HD for volume overload\n - f/u sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA - pending\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: Bolused IV phenytoin 300mg and f/u dilantin level in AM\n - touch base re: anti-seizure regimen given -EEG\n # ESRD:\n - HD on monday\n - femoral temp line placement today\n - d/c of infected HD line\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, temp line for HD (infected); weaning\n pressors in attempt to pull HD line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 22 Gauge - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 600557,
"text": "Subjective\n patient/ RN off floor\n Objective\n Pertinent medications: notec\n Labs:\n Value\n Date\n Glucose\n 300 mg/dL\n 03:25 AM\n Glucose Finger Stick\n 206\n 12:00 PM\n BUN\n 24 mg/dL\n 03:25 AM\n Creatinine\n 6.0 mg/dL\n 03:25 AM\n Sodium\n 141 mEq/L\n 03:25 AM\n Potassium\n 4.0 mEq/L\n 03:25 AM\n Chloride\n 100 mEq/L\n 03:25 AM\n TCO2\n 30 mEq/L\n 03:25 AM\n PO2 (arterial)\n 127 mm Hg\n 04:05 PM\n PO2 (venous)\n 76. mm Hg\n 04:56 AM\n PCO2 (arterial)\n 47 mm Hg\n 04:05 PM\n PCO2 (venous)\n 43 mm Hg\n 04:56 AM\n pH (arterial)\n 7.41 units\n 04:05 PM\n pH (venous)\n 7.31 units\n 04:56 AM\n CO2 (Calc) arterial\n 31 mEq/L\n 04:05 PM\n CO2 (Calc) venous\n 23 mEq/L\n 04:56 AM\n Albumin\n 2.5 g/dL\n 03:38 AM\n Calcium non-ionized\n 8.5 mg/dL\n 03:25 AM\n Phosphorus\n 4.2 mg/dL\n 03:25 AM\n Ionized Calcium\n 1.11 mmol/L\n 04:03 AM\n Magnesium\n 1.9 mg/dL\n 03:25 AM\n ALT\n 23 IU/L\n 03:34 AM\n Alkaline Phosphate\n 168 IU/L\n 03:34 AM\n AST\n 44 IU/L\n 03:34 AM\n Amylase\n 41 IU/L\n 03:38 AM\n Total Bilirubin\n 0.4 mg/dL\n 03:34 AM\n Triglyceride\n 205 mg/dL\n 02:26 AM\n Phenytoin (Free)\n 3.0 ug/mL\n 04:51 AM\n Phenytoin (Dilantin)\n 6.8 ug/mL\n 04:50 AM\n WBC\n 7.7 K/uL\n 03:25 AM\n Hgb\n 9.0 g/dL\n 03:25 AM\n Hematocrit\n 28.4 %\n 03:25 AM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Nutren 2.0 @ 45ml/hr + 30g Beneprotein\n GI: soft/distended, hypoactive bowel sounds, (+) flatus; (+) loose\n stool\n Assessment of Nutritional Status\n Specifics:\n Patient remains intubated, pressor support off. Currently tube feed\n off as patient off floor at procedure. Verbal consult for new tube\n feed recommendations. wound RN, patient with frequent loose stool\n which is irritating wounds. Current tube feed formula does not contain\n fiber. Option of adding banana flakes, however these contain potassium\n and team concerned with adding given renal failure. Recommend change\n to fiber containing tube feed formula to hopefully increase stool bulk.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Change tube feed formula to\n Isosource 1.5 calorie with goal of 60ml/hr + 15g Beneprotein = 2213\n calories and 111g protein\n Monitor stool output\n if it does not improve with new tube\n feed formula and if potassium remains WNL, consider trialing banana\n flakes - usual dose is 1 packet TID; could start with 1 packet and\n assess labs.\n Will follow, page if questions *\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600659,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD on , 800mls fluid removal, patient is anuric, rt fem\n dialysis cath in place\n Action:\n Continue monitor labs\n Response:\n Plan:\n Plan HD as per renal\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated, vented, on PSV 10/peep 5 and 50% O2,. Bilateral lung\n sounds rhonchorous, and diminished bases. O2 sats 100%. Large amount of\n thick whitish secretion\n Action:\n Bolus of sedation given, changed to A/C mode while patient was in MRI,\n continue pul toilet and MDI\ns as ordered. NPO after midnight for\n possible trach/PEG\n Response:\n Stable overnight, back on PSV with same settings,O2 sats 100%\n Plan:\n For trach/PEG in AM, NPO after midnight\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp, off levophed gtt\n Action:\n MRI spine to r/o osteomylitis or source of infection, temp spike to\n 101.5, patient has been cultured yesterday afternoon\n Response:\n Continues to have low grade temp\n Plan:\n F/U culture results, continue antibiotics, monitor temp curve\n Impaired Skin Integrity\n Assessment:\n Red bases, partial thickness ulcer on perineum, soft tissue of gluts\n and underside of scortum. Patient is in incontinence with loose stool,\n On air bed\n Action:\n Wound care as per wound care consult, keep clean and dry, frequent\n position change\n Response:\n Continue to have incontinence, ulcer remains same\n Plan:\n wound care as per wound care recommendations, position change, kinair\n bed\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600032,
"text": "73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n Altered mental status (not Delirium)\n Assessment:\n Patient alert, not following commands. L arm with normal strength,\n continuously trying to pull out ETT. R arm with no movement. Moves\n bilat legs on bed. L pupil dilated, non reactive. R pupil surgical, non\n reactive. No seizure activity noted this shift.\n Action:\n Patient remains off all sedation. Continues on Dilantin. Level checked\n this afternoon prior to 1600 dose.\n Response:\n Mental status unchanged. No seizure activity noted this shift.\n Plan:\n need Dilantin bolus; follow up on levels drawn at 1600. Continue to\n monitor mental status. Maintain safety with lines and tubes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on CMV 450 /RR 16/ 5 peep/ 50%. SAT 100%. Suctioning\n for large amounts thick white sputum. Lung sounds rhonchorous.\n Action:\n Weaned vent to PSV 10 PS/ % peep/ 50%.\n Response:\n SAT remains 100% ABG sent at 1600 pending.\n Plan:\n To remain on PSV as tolerated. This is 3^rd intubation for this\n admission, may require trach placement.\n Hypotension (not Shock)\n Assessment:\n Received patient on Levophed 0.01mcg/kg/min. BP 140\ns/50\ns (70-80\n HR 80-90\ns NSR.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600037,
"text": "Chief Complaint:\n 24 Hour Events:\n - Neuro recs: fosphenytoin 200mg TID, check daily levels, q3-4d check\n free level (doesn't need to be daily)\n - Midodrine increased to 15mg TID\n - Family informed of possibility of trach/peg\n - HSV DFA sample done from sacral wound\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:07 PM\n Vancomycin - 01:45 PM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 04:32 PM\n Fentanyl - 06:20 PM\n Midazolam (Versed) - 03:50 AM\n Fosphenytoin - 07:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.8\nC (98.2\n HR: 84 (81 - 98) bpm\n BP: 142/49(84) {71/30(42) - 180/71(106)} mmHg\n RR: 20 (13 - 51) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,867 mL\n 504 mL\n PO:\n TF:\n 966 mL\n 323 mL\n IVF:\n 531 mL\n 21 mL\n Blood products:\n Total out:\n 3,000 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,133 mL\n 505 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 22 cmH2O\n Compliance: 26.5 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/45/129/30/5\n Ve: 8.2 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 196 K/uL\n 9.5 g/dL\n 116 mg/dL\n 5.7 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.2 %\n 8.6 K/uL\n [image002.jpg]\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n WBC\n 10.4\n 10.0\n 8.6\n Hct\n 29.4\n 28.4\n 30.2\n Plt\n 185\n 234\n 196\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n TCO2\n 32\n 31\n Glucose\n 147\n 95\n 88\n 88\n 75\n 77\n 135\n 183\n 116\n Other labs: PT / PTT / INR:14.4/26.8/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:3.1 mg/dL\n Imaging: EEG - negative\n : CXR\n FINDINGS: The position of the ET tube is unchanged with the tip at the\n thoracic inlet 3 cm above the carina, the right venous line and NG tube\n are\n unchanged.\n Median sternotomy wires are intact.\n Left lateral lower lobe atelectasis is stable. No new consolidation,\n pneumothorax or pleural effusion. Cardiomediastinal silhouette is\n unchanged.\n MRV:\n 1. Narrowing of the right subclavian as well as right brachiocephalic\n veins\n as described above.\n 2. Narrowing of the left subclavian as well as left internal jugular\n vein.\n 3. Widely patent SVC and the right-sided internal jugular line ends in\n the\n distal SVC. Linear filling defect in the left internal jugular vein is\n suggestive of a fibrin sheath from prior catheterization.\n 4. Enlarged mediastinal lymph nodes, some of which are unchanged from\n prior\n CT and of uncertain significance. Assessment by chest CT could be\n obtained as\n per clinical need.\n Microbiology: : growing MRSA in sputum\n line cx - NGTD\n Assessment and Plan\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers concerning for VAP with sputum + for\n minimal Staph aureus () also gross pus from R HD line could be\n source. On day 8 vancomycin, pan cultured . Requires continued\n pressure support w levophed. Midodrine started to wean pressors, but\n unchanged levo demand. All Bcx negative to todate,\n - Continue midodrine and reduce levophed as tolerated\n -Can try adding florinef for further BP support\n - f/u cultures\n -keep MAP > 65\n -continue vancomycin given recent positive cx for MRSA to complete 10 d\n course\n # Respiratory Distress: likely secondary to PNA vs pulmonary edema.\n Attempted trial of extubation 2d ago, pt failed and is reintubated.\n - attempt switch to pressure support today; consider possibility of\n trach placement for long term ventilation\n - continue HD for volume overload\n - on day 8 of vanc for pneumonia, s/p 10d tx for MRSA pna\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: Bolused IV phenytoin 300mg and f/u dilantin level in AM\n - touch base re: anti-seizure regimen given -EEG\n # ESRD:\n - may go for HD today, f/u with renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, temp line for HD (infected); weaning\n pressors in attempt to pull HD line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 22 Gauge - 03:00 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": "2191-09-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600138,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:00 PM\n 1st of 2 blood cultures\n BLOOD CULTURED - At 12:30 AM\n 2nd of 2 blood cultures\n -phenytoin level was 3.4 this AM; free phenyotin/phenytoin level was\n checked this PM prior to afternoon dose; given low total phenytoin, he\n got 300 mg IV X 1 of phenytoin this evening at 8 PM in addition to his\n usual TID phenytoin\n -starting fluorinef for pressure support\n -changed ventilator settings to PSV and repeat blood gas was 7.4 47\n 127\n -attempted to pull off pressors... No overnight pressor requirement.\n -renal recs: next HD will be on Monday; would use free phenytoin as a\n guide to dose (2.7 - 3 per neurology)\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:07 PM\n Vancomycin - 01:45 PM\n Infusions:\n Norepinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (100.9\n Tcurrent: 37.5\nC (99.5\n HR: 84 (74 - 99) bpm\n BP: 139/53(85) {84/29(49) - 171/64(104)} mmHg\n RR: 20 (15 - 32) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,390 mL\n 326 mL\n PO:\n TF:\n 959 mL\n 273 mL\n IVF:\n 51 mL\n 3 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 1,390 mL\n 326 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 271 (262 - 783) mL\n PS : 10 cmH2O\n RR (Set): 16\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: 7.41/47/127/27/4\n Ve: 10.8 L/min\n PaO2 / FiO2: 254\n Physical Examination\n Cardiovascular: Gen: NAD, sedated, intubated\n CV: RRR, nl S1 and S2\n Lungs: clear anteriorly\n Abd: soft, NT, ND, ABS\n Ext: no c/c/e\n Neuro: , , opens eyes\n Peripheral 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 241 K/uL\n 8.8 g/dL\n 155 mg/dL\n 8.0 mg/dL\n 27 mEq/L\n 4.4 mEq/L\n 37 mg/dL\n 100 mEq/L\n 139 mEq/L\n 27.7 %\n 8.6 K/uL\n [image002.jpg]\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n Plt\n 185\n 234\n 196\n 241\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n TCO2\n 32\n 31\n 31\n Glucose\n 88\n 88\n 75\n 77\n 135\n 183\n 116\n 155\n Other labs: PT / PTT / INR:14.4/26.8/1.2, Ca++:8.4 mg/dL, Mg++:1.9\n mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: Phenytoin 6.8\n Imaging: CXR: low lung volumes, no opacities,\n Microbiology: - sputum pos MRSA\n PICC catheter tip - no growth\n Blood, stool, RPR - negative\n HSV pending\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers concerning for VAP with sputum + for\n minimal Staph aureus () also gross pus from R HD line could be\n source. On day 8 vancomycin, pan cultured . Off pressors\n overnight with addition of midodren and florinef.\n - Continue midodrine and reduce levophed as tolerated\n -Can try adding florinef for further BP support\n -keep MAP > 65\n -continue vancomycin given recent positive cx for MRSA to complete 10 d\n course\n # Respiratory Distress: likely secondary to PNA vs pulmonary edema.\n Attempted trial of extubation 2d ago, pt failed and is reintubated.\n - attempt switch to pressure support today; consider possibility of\n trach placement for long term ventilation\n - continue HD for volume overload\n - on day 8 of vanc for pneumonia, s/p 10d tx for MRSA pna\n - repeat sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: Bolused IV phenytoin 300mg and f/u dilantin level in AM\n - touch base re: anti-seizure regimen given -EEG\n # ESRD:\n - HD on monday\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, temp line for HD (infected); weaning\n pressors in attempt to pull HD line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 22 Gauge - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600140,
"text": "73 yo man admitted , with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the MICU for respiratory\n distress, hypotension & hypoxia. Now intubated, (2 failed\n extubations). Has h/o IDDM and AFIB, not on coumadin due to recent\n SDH.\n Altered mental status (not Delirium)\n Assessment:\n Patient alert, not following commands. L arm with normal strength,\n continuously trying to pull out ETT. R arm with no movement. Moves\n bilat legs on bed. L pupil dilated, non reactive. R pupil surgical, non\n reactive. No seizure activity noted this shift. Received additional\n 300mg dose of Fosphenytoin times one at . Bowel meds held last\n night due to multiple loose stools. Rectal area excoriated and\n bleeding. Barrier ointment applied.\n Action:\n Patient remains off all sedation. Continues on Dilantin.\n Response:\n Mental status unchanged. No seizure activity noted this shift. Having\n difficulty performing mouth care due to pt resisting.\n Plan:\n Will need to follow dialntin level. Continue to monitor mental status.\n Maintain safety with lines and tubes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Suctioning for moderate amounts thick white sputum. Lung sounds\n rhonchorous. Suctioned frequently for thick white secretions.\n Action:\n PSV 10, peep 5, 50% FiO2 STV\ns ranging 400\ns-600\n Response:\n SAT remains mid 90\ns-100%\n Plan:\n Tolerating current vent settings. This is 3^rd intubation for this\n admission, may require trach placement.\n Hypotension (not Shock)\n Assessment:\n Received patient on Levophed 0.01mcg/kg/min. BP 110\ns to 150(70-80\n HR 80-90\ns NSR. At 2220, levo was shut off and pt\ns BP remained stable\n without any hypotensive drops until ~0500. At this time BP dropping\n into the 70\ns and con\nt to stay in the low 80\ns. Levo restarted at\n 0.01 mcg/kg at 0530, with BP gradually improving to 120\n Action:\n Attempted to wean off pressor, without success.\n Response:\n BP tolerating removal of pressor for ~7hr. Requiring restart of levo.\n Plan:\n Continue Midodrine, Fludrocortisone. Continue to attempt to wean\n pressor.\n Diabetes Mellitus (DM), Type II\n Assessment:\n FS 90-123. Requiring no insulin coverage per SS. Tolerating TF\n Action:\n Stable\n Response:\n Minimal residuals\n Plan:\n Cover q6hr FS\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600791,
"text": "Impaired Skin Integrity\n Assessment:\n Pt with multiple skin issues (see metavision for specifics).\n Action:\n On Kinair bed, pt turned and repositioned frequently when dialysis was\n completed. Skin kept clean and dry. Acyclovir ointment and lidocaine\n applied to excoriated gluteals and scrotum. Evaluated today with MICU\n CNS.\n Response:\n No further breakdown in skin. MICU CNS stated the area looks improved.\n Plan:\n Continue to turn patient frequently, provide skin care as needed,\n maintain Kinair, treat wounds per wound care recommendations.\n Alteration in Nutrition\n Assessment:\n Pt received NPO for trach placement today.\n Action:\n Pt trached today and OGT was pulled with ETT. NGT placed in left nare.\n Pt given\n dose of lantus this afternoon because NPO.\n Response:\n NGT confirmed by CXR. Tube feeds not restarted today due to likely\n placement of PEG tomorrow. PEG not placed today because pt was febrile\n overnight.\n Plan:\n If pt spikes temp then can restart tube feeds because PEG won\nt be\n placed until 24hours afebrile. Q6hour finger sticks\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600792,
"text": "Impaired Skin Integrity\n Assessment:\n Pt with multiple skin issues (see metavision for specifics).\n Action:\n On Kinair bed, pt turned and repositioned frequently when dialysis was\n completed. Skin kept clean and dry. Acyclovir ointment and lidocaine\n applied to excoriated gluteals and scrotum. Evaluated today with MICU\n CNS.\n Response:\n No further breakdown in skin. MICU CNS stated the area looks improved.\n Plan:\n Continue to turn patient frequently, provide skin care as needed,\n maintain Kinair, treat wounds per wound care recommendations.\n Alteration in Nutrition\n Assessment:\n Pt received NPO for trach placement today.\n Action:\n Pt trached today and OGT was pulled with ETT. NGT placed in left nare.\n Pt given\n dose of lantus this afternoon because NPO.\n Response:\n NGT confirmed by CXR. Tube feeds not restarted today due to likely\n placement of PEG tomorrow. PEG not placed today because pt was febrile\n overnight.\n Plan:\n If pt spikes temp then can restart tube feeds because PEG won\nt be\n placed until 24hours afebrile. Q6hour finger sticks.\n Altered mental status (not Delirium)\n Assessment:\n Pt is alert with eyes open, does not follow commands, makes purposeful\n movement with left arm only (eg trying to pull at NGT and trach.\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 599760,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\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 / Thick\n Sputum source/amount: Suctioned / Moderate\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: Intolerant of\n weaning attempts, Cannot protect airway, Underlying illness not\n resolved\n Comments: Pt. remains intubated on A/C overnoc. Suctioned for thick tan\n sputum. RSBI 100 this am.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 601290,
"text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: pt on trach collar since 1600, ABG within the normal limits.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Pt to rest on ventilator over night.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600242,
"text": "Day of mechanical ventilation: 5\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\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 / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Pt weaned to CSV, with NAD. No further weaning today as pt still\n needs to go to IR for new HD cath. After procedure will try to\n extubate. If he fails again, will move forward with trach and PEG.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599937,
"text": "Events: BP remains labile w/ any attempt to wean SBP 77- 180\ns/ MAP\n 40-70\ns and remains on low dose Levo gtt @ .02mcg/kg/hr. Pt alert all\n night and will intermittently approp respond to questioning- cont to be\n agitated with nursing care, oral care, turning, wound care,? pt is back\n pain/wound. Pt s/p fall with known SDH medically treated since\n admission for ? seizure activity since admission. Neuro following but\n medical plan to optimize Dilanin therapy. Pt with intermittent left\n hand rhythmic twitch, noted x1 to have left facial and left leq\n twitch- all less than 20 sec and resolving on own- pt the agitated and\n given 1mg IVP Midaz. Increased anxiety and audibly rhonchi x 1\n overnight, pt coughing- suction for thick white secretions and sm mucus\n plug. T max 100.8 ax.\n Alteration in Nutrition\n Assessment:\n Changed to Nutren 2.0 FS with 30 mg beneproteein\n Action:\n 20 cc residuals, TF @ goal 40cc/hr with 50cc free water flush Q6\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600237,
"text": "73 yo man admitted , with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open to voice, and spontaneously\n Tracking voice with eyes\n Left LUE flaccid\n Purposeful movement of RUE\n BLE moving on bed\n Action:\n No sedation\n Continues on seizure prophylaxis\n Response:\n Ongoing assessment\n No seizure activity noted\n Plan:\n Continue serial neuro exams\n Continue anticonvulsants\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear in upper lobes and scattered rhonchi/rales at bases\n Suctioning q2-3h for small amts frothy secretions\n Action:\n PSV reduced to 5+5/0.4\n Response:\n Pt tolerating reduced ventilatory support\n Plan:\n Plan for extubation tomorrow after hemodialysis and new HD catheter\n placement in IR\n Family meeting to discuss plan of care regarding extubation and\n potential for re-intubation\n Plan for trach/PEG it he fails extubation\n Hypotension (not Shock)\n Assessment:\n Received on low dose norepinepherine\n Pt has been hypotensive most of the day\n Action:\n Norepinepherine stopped\n Midodrine TID\n Response:\n Pt has been normotensive to hypertensive all day\n Plan:\n Continue Midodrine, Fludrocortisone.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600603,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD on , 800mls fluid removal, patient is anuric\n Action:\n Continue monitor labs\n Response:\n AM labs\n Plan:\n Plan HD as per renal\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated, vented, on PSV mode,\n.. . Bilateral lung sounds\n rhonchorous, and diminished bases. O2 sats 100%. Large amount of thick\n whitish secretion\n Action:\n Bolus of sedation given, changed to A/C mode while patient was in MRI,\n continue pul toilet and MDI\ns as ordered. NPO after midnight for\n possible trach/PEG\n Response:\n Plan:\n For trach/PEG in AM, NPO after midnight\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp, off levophed gtt\n Action:\n MRI spine to r/o osteomylitis or source of infection,\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600604,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD on , 800mls fluid removal, patient is anuric\n Action:\n Continue monitor labs\n Response:\n AM labs\n Plan:\n Plan HD as per renal\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated, vented, on PSV mode,\n.. . Bilateral lung sounds\n rhonchorous, and diminished bases. O2 sats 100%. Large amount of thick\n whitish secretion\n Action:\n Bolus of sedation given, changed to A/C mode while patient was in MRI,\n continue pul toilet and MDI\ns as ordered. NPO after midnight for\n possible trach/PEG\n Response:\n Plan:\n For trach/PEG in AM, NPO after midnight\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp, off levophed gtt\n Action:\n MRI spine to r/o osteomylitis or source of infection,\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Red bases, partial thickness ulcer on perineum, soft tissue of gluts\n and underside of scortum. Patient is in incontinence with loose stool,\n On air bed\n Action:\n Wound care as per wound care consult, keep clean and dry, frequent\n position change\n Response:\n Continue to have incontinence, ulcer remains same\n Plan:\n wound care as per wound care recommendations, position change, kinair\n bed\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600535,
"text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 10:30 AM\n DIALYSIS CATHETER - STOP 11:00 AM\n sideport\n ARTERIAL LINE - STOP 05:05 AM\n - renal recs: zosyn after HD today\n - temporary R femoral line placed in IR\n - Wife is concerned pt is not getting his enough fiber in diet\n requesting nutirition consult, also ask if can add probiotics from\n home, also with h/o recent eye surgery that has been monitored qwk for\n adjustment, consider opthomology c/s\n - Wife aware that next step is extubation and if fails, then trach\n - unable to tolerate fully weaning levo\n - ECHO this AM\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 11:40 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 76 (73 - 96) bpm\n BP: 168/65(80) {138/47(70) - 168/65(80)} mmHg\n RR: 23 (0 - 35) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 853 mL\n 423 mL\n PO:\n TF:\n 380 mL\n 316 mL\n IVF:\n 188 mL\n 77 mL\n Blood products:\n Total out:\n 800 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 53 mL\n 423 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 250 (250 - 532) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 65\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: ///30/\n Ve: 10.4 L/min\n Physical Examination\n Cardiovascular: Gen: NAD, opens eyes\n CV: RRR\n Lungs: CTAB\n Abd: ND NT ABS\n Ext: no c/c/e\n Peripheral 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 220 K/uL\n 9.0 g/dL\n 300 mg/dL\n 6.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 100 mEq/L\n 141 mEq/L\n 28.4 %\n 7.7 K/uL\n [image002.jpg]\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n 9.6\n 7.7\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n 26.7\n 28.4\n Plt\n 185\n 234\n 196\n 241\n 280\n 220\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n 6.0\n TCO2\n 32\n 31\n 31\n Glucose\n 75\n 77\n 135\n 183\n 116\n 155\n 114\n 300\n Other labs: PT / PTT / INR:13.3/24.6/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:7.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers most likely source is line infection.\n On vancomycin. On and off pressors despite addition of midodrine and\n florinef. More likely due to abnormal autonomic dysfunction to\n renal failure, but ddx includes infectious etiology given recent h/o\n sepsis.\n - Continue midodrine and florinef and reduce levophed as tolerated\n -keep MAP > 65\n -continue vancomycin given skin infection.\n - CIS\n - CT torso to evaluate for infection\n # Respiratory Distress: Problem of inability to maintain secretions,\n based on failure of attempted trial of extubation. VS direct Trach\n placement\n - On pressure support . SBT and attempt extubation today.\n - continue HD for volume overload\n - f/u sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: continue on fosphenytoin, q4d free phenytoin level\n checks.\n - touch base re: anti-seizure regimen given\n - EEG\n # ESRD:\n - cont HD w/ femoral temp line\n - replace RIJ HD line when infection heals.\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops. Call optho re: eval.\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, femoral line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:15 PM 45. mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 AM\n Dialysis Catheter - 10:30 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": "2191-09-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600770,
"text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\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: Bloody / 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 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 Periodic SBT's for conditioning; Comments: Trach collar as tolerated.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bedside tracheostomy (11:30)\n Comments: Pt trach at bedside without complication, placed on AC and\n 100% for procedure, then wean to PSV.\n PM\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600846,
"text": "Altered mental status (not Delirium)\n Assessment:\n Alert, does not focus on examiner, does not follow commands. LUE and\n BLE\ns move spontaneously/purposefully. Pt. does not move RUE\n spontaneously, but strong withdrawal to pain noted, able to lift off\n bed. Pt. very agitated this shift. Frequently moving/squirming in\n bed, appearing uncomfortable.\n Action:\n Neuro exam Q4hrs. Pt. given multiple dose of fentanyl/midaz overnight\n as documented.\n Response:\n No significant neurological change overnight. Pt. has not followed\n commands since . Fair effects from fent/midaz, overall pt.\n remains agitated/uncomfortable/restless.\n Plan:\n Continue to monitor and treat as indicated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. POD 1 s/p trach placement. Received pt. on PSV with RR in low\n 30\ns, increased WOB evident. Large area soft swelling ?subcutaneous\n air noted from left midclavicular to below breast with ?scatterd,\n barely noticeable crepitus palpated.\n Action:\n CXR done. ABG drawn by HO revealed hyperventilation. Pt. placed on\n CMV. Suctioned Q2-4 for blood-tinged secretions.\n Response:\n CXR stable per radiologist. Pt. initially restful on CMV, but\n tachypneic since about midnight, 26-30. Repeat VBG stable. Area of\n soft swelling remains present, but no further crepitus palpated since\n 2200.\n Plan:\n Monitor closely, wean vent as tolerated. Continue to assess for\n subcutaneous air.\n Impaired Skin Integrity\n Assessment:\n Perineum remains markedly excoriated. Pt. levitating off bed during\n skin care which he needs Q2hrs for continuous oozing stool.\n Action:\n Pre-medicated prior to cleaning. Skin care skin RN recs.\n Response:\n Skin appears more\n, with bleeding from incontinence and care.\n Plan:\n Cont. peri care as needed with premedication.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600413,
"text": "Day of mechanical ventilation: 6\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\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:\n No vent changes or ABG\ns this shift. Pt to IR for insertion of new HD\n cath. Team considering extubation tomorrow but today\ns SBT was 167.\n They will discuss with family whether reitubation and/or trach is\n appropriate.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600415,
"text": ": 73 yo man admitted , with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.6,. Pt thought to have infected infected RSC HD line\n which is slatted to be d/c\ned in IR later today.\n Action:\n Pt had old infected HD line DCd today. Given Abx with HD.\n Response:\n Recent temp 99.7 axillary.\n Plan:\n Closely monitor temp curve,Dollow up with culture data,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP/PS 5/5 with 50% FiO2. R$R in 20\ns with SPO2\n 98-100%Pt appears lethargic, noted to have Hiccough ups x 3 days,Team\n aware. Soft restraints in place to protect airway.\n Action:\n No changes made with Vent. Pt suctioned PRN for thick tan secretions.\n Given Abx as ordered.\n Response:\n SPO2 98-100%,RR in 25\n Plan:\n Cont Vigorous Pulm toileting.PRN suction,Cont Abx,follow up with\n culture. Tem hoping to try extubation tomorrow.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.01 mics/hr for low BP. Pt drops his BP with turning.\n Other VSS stable.\n Action:\n IV Levophed titrated to keep up Map above 65, Pt dropped BP after line\n placement during HD sedation?\n Response:\n Pt is currently normotensive on 0.02mcg/kg/min IV Levophed gtt.\n Plan:\n Cont to closely follow SBP values, Titrate IV Levophed gtt to maintain\n MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Ptwith ESRD on HD, Pt had RSC for hD looked infected. TF was held\n since 0300 for new HD line.\n Action:\n Pt went to IR for new HD line this morning, put a new Right fem line\n and pulled out old infected line and tip sent for culture. Pt started\n on HD at 1230 and removed 800cc out. Restarted on TF\n Response:\n .\n Plan\n Closely monitoring renal function, Follow up with renal team.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600601,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\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"
},
{
"category": "Nursing",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600602,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\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 Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600843,
"text": "Altered mental status (not Delirium)\n Assessment:\n Alert, does not focus on examiner, does not follow commands. LUE and\n BLE\ns move spontaneously/purposefully. Pt. does not move RUE\n spontaneously, but strong withdrawal to pain noted, able to lift off\n bed. Pt. very agitated this shift. Frequently moving/squirming in\n bed, appearing uncomfortable.\n Action:\n Neuro exam Q4hrs. Pt. given multiple dose of fentanyl/midaz overnight\n as documented.\n Response:\n No significant neurological change overnight. Pt. has not followed\n commands since . Fair effects from fent/midaz, overall pt.\n remains agitated/uncomfortable/restless.\n Plan:\n Continue to monitor and treat as indicated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599933,
"text": "Events: BP remains labile w/ any attempt to wean SBP 77- 180\ns/ MAP\n 40-70\ns and remains on low dose Levo gtt @ .02mcg/kg/hr. Pt alert all\n night and will intermittently approp respond to questioning- cont to be\n agitated with nursing care, oral care, turning, wound care,? pt is back\n pain/wound. Increased anxiety and audibly rhonchi x 1 overnight, pt\n coughing- suction for thick white secretions and sm mucus plug. T max\n 100.8 ax.\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600400,
"text": ": 73 yo man admitted , with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with an oral temp max of 102.4, team notified -- blood and sputum\n C&S subsequently sent for analysis. Pt thought to have infected\n infected RSC HD line which is slatted to be d/c\ned in IR later today.\n Action:\n Following serial oral temp values. Pt med with 650mg PO Acetaminophen\n for comfort.\n Response:\n Pt remains febrile @ this time.\n Plan:\n Cont to follow fever curve, culture data, provide antibx on timed\n schedule, wait AM CXR results, send random Vanco level today @ 06:00.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP/PS 5/5 with 50% FiO2. R$R in 20\ns with SPO2\n 98-100%Pt appears lethargic, noted to have Hiccough ups x 3 days,Team\n aware. Soft restraints in place to protect airway.\n Action:\n No changes made with Vent. Pt suctioned PRN for thick tan secretions.\n Given Abx as ordered.\n Response:\n SPO2 98-100%,RR in 25\n Plan:\n Cont Vigorous Pulm toileting.PRN suction,Cont Abx,follow up with\n culture. Tem hoping to try extubation tomorrow.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.01 mics/hr for low BP. Pt drops his BP with turning.\n Other VSS stable.\n Action:\n IV Levophed titrated to keep up Map above 65, Pt dropped BP after line\n placement during HD sedation?\n Response:\n Pt is currently normotensive on 0.02mcg/kg/min IV Levophed gtt.\n Plan:\n Cont to closely follow SBP values, Titrate IV Levophed gtt to maintain\n MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Ptwith ESRD on HD, Pt had RSC for hD looked infected. TF was held\n since 0300 for new HD line.\n Action:\n Pt went to IR for new HD line this morning, put a new Right fem line\n and pulled out old infected line and tip sent for culture. Pt started\n on HD at 1230 for 1L\n Response:\n Restarted on TF.\n Plan\n Closely monitoring renal function, Follow up with renal team.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600420,
"text": ": 73 yo man admitted , with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.6, Pt thought to have infected RSC HD line.\n Action:\n Pt had old infected HD line DCd today. Given Abx with HD.\n Response:\n Recent temp 99.7 axillary.\n Plan:\n Closely monitor temp curve,Follow up with culture data,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP/PS 5/5 with 50% FiO2. R$R in 20\ns with SPO2\n 98-100%Pt appears lethargic, noted to have Hiccough ups x 3 days, Team\n aware. Soft restraints in place to protect airway.\n Action:\n No changes made with Vent. Pt suctioned PRN for thick tan secretions.\n Given Abx as ordered.\n Response:\n SPO2 98-100%,RR in 25\n Plan:\n Cont Vigorous Pulm toileting.PRN suction,Cont Abx,follow up with\n culture. Team hoping to try extubation two days.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.01 mics/hr for low BP. Pt drops his BP with turning.\n Other VSS stable.\n Action:\n IV Levophed titrated to keep up Map above 65, Pt dropped BP after line\n placement during HD sedation?\n Response:\n Pt is currently normotensive on 0.03mcg/kg/min IV Levophed gtt.\n Plan:\n Cont to closely follow SBP values, Titrate IV Levophed gtt to maintain\n MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with ESRD on HD, Pt had infected RSC for HD. TF was held since\n 0300 for new HD line.\n Action:\n Pt went to IR for new HD line this morning, put a new Right fem line\n and pulled out old infected line and tip sent for culture.\n Response:\n Pt had HD and removed 800cc out. Restarted on TF\n Plan\n Closely monitoring renal function, Follow up with renal team.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600598,
"text": "HPI: 73 yo man admitted , with left SDH c/b seizure and possible\n line infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102 F oral this afternoon.\n Action:\n Pan cultured.Admin Tylenol, tepid bath given. Pt had torso CT this\n afternoon,showed osteomylitis,ordered MRI\n Response:\n Temp down to 100.8 axillary. Sent Mri checklist,awaiting their call.\n Plan:\n . Closely monitor temp curve,Follow up with culture,MRI tonight.\n Hypotension (not Shock)\n Assessment:\n Pt received pt on 0.02 mcg/kg/min levophed. A line Dcd yesterday.\n Action:\n Pt on and Off levo,currently off,VSS.\n Response:\n BP stable now.\n Plan:\n Closely monitor BP,Levo gtt as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600643,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD on , 800mls fluid removal, patient is anuric, rt fem\n dialysis cath in place\n Action:\n Continue monitor labs\n Response:\n AM labs\n Plan:\n Plan HD as per renal\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated, vented, on PSV 10/peep 5 and 50% O2,. Bilateral lung\n sounds rhonchorous, and diminished bases. O2 sats 100%. Large amount of\n thick whitish secretion\n Action:\n Bolus of sedation given, changed to A/C mode while patient was in MRI,\n continue pul toilet and MDI\ns as ordered. NPO after midnight for\n possible trach/PEG\n Response:\n Stable overnight, back on PSV with same settings,O2 sats 100%\n Plan:\n For trach/PEG in AM, NPO after midnight\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp, off levophed gtt\n Action:\n MRI spine to r/o osteomylitis or source of infection, temp spike to\n 101.5, patient has been cultured yesterday afternoon\n Response:\n Continues to have low grade temp\n Plan:\n F/U culture results, continue antibiotics, monitor temp curve\n Impaired Skin Integrity\n Assessment:\n Red bases, partial thickness ulcer on perineum, soft tissue of gluts\n and underside of scortum. Patient is in incontinence with loose stool,\n On air bed\n Action:\n Wound care as per wound care consult, keep clean and dry, frequent\n position change\n Response:\n Continue to have incontinence, ulcer remains same\n Plan:\n wound care as per wound care recommendations, position change, kinair\n bed\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600279,
"text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\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 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); Comments: at times tachypneic, with VT\n 200-250.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 600489,
"text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 10:30 AM\n DIALYSIS CATHETER - STOP 11:00 AM\n sideport\n ARTERIAL LINE - STOP 05:05 AM\n - renal recs: zosyn after HD today\n - temporary R femoral line placed in IR\n - Wife is concerned pt is not getting his enough fiber in diet\n requesting nutirition consult, also ask if can add probiotics from\n home, also with h/o recent eye surgery that has been monitored qwk for\n adjustment, consider opthomology c/s\n - Wife aware that next step is extubation and if fails, then trach\n - unable to tolerate fully weaning levo\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 11:40 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.1\nC (98.8\n HR: 76 (73 - 96) bpm\n BP: 168/65(80) {138/47(70) - 168/65(80)} mmHg\n RR: 23 (0 - 35) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 853 mL\n 423 mL\n PO:\n TF:\n 380 mL\n 316 mL\n IVF:\n 188 mL\n 77 mL\n Blood products:\n Total out:\n 800 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 53 mL\n 423 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 250 (250 - 532) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 65\n PIP: 12 cmH2O\n SpO2: 99%\n ABG: ///30/\n Ve: 10.4 L/min\n Physical Examination\n Cardiovascular: Gen: NAD, opens eyes\n CV: RRR\n Lungs: CTAB\n Abd: ND NT ABS\n Ext: no c/c/e\n Peripheral 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 220 K/uL\n 9.0 g/dL\n 300 mg/dL\n 6.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 100 mEq/L\n 141 mEq/L\n 28.4 %\n 7.7 K/uL\n [image002.jpg]\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n 9.6\n 7.7\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n 26.7\n 28.4\n Plt\n 185\n 234\n 196\n 241\n 280\n 220\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n 6.0\n TCO2\n 32\n 31\n 31\n Glucose\n 75\n 77\n 135\n 183\n 116\n 155\n 114\n 300\n Other labs: PT / PTT / INR:13.3/24.6/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:7.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers most likely source is line infection.\n On vancomycin. On and off pressors despite addition of midodrine and\n florinef. More likely due to abnormal autonomic dysfunction to\n renal failure, but ddx includes infectious etiology given recent h/o\n sepsis.\n - Continue midodrine and florinef and reduce levophed as tolerated\n - Zosyn after HD\n -keep MAP > 65\n -continue vancomycin given skin infection.\n - CIS\n # Respiratory Distress: Problem of inability to maintain secretions,\n based on failure of attempted trial of extubation. VS direct Trach\n placement\n - On pressure support . SBT and attempt extubation today.\n - continue HD for volume overload\n - f/u sputum cx\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA - negative\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: continue on fosphenytoin, q4d free phenytoin level\n checks.\n - touch base re: anti-seizure regimen given\n - EEG\n # ESRD:\n - cont HD w/ femoral temp line\n - replace RIJ HD line when infection heals.\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, femoral line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:15 PM 45. mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 AM\n Dialysis Catheter - 10:30 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": "2191-09-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600421,
"text": ": 73 yo man admitted , with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.6, Pt thought to have infected RSC HD line.\n Action:\n Pt had old infected HD line DCd today. Given Abx with HD.\n Response:\n Recent temp 99.7 axillary.\n Plan:\n Closely monitor temp curve,Follow up with culture data,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP/PS 5/5 with 50% FiO2. R$R in 20\ns with SPO2\n 98-100%Pt appears lethargic, noted to have Hiccough ups x 3 days, Team\n aware. Soft restraints in place to protect airway.\n Action:\n No changes made with Vent. Pt suctioned PRN for thick tan secretions.\n Given Abx as ordered.\n Response:\n SPO2 98-100%,RR in 25\n Plan:\n Cont Vigorous Pulm toileting.PRN suction,Cont Abx,follow up with\n culture. Team hoping to try extubation two days.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.01 mics/hr for low BP. Pt drops his BP with turning.\n Other VSS stable.\n Action:\n IV Levophed titrated to keep up Map above 65, Pt dropped BP after line\n placement during HD sedation?\n Response:\n Pt is currently normotensive on 0.03mcg/kg/min IV Levophed gtt.\n Plan:\n Cont to closely follow SBP values, Titrate IV Levophed gtt to maintain\n MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with ESRD on HD, Pt had infected RSC for HD. TF was held since\n 0300 for new HD line.\n Action:\n Pt went to IR for new HD line this morning, put a new Right fem line\n and pulled out old infected line and tip sent for culture.\n Response:\n Pt had HD and removed 800cc out. Restarted on TF\n Plan\n Closely monitoring renal function, Follow up with renal team.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600422,
"text": ": 73 yo man admitted , with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp max 100.6, Pt thought to have infected RSC HD line.\n Action:\n Pt had old infected HD line DCd today. Given Abx with HD.\n Response:\n Recent temp 99.7 axillary.\n Plan:\n Closely monitor temp curve,Follow up with culture data,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP/PS 5/5 with 50% FiO2. R$R in 20\ns with SPO2\n 98-100%Pt appears lethargic, noted to have Hiccough ups x 3 days, Team\n aware. Soft restraints in place to protect airway.\n Action:\n No changes made with Vent. Pt suctioned PRN for thick tan secretions.\n Given Abx as ordered.\n Response:\n SPO2 98-100%,RR in 25\n Plan:\n Cont Vigorous Pulm toileting.PRN suction,Cont Abx,follow up with\n culture. Team hoping to try extubation in two days vs trach.\n Hypotension (not Shock)\n Assessment:\n Pt received on 0.01 mics/hr for low BP. Pt drops his BP with turning.\n Other VSS stable.\n Action:\n IV Levophed titrated to keep up Map above 65, Pt dropped BP after line\n placement during HD sedation? . Pt received Midodrine as ordered.\n Response:\n Pt is currently normotensive on 0.03mcg/kg/min IV Levophed gtt.\n Plan:\n Cont to closely follow SBP values, Titrate IV Levophed gtt to maintain\n MAP\ns > 65.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with ESRD on HD, Pt had infected RSC for HD. TF was held since\n 0300 for new HD line.\n Action:\n Pt went to IR for new HD line this morning, put a new Right fem line\n and pulled out old infected line and tip sent for culture.\n Response:\n Pt had HD and removed 800cc out. Restarted on TF\n Plan\n Closely monitoring renal function, Follow up with renal team.\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 600519,
"text": "Chief Complaint: Respiratory Failure, Subdural hematoma, 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 Had femoral HD line placed yesterday and HD in the afternoon\n 24 Hour Events:\n DIALYSIS CATHETER - START 10:30 AM\n DIALYSIS CATHETER - STOP 11:00 AM\n sideport\n ARTERIAL LINE - STOP 05:05 AM\n History obtained from Medical records, icu team\n Patient unable to provide history: Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Fosphenytoin - 08:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: No(t) Tachycardia\n Nutritional Support: Tube feeds\n Genitourinary: Foley, Dialysis\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.4\nC (97.6\n HR: 82 (73 - 96) bpm\n BP: 112/69(80) {112/15(34) - 168/69(80)} mmHg\n RR: 14 (0 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 853 mL\n 638 mL\n PO:\n TF:\n 380 mL\n 485 mL\n IVF:\n 188 mL\n 123 mL\n Blood products:\n Total out:\n 800 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 53 mL\n 638 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (250 - 418) mL\n PS : 5 cmH2O\n RR (Spontaneous): 22\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 65\n PIP: 12 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 8 L/min\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: scattered )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, following some\n commands but still confused\n Labs / Radiology\n 9.0 g/dL\n 220 K/uL\n 300 mg/dL\n 6.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 100 mEq/L\n 141 mEq/L\n 28.4 %\n 7.7 K/uL\n [image002.jpg]\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n 04:05 PM\n 04:50 AM\n 02:40 AM\n 03:25 AM\n WBC\n 10.4\n 10.0\n 8.6\n 8.6\n 9.6\n 7.7\n Hct\n 29.4\n 28.4\n 30.2\n 27.7\n 26.7\n 28.4\n Plt\n 185\n 234\n 196\n 241\n 280\n 220\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n 8.0\n 9.9\n 6.0\n TCO2\n 32\n 31\n 31\n Glucose\n 75\n 77\n 135\n 183\n 116\n 155\n 114\n 300\n Other labs: PT / PTT / INR:13.3/24.6/1.1, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:80.0 %, Band:0.0 %,\n Lymph:3.0 %, Mono:5.0 %, Eos:7.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.5 mg/dL, Mg++:1.9 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently - now with persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Septic shock-\n Ongoing fevers and intermittent pressor requirement. Cont vanc for\n MRSA in sputum. Cont midodrine. Femoral HD line. CT torso for\n ongoing fevers\n 2)Respiratory Failure- Given ongoing lack of improvement in mental\n status and ongoing secretions will consult IP for trach and PEG.\n 3)Renal Failure- next HD per renal\n 4)Sub-Dural Hematoma/Altered Mental Status- Awake but still not fully\n interactive\n 5)Seizure Disorder- Neurontin, Dilantin\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:15 PM 45. mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 03:00 AM\n Dialysis Catheter - 10:30 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600599,
"text": "HPI: 73 yo man admitted , with left SDH c/b seizure and possible\n line infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 102 F oral this afternoon.\n Action:\n Pan cultured.Admin Tylenol, tepid bath given. Pt had torso CT this\n afternoon,showed osteomylitis,ordered MRI\n Response:\n Temp down to 100.8 axillary. Sent Mri checklist,awaiting their call.\n Plan:\n . Closely monitor temp curve,Follow up with culture,MRI tonight.\n Hypotension (not Shock)\n Assessment:\n Pt received pt on 0.02 mcg/kg/min levophed. A line Dcd yesterday.\n Action:\n Pt on and Off levo,currently off,VSS.\n Response:\n BP stable now.\n Plan:\n Closely monitor BP,Levo gtt as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt intubated 50% PS 5/5. BLS Rhonchi to diminish at the\n bases. Sp02 100%, TV 300-350.\n Action:\n Suction PRN for thick secretions from ETT, Cont pulm toilet, MDIs. IP\n came and evaluated for trach and peg,got consent.\n Response:\n No changed made on the vent.\n Plan:\n Cont pulm toileting,NPO after midnight for trach and peg tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599727,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Alteration in Nutrition\n Assessment:\n Tube feedings with 50cc residual. Stooling gold brwn stool\n Action:\n Increase tf to goal of 40 cc hr, with flush q 6 hr, following\n residuals, held stool softner this night for multiple stools\n Response:\n Min. residual tf at goal\n Plan:\n Tf to goal,\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 40%, cmv for night. No distress, suction for mod amt light\n color\n Action:\n No changes in vent sets this night, pulm. Care and support\n Response:\n Sats 100%\n Plan:\n Consideration of trach.\n Hypotension (not Shock)\n Assessment:\n Cont. on levo gtt at .04, started on midodrine today\n Action:\n Increased dose of 10 mgm midodrine tonight given\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 599655,
"text": "Chief Complaint: Respiratory Failure, renal failure, subdural hematoma\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 Extubated yesterday, but had to be reintubated yesterday evening due to\n increased work of breathing, inability to clear secretions\n 24 Hour Events:\n STOOL CULTURE - At 10:43 AM\n c. diff\n INVASIVE VENTILATION - STOP 04:33 PM\n INVASIVE VENTILATION - START 10:20 PM\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:37 PM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 09:40 PM\n Fosphenytoin - 08:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Tachycardia\n Respiratory: mechanical ventilation\n Genitourinary: Dialysis\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 38.1\nC (100.5\n HR: 92 (81 - 100) bpm\n BP: 127/49(78) {86/37(53) - 155/63(96)} mmHg\n RR: 15 (12 - 44) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 545 mL\n 436 mL\n PO:\n TF:\n 43 mL\n 135 mL\n IVF:\n 363 mL\n 121 mL\n Blood products:\n Total out:\n 2,400 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,855 mL\n 436 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (400 - 450) mL\n Vt (Spontaneous): 486 (486 - 486) 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: 21 cmH2O\n Plateau: 17 cmH2O\n SpO2: 100%\n ABG: 7.43/47/98./31/5\n Ve: 8.8 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General Appearance: No acute distress, intubated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: scattered)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Not assessed,\n Movement: Not assessed, Tone: Not assessed, follow some commands,\n somnolent\n Labs / Radiology\n 9.3 g/dL\n 185 K/uL\n 77 mg/dL\n 6.0 mg/dL\n 31 mEq/L\n 3.2 mEq/L\n 25 mg/dL\n 104 mEq/L\n 141 mEq/L\n 29.4 %\n 10.4 K/uL\n [image002.jpg]\n 03:56 AM\n 02:20 PM\n 05:59 PM\n 09:34 PM\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n WBC\n 10.4\n Hct\n 29.8\n 29.4\n Plt\n 185\n Cr\n 6.0\n TCO2\n 29\n 34\n 33\n 32\n Glucose\n 50\n 147\n 95\n 88\n 88\n 75\n 77\n Other labs: PT / PTT / INR:13.9/28.7/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.4 mg/dL, Mg++:1.9 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n .H/O RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n HYPOGLYCEMIA\n DIABETES MELLITUS (DM), TYPE II\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n 73 yo man with initial history notable for sub-dural hematoma\n complicated by seizures subsequently who now has persistent renal\n failure and recurrent fever in the setting of sepsis.\n 1)Septic shock-\n Ongoing low grade fevers. WBC trending down. Cont vanc/. Ongoing\n pressor requirement. He has purulent discharge from HD line - access\n is a major issue at the moment. His HD line VIP port is his only\n central access for pressors. All other potential line insertion sites\n are suboptimal (fistula on L, clot on R, femorals) - will treat through\n today, start midodrine and hope BP improves as he moves away from last\n dialysis session, with goal of line tomorrow and establishing\n line holiday. MRV for purpose of mapping out access sites\n 2)Respiratory Failure- Failed extubation yesterday. Mental status slow\n to clear - probably heading toward a trach, will d/w family\n 3)Renal Failure- HD as above.\n 4)Sub-Dural Hematoma/Altered Mental Status- Waxing and MS not\n great progressive improvement\n 5)Seizure Disorder-\n -Neurontin\n -Dilantin\n 6)PICC line clot: PICC line removed\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n NovaSource Renal (Full) - 02:00 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 12:25 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "General",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Generic Note",
"row_id": 599995,
"text": "TITLE: CRITICAL CARE\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with plan as outlined during multidisciplinary rounds\n this morning. Alert.\n 98.2 (ax) 82 103/39\n Alert\n shakes head to questioning but inconsistent and does not follow\n commands\n Chest\n few crackles\n CV 2/6 SEM\n Abd\n soft\n WBC 8.6 (down)\n Hct 30\n BC\n all remain neg\n He remains hypotensive, dependent on norepi, but no source of sepsis.\n Sputum remains pos for GPC but sputum vol has improved. Started on\n midodrine\n now at max dose. Remains febrile. Etiol of hypotension\n remains unclear\n w/o pos BC and with nl WBC I am skeptical that he is\n septic. I wonder if hypotension is actually vasoregulatory due to\n CRF? If so, may be very difficult to wean from norepi. Will speak\n with renal about Fluorinef. Will discuss more aggressive HD. I am\n inclined to complete abx course and d/c abx. Will also review all meds\n for possible drug fever. Have switched vent to PSV and will try to\n wean through the day. Holding TF as he should probably be tried with\n extubation one more time before trache.\n Time spent 45 min\n Critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600280,
"text": "Demographics\n Day of mechanical ventilation: 6\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\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 Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Able to wean Pt to PSV, tolerated well through the night.\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600593,
"text": "Day of mechanical ventilation: 7\n ETT:\n Position:21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\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: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n No vent changes or ABG\ns this shift. Torso CT to evaluate possible\n source of sepsis\n apparently non-revelatory. IP will do trach and PEG\n tomorrow. Still requiring pressors and with intermittent fevers.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599728,
"text": "73 yo man admitted with left SDH c/b seizure and possible line\n infection on cefapime/vanco. Transferred to the micu for respiratory\n distress, hypotension & hypoxia. Now intubated, oxygentating well,\n likely has PNA per chest Xray and fevers. Continues to require low\n dose levophed. Also has h/o iddm and afib, not on coumadin due to\n recent SDH.\n Alteration in Nutrition\n Assessment:\n Tube feedings with 50cc residual. Stooling gold brwn stool\n Action:\n Increase tf to goal of 40 cc hr, with flush q 6 hr, following\n residuals, held stool softner this night for multiple stools\n Response:\n Min. residual tf at goal\n Plan:\n Tf to goal,\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on 40%, cmv for night. No distress, suction for mod amt light\n color\n Action:\n No changes in vent sets this night, pulm. Care and support\n Response:\n Sats 100%\n Plan:\n Consideration of trach.\n Hypotension (not Shock)\n Assessment:\n Cont. on levo gtt at .04, started on midodrine today\n Action:\n Increased dose of 10 mgm midodrine tonight given\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599831,
"text": "Chief Complaint:\n 24 Hour Events:\n - Bolused IV phenytoin 300mg and check free dilantin in AM\n - Pt started on midodrine\n - MRV - narrowing of R Subclav and R Brachiocephalic. Narrowing of L\n subclavian and L IJ. Patent SVC and RIJ. Enlarged mediastinal LN\n unchanged from prior.\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:07 PM\n Infusions:\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Dilantin - 10:00 PM\n Fentanyl - 12:24 AM\n Fosphenytoin - 12:35 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 06:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 37.1\nC (98.8\n HR: 85 (81 - 93) bpm\n BP: 131/48(79) {96/40(59) - 149/61(94)} mmHg\n RR: 77 (13 - 77) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 945 mL\n 295 mL\n PO:\n TF:\n 390 mL\n 210 mL\n IVF:\n 375 mL\n 85 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 945 mL\n 295 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 233 (233 - 233) mL\n RR (Set): 16\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 100\n PIP: 18 cmH2O\n Plateau: 14 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 100%\n ABG: ///29/\n Ve: 7.9 L/min\n Physical Examination\n Intubated, awake, follows some commands\n RRR, cta\n Abd soft, nontender\n Extremities with edema, greater in RUE\n Ulcers along posterior scrotum and sacrum\n Labs / Radiology\n 234 K/uL\n 9.0 g/dL\n 183 mg/dL\n 7.7 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 31 mg/dL\n 104 mEq/L\n 141 mEq/L\n 28.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:59 PM\n 09:34 PM\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n WBC\n 10.4\n 10.0\n Hct\n 29.4\n 28.4\n Plt\n 185\n 234\n Cr\n 6.0\n 7.4\n 7.7\n TCO2\n 34\n 33\n 32\n Glucose\n 50\n 147\n 95\n 88\n 88\n 75\n 77\n 135\n 183\n Other labs: PT / PTT / INR:14.4/25.4/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL, PO4:3.8 mg/dL\n Fluid analysis / Other labs: RPR negative\n Imaging: - MRV: narrowing of R Subclav and R Brachiocephalic.\n Narrowing of L subclavian and L IJ. Patent SVC and RIJ. Enlarged\n mediastinal LN unchanged from prior.\n CXR: cardiomegaly, pulmonary congestion unchanged\n Microbiology: SPUTUM\n -GRAM STAIN: 1+ GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS.\n -RESPIRATORY CULTURE (Preliminary): STAPH AUREUS COAG +. SPARSE\n GROWTH.\n CATHETER TIP: No significant growth.\n Stool: C. diff negative\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers concerning for VAP with sputum + for\n minimal Staph aureus also gross pus from R HD line could be source. On\n day 7 vancomycin / meropenem, pan cultured . Requires pressure\n support. Midodrine started to wean pressors, but unchanged levo\n demand. All Bcx negative to todate,\n - Increase Midodrine and decrease levo as tolerated\n - d/c Meropenum\n - f/u cultures\n # Respiratory Distress: volume overload vx PNA. Attempted trial of\n extubation 2d ago, pt failed and is reintubated.\n - attempt one additional trial of extubation because mental status\n improved, also consider possibility of trach, and long term ventilation\n - continue HD for volume overload\n - on day 7 of vanc for pneumonia, s/p 10d tx for MRSA pna\n #Scrotal and buttock lesions\n most likely dependent skin ulcers, RPR\n negative\n - Herpes DFA\n - continue wound care\n # Mental status: - improving, CT head showed no worsening of SDH, Vit\n B12, folate, TSH all normal\n # Seizure: no gross evidence of ongoing seizure activity\n - Neuro recs: Bolused IV phenytoin 300mg and check free dilantin in AM\n - f/u EEG\n # Right Upper Extremity Swelling: u/s shows non occlusive clot, MRV\n without evidence of SVC\n -continue to monitor\n # ESRD:\n - HD today\n - f/u renal recs\n # AF: patient in NSR. Continue to hold anti-coagulation for underlying\n SDH\n # High Bilious Output: Resolved. Is able to tolerate TF with clear\n residuals. h/o Guaic posive output.\n - continue PPI\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # R renal cyst\n one complex cyst and one simple cyst on right kidney.\n Radiology rec 12 month follow up.\n # Glaucoma / Cataracts: continue home eye drops\n # DM: d/c insulin gtt, restart SSI with lantus baseline\n # Access: axillary A-line, temp line for HD (infected)\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n - Family Meeting\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 20 Gauge - 12:25 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": "2191-09-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600212,
"text": "73 yo man admitted , with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n Altered mental status (not Delirium)\n Assessment:\n Eyes open to voice, and spontaneously\n Tracking voice with eyes\n Left LUE flaccid\n Purposeful movement of RUE\n BLE moving on bed\n Action:\n No sedation\n Continues on seizure prophylaxis\n Response:\n Ongoing assessment\n No seizure activity noted\n Plan:\n Continue serial neuro exams\n Continue anticonvulsants\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear in upper lobes and scattered rhonchi/rales at bases\n Suctioning q2-3h for small amts frothy secretions\n Action:\n PSV reduced to 5+5/0.4\n Response:\n Pt tolerating reduced ventilatory support\n Plan:\n Plan for extubation tomorrow after hemodialysis and new HD catheter\n placement in IR\n Family meeting to discuss plan of care regarding extubation and\n potential for re-intubation\n Plan for trach/PEG it he fails extubation\n Hypotension (not Shock)\n Assessment:\n Received on low dose norepinepherine\n Pt has been hypotensive most of the day\n Action:\n Norepinepherine stopped\n Midodrine TID\n Response:\n Pt has been normotensive to hypertensive all day\n Plan:\n Continue Midodrine, Fludrocortisone.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600271,
"text": "TITLE: 73 yo man admitted , with left SDH c/b seizure and possible\n line infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2.\n UPDATE: Pt spiked oral temp to 102.4 overnight, blood C&S times two\n along with sputum C&S sent for analysis. Transiently On/Off IV\n Levophed gtt for SBP values dropping down to the 80\ns assoc with poor\n tol of turns. Of note, the pts mixed venous O2 sat with a SABP value\n in the 80\ns was found to be 61%. RUE Ax a-line remains positional.\n Tube feeds off @ 03:00 per team request with plan to go to IR for new\n temp Fem HD line placement. MRSA Contact Isolation Precautions in\n place. The pt remains a Full Code.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with an oral temp max of 102.4, team notified -- blood and sputum\n C&S subsequently sent for analysis. Pt thought to have infected\n infected RSC HD line which is slatted to be d/c\ned in IR later today.\n Action:\n Following serial oral temp values. Pt med with 650mg PO Acetaminophen\n for comfort.\n Response:\n Pt remains febrile @ this time.\n Plan:\n Cont to follow fever curve, culture data, provide antibx on timed\n schedule, await AM CXR results, send random Vanco level today @ 06:00.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received/maintained on CPAP/PS 5/5 with 50% FiO2 in place. Sxn\n ETT for sm to mod amounts of thick tan sec with plugs noted on\n occasion. LS have varied from diffuse coarse rhonchi to fairly clear\n s/p effective sxn\ning. RR noted to be in the high 30\ns when pt is\n rhonchorous, improving to the 20\ns with clearance of sec. RT to obtain\n AM RSBI prior to start of AM shift. Nl sat values all shift. Mixed\n venous O2 sat of 61% noted when pts SBP values dropped to 80\n Action:\n Pt sat upright 30 to 45 degrees to optimize resp fxn. Sputum C&S sent\n for analysis. Pt sxn\ned Q2-3 hrs PRN. AM CXR obtained, results\n currently pending.\n Response:\n Pts mixed venous O2 sat was low when pt was in a low flow cardiac\n state.\n Plan:\n Cont to follow lung exam closely, provide sxn\ning as needed for sec\n clearance, provide IV Vanco with HD treatments/follow Vanco serum\n levels. Adjust MV settings to ensure optimal gas exchange. Move pt\n OOB to chair during day shift to maximize resp fxn. Team hopes to\n possibly extubate pt s/p new HD line placement followed by HD treatment\n later today.\n Hypotension (not Shock)\n Assessment:\n Pt became transiently hypotensive on two occasions thus far tonight\n with SBP values dropping/staying in the 80\ns. Both episodes were assoc\n with pt turns. RUE Ax a-line remains positional. Pt is likely\n septic.\n Action:\n IV Levophed briefly started/stopped to maintain MAP values > 60 earlier\n in shift. IV Levophed gtt is currently infusing @ 0.02mcg/kg/min.\n Response:\n Pt is currently normotensive on 0.02mcg/kg/min IV Levophed gtt.\n Plan:\n Cont to closely follow SBP values, calibrate IV Levophed gtt to\n maintain MAP\ns > 65, follow C&S/CXR data.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt is HD dependent. Plan for Monday is to remove RSC HD line and place\n a Fem HD line.\n Action:\n Tube feeds held @ 03:00 in prep for IR proc later today. Blood\n specimen sent to blood bank for routine type/ cross. AM labs\n drawn/sent to assess renal/metabolic fxn.\n Response:\n Plan:\n Will keep pt NPO prior to IR proc. Pt will be hemodialyzed today s/p\n new HD line placement.\n Altered mental status (not Delirium)\n Assessment:\n Pt appears confused/lethargic, inconsistently follows simple commands.\n Pt noted to have hiccoughs all shift. LUE soft wrist restraints in\n place to protect airway. Pt unable/unwilling to nod head\n appropriately to simple yes/no questions.\n Action:\n No psycho-active agents provided to pt. Pt freq re-oriented to\n person/place/time/care rationale to facilitate nl cognition. Verbal\n reassurance provided.\n Response:\n Pt MS with waxing/ delirium.\n Plan:\n Cont to freq re-orient pt, encourage family members to visit pt/engage\n pt psychologically, avoid use of sedatives when possible.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600638,
"text": "Demographics\n Day of intubation: 8\n Day of mechanical ventilation: 8\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Re-intubation\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n 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: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\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 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 Tracheostomy planned\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Hemodynimic instability,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n MRI\n 2100\n Transported to MRI and back into unit without a problem.\n"
},
{
"category": "Respiratory ",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 600832,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 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 / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use; Comments:\n Pt is having abnormal abdominal movement throughout shift\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate, High min.\n ventilation)\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, Adjust\n Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved; Comments: Pt was very agitated and grimacing throughout\n beginning of shift. Pt was also using actively breathing using\n abdomen/diaphragm (looked like hiccups). Pt had ABG checked which\n showed respiratory alkalosis. Pt was returned to AC settings, and\n remains there. MDs unable to get ABG after AC setting were initiated.\n Pt to be assessed by MD \nIDE RSBI- 67\n"
},
{
"category": "Nutrition",
"chartdate": "2191-09-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 600388,
"text": "Subjective: RN, will restart tube feeds later this afternoon after\n HD and bed change.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 178 cm\n 94.2 kg\n 89.4 kg ()\n 30.4\n Pertinent medications: Norepinephrine drip, RISS, Glargine, ABx, others\n noted\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 02:40 AM\n Glucose Finger Stick\n 118\n 12:00 PM\n BUN\n 49 mg/dL\n 02:40 AM\n Creatinine\n 9.9 mg/dL\n 02:40 AM\n Sodium\n 138 mEq/L\n 02:40 AM\n Potassium\n 5.1 mEq/L\n 02:40 AM\n Chloride\n 101 mEq/L\n 02:40 AM\n TCO2\n 24 mEq/L\n 02:40 AM\n PO2 (arterial)\n 127 mm Hg\n 04:05 PM\n PO2 (venous)\n 76. mm Hg\n 04:56 AM\n PCO2 (arterial)\n 47 mm Hg\n 04:05 PM\n PCO2 (venous)\n 43 mm Hg\n 04:56 AM\n pH (arterial)\n 7.41 units\n 04:05 PM\n pH (venous)\n 7.31 units\n 04:56 AM\n CO2 (Calc) arterial\n 31 mEq/L\n 04:05 PM\n CO2 (Calc) venous\n 23 mEq/L\n 04:56 AM\n Albumin\n 2.5 g/dL\n 03:38 AM\n Calcium non-ionized\n 8.6 mg/dL\n 02:40 AM\n Phosphorus\n 3.8 mg/dL\n 02:40 AM\n Ionized Calcium\n 1.11 mmol/L\n 04:03 AM\n Magnesium\n 1.9 mg/dL\n 02:40 AM\n ALT\n 23 IU/L\n 03:34 AM\n Alkaline Phosphate\n 168 IU/L\n 03:34 AM\n AST\n 44 IU/L\n 03:34 AM\n Amylase\n 41 IU/L\n 03:38 AM\n Total Bilirubin\n 0.4 mg/dL\n 03:34 AM\n Triglyceride\n 205 mg/dL\n 02:26 AM\n Phenytoin (Free)\n 3.0 ug/mL\n 04:51 AM\n Phenytoin (Dilantin)\n 6.8 ug/mL\n 04:50 AM\n WBC\n 9.6 K/uL\n 02:40 AM\n Hgb\n 8.6 g/dL\n 02:40 AM\n Hematocrit\n 26.7 %\n 02:40 AM\n Current diet order / nutrition support: Tube Feeds: Nutren 2.0 @\n 45mL/hr + 30g Beneprotein (2262kcals, 112g protein)\n GI: abd firm, distended, bowel sounds present, loose brown stool\n Assessment of Nutritional Status\n 73 y.o. man admitted with left SDH c/b seizure and possible line\n infection. Transferred to the MICU for respiratory distress,\n hypotension & hypoxia. Failed trial of extubation x2. Patient remains\n intubated, now on pressor support and receiving HD after line change\n earlier today. Tube feeds have been off since this a.m. due to trip to\n IR for HD line placement, but plan is to restart this afternoon, \n RN. Tube feeds meet 100% of estimated needs while patient is on HD.\n Of note, patient\ns abd has changed from soft to firm/distended as of\n yesterday () afternoon. Will monitor. K high, will likely\n decrease with HD.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend restarting tube feeds when able .\n Monitor abd exam and tube feed tolerance.\n Montior lytes and hydration.\n Following - #\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 600639,
"text": ".H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Last HD on , 800mls fluid removal, patient is anuric, rt fem\n dialysis cath in place\n Action:\n Continue monitor labs\n Response:\n AM labs\n Plan:\n Plan HD as per renal\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Orally intubated, vented, on PSV mode,\n.. . Bilateral lung sounds\n rhonchorous, and diminished bases. O2 sats 100%. Large amount of thick\n whitish secretion\n Action:\n Bolus of sedation given, changed to A/C mode while patient was in MRI,\n continue pul toilet and MDI\ns as ordered. NPO after midnight for\n possible trach/PEG\n Response:\n Stable overnight, O2 sats 100%\n Plan:\n For trach/PEG in AM, NPO after midnight\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp, off levophed gtt\n Action:\n MRI spine to r/o osteomylitis or source of infection, temp spike to\n 101.5, patient has been cultured yesterday afternoon\n Response:\n Low grade temp\n Plan:\n F/U culture results, continue antibiotics, monitor temp curve\n Impaired Skin Integrity\n Assessment:\n Red bases, partial thickness ulcer on perineum, soft tissue of gluts\n and underside of scortum. Patient is in incontinence with loose stool,\n On air bed\n Action:\n Wound care as per wound care consult, keep clean and dry, frequent\n position change\n Response:\n Continue to have incontinence, ulcer remains same\n Plan:\n wound care as per wound care recommendations, position change, kinair\n bed\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599721,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max today 100.8 F oral. WBC recently WNL. Purulent drainage at HL\n line site.\n Action:\n Admin tepid bath. Cont abx tx. Resend blood cx\ns via HD line.\n Response:\n Pt remains febrile.\n Plan:\n D/c HD line tomorrow and give line holiday. Follow cx data.\n Hypotension (not Shock)\n Assessment:\n Received pt on 0.04 mcgs/kg/min levophed gtt.\n Action:\n Admin midodrine PO.\n Response:\n Pt still requires levophed gtt.\n Plan:\n Attempt to transition to PO midodrine and d/c levophed, then d/c\n central line.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/450/16/5, no sedation. SRR approx 5. Sp02\n 100%. Copious clear oral secretions.\n Action:\n Suction PRN. Pulm toilet.\n Response:\n Resp status unchanged.\n Plan:\n Supportive care, may need trach / PEG. Will need to coordinate family\n mtng.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Anuric w/ ESRD. Last HD Weds.\n Action:\n Hold HD today.\n Response:\n Stable.\n Plan:\n Hold HD tomorrow b/c pt will need line holiday d/t probable line infex\n / sepsis.\n Seizure, without status epilepticus\n Assessment:\n Received pt on EEG cont monitoring. Continuing tremor L hand.\n Dilantin level subtherapeutic.\n Action:\n Monitor accordingly. Admin fosphenytoin.\n Response:\n No changes. EEG d/c\n Plan:\n Monitor neuro status. Admin extra dose dilantin tonight.\n"
},
{
"category": "Nursing",
"chartdate": "2191-09-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 599725,
"text": "Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2191-09-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 599972,
"text": "Chief Complaint:\n 24 Hour Events:\n - Neuro recs: fosphenytoin 200mg TID, check daily levels, q3-4d check\n free level (doesn't need to be daily)\n - Midodrine increased to 15mg TID\n - Family informed of possibility of trach/peg\n - HSV DFA sample done from sacral wound\n Allergies:\n Hydromorphone\n Unknown;\n Metoclopramide\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:07 PM\n Vancomycin - 01:45 PM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 04:32 PM\n Fentanyl - 06:20 PM\n Midazolam (Versed) - 03:50 AM\n Fosphenytoin - 07:32 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 36.8\nC (98.2\n HR: 84 (81 - 98) bpm\n BP: 142/49(84) {71/30(42) - 180/71(106)} mmHg\n RR: 20 (13 - 51) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 89.4 kg (admission): 94.2 kg\n Height: 70 Inch\n Total In:\n 1,867 mL\n 504 mL\n PO:\n TF:\n 966 mL\n 323 mL\n IVF:\n 531 mL\n 21 mL\n Blood products:\n Total out:\n 3,000 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,133 mL\n 505 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 450 (450 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: No Spon Resp\n PIP: 23 cmH2O\n Plateau: 22 cmH2O\n Compliance: 26.5 cmH2O/mL\n SpO2: 100%\n ABG: 7.43/45/129/30/5\n Ve: 8.2 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 196 K/uL\n 9.5 g/dL\n 116 mg/dL\n 5.7 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 100 mEq/L\n 141 mEq/L\n 30.2 %\n 8.6 K/uL\n [image002.jpg]\n 10:00 PM\n 12:00 AM\n 01:00 AM\n 02:00 AM\n 03:38 AM\n 04:08 AM\n 09:22 PM\n 02:21 AM\n 03:31 AM\n 04:03 AM\n WBC\n 10.4\n 10.0\n 8.6\n Hct\n 29.4\n 28.4\n 30.2\n Plt\n 185\n 234\n 196\n Cr\n 6.0\n 7.4\n 7.7\n 5.7\n TCO2\n 32\n 31\n Glucose\n 147\n 95\n 88\n 88\n 75\n 77\n 135\n 183\n 116\n Other labs: PT / PTT / INR:14.4/26.8/1.2, CK / CKMB /\n Troponin-T:75/2/0.28, ALT / AST:23/44, Alk Phos / T Bili:168/0.4,\n Amylase / Lipase:41/64, Differential-Neuts:68.0 %, Band:4.0 %,\n Lymph:7.0 %, Mono:8.0 %, Eos:8.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.5\n g/dL, LDH:266 IU/L, Ca++:8.5 mg/dL, Mg++:1.7 mg/dL, PO4:3.1 mg/dL\n Imaging: EEG - negative\n : CXR\n FINDINGS: The position of the ET tube is unchanged with the tip at the\n thoracic inlet 3 cm above the carina, the right venous line and NG tube\n are\n unchanged.\n Median sternotomy wires are intact.\n Left lateral lower lobe atelectasis is stable. No new consolidation,\n pneumothorax or pleural effusion. Cardiomediastinal silhouette is\n unchanged.\n MRV:\n 1. Narrowing of the right subclavian as well as right brachiocephalic\n veins\n as described above.\n 2. Narrowing of the left subclavian as well as left internal jugular\n vein.\n 3. Widely patent SVC and the right-sided internal jugular line ends in\n the\n distal SVC. Linear filling defect in the left internal jugular vein is\n suggestive of a fibrin sheath from prior catheterization.\n 4. Enlarged mediastinal lymph nodes, some of which are unchanged from\n prior\n CT and of uncertain significance. Assessment by chest CT could be\n obtained as\n per clinical need.\n Microbiology: : growing MRSA in sputum\n line cx - NGTD\n Assessment and Plan\n Assessment and Plan\n 73 yom HD-dependent, admitted with left acute on chronic SDH c/b\n seizure, transferred to MICU for concern of sepsis with hypoxia and\n hypotension.\n # Sepsis: Continues with fevers concerning for VAP with sputum + for\n minimal Staph aureus () also gross pus from R HD line could be\n source. On day 8 vancomycin, pan cultured . Requires continued\n pressure support w levophed. Midodrine started to wean pressors, but\n unchanged levo demand. All Bcx negative to todate,\n - Continue midodrine and reduce levophed as tolerated\n - f/u cultures\n -keep MAP > 65\n -continue vancomycin given recent positive cx for MRSA to complete 10 d\n course\n # Respiratory Distress: likely secondary to PNA vs pulmonary edema.\n Attempted trial of extubation 2d ago, pt failed and is reintubated.\n - attempt switch to pressure support today; consider possibility of\n trach placement for long term ventilation\n - continue HD for volume overload\n - on day 8 of vanc for pneumonia, s/p 10d tx for MRSA pna\n #Scrotal and buttock lesions\n most likely dependent skin ulcers\n - Herpes DFA\n - continue wound care\n # Seizure: no gross evidence of ongoing seizure activity; EEG is\n negative\n - Neuro recs: Bolused IV phenytoin 300mg and f/u dilantin level in AM\n - touch base re: anti-seizure regimen given -EEG\n # ESRD:\n - may go for HD today, f/u with renal\n # SDH: continue to hold anticoagulation, will follow neurology recs\n # Glaucoma / Cataracts: continue home eye drops\n # DM: On SSI + lantus 40 daily; sugars well controlled 100-200\n # Access: axillary A-line, temp line for HD (infected); weaning\n pressors in attempt to pull HD line\n # Nutrition: tolerating TF\n # PPX: pneumoboots, PPI; bowel reg\n # Code: full; confirmed with wife on admission via phone\n # Dispo: to remain in ICU while intubated\n -update family\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 01:00 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Dialysis Catheter - 04:10 PM\n Arterial Line - 11:58 AM\n 22 Gauge - 03:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Echo",
"chartdate": "2191-09-06 00:00:00.000",
"description": "Report",
"row_id": 72400,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypotension.\nHeight: (in) 68\nWeight (lb): 190\nBSA (m2): 2.00 m2\nBP (mm Hg): 100/52\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 09:59\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.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Normal descending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA 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. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality - poor\nsuprasternal views.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand global systolic function (LVEF>55%). Due to suboptimal technical quality,\na focal wall motion abnormality cannot be fully excluded. The estimated\ncardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and\nfree wall motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the\nseverity of mitral regurgitation may be significantly UNDERestimated.] There\nis borderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nbiventricular systolic function. Mild mitral regurgitation. Mildly dilated\nascending aorta.\nThese findings are c/w hypertensive heart.\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": "2191-08-31 00:00:00.000",
"description": "Report",
"row_id": 161719,
"text": "Sinus rhythm. Left atrial abnormality. Prior inferior myocardial infarction.\nBaseline artifact. Compared to the previous tracing of the rate has\nslowed. There is non-specific ST-T wave flattening and biphasic T waves in\nleads V1-V4 and ST-T wave flattening in leads V5-V6. In the context of prior\ninferior myocardial infarction the ST-T wave changes may represent an active\nischemic process. Followup and clinical correlation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2191-08-26 00:00:00.000",
"description": "Report",
"row_id": 161720,
"text": "Sinus tachycardia. Prior inferior myocardial infarction cannot be excluded.\nNon-specific lateral ST-T wave changes persist as recorded on without\ndiagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2191-08-21 00:00:00.000",
"description": "Report",
"row_id": 161721,
"text": "Baseline artifact. Sinus rhythm. Non-diagnostic Q waves in the inferior leads.\nNon-specific ST-T wave changes. Compared to the previous tracing no significant\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2191-08-17 00:00:00.000",
"description": "Report",
"row_id": 161722,
"text": "Sinus rhythm. Possible inferior myocardial infarction of indeterminate age.\nLateral T wave inversions may be due to myocardial ischemia. Compared to\ntracing #1 the apical T waves are mildly flattened.\nTracing #2\n\n"
},
{
"category": "ECG",
"chartdate": "2191-08-17 00:00:00.000",
"description": "Report",
"row_id": 161723,
"text": "Sinus rhythm. Possible inferior infarction of indeterminate age. T wave\ninversions laterally. Consider myocardial ischemia. Compared to the previous\ntracing of no significant difference.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2191-08-12 00:00:00.000",
"description": "Report",
"row_id": 161724,
"text": "Sinus rhythm. Consider inferior myocardial infarction. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102760,
"text": " 1:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 3:04 PM\n PFI: Stable chest findings, no pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: A 73-year-old male patient intubated, evaluate for interval\n change.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Analysis is performed in direct comparison\n with the next preceding similar study of . The patient remains\n intubated, the ETT terminating in the trachea some 4 cm above the level of the\n carina. Right-sided internal jugular approach central venous line is\n unchanged. The same holds for an NG tube terminating below the diaphragm. No\n pneumothorax has developed. No new infiltrates are identified. Crowded\n vasculature on the bases indicate some plate atelectasis. No new infiltrates.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1099688,
"text": " 12:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: LT SDH FROM OSH. ? PROGRESSION OF BLEED.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man tx from OSH for L frontparietal SDH\n REASON FOR THIS EXAMINATION:\n ?progression of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl FRI 2:45 AM\n left acute on chronic SDH overlying hemisphere, along tentoriu and\n parafalcine. 8mm rounded area of hemorrhage on left toward vertex appears\n contiguous w/ SDH on reformats (less likely EDH)\n 3mm rightward shift, unhanged. no uncal or transtentorial herniation\n small rt SDH (3mm), unchanged\n WET READ VERSION #1 JXRl FRI 1:44 AM\n left acute on chronic SDH overlying hemisphere, along tentoriu and\n parafalcine. rounded area of hemorrhage on left toward vertex appears\n contiguous w/ SDH on reformats (less likely EDH)\n 3mm leftward shift, unhanged. no uncal or transtentorial herniation\n small rt SDH (3mm), unchanged\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with left frontoparietal subdural hematoma.\n\n COMPARISON: Non-contrast head CT performed at 4.5 hours\n prior.\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: An acute on chronic subdural hematoma overlies the left hemisphere\n and layers along the tentorium and falx. The extra-axial collection measures\n up to 11 mm at the vertex, where the hyperdensity has a rounded configuration.\n However, on the reformatted images, this appears to be contiguous with the\n subdural hematoma. There is associated effacement of the sulci, particularly\n involving the parietooccipital lobe. 3 mm leftward shift of midline\n structures is unchanged.\n\n Extra-axial hyperdensity overlying the right frontoparietal lobe measuring up\n to 4 mm consistent with a smaller acute subdural hematoma. Periventricular\n regions of hypoattenuation consistent with chronic small vessel ischemic\n change. The -white matter differentiation is preserved. There is no\n intraventricular extension of blood. There is partial opacification of right\n mastoid air cells. No fractures are identified. The left sphenoid sinus is\n partially opacified.\n\n IMPRESSION:\n 1. Acute on chronic left subdural hematoma. It is measuring up to 11 mm in\n greatest dimension. A component of extra-axial hemorrhage towards the vertex\n appears contiguous with the subdural collection and is less likely epidural.\n 2. Left hemisphere sulcal effacement and unchanged 3-mm rightward shift of\n midline structures.\n (Over)\n\n 12:08 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: LT SDH FROM OSH. ? PROGRESSION OF BLEED.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Small right frontoparietal acute subdural hematoma.\n 4. Partial opacification of right mastoid air cells. No fracture is\n identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-22 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1101133,
"text": " 2:56 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: requires temporary line with three ports, as pt has no acces\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 5\n ********************************* CPT Codes ********************************\n * NON-TUNNELED -79 UNRELATED PROCEDURE/SERVICE DURI *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with renal failure on HD, intubated for respiratory failure\n REASON FOR THIS EXAMINATION:\n requires temporary line with three ports, as pt has no access for blood draws.\n Please page if questions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BTCa MON 4:55 PM\n PFI: Successful placement of temporary hemodialysis catheter with the tip\n located in the right atrium. The line is ready for use.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 73-year-old male with renal failure requiring\n hemodialysis. Request for temporary line with three ports as the patient has\n no access for blood draws.\n\n OPERATORS: Dr. and Dr. , the attending\n radiologist who was present and supervising throughout the procedure.\n\n ANESTHESIA: Lidocaine was used for local anesthesia.\n\n PROCEDURE AND FINDINGS: After the risks and benefits of the procedure were\n explained to the patient's wife, informed consent was obtained. The patient\n was brought to the angiography suite and placed supine on the imaging table.\n The right neck and upper chest was prepped and draped in the usual sterile\n fashion. The right internal jugular vein was accessed with a micropuncture\n needle under ultrasound guidance. Hard copies of ultrasound were stored. A\n 0.018 wire was then placed through the needle into the SVC using flouroscopic\n guidance and the needle was exchanged for a micropuncture sheath. The wire was\n then exchanged for wire which was then advanced into the IVC. The\n sheath was removed and dilatations were performed over the wire.\n Ultimately, a 12-French 16 cm long hemodialysis with a VIP port placed over\n the guidewire with the tip terminating within the upper right atrium. The\n guidewire was removed and all ports flushed and aspirated easily. The\n catheter was secured to the skin with 0 silk sutures and a sterile dressing\n was applied. There is a final spot fluoroscopic radiograph demonstrating\n satisfactory placement of the catheter with the tip terminating within the\n right atrium.\n\n The patient tolerated the procedure well with no immediate complications.\n\n IMPRESSION:\n Uncomplicated successful placement of a 12-French x 16 cm with dialysis\n catheter with VIP port terminating within the right atrium. The line is\n (Over)\n\n 2:56 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: requires temporary line with three ports, as pt has no acces\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 5\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n flushed and ready to use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-22 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1101134,
"text": ", MED MICU 2:56 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: requires temporary line with three ports, as pt has no acces\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 5\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with renal failure on HD, intubated for respiratory failure\n REASON FOR THIS EXAMINATION:\n requires temporary line with three ports, as pt has no access for blood draws.\n Please page if questions\n ______________________________________________________________________________\n PFI REPORT\n PFI: Successful placement of temporary hemodialysis catheter with the tip\n located in the right atrium. The line is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102270,
"text": " 3:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fever, white count, intubated\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:07 A.M., \n\n HISTORY: Fever and white count.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes are still low, though improved, as interstitial edema resolves.\n Peribronchial opacification in both lower lungs is more likely atelectasis and\n residual edema than pneumonia. Upper lungs are clear. No appreciable pleural\n effusion. Heart size normal. ET tube in standard placement. Nasogastric\n tube passes below the diaphragm and out of view. Right dual-channel central\n venous line ends in the upper right atrium, as before. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102761,
"text": ", MED MICU 1:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Stable chest findings, no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100620,
"text": " 2:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ngt location\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with new NGT placement\n REASON FOR THIS EXAMINATION:\n ngt location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with new NG tube. Evaluate placement location.\n\n Single AP chest radiograph compared to , shows\n repositioning of the NG tube, which terminates in the stomach. Right PICC\n line can be traced to the mid SVC. Two left IJ central venous catheters\n terminates in the mid and distal SVC. There is no pneumothorax. Mild cardiac\n enlargment and pulmonary vascular congestion is unchanged. Bibasilar\n atelectasis persists. There is no pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-01 00:00:00.000",
"description": "MRV CHEST W/O CONTRAST",
"row_id": 1102781,
"text": " 3:04 PM\n MRV CHEST W/O CONTRAST Clip # \n Reason: SVC syndrome, anatomy for line replacement\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with UE/LE edema\n REASON FOR THIS EXAMINATION:\n SVC syndrome, anatomy for line replacement\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 5:34 PM\n The right subclavian vein is narrowed in its medial course. The right\n brachiocephalic vein is narrowed at the thoracic inlet, near its junction with\n the left brachiocephalic vein. The right internal jugular line is visualized\n in situ and terminates in the distal SVC. The SVC itself is widely patent.\n\n The left subclavian vein is narrowed at the thoracic inlet, near its\n confluence with the left internal jugular vein. There is a linear filling\n defect in the left internal jugular vein, most likely representing a fibrin\n sheet from prior catheterization. The left external jugular vein is\n prominent, most likely representing collateralization.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with upper extremity edema, to exclude SVC syndrome\n and also to assess anatomy for line placement.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired without\n gadolinium due to patient's renal compromise. Correlation is made with prior\n CT neck of .\n\n FINDINGS:\n\n The examination is limited due to lack of intravenous contrast as well as\n artifact from breathing during the examination.\n\n There is a right internal jugular central line with the distal tip in the SVC.\n The right subclavian vein is narrowed in its medial course at its junction\n with the right brachicephalic vein (5:10). The right brachiocephalic vein is\n narrowed in its distal course near the confluence with the left\n brachiocephalic vein (5:16). The SVC is widely patent. The left subclavian\n vein is narrowed at the thoracic inlet (5:12, 14:24). There is a linear\n filling defect in the left internal jugular vein and the appearances are\n suggestive of a fibrin sheath from prior left internal jugular central line.\n There is narrowing of the left internal jugular vein near its confluence with\n the left subclavian (8:11). The left brachiocephalic vein is patent.\n\n There are several scattered, up to 11 mm mediastinal lymph nodes, some of\n which were visualized on prior CT cervical spine of and are unchanged.\n There is no pericardial effusion. There is no pleural effusion. There is no\n abnormal marrow signal. Sternotomy sutures are present.\n\n Prominent left external jugular vein likely represents sequelae of\n (Over)\n\n 3:04 PM\n MRV CHEST W/O CONTRAST Clip # \n Reason: SVC syndrome, anatomy for line replacement\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n collateralization and is unchanged from previous CT.\n\n IMPRESSION:\n\n The examination is limited due to lack of intravenous contrast and artifact\n from breathing during the examination.\n\n 1. Narrowing of the right subclavian as well as right brachiocephalic veins\n as described above.\n 2. Narrowing of the left subclavian as well as left internal jugular vein.\n 3. Widely patent SVC and the right-sided internal jugular line ends in the\n distal SVC. Linear filling defect in the left internal jugular vein is\n suggestive of a fibrin sheath from prior catheterization.\n 4. Enlarged mediastinal lymph nodes, some of which are unchanged from prior\n CT and of uncertain significance. Assessment by chest CT could be obtained as\n per clinical need.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-19 00:00:00.000",
"description": "REMOVE TUNNELED CENTRAL W/O PORT",
"row_id": 1100812,
"text": " 5:05 PM\n DIALYSIS REMOVE Clip # \n Reason: PLEASE REMOVE TUNNELED CATHETER\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with HD-dep ESRD\n REASON FOR THIS EXAMINATION:\n PLEASE REMOVE TUNNELED CATHETER\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 73-year-old male with hemodialysis-dependent end-stage\n renal disease, presenting with low-grade fevers and poor return from an\n indwelling tunneled left IJ catheter. Request for tunneled catheter removal.\n\n FELLOW: , M.D.\n\n ATTENDING: Dr. and , who were present and supervising\n throughout the procedure.\n\n ANESTHESIA: Local anesthesia was provided with 1% lidocaine.\n\n PROCEDURE AND FINDINGS: After the risks and benefits of the procedure were\n explained to the patient's family, informed consent was obtained. The patient\n was brought to the angiography suite and his indwelling tunneled left internal\n jugular hemodialysis catheter was prepped and draped in the usual sterile\n fashion. Preprocedure timeout was performed. Approximately 15 cc of\n lidocaine were administered to the tunneled site. Blunt dissection was\n performed around both catheters and around the catheter cuffs. Gentle\n pressure was used to remove the parallel catheters and pressure was placed at\n the venous entry site for approximately 15 minutes. A sterile dressing was\n placed over the puncture site and the patient was transferred back to the\n inpatient floor. No immediate post-procedural complications demonstrated.\n\n IMPRESSION: Successful removal of a tunneled hemodialysis catheter. The tip\n was removed for culture.\n\n PLAN: The patient is to return on Monday for placement of a new tunneled\n dialysis catheter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102644,
"text": " 11:38 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval ET and OG tube placement\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p intubaton\n REASON FOR THIS EXAMINATION:\n pls eval ET and OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation for endotracheal and nasogastric tube placement.\n\n COMPARISON: , 3:07.\n\n FINDINGS: As compared to the previous examination, the position and course of\n nasogastric tube, endotracheal tube and right-sided central venous access\n lines are unchanged. Also unchanged are the pre-existing bilateral areas of\n atelectasis. Unchanged size of the cardiac silhouette. No evidence of\n pneumothorax, no pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1101715,
"text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema, pneumonia\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with respiratory failure, renal failure\n REASON FOR THIS EXAMINATION:\n eval for pulm edema, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with respiratory and renal failure. Evaluation\n for pulmonary edema or pneumonia.\n\n TECHNIQUE: Single portable chest radiograph.\n\n COMPARISON: Portable chest radiograph dated .\n\n FINDINGS: In comparison to the previous examination, there is increased\n bilateral hilar engorgement and increased prominence of the pulmonary\n vasculature. There is bilateral infrahilar atelectasis. The heart size is\n top normal. The apparent enlargement of the heart in comparison to prior is\n accounted for by the rotation of the patient. There is a right-sided IJ\n catheter which terminates within the right atrium. A right PICC line appears\n to terminate at the thoracic inlet beneath the right clavicle. An\n endotracheal tube is in place approximately 3.4 cm superior to the carina. An\n NG tube demonstrates standard placement. There are no significant pleural\n effusions.\n\n IMPRESSION: Mild pulmonary vascular congestion. Bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-01 00:00:00.000",
"description": "MRV CHEST W/O CONTRAST",
"row_id": 1102782,
"text": ", MED MICU 3:04 PM\n MRV CHEST W/O CONTRAST Clip # \n Reason: SVC syndrome, anatomy for line replacement\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with UE/LE edema\n REASON FOR THIS EXAMINATION:\n SVC syndrome, anatomy for line replacement\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n The right subclavian vein is narrowed in its medial course. The right\n brachiocephalic vein is narrowed at the thoracic inlet, near its junction with\n the left brachiocephalic vein. The right internal jugular line is visualized\n in situ and terminates in the distal SVC. The SVC itself is widely patent.\n\n The left subclavian vein is narrowed at the thoracic inlet, near its\n confluence with the left internal jugular vein. There is a linear filling\n defect in the left internal jugular vein, most likely representing a fibrin\n sheet from prior catheterization. The left external jugular vein is\n prominent, most likely representing collateralization.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1101902,
"text": " 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD on HD with ?pneumonia\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: End-stage renal disease.\n\n FINDINGS:\n\n Portable upright chest radiograph demonstrates nasogastric tube coiled in the\n stomach. Endotracheal tube is at the thoracic inlet in appropriate position.\n Patient is status post median sternotomy. There is congestive failure, not\n appreciably changed from the prior study. There is eventration of the right\n hemidiaphragm. There is mild bibasilar atelectasis. No appreciable change\n from the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100497,
"text": " 8:19 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate NG T\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with subdural hematoma\n REASON FOR THIS EXAMINATION:\n please evaluate NG T\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for nasogastric tube placement.\n\n COMPARISON: , 7:47 p.m.\n\n FINDINGS: As compared to the previous radiograph, the course of the\n nasogastric tube is less tortuous. The tip of the tube now projects over the\n stomach, the side port projects over the gastroesophageal junction. The tube\n should be advanced by approximately 5-10 cm.\n\n There is no evidence of complication, notably no pneumothorax.\n\n Otherwise, the radiograph is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-24 00:00:00.000",
"description": "RP UNILAT UP EXT VEINS US RIGHT PORT",
"row_id": 1101490,
"text": " 4:56 PM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: evaluate for DVT\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with enlarge R arm w/ PICC in place\n REASON FOR THIS EXAMINATION:\n evaluate for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc WED 6:11 PM\n Nonocclusive thrombus along the PICC in the right axillary vein, with\n peripheral flow noted. Does not propagate centrally into the subclavian vein\n at this time. No thrombus noted more distally, brachial veins are patent.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with enlarged right arm, PICC in place.\n\n COMPARISON: No prior right upper extremity ultrasound is available for\n comparison. Please note the prior upper extremity ultrasound obtained \n is entitled \"Right upper extremity ultrasound\" in PACS, but images are\n labeled \"left.\"\n\n RIGHT UPPER EXTREMITY ULTRASOUND: scale, color and Doppler ultrasound\n was used to evaluate the right internal jugular, subclavian, axillary,\n brachial, cephalic and basilic veins. In the mid axillary vein, surrounding\n the PICC, there is echogenic material expanding the vessel lumen. The vessel\n is not compressible at this level. Color flow demonstrates peripheral flow in\n this area, indicating non-occlusive thrombus. Thrombus material does not\n propagate into the subclavian vein. Additionally, no thrombus is evident\n distally in the brachial, cephalic or basilic veins. Remaining vessels\n compress normally, and demonstrate normal flow and waveforms.\n\n IMPRESSION: Non-occlusive thrombus in the right axillary vein surrounding the\n PICC. Thrombus does not propagate proximally into the right subclavian vein,\n or distally into the right basilic vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-24 00:00:00.000",
"description": "RP UNILAT UP EXT VEINS US RIGHT PORT",
"row_id": 1101491,
"text": ", MED MICU 4:56 PM\n UNILAT UP EXT VEINS US RIGHT PORT Clip # \n Reason: evaluate for DVT\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with enlarge R arm w/ PICC in place\n REASON FOR THIS EXAMINATION:\n evaluate for DVT\n ______________________________________________________________________________\n PFI REPORT\n Nonocclusive thrombus along the PICC in the right axillary vein, with\n peripheral flow noted. Does not propagate centrally into the subclavian vein\n at this time. No thrombus noted more distally, brachial veins are patent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1100203,
"text": " 3:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: tip of 48 cm brachail right\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with infection\n REASON FOR THIS EXAMINATION:\n tip of 48 cm brachail right\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with infection. Evaluate PICC line.\n\n SINGLE AP CHEST RADIOGRAPH: Non-diagnostic exam secondary to motion. Position\n of catheters not well seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1101819,
"text": " 2:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with acute on chronic SDH, seizures w/ no improvement in mental\n status\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n CONTRAINDICATIONS for IV CONTRAST:\n not indicated\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 73-year-old male with acute-on-chronic subdural hematomas,\n seizures with no improvement in mental status.\n\n TECHNIQUE: CT of the head without IV contrast.\n\n COMPARISON: Head CT available from .\n\n FINDINGS: There is further evolution and resorption of this mixed attenuation\n subdural collection at the left cerebral convexity, currently measuring 8 mm,\n which is slightly smaller in comparison to the CT\n examination. There is a more clearly defined subdural collection inferior to\n this area, measuring 4 mm at the thickest margin, which was obscured by\n hardware artifacts in the previous study. There is no significant mass effect\n and no change from prior examination.\n\n The ventricles are unchanged in size in comparison to the prior study.\n\n There is no fracture. Included views of the mastoid air cells reveals\n moderate opacification, unchanged from prior examination. Included views of\n the paranasal sinuses shows opacification of the left sphenoid sinus, and\n mucosal thickening of the right sphenoid sinus, with some hyperdense foci,\n which could indicate inspissated mucus secretions or underlying fungal\n infection. This appearance is unchanged from the prior examination.\n\n IMPRESSION:\n 1. No significant change in evolving subdural hematoma overlying the left\n cerebral convexity, with minimal mass effect, unchanged from prior exams.\n 2. No new hemorrhage or mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-22 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1101150,
"text": " 4:47 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: evaluate for obstruction\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with distended abdomen.\n REASON FOR THIS EXAMINATION:\n evaluate for obstruction\n ______________________________________________________________________________\n WET READ: DLrc MON 7:12 PM\n echnically limited. Non-specific examination with no gaseously distended\n loops of small bowel identified. HD catheter in Right atrium. Status post\n median sternotomy. Suggestion of bilateral pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old man with distended abdomen, here for evaluation of\n obstruction.\n\n COMPARISON: None available.\n\n TECHNIQUE: Supine and erect abdominal radiographs.\n\n FINDINGS: Current examination is limited by technique. Within that\n limitation, a small amount of air is visualized in a nondistended stomach.\n Distally there is paucity of bowel gas and general increase of haziness,\n suggestive of presence of ascites. No dilated bowel loop or free air\n identified.\n\n Bilateral blunting of costophrenic angles are suggestive of small pleural\n effusions. Cardiac silhouette is enlarged. Multiple median sternotomy wires\n are intact. A right-sided hemodialysis catheter terminates in mid-to-lower\n SVC.\n\n Multiple phleboliths are present in the right pelvis. Additional tubular\n opacities may represent vascular calcification. Osseous structures are grossly\n intact.\n\n IMPRESSION:\n 1. No dilated bowel loops to suggest obstruction.\n 2. Paucity of bowel gas and general increase of haziness may suggest ascites.\n\n 3. Possible small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100951,
"text": " 1:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?aspiration ? PNA\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with stroke, ESRD, with worsening respiration\n REASON FOR THIS EXAMINATION:\n ?aspiration ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 1:44 A.M. \n\n HISTORY: Stroke. End-stage renal disease. Worsening respiratory function.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Lung volumes are very low and respiratory motion obscures the anatomic detail.\n Heart is mildly to moderately enlarged and mediastinal vasculature is dilated.\n No large area of consolidation or substantial pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1099954,
"text": " 4:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with chronic renal failure, subdurals, now with increased O2\n requ't, low-grade fever, and chest pain.\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 16:40\n\n INDICATION: Low-grade fever and chest pain.\n\n COMPARISON: .\n\n FINDINGS: The central venous catheter tips remain in place. There is some\n motion degradation on the current study, but no definite evidence for interval\n development of focal consolidation. Study is also limited by shallow\n inspiration, but in the technique, I do not see progressive distention of the\n pulmonary vasculature.\n\n IMPRESSION: No significant interval change versus prior.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100955,
"text": " 2:56 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: 73 year old man with respiratory distress for likely aspirat\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with respiratory distress for likely aspiration PNA vs. volume\n overload. Now intubated. Please evaluate for ET tube placement.\n REASON FOR THIS EXAMINATION:\n 73 year old man with respiratory distress for likely aspiration PNA vs. volume\n overload. Now intubated. Please evaluate for ET tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:22 A.M. \n\n HISTORY: Likely aspiration and volume overload. Check ET tube placement.\n\n IMPRESSION: AP chest compared to , 1:44 a.m.:\n\n Lateral aspect of left lower chest is excluded from the examination.\n Remainder of the left lung shows mild vascular congestion. Right\n hemidiaphragm is elevated suggesting right infrahilar opacity, is due to\n atelectasis. Heart is mildly enlarged. There is no pulmonary edema. ET tube\n in standard placement. Nasogastric tube ends in the stomach. No pneumothorax\n or appreciable pleural effusion. Right PIC catheter ends at the junction of\n brachiocephalic veins.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-30 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1102343,
"text": " 10:27 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: eval for cholecystitis, other hepatic/biliary pathology\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with continued fevers, rising LFTs.\n REASON FOR THIS EXAMINATION:\n eval for cholecystitis, other hepatic/biliary pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 73-year-old man with fevers and rising LFTs.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Note is made in the medical record of a report that the\n patient is status post laparoscopic cholecystectomy. This examination is\n limited due to the patient's body habitus. No focal liver lesion is\n identified. There is no biliary dilatation and the common duct measures 0.4\n cm. The portal vein is patent with hepatopetal flow. The midline structures\n are obscured from view by overlying bowel. The spleen is unremarkable and\n measures 10.0 cm. There is no hydronephrosis. The right kidney measures 11.6\n cm. There is a complex cyst in the interpolar region of the right kidney\n measuring 3.2 x 2.6 x 3.2 cm. A simple cyst is seen at the upper pole of the\n right kidney measuring 2.2 x 2.5 x 2.4 cm. The left kidney measures 11.7 cm.\n\n IMPRESSION:\n 1. The patient is status post cholecystectomy. No biliary dilatation.\n 2. No focal liver lesion.\n 3. Complex right renal cyst and simple right renal cyst. Followup of right\n renal cyst recommended in 12 months.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1100462,
"text": " 2:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD on HD, SDH with worsening mental status\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT WED 4:23 PM\n IMPRESSION: No significant change since the examination with\n continued evolution of the mixed-attenuation subdural hematoma overlying the\n left cerebral convexity, with minimal mass effect and no significant shift of\n the normally midline structures, and no new hemorrhage or evidence of acute\n vascular territorial infarction.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST .\n\n HISTORY: 73-year-old man with ESRD on HD, with SDH and worsening mental\n status; 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\n FINDINGS: The study is compared with most recent NECT of , previous\n (motion-degraded) study of and MR examination of . There has been\n slight further resorption/redistribution of the relatively thin\n mixed-attenuation subdural collection overlying the left cerebral convexity,\n at the vertex. This now measures 9 mm in maximal thickness (from the inner\n table of the skull), with unchanged degree of mass effect on the subjacent\n gyri, and no significant shift of normally-midline structures or evidence of\n re-hemorrhage. While there is prominence of the extra-axial CSF space\n overlying the contralateral convexity, no other extra-axial hemorrhage is\n seen, and there is no finding to suggest acute vascular territorial\n infarction.\n\n The remainder of the examination, including fluid-opacification with central\n hyperattenuating contents of the left sphenoid sinus and its pterygoid recess,\n as well as extensive atherosclerotic calcification in the subcutaneous and\n vessels of the scalp, likely related to the patient's underlying ESRD, are\n unchanged. Again demonstrated are numerous scalp electrodes.\n\n IMPRESSION: No significant change since the examination with\n continued evolution of the mixed-attenuation subdural hematoma overlying the\n left cerebral convexity, with minimal mass effect and no significant shift of\n the normally midline structures, and no new hemorrhage or evidence of acute\n vascular territorial infarction.\n (Over)\n\n 2:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1101194,
"text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ? pneumonia, pulm edema\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Pneumonia or pulmonary edema.\n\n FINDINGS: Compared to the previous chest radiograph, there has been a slight\n improvement in the degree of pulmonary edema which is moderate. Left lower\n lobe atelectasis remains unchanged. The mediastinal silhouette is stable.\n The NG tube passes into the stomach. The ET tube is unchanged with its tip at\n the thoracic inlet. A newly placed right subclavian line tip is at the\n cavoatrial junction.\n\n IMPRESSION:\n\n Slight overall improvement in the pulmonary edema, which remains moderate.\n Unchanged bibasilar atelectasis and low lung volumes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-29 00:00:00.000",
"description": "R VENOUS DUP EXT UNI (MAP/DVT) RIGHT",
"row_id": 1102169,
"text": " 12:00 PM\n VENOUS DUP EXT UNI (MAP/DVT) RIGHT Clip # \n Reason: re-eval right sided upper extremity for new clots/worsening\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with hx of renal failure, respiratory failure, hx of right PICC\n thrombus.\n REASON FOR THIS EXAMINATION:\n re-eval right sided upper extremity for new clots/worsening of prior clot\n ______________________________________________________________________________\n WET READ: DLrc MON 3:34 PM\n Stable appearance since with non occlusive thrombus in nid axillary vein.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 73-year-old male with history of renal failure,\n respiratory failure with history of right-sided PICC thrombus. Please\n evaluate right upper extremity for new clots or worsening of prior clot.\n\n EXAMINATION: Right upper extremity DVT study.\n\n COMPARISONS: Comparison to a recent upper right extremity DVT study from\n .\n\n FINDINGS: Grayscale and Doppler son of the right subclavian, right\n internal jugular, right brachial, right basilic and right cephalic veins were\n performed. There is normal flow and compressibility. Redemonstrated is a\n catheter within the right axillary vein with surrounding thrombus that is\n nonocclusive with flow seen surrounding the catheter. This is largely\n unchanged in appearance since exam from . In addition, demonstrated is\n a catheter seen within the right subclavian vein. There is symmetric venous\n waveform seen within the left and right subclavian veins.\n\n IMPRESSION: Stable appearance of right mid axillary nonocclusive thrombus\n surrounding central venous catheter. No evidence of new thrombus or extension\n of thrombus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1100463,
"text": ", D. MED MICU-7 2:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD on HD, SDH with worsening mental status\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION: No significant change since the examination with\n continued evolution of the mixed-attenuation subdural hematoma overlying the\n left cerebral convexity, with minimal mass effect and no significant shift of\n the normally midline structures, and no new hemorrhage or evidence of acute\n vascular territorial infarction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102067,
"text": " 3:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with pneumonia and rising WBC count\n REASON FOR THIS EXAMINATION:\n please eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Pneumonia, rising white count.\n\n FINDINGS:\n\n AP view of the chest compared to the prior study from . Endotracheal\n tube is present at the thoracic inlet. Nasogastric tube courses below the\n diaphragm, but the tip is not seen. Right IJ catheter terminates in the\n cavoatrial junction.\n\n There is mild congestive failure. There are small bilateral pleural effusions\n and mild bibasilar atelectasis. Overall, there is mild improvement in the\n appearance of the chest since the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100841,
"text": " 11:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate placement of NGT\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with afib, dm, hd-dependent esrd here with SDH\n REASON FOR THIS EXAMINATION:\n please evaluate placement of NGT\n ______________________________________________________________________________\n FINAL REPORT\n AN AP CHEST 11:47 P.M. ON \n\n HISTORY: AFib. Diabetes.\n\n IMPRESSION: AP chest compared to :\n\n A moderate-to-severe cardiomegaly has worsened and there is slightly greater\n pulmonary vascular congestion in the lungs and venous engorgement in the\n mediastinum, and mild pulmonary edema is unchanged. Pleural effusion if any\n is small. Bilateral infrahilar opacification is generally atelectasis, but\n aspiration cannot be excluded. A new nasogastric tube passes into the stomach\n and out of view.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-24 00:00:00.000",
"description": "EXCH CENTRAL NON-TUNNELED",
"row_id": 1101454,
"text": " 1:42 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: placement of HD line - VIP port for access\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ********************************* CPT Codes ********************************\n * EXCH CENTRAL NON-TUNNELED -79 UNRELATED PROCEDURE/SERVICE DURI *\n * FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with renal failure\n REASON FOR THIS EXAMINATION:\n placement of HD line - VIP port for access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with renal failure with hemodialysis catheter\n (VIP) which has poor flows. Requesting check and possible exchange.\n\n OPERATORS: Drs. and . Dr. , the Attending\n Radiologist, was present and supervising the entire procedure.\n\n PROCEDURE: After the risks and benefits of the procedure were explained,\n written informed consent was obtained. The patient was brought to the\n angiography suite and placed supine on the table. His right neck and\n indwelling catheter were prepped and draped in standard sterile fashion. A\n preprocedure timeout and huddle were performed per protocol.\n\n A scout image was performed demonstrating the tip of the catheter to terminate\n at the cavoatrial junction. Given this high location with side port located\n within the superior vena cava, it was decided to exchange this catheter for a\n longer 20 cm (VIP catheter). wire was advanced through the catheter\n down into the IVC using flouroscopic guidance. The catheter was removed and a\n 20- cm triple- lumen catheter (two lumens for dialysis and a third for\n medicine) was placed over the wire with tip terminating in the low right\n atrium. The wire was removed and the catheter was aspirated easily. It was\n then flushed, capped, and secured to the skin with suture. There were no\n immediate complications. A final fluoroscopic image of the chest demonstrates\n catheter tip to terminate in the mid right atrium. There is approximately 2\n cm of extravascular catheter due to the slightly long length of this\n catheter.\n\n There were no immediate complications.\n\n IMPRESSION: Successful exchange of triple-lumen VIP catheter for new triple-\n lumen VIP catheter with a length of 20 cm now, previously 16 cm. The line is\n ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1100219,
"text": " 4:22 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: ? placement of picc line\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with afib, DM II, HD-dependent ESRD, now with SDH and seizures\n REASON FOR THIS EXAMINATION:\n ? placement of picc line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with afib, diabetes, hemodialysis-dependent end-\n stage renal disease. Evaluate PICC line.\n\n Single AP chest radiograph compared to shows placement of a\n right PICC line, which terminates in the distal SVC. Two left IJ central\n venous catheters are present, one which terminates in the mid and the other in\n the distal SVC. The lung volumes remain low and the heart is mildly enlarged.\n Mild central vascular congestion is compatible with fluid overload. There is\n no pleural effusion or pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102874,
"text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Intubated, assess interval change.\n\n FINDINGS: The position of the ET tube is unchanged with the tip at the\n thoracic inlet 3 cm above the carina, the right venous line and NG tube are\n unchanged.\n\n Median sternotomy wires are intact.\n\n Left lateral lower lobe atelectasis is stable. No new consolidation,\n pneumothorax or pleural effusion. Cardiomediastinal silhouette is unchanged.\n\n IMPRESSION: No interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1101357,
"text": " 3:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man SDH, renal failure HD dependent, PNA and fluid overload\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with subdural hematoma, renal\n failure, on hemodialysis.\n\n Portable AP chest radiograph was compared to , obtained at\n 03:16 a.m.\n\n The ET tube tip is 5 cm above the carina. The NG tube is most likely in the\n stomach, although note is made that the study quality is suboptimal and should\n be further repeated for precise evaluation of small details. The right\n subclavian line tip is at the level of right atrium.\n\n Cardiomediastinal silhouette is unchanged as well as there is no change in\n bilateral hilar engorgement. The patient might be in the mild pulmonary\n edema, but again, this diagnosis is difficult on this suboptimal study that\n should be repeated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100413,
"text": " 1:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with seizures and SDH now with fever\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the extent of the\n pre-existing retrocardiac atelectasis has minimally increased. Otherwise,\n there is no relevant change. Borderline size of the cardiac silhouette,\n tortuosity of the thoracic aorta. Minimal thickening of the right minor\n fissure. No newly occurred focal parenchymal opacities suggesting pneumonia.\n No evidence of pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103167,
"text": " 3:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA/ pulmonary edema\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with renal failure, sepsis\n REASON FOR THIS EXAMINATION:\n eval for PNA/ pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Sepsis, pulmonary edema and renal failure.\n\n Comparison is made with prior study of .\n\n Cardiomediastinal contours with mild-to-marked cardiomegaly is unchanged. Low\n lung volumes are persistent. Small left pleural effusion has decreased.\n Vascular congestion has improved. Bibasilar opacities are likely atelectasis,\n unchanged. There are no new lung abnormalities. Lines and tubes are in\n unchanged standard position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103254,
"text": " 3:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man anuric, on HD\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Unchanged position of monitoring and support devices. Unchanged\n moderate cardiomegaly with slight overhydration and small lung volumes.\n Subsequent small retrocardiac atelectasis. No newly occurred focal\n parenchymal opacities suggesting pneumonia. No larger pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-09 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1104178,
"text": ", MED MICU 5:06 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: FEVER, BLE SWELLING EVAL FOR DVT\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ongoing fevers\n REASON FOR THIS EXAMINATION:\n please evaluate for DVTs\n ______________________________________________________________________________\n PFI REPORT\n no dvt in b/l lower extremities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-16 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 1100267,
"text": " 8:10 AM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: ?clot or just extravasation of fluids.\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with seizures, SDH and ESRD - increased swelling at L\n hemodialysis catheter site.\n REASON FOR THIS EXAMINATION:\n ?clot or just extravasation of fluids.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with increased swelling of the left hemodialysis\n catheter site.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler son of the left IJ, subclavian,\n axillary, brachial, basilic and cephalic veins were performed. There is\n normal flow, compression and augmentation seen in all of the vessels. No\n subcutaneous fluid collection is identified. Note is made of a fistula graft\n within the upper left arm which is occluded. An intravenous line is\n identified within the right subclavian vein and there is a small amount of\n non-occlusive thrombus material identified along the course of the line.\n Vascular flow is still identified within the right subclavian vein.\n\n IMPRESSION:\n 1. No deep vein thrombosis seen in the left arm. No subcutaneous fluid\n collection identified.\n 2. Occluded left arm fistula graft.\n 3. Small amount of non-occlusive thrombus material seen adherent to the\n intravenous line which is identified within the right subclavian veins.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-09 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1104177,
"text": " 5:06 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: FEVER, BLE SWELLING EVAL FOR DVT\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ongoing fevers\n REASON FOR THIS EXAMINATION:\n please evaluate for DVTs\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MBue FRI 6:57 PM\n no dvt in b/l lower extremities.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: EDEMA\n\n FINDINGS: Duplex ultrasound evaluation of the bilateral lower extremities was\n performed. The common femoral vein, superficial femoral vein, popliteal vein,\n and calf veins demonstrate normal color doppler flow and response to\n compression and augmentation without evidence of deep venous thrombosis.\n\n IMPRESSION:\n\n No deep venous thrombosis in the lower extremities bilaterally.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-05 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1103284,
"text": " 8:32 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: for placment of a temporary femoral line, with side port for\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 5\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD requiring access for HD, currently with infected RIJ,\n and diffuse stenosis per MRV.\n REASON FOR THIS EXAMINATION:\n for placment of a temporary femoral line, with side port for central access,\n please d/c temp HD line AFTER placement of new femoral line\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 73-year-old man with ESRD requiring access for hemodialysis,\n currently with infected right IJ temporary HD line, and diffuse stenosis per\n MRV. Placement of temporary HD catheter with a VIP port and discontinuation\n of right IJ temporary HD line requested.\n\n CLINICIANS: Dr. and Dr. . Dr. is the\n attending radiologist who was present and supervising throughout.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n 100 mg of fentanyl and 1.5 mg of Versed throughout the total intraservice time\n of 68 minutes during which the patient's hemodynamic parameters were\n continuously monitored. Local anesthesia with 1% lidocaine.\n\n PROCEDURE AND FINDINGS: An informed consent was obtained from patient's wife\n after explaining the procedure and complications. Patient was brought to the\n angiography suite and an initial ultrasound scan of the neck demonstrated an\n open internal jugular vein on the left side. After discussing with the team,\n it was decided to try and place the line via a left IJ access. The left side\n of neck was prepped and draped in the usual sterile fashion. A preprocedure\n huddle and timeout was performed. Under ultrasound guidance hard copy images\n on file, the left internal jugular vein was accessed with a micropuncture\n needle. However, the guidewire could not be advanced below the level of\n clavicle and central obstruction was noted. Therefore this procedure was\n abandoned and after again discussing with the primary team, it was decided to\n place a temporary HD catheter via the right femoral vein access.\n\n The right groin was prepped and draped in the usual sterile fashion. Under\n ultrasound and fluoroscopic guidance the right femoral vein was punctured with\n a micropuncture needle and a micropuncture sheath was placed over the\n guidewire. This in turn was used to upsize the wire to wire which was\n advanced into the IVC. After dilating the tract a 14 French double-lumen HD\n catheter with a VIP port measuring 20 cm in length was placed over the\n guidewire and advanced into the IVC. The wire was removed and all three ports\n were easily aspirated and flushed. Tip of the catheter is in the distal IVC. A\n spot fluoroscopic image was saved digitally. Sterile dressings were applied.\n (Over)\n\n 8:32 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: for placment of a temporary femoral line, with side port for\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 5\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Next, the patient was shifted on to the trolley and head elevated. Under\n aseptic precautions, the right IJ line was pulled out and catheter tip sent\n for culture and sensitivity. Hemostasis was achieved with digital compression\n and sterile dressings were applied.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION:\n 1. Failed attempt to place a temporary HD line via left IJ.\n 2. Successful placement of a double-lumen HD catheter with VIP port via right\n femoral vein access. The length of the catheter is 20 cm and tip position is\n in the distal IVC. The line is ready to use.\n 3. Discontinuation of right IJ temporary HD catheter with the tip sent for\n culture and sensitivity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100229,
"text": " 7:43 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please check placement of NG tube. Thanks\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with SDH and change in mental status.\n REASON FOR THIS EXAMINATION:\n Please check placement of NG tube. Thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of a nasogastric tube that appears to extend to the upper portion of\n the stomach. However, the image is extremely light in the upper abdomen. To\n better evaluate the tip of the tube, a repeat study could be obtained showing\n the lower chest and upper abdomen and using abdominal technique.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103435,
"text": " 2:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with respiratory failure, pneumonia\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Unchanged size of the cardiac silhouette, unchanged mild\n overhydration. No newly appeared focal parenchymal opacity suggesting\n pneumonia. Unchanged position and course of monitoring and support devices.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1101036,
"text": " 3:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with hypoxic respiratory failure, now intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Hypoxic respiratory failure, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The size of the cardiac silhouette is unchanged. Unchanged signs of\n fluid overload. Unchanged retrocardiac opacities, likely to suggest\n atelectasis. The monitoring and support devices are also unchanged. No\n evidence of newly occurred focal parenchymal opacities suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-06 00:00:00.000",
"description": "MR L SPINE W/O CONTRAST",
"row_id": 1103610,
"text": " 8:43 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: eval for osteomyelitis at lumbar region\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with sepsis, fever of unknown origin, ? of osteomyelitis per CT\n torso at L2-L4 region\n REASON FOR THIS EXAMINATION:\n eval for osteomyelitis at lumbar region\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 73-year-old male with fever of unknown origin. Osteomyelitis\n seen on CT torso at L2-L4.\n\n COMPARISON: CT torso from .\n\n TECHNIQUE: Sagittal T1, T2, STIR, axial T2 images of the lumbar spine were\n obtained.\n\n FINDINGS: The scout images were reviewed. The lumbar spine demonstrates\n normal alignment. This study is severely limited due to motion artifact. The\n cord ends at T12-L1. Normal marrow signal is seen. Multiple large Schmorl\n nodes are identified. T1, T2 and STIR hyperintense areas in the vertebral body\n endplates at L2, L3 and L4 adjacent to large Schmorl nodes likely represent\n type 2 changes. Mildly increased signal in T12-L1 and L1-L2 disks on\n STIR images likely represents nucleus pulposus. There is no definite evidence\n of osteomyelitis.\n\n At L2-L3, there is mild posterior disc bulge, facet joint hypertrophy and\n ligamentum flavum thickening with no significant neural foraminal narrowing or\n spinal canal stenosis.\n\n At L3-L4, there is mild posterior disc bulge, facet joint hypertrophy and mild\n ligamentum flavum thickening causing moderate left and mild right neural\n foraminal narrowing. There is no significant spinal canal stenosis.\n\n At L4-L5, there is diffuse disc bulge, more on the left than right, facet\n joint hypertrophy and ligamentum flavum thickening causing mild-to-moderate\n bilateral neural foraminal narrowing and mild spinal canal stenosis.\n\n At L5-S1, there is diffuse disc bulge with no significant neural foramen\n narrowing or spinal canal stenosis.\n\n The kidnys are small in size. Multiple renal cysts with the largest measuring\n 1.9 cm in the interpolar region of the right kidney are seen.\n\n IMPRESSION:\n 1. No evidence of osteomyelitis or discitis.\n (Over)\n\n 8:43 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: eval for osteomyelitis at lumbar region\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Multiple Schmorl's nodes.\n 3. Multilevel degenerative changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1104337,
"text": " 3:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man intubated, new white count\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Elevated white count, to evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , allowing for decreased\n inspiration, there is probably little overall change. Monitoring and support\n devices remain in place in this patient with intact sternal wires. Bibasilar\n atelectasis, more prominent on the left is again seen with continued elevation\n of the right hemidiaphragm. No definite acute focal pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1100491,
"text": " 7:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate NG tube\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fever\n REASON FOR THIS EXAMINATION:\n please evaluate NG tube\n ______________________________________________________________________________\n WET READ: IPf WED 8:56 PM\n Suboptimal radiograph, tip of NG tube not seen. There is unusual curving of\n the NG at the top. Correlate clinically the positioning of the NG tube.\n Radiograph should be repated if there is clinical concern. Dr \n was paged twice.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for nasogastric tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The nasogastric tube is visible along its esophageal course only.\n The course is more tortuous than on the previous examination. The tip of the\n nasogastric tube appears to project over the gastroesophageal junction.\n Advancement of the tube and subsequent acquisition of a new radiograph would\n be necessary to ensure correct position.\n\n There is no evidence of complication, notably no evidence of pneumothorax.\n\n Otherwise, the radiograph is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103704,
"text": " 12:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Confirm placement\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with new NGT placement\n REASON FOR THIS EXAMINATION:\n Confirm placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post nasogastric tube placement.\n\n COMPARISON: .\n\n FINDINGS: The endotracheal tube has been removed. A tracheostomy tube has\n been newly inserted. The tip of the tracheostomy tube projects 5 cm above the\n carina. The nasogastric tube shows unchanged course, the tip of the tube is\n not imaged on the examination.\n\n There is no evidence of complications, no pneumothorax.\n\n The pre-existing retrocardiac opacities have minimally increased in extent.\n Otherwise, unchanged appearance of the lung parenchyma.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103790,
"text": " 8:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? eval for pneumothorax\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with new trach placement, possible subcut air\n REASON FOR THIS EXAMINATION:\n ? eval for pneumothorax\n ______________________________________________________________________________\n WET READ: SPfc WED 9:35 PM\n No evidence of pneumothorax or subcutaneous gas. Overall, minimal change from\n the previous study. Notably a nasogastric tube terminates in the proximal\n stomach and could be advanced. Discussed with Dr. from medicine at\n 21:33 on \n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Tracheostomy tube, assess for subcutaneous air or\n pneumothorax.\n\n Comparison is made with prior study performed seven hours earlier.\n\n There is no evident pneumothorax or subcutaneous gas. NG tube terminates in\n the proximal stomach. The low lung volumes, cardiomediastinal contours are\n unchanged. There are no enlarging pleural effusions. Bibasilar atelectasis\n greater on the left side are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-06 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1103573,
"text": " 3:18 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for intra-abdominal process\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with renal failure, fever of unknown origin\n REASON FOR THIS EXAMINATION:\n eval for intra-abdominal process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITH CONTRAST\n\n COMPARISON: None.\n\n HISTORY: Fever of unknown origin with renal failure. Evaluate for intra-\n abdominal process.\n\n TECHNIQUE: MDCT axially acquired images through the chest, abdomen, and\n pelvis were obtained. IV contrast was administered. Coronal and sagittal\n reformats were performed.\n\n FINDINGS:\n\n CT CHEST: Patient is intubated. There are increased hazy ground-glass\n opacities seen in bilateral lung fields with prominent pulmonary vasculature,\n likely representing mild fluid overload. There are tiny bilateral pleural\n effusions and bibasilar atelectasis. The airways are patent to the\n subsegmental level. There is no focal consolidation noted. Extensive\n vascular calcifications of the arch of the aorta and coronary arteries are\n identified. There is no pericardial effusion. There is no axillary\n lymphadenopathy. Multiple prominent mediastinal lymph nodes are identified.\n For example, there is a 1.5 x 2.1 cm prevascular lymph node (2, 20). In\n addition, there is a precarinal lymph node measuring 2.2 x 0.7 cm.\n\n CT OF THE ABDOMEN: The spleen, pancreas, liver, adrenal glands are\n unremarkable. The patient is status post cholecystectomy. Incidental note is\n made of a replaced left hepatic artery. Heavy calcification of the descending\n aorta and its branches are identified. There is no mesenteric or\n retroperitoneal lymphadenopathy. An NG tube terminates in the stomach. Small\n bowel loops are normal in caliber. There is no focal wall thickening. The\n bilateral kidneys contain multiple hypodense lesions, some of which are too\n small to characterize. The largest lesion measures approximately 2.4 cm (2,\n 70) and measures as a simple cyst. An exophytic hypodense lesion arising from\n the right kidney measures 1.9 x 1.9 cm and is consistent with a simple cyst.\n Bilateral nonspecific perinephric fat stranding is noted. There is no\n evidence of hydronephrosis. There is no mesenteric or retroperitoneal\n lymphadenopathy. There is no free fluid or free air. There is an anterior\n abdominal wall hernia which contains a loop of small bowel. There is no\n evidence of obstruction (2, 92).\n (Over)\n\n 3:18 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for intra-abdominal process\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS: The rectum, sigmoid colon, and bladder are unremarkable.\n The prostate gland measures 5.0 cm. Incidental note is made of multiple cecal\n and ascending colonic diverticula (2, 88). There is no evidence of acute\n diverticulitis. There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: At the inferior and superior endplates of L2, L3, and L4, there\n are erosive changes which include endplate sclerosis and focal lucencies which\n have the classic location for Schmorl's nodes. However, atypical haziness\n surrounding these lucent lesions is worrisome for possible infectious\n etiology.\n\n IMPRESSION:\n 1. Endplate erosive changes involving L2 through L4. While these have a\n typical location for Schmorl's nodes, the increased hazy border is concerning\n for underlying infectious etiology. MRI of the lumbar spine is recommended for\n further evaluation.\n 2. Prominent mediastinal lymph nodes as described above. These are\n nonspecific. The largest lymph node measures 1.6 x 2.1 cm in the prevascular\n space.\n 3. Mild fluid overload.\n 4. Multiple renal hypodensities, likely cysts.\n 5. Extensive vascular calcifications.\n 6. Anterior abdominal wall hernia containing loops of small bowel without\n evidence of obstruction.\n\n Findings discussed with Dr. at 4:30 pm via telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1099716,
"text": " 4:49 AM\n CHEST (PA & LAT) Clip # \n Reason: ?infection or effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with shortness of breath\n REASON FOR THIS EXAMINATION:\n ?infection or effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73 year-old male with shortness of breath.\n\n COMPARISON: CT cervical spine .\n\n CHEST, SUPINE FRONTAL VIEW: Dual lumen dialysis catheter terminates in the\n SVC and at the cavoatrial junction. Sternal closure wires are intact. The\n heart is enlarged.\n\n The pulmonary vasculature is prominent, and the esophagus is distended. There\n are vascular calcifications of the aortic arch.\n\n IMPRESSION:\n 1. Pulmonary vascular congestion.\n 2. Narrowing of the trachea and esophageal dilation could indicate additional\n pathology, such as tracheomalacia or an esophageal mass.\n Findings entered into the ED critical results reporting system on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1099932,
"text": " 1:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: expansion\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with subdural more confused\n REASON FOR THIS EXAMINATION:\n expansion\n CONTRAINDICATIONS for IV CONTRAST:\n dialysis/ERD\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc SAT 7:38 PM\n 1. Left greater than right acute subdural hematomas are not larger, with\n unchanged left mild sulcal effacement. No new focus of hemorrhage or new mass\n effect seen.\n 2. Slight increased opacification of the sphenoid sinuses bilaterally, with\n small amount of layering fluid.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with subdural hematoma, now more confused.\n\n COMPARISON: MRI brain of and CT head of .\n\n TECHNIQUE: MDCT axial imaging was performed through the brain without\n administration of IV contrast.\n\n NON-CONTRAST HEAD CT: Left subdural hematoma, which also layers along the\n falx and tentorium, appears unchanged from one day prior, measuring up to 11\n mm at the vertex where the hyperdensity has a rounded configuration again.\n There is mild associated effacement of the adjacent sulci as before but no new\n shift of normally midline structures or effacement of the basal cisterns.\n Small amount of acute subdural hematoma along the right frontal lobe is also\n not larger.\n\n No definite new focus of acute intracranial hemorrhage, edema, hydrocephalus,\n or large vascular territory infarction is seen. The study is degraded by some\n motion despite reimaging twice through the skull base. Extensive vascular\n calcifications along the scalp, dense calcifications along the carotid\n siphons, and calcifications along the vertebral arteries are as before.\n Partial opacification of right mastoid air cells inferiorly is as before.\n There is also partial opacification of the sphenoid sinus which is slightly\n increased bilaterally, with appearance of layering fluid on the right side.\n There is also mucosal thickening along the frontal and ethmoid air cells.\n\n IMPRESSION:\n 1. Left greater than right acute subdural hematomas are not larger, with\n unchanged left mild sulcal effacement. No new focus of hemorrhage or new mass\n effect seen.\n 2. Slight increased opacification of the sphenoid sinuses bilaterally, with\n small amount of layering fluid.\n\n ADDENDUM AT ATTENDING REVIEW: Both prior and present CT scans reveal a 1cm\n (Over)\n\n 1:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: expansion\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n linear hyperdensity in the left cerebellar hemisphere (see image 20, series\n 2b). The morphology seems more in keeping with a calcification, perhaps in\n the dentate nucleus, as opposed to a most unusual hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1099933,
"text": ", H. NMED FA11 1:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: expansion\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with subdural more confused\n REASON FOR THIS EXAMINATION:\n expansion\n CONTRAINDICATIONS for IV CONTRAST:\n dialysis/ERD\n ______________________________________________________________________________\n PFI REPORT\n 1. Left greater than right acute subdural hematomas are not larger, with\n unchanged left mild sulcal effacement. No new focus of hemorrhage or new mass\n effect seen.\n 2. Slight increased opacification of the sphenoid sinuses bilaterally, with\n small amount of layering fluid.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1100034,
"text": " 12:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? evidence of progression of subdural, acute hemorrhage or i\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with DM2, a fib on coumadin, HD-dependent ESRD adm with\n SDH\n REASON FOR THIS EXAMINATION:\n ? evidence of progression of subdural, acute hemorrhage or infarct\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SUN 3:26 PM\n Expected interval evolution of the left subdural hematoma and right subdural\n hematoma without evidence of new hemorrhage or infarct. Progression of\n sphenoid, ethmoids and right frontal mucosal thickening with near-complete\n opacification of the left sphenoid sinus.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with type 2 diabetes, atrial fibrillation, on\n Coumadin and hemodialysis-dependent end-stage renal disease, admitted on \n for subdural hematoma. Evaluate for progression of subdural or acute\n hemorrhage or infarct.\n\n COMPARISON: and , MRI brain of .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered. Several initial sections were degraded by motion\n artifact and subsequently repeated.\n\n FINDINGS: There has been expected interval evolution of the left\n frontoparietal acute-on-chronic subdural hematoma with a maximum extra-axial\n dimension of 10 mm compared to 11 mm previously. There is persistent\n associated effacement of the subjacent sulci. There is 2 mm shift of the\n normally midline structures rightward which is slightly decreased compared to\n prior. Small extra-axial hyperdensity is again noted overlying the right\n frontoparietal lobe and not significantly changed compared to prior. The\n suprasellar and basilar cisterns are preserved.\n\n -white matter differentiation is preserved. There is no major vascular\n territory infarction. Age-appropriate prominence of the ventricles and sulci\n is consistent with a mild degree of diffuse parenchymal volume loss. Mild\n periventricular white matter hypodensity is consistent with chronic small\n vessel ischemic disease and unchanged. There is interval increase in\n opacification of the left sphenoid sinus. Mucosal thickening is noted in the\n right sphenoid, bilateral ethmoid and right frontal sinuses. In addition\n there is opacification of some of the right mastoid air cells. The remainder\n left mastoid air cells are well aerated. No osseous abnormality is\n identified.\n\n IMPRESSION:\n\n (Over)\n\n 12:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? evidence of progression of subdural, acute hemorrhage or i\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Little interval evolution of the left acute-on-chronic subdural hematoma, now\n measuring up to 10 mm in greatest dimension. No significant change in\n effacement of the subjacent sulci or minimal rightward shift of the midline\n structures.\n\n 2. Unchanged right frontoparietal acute subdural hematoma.\n\n 3. Interval increase in mucosal thickening and opacification in the left\n sphenoid, right sphenoid and bilateral ethmoid and right frontal sinus.\n Unchanged opacification of some of the right mastoid air cells.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1100035,
"text": ", H. NMED FA11 12:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? evidence of progression of subdural, acute hemorrhage or i\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with DM2, a fib on coumadin, HD-dependent ESRD adm with\n SDH\n REASON FOR THIS EXAMINATION:\n ? evidence of progression of subdural, acute hemorrhage or infarct\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n PFI REPORT\n Expected interval evolution of the left subdural hematoma and right subdural\n hematoma without evidence of new hemorrhage or infarct. Progression of\n sphenoid, ethmoids and right frontal mucosal thickening with near-complete\n opacification of the left sphenoid sinus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-12 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1099709,
"text": " 4:32 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: FALL\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fall and ICH\n REASON FOR THIS EXAMINATION:\n ? c-spine fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl FRI 5:30 AM\n no fracture, no prevertebral swelling\n C3 on 4 grade 1 , be degenerative although no priors for\n comparison\n fluid in cervical esophagus - at risk for aspiration\n lung apices - b/l effusions L>R septal thickening, likely edema\n rt mastoid fluid/partial opacitification. no fx identified\n WET READ VERSION #1 JXRl FRI 5:17 AM\n no fracture, no prevertebral swelling\n C3 on 4 grade 1 , be degenerative although no priors for\n comparison\n fluid in cervical esophagus - at risk for aspiration\n lung apices - b/l effusions L>R septal thickening, likely edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with fall and intracranial hemorrhage.\n\n COMPARISON: Noncontrast head CT four hours prior.\n\n TECHNIQUE: Noncontrast CT of the cervical spine was performed. Multiplanar\n reformatted images were generated.\n\n FINDINGS: Vertebral body heights are maintained. Disc space height is\n decreased throughout the cervical spine. There is grade lobe \n of L3 on L4. There is no prevertebral swelling. Multilevel degenerative\n changes are present throughout the cervical spine. At C3-4, there is loss of\n disc height and endplate sclerosis. Osteophyte formation and uncovertebral\n hypertrophy result in mild narrowing of the left neural foramen. There is\n multilevel uncovertebral degenerative change, without canal stenosis. There\n is fluid within the cervical esophagus. Small bilateral effusions and left\n apical ground-glass opacities may indicate pulmonary edema. Dense vascular\n calcifications are noted.\n\n IMPRESSION:\n 1. Multilevel degenerative changes. Grade 1 C3 on C4 , which\n is most likely degenerative, although if there is concern for ligamentous or\n cord injury, MRI is recommended. No fracture identified.\n 2. Fluid in the cervical esophagus placing the patient at risk for\n aspiration.\n 3. Bilateral pleural effusions and left apical ground-glass opacity\n suggestive of pulmonary edema.\n\n (Over)\n\n 4:32 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: FALL\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-12 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1099763,
"text": " 11:09 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: ? evidence of stroke\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with pmh including afib, DM, CKD foound to have SDH in setting\n of fall, now with word-finding difficulty and right upper extremity deficits\n REASON FOR THIS EXAMINATION:\n ? evidence of stroke\n CONTRAINDICATIONS for IV CONTRAST:\n HD-dependent CKD, left chest access\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa FRI 3:47 PM\n 1. Left-sided subdural hematoma with fluid-fluid level. No new hemorrhage or\n shift of normally midline structures.\n\n 2. No evidence of acute infarction.\n\n 3. No significant stenosis, occlusion, or aneurysmal formation, although\n evaluation of intracranial vessels is somewhat limited due to patient motion.\n\n 4. Left sphenoid sinus opacification.\n ______________________________________________________________________________\n FINAL REPORT\n MRI AND MRA OF THE BRAIN.\n\n COMPARISON: CT head without contrast of .\n\n HISTORY: Subdural hematoma in the setting of word-finding difficulty and\n right upper extremity deficits; evaluate for infarct.\n\n TECHNIQUE: Multiplanar T1, T2, FLAIR, diffusion- weighted gradient echo\n imaging was performed of the brain. 3D time-of-flight MRA, with rotational\n targeted MIP imaging was performed. Note that scan was somewhat limited as\n patient would not cooperate and was unable to hold still (according to the\n technologist's note).\n\n FINDINGS:\n\n MRI BRAIN: There is a subdural hematoma layering over the left cerebral\n convexity. This collection is heterogeneous in signal intensity with a\n fluid-fluid level (6:12), with focal clot identified more superiorly within\n the collection (6:20). There is also a thin subdural hematoma overlying the\n right frontal convexity. No new hemorrhage is identified. There is no\n evidence of shift of normally midline structures or mass lesion. There is no\n evidence of acute territorial or lacunar infarct, and normal flow voids are\n identified on T2-weighted imaging. There is no evidence of hydrocephalus.\n Focus of faintly-increased FLAIR-hyperintensity anteriorly, at the level of\n the middle cerebellar peduncle, possibly represents faint microvascular and\n chronic infarction. There is fluid within the left sphenoid sinus.\n (Over)\n\n 11:09 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: ? evidence of stroke\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MRA OF THE BRAIN: Evaluation, particularly at the skull base, is markedly\n limited due to patient motion. However, within this limitation, there is no\n apparent significant stenosis, occlusion, or aneurysm greater than 3 mm in\n diameter within the intracranial vessels.\n\n IMPRESSION:\n\n 1. Left-sided subdural hematoma with fluid-fluid level, unchanged in size or\n mass effect. No new hemorrhage or shift of normally midline structures. Thin\n subdural hematoma layering over the right frontal convexity is also unchanged.\n\n 2. No evidence of acute infarction.\n\n 3. No significant stenosis, occlusion, or aneurysm, although evaluation of\n intracranial vessels is somewhat limited due to patient motion.\n\n 4. Left sphenoid sinus opacification.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-08-12 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1099764,
"text": ", H. NMED FA11 11:09 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: ? evidence of stroke\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with pmh including afib, DM, CKD foound to have SDH in setting\n of fall, now with word-finding difficulty and right upper extremity deficits\n REASON FOR THIS EXAMINATION:\n ? evidence of stroke\n CONTRAINDICATIONS for IV CONTRAST:\n HD-dependent CKD, left chest access\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n PFI REPORT\n 1. Left-sided subdural hematoma with fluid-fluid level. No new hemorrhage or\n shift of normally midline structures.\n\n 2. No evidence of acute infarction.\n\n 3. No significant stenosis, occlusion, or aneurysmal formation, although\n evaluation of intracranial vessels is somewhat limited due to patient motion.\n\n 4. Left sphenoid sinus opacification.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1104452,
"text": " 2:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with AMS, Fevers, trach\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever and tachycardia.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is 6 cm above the carina. The NG tube tip passes below the\n diaphragm most likely in the stomach. Cardiomediastinal silhouette is\n unchanged. There is slight interval worsening in bibasal opacities and\n perihilar vascular engorgement although it might be explained by mild motion\n artifacts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1104614,
"text": " 5:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? sinusitis. ? acute process\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with persistent fevers and altered mental status, long term NGT\n with significant pain.\n REASON FOR THIS EXAMINATION:\n ? sinusitis. ? acute process\n CONTRAINDICATIONS for IV CONTRAST:\n On dialysis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp MON 6:07 PM\n PFI:\n 1. No acute intracranial hemorrhage.\n 2. Persistent opacification of mastoid air cells, sinus mucosal thickening\n and ethmoidal, left maxillary and sphenoidal sinuses with hyperdense material\n in the sphenoidal sinus on the left which could represent persistent\n inspissated mucus secretions or underlying fungal infection. The appearance\n is overall similar to prior.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Persistent fevers and altered mental status, long-term NG tube\n with significant pain, query sinusitis, query acute process.\n\n COMPARISON: ; .\n\n TECHNIQUE: Non-contrast head CT. 0.625 mm axial slices through the sinus\n with coronal reformations.\n\n FINDINGS: There is no new intracranial hemorrhage. -white matter\n differentiation is preserved. There is no mass effect or edema. Basal\n ganglia hypodensities likely reflect calcifications that are unchanged.\n Ventricles, sulci and cisterns are of unchanged configuration and size. Basal\n cisterns are preserved. Mastoid air cells are again mostly opacified.\n\n There is ethmoidal sinus mucosal thickening and an NG tube is seen. There is\n polypoidal mucosal thickening in the left maxillary sinus. There is mucosal\n thickening in the sphenoidal sinus with unchanged hyperdense material in the\n left that could represent persistent inspissated mucus or fungal infection.\n This is unchange dcomapred to the most recent but increased from .\n\n Extensive vascular calcifications are noted. Oblique and\n discontinuous orientation of the pterygoid plates can relate to old trauma/\n obliquity.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage.\n\n 2. Persistent opacification of the mastoid air cells and sinus mucosal\n disease with hyperdense material that could represent persistent inspissated\n (Over)\n\n 5:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? sinusitis. ? acute process\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mucus versus fungal infection, increased since . Correlate\n clinically.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1104615,
"text": ", MED MICU 5:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? sinusitis. ? acute process\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with persistent fevers and altered mental status, long term NGT\n with significant pain.\n REASON FOR THIS EXAMINATION:\n ? sinusitis. ? acute process\n CONTRAINDICATIONS for IV CONTRAST:\n On dialysis\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. No acute intracranial hemorrhage.\n 2. Persistent opacification of mastoid air cells, sinus mucosal thickening\n and ethmoidal, left maxillary and sphenoidal sinuses with hyperdense material\n in the sphenoidal sinus on the left which could represent persistent\n inspissated mucus secretions or underlying fungal infection. The appearance\n is overall similar to prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1104659,
"text": " 2:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with fevers.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever.\n\n FINDINGS: In comparison with the study of , there are slightly improved\n lung volumes. The nasogastric tube has been removed and the tracheostomy tube\n remains in place. There is little change in the cardiomediastinal silhouette.\n The opacification at the left base may be slightly improving. Mild prominence\n of the interstitial markings is consistent with elevated pulmonary venous\n pressure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-13 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 1104736,
"text": " 12:47 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: left tunneled IJ for HD\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Type of Port: Power Port, double lumen\n ********************************* CPT Codes ********************************\n * TUNNELED W/O PICC W/O PORT *\n * -59 DISTINCT PROCEDURAL SERVICE FLUORO GUID PLCT/REPLCT/REMOVE *\n * FLUORO GUID PLCT/REPLCT/REMOVE -59 DISTINCT PROCEDURAL SERVICE *\n * US GUID FOR VAS. ACCESS US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD s/p trache\n REASON FOR THIS EXAMINATION:\n left tunneled IJ for HD\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 73-year-old man with end-stage renal disease status post\n tracheostomy. He has a previously higher placed right groin temporary HC\n line. A request was placed for a tunneled HD catheter possibly via right IJ\n access, and placement of a PICC line as well as removal of right guide line.\n\n CLINICIANS: Dr. and Dr. and Dr. . Dr.\n is the attending radiologist who was present and supervising throughout.\n\n ANESTHESIA: Moderate sedation was provided by administering divided dose of\n 150 mcg of fentanyl and 2 mg of Versed throughout the total intraservice time\n of 2 hours 25 minutes. During this the patient's hemodynamic parameters are\n continuously monitored. Local anesthesia with 1% lidocaine with epinephrine.\n\n PROCEDURE AND FINDINGS: After explaining the proposed procedure and risks\n involved a verbal consent was obtained from patient's wife who is his\n healthcare proxy. was brought to angiography suite and placed supine\n on the imaging table. A preprocedural huddle and timeout were performed.\n\n First left upper arm was prepped and draped in the standard sterile fashion\n for a PICC line placement. Using sterile technique and local anesthesia, the\n left basilic vein was punctured under direct ultrasound guidance using a\n micropuncture needle. Hard copies of ultrasound images are obtained before\n and after establishing intervenous access. A peel-away sheath was then placed\n over the guidewire and a double lumen PICC line measuring 44 cm in length was\n placed with a peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. The peel-away sheath and guidewire were then removed.\n Position of the catheter was confirmed via fluoroscopic spot film of the\n chest. The catheter was secured to skin with a StatLock device. Both ports\n of the catheter were easily aspirated and flushed. A sterile dressing was\n applied.\n\n Then attention was directed to placing tunneled HC catheter via right IJ\n access. The right side of neck and chest wall were prepped and draped in the\n usual sterile fashion. Under ultrasound guidance with hard copy images on\n file, the right internal jugular vein was accessed with a micropuncture\n (Over)\n\n 12:47 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: left tunneled IJ for HD\n Admitting Diagnosis: SUBDURAL HEMORRHAGE\n Type of Port: Power Port, double lumen\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n needle. An 0.018 guidewire was placed through the needle and advanced into SVC\n under fluoroscopic guidance. Then the needle was exchanged for a micropuncture\n sheath which in return were used to upsize the wire to wire. After\n taking appropriate measurements the wire was advanced into IVC under\n fluoroscopic guidance. Then attention was directed to creating a subcutaneous\n tunnel. After instilling local anesthesia with 1% lidocaine and epinephrine a\n small skin incision was made over the upper anterior chest. The subcutaneous\n tunnel was cleared with a tunneling device and a tunneled HD catheter\n measuring 23 cm from tip to cuff pulled through the tunnel exiting at a venous\n access site in the neck. Then the micropuncture sheath was removed and the\n duct was dilated sequentially over the guidewire. Then a peel-away sheath was\n placed over the guidewire and inner dilator removed. The previously tunneled\n 15.5-French HD catheter measuring 23 cm from tip to cuff was advanced to the\n peel-away sheath and the sheath removed. The catheter tip was positioned in\n the right atrium and both ports were easily aspirated and flushed. A\n fluoroscopic spot film along the chest was obtained demonstrating the catheter\n position. The catheter was secured to skin with 0-silk suture and the\n incision at the venous access site sutured with 4-0 subcuticular Vicryl.\n Sterile dressings were applied.\n\n ASEPTIC PRECAUTIONS: The right groin non-tunneled line was removed and tip\n sent for culture and sensitivities. Hemostasis was achieved with digital\n compression. A sterile dressing was applied.\n\n Patient tolerated the procedure well with no immediate complications.\n\n IMPRESSION:\n 1. Uncomplicated ultrasound under fluoroscopically guided 5-French double\n lumen PICC line placement where the left basilic venous approach. Final\n internal length is 44 cm with the tip positioned in SVC. The line is ready is\n use.\n 2. Uncomplicated ultrasound under fluoroscopically guided double lumen\n tunneled HG catheter placement via right internal jugular venous approach. The\n tip-to-cuff length of the catheter appears 23 cm with tip positioned in right\n atrium. The line is ready to use.\n 3. Uncomplicated removal of temporary HD catheter placed previously via right\n common femoral approach. The catheter tip was sent for culture and\n sensitivity.\n\n"
}
] |
93,422 | 116,219 | 71yo man with HTN, COPD, and metastatic rectal CA admitted for back and bilateral rib pain. Pain improved with IV hydromorphone. MRI T-spine confirmed T1 cord compression. Neurosurgery and Radiation Oncology were consulted. Dexamethasone was started. He went for neurosurgical decompression at T1 . After surgery, he developed atrial fibrillation, which was controlled with metoprolol. He was not anticoagulated because of the recent neurosrugery. Radiation Oncology planned radiation to the remaining T-spine regions at risk and pt scheduled to start as an outpt. # Back and rib pain and T1 cord compression: MRI T-SPINE showed severe T1 cord compression. Dexamethasone started. Consulted Neurosurgery and Radiation Oncology. He went for neurosurgical decompression of T1 .Palliative care was also consulted for pain control.Fentanyl patch was increased to 250 mcg /hr. In addition hydromorphone was added for breakthrough pain. Scheduled acetamoniphen was also state gabapentin increased to 600 mg. Pain wa soverall well ocntrolled with this regimen. . # Rectal CA, KRAS wild-type: Hold capecitabine. Mr. did not qualify for this recent clinical trial. He plans to pursue other trials or chemo agents after discharge. . # Atrial fibrillation: Developed after surgery and controlled with increased doses of metoprolol. Not anticoagulated because of recent neurosurgery.A chest CTA was done and was neagtive fo ra PE. . # Anemia: Likely chemo-induced. Stable. . # Renal vein clot: Mr. had decided in the past to discontinue enoxaparin, so this was not restarted during this admission. . # HTN: Changed metoprolol XL to short-acting and increased dose to 25mg to improve BP, tachycardia, and prep for surgery. . # COPD: Continued albuterol/ipratropium and fluticasone/salmeterol. . # BPH: Continued tamsulosin. . # Depression: Continued citalopram. . # FEN: Regular diet. IV fluids given for decreased PO and clinical dehydration. Repleted hypophosphatemia. . # GI PPx: PPI and bowel regimen. . # CODE: FULL. | Admitting Diagnosis: BACK PAIN Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) right renal hilum (image 3A:67), unchanged from prior. ET tube is in standard placement, right subclavian infusion port ends low in the SVC and a nasogastric tube ends in the mid stomach. Minimal aortic atherosclerotic calcification is present. 4. bilateral small pleural effusions, slightly increased from torso CT. 5. no pericardial effusion. 4. bilateral small pleural effusions, slightly increased from torso CT. 5. no pericardial effusion. At T9 level, there is a large anterior and lateral epidural deposit causing mild cord indentation. Small epidural deposit at T12 level indenting the dorsal aspect of the distal cord as seen on the recent thoracic spine study. At L5-S1, a tiny central protrusion superimposed on a broad-based disc bulge is causing bilateral moderate neural foraminal narrowing. A diverting loop ileostomy in the right lower quadrant is again noted with a small para-stomal hernia (image 3A:87). There is a sclerotic lesion in the right hemipelvis. Mild coronary artery atherosclerotic calcification is present. Since the previous tracingof probable multifocal atrial tachycardia has replaced sinustachycardia. (series 19-1, 19-6 and series 13-11) Minor disc bulges causing thecal effacement is seen at L3-4, L4-5 and L5-S1 levels. Unchanged small para-stomal hernia, but otherwise stable appearance of loop ileostomy. Probable multifocal atrial tachycardia. T1 hypointense signal is seen in the posterior arch of C2 and posterior spinous process of C7 consistent with sclerotic metastasis. At T12, there is a large posterior epidural deposit causing mild canal narrowing and dorsal cord remodeling. Trace bilateral pleural effusions are present. In the right frontal region, there is a low-intensity excrescence identified along the inner table of the skull. TECHNIQUE: MRI thoracic spine with and without contrast, sagittal T1, T2, STIR, axial T1, T2, and post-contrast sagittal and axial T1 images. There has been prior right upper lobectomy. epidural metastasis. In the visualized upper abdomen, a small focus of enhancement in the right lobe of the liver corresponds to a previously noted hypodensity in the liver thought to represent a hemangioma. 7. numerous sclerotic mets in the scapulae, sternum, R clavicle, vertebrae, and ribs w/ adjacent pleural thickening; slightly progressed compared to CT. 8. post-surgical changes at the cervico-thoracic junction. These findings are suggestive of sclerotic metastases with dural involvement in the right frontal and left temporal regions. Trace bilateral pleural effusions minimally increased from . FINDINGS: There are focal areas of low signal on T1 and T2 images in the right frontal bone, left temporal bone, and the left frontal convexity region. CT PELVIS WITH CONTRAST: The urinary bladder is normally distended without focal abnormality. A large posterior epidural mass causing cord compression at T1 level is redemonstrated. Small right pleural effusion. Unchanged 4-mm nodule in the left upper lobe (5:40) and a 4-mm nodule in the left lower lobe (5:38) are unchanged from . Admitting Diagnosis: BACK PAIN Contrast: MAGNEVIST Amt: 11 FINAL REPORT (Cont) 11:48 AM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: Restaging. COMPARISON: MRI thoracic spine . A small soft tissue nodule measures 1.1 cm in the (Over) 11:48 AM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: Restaging. There is narrowing of bilateral subarticular recesses. TECHNIQUE: MRI cervical and lumbar spine with and without contrast, sagittal T1, T2, STIR, axial T1, T2, and post-contrast sagittal and axial T1 images. Diffusely sclerotic lesions are seen at T1, T3, T6, T7, T9, T11, T12 and the L2 levels. At L4-5, there is a small central disc protrusion superimposed on a broad-based disc bulge causing mild bilateral neural foraminal narrowing and narrowing the subarticular recesses. A 4-mm nodule in the left upper lobe (5:40) and a 4-mm nodule in the left lower lobe (5:38) are unchanged from . A small T2 hyperintense focus is seen in the right lower lobe. No contraindications for IV contrast PFI REPORT Sclerotic bony metastatic lesions are identified in both frontal bones and left temporal bone with dural enhancement adjacent to the bony metastases in the right frontal and left temporal regions. FINDINGS: The sagittal alignment demonstrates kyphosis centered at T7. Interval worsening of extensive osseous metastasis, most prominently noted along the right rib cage, with expansile osseous and soft tissue components. A midthoracic enhanincing mass is better evaluated on recent MRI. 8. post-surgical changes at the cervico-thoracic junction. No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): 6:37 PM Sclerotic bony metastatic lesions are identified in both frontal bones and left temporal bone with dural enhancement adjacent to the bony metastases in the right frontal and left temporal regions. | 10 | [
{
"category": "Radiology",
"chartdate": "2144-05-26 00:00:00.000",
"description": "MR T-SPINE W &W/O CONTRAST",
"row_id": 1195011,
"text": " 7:08 PM\n MR W &W/O CONTRAST Clip # \n Reason: Epidural mets?\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with metastatic rectal CA admitted for severe upper back pain,\n asymmetric reflexes.\n REASON FOR THIS EXAMINATION:\n Epidural mets?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic rectal cancer, severe upper back pain and asymmetric\n reflexes, ? epidural metastasis.\n\n TECHNIQUE: MRI thoracic spine with and without contrast, sagittal T1, T2,\n STIR, axial T1, T2, and post-contrast sagittal and axial T1 images.\n\n COMPARISON: CT chest and MRI thoracic spine .\n\n FINDINGS:\n\n The sagittal alignment demonstrates kyphosis centered at T7. There is\n significant progression of sclerotic metastatic lesions involving multiple\n levels of the thoracic spine and visualized lumbar vertebrae. Diffusely\n sclerotic lesions are seen at T1, T3, T6, T7, T9, T11, T12 and the L2 levels.\n Posterior spinous processes are involved with sclerotic deposits at multiple\n levels. There is no vertebral collapse. No abnormal cord signal is shown.\n Post contrast images demonstrate mildly enhancing emultiple epidural deposits.\n\n\n There are numerous epidural deposits at multiple levels throughout the\n thoracic spine. The largest lesion causing severe cord compression is seen at\n T1 level arising from the posterior epidural space and measuring 1 cm in\n anteroposterior and 1.1 cm in transverse dimension. At T9 level, there is a\n large anterior and lateral epidural deposit causing mild cord indentation. At\n T12, there is a large posterior epidural deposit causing mild canal narrowing\n and dorsal cord remodeling.\n\n There is a 2.6 cm left paraspinal deposit along the posterior rib at T9 level.\n Multiple rib lesions are shown, the largest lesion is at the right posterior\n rib of T3, measuring 3 cm.\n\n A small T2 hyperintense focus is seen in the right lower lobe.\n\n IMPRESSION:\n\n 1. Significant progression of metastatic lesions involving the thoracic and\n visualized lumbar spine since the previous MRI from . Multiple\n sclerotic deposits are demonstrated throughout the thoracic spine with diffuse\n involvement at multiple sites.\n (Over)\n\n 7:08 PM\n MR W &W/O CONTRAST Clip # \n Reason: Epidural mets?\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Large epidural deposit causing cord compression is demonstrated at T1\n level. Several other epidural deposits are seen, most prominent at T9 and T12\n levels.\n\n Results were communicated to Dr MD via telephone 10:30 ,.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-05-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1195394,
"text": " 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate/effusion\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with metastatic rectal ca s/p spinal fusion\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:19 A.M. ON \n\n HISTORY: Metastatic rectal carcinoma following spinal fusion.\n\n IMPRESSION: AP chest compared to preoperative chest radiograph on :\n\n Lung volumes are slightly lower, but lungs are clear of any focal abnormality.\n Blastic bone lesions in the ribs and the thoracic spine have increased\n substantially. There is no pneumonia or pulmonary edema or even appreciable\n pleural effusion. ET tube is in standard placement, right subclavian infusion\n port ends low in the SVC and a nasogastric tube ends in the mid stomach. No\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-05-28 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1195290,
"text": " 12:38 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Mets?\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with metastatic rectal CA admitted for back pain and cord\n compression. Dural involvement.\n REASON FOR THIS EXAMINATION:\n Mets?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:37 PM\n Sclerotic bony metastatic lesions are identified in both frontal bones and\n left temporal bone with dural enhancement adjacent to the bony metastases in\n the right frontal and left temporal regions. Sclerotic metastatic disease to\n the spinous process of C2 is also noted, which was observed on the cervical\n spine MRI of . No brain parenchymal metastasis is seen.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain.\n\n CLINICAL INFORMATION: Patient with rectal cancer and back pain and cord\n compression, for further evaluation of the brain to exclude dural involvement.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility and diffusion\n axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal\n images acquired following the administration of gadolinium. There are no\n prior brain MRI examinations for comparison.\n\n FINDINGS: There are focal areas of low signal on T1 and T2 images in the\n right frontal bone, left temporal bone, and the left frontal convexity region.\n In the right frontal region, there is a low-intensity excrescence identified\n along the inner table of the skull. In this area, there is also subtle T2\n hyperintensity identified. Following gadolinium, there is dural enhancement\n seen surrounding this area. In addition, in the left posterior temporal\n region, there is dural enhancement identified adjacent to the low signal bony\n area within the skull. These findings are suggestive of sclerotic metastases\n with dural involvement in the right frontal and left temporal regions. There\n is no area of brain metastasis seen or abnormal enhancement within the brain\n identified. There is no mass effect, midline shift, or hydrocephalus seen.\n\n IMPRESSION:\n Sclerotic bony metastatic lesions are identified in both frontal bones and\n left temporal bone with dural enhancement adjacent to the bony metastases in\n the right frontal and left temporal regions. Sclerotic metastatic disease to\n the spinous process of C2 is also noted, which was observed on the cervical\n spine MRI of . No brain parenchymal metastasis is seen.\n\n (Over)\n\n 12:38 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Mets?\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-05-28 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1195291,
"text": ", D. OMED 11R 12:38 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Mets?\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with metastatic rectal CA admitted for back pain and cord\n compression. Dural involvement.\n REASON FOR THIS EXAMINATION:\n Mets?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Sclerotic bony metastatic lesions are identified in both frontal bones and\n left temporal bone with dural enhancement adjacent to the bony metastases in\n the right frontal and left temporal regions. Sclerotic metastatic disease to\n the spinous process of C2 is also noted, which was observed on the cervical\n spine MRI of . No brain parenchymal metastasis is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-05-27 00:00:00.000",
"description": "MR C-SPINE W& W/O CONTRAST",
"row_id": 1195151,
"text": " 6:16 PM\n MR W& W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: Cord compromise? Prior to neurosurgical decompression.\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with metastatic rectal CA admitted for back pain and cord\n compression.\n REASON FOR THIS EXAMINATION:\n Cord compromise? Prior to neurosurgical decompression.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic rectal cancer, admitted for back pain and cord\n compression.\n\n TECHNIQUE: MRI cervical and lumbar spine with and without contrast, sagittal\n T1, T2, STIR, axial T1, T2, and post-contrast sagittal and axial T1 images.\n\n COMPARISON: MRI thoracic spine . MRI cervical spine , and MRI lumbar spine .\n\n FINDINGS:\n\n CERVICAL:\n The alignment is normal. Marrow signal is slightly heterogeneous. T1\n hypointense signal is seen in the posterior arch of C2 and posterior spinous\n process of C7 consistent with sclerotic metastasis. A large posterior\n epidural mass causing cord compression at T1 level is redemonstrated. There\n are no epidural lesions within the cervical spine. No paravertebral mass is\n demonstrated.\n\n Minor degenerative changes are seen at C5-6 and C6-7 levels.\n\n LUMBAR:\n The alignment is normal. Multiple sclerotic lesions are seen throughout the\n lumbar spine as areas of T1 hyperintensities. The vertebral body height is\n maintained. The epidural soft tissue lesion at T12 level is unchanged since\n the recent study.\n\n Small epidural deposits are seen in the posterior epidural fat at L2-3 and\n L3-4 levels. (series 19-1, 19-6 and series 13-11)\n\n Minor disc bulges causing thecal effacement is seen at L3-4, L4-5 and L5-S1\n levels.\n\n At L4-5, there is a small central disc protrusion superimposed on a\n broad-based disc bulge causing mild bilateral neural foraminal narrowing and\n narrowing the subarticular recesses.\n\n At L5-S1, a tiny central protrusion superimposed on a broad-based disc bulge\n is causing bilateral moderate neural foraminal narrowing. Bilateral facet\n (Over)\n\n 6:16 PM\n MR W& W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: Cord compromise? Prior to neurosurgical decompression.\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 12\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n arthropathy is shown. There is narrowing of bilateral subarticular recesses.\n\n There is a sclerotic lesion in the right hemipelvis.\n\n IMPRESSION:\n 1. Multiple sclerotic metastases in the cervical, visualized thoracic and\n lumbar spine.\n 2. Large epidural mass at T1 causing severe cord compression as seen on the\n earlier thoracic spine study.\n 3. Small epidural deposit at T12 level indenting the dorsal aspect of the\n distal cord as seen on the recent thoracic spine study.\n 4. Small posterior epidural deposits at L2-3 and L3-4 levels without canal\n compromise.\n 5. Minor degenerative changes in the lower lumbar spine with disc bulges,\n small protrusions and facet arthropathy causing foraminal narrowing.\n\n Results were communicated to Dr. by telephone, 4 p.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-05-27 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1195096,
"text": " 11:48 AM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Restaging.\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with metastatic rectal CA admitted for upper back and bilateral\n rib pain.\n REASON FOR THIS EXAMINATION:\n Restaging.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa WED 5:43 PM\n 1. Interval moderate worsening of the already extensive osseous metastases\n along the spine and rib cage, most notable in the right rib cage.\n 2. No definite evidence of intra-abdominal disease.\n 3. Unchanged small para-stomal hernia, but otherwise stable appearance of loop\n ileostomy. No bowel obstruction.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old man, with metastatic rectal cancer. Now with increasing\n upper back and bilateral rib pain. Now restaging.\n\n COMPARISON: Multiple prior studies with the most recent CT PET on and also multiple prior CT torso with the latest on .\n\n TECHNIQUE: MDCT images were acquired from the thoracic inlet to the pubic\n symphysis after administration of IV and oral contrast. Additional\n three-minute delayed images were acquired through the kidneys. Multiplanar\n reformatted images were obtained for evaluation.\n\n CT CHEST WITH CONTRAST: There is interval worsening of the previously known\n extensive multifocal rib metastases now with increase of both osseous and soft\n tissue components, right worse then left. A right pleural effusion is small.\n\n\n There is no discrete lung mass or nodule. Centrilobular emphysema is moderate\n with upper zone predominance. There is no focal airspace consolidation or\n pneumothorax. The heart is normal in size without pericardial effusion. The\n Port-A-Cath from the right upper chest terminates in the right atrium. The\n great mediastinal vessels are intact. Small mediastinal lymph nodes are not\n pathologically enlarged. There is no hilar or axillary lymphadenopathy.\n\n CT ABDOMEN WITH CONTRAST: In the liver, a hypodense lesion with peripheral\n arterial puddling measures 1.6 cm in segment II, measuring 1.6 cm (image\n 3A:54), compatible with a hemangioma. There are no suspicious focal hepatic\n lesions. The spleen, gallbladder, pancreas, adrenal glands and kidneys are\n normal. The renal parenchyma enhances homogeneously and symmetrically, with\n prompt excretion of IV contrast into the collecting system without\n hydronephrosis or hydroureter. There is no free air or fluid in the\n intra-abdominal cavity. A small soft tissue nodule measures 1.1 cm in the\n (Over)\n\n 11:48 AM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Restaging.\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n right renal hilum (image 3A:67), unchanged from prior.\n\n The stomach, duodenum and loops of small bowel are patent with oral contrast.\n A diverting loop ileostomy in the right lower quadrant is again noted with a\n small para-stomal hernia (image 3A:87). Oral contrast has reached the ostomy\n bag. There is no free air, fluid or mesenteric lymphadenopathy in the\n intra-abdominal cavity.\n\n CT PELVIS WITH CONTRAST: The urinary bladder is normally distended without\n focal abnormality. Persistent presacral soft tissue now measures 19 mm in\n thickness, compared to 18 mm previously, essentially unchanged. Fiducial\n seeds are again noted in the presacral region. The right colon is normal with\n fecal matter. The left colon is mostly decompressed. There is no free air,\n fluid or lymphadenopathy in the pelvis.\n\n BONE WINDOW: Extensive and severe osseous metastases are seen throughout the\n spine, sternum, ribs, with overall moderate interval increase in severity. In\n particular, metastatic lesions in the right rib cage are more expansile in\n appearance. Multilevel diffusely sclerotic changes are worse in T3, T6, T7,\n T9, T10, T11, T12, L2 and L4.\n\n There is no evidence of pathologic fracture or acute spinal malalignment.\n\n IMPRESSION:\n 1. Interval worsening of extensive osseous metastasis, most prominently noted\n along the right rib cage, with expansile osseous and soft tissue components.\n Small right pleural effusion. Worsening of multilevel osseous metastases in\n the spine as described. No acute pathologic fracture.\n 2. Unchanged small parastomal hernia, but without bowel obstruction at the\n loop ileostomy in the right lower quadrant.\n 3. Stable presacral soft tissues.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-05-28 00:00:00.000",
"description": "O C-SPINE (PORTABLE) IN O.R.",
"row_id": 1195353,
"text": " 6:06 PM\n C-SPINE (PORTABLE) IN O.R. Clip # \n Reason: C7-T2 POSTERIOR LAMI FUSION\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n WET READ: 8:28 PM\n Intraoperative films demonstrating posterior transpedicle screws at C7 and\n T2. Limited evaluation of T1 and T2 from overlying soft tissues, but no gross\n malalignment is seen.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Cervical spine .\n\n CLINICAL HISTORY: Patient with C7 to T2 posterior fusion.\n\n FINDINGS: Multiple fluoroscopic images of the cervical spine from the\n operating room demonstrate placement of pedicle screws within T2 and C7 on the\n lateral view. Please refer to the operative note for additional details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-06-01 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1195911,
"text": " 6:19 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE.\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with met rectal ca and cord compression s/p surgical\n decompression with acute onset of a.fib with rvr\n REASON FOR THIS EXAMINATION:\n eval for PE.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JEKh MON 8:55 PM\n 1. no PE; \"kinked\" appearance of R lower lobe -obstructive and\n unchanged compared to torso CT.\n 2. normal caliber aorta, no dissection\n 3. mild-to-moderate centrilobular emphysema; no pulmonary consolidation.\n 4. bilateral small pleural effusions, slightly increased from torso\n CT.\n 5. no pericardial effusion.\n 6. no lymphadenopathy.\n 7. numerous sclerotic mets in the scapulae, sternum, R clavicle, vertebrae,\n and ribs w/ adjacent pleural thickening; slightly progressed compared to\n CT.\n 8. post-surgical changes at the cervico-thoracic junction.\n 9. enhancing soft tissue mass in the R spinal canal ~ T9 level, abutting the\n cord, similar to spine MR.\n 10. arterially enhancing focus in the R liver lobe (5;69-70).\n WET READ VERSION #1 JEKh MON 7:20 PM\n 1. no PE; \"kinked\" appearance of R lower lobe -obstructive and\n unchanged compared to torso CT.\n 2. normal caliber aorta, no dissection\n 3. mild-to-moderate centrilobular emphysema; no pulmonary consolidation.\n 4. bilateral small pleural effusions, slightly increased from torso\n CT.\n 5. no pericardial effusion.\n 6. no lymphadenopathy.\n 7. numerous sclerotic mets in the scapulae, sternum, R clavicle, vertebrae,\n and ribs w/ adjacent pleural thickening.\n 8. post-surgical changes at the cervico-thoracic junction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with metastatic rectal cancer and cord\n compression status post surgical decompression with acute onset AFib and RVR.\n Evaluate for PE.\n\n COMPARISON: Multiple prior chest CTs including most recent CTA of and CT torso of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest after\n administration of 70 cc IV Optiray contrast. Coronal, sagittal and oblique\n reformats were displayed.\n (Over)\n\n 6:19 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE.\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n FINDINGS: Imaged thyroid gland is normal. Small mediastinal nodes do not meet\n CT criteria for pathologic enlargement. There is no axillary or hilar\n lymphadenopathy. The heart is normal without pericardial effusion. Mild\n coronary artery atherosclerotic calcification is present. Minimal aortic\n atherosclerotic calcification is present. A right-sided Port-A-Cath follows a\n normal course terminating in the distal SVC.\n\n The pulmonary arteries are well opacified. There is no filling defect to\n suggest pulmonary embolus. In addition there are no secondary signs of\n pulmonary embolus such as parenchymal opacity or bowing of the\n intraventricular septum.\n\n There has been prior right upper lobectomy. Centrilobular emphysema is severe.\n There are multiple sub-4mm nodules, but comparison to prior studies is limited\n due to differences in technique. A 4-mm nodule in the left upper lobe (5:40)\n and a 4-mm nodule in the left lower lobe (5:38) are unchanged from .\n There is no consolidation. Trace bilateral pleural effusions are present.\n\n In the visualized upper abdomen, a small focus of enhancement in the right\n lobe of the liver corresponds to a previously noted hypodensity in the liver\n thought to represent a hemangioma.\n\n Multiple sclerotic lesions within the scapulae, sternum, right clavicle and\n vertebral bodies and several ribs with adjacent periosteal reaction and\n pleural thickening have progressed compared to the CT chest of .\n Post-surgical change at the cervicothoracic junction is present. A midthoracic\n enhanincing mass is better evaluated on recent MRI.\n\n IMPRESSION:\n\n 1. No evidence of acute pulmonary embolus.\n\n 2. Trace bilateral pleural effusions minimally increased from .\n\n 3. Multiple punctate pulmonary nodules which are difficult to compare to\n prior studies due to differences in technique, but likely unchanged. Unchanged\n 4-mm nodule in the left upper lobe (5:40) and a 4-mm nodule in the left lower\n lobe (5:38) are unchanged from .\n\n 4. Numerous sclerotic bone mets progressed from prior CT chest of .\n (Over)\n\n 6:19 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE.\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2144-05-30 00:00:00.000",
"description": "Report",
"row_id": 280930,
"text": "Probable multifocal atrial tachycardia. Delayed R wave progression with late\nprecordial QRS transition is non-specific. Since the previous tracing\nof probable multifocal atrial tachycardia has replaced sinus\ntachycardia.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-05-26 00:00:00.000",
"description": "Report",
"row_id": 280931,
"text": "Sinus tachycardia. Otherwise, normal tracing. Since the previous tracing\nof no significant change.\n\n"
}
] |
72,043 | 182,814 | NON-CONTRAST HEAD CT: A 6.2 x 3.7 cm left parietal hemorrhage with peripheral zone of edema appears similar in configuration as compared to . No contraindications for IV contrast PFI REPORT PFI: Left parietal intra-axial hematoma with a small less than 5-mm nodular enhancement in the superior aspect and an additional 5-mm enhancing lesion in the left frontal lobe anterior to the hematoma suggestive of underlying metastatic disease. No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 12:19 PM PFI: Left parietal intra-axial hematoma with a small less than 5-mm nodular enhancement in the superior aspect and an additional 5-mm enhancing lesion in the left frontal lobe anterior to the hematoma suggestive of underlying metastatic disease. Note is made of a T1 hyperintense fluid within the pneumatized bilateral petrous apex air cells. Following gadolinium, there is no distinct enhancement identified within the region of hematoma in its lower portion, but there is subtle nodular enhancement seen in the superior portion, series 28, image 21. IMPRESSION: Overall unchanged appearance of left parietal hemorrhage with mild peripheral zone of edema, without increased mass effect as compared to . MRA neck demonstrates no vascular occlusion or stenosis but shows 7 mm protuberance of the left subclavian artery proximal to the origin of left vertebral artery which could be due to a subclavian artery diverticulum or aneurysm. MRA neck demonstrates no vascular occlusion or stenosis but shows 7 mm protuberance of the left subclavian artery proximal to the origin of left vertebral artery which could be due to a subclavian artery diverticulum or aneurysm. Small nodular enhancement at the superior aspect of the hematoma and an additional 5-mm focus anterior to the hematoma in the left frontal lobe are suggestive of underlying metastatic disease. TECHNIQUE: Contiguous axial MDCT-acquired images of the head were obtained without administration of intravenous contrast. Small amount of blood within the ventricles indicate intraventricular extension. 7-mm protuberance in the left subclavian artery proximal to the vertebral artery origin could be a subclavian artery diverticulum or aneurysm. Small fluid level identified within the ventricle indicating intraventricular extension. MRA HEAD: Head MRA demonstrates normal flow signal in the arteries of anterior and posterior circulation without stenosis, occlusion, or an aneurysm greater than 3 mm in size. IMPRESSION: No significant abnormalities on MRA of the head. There is a 6-mm protuberance seen in the left subclavian artery proximal to the origin of left vertebral artery, which likely due to a small aneurysm. Large intra-axial hematoma in the left parietal lobe with blood products suggestive of hyperacute/acute hematoma. Restricted diffusion visualized within the hematoma secondary to blood products. There is extension of blood products into the left atrium and bilateral occipital horns, new since prior CT. T1 axial and MP-RAGE sagittal images acquired following gadolinium. Question worsening hemorrhage or edema. IMPRESSION: Large intraparenchymal hematoma involving the left frontotemporal and occipital lobes. There is a large area of hyperacute and acute intra-axial hematoma identified in the left parietal lobe with surrounding edema and mass effect on the left lateral ventricle. There is no new focus of hemorrhage. COMPARISON: Multiple prior CTs from , and . enhancement and metastatic disease. MRA NECK: The neck MRA demonstrates normal flow in the carotid and vertebral arteries. No new focus of hemorrhage. No other focus of hemorrhage is noted. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images were obtained before gadolinium. Surrounding edema and mass effect is seen. The ventricles and sulci are otherwise normal in size and configuration for patient's age. Coronal and sagittal reformats were reviewed. 3D time-of-flight MRA of the circle of and gadolinium-enhanced 3D time-of-flight MRA of the neck were obtained. There is marked adjacent surrounding edema with mild effacement of the adjacent sulci. FINDINGS: There is a large intraparenchymal hematoma measuring 5.5 AP x 3.3 TV x 4.3 CC cm (2:39 and 103B:63) involving the posterior left frontal lobe. There is no significant increase in the extent of sulcal effacement as compared to before. Admitting Diagnosis: INTRACRANIAL HEMORRHAGE Contrast: MAGNEVIST Amt: 15 FINAL REPORT (Cont) seen. Ventricles are similar in size as before. Additionally, there is a 5-mm focus of enhancement identified in the left frontal lobe anterior to the hematoma. 8:23 PM MR HEAD W & W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # MRA BRAIN W/O CONTRAST Reason: stenosis, aneurysm, mass, plaque? FINAL REPORT HISTORY: History of metastatic melanoma. No other foci of abnormal brain enhancement identified. Normal MRA of the head. Normal MRA of the head. No definite area of acute infarct identified. Suprasellar and basilar cisterns are patent. MRI is more sensitive to evaluate underlying mass in this patient with history of metastatic melanoma. No major acute vascular territorial infarction is seen. Paranasal sinuses and mastoid air cells are well aerated. There is no subfalcine herniation. , R. NMED MICU-7 8:23 PM MR HEAD W & W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # MRA BRAIN W/O CONTRAST Reason: stenosis, aneurysm, mass, plaque? | 4 | [
{
"category": "Radiology",
"chartdate": "2117-08-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1155044,
"text": " 10:14 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for change from OSH scan, should be uploaded\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man metastatic melanoma here with with occipital hematoma on osh\n head CT.\n REASON FOR THIS EXAMINATION:\n eval for change from OSH scan, should be uploaded\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: VSFa FRI 10:58 AM\n Intraparenchymal frontoparietal hematoma with adjacent vasogenic edema are\n without significant changes from outside study. MRI is more sensitive for\n evaluation of underlying mass.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of metastatic melanoma.\n\n COMPARISON: Outside study five hours earlier.\n\n TECHNIQUE: Contiguous axial MDCT-acquired images of the head were obtained\n without administration of intravenous contrast. Coronal and sagittal\n reformats were reviewed.\n\n FINDINGS: There is a large intraparenchymal hematoma measuring 5.5 AP x 3.3\n TV x 4.3 CC cm (2:39 and 103B:63) involving the posterior left frontal lobe.\n There is marked adjacent surrounding edema with mild effacement of the\n adjacent sulci. There is no subfalcine herniation. No other focus of\n hemorrhage is noted.\n\n No major acute vascular territorial infarction is seen. The ventricles and\n sulci are otherwise normal in size and configuration for patient's age. The\n visualized paranasal sinuses and mastoid air cells are clear. No osseous\n lesions are noted.\n\n When compared to prior study five hours earlier, there is no significant\n change in size accounting for differences in technique and positioning.\n\n IMPRESSION: Large intraparenchymal hematoma involving the left frontotemporal\n and occipital lobes. No herniation is noted.\n\n MRI is more sensitive to evaluate underlying mass in this patient with history\n of metastatic melanoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-08-27 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1155141,
"text": " 8:23 PM\n MR HEAD W & W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST\n Reason: stenosis, aneurysm, mass, plaque?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic melanoma and new L-IPH\n REASON FOR THIS EXAMINATION:\n stenosis, aneurysm, mass, plaque?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SAT 12:19 PM\n PFI: Left parietal intra-axial hematoma with a small less than 5-mm nodular\n enhancement in the superior aspect and an additional 5-mm enhancing lesion in\n the left frontal lobe anterior to the hematoma suggestive of underlying\n metastatic disease. Normal MRA of the head. MRA neck demonstrates no\n vascular occlusion or stenosis but shows 7 mm protuberance of the left\n subclavian artery proximal to the origin of left vertebral artery which could\n be due to a subclavian artery diverticulum or aneurysm. CTA can help for\n further assessment.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain and MRA head and neck.\n\n CLINICAL INFORMATION: Patient with metastatic disease.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal\n images acquired following gadolinium. 3D time-of-flight MRA of the circle of\n and gadolinium-enhanced 3D time-of-flight MRA of the neck were\n obtained. Maximum intensity projections were acquired.\n\n FINDINGS:\n\n BRAIN MRI:\n\n Comparison was made with the brain, MRI of . Comparison was also\n made with the CT examination of .\n\n There is a large area of hyperacute and acute intra-axial hematoma identified\n in the left parietal lobe with surrounding edema and mass effect on the left\n lateral ventricle. Small fluid level identified within the ventricle\n indicating intraventricular extension. There is no midline shift. No\n definite area of acute infarct identified. Restricted diffusion visualized\n within the hematoma secondary to blood products. Following gadolinium, there\n is no distinct enhancement identified within the region of hematoma in its\n lower portion, but there is subtle nodular enhancement seen in the superior\n portion, series 28, image 21. Additionally, there is a 5-mm focus of\n enhancement identified in the left frontal lobe anterior to the hematoma.\n This is best visualized on series 28, image 22. No other foci of abnormal\n brain enhancement identified. There is no midline shift or hydrocephalus\n (Over)\n\n 8:23 PM\n MR HEAD W & W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST\n Reason: stenosis, aneurysm, mass, plaque?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n seen.\n\n Note is made of a T1 hyperintense fluid within the pneumatized bilateral\n petrous apex air cells.\n\n IMPRESSION:\n\n 1. Large intra-axial hematoma in the left parietal lobe with blood products\n suggestive of hyperacute/acute hematoma. The hematoma measures approximately\n 6 x 4 cm. Surrounding edema and mass effect is seen. Small amount of blood\n within the ventricles indicate intraventricular extension.\n\n 2. Small nodular enhancement at the superior aspect of the hematoma and an\n additional 5-mm focus anterior to the hematoma in the left frontal lobe are\n suggestive of underlying metastatic disease.\n\n MRA HEAD:\n\n Head MRA demonstrates normal flow signal in the arteries of anterior and\n posterior circulation without stenosis, occlusion, or an aneurysm greater than\n 3 mm in size. T1 hyperintense area adjacent to the carotid arteries on the\n source images are secondary to pneumatized petrous apex air cells with high\n protein content and T1 pre-gadolinium hyperintensities.\n\n IMPRESSION: No significant abnormalities on MRA of the head.\n\n MRA NECK:\n\n The neck MRA demonstrates normal flow in the carotid and vertebral arteries.\n There is a 6-mm protuberance seen in the left subclavian artery proximal to\n the origin of left vertebral artery, which likely due to a small aneurysm.\n\n IMPRESSION: No evidence of carotid stenosis or occlusion on neck MRA. 7-mm\n protuberance in the left subclavian artery proximal to the vertebral artery\n origin could be a subclavian artery diverticulum or aneurysm. CTA can help\n for further assessment if clinically indicated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-08-27 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1155142,
"text": ", R. NMED MICU-7 8:23 PM\n MR HEAD W & W/O CONTRAST; MRA NECK W&W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST\n Reason: stenosis, aneurysm, mass, plaque?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with metastatic melanoma and new L-IPH\n REASON FOR THIS EXAMINATION:\n stenosis, aneurysm, mass, plaque?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left parietal intra-axial hematoma with a small less than 5-mm nodular\n enhancement in the superior aspect and an additional 5-mm enhancing lesion in\n the left frontal lobe anterior to the hematoma suggestive of underlying\n metastatic disease. Normal MRA of the head. MRA neck demonstrates no\n vascular occlusion or stenosis but shows 7 mm protuberance of the left\n subclavian artery proximal to the origin of left vertebral artery which could\n be due to a subclavian artery diverticulum or aneurysm. CTA can help for\n further assessment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-08-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1155281,
"text": " 8:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o worsening hemorrhage, edema\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with melanoma and previous hemorrhage now with progressive\n confusion , h/a, and new left sided weakness\n REASON FOR THIS EXAMINATION:\n r/o worsening hemorrhage, edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old male with melanoma and a previous hemorrhage, now\n with progressive confusion, headache, and left-sided weakness. Question\n worsening hemorrhage or edema.\n\n COMPARISON: Multiple prior CTs from , and .\n\n Non-contrast contiguous images were acquired through the brain.\n\n NON-CONTRAST HEAD CT: A 6.2 x 3.7 cm left parietal hemorrhage with peripheral\n zone of edema appears similar in configuration as compared to . There is extension of blood products into the left atrium and bilateral\n occipital horns, new since prior CT. There is no significant increase in the\n extent of sulcal effacement as compared to before. There is no new focus of\n hemorrhage. There is no shift of normally midline structures. Ventricles are\n similar in size as before. Suprasellar and basilar cisterns are patent.\n\n Paranasal sinuses and mastoid air cells are well aerated. Globes and soft\n tissues are unremarkable.\n\n IMPRESSION: Overall unchanged appearance of left parietal hemorrhage with\n mild peripheral zone of edema, without increased mass effect as compared to\n . No new focus of hemorrhage. See prior MR report for\n details reg. enhancement and metastatic disease.\n\n Findings reported to Dr. by phone at the time of dictation on\n .\n\n"
}
] |
|
90,392 | 108,989 | 52 M with history of ETOH abuse transfered from OSH for concern of epidural abscess and osteomyelitis in L4-S1 region. OSH hospital coarse complicated by: new dx of ETOH cirhosis, with Cr peaking at 2.8 thought to be ATN, persistent fevers despite adequate antibiotic coverage. | Redemonstration of known discitis of the L4-S1 vertebral body levels. The diameters of aorta at the sinus, ascending and arch levels arenormal. This measures up to 11 mm (AP) x 17 mm (TRV) x 3.6 cm (CC) and demonstrates several central non-enhancing T2-hyperintense foci, representing liquefactive necrosis. Small right pleural effusion and atelectasis. Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Normal ascending aortadiameter. Unchanged confluent opacities at the right lung base. There is mild endplate irregularity at L4-S1 with subchondral sclerosis which is consistent with known osteomyelitis/discitis. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor suprasternal views.Conclusions:The left atrium is mildly dilated. There is a trivial/physiologic pericardial effusion.IMPRESSION: Normal left ventricular cavity size and wall thickness withpreserved global and regional biventricular systolic and diastolic function.No echocardiographic evidence of endocarditis. Tissue Doppler imaging suggests a normal leftventricular filling pressure (PCWP<12mmHg). PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 68Weight (lb): 197BSA (m2): 2.03 m2BP (mm Hg): 121/72HR (bpm): 108Status: InpatientDate/Time: at 13:53Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 68Weight (lb): 180BSA (m2): 1.96 m2BP (mm Hg): 130/72HR (bpm): 83Status: InpatientDate/Time: at 09:58Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. The apparently known L4 through S1 vertebral osteomyelitis with intervening discitis is confirmed. Known L4 through S1 vertebral osteomyelitis with intervening discitis is confirmed. Known L4 through S1 vertebral osteomyelitis with intervening discitis is confirmed. There is a small right pleural effusion with associated minimal atelectasis. Normal interatrial septum. Trivial mitral regurgitation is seen. FINDINGS: LIVER DOPPLER: There is nodular liver contour in keeping with known diagnosis of cirrhosis. Right knee x-ray examination otherwise within normal limits. Right knee x-ray examination otherwise within normal limits. There is minimal degenerative spurring about the patella and possible minimal degenerative narrowing in the medial compartment. There is noventricular septal defect. Non-specific ST junctional depression. COMPARISON: MRI dated . There is accompanying cortical irregularity involving the L4 inferior and L5 superior endplates, with pathologic T2-/STIR-hyperintensity and patchy enhancement involving the intervening discs. REASON FOR THIS EXAMINATION: epidural abscess? REASON FOR THIS EXAMINATION: epidural abscess? Known MSSA bacteremia. source of infection Admitting Diagnosis: SPINAL EPIDURAL ABCESS Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) discitis. These findings represent the known vertebral osteomyelitis/discitis. PLEASE IMAGE LUMBAR AND SACRAL SPINE No contraindications for IV contrast PFI REPORT 1. RIGHT ANKLE THREE VIEWS: Exam slightly limited due to oblique positioning on portable views, slight motion on the AP view, absence of a true mortise view, and overlying material. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Cirrhosis adn varices. Right Ankle -- no definite lytic or sclerotic lesion. Edema within the left gluteus musculature. Trace aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. Also demonstrated is more cephalad thinner subligamentous enhancement, dorsal to the more superior L4 and L3 vertebral bodies, which does not demonstrate the central T2-bright foci of the more organized abscess, more inferiorly. Unchanged size of the cardiac silhouette. Esophageal and gastric varices, findings compatible with the provided history of cirrhosis. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). Clip # Reason: L4-S1 SPINAL ABCESS Admitting Diagnosis: SPINAL EPIDURAL ABCESS FINAL REPORT INDICATION: Spinal abscess. No MS.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. This stenosis may relate to the possible engorgement of the immediately-superior epidural venous plexus, described above. source of infection No contraindications for IV contrast WET READ: YGd WED 9:43 PM L4-S1 discitis osteomyelitis with anterior rim enhancing epidural abscesses (ex. There is minimal improvement of the central pulmonary vasculature. The mitral valve appearsstructurally normal with trivial mitral regurgitation. FINDINGS: A new PICC line has been inserted over the right upper extremity. osteomyelitis? osteomyelitis? osteomyelitis? osteomyelitis? osteomyelitis? osteomyelitis? REASON FOR THIS EXAMINATION: intra-abd abscess? OSSEOUS STRUCTURES: Focal endplate irregularity andh sclerosis is noted at the L4-L5 and L5-S1 levels, with associated soft tissue thickening and enhancement involving the L4 through S1 disc spaces. TDI E/e' < 8, suggesting normal PCWP (<12mmHg).No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. 6:32 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: intra-abd abscess? The conus medullaris is normal in morphology and intrinsic signal intensity and terminates at the L1-L2 level. PLEASE IMAGE LUMBAR AND SAC Admitting Diagnosis: SPINAL EPIDURAL ABCESS Contrast: MAGNEVIST Amt: 16 FINAL REPORT (Cont) STIR-hyperintensity and relatively uniform enhancement after contrast administration. | 15 | [
{
"category": "Radiology",
"chartdate": "2172-03-25 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1182486,
"text": " 6:32 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: intra-abd abscess? source of infection\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with fevers, rigors, epidural abscess, evelated lipase and\n ?pancreatitis. Concern for possible intraabdominal abscess. Blood cx positive\n for MSSA, still spiking temp to 103 despite appropriate therapy x3 weeks.\n REASON FOR THIS EXAMINATION:\n intra-abd abscess? source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd WED 9:43 PM\n L4-S1 discitis osteomyelitis with anterior rim enhancing epidural abscesses\n (ex. 2, 64; 2, 66). No e/o pancreatitis or intraabd abscess. Cirrhosis adn\n varices. No ascites. - \n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 52-year-old male with fevers, rigors, and known epidural\n abscess. Assess for intra-abdominal abscess.\n\n TECHNIQUE: Multidetector CT of the abdomen and pelvis was performed following\n the administration of oral along with 130 mL of intravenous contrast.\n Multiplanar reformations were also obtained.\n\n COMPARISON: MR lumbar spine from .\n\n FINDINGS:\n\n CONTRAST-ENHANCED CT OF THE ABDOMEN:\n\n The lung bases are clear. Heart size is within normal limits. No focal\n abnormalities are noted in the liver. There is no intra- or extra-hepatic\n biliary duct dilation. The spleen is normal in size. Numerous esophageal and\n gastric varices are noted. The pancreas, adrenals, and kidneys are\n unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy.\n There is no abdominal ascites. Bowel loops are normal in caliber.\n\n CONTRAST-ENHANCED CT OF THE PELVIS:\n\n There is no pelvic or inguinal lymphadenopathy. There is no pelvic ascites.\n Bowel loops are normal in caliber. The bladder is unremarkable. The appendix\n is visualized and is normal. Bilateral areas of fatty stranding and gas are\n noted along the ventral wall of the pelvis, likely related to subcutaneous\n injection sites.\n\n OSSEOUS STRUCTURES:\n\n Focal endplate irregularity andh sclerosis is noted at the L4-L5 and L5-S1\n levels, with associated soft tissue thickening and enhancement involving the\n L4 through S1 disc spaces. Findings are compatible with the known history of\n (Over)\n\n 6:32 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: intra-abd abscess? source of infection\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n discitis. A 5 cm area of edema is noted within the left gluteus musculature.\n Additional multilevel degenerative changes are noted.\n\n IMPRESSION:\n\n 1. No evidence of intra-abdominal or intrapelvic abscess, as questioned.\n 2. Redemonstration of known discitis of the L4-S1 vertebral body levels. The\n known epidural component is not well evaluated on this study.\n 3. Edema within the left gluteus musculature.\n 4. Esophageal and gastric varices, findings compatible with the provided\n history of cirrhosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1183178,
"text": " 3:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change.\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with MSSA bacteremia and increased 02 requirement.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bacteremia with increased oxygen requirement.\n\n FINDINGS: In comparison with the study of , there is increased\n opacification at the right base, concerning for pneumonia. Prominence of\n pulmonary vessels suggests a possible overhydration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1182389,
"text": " 10:17 AM\n CHEST (PA & LAT) Clip # \n Reason: pneumonia? lung abscess?\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with fevers up to 102.8, recent multifocal pna in setting of\n aspiration sp intubation and extubation on . till with fevers, despite broad\n antibiotic coverage.\n REASON FOR THIS EXAMINATION:\n pneumonia? lung abscess?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever with recent multifocal pneumonia.\n\n FINDINGS: No previous images. Low lung volumes may account for some of the\n prominence of the transverse diameter of the heart. No evidence of acute\n focal pneumonia, vascular congestion, or pleural effusion on a somewhat\n limited study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1182930,
"text": " 6:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for infiltrate.\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with MSSA bacteremia now with new fevers and hypotension.\n REASON FOR THIS EXAMINATION:\n Assess for infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Fever, hypotension.\n\n FINDINGS:\n\n Frontal view of the chest compared to prior examination demonstrates increased\n bilateral airspace opacities, particularly at the lower lung zone, concerning\n for developing pneumonia, or possibly superimposed congestive failure. Heart\n and mediastinum within normal limits.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-30 00:00:00.000",
"description": "RP KNEE (AP, LAT & OBLIQUE) RIGHT PORT",
"row_id": 1183076,
"text": " 10:08 AM\n KNEE (AP, LAT & OBLIQUE) RIGHT PORT; ANKLE (AP, MORTISE & LAT) RIGHT PORTClip # \n Reason: Assess for pathology\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with right knee pain, erythema, swelling. Known MSSA\n bacteremia.\n REASON FOR THIS EXAMINATION:\n Assess for pathology\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right knee pain, erythema, swelling, known MSSA bacteremia, question\n pathology.\n\n RIGHT KNEE THREE VIEWS. RIGHT ANKLE THREE VIEWS.\n\n RIGHT KNEE: There is probable soft tissue swelling. I suspect the presence\n of a joint effusion, though assessment is limited due to obliquity of the\n lateral view. There is minimal degenerative spurring about the patella and\n possible minimal degenerative narrowing in the medial compartment. Right knee\n x-ray examination otherwise within normal limits.\n\n RIGHT ANKLE THREE VIEWS: Exam slightly limited due to oblique positioning on\n portable views, slight motion on the AP view, absence of a true mortise view,\n and overlying material. There is spurring about both the medial malleolus and\n distal fibula. There is relative lucency at the adjoining portions of the\n medial malleolus and talus, which may also reflect degenerative changes. The\n tibiotalar joint space is preserved.\n\n IMPRESSION:\n\n 1. Equivocal right knee joint effusion. Probable soft tissue swelling.\n\n 2. Minimal degenerative changes in the right knee and ankle.\n\n 3. Right knee x-ray examination otherwise within normal limits.\n\n 4. Right Ankle -- no definite lytic or sclerotic lesion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-04-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1183494,
"text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: any interval change?\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with ? HAP now diuresed\n REASON FOR THIS EXAMINATION:\n any interval change?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52 year old man, now diuresed. Assess for interval change.\n\n COMPARISON: Multiple priors, most recent of .\n\n SINGLE FRONTAL VIEW OF THE CHEST: The patchy opacity at the right lung base\n persists despite diuresis and remains concerning for pneumonia. The\n retrocardiac opacity has slightly improved. There is minimal improvement of\n the central pulmonary vasculature. The cardiomediastinal contours remain\n stable. There may be a small right sided pleural effusion. There is no\n pneumothorax.\n\n IMPRESSION: Persistent opacity at the right lung base may represent\n atelectasis and a small right pleural effusion; however, pneumonia cannot be\n excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-29 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 1182950,
"text": " 11:04 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; DUPLEX DOPP ABD/PEL Clip # \n Reason: ETOH CIRRHOSIS ,EPIDURAL ABSCESS,RENAL FAILURE ,EVAL FOR HYDRO,PATENCY LIVER VESSELS,PORKET OF FLUID ,HEMATOMA\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with EtOH cirrhosis, MSSA bacteremia, epidural abscess now with\n renal failure.\n REASON FOR THIS EXAMINATION:\n Assess for hydronephrosis, patency of hepatic vessels.\n ______________________________________________________________________________\n WET READ: IPf SUN 12:19 PM\n No hydro\n Liver vessels open\n No fluid collection in the area of redness at the left flank\n Small right plueral effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Alcohol cirrhosis, MRSA bacteremia, and epidural abscess, now with\n renal failure. Assess for hydronephrosis, patency of hepatic vessels, and\n assess area of redness in the left flank.\n\n FINDINGS:\n\n LIVER DOPPLER: There is nodular liver contour in keeping with known diagnosis\n of cirrhosis. There is no intra- or extra-hepatic biliary duct dilatation.\n The common bile duct measures 3 mm. The gallbladder is contracted. There is\n a small right pleural effusion with associated minimal atelectasis. Spleen\n measures 14 cm.\n\n The color Doppler of the liver vessels shows normal flow, waveform in the\n main, right, and left portal vein (with hepatopetal flow), hepatic veins and\n hepatic artery.\n\n RENAL ULTRASOUND: The right kidney measures 11.6 cm. The left kidney\n measures 12 cm. There is no evidence of hydronephrosis.\n\n FOCAL ULTRASOUND OF THE SUBCUTANEUS TISSUE IN THE LEFT FLANK AT THE AREA OF\n REDNESS: No evidence of fluid collection in this area.\n\n IMPRESSION:\n 1. Cirrhotic liver with patent liver vessels. No intra- or extra-hepatic\n biliary duct dilatation.\n 2. Small right pleural effusion and atelectasis.\n 3. Splenomegaly.\n 4. No hydronephrosis.\n 5. No fluid collection in the subcutaneous tissue at the area of redness in\n the left flank.\n (Over)\n\n 11:04 AM\n ABDOMEN U.S. (COMPLETE STUDY) PORT; DUPLEX DOPP ABD/PEL Clip # \n Reason: ETOH CIRRHOSIS ,EPIDURAL ABSCESS,RENAL FAILURE ,EVAL FOR HYDRO,PATENCY LIVER VESSELS,PORKET OF FLUID ,HEMATOMA\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-04-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1183966,
"text": " 7:43 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 42cm SL R basilic PICC placed - \n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with new R PICC\n REASON FOR THIS EXAMINATION:\n 42cm SL R basilic PICC placed - \n ______________________________________________________________________________\n WET READ: SUN 8:04 PM\n right picc tip projects 1.1 cm below the cavoatrial junction. findings\n discussed with at 8pm on via tel. confluent\n opacities at the right lung base are again noted slightly increased allowing\n for technical differences.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New PICC line.\n\n COMPARISON: .\n\n FINDINGS: A new PICC line has been inserted over the right upper extremity.\n The tip of the line projects 1 cm below the cavoatrial junction. A wet read\n and a telephone contact was paged with the IV nurse, at 8 p.m.\n on and the findings were communicated.\n\n No evidence of complications, notably no pneumothorax. Unchanged confluent\n opacities at the right lung base. Unchanged size of the cardiac silhouette.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-25 00:00:00.000",
"description": "MR L-SPINE W & W/O CONTRAST",
"row_id": 1182411,
"text": " 12:15 PM\n MR W & W/O CONTRAST Clip # \n Reason: epidural abscess? osteomyelitis? PLEASE IMAGE LUMBAR AND SAC\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with epidural abscess in L5-S1 region, osteomyelitis of L4 and\n L5 at OSH. Recurrent fevers.\n REASON FOR THIS EXAMINATION:\n epidural abscess? osteomyelitis? PLEASE IMAGE LUMBAR AND SACRAL SPINE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DRT WED 4:39 PM\n 1. Known L4 through S1 vertebral osteomyelitis with intervening discitis is\n confirmed. There is an extensive associated multilocular abscess in the\n ventral epidural space, which occupies a large amount of the canal\n cross-sectional area, with marked mass effect upon the thecal sac.\n\n 2. Prominent enhancing tissue dorsal to the more cephalad portion of the L4\n and the L3 vertebrae. Given the overall appearance this more likely\n represents epidural venous engorgement in response to the inflammatory\n process, above, superimposed on relatively severe spinal canal stenosis at the\n L3-L4 level, on a degenerative basis.\n\n 3. No definite other focus of infection is identified, elsewhere in the\n imaged spine.\n\n 4. Marked deep paraspinal muscle edema and enhancement, while this may simply\n be reactive, direct involvement and pyogenic myositis is not excluded.\n\n These findings were discussed with Dr. (the requesting physician and\n primary house officer), 15:25 H, . As discussed, if the OSH MR study\n can be obtained and uploaded to PACS, a comparison can be performed.\n ______________________________________________________________________________\n FINAL REPORT\n MR EXAMINATION OF THE LUMBAR SPINE WITH CONTRAST, \n\n HISTORY: 52 year-old male with known (from OSH) epidural abscess in the L5-S1\n region, osteomyelitis at L4-L5, with recurrent fever; ? epidural abscess and\n osteomyelitis.\n\n TECHNIQUE: Routine enhanced MR examination, including sagittal STIR FSE\n sequence, pre-, and sagittal and axial T1-weighted SE sequences, post-contrast\n administration. N.B. According to the technologist's note \"the patient is\n sedated (and) sleeps throughout most of the exam and moves around\n periodically\"; for this reason, the STIR and post-gadolinium sequences were\n repeated, though still somewhat degraded by motion artifact.\n\n FINDINGS: No previous examination (including prompting study from the outside\n institution) is available on PACS for comparison. There is a markedly\n abnormal appearance to much of the L4 and the entire L5 vertebrae and the S1\n superior endplate. This includes extensive T1-hypo- with corresponding\n (Over)\n\n 12:15 PM\n MR W & W/O CONTRAST Clip # \n Reason: epidural abscess? osteomyelitis? PLEASE IMAGE LUMBAR AND SAC\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n STIR-hyperintensity and relatively uniform enhancement after contrast\n administration. There is accompanying cortical irregularity involving the L4\n inferior and L5 superior endplates, with pathologic T2-/STIR-hyperintensity\n and patchy enhancement involving the intervening discs. These findings\n represent the known vertebral osteomyelitis/discitis. There is accompanying\n transgression of, particularly, the L5 vertebral cortex, ventrally, with a\n cuff of enhancing prevertebral soft tissue, representing paraosseous extension\n of infection.\n\n There is a complex, bilobed and overall fusiform, predominantly thick\n rim-enhancing collection occupying virtually the entirety of the ventral\n epidural space from the L5 superior endplate through the mid- S1 level. This\n measures up to 11 mm (AP) x 17 mm (TRV) x 3.6 cm (CC) and demonstrates several\n central non-enhancing T2-hyperintense foci, representing liquefactive\n necrosis. This process corresponds to the known epidural abscess and, in\n places, occupies at least 90% of the spinal canal cross-sectional area with\n severe mass effect and virtual-complete effacement of the thecal sac,\n posteriorly. Also demonstrated is more cephalad thinner subligamentous\n enhancement, dorsal to the more superior L4 and L3 vertebral bodies, which\n does not demonstrate the central T2-bright foci of the more organized abscess,\n more inferiorly. This finding more likely represents \"bland\" distention of\n the epidural venous plexus, immediately dorsal to these vertebrae, either\n reactive or related to the pre-existent spinal stenosis, rather than further\n cephalad extension of the infectious phlegmon.\n\n There is also a markedly abnormal appearance to the deep dorsal paraspinal\n muscles, throughout the lower lumbosacral spine, demonstrating geographic\n STIR-hyperintensity and moderate enhancement. These findings are most marked\n in the epicenter of the infection, namely the L4 and L5 levels, and pyogenic\n myositis is a consideration. Of note, no similar process is definitely seen\n to involve the psoas muscles to specifically suggest psoas phlegmon/abscess.\n\n The spine is imaged to the mid-T11 level, and no separate and distinct focus\n of infection is seen elsewhere. The conus medullaris is normal in morphology\n and intrinsic signal intensity and terminates at the L1-L2 level. No\n pathologic leptomeningeal enhancement is seen along the included distal spinal\n cord, the conus medullaris or the more proximal cauda equina nerve roots.\n\n There is multilevel degenerative disc disease, particularly at the L3-L4 level\n and more caudally. At L3-L4, the combination of posterior disc bulge with\n congenitally abnormal spinal canal geometry, facet arthrosis, and prominent\n epidural fat, results in relatively severe spinal canal stenosis and central\n crowding of the traversing nerve roots. This stenosis may relate to the\n possible engorgement of the immediately-superior epidural venous plexus,\n described above. The largely included portion of SI joints is unremarkable;\n (Over)\n\n 12:15 PM\n MR W & W/O CONTRAST Clip # \n Reason: epidural abscess? osteomyelitis? PLEASE IMAGE LUMBAR AND SAC\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n specifically, there is no subchondral bone marrow edema, erosive or\n destructive change, or joint fluid to suggest septic arthritis.\n\n IMPRESSION:\n 1. The apparently known L4 through S1 vertebral osteomyelitis with\n intervening discitis is confirmed. There is an extensive associated\n multilocular abscess in the ventral epidural space, which occupies a large\n amount of the canal cross-sectional area, with marked mass effect upon and\n effacement of the thecal sac and compression of the cauda equina nerve roots\n within.\n\n 2. Prominent enhancing tissue dorsal to the more cephalad portion of the L4\n and the L3 vertebrae. Given the overall appearance, this more likely\n represents epidural venous engorgement in response to the inflammatory\n process, above, superimposed on relatively severe spinal canal stenosis at the\n L3-L4 level, on a degenerative basis.\n\n 3. No definite other focus of infection is identified, elsewhere in the\n imaged lumbar spine.\n\n 4. Marked deep paraspinal muscle edema and enhancement, without evidence of\n liquefactive necrosis; while this may simply be reactive in nature, contiguous\n involvement and pyogenic myositis is not completely excluded.\n\n 5. Unremarkable appearance to the largely included SI joints, without\n evidence of septic arthritis.\n\n COMMENT: These findings were discussed in detail with Dr. (the\n requesting primary houseofficer), in two separate telephone conversations, the\n first at 1525H, . As discussed, if the OSH MR study can be obtained\n and uploaded to PACS, a comparison can be made.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-25 00:00:00.000",
"description": "MR L-SPINE W & W/O CONTRAST",
"row_id": 1182412,
"text": ", A. MED CC7A 12:15 PM\n MR W & W/O CONTRAST Clip # \n Reason: epidural abscess? osteomyelitis? PLEASE IMAGE LUMBAR AND SAC\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n Contrast: MAGNEVIST Amt: 16\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with epidural abscess in L5-S1 region, osteomyelitis of L4 and\n L5 at OSH. Recurrent fevers.\n REASON FOR THIS EXAMINATION:\n epidural abscess? osteomyelitis? PLEASE IMAGE LUMBAR AND SACRAL SPINE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Known L4 through S1 vertebral osteomyelitis with intervening discitis is\n confirmed. There is an extensive associated multilocular abscess in the\n ventral epidural space, which occupies a large amount of the canal\n cross-sectional area, with marked mass effect upon the thecal sac.\n\n 2. Prominent enhancing tissue dorsal to the more cephalad portion of the L4\n and the L3 vertebrae. Given the overall appearance this more likely\n represents epidural venous engorgement in response to the inflammatory\n process, above, superimposed on relatively severe spinal canal stenosis at the\n L3-L4 level, on a degenerative basis.\n\n 3. No definite other focus of infection is identified, elsewhere in the\n imaged spine.\n\n 4. Marked deep paraspinal muscle edema and enhancement, while this may simply\n be reactive, direct involvement and pyogenic myositis is not excluded.\n\n These findings were discussed with Dr. (the requesting physician and\n primary house officer), 15:25 H, . As discussed, if the OSH MR study\n can be obtained and uploaded to PACS, a comparison can be performed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1182802,
"text": " 7:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for acute process.\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with MSSA bacteremia, recent laminectomy, now with rigors.\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute process.\n ______________________________________________________________________________\n WET READ: YGd SAT 1:24 AM\n R costophrenic angle excluded. No definite acute process. - \n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Bacteriemia, rigors.\n\n FINDINGS:\n\n Portable chest compared to the prior study from . Right costophrenic\n angle excluded from film. Lungs are clear. Cardiomediastinal silhouette is\n unremarkable.\n\n IMPRESSION:\n\n No acute pulmonary process identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2172-03-27 00:00:00.000",
"description": "O L-SPINE (AP & LAT) IN O.R.",
"row_id": 1182749,
"text": " 11:17 AM\n L-SPINE (AP & LAT) IN O.R. Clip # \n Reason: L4-S1 SPINAL ABCESS\n Admitting Diagnosis: SPINAL EPIDURAL ABCESS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Spinal abscess.\n\n COMPARISON: MRI dated .\n\n ONE VIEW LUMBAR SPINE: Surgical localization devices are seen posterior to\n the L4 and L5 vertebral bodies. There is mild endplate irregularity at L4-S1\n with subchondral sclerosis which is consistent with known\n osteomyelitis/discitis. For further details, please see the intraoperative\n report.\n\n"
},
{
"category": "Echo",
"chartdate": "2172-03-30 00:00:00.000",
"description": "Report",
"row_id": 92605,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 68\nWeight (lb): 197\nBSA (m2): 2.03 m2\nBP (mm Hg): 121/72\nHR (bpm): 108\nStatus: Inpatient\nDate/Time: at 13:53\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\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. 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. Indeterminate 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) 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. No mass or vegetation\nis seen on the mitral valve. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2172-03-26 00:00:00.000",
"description": "Report",
"row_id": 92606,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 68\nWeight (lb): 180\nBSA (m2): 1.96 m2\nBP (mm Hg): 130/72\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 09:58\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color\nDoppler. Normal IVC diameter (<2.1cm) with >55% decrease during respiration\n(estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg).\nNo 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 descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Physiologic TR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor suprasternal views.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. The estimated right atrial pressure is 0-5 mmHg. Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF >55%). Tissue Doppler imaging suggests a normal left\nventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic stenosis. 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. Trivial mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. The estimated pulmonary artery systolic\npressure is normal. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Normal left ventricular cavity size and wall thickness with\npreserved global and regional biventricular systolic and diastolic function.\nNo echocardiographic evidence of endocarditis. No clinically significant\nvalvular disease. Normal pulmonary artery systolic pressure.\nThe absence of a vegetation on transthoracic echocardiogram does not preclude\nthe presence of endocarditis. If clinical suspicion is high, a transesophageal\nechocardiogram may be considered.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2172-03-29 00:00:00.000",
"description": "Report",
"row_id": 257260,
"text": "Sinus rhythm. Non-specific ST junctional depression. No previous tracing\navailable for comparison.\n\n"
}
] |
21,866 | 199,419 | The patient was admitted on the with the plan to admit to telemetry bed, check an echocardiogram, an EKG and perform a CT and also start the patient on DVT prophylaxis. The concern was for a pericardial effusion, rule out an early tamponade versus pulmonary embolism. On hospital day number 2, the patient was on no antibiotics. She had no malignancy pleural effusion, an enlarged cardiac silhouette that was concerning certainly for pericardial effusion. She was hemodynamically stable. She was started on IV fluids. On the afternoon of hospital day number 2, the patient had a pericardial drain placed which put out 200 cc of bloody drainage. Her hematocrit had dropped from 33 prior to the pericardial tap to 24.6. She was hemodynamically stable; however, she received 2 units of packed red cells, a unit of FFP and a Foley catheter was placed. A repeat hematocrit after the initial 24 demonstrated the hematocrit was actually 33.6 and the blood products were canceled. The patient had a chest x-ray which looked okay. There appeared to be no bleeding into the chest. On hospital day number 3, the patient was doing well without complaints. She was hemodynamically stable. A CT scan of the chest with contrast was in the morning and the patient was preopped for the operating room of a left video assisted thoracoscopy with a left sided subxiphoid window. The patient was seen and examined by the thoracic surgery staff, Dr. . The patient ended up undergoing a right thoracotomy and a pericardial window. The patient tolerated the surgery well and was without complaints. The patient initially stayed in the cardiac surgery intensive care unit after surgery. Her hematocrit was stable. She seemed to do well. Her chest tube had put out 140 cc. There was no leak and the patient was hemodynamically stable. On postoperative day number one, the pericardial drain that had previously been placed was removed. A follow-up chest x- ray was ordered and her Pleur-X catheter was drained by the interventional pulmonology team. The patient was followed in hospital by the hematology/oncology service. On postoperative day number 2, the patient's oxygen was weaned. A physical therapy consult was ordered. drain from the operating room was clamped with the intention of it being removed. On postoperative day number 3, her drain was removed. Again a follow-up chest x-ray was ordered. The patient did well and was without any complaints. On postoperative day number 4, the patient's Pleur-X catheter was again drained. The plan was to remove her drain, have the patient ambulate with physical therapist in order to determine if the patient would be stable to go home. The physical therapist saw the patient and were involved in her care. The recommendation was that she be discharged to home when she was ready per her medical doctors. On postoperative day number 5, the patient was discharged to home. | Mild (1+) aortic regurgitation is seen. Mild (1+) MR. LV inflow pattern c/w impairedrelaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. SINGLE VIEW CHEST, AP UPRIGHT: There has been interval placement of a right subclavian CVL with the tip in the mid SVC. Normal ascending aorta diameter. Normal interatrial septum. Low u/o, PA and MD aware, received fluid bolus w/ minimla results. 1 unit prbc ordered by Dr. for low hct. There is again seen a very small right apical pneumothorax. Pleural catheter is seen at right base, unchanged. Neuro: A&Ox3, behavior appropriate; follows commandCV: Afebrile; SBP 110's-120's; mediastinal drain with scant amount serrousang drainage; no BP or IV in L arm d/t hx of mastectomyResp: Lung sound clear; atrovent neb around the clock; 2L NC, sat high 90's; Pleurx drain in place with drsg, C/D/IGI: NPO for OR later in PM; bowel sound x4; +flatusGU: Foley draining minimal amount yellow clear urineInteg: Intact, old bruises noted on R armPain: stated pain tolerable, denies pain medicationPlan: NPO for OR in PM; monitor resp status Right-sided pleural catheters are in unchanged position. Sinus rhythmModest ST-T wave changes with slight inferolateral ST segment elevation - arenonspecific but clinical correlation is suggestedSince previous tracing of the same date, atrial flutter now absent Mild mitralannular calcification. NoASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Large pericardial effusion. D/C pericardial drainage. There is mild pulmonary artery systolichypertension. Echocardiographic signs of tamponademay be absent in the presence of elevated right sided pressures.Compared with the report of the prior study (images unavailable for review) of, the pericardial effusion is new. IMPRESSION: Stable bibasilar airspace disease versus atelectasis. Normal regional LVsystolic function. +perrl.cv: sr 80s, no ectopy, becomes st 100s while talking; nbp 120s-130s. FINDINGS: Stable positioning of right subclavian line and right chest tube is identified. Right posterior Pleurx capped, dsg cdi.GI/GU: Abd obese, hypoactive BS. There is no mitral valve prolapse.Trace/Mild (1+) mitral regurgitation is seen. Brief RA diastolic collapse. Continued note:gi/gu: +bs, +flatus. 1 unit ffp ordered per Dr. . cxr done. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. There are no echocardiographic signs of tamponade.Compared with the prior study (images reviewed) of , the pericardialeffusion is mostly resolved. Left greater than right small pleural effusions. no c/o pain overnight. The right chest tube is again demonstrated. Right ventricular chamber size and freewall motion are normal. Poor access, TLC right subclavian inserted at bedside by PA ok to use per PA . Left atrial abnormality. The aortic valve leaflets are moderately thickened.There is no aortic valve stenosis. The effusion appearscircumferential. There isbrief right atrial diastolic collapse. There is again seen left- sided pleural effusion. PATIENT/TEST INFORMATION:Indication: Assess for Pericardial effusion/Tamponade.Height: (in) 66Weight (lb): 173BSA (m2): 1.88 m2BP (mm Hg): 130/40HR (bpm): 85Status: InpatientDate/Time: at 10:46Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. extrs w/d. There is a very small pericardialeffusion. The cardiomediastinal silhouette is unchanged. Moderately thickened aortic valveleaflets. No new orders at this time for low u/o.Endo: Per pt's own scale.Plan: Monitor hemodynamics. Dsg moderately soaked w/ serosang drainiage, dsg reinforced. The aortic arch is mildly dilated. CXR taken.Resp: LS clear diminished, coarse but cleared w/ cough. Monitor resp. The resolving ill-defined opacity at the right base is unchanged but improved since the radiographs from . Assess for residual effusionHeight: (in) 65Weight (lb): 171BSA (m2): 1.85 m2BP (mm Hg): 134/70HR (bpm): 88Status: InpatientDate/Time: at 16:05Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV systolic function.PERICARDIUM: Small pericardial effusion. Technically difficult studySinus rhythmProbable old septal infarctInferior ST elevationLateral T wave changesSince previous tracing, no significant change Rightventricular systolic function is normal. There is a right-sided central venous catheter with the distal tip in the distal SVC. The effusions and areas of atelectasis are unaltered. rpt hct 33. bld tranfusion stopped. The left ventricular inflowpattern suggests impaired relaxation. No echocardiographic signs oftamponade.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:Overall left ventricular systolic function is normal (LVEF>55%). SBP 120-130s when in SR. SBP 100-110s when in afib. Compared to the previous tracingof no diagnostic interim change. resp rate 20s, no distress. There is improved aeration of the right lower lobe with persistent small bilateral pleural effusions. Pt w/ hx of afib. Echocardiographic signs oftamponade may be absent in the presence of elevated right sided pressures.GENERAL COMMENTS: Echocardiographic results were reviewed by telephone withthe houseofficer caring for the patient.Conclusions:The left atrium is normal in size. The position of the various lines and tubes is unchanged. rt ct site cdi. Mg repleted. Dense retrocardiac opacity consistent with atelectasis versus airspace disease. No RVdiastolic collapse. Hyperdynamic LVEF. Left ventricular wall thicknesses and cavity size are normal.Regional left ventricular wall motion is normal. Mildlydilated aortic arch.AORTIC VALVE: Three aortic valve leaflets. No right ventricular diastolic collapse is seen. IMPRESSION: No change. Hx of right herpes simplex to right eye per pt. Pt medicated w/ morphine pca w/ good relief of CT pain.CV: HR 80-110s SR/ switches btw afib and SR. PA aware. Sinus rhythm. Right-sided basilar airspace disease versus atelectasis is also identified. COMPARISON: CXR . Tolerating sips of clears. D5W w/150meq bicarb started @ 80cc/hr.endo: bs monitored per csru ss protocol; no coverage required this shift.plan: continue monitoring cardioresp status. oob->commode x1. Calcifications of the aortic arch are seen. No overt tamponade (No diastolic RV collapse) however this likelyrepresents early tamponade. Previous mediastinal drainage tube has been removed. | 17 | [
{
"category": "Nursing/other",
"chartdate": "2190-11-04 00:00:00.000",
"description": "Report",
"row_id": 1549190,
"text": "Continued note:\n\ngi/gu: +bs, +flatus. no bm. voided 50cc clr yellow urine @ 2130; foley to gravity placed, huo >25cc/hr. D5W w/150meq bicarb started @ 80cc/hr.\n\nendo: bs monitored per csru ss protocol; no coverage required this shift.\n\nplan: continue monitoring cardioresp status. monitor labs, mediastinal drng, UO. prepare pt for OR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-04 00:00:00.000",
"description": "Report",
"row_id": 1549191,
"text": "Neuro: A&Ox3, behavior appropriate; follows command\n\nCV: Afebrile; SBP 110's-120's; mediastinal drain with scant amount serrousang drainage; no BP or IV in L arm d/t hx of mastectomy\n\nResp: Lung sound clear; atrovent neb around the clock; 2L NC, sat high 90's; Pleurx drain in place with drsg, C/D/I\n\nGI: NPO for OR later in PM; bowel sound x4; +flatus\n\nGU: Foley draining minimal amount yellow clear urine\n\nInteg: Intact, old bruises noted on R arm\n\nPain: stated pain tolerable, denies pain medication\n\nPlan: NPO for OR in PM; monitor resp status\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-04 00:00:00.000",
"description": "Report",
"row_id": 1549192,
"text": "Shift Note\n# 20 angio started by IV team D/T poor access, to CT Scan with contrast @ 1015, results pending, NPO all shift, pt A&O X3, denies pain or discomfort, pt aware of plan to go to OR today, pt's son called and aware of plan, OR team up to take pt to OR at this time\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-05 00:00:00.000",
"description": "Report",
"row_id": 1549193,
"text": "7p-7a\nReceived pt back from OR at 2245, extubated on face mask, lethargic but agitated, confused on arrival. S/P right thoractomy pericardial window, draining via 2 blakes through pleuravac to suction.\n\nNeuro: Received agitated and oriented to self only, by midnight pt alert and oriented, calm, anxious at times. Hx of right herpes simplex to right eye per pt. Left eye 2mm briskly reactive. Pt medicated w/ morphine pca w/ good relief of CT pain.\n\nCV: HR 80-110s SR/ switches btw afib and SR. PA aware. Mg repleted. Last K 3.9, PA awaare no new orders at this time. SBP 120-130s when in SR. SBP 100-110s when in afib. Pt w/ hx of afib. + palpable pulses. Pericardial window draining via drains through pleuravac, draining serosang drainage. Dsg moderately soaked w/ serosang drainiage, dsg reinforced. PA aware. Poor access, TLC right subclavian inserted at bedside by PA ok to use per PA . CXR taken.\n\nResp: LS clear diminished, coarse but cleared w/ cough. Recieved on face mask, able to wean to open face tent fio2 70%, desats w/ nc to 91-92%. Sats >96% on face tent 70%. Right posterior Pleurx capped, dsg cdi.\n\nGI/GU: Abd obese, hypoactive BS. Tolerating sips of clears. Low u/o, PA and MD aware, received fluid bolus w/ minimla results. No new orders at this time for low u/o.\n\nEndo: Per pt's own scale.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Pain control. ? D/C pericardial drainage. IP to drain Pleurx today. OOB to chair. Aggressive pulmonary hygeine.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-03 00:00:00.000",
"description": "Report",
"row_id": 1549188,
"text": "Admission Note\nPt arrived at 1700 from OR, pericardialcentesis done, 550 cc tapped, drain left in place, also has a righ thorcotomy PleurX drain and a #22 angio RLA, arrived in afib with rare PVC,alert and oriented, food eye contact\n\nNeuro: alert and oriented X3, denies pain, pt discussed plan with Dr., pt request that Dr. speak with her son about it prior to making a decision, MAE's well, right eye glazed over and pt can only see shadows, good eyesight out of left eye\nResp: lungs clear, O2 @ 4LPM via NC, right chest PleurX drain covered by DSD\nCardiac: arrived in afib but converted to SR, pt becomes tachycardic with min activity(talking), rare PVC\nGI: + BS, no flatus, no BM, OK to eat dinner, NPO after MN\nGU: HNV post surgery\nSocial: pt's son in to see her, Dr. in with both discussing plan\nPlan: CT with contrast in AM, ? pericardial window later on \n"
},
{
"category": "Nursing/other",
"chartdate": "2190-11-04 00:00:00.000",
"description": "Report",
"row_id": 1549189,
"text": "neuro: pt & a&ox3, talkative, maes equally to command, repositions self without difficulty. oob->commode x1. no c/o pain overnight. +perrl.\n\ncv: sr 80s, no ectopy, becomes st 100s while talking; nbp 120s-130s. palpable pulses. extrs w/d. afebrile. 1 unit prbc ordered by Dr. for low hct. cxr done. rpt hct drawn per Dr. request before bld transfused. rpt hct 33. bld tranfusion stopped. 1 unit ffp ordered per Dr. . mediastinal ct to gravity, draining minimal serosang fluid overnight.\n\nresp: ls clr bilaterally; o2sats 93-95% on ra, sats decreased to high 80s when at rest; sats now >96% after 2L nc added. resp rate 20s, no distress. rt ct site cdi. anesthesia consent pt for OR procedure tomorrow-pt scheduled for flex bronch, vats, pericardial window.\n\ngi/gu: pt tolerated dinner, no c/o nausea; npo after midnight for AM surgery.\n"
},
{
"category": "Echo",
"chartdate": "2190-11-03 00:00:00.000",
"description": "Report",
"row_id": 103624,
"text": "PATIENT/TEST INFORMATION:\nIndication: s/p Pericardial tap of 560cc. Assess for residual effusion\nHeight: (in) 65\nWeight (lb): 171\nBSA (m2): 1.85 m2\nBP (mm Hg): 134/70\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 16:05\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular systolic function is normal. There is a very small pericardial\neffusion. There are no echocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is mostly resolved.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2190-11-03 00:00:00.000",
"description": "Report",
"row_id": 103625,
"text": "PATIENT/TEST INFORMATION:\nIndication: Assess for Pericardial effusion/Tamponade.\nHeight: (in) 66\nWeight (lb): 173\nBSA (m2): 1.88 m2\nBP (mm Hg): 130/40\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 10:46\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) 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 thicknesses and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild (1+) MR. LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Large pericardial effusion. Effusion circumferential. No RV\ndiastolic collapse. Brief RA diastolic collapse. Echocardiographic signs of\ntamponade may be absent in the presence of elevated right sided pressures.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses and cavity size are normal.\nRegional left ventricular wall motion is normal. Left ventricular systolic\nfunction is hyperdynamic (EF>75%). Right ventricular chamber size and free\nwall motion are normal. The aortic arch is mildly dilated. There are three\naortic valve leaflets. The aortic valve leaflets are moderately thickened.\nThere is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nTrace/Mild (1+) mitral regurgitation is seen. The left ventricular inflow\npattern suggests impaired relaxation. There is mild pulmonary artery systolic\nhypertension. There is a large pericardial effusion. The effusion appears\ncircumferential. No right ventricular diastolic collapse is seen. There is\nbrief right atrial diastolic collapse. Echocardiographic signs of tamponade\nmay be absent in the presence of elevated right sided pressures.\n\nCompared with the report of the prior study (images unavailable for review) of\n, the pericardial effusion is new. Pulmonary hypertension is\nprobably similar.\n\nIMPRESSION: Large pericardial effusion with elevated intrapericardial\npressure. No overt tamponade (No diastolic RV collapse) however this likely\nrepresents early tamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2190-11-06 00:00:00.000",
"description": "Report",
"row_id": 297929,
"text": "Sinus rhythm. Left atrial abnormality. Compared to the previous tracing\nof no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-11-03 00:00:00.000",
"description": "Report",
"row_id": 297930,
"text": "Sinus rhythm\nModest ST-T wave changes with slight inferolateral ST segment elevation - are\nnonspecific but clinical correlation is suggested\nSince previous tracing of the same date, atrial flutter now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2190-11-03 00:00:00.000",
"description": "Report",
"row_id": 297931,
"text": "Atrial flutter with rapid ventricular response\nNonspecific ST-T wave changes\nSince previous tracing of , atrial flutter now present\n\n"
},
{
"category": "ECG",
"chartdate": "2190-11-02 00:00:00.000",
"description": "Report",
"row_id": 298163,
"text": "Technically difficult study\nSinus rhythm\nProbable old septal infarct\nInferior ST elevation\nLateral T wave changes\nSince previous tracing, no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-11-03 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 935048,
"text": " 9:24 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: patient with 200cc of bloody drainage from pericardial drain\n Admitting Diagnosis: PERICARDIAL EFFUSION;DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with R pleur-x catheter ? pericardial effusion\n\n REASON FOR THIS EXAMINATION:\n patient with 200cc of bloody drainage from pericardial drainage bag and 9 point\n crit drop\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of patient after pericardiocentesis.\n\n Portable AP chest radiograph compared to done at 08:31. The\n patient is after insertion of pericardial drainage which is demonstrated on\n the current chest radiograph. The heart silhouette is slightly decreased\n compared to the previous film, most likely due to removing of some of the\n pericardial effusion. The right chest tube is again demonstrated. The lungs\n are clear. There is no sizeable pleural effusion. There is no evidence of\n congestive heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-11-05 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 935309,
"text": " 1:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: PLEASE REMEMBER TO PUT THIS X-RAY IN CAREVIEW!!!!!\n Admitting Diagnosis: PERICARDIAL EFFUSION;DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with R pleur-x catheter s/p pericardial window, removal of\n mediastinal drain\n REASON FOR THIS EXAMINATION:\n PLEASE REMEMBER TO PUT THIS X-RAY IN CAREVIEW!!!!!\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 87-year-old female status post pericardial window.\n\n COMPARISON: CXR .\n\n FINDINGS: Stable positioning of right subclavian line and right chest tube is\n identified. Previous mediastinal drainage tube has been removed. The\n cardiomediastinal silhouette is unchanged. Calcifications of the aortic arch\n are seen. Dense retrocardiac opacity consistent with atelectasis versus\n airspace disease. Right-sided basilar airspace disease versus atelectasis is\n also identified. Left greater than right small pleural effusions. No\n pneumothorax is identified.\n\n IMPRESSION: Stable bibasilar airspace disease versus atelectasis. Bilateral\n small pleural effusions also appear stable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-11-05 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 935236,
"text": " 1:17 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p R TLC insertion-check placement\n Admitting Diagnosis: PERICARDIAL EFFUSION;DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with R pleur-x catheter s/p pericardial window\n\n REASON FOR THIS EXAMINATION:\n s/p R TLC insertion-check placement\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Status post pericardial window and pleural catheter placement.\n New central line placement.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP UPRIGHT: There has been interval placement of a right\n subclavian CVL with the tip in the mid SVC. Right-sided pleural catheters are\n in unchanged position. There is improved aeration of the right lower lobe\n with persistent small bilateral pleural effusions. There is no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-11-08 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 935692,
"text": " 3:02 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p Drainage of pleura-vac catheter. PLEASE PERFORM STAT\n Admitting Diagnosis: PERICARDIAL EFFUSION;DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with R pleur-x catheter and pericardial window for\n malignant pericardial effusion\n REASON FOR THIS EXAMINATION:\n s/p Drainage of pleura-vac catheter. PLEASE PERFORM STAT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Malignant pericardial effusion status post drainage.\n\n CHEST:\n\n Comparison is made to the prior chest x-ray of .\n\n There has been no significant change since the prior chest x-ray. The\n position of the various lines and tubes is unchanged. No pneumothorax is\n present. The effusions and areas of atelectasis are unaltered.\n\n IMPRESSION: No change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-11-06 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 935441,
"text": " 1:25 PM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: please take film 7am\n Admitting Diagnosis: PERICARDIAL EFFUSION;DYSPNEA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with R pleur-x catheter and pericardial window for\n malignant pericardial effusion\n REASON FOR THIS EXAMINATION:\n please take film 7am\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n HISTORY: 87-year-old woman with right Pleurx catheter and pericardial window\n for malignant pericardial effusion.\n\n FINDINGS: Comparison is made to prior study from .\n\n There is again seen a very small right apical pneumothorax. Pleural catheter\n is seen at right base, unchanged. There is a right-sided central venous\n catheter with the distal tip in the distal SVC. There is again seen left-\n sided pleural effusion. The resolving ill-defined opacity at the right base\n is unchanged but improved since the radiographs from . Overall,\n there is no interval change since the most recent study from at\n 8:00 a.m.\n\n\n\n\n"
}
] |
54,421 | 170,365 | 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this morning requiring bilateral nasal packing ("rapid rhino") with reported prior history of severe epistaxis resulting in bradycardic arrest admitted to MICU for close monitoring. | # Epistaxis: Epistaxis most likley secondary to recently starting plavix , and intermittent use of ASA. Plan: Cont w/ current antihypertensive regimen, Keep BP <180 Epistaxis Assessment: Action: Response: Plan: # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA Hypertension, benign Assessment: BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA Hypertension, benign Assessment: BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA Hypertension, benign Assessment: BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted. vascular malformation vs. tumor No contraindications for IV contrast WET READ: JXKc MON 9:40 PM Non-contrast CT: Opacification of the ethmoid sinuses and partial opacification of the maxillary sinuses bilaterally with air-fluid levels. vascular malformation vs. tumor Admitting Diagnosis: EPISTAXIS Contrast: OPTIRAY Amt: 80 FINAL REPORT (Cont) IMPRESSION: 1. Plan: Cont w/ current antihypertensive regimen, Keep systolic BP <160 Epistaxis Assessment: Pt w/ nasal packing to bilateral nares w/ balloons inflated. - Continue metoprolol, Nifedipine, Nitropatch, and prn Hydral or lopressor to maintain SBP<160 . 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who presents after developing bilateral epistaxis morning associated with fatigue but not associated with lightheadedness or syncope. 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who presents after developing bilateral epistaxis morning associated with fatigue but not associated with lightheadedness or syncope. - Continue metoprolol, Nifedipine, Nitropatch, lisinopril, and prn Hydral or lopressor to maintain SBP<160 . Allergies: Last dose of Antibiotics: Infusions: Other ICU medications: Metoprolol - 11:10 PM Hydralazine - 03:54 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Denies chest pain, abdominal pain, lightheadedness, dizziness, palpitations, headache, vision changes, feeling of blood in back of throat. # PPx: no sQ heparin given bleed, will use pboots, bowel reg, home PPI . # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , and intermittent use of ASA. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA Hypertension, benign Assessment: BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted. # Epistaxis: Epistaxis most likley secondary to recently starting plavix , hypertension, and intermittent use of ASA Hypertension, benign Assessment: BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted. Hypertension, benign Assessment: On adm to MICU pt was very hypertensive at 190- 180s. - Continue metoprolol, Nifedipine, Nitropatch, and prn Hydral or lopressor to maintain SBP<160 . - Continue metoprolol, Nifedipine, Nitropatch, and prn Hydral or lopressor to maintain SBP<160 . Allergies: Last dose of Antibiotics: Infusions: Other ICU medications: Metoprolol - 11:10 PM Hydralazine - 03:54 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Denies chest pain, abdominal pain, lightheadedness, dizziness, palpitations, headache, vision changes, feeling of blood in back of throat. Allergies: Last dose of Antibiotics: Infusions: Other ICU medications: Metoprolol - 11:10 PM Hydralazine - 03:54 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Denies chest pain, abdominal pain, lightheadedness, dizziness, palpitations, headache, vision changes, feeling of blood in back of throat. Allergies: Last dose of Antibiotics: Infusions: Other ICU medications: Metoprolol - 11:10 PM Hydralazine - 03:54 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Denies chest pain, abdominal pain, lightheadedness, dizziness, palpitations, headache, vision changes, feeling of blood in back of throat. Allergies: Last dose of Antibiotics: Infusions: Other ICU medications: Metoprolol - 11:10 PM Hydralazine - 03:54 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Denies chest pain, abdominal pain, lightheadedness, dizziness, palpitations, headache, vision changes, feeling of blood in back of throat. | 23 | [
{
"category": "Radiology",
"chartdate": "2113-10-09 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1039808,
"text": " 3:06 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ? vascular malformation vs. tumor\n Admitting Diagnosis: EPISTAXIS\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with severe bilataral epsistaxis, with packing currently,\n please evlauate for cause of bleeding.\n REASON FOR THIS EXAMINATION:\n ? vascular malformation vs. tumor\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc MON 9:40 PM\n Non-contrast CT: Opacification of the ethmoid sinuses and partial\n opacification of the maxillary sinuses bilaterally with air-fluid levels.\n Small amount of fluid seen in the nasopharynx. Periventricular white matter\n low attenuation c/w chronic small vessel ischemic disease. On CTA, there is\n a 4mm anuerysm arising from the basilar artery as well as a 2 mm basilar tip\n aneurysm. Extensive atherosclerotic calcifications of the carotid arteries\n are seen bilaterally, with suggestion of a small aneurysm arising from the\n left internal carotid artery. FINAL REPORT will be issued once 3 D\n reconstructions available. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old woman with severe bilateral epistaxis, with _____,\n please evaluate for cause of bleeding. Question vascular malformation versus\n tumor.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. An axial perfusion CT run was performed during infusion of\n 80 cc of Optiray intravenously contrast. Subsequently, rapid axial imaging\n was performed through the brain during infusion of intravenous contrast\n material. Reconstructions were performed demonstrating vascular anatomy.\n\n COMPARISONS: None.\n\n FINDINGS:\n\n HEAD CT: There is no evidence of hemorrhage, edema, masses, mass effect, or\n infarction. The ventricles and sulci are normal in caliber and configuration.\n No fractures are identified.\n\n Air-fluid levels are seen in the maxillary sinuses bilaterally. There is also\n a small amount of fluid seen within the nasopharynx. There is an old medial\n wall blowout fracture on the right.\n\n There are small vessel ischemic changes in the white matter.\n\n HEAD CTA: There is atheromatous disease in the A1 branch of the right MCA,\n basilar artery, and vertebral arteries. At the LMCA bifurcation, there is a\n small aneurysm which measures less than 2 mm.\n\n (Over)\n\n 3:06 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ? vascular malformation vs. tumor\n Admitting Diagnosis: EPISTAXIS\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. No evidence for vascular malformation or tumor. However, the sensitivity\n of most causes of epistaxis is poor on this study. If further evaluation is\n warranted, a catheter arteriogram is recommended.\n 2. Small sub-2-mm aneurysm at the LMCA bifurcation.\n 3. Air-fluid levels within bilateral maxillary sinuses.\n 4. Old right medial wall blowout fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1038750,
"text": " 5:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with epistaxis\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n CLINICAL HISTORY: 83-year-old woman with epistaxis. Evaluate for acute\n process.\n\n COMPARISON: None.\n\n FINDINGS: Single AP upright portable chest radiograph is obtained. The lungs\n are clear bilaterally demonstrating no evidence of pneumonia or CHF. No\n pleural effusion or pneumothorax is seen. A linear density in the left mid-\n to-lower lung may represent plate-like atelectasis or scarring. There is\n hyperaeration of the lungs which may indicate underlying emphysema. Heart\n size appears within normal limits. There is some unfolding of the thoracic\n aorta, resulting in a slightly widened mediastinal contour. Bony structures\n appear diffusely osteopenic, though no definite fractures are identified.\n\n IMPRESSION:\n\n No pneumonia or CHF.\n\n Suggestion of emphysema. Unfolded thoracic aorta.\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2113-10-04 00:00:00.000",
"description": "L KNEE (2 VIEWS) LEFT",
"row_id": 1038739,
"text": " 2:15 PM\n KNEE (2 VIEWS) LEFT Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old woman with aka pain\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 83-year-old female with leg pain, to rule out pathology.\n\n TECHNIQUE: The AP and lateral radiographs were performed of the left mid\n femur. The patient is status post amputation.\n\n FINDINGS:\n\n There is extensive vascular calcification noted. The patient is status post\n amputation. The visualized distal femur does not show any fracture. The\n overlying soft tissues appear unremarkable.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2113-10-04 00:00:00.000",
"description": "Report",
"row_id": 223407,
"text": "Sinus rhythm. Possible left atrial abnormality. Possible prior inferior\nmyocardial infarction. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 638962,
"text": "83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this\n morning, and treated with bilateral nasal packing with reported prior\n history of epistaxis resulting in bradycardic arrest admitted to MICU\n for monitoring.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA\n Hypertension, benign\n Assessment:\n BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted.\n Action:\n Pt cont on metopr\n Response:\n Plan:\n Epistaxis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638965,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:01 AM\n Held plavix. Pt had large guaiac pos stool at 2am\n C/o Sore Throat. Otherwise well.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Denies chest pain, abdominal pain, lightheadedness, dizziness,\n palpitations, headache, vision changes, feeling of blood in back of\n throat.\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.6\nC (96.1\n HR: 73 (73 - 95) bpm\n BP: 112/53(67) {112/53(67) - 196/105(127)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 117 mL\n PO:\n 60 mL\n TF:\n IVF:\n 8 mL\n 57 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Gen: NAD, pleasant, sitting up in bed.\n Face: symmetric, FN normal\n HEENT: PERRL EOMI, no conjunctival pallor; nose with bilateral packings\n with inflatable attachments inflated with air. No evident bleeding\n anteriorly through packing. OP clear without active bleeding, no clots\n in posterior oropharynx. MMM\n Neck: Supple, thin, no LAD, no mass\n CV: RRR. No m/r/g\n Resp: CTAB, No WRR\n Abd: Soft. NT/ND +BS, +abdominal scarring\n Ext: No c/c/e, Left groin pusatile mass, baseline per daughter. \n bruit.\n Labs / Radiology\n 234 K/uL\n 9.5 g/dL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this\n morning, and treated with bilateral nasal packing with reported prior\n history of epistaxis resulting in bradycardic arrest admitted to MICU\n for monitoring.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA. HCT\n slight decrease from time of admission. She has had no further episodes\n of bleeding.\n -- f/u ENT recs\n -- epistaxis precautions (No nose-blowing, no straining, no heavy\n lifting, no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n ; after removal, saline nasal spray QID\n -- continue keflex for staph prophylaxis\n -- Recheck HCT at 5pm ()\n -- If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n # CAD s/p MI: Holding Plavix for now given severe epistaxis which has\n been recurrent in last 2 months\n .\n # HTN: Pt has difficult to control HTN on multiple home medications.\n Will continue home meds and give Hydralazine 10mg IV prn or Lopressor 5\n mg IV prn to keep SBP<160.\n - Continue metoprolol, Nifedipine, Nitropatch, lisinopril, and prn\n Hydral or lopressor to maintain SBP<160\n .\n # Renal failure: Likely chronic but no prior data avilable. Cr stable\n at 1.6. Most likley HTN.\n - Follow Cr, lytes\n - Will obtain old records from OSH.\n .\n # Decreased Bicarb: Unclear if acute or chronic ? renal disease.\n Improving.\n -Continue to monitor with BMP in am\n .\n # FEN: Regular Cardiac, low salt\n .\n # PPx: no sQ heparin given bleed, will use pboots, bowel reg, home PPI\n .\n # Access: PIV\n .\n # Code: Full, confirmed with patient and daughter.\n .\n # Comm\n -- Will obtain records from OSH. Will contact in am who\n lives with pt, has more info regarding PMH\n .\n # Dispo\n ICU until recs from ENT; possible cal out to floor for\n cardiac monitoring while nasal packing in place.\n"
},
{
"category": "Nursing",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 638967,
"text": "83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who\n presents after developing bilateral epistaxis morning associated\n with fatigue but not associated with lightheadedness or syncope. she\n had an epistaxis episode 6 weeks ago per report resulting in\n bradycardia/cardiac arrest . She denies other prior episodes of\n epistaxis and has never previously required nasal packing. She also\n noted spitting up of blood with some nausea. Pt sent t o MICU for\n further care.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA\n Hypertension, benign\n Assessment:\n BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted.\n Action:\n Pt on home regimen of antihypertensives, in addition to Ntg patch and\n nifedipine patch\n Response:\n VSS. BP 100s systolic.\n Plan:\n Cont w/ current antihypertensive regimen, Keep BP <180\n Epistaxis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638911,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:01 AM\n held plavix. had large guaiac pos stool at 2am\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.6\nC (96.1\n HR: 73 (73 - 95) bpm\n BP: 112/53(67) {112/53(67) - 196/105(127)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 117 mL\n PO:\n 60 mL\n TF:\n IVF:\n 8 mL\n 57 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 234 K/uL\n 9.5 g/dL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638912,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:01 AM\n held plavix. had large guaiac pos stool at 2am\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.6\nC (96.1\n HR: 73 (73 - 95) bpm\n BP: 112/53(67) {112/53(67) - 196/105(127)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 117 mL\n PO:\n 60 mL\n TF:\n IVF:\n 8 mL\n 57 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Gen: NAD, pleasant\n Eyes: PERRL EOMI\n Face: symmetric, FN normal\n HEENT: Nose with bilateral packings with inflatable attachments\n inflated with air. No evident bleeding anteriorly. OP clear without\n active bleeding, no clots in posterior oropharynx. MMM\n Neck: Supple, thin, no LADd, no mass\n CV: Tachy. Reg. No m/r/g\n Resp: CTA BL\n Abd: Soft. NT/ND +BS\n Ext: No c/c/e Left groin pusatile mass, baseline per daughter. bruit\n Labs / Radiology\n 234 K/uL\n 9.5 g/dL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638913,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:01 AM\n held plavix. had large guaiac pos stool at 2am\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.6\nC (96.1\n HR: 73 (73 - 95) bpm\n BP: 112/53(67) {112/53(67) - 196/105(127)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 117 mL\n PO:\n 60 mL\n TF:\n IVF:\n 8 mL\n 57 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Gen: NAD, pleasant\n Eyes: PERRL EOMI\n Face: symmetric, FN normal\n HEENT: Nose with bilateral packings with inflatable attachments\n inflated with air. No evident bleeding anteriorly. OP clear without\n active bleeding, no clots in posterior oropharynx. MMM\n Neck: Supple, thin, no LADd, no mass\n CV: Tachy. Reg. No m/r/g\n Resp: CTA BL\n Abd: Soft. NT/ND +BS\n Ext: No c/c/e Left groin pusatile mass, baseline per daughter. bruit\n Labs / Radiology\n 234 K/uL\n 9.5 g/dL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this\n morning, and treated with bilateral nasal packing with reported prior\n history of epistaxis resulting in bradycardic arrest admitted to MICU\n for monitoring.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , and intermittent use of ASA. HCT stable. Will\n follow. She has had no further episodes of bleeding.\n -- f/u ENT recs as below\n -- epistaxis precautions (No nose-blowing, no straining, no heavy\n lifting, no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n \n -- continue keflex\n -- after removal, saline nasal spray QID\n --If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n # CAD s/p MI: Holding Plavix for now given severe epistaxis which has\n been recurrent in last 2 months\n .\n # HTN: Pt has difficult to control HTN on multiple home medications.\n Will continue home meds and give Hydral 10mg IV prn or Lopressor 5 mg\n IV prn to keep SBP<160.\n - Continue metoprolol, Nifedipine, Nitropatch, and prn Hydral or\n lopressor to maintain SBP<160\n .\n # Renal failure: Likely chronic but no prior data avilable. Cr was 1.7\n yesterday at OSH, so stable x 24 hours. Most likley HTN, although\n old records not available.\n - Follow Cr, lytes\n .\n # Elevated Bicarb: Unclear if acute or chronic ? renal disease.\n Will follow.\n .\n # FEN: Regular Cardiac, low salt\n .\n # PPx: no sQ heparin given bleed, will use pboots, bowel reg, home PPI\n .\n # Access: PIV\n .\n # Code: Full, confirmed with patient and daughter.\n .\n # Comm\n -- with patient and daughter . contact in\n am who lives with pt, has more info regarding PMH\n .\n # Dispo -- ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 639006,
"text": "Chief Complaint: epistaxis, 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 24 Hour Events:\n EKG - At 12:01 AM\n Came to MICU\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 36.4\nC (97.5\n Tcurrent: 36.1\nC (96.9\n HR: 75 (71 - 95) bpm\n BP: 109/66(77) {101/51(63) - 196/105(127)} mmHg\n RR: 21 (9 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 207 mL\n PO:\n 120 mL\n TF:\n IVF:\n 8 mL\n 87 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///19/\n Physical Examination\n Gen: sitting up in bed, NAD\n HEENT: nasal packing in place\n CV: RR nl s1/s2\n Chest: CTA\n ABd: soft NT\n Ext: left AKA\n Labs / Radiology\n 9.5 g/dL\n 234 K/uL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo female with history of CAD, HTN and on anti-platelet agents. She\n now has evolved significant epistaxis and on previous event had\n significant bradycardia now to ICU for care.\n Epistaxis-\n -Hold Plavix and ASA\n -Maintain packing\n -Epistaxis precautions\n -ENT consult in place\n -Will keep SBP <160\n -Keflex for prophylaxis\n -No nasal cannula O2\n Bradycardia-\n -Telemetry\n Hypertension-\n -continue home meds\n -Will utilize Hydralazine as needed IV for worsening\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:20 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer:\n Communication: with pt\n status: Full code\n Disposition : call out top floor for if ENT fine\n"
},
{
"category": "Nursing",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 638982,
"text": "83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who\n presents after developing bilateral epistaxis morning associated\n with fatigue but not associated with lightheadedness or syncope. she\n had an epistaxis episode 6 weeks ago per report resulting in\n bradycardia/cardiac arrest . She denies other prior episodes of\n epistaxis and has never previously required nasal packing. She also\n noted spitting up of blood with some nausea. Pt sent t o MICU for\n further care.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA\n Hypertension, benign\n Assessment:\n BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted.\n Action:\n Pt on home regimen of antihypertensives, in addition to Ntg patch\n Response:\n VSS. BP 100s systolic.\n Plan:\n Cont w/ current antihypertensive regimen, Keep systolic BP <160\n Epistaxis\n Assessment:\n Pt w/ nasal packing to bilateral nares w/ balloons inflated. No\n additional bleeding since admit to MICU.\n Action:\n Cont nasal packing for total of 5 days per ENT.\n Response:\n Plan:\n no ASA or plavix.\n epistaxis precautions (No nose-blowing, no straining, no heavy lifting,\n no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n ; after removal, saline nasal spray QID\n -- continue keflex for staph prophylaxis\n -- HCT checks \n -- If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n"
},
{
"category": "Nursing",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 638983,
"text": "83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who\n presents after developing bilateral epistaxis morning associated\n with fatigue but not associated with lightheadedness or syncope. she\n had an epistaxis episode 6 weeks ago per report resulting in\n bradycardia/cardiac arrest . She denies other prior episodes of\n epistaxis and has never previously required nasal packing. She also\n noted spitting up of blood with some nausea. Pt sent t o MICU for\n further care.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA\n Hypertension, benign\n Assessment:\n BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted.\n Action:\n Pt on home regimen of antihypertensives, in addition to Ntg patch\n Response:\n VSS. BP 100s systolic.\n Plan:\n Cont w/ current antihypertensive regimen, Keep systolic BP <160\n Epistaxis\n Assessment:\n Pt w/ nasal packing to bilateral nares w/ balloons inflated. No\n additional bleeding since admit to MICU.\n Action:\n Cont nasal packing for total of 5 days per ENT.\n Response:\n Plan:\n no ASA or plavix.\n epistaxis precautions (No nose-blowing, no straining, no heavy lifting,\n no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n ; after removal, saline nasal spray QID\n -- continue keflex for staph prophylaxis\n -- HCT checks \n -- If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n ------ Protected Section ------\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n EPISTAXIS\n Code status:\n Height:\n Admission weight:\n 40.4 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: HTN,AAA, Gerd, Lt AKA and angina.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:110\n D:60\n Temperature:\n 96.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 63 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 774 mL\n 24h total out:\n 300 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:28 AM\n Potassium:\n 4.9 mEq/L\n 03:28 AM\n Chloride:\n 107 mEq/L\n 03:28 AM\n CO2:\n 19 mEq/L\n 03:28 AM\n BUN:\n 34 mg/dL\n 03:28 AM\n Creatinine:\n 1.6 mg/dL\n 03:28 AM\n Glucose:\n 130 mg/dL\n 03:28 AM\n Hematocrit:\n 28.8 %\n 03:28 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: CC729\n Date & time of Transfer: \n ------ Protected Section Addendum Entered By: , RN\n on: 11:24 ------\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638984,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:01 AM\n Held plavix. Pt had large guaiac pos stool at 2am\n C/o Sore Throat. Otherwise well.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Denies chest pain, abdominal pain, lightheadedness, dizziness,\n palpitations, headache, vision changes, feeling of blood in back of\n throat.\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.6\nC (96.1\n HR: 73 (73 - 95) bpm\n BP: 112/53(67) {112/53(67) - 196/105(127)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 117 mL\n PO:\n 60 mL\n TF:\n IVF:\n 8 mL\n 57 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Gen: NAD, pleasant, sitting up in bed.\n Face: symmetric, FN normal\n HEENT: PERRL EOMI, no conjunctival pallor; nose with bilateral packings\n with inflatable attachments inflated with air. No evident bleeding\n anteriorly through packing. OP clear without active bleeding, no clots\n in posterior oropharynx. MMM\n Neck: Supple, thin, no LAD, no mass\n CV: RRR. No m/r/g\n Resp: CTAB, No WRR\n Abd: Soft. NT/ND +BS, +abdominal scarring\n Ext: No c/c/e, Left groin pusatile mass, baseline per daughter. \n bruit.\n Labs / Radiology\n 234 K/uL\n 9.5 g/dL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this\n morning, and treated with bilateral nasal packing with reported prior\n history of epistaxis resulting in bradycardic arrest admitted to MICU\n for monitoring.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA. HCT\n slight decrease from time of admission. She has had no further episodes\n of bleeding.\n -- f/u ENT recs\n -- epistaxis precautions (No nose-blowing, no straining, no heavy\n lifting, no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n ; after removal, saline nasal spray QID\n -- continue keflex for staph prophylaxis\n -- Recheck HCT at 5pm ()\n -- If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n # CAD s/p MI: Holding Plavix for now given severe epistaxis which has\n been recurrent in last 2 months\n .\n # HTN: Pt has difficult to control HTN on multiple home medications.\n Will continue home meds and give Hydralazine 10mg IV prn or Lopressor 5\n mg IV prn to keep SBP<160.\n - Continue metoprolol, Nifedipine, Nitropatch, lisinopril, and prn\n Hydral or lopressor to maintain SBP<160\n .\n # Renal failure: Likely chronic but no prior data avilable. Cr stable\n at 1.6. Most likley HTN.\n - Follow Cr, lytes\n - Will obtain old records from OSH.\n .\n # Decreased Bicarb: Unclear if acute or chronic ? renal disease.\n Improving.\n -Continue to monitor with BMP in am\n .\n # FEN: Regular Cardiac, low salt\n .\n # PPx: no sQ heparin given bleed, will use pboots, bowel reg, home PPI\n .\n # Access: PIV\n .\n # Code: Full, confirmed with patient and daughter.\n .\n # Comm\n -- Will obtain records from OSH. Will contact in am who\n lives with pt, has more info regarding PMH\n .\n # Dispo\n ICU until recs from ENT; possible cal out to floor for\n cardiac monitoring while nasal packing in place.\n MSIV\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638992,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:01 AM\n Held plavix. Pt had large guaiac pos stool at 2am\n C/o Sore Throat. Otherwise well.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Denies chest pain, abdominal pain, lightheadedness, dizziness,\n palpitations, headache, vision changes, feeling of blood in back of\n throat.\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.6\nC (96.1\n HR: 73 (73 - 95) bpm\n BP: 112/53(67) {112/53(67) - 196/105(127)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 117 mL\n PO:\n 60 mL\n TF:\n IVF:\n 8 mL\n 57 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Gen: NAD, pleasant, sitting up in bed.\n Face: symmetric, FN normal\n HEENT: PERRL EOMI, no conjunctival pallor; nose with bilateral packings\n with inflatable attachments inflated with air. No evident bleeding\n anteriorly through packing. OP clear without active bleeding, no clots\n in posterior oropharynx. MMM\n Neck: Supple, thin, no LAD, no mass\n CV: RRR. No m/r/g\n Resp: CTAB, No WRR\n Abd: Soft. NT/ND +BS, +abdominal scarring\n Ext: No c/c/e, Left groin pusatile mass, baseline per daughter. \n bruit.\n Labs / Radiology\n 234 K/uL\n 9.5 g/dL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this\n morning, and treated with bilateral nasal packing with reported prior\n history of epistaxis resulting in bradycardic arrest admitted to MICU\n for monitoring.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA. HCT\n slight decrease from time of admission. She has had no further episodes\n of bleeding.\n -- f/u ENT recs\n -- epistaxis precautions (No nose-blowing, no straining, no heavy\n lifting, no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n ; after removal, saline nasal spray QID\n -- continue keflex for staph prophylaxis\n -- Recheck HCT at 5pm ()\n -- If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n # CAD s/p MI: Holding Plavix for now given severe epistaxis which has\n been recurrent in last 2 months\n .\n # HTN: Pt has difficult to control HTN on multiple home medications.\n Will continue home meds and give Hydralazine 10mg IV prn or Lopressor 5\n mg IV prn to keep SBP<160.\n - Continue metoprolol, Nifedipine, Nitropatch, lisinopril, and prn\n Hydral or lopressor to maintain SBP<160\n .\n # Renal failure: Likely chronic but no prior data avilable. Cr stable\n at 1.6. Most likley HTN.\n - Follow Cr, lytes\n - Will obtain old records from OSH.\n .\n # Decreased Bicarb: Unclear if acute or chronic ? renal disease.\n Improving.\n -Continue to monitor with BMP in am\n .\n # FEN: Regular Cardiac, low salt\n .\n # PPx: no sQ heparin given bleed, will use pboots, bowel reg, home PPI\n .\n # Access: PIV\n .\n # Code: Full, confirmed with patient and daughter.\n .\n # Comm\n n I called this am; they will fax over her MRs\n the end of through , including her past epistaxis\n and presumed cardiac event episode. Also, I called the patient\n daughter, , this am () who lives with the patient in\n . HPI addendum includes the following bulletpoints:\n n -HPI: pt was bleeding from both nose and mouth on am.\n n -PMH: During her first episode of epistaxis 5-6weeks ago at\n , she was intubated, transferred to the ICU, and her\nheart might have stopped.\n Upon d/c, she was f/u with an ENT who did\n not know why this past epistaxis event occurred. The patient has had a\n CABGx3 10yrs ago, a L carotid stenosis without CEA diagnosed on ,\n and a\nright groin aneruysm that has been increasing in size.\n The\n patient is seen by Dr. (Vascular, ) and Dr. \n (PCP)\n n -Meds: Daughter confirmed current med list. The patient takes\n NTG patch 0.6mg qday. Also, Benadryl PRN for sleep\n n -FHx: Denies FHx of bleeding d/o\n n -Allergies: Tagament\n throat swelling\n .\n # Dispo\n ICU until recs from ENT; possible cal out to floor for\n cardiac monitoring while nasal packing in place.\n MSIV\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638993,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:01 AM\n Held plavix. Pt had large guaiac pos stool at 2am\n C/o Sore Throat. Otherwise well.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Denies chest pain, abdominal pain, lightheadedness, dizziness,\n palpitations, headache, vision changes, feeling of blood in back of\n throat.\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.6\nC (96.1\n HR: 73 (73 - 95) bpm\n BP: 112/53(67) {112/53(67) - 196/105(127)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 117 mL\n PO:\n 60 mL\n TF:\n IVF:\n 8 mL\n 57 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Gen: NAD, pleasant, sitting up in bed.\n Face: symmetric, FN normal\n HEENT: PERRL EOMI, no conjunctival pallor; nose with bilateral packings\n with inflatable attachments inflated with air. No evident bleeding\n anteriorly through packing. OP clear without active bleeding, no clots\n in posterior oropharynx. MMM\n Neck: Supple, thin, no LAD, no mass\n CV: RRR. No m/r/g\n Resp: CTAB, No WRR\n Abd: Soft. NT/ND +BS, +abdominal scarring\n Ext: No c/c/e, Left groin pusatile mass, baseline per daughter. \n bruit.\n Labs / Radiology\n 234 K/uL\n 9.5 g/dL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this\n morning, and treated with bilateral nasal packing with reported prior\n history of epistaxis resulting in bradycardic arrest admitted to MICU\n for monitoring.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA. HCT\n slight decrease from time of admission. She has had no further episodes\n of bleeding.\n -- f/u ENT recs\n -- epistaxis precautions (No nose-blowing, no straining, no heavy\n lifting, no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n ; after removal, saline nasal spray QID\n -- continue keflex for staph prophylaxis\n -- Recheck HCT at 5pm ()\n -- If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n # CAD s/p MI: Holding Plavix for now given severe epistaxis which has\n been recurrent in last 2 months\n .\n # HTN: Pt has difficult to control HTN on multiple home medications.\n Will continue home meds and give Hydralazine 10mg IV prn or Lopressor 5\n mg IV prn to keep SBP<160.\n - Continue metoprolol, Nifedipine, Nitropatch, lisinopril, and prn\n Hydral or lopressor to maintain SBP<160\n .\n # Renal failure: Likely chronic but no prior data avilable. Cr stable\n at 1.6. Most likley HTN.\n - Follow Cr, lytes\n - Will obtain old records from OSH.\n .\n # Decreased Bicarb: Unclear if acute or chronic ? renal disease.\n Improving.\n -Continue to monitor with BMP in am\n .\n # FEN: Regular Cardiac, low salt\n .\n # PPx: no sQ heparin given bleed, will use pboots, bowel reg, home PPI\n .\n # Access: PIV\n .\n # Code: Full, confirmed with patient and daughter.\n .\n # Comm\n n I called this am; they will fax over her MRs\n the end of through , including her past epistaxis\n and presumed cardiac event episode. Also, I called the patient\n daughter, , this am () who lives with the patient in\n . H&P addendum includes the following bulletpoints:\n n -HPI: pt was bleeding from both nose and mouth on am.\n n -PMH: During her first episode of epistaxis 5-6weeks ago at\n , she was intubated, transferred to the ICU, and her\nheart might have stopped.\n Upon d/c, she was f/u with an ENT who did\n not know why this past epistaxis event occurred. The patient has had a\n CABGx3 10yrs ago, a L carotid stenosis without CEA diagnosed on ,\n and a\nright groin aneruysm that has been increasing in size.\n The\n patient is seen by Dr. (Vascular, ) and Dr. \n (PCP)\n n -Meds: Daughter confirmed current med list. The patient takes\n NTG patch 0.6mg qday. Also, Benadryl PRN for sleep\n n -FHx: Denies FHx of bleeding d/o\n n -Allergies: Tagament\n throat swelling\n .\n # Dispo\n ICU until recs from ENT; possible cal out to floor for\n cardiac monitoring while nasal packing in place.\n MSIV\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 638869,
"text": "Chief Complaint: Nosebleed\n HPI:\n 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who\n presents after developing bilateral epistaxis morning associated\n with fatigue but not associated with lightheadedness or syncope. Of\n note, she had an epistaxis episode 6 weeks ago per report resulting in\n bradycardia/cardiac arrest although patient and daughter deny. She\n denies other prior episodes of epistaxis and has never previously\n required nasal packing. She also noted spitting up of blood with some\n nausea. Denies any BRBPR, melena, diarrhea/ constipation. She initially\n presented to an OSH ED where they used expanding gelfoam for an\n anterior deep packing. Also given unasyn 3g morphine 2mg and\n transferred to . OSH VS HR 49-62, RR 18-20, BP 134-178/63-80,\n 100%RA\n .\n In the ED, VS: 99.0 92 180/100 18 100%RA. ENT was consulted and\n assessed bilateral nasal packing. No repeat episodes of bleeding were\n noted. ENT was consulted and thought that she ran the risk of repeat\n bradycardia given extent of packing, recommended monitoring in ICU.\n .\n Currently, pt reports some discomfort at the back of her throat and\n mild nausea but is otherwise without complaints.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 12:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n CAD s/p MI 3 months ago, no stent, PCI\n AAA\n PVD\n GERD\n Afib\n Angina\n .\n PSurgHx:\n Tonsils & adenoids\n sigmoid colectomy ischemic bowel with colostomy, take down of\n splenic flexure and pouch\n L AKA \n No FH bleeding d/o\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Patient lives at home with daughter . She uses wheelchair\n and walker at home. Accomplishes bed transfers on her own\n Review of systems:\n Flowsheet Data as of 01:19 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: 88 (88 - 95) bpm\n BP: 164/84(105) {164/84(105) - 196/105(127)} mmHg\n RR: 30 (18 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 13 mL\n PO:\n TF:\n IVF:\n 8 mL\n 13 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -287 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n Physical Examination\n VS: 96.7 95 196/100-> 164/84 18 98% RA\n Gen: NAD, pleasant\n Eyes: PERRL EOMI\n Face: symmetric, FN normal\n HEENT: Nose with bilateral packings with inflatable attachments\n inflated with air. No evident bleeding anteriorly. OP clear without\n active bleeding, no clots in posterior oropharynx. MMM\n Neck: Supple, thin, no LADd, no mass\n CV: Tachy. Reg. No m/r/g\n Resp: CTA BL\n Abd: Soft. NT/ND +BS\n Ext: No c/c/e Left groin pusatile mass, baseline per daughter. bruit\n / Radiology\n 224\n 10.1\n 144\n 1.7\n 21\n 17\n 110.\n 5.0\n 138\n 31.3\n 11.4\n [image002.jpg]\n OSH \n PT 12.6 INR 1.01 APTT 27.7\n Na 137 K 5.0 Cl 108 CO2 22 Glucose 7 Cr 1.7 BUN 22 Ca 9.5\n U/A: 30 protein\n STUDIES:\n CXR:IMPRESSION: No pneumonia or CHF.\n EKG: Ordered\n KNEE FILM:There is extensive vascular calcification noted. The patient\n is status post amputation. The visualized distal femur does not show\n any fracture. The overlying soft tissues appear unremarkable.\n Assessment and Plan\n 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this\n morning, and treated with bilateral nasal packing with reported prior\n history of epistaxis resulting in bradycardic arrest admitted to MICU\n for monitoring.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , and intermittent use of ASA. HCT stable. Will\n follow. She has had no further episodes of bleeding.\n -- f/u ENT recs as below\n -- epistaxis precautions (No nose-blowing, no straining, no heavy\n lifting, no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n \n -- continue keflex\n -- after removal, saline nasal spray QID\n --If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n # CAD s/p MI: Holding Plavix for now given severe epistaxis which has\n been recurrent in last 2 months\n .\n # HTN: Pt has difficult to control HTN on multiple home medications.\n Will continue home meds and give Hydral 10mg IV prn or Lopressor 5 mg\n IV prn to keep SBP<160.\n - Continue metoprolol, Nifedipine, Nitropatch, and prn Hydral or\n lopressor to maintain SBP<160\n .\n # Renal failure: Likely chronic but no prior data avilable. Cr was 1.7\n yesterday at OSH, so stable x 24 hours. Most likley HTN, although\n old records not available.\n - Follow Cr, lytes\n .\n # Elevated Bicarb: Unclear if acute or chronic ? renal disease.\n Will follow.\n .\n # FEN: Regular Cardiac, low salt\n .\n # PPx: no sQ heparin given bleed, will use pboots, bowel reg, home PPI\n .\n # Access: PIV\n .\n # Code: Full, confirmed with patient and daughter.\n .\n # Comm\n -- with patient and daughter . contact in\n am who lives with pt, has more info regarding PMH\n .\n # Dispo -- ICU for now\n ICU Care\n Nutrition:\n Comments: Regular heart healthy\n Glycemic Control:\n Lines:\n 18 Gauge - 10:20 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": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 638871,
"text": "Chief Complaint: Epistaxis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient with evolution of epistaxis 6 weeks prior to today ()\n and now has recurrence. This presented as some coughing up of blood.\n She was given rhino-rocket and posterior packing and ENT consulted\n here. Packing was determined to be adequate and patient to ICU for\n monitoring with history on previous event.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 01:00 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN\n MI\n A-Fib\n AKA\n GERD\n S/P Colectomy\n No h/o bleeding disorder\n Occupation: At home with daughter\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: No(t) Fever\n Respiratory: Cough, No(t) Dyspnea\n Gastrointestinal: Nausea\n Heme / Lymph: Anemia\n Psychiatric / Sleep: No(t) Agitated\n Flowsheet Data as of 02:41 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: 81 (81 - 95) bpm\n BP: 157/76(96) {157/76(96) - 196/105(127)} mmHg\n RR: 25 (18 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 26 mL\n PO:\n TF:\n IVF:\n 8 mL\n 26 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -275 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Packing 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), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Left groin with mass lesion\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 224\n 31\n 1.7\n 11.4\n [image002.jpg]\n Other labs: PT / PTT / INR://1.1\n Imaging: No significant infiltrates defined\n Assessment and Plan\n 83 yo female with history of CAD, HTN and on anti-platelet agents. She\n now has evolved significant epistaxis and on previous event had\n significant bradycardia now to ICU for care.\n Will-->\n Epistaxis-\n -Hold Plavix and ASA tonight\n -Maintain packing\n -Epistaxis precautions\n -ENT consult in place\n -Will keep SBP <160\n -Keflex for prophylaxis\n -Avoid nasal cannula O2\n -Neo if recurrent bleeding seen\n Bradycardia-\n -Telemetry\n Hypertension-\n -continue home meds\n -Will utilize Hydralazine as needed IV for worsening\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 10:20 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 638981,
"text": "83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who\n presents after developing bilateral epistaxis morning associated\n with fatigue but not associated with lightheadedness or syncope. she\n had an epistaxis episode 6 weeks ago per report resulting in\n bradycardia/cardiac arrest . She denies other prior episodes of\n epistaxis and has never previously required nasal packing. She also\n noted spitting up of blood with some nausea. Pt sent t o MICU for\n further care.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA\n Hypertension, benign\n Assessment:\n BP stable 100s-1 teens/60s, HR 60s-70s, SR. No ectopy noted.\n Action:\n Pt on home regimen of antihypertensives, in addition to Ntg patch\n Response:\n VSS. BP 100s systolic.\n Plan:\n Cont w/ current antihypertensive regimen, Keep systolic BP <180\n Epistaxis\n Assessment:\n Pt w/ nasal packing to bilateral nares w/ balloons inflated. No\n additional bleeding since admit to MICU.\n Action:\n Cont nasal packing for total of 5 days per ENT.\n Response:\n Plan:\n Afrin spray at bedside if pt rebleeds, no blowing nose, keep BP <180,\n no ASA or plavix.\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 638952,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 12:01 AM\n Held plavix. Pt had large guaiac pos stool at 2am\n C/o Sore Throat. Otherwise well.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Denies chest pain, abdominal pain, lightheadedness, dizziness,\n palpitations, headache, vision changes, feeling of blood in back of\n throat.\n Flowsheet Data as of 05:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.6\nC (96.1\n HR: 73 (73 - 95) bpm\n BP: 112/53(67) {112/53(67) - 196/105(127)} mmHg\n RR: 9 (9 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 117 mL\n PO:\n 60 mL\n TF:\n IVF:\n 8 mL\n 57 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///19/\n Physical Examination\n Gen: NAD, pleasant, sitting up in bed.\n Face: symmetric, FN normal\n HEENT: PERRL EOMI, no conjunctival pallor; nose with bilateral packings\n with inflatable attachments inflated with air. No evident bleeding\n anteriorly through packing. OP clear without active bleeding, no clots\n in posterior oropharynx. MMM\n Neck: Supple, thin, no LAD, no mass\n CV: RRR. No m/r/g\n Resp: CTAB, No WRR\n Abd: Soft. NT/ND +BS, +abdominal scarring\n Ext: No c/c/e, Left groin pusatile mass, baseline per daughter. \n bruit.\n Labs / Radiology\n 234 K/uL\n 9.5 g/dL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo F wth history of HTN, MI, AAA, Afib, on Plavix had epistaxis this\n morning, and treated with bilateral nasal packing with reported prior\n history of epistaxis resulting in bradycardic arrest admitted to MICU\n for monitoring.\n # Epistaxis: Epistaxis most likley secondary to recently starting\n plavix , hypertension, and intermittent use of ASA. HCT\n slight decrease from time of admission. She has had no further episodes\n of bleeding.\n -- f/u ENT recs\n -- epistaxis precautions (No nose-blowing, no straining, no heavy\n lifting, no hot showers)\n -- aggressive BP control, goal SBP <160\n -- avoid nasal cannula although no need for O2 at this time.\n -- per ENT, nasal packing should stay 5 days, with removal Tues.\n \n -- continue keflex for staph prophylaxis\n -- after removal, saline nasal spray QID\n --If bleeds, Afrin nasal spray and hold anterior aspect of nose by\n pinching for at least 20 min. need IR embolization.\n -- Monitor on telemetry for any episodes of bradycardia, vasovagal\n stimulation secondary to nasal packing\n .\n # CAD s/p MI: Holding Plavix for now given severe epistaxis which has\n been recurrent in last 2 months\n .\n # HTN: Pt has difficult to control HTN on multiple home medications.\n Will continue home meds and give Hydral 10mg IV prn or Lopressor 5 mg\n IV prn to keep SBP<160.\n - Continue metoprolol, Nifedipine, Nitropatch, and prn Hydral or\n lopressor to maintain SBP<160\n .\n # Renal failure: Likely chronic but no prior data avilable. Cr was 1.7\n yesterday at OSH, so stable x 24 hours. Most likley HTN, although\n old records not available.\n - Follow Cr, lytes\n .\n # Elevated Bicarb: Unclear if acute or chronic ? renal disease.\n Will follow.\n .\n # FEN: Regular Cardiac, low salt\n .\n # PPx: no sQ heparin given bleed, will use pboots, bowel reg, home PPI\n .\n # Access: PIV\n .\n # Code: Full, confirmed with patient and daughter.\n .\n # Comm\n -- with patient and daughter . contact in\n am who lives with pt, has more info regarding PMH\n .\n # Dispo -- ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638957,
"text": "Chief Complaint: epistaxis, 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 24 Hour Events:\n EKG - At 12:01 AM\n Came to MICU\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 36.4\nC (97.5\n Tcurrent: 36.1\nC (96.9\n HR: 75 (71 - 95) bpm\n BP: 109/66(77) {101/51(63) - 196/105(127)} mmHg\n RR: 21 (9 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 207 mL\n PO:\n 120 mL\n TF:\n IVF:\n 8 mL\n 87 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///19/\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n ABd\n Ext\n Labs / Radiology\n 9.5 g/dL\n 234 K/uL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo female with history of CAD, HTN and on anti-platelet agents. She\n now has evolved significant epistaxis and on previous event had\n significant bradycardia now to ICU for care.\n Epistaxis-\n -Hold Plavix and ASA tonight\n -Maintain packing\n -Epistaxis precautions\n -ENT consult in place\n -Will keep SBP <160\n -Keflex for prophylaxis\n -Avoid nasal cannula O2\n -Neo if recurrent bleeding seen\n Bradycardia-\n -Telemetry\n Hypertension-\n -continue home meds\n -Will utilize Hydralazine as needed IV for worsening\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:20 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": "2113-10-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 638959,
"text": "Chief Complaint: epistaxis, 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 24 Hour Events:\n EKG - At 12:01 AM\n Came to MICU\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 11:10 PM\n Hydralazine - 03:54 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 36.4\nC (97.5\n Tcurrent: 36.1\nC (96.9\n HR: 75 (71 - 95) bpm\n BP: 109/66(77) {101/51(63) - 196/105(127)} mmHg\n RR: 21 (9 - 30) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8 mL\n 207 mL\n PO:\n 120 mL\n TF:\n IVF:\n 8 mL\n 87 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 8 mL\n -94 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///19/\n Physical Examination\n Gen: sitting up in bed, NAD\n HEENT: nasal packing in place\n CV: RR nl s1/s2\n Chest: CTA\n ABd: soft NT\n Ext: left AKA\n Labs / Radiology\n 9.5 g/dL\n 234 K/uL\n 130 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 4.9 mEq/L\n 34 mg/dL\n 107 mEq/L\n 138 mEq/L\n 28.8 %\n 11.8 K/uL\n [image002.jpg]\n 03:28 AM\n WBC\n 11.8\n Hct\n 28.8\n Plt\n 234\n Cr\n 1.6\n Glucose\n 130\n Other labs: PT / PTT / INR:12.8/25.2/1.1, Ca++:9.8 mg/dL, Mg++:1.8\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 83 yo female with history of CAD, HTN and on anti-platelet agents. She\n now has evolved significant epistaxis and on previous event had\n significant bradycardia now to ICU for care.\n Epistaxis-\n -Hold Plavix and ASA\n -Maintain packing\n -Epistaxis precautions\n -ENT consult in place\n -Will keep SBP <160\n -Keflex for prophylaxis\n -No nasal cannula O2\n Bradycardia-\n -Telemetry\n Hypertension-\n -continue home meds\n -Will utilize Hydralazine as needed IV for worsening\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:20 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer:\n Communication: with pt\n status: Full code\n Disposition : call out top floor for if ENT fine\n"
},
{
"category": "Nursing",
"chartdate": "2113-10-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 638931,
"text": "83 yo F wth history of HTN, MI, AAA, Afib, on Plavix +/- ASA who\n presents after developing bilateral epistaxis morning associated\n with fatigue but not associated with lightheadedness or syncope. she\n had an epistaxis episode 6 weeks ago per report resulting in\n bradycardia/cardiac arrest . She denies other prior episodes of\n epistaxis and has never previously required nasal packing. She also\n noted spitting up of blood with some nausea. Pt sent t o MICU for\n further care.\n Hypertension, benign\n Assessment:\n On adm to MICU pt was very hypertensive at 190- 180\ns. Pt given\n lopressor IV w/o effect. Hydralazine given with good given\n Action:\n SBP back to baseline after several dosages of hydralazine and ntg patch\n and po nifedipine given.\n Response:\n SBP now 100-110.\n Plan:\n Continue to monitor BP.\n Problem - epistaxis\n Assessment:\n Pt adm to MICU with nasal packing to bil nares with balloons inflated\n bil. Pt has not had any more nasal bleeding since adm. Pt was also\n slight nauseated on adm, which resolved with zofran.\n Action:\n Continue nasal packing as planed.\n Response:\n Plan:\n Afrin spray at bedside. Continue to monitor for nasal bleed and keep\n SBP stable.\n"
}
] |
90,120 | 117,195 | 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis, abdominal pain, hypotension and concern for acute abdomen. Noted pt with recent tx course with Ceftriaxone for CNS lyme - developing later f/c - admitted to OSH for line infx from PICC, later developed severe drug rash (? ) - tx with steroids - later developed reported hypoxia - had CTA chest eval showing PE - started on fundaparinux on - on - pt with acute ab pain - SBP dropped to 70s - felt to have acute ab - CT showing fluid surrounding pancreas - tx to for acute surgical eval - found here via CT as to have retroperitoneal bleed centered around the third and fourth portions of the duodenum in the retroperitoneum, EGD done by GI - +non-bleeding duodenal ulcer. Since admission no further anti-coagulation/PE tx, IVF filter placed , LE US NEG for DVTs, Hct lower when admitted from RP bleed - required 3u PRBC in total since (though last unit given with Hct 25s but felt erroneous.) Pt felt stable on to be tx to medical floor for further care from . Pt further monitored, Hct remained stable along with sx. PT evaluated pt - ok for home PT but needs 4L of o2 with ambulation, ok for 2-3L at rest with goal o2 sats >93/94%. Called PCP's office and arranged follow-up for (monday) ******will need f/u on rash (improving exam but increase in pruritis at time of d/c - presnisone taper mildly stretched as below). *****Note overall this patient is very sick as with untreated PE with details of her hospital course as below: <br> # pt presented w/ hypotension GIB. Pt was hypotensive to 90/60s on arrival to ICU and received nearly 2L fluid initially overnight. Hct here also lower (23.7 from 29.6 prior Hct at OSH). Given leukocytosis sepsis was high on the differential initially by . After the first night pt was not hypotensive. Pt was noted tx with cipro/flagyl/vanc in - there were d/c just prior to transfer to medical floor. BPs controlled. -overall resolved since out of <br> # Anemia, acute blood loss, retroperitoneal bleed, duodenal ulcer, non-bleed per EGD report/coagulopathy - Pt had a drop from Hct 23.7 from 29.6 initially as above. CT abd showed hemorrhage centered around the third and foruth portion of the duodenem in the retroperitoneum, not coming from the pancreas. No free air. The extensive hemorrhage extended into the intraperitoneal space and the pelvis where the high-attenuation foci along the left paracolic gutter are presumed clots. Surgery wanted GI to scope the pt and plan was that if significant intraluminal bleeding was seen they would operate, and if nothing was seen pt would proceed w/ angiography for RP bleed. EGD showed small duodenal ulcer likely her steriod use, and GI wanted to treat conservatively, and likely also has RP bleed fondaparinox use vs. duodenal bleed. Though still unclear completely given ulcer not sig deep and pt without symptoms of UGIB as well (no melena). Pt is being treated conservatively for both per GI and Surgery perspective. Noted - continue PPI po bid for atleast 2-3 months - surgery final rec for no plans on intervention - H/H controlled and stable at time of d/c (not had mild epitaxis day prior to d/c that resolved spontaneously - tx with saline sprays as likely dry from continuous NC, also note pt had applyed mild trauma at the time rubbing nose) - H. pylori noted NEG - no treatment to be given - just ppi as above - INR improved to 1.3 from 1.6 - treated with dose of vit K (pharmacy adjusted to 2.5mg dose 3/30 as note pt was on prolonged antibiotics prior) - epitaxis likely to drying effect from nc - support with saline nasal sprays - no repeated events noted - will further tx if re-occurs - d/c Hct was 32.2 of note <br> | hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. Upon arrival here, surgery evaluated - abdomen not acute. - Holding anticoagulation for now in setting of bleeding - S/p IVC filter on - d/c nebs #. Started on solumedrol which was being tapered. Started on solumedrol which was being tapered. Started on solumedrol which was being tapered. DISPOSITION: ICU for now ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 04:47 PM 18 Gauge - 05:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: In the OSH ED she was found to be tachy with HR 133 and temp 101. Action: Medicated with q 4 hrs prn. vanc/cipro/flagyl per surgery recommendation - Add on differential . vanc/cipro/flagyl per surgery recommendation - Add on differential . FEN: NPO for now, IVF . FEN: NPO for now, IVF . No no longer hypotensive after fluid resuscitaiton - Cont. Pneumo boots Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding) Assessment: Hct stable overnight. Action: Supplemental O2, assessed filter site Response: Pt remains dependent on 2 liters n/c Plan: Continue to monitor pt closely.. follow O2 sats Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding) Assessment: Bp stable 116/64 HR 70-80s SR no vea noted. ON arrival to ICU, pt is slightly hypotensive 90s. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. hypotensive with signs of acute abdomen and transferred to for management. Started on solumedrol which was being tapered. Started on solumedrol which was being tapered. Started on solumedrol which was being tapered. Started on solumedrol which was being tapered. Started on solumedrol which was being tapered. No no longer hypotensive after fluid resuscitaiton - Cont. BS clear left diminished on rt. FEN: NPO for now, IVF . - Holding anticoagulation for now in setting of bleeding - S/p IVC filter on #. - Holding anticoagulation for now in setting of bleeding - S/p IVC filter on #. - Holding anticoagulation for now in setting of bleeding - S/p IVC filter on #. vanc/cipro/flagyl per surgery recommendation - Add on differential # PE: CTA confirmed PE at OSH, was on , Unclear what precipitated this except for risk factor of being hospitalized. vanc/cipro/flagyl per surgery recommendation - Add on differential # PE: CTA confirmed PE at OSH, was on , Unclear what precipitated this except for risk factor of being hospitalized. vanc/cipro/flagyl per surgery recommendation - Add on differential # PE: CTA confirmed PE at OSH, was on , Unclear what precipitated this except for risk factor of being hospitalized. Pertinent medications: protonix, vanco, cipro, RISS. Pertinent medications: protonix, vanco, cipro, RISS. PCC line sepsis.Height: (in) 65Weight (lb): 147BSA (m2): 1.74 m2BP (mm Hg): 110/60HR (bpm): 82Status: InpatientDate/Time: at 11:49Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: Aneurysmal interatrial septum.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%). In the OSH ED she was found to be tachy with HR 133 and temp 101. There is contact of this high- attenuation fluid with the uncinate process, but otherwise, the remainder and majority of the pancreas is uninvolved and normal. CT abdomen showed an inflammatory mass in the pancreas, free fluid and ? OSH scans ~ + PE, IVC filter placed , GI performed EGD diffuse edema in duodenum, no fresh blood. Started on solumedrol which was being tapered. PPX: -DVT ppx, holding pneumoboots in setting of possible DVT, holding heparin in setting of possible bleed, received arixtra this am so covered today. OSH scans - + PE, IVC filter placed , GI performed EGD diffuse edema in duodenum, no fresh blood. of free air in abdomen Assessment and Plan 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis, abdominal pain, hypotension and concern for acute abdomen. FINDINGS: scale and Doppler evaluation of bilateral common femoral, superficial femoral, popliteal veins demonstrate normal compressibility, flow, augmentation. Indeterminate radiodensity of the upper abdomen as above. No definite extravasated oral contrast is noted, although contrast does reach (Over) 8:46 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: FEVER, COUGH, ABD PAIN Admitting Diagnosis: PERFORATED DUODENUM Field of view: 38 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) the distal small bowel and colon. | 41 | [
{
"category": "Physician ",
"chartdate": "2186-03-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 665392,
"text": "TITLE:\n Chief Complaint: 53 y/o F with PMH of CNS lyme who presents from OSH\n with leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen.\n 24 Hour Events:\n MULTI LUMEN - START 04:47 PM\n - 2 units PRBC overnight\n - IVF given\n - Surgery wanted to cancel LENI\n - passing gas\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Metronidazole - 12:00 AM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:50 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.4\nC (99.4\n HR: 93 (75 - 108) bpm\n BP: 111/54(67) {81/40(52) - 111/72(77)} mmHg\n RR: 22 (15 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 3 (2 - 13)mmHg\n Total In:\n 2,128 mL\n 1,674 mL\n PO:\n TF:\n IVF:\n 2,128 mL\n 1,074 mL\n Blood products:\n 600 mL\n Total out:\n 215 mL\n 375 mL\n Urine:\n 215 mL\n 300 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 1,913 mL\n 1,299 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n GENERAL: Pleasant, tired-appearing, alert, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Hyperactive BS. Soft, diffusely tender to palpation, no\n guarding, does have diffuse rebound\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: Diffuse maculo-papular rash over entire body, sparing area\n surrounding lips, areas of confluence on face and back.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 225 K/uL\n 9.9 g/dL\n 119 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.2 %\n 10.5 K/uL\n [image002.jpg]\n 06:13 PM\n 11:15 PM\n 04:54 AM\n WBC\n 13.8\n 10.5\n Hct\n 23.7\n 24.0\n 28.2\n Plt\n 276\n 225\n Cr\n 0.4\n 0.5\n Glucose\n 108\n 119\n Other labs: PT / PTT / INR:14.7/31.0/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:37/17, Alk Phos / T Bili:49/0.5, Amylase / Lipase:31/21,\n Differential-Neuts:49.2 %, Lymph:39.6 %, Mono:3.6 %, Eos:7.0 %,\n Albumin:2.9 g/dL, Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 53 y/o F with PMH of CNS lyme who presents from\n OSH with leukocytosis, abdominal pain, hypotension and concern for\n acute abdomen.\n .\n # Abdominal pain: Differential is broad including gastritis, PUD,\n perforated ulcer, pancreatitis, colitis. Abdominal pain is fairly\n diffuse, however her abdomen is soft. There was concern for free air\n at OSH, unfortunately we do not have the data here to confirm this. At\n OSH the patient's abdomen was reportedly rigid and there was concern\n for an acute process which prompted urgent transfer for possible\n surgery. At this point she is hemodynamically stable and her exam is\n not concerning for peritoneal signs. Surgery is following closely.\n Patient has been on high-dose steroids so an ulcer is possible, however\n was on GI ppx at OSH with Pepsid. KUB was also concerning for possible\n obstruction. Labs here show LFTs and pancreatic enzymes wnl making\n pancreatitis less likely. C. diff is of concern given recent long\n antibiotics course and leukocytosis, however was neg. x 1 at OSH.\n - Surgery wants GI to scope to provide evidence for/against\n intraluminal cause\n PUD, etc., such that if positive will proceed w/\n surgery, if negative will proceed with angiography for RP bleed\n - GI: scoping this AM\n - will discuss final management plan in coordination w/ GI and Surgery\n - continue serial abd exams\n - continue PPI gtt\n - Cipro/flagyl and Vanco ppx, day#2\n - obtain OSH records\n .\n # Hypotension: Differential includes sepsis, bleeding, volume\n depletion, toxic shock. Given leukocytosis an infection is high on the\n differential. No no longer hypotensive after fluid resuscitaiton\n - Cont. IVF boluses to maintain MAP>60 and UOP>30\n - Consider pressors if unable to maintain with IVF\n - Hct q6\n - CIS\n .\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8.\n Currently 13, however this is after abx since this am. Sources include\n abdomen, line-infection, urine, lungs. Cultures at OSH reportedly\n negative, however UA there showed 1+ bacteria and WBC. Given\n recent antibiotics, diarrhea and abdominal pain, c. diff is of\n concern. Was neg. x1 at OSH. CT at OSH also concerning for PNA,\n however patient does not have cough and lungs are clear. Has low grade\n fever here.\n - f/u OSH culture data\n - f/u CT read here for possible abdominal source\n - CIS\n - Cont. vanc/cipro/flagyl per surgery recommendation\n - Add on differential\n .\n # PE: CTA confirmed PE at OSH, was on Arixtra, last dose this morning.\n Unclear what precipitated this exept for risk factor of being\n hospitalized. No h/o malignancy, has been getting routine mom\n and Paps, has not had colonoscopy. No personal or fam hx. of clot, not\n on HRT.\n - Holding anticoagulation for now in setting of possible procedure\n - Attempt to obtain OSH CT films to confirm PE\n .\n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - follow as outpt\n .\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Continue steroid taper once discussed with surgery\n .\n # Anxiety:\n - Cont. ativan and effexor once not NPO\n .\n FEN: NPO for now, IVF\n .\n PPX:\n -DVT ppx with , restart heparin if no surgery planned\n -Bowel regimen on hold\n -Pain management with morphine\n .\n ACCESS: will take out R IJ from OSH, likely need central access\n .\n CODE STATUS: Full\n .\n EMERGENCY CONTACT: \n .\n DISPOSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:47 PM\n 18 Gauge - 05:00 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": "2186-03-03 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 665366,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n MULTI LUMEN - START 04:47 PM\n Abdominal/pelvic CT: fluid collection around the 3rd and 4th portion of\n the duodenum concerning for acute bleed; no free air\n NGT not showing coffee grounds or blood\n Transfused 2 u pRBCs and IVF for hypotension; no pressors required\n Patient notes that she passed gas from below\n History obtained from Patient\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 04:00 AM\n Vancomycin - 07:30 AM\n Metronidazole - 08:25 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:50 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Flowsheet Data as of 09:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.5\nC (99.5\n HR: 82 (75 - 108) bpm\n BP: 111/53(66) {81/40(52) - 111/72(77)} mmHg\n RR: 14 (14 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 3 (1 - 13)mmHg\n Total In:\n 2,128 mL\n 2,190 mL\n PO:\n TF:\n IVF:\n 2,128 mL\n 1,590 mL\n Blood products:\n 600 mL\n Total out:\n 215 mL\n 505 mL\n Urine:\n 215 mL\n 430 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 1,913 mL\n 1,685 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///29/\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender: diffuse mild\n tenderness, No guarding, rebound\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, Rash: diffuse maculopapular rash more confluent on back\n and trunk\n Neurologic: Responds to: Not assessed, Oriented (to): Fully oriented,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 225 K/uL\n 119 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.2 %\n 10.5 K/uL\n [image002.jpg]\n 06:13 PM\n 11:15 PM\n 04:54 AM\n WBC\n 13.8\n 10.5\n Hct\n 23.7\n 24.0\n 28.2\n Plt\n 276\n 225\n Cr\n 0.4\n 0.5\n Glucose\n 108\n 119\n Other labs: PT / PTT / INR:14.7/31.0/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:37/17, Alk Phos / T Bili:49/0.5, Amylase / Lipase:31/21,\n Differential-Neuts:49.2 %, Lymph:39.6 %, Mono:3.6 %, Eos:7.0 %,\n Albumin:2.9 g/dL, Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\nANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING):\n Transfused 2 units pRBCs with appropriate bump in Hct.\n Hemmodynamically stable this morning. Unclear whether this was related\n to a perforated duodenal ulcer, course not consistent albeit some\n symptoms may be masked on steroids. Also may have had a spontaneous\n retroperitoneal bleed on antiocoagulation for possible PE.\n HYPOTENSION (NOT SHOCK): In setting of acute blood loss and\n hypovolemia, responsive to blood transfusions and IVF resusitation.\n Also concerned for early sepsis, most likely source would be the\n abdomen. Positive UA. Now on vanco/cipro/flagyl. Had 3 sets of blood\n cultures and urine culture at the outside hospital no growth to date.\n Continue antibiotics.\n PULMONARY EMBOLISM (PE), ACUTE: Unclear that she has had a PE,\n reports from the outside hospital inconsistent documenting RUL and then\n RLL embolism, now holding anticoagulation in setting of acute blood\n loss. Awaiting outside hospital films.\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN): Adequately controlled on\n morphine IV\n DIFFUSE RASH: Rash seems most consistent with drug reaction related\n to CTX. No oral lesions on exam here. Steroids discontinued.\n CNS LYME DISEASE: Has completed a course of CTX for presumed lyme.\n RIGHT IJ from outside hospital to be discontinued.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:47 PM\n 18 Gauge - 05:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 65 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665552,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Significant Events:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct stable over night. HR 80\ns-low 100\ns, NBP 100-110/50-60\ns. Skin\n warm with resolving macular rash from abx rxn, (+) pedal pulses.\n Abdomen soft but diffusely tender, hypoactive bowel sounds, (+) flatus\n but no bowel movement. Foley draining clear yellow urine, 100-200\n cc/hr.\n Action:\n Pt OOB with nurse assist, HR increased to 120\ns r/t pain with\n activity\npt settled down and VSS until about an hour later HR increased\n to 130\ns and SBP dropped to 80\ns- got pt back to bed, bolused with 500\n cc NS, and Hct drawn- 3 pt drop in Hct noted and transfused with 1 U\n PRBC; advanced diet to clear liquids\n Response:\n Hemodynamically stable once back to bed; Post transfusion Hct pending ;\n UO remains adequate; abdominal still soft and appears slightly less\n tender, tolerating clear liquids\n Plan:\n Follow hemodynamics; Hct draw and PRN; Transfuse as needed\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 2 L NC with Sp02 in mid 90\ns. RR 20\ns. Pt denies any\n difficulty with breathing; lungs clear, diminished at bases. Filter\n placed yesterday without difficulty, site WNL\n Action:\n Supplemental 02; assessed filter site\n Response:\n Pt remains dependent on 2 L NC\n Plan:\n Wean 02 as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal and mid back pain at beginning of shift.\n Stating she did not want morphine as she did not like how it made her\n feel.\n Action:\n Started pt on Ultram PRN q4h.\n Response:\n Pt stating she feels much better, abdominal and back pain.\n Plan:\n Pain assessment, Ultram PRN\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665547,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Significant Events:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct stable over night. HR 80\ns-low 100\ns, NBP 100-110/50-60\ns. Skin\n warm with resolving macular rash from abx rxn, (+) pedal pulses.\n Abdomen soft but diffusely tender, hypoactive bowel sounds, (+) flatus\n but no bowel movement. Foley draining clear yellow urine, 100-200\n cc/hr.\n Action:\n Pt OOB with nurse assist, HR increased to 120\ns r/t pain with\n activity\npt settled down and VSS until about an hour later HR increased\n to 130\ns and SBP dropped to 80\ns- got pt back to bed, bolused with 500\n cc NS, and Hct drawn- 3 pt drop in Hct noted and transfused with 1 U\n PRBC; advanced diet to clear liquids\n Response:\n Hemodynamically stable once back to bed; Post transfusion Hct ; UO\n remains adequate; abdominal still soft and appears slightly less\n tender, tolerating clear liquids\n Plan:\n Follow hemodynamics; Hct draw and PRN; Transfuse as needed\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 2 L NC with Sp02 in mid 90\ns. RR 20\ns. Pt denies any\n difficulty with breathing; lungs clear, diminished at bases. Filter\n placed yesterday without difficulty, site WNL\n Action:\n Supplemental 02; assessed filter site\n Response:\n Pt remains on 2 L NC; ok without 02 if 90 degrees but requires during\n sleep\n Plan:\n Wean 02 as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal and mid back pain at beginning of shift.\n Stating she did not want morphine as she did not like how it made her\n feel.\n Action:\n Started pt on Ultram PRN q4h.\n Response:\n Pt stating she feels much better, abdominal and back pain.\n Plan:\n Pain assessment, Ultram PRN\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665548,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Significant Events:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct stable over night. HR 80\ns-low 100\ns, NBP 100-110/50-60\ns. Skin\n warm with resolving macular rash from abx rxn, (+) pedal pulses.\n Abdomen soft but diffusely tender, hypoactive bowel sounds, (+) flatus\n but no bowel movement. Foley draining clear yellow urine, 100-200\n cc/hr.\n Action:\n Pt OOB with nurse assist, HR increased to 120\ns r/t pain with\n activity\npt settled down and VSS until about an hour later HR increased\n to 130\ns and SBP dropped to 80\ns- got pt back to bed, bolused with 500\n cc NS, and Hct drawn- 3 pt drop in Hct noted and transfused with 1 U\n PRBC; advanced diet to clear liquids\n Response:\n Hemodynamically stable once back to bed; Post transfusion Hct ; UO\n remains adequate; abdominal still soft and appears slightly less\n tender, tolerating clear liquids\n Plan:\n Follow hemodynamics; Hct draw and PRN; Transfuse as needed\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 2 L NC with Sp02 in mid 90\ns. RR 20\ns. Pt denies any\n difficulty with breathing; lungs clear, diminished at bases. Filter\n placed yesterday without difficulty, site WNL\n Action:\n Supplemental 02; assessed filter site\n Response:\n Pt remains on 2 L NC; ok without 02 if 90 degrees but requires during\n sleep\n Plan:\n Wean 02 as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal and mid back pain at beginning of shift.\n Stating she did not want morphine as she did not like how it made her\n feel.\n Action:\n Started pt on Ultram PRN q4h.\n Response:\n Pt stating she feels much better, abdominal and back pain.\n Plan:\n Pain assessment, Ultram PRN\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665539,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Significant Events:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct stable over night. HR 80\ns-low 100\ns, NBP 100-110/50-60\ns. Skin\n warm with resolving macular rash from abx rxn, (+) pedal pulses.\n Abdomen soft but diffusely tender, hypoactive bowel sounds, (+) flatus\n but no bowel movement. Foley draining clear yellow urine, 100-200\n cc/hr.\n Action:\n Pt OOB with nurse assist, HR increased to 120\ns r/t pain with\n activity\npt settled down and VSS until about an hour later HR increased\n to 130\ns and SBP dropped to 80\ns- got pt back to bed, bolused with 500\n cc NS, and Hct drawn- 3 pt drop in Hct noted and transfused with 1 U\n PRBC; advanced diet to clear liquids\n Response:\n Hemodynamically stable once back to bed; Post transfusion Hct ; UO\n remains adequate; abdominal assessment remains unchanged, tolerating\n clear liquids\n Plan:\n Follow hemodynamics; Hct draw and PRN; Tranfuse as needed\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 2 L NC with Sp02 in mid 90\ns. RR 20\ns. Pt denies any\n difficulty with breathing; lungs clear, diminished at bases. Filter\n placed yesterday without difficulty, site WNL\n Action:\n Supplemental 02; assessed filter site\n Response:\n Pt remains on 2 L NC; ok without 02 if 90 degrees but requires during\n sleep\n Plan:\n Continue with supplemental 02 and wean as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal and mid back pain at beginning of shift.\n Stating she did not want morphine as she did not like how it made her\n feel.\n Action:\n Started pt on\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665540,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Significant Events:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct stable over night. HR 80\ns-low 100\ns, NBP 100-110/50-60\ns. Skin\n warm with resolving macular rash from abx rxn, (+) pedal pulses.\n Abdomen soft but diffusely tender, hypoactive bowel sounds, (+) flatus\n but no bowel movement. Foley draining clear yellow urine, 100-200\n cc/hr.\n Action:\n Pt OOB with nurse assist, HR increased to 120\ns r/t pain with\n activity\npt settled down and VSS until about an hour later HR increased\n to 130\ns and SBP dropped to 80\ns- got pt back to bed, bolused with 500\n cc NS, and Hct drawn- 3 pt drop in Hct noted and transfused with 1 U\n PRBC; advanced diet to clear liquids\n Response:\n Hemodynamically stable once back to bed; Post transfusion Hct ; UO\n remains adequate; abdominal assessment remains unchanged, tolerating\n clear liquids\n Plan:\n Follow hemodynamics; Hct draw and PRN; Tranfuse as needed\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 2 L NC with Sp02 in mid 90\ns. RR 20\ns. Pt denies any\n difficulty with breathing; lungs clear, diminished at bases. Filter\n placed yesterday without difficulty, site WNL\n Action:\n Supplemental 02; assessed filter site\n Response:\n Pt remains on 2 L NC; ok without 02 if 90 degrees but requires during\n sleep\n Plan:\n Continue with supplemental 02 and wean as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abdominal and mid back pain at beginning of shift.\n Stating she did not want morphine as she did not like how it made her\n feel.\n Action:\n Started pt on Ultram PRN q4h.\n Response:\n Pt stating she feels much better, abdominal and back pain.\n Plan:\n Pain assessment, Ultram PRN\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665603,
"text": "53 y/o female with PMH of CNS Lyme who presented from OSH with\n Leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen. OSH scans ~ + PE, IVC filter placed , GI\n performed EGD\n diffuse edema in duodenum, no fresh blood.\n Rash - ?reaction to ceftriaxone. Pt on steroid taper\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abd pain with turning, pt states is on Ativan and\n Effexor at home , c/o itching\n. Pt on clear liquid diet, no\n stool.\n Action:\n Medicated with q 4 hrs prn. Pt received .5 mg po Ativan\n and 75 mg Effexor. Also received 50 mg po Benadryl x1 dose for her\n itching -\n Response:\n Abd pain somewhat relieved by , pt able to sleep all night,\n itching resolved with the benadryl.\n Plan:\n Continue with q 4 hrs and prn. Continue ativan and effexor.\n Sarna lotion as needed.\n Pulmonary Embolism (PE), Acute\n Assessment:\n On 2 l n/p, rr 20\ns, resp increase with activity\n lungs with\n decreased breath sounds\n.. filter placed , site WNL O2 sats\n low 90\ns, FIO2 increased to 3 liters.\n Action:\n Supplemental O2, assessed filter site\n Response:\n Pt remains dependent on 2 liters n/c\n Plan:\n Continue to monitor pt closely\n.. follow O2 sats\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Bp stable 116/64 HR 70-80\ns SR no vea noted. Hct this am~\n 29.2 no stool, belly distended. Skin warm with resolving\n macular rash from abx rxn, + pedal pulses. Pt on PPI\n Action:\n VSS\n Response:\n Hemodynamically stable, Hct stable.\n Plan:\n Continue to monitor Hcts. Monitor abd closely.\n ID: afebrile WBC 12.2 pt remains on Flagyl, Cipro, Vanco.\n GU: good urine output via foley\n"
},
{
"category": "General",
"chartdate": "2186-03-05 00:00:00.000",
"description": "Generic Note",
"row_id": 665658,
"text": "MICU ATTENDING NOTE\n I saw and examined Mrs , and was physically present with the ICU\n team for the key portions of the services provided. I agree with the Dr\n \ns note, including the assessment and plan. I would emphasize\n and add the following points:\n Mrs has needed one unit of pRBC's yesterday for short lived\n orthostasis and hct drop to 25 ( ? real). her repeat hct has been\n closer to 30. She is feeling better with resolving rash sitting in a\n chair!\n Exam notable for Tmof 101 BP104/59 HR of 103 RR of 22 with sats of\n 96% on 3lpm O2 . She has a diffuse maculopapular rash that appears to\n be resolving. her abdomen is still tender to touch. She has diminshed\n air entry at bases\n Labs notable for WBC of 12.2K, HCTof 29.2 , K+of 4 , Crof 0.5 , INR of\n 3.0, lactate of 0.7.\n Agree with plan to advance diet slowly as tolerated today.. She may\n need short term TPN until PO intake has improved. Prednisone will be\n continued till rash has resolved and Eos have decreased ( taper\n ongoing)\n IV PPI to be continued on a basis and anitibiotics will be stopped\n ( has completed course for Lyme). She is ready to transition to regular\n floor today. hypercoaguable workup and follow up of outside labs will\n be done by team assuming her care.\n Remainder of plan as outlined above.\n Patient is ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n"
},
{
"category": "Physician ",
"chartdate": "2186-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 665664,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - STOP 09:55 AM\n - Hct dropped 3 points so transfused 1 unit but bumped appropriately as\n if drop was lab error. 28-> 25-> 1U-> 30\n - short episode of tachycardia, hypotension while sitting up, resolved\n spontaneously without intervention. Thought to be volume related.\n - restarted home ativan and effexor\n - rash is itchy, started Sarna\n - was irritated/agitated after albuterol, given 50mg PO benadryl\n - ECHO not done today\n - central line pulled\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Hives;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 12:15 AM\n Ciprofloxacin - 04:00 AM\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 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 35.8\nC (96.4\n HR: 79 (78 - 129) bpm\n BP: 116/65(78) {98/49(64) - 116/71(80)} mmHg\n RR: 22 (16 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 3,431 mL\n 577 mL\n PO:\n 120 mL\n 200 mL\n TF:\n IVF:\n 3,034 mL\n 377 mL\n Blood products:\n 277 mL\n Total out:\n 3,425 mL\n 570 mL\n Urine:\n 3,425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6 mL\n 7 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///30/\n Physical Examination\n GENERAL: Pleasant, tired-appearing, alert, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Hyperactive BS. Soft, diffusely tender to palpation, no\n rebound or guarding, No HSM appreciate.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: Diffuse maculo-papular rash over entire body, sparing area\n surrounding lips, areas of confluence on face and back.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 187 K/uL\n 10.2 g/dL\n 182 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 101 mEq/L\n 136 mEq/L\n 29.2 %\n 12.2 K/uL\n [image002.jpg]\n 06:13 PM\n 11:15 PM\n 04:54 AM\n 11:36 AM\n 08:39 PM\n 03:09 AM\n 01:26 PM\n 05:40 PM\n 04:12 AM\n WBC\n 13.8\n 10.5\n 10.6\n 10.0\n 12.2\n Hct\n 23.7\n 24.0\n 28.2\n 30.1\n 26.5\n 28.5\n 25.6\n 30.4\n 29.2\n Plt\n 82\n 187\n Cr\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 108\n 119\n 101\n 182\n Other labs: PT / PTT / INR:29.7/36.7/3.0, CK / CKMB / Troponin-T:/2/,\n ALT / AST:26/9, Alk Phos / T Bili:48/0.6, Amylase / Lipase:31/21,\n Differential-Neuts:45.0 %, Band:2.0 %, Lymph:32.0 %, Mono:4.0 %,\n Eos:16.0 %, Lactic Acid:0.7 mmol/L, Albumin:2.9 g/dL, LDH:305 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis,\n abdominal pain, hypotension and concern for acute abdomen.\n # GIB- EGD showed small duodenal ulcer likely her steriod use, and\n likely also has RP bleed fondaparinox use. Pt is being treated\n conservatively for both per GI and Surgery.\n - continue PPI \n - f/u surgery recs\n no plans on intervention\n # Abdominal pain: likely due to compression of retroperitoneal hematoma\n on celiac plexus. Appears that this may have occurred in the setting of\n falling while on fondaparinux.\n - will likely resolve once RP bleed resolves, continue to moniter\n # Hypotension resolved. Likely due to blood loss. Now with stable hct x\n several days.\n - hct check\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8. Likely\n sterioids. No ID source identified.\n - D/c antibiotics today (was on vanc/cipro/flagyl day #4)\n # PE: CTA confirmed PE at OSH, was on , Unclear what\n precipitated this except for risk factor of being hospitalized. No h/o\n malignancy, has been getting routine mammogram and Paps, has not had\n colonoscopy. No personal or fam hx. of clot, not on HRT.\n - Holding anticoagulation for now in setting of bleeding\n - S/p IVC filter on \n - d/c nebs\n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - follow as outpt\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Continue steroid taper once discussed with surgery - to be on 20\n prednisone otmorrow\n # Anxiety:\n - Cont. ativan and effexor\n FEN: advance to clears\n PPX:\n -DVT ppx with IVC filter.\n -Bowel regimen on hold\n -Pain management with ultram as pt getting GI upset and hallucinations\n on morphine\n ACCESS: will take out R IJ from OSH, likely need central access\n CODE STATUS: Full\n EMERGENCY CONTACT: \n OSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 AM\n 20 Gauge - 06:42 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": "2186-03-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 665669,
"text": "53 y/o female with PMH of CNS Lyme who presented from OSH with\n Leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen. OSH scans ~ + PE, IVC filter placed , GI performed\n EGD\n diffuse edema in duodenum, no fresh blood.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 3 L NC with Sp02 low 90\ns. SOB with exertion ie.\n Transfer to chair otherwise pt states no difficulty with breathing at\n rest. RR 18-22 and also increases to low 30\ns with exertion. IVC\n filter in place- site WNL. Lungs clear, diminished at bases.\n Action:\n Encouraged pt to CDB and IS use. OOB to chair- VSS during transfer.\n Dropped 02 to 2 L NC. Pneumo boots\n Response:\n Pt remains on 2 L NC with SP02 mid 90\ns. Pt in chair for 4 hours.\n Plan:\n Wean 02 as tolerated. Encourage CDB and IS. Pneumo boots\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct stable overnight. Currently Hct 29.2- last PRBC given yesterday.\n Abdomen soft and still slightly distended and tender but improving. (+)\n bowel sounds and flatus. Urine yellow and clear, adequate amounts- body\n balance even. Hemodynamically stable, SBP 100-110, NSR 80\n Action:\n Advanced diet to full- tolerating but states she does not really have\n an appetite. Started bowel regimen due to no bowel movement since\n admission\n Response:\n Pt continues to be hemodynamically stable. Abdominal assessment\n improving.\n Plan:\n Monitor hemodynamics. Tranfuse PRN\n Pain control (acute pain, chronic pain)\n Assessment:\n Mid abdominal and back pain initially being treated with morphine PRN\n but stated she did not like how it made her feel and therefore switched\n to Ultram q4h. Pain has been managed well today with c/o and a\n after being in chair. Pt also restarted on Effexor and Ativan PRN\n for anxiety which she was on prior to admission\n Action:\n Ultram PRN for abdominal and back pain.\n Response:\n Pt\ns pain is well controlled with Ultram and states she feels much\n better than yesterday\n Plan:\n Continue frequent pain assessments. Ultram for pain PRN. Standing\n effexor and PRN Ativan for anxiety.\n Endo: Pt on sliding scale due to elevated BS r/t predisone taper\n Skin: Prednisone taper due to macular rash from ceftriaxone, rash\n improving\n"
},
{
"category": "Physician ",
"chartdate": "2186-03-02 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 665313,
"text": "Chief Complaint: blood loss anemia\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 53W recently completed 4 week course of CTX for possible CNS Lyme\n disease. Developed rash 2 weeks ago, 1 day after her last CTX dose,\n followed by fever, nausea, vomiting. In ER at - hypotensive\n requiring IVF and bandemia. CVL placed and admitted to ICU. Right\n infiltrate seen on CXR. Old PICC line removed. On vanco and levoflox\n for about 3 days.\n Derm there thought rash was drug reaction - started on solumedrol and\n rash improving.\n Yesterday was walking and apparently desaturated - CT-A supposedly\n showed ? RUL PE and started on a arixtra.\n This AM developed abdominal pain and vomiting. Later in the morning\n found down, unresponsive briefly. Hypotension improved with IVF and did\n not need intubation. Neck CT negative. Abdomen remained tender and WBC\n rising. Abd CT showed inflammatory mass in head of pancreas.\n Upon arrival here, surgery evaluated - abdomen not acute. Abdominal CT\n here showed stranding around pancreas with ? blood tracking into pelvis\n according to surgery - await radiology interpretation. Surgery\n concerned about intra-abdominal bleeding though source unclear. Hct has\n fallen from 33 yesterday to 23, she has received IVF for hypoetension.\n Patient admitted from: Transfer from other hospital\n History obtained from housestaff\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:00 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n ? CNS lyme disease\n MV prolapse\n no thromboses\n Occupation: pharmacy tech\n Drugs:\n Tobacco: none\n Alcohol: none\n Other:\n Review of systems:\n Flowsheet Data as of 10:48 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 98 (91 - 108) bpm\n BP: 93/45(55) {83/40(52) - 96/52(62)} mmHg\n RR: 29 (18 - 29) insp/min\n SpO2: 99% 3L NC\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 13 (4 - 13)mmHg\n Total In:\n 1,846 mL\n PO:\n TF:\n IVF:\n 1,846 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,716 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///32/\n Physical Examination\n No ditress\n Lung decreased BS\ns at bases\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Bowel sounds present, Tender:\n Skin: rash: diffuse erythematous\n Neurologic: Attentive, oriented\n No LE edema\n Labs / Radiology\n 276 K/uL\n 23.7 %\n 8.2 g/dL\n 108 mg/dL\n 0.4 mg/dL\n 15 mg/dL\n 32 mEq/L\n 106 mEq/L\n 3.8 mEq/L\n 143 mEq/L\n 13.8 K/uL\n [image002.jpg]\n 06:13 PM\n WBC\n 13.8\n Hct\n 23.7\n Plt\n 276\n Cr\n 0.4\n Glucose\n 108\n Other labs: PT / PTT / INR:14.6/30.7/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:37/17, Alk Phos / T Bili:49/0.5, Amylase / Lipase:31/21,\n Albumin:2.9 g/dL, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Imaging: Abd CT per HPI, also basilar atelectasis, await interp\n Assessment and Plan\n 53W admitted with fever and rash shortly after a course of CTX.\n Hospitalization complicated by ? PE and acute abdominal pain following\n inititation of anticoagulation (she was receiving DVT prophylaxis).\n Abdominal imaging with collection near pancreas concerning for hematoma\n and Hct has fallen. One scenario is that she developed a drug rash to\n CTX and hematoma once anticoagulated\n unclear cause. We need to\n review her CT-A though there was no strong reason to suspect PE. Will\n check LENI\ns tomorrow and get films from \n hold\n anti-coagulation for now. Serial Hct\ns, NG lavage. Surgery requesting\n EGD to work-up perforated PUD.\n Another possibility is an intra-abdominal infection and toxic shock\n syndrome explaining the rash. Because her abdominal symptoms did not\n start until 18 or so hours ago\n this seems less likely. She is being\n covered with antibiotics.\n Will stop steroids for rash.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 04:47 PM\n 20 Gauge - 05:06 PM\n Comments:\n Prophylaxis:\n DVT: holding, received arixtra this morning\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 36 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2186-03-02 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 665314,
"text": "Chief Complaint: Transfer from OSH with abdominal pain\n HPI:\n Patient is a 53 y/o F with PMH of CNS lyme who presents from OSH for\n evaluation of possible acute abdomen. Of note, the patient recently\n completed 28 days of IV Ceftriaxone for CNS lyme on . She\n initially presented to an OSH on with rash and fever. She also\n had chills, nausea and vomiting. In the OSH ED she was found to be\n tachy with HR 133 and temp 101. Her BP was as low as 90 and responded\n to IVF. WBC was 11.9 with 22% bands. CXR showed a R hilar\n infiltrate. A RIJ was placed and she was admitted to the ICU for\n presumed line sepsis from her PICC. She was given vanc/levo. Blood\n cultures were checked x3 and were NGTD. Her levo was discontinued and\n her vanco was continued for 3 days. Dermatology was consulted for ? of\n , however drug rxn was felt to be more likely. She was\n started on solumedrol 80mg q8hr which has been tapered down to 60mg\n q12. On the patient was noted to be hypoxic to 88% with\n ambulation. CTA confirmed LUL PE and she was started on Arixtra 7.5mg\n daily. CT also showed bilateral lower lobe PNA and pleural effusions.\n .\n At 3am on the morning of transfer the patient developed sudden onset,\n severe abdominal pain and cramps. She describes it as a severe gas\n pain. She then had 4-5 episodes of emesis of greenish material, denies\n blood. At 7am she was found on the floor with a BP of 73/53 and O2 sat\n 88%. She was placed on NRB and given 250cc NS and BP improved to\n 90/50. CT neck was neg. for fracture. Exam showed diffusely tender\n abdomen with guarding and rebound. CT abdomen showed an inflammatory\n mass in the pancreas, free fluid and ? free air. WBC at that time was\n 20.8. The patient does not recall the events leading up to the fall\n and remembers waking up on the floor.\n .\n Currently, the patient reports that her abdominal pain is improved\n after she received morphine. She reports that the pain is diffuse,\n continues to feel like bad gas. Up until yesterday she was passing\n gas, however she has not today. She also reports having diarrhea 3\n days ago with 4-5 loose stools/day. She has had some SOB since her\n admission and reports that her breathing is improved today. She denies\n cough. She reports having low grade fevers at OSH. She feels that her\n rash is significantly improved. ROS is otherwise negative.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:00 PM\n Other medications:\n MEDICATIONS AT HOME:\n Ativan 0.5mg q6hr prn\n Effexor 75mg \n .\n MEDICATIONS ON TRANSFER:\n Nystatin swish and swallow 5cc qid\n Effexor 75mg \n Solumedrol 60mg IV q12\n Arixtra 7.5 SQ daily\n Humalog SS\n Morphine 1-2 mg IV q4hr prn\n Flagyl 500mg IV q8hr\n Cipro 400mg IV q12\n Protonix gtt\n Past medical history:\n Family history:\n Social History:\n Lyme disease with neurologic manifestations\n Mitral valve prolapse\n NC, no family h/o blood clots\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Works as pharmacist technician at Wallgreens. Lives with her\n husband and children. Denies tobacco use. Drinks wine occasionally.\n Review of systems:\n Constitutional: Fatigue, Fever\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Integumentary (skin): Rash\n Neurologic: Numbness / tingling\n Flowsheet Data as of 10:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 98 (91 - 108) bpm\n BP: 93/45(55) {83/40(52) - 96/52(62)} mmHg\n RR: 29 (18 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 13 (4 - 13)mmHg\n Total In:\n 1,846 mL\n PO:\n TF:\n IVF:\n 1,846 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,716 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///32/\n Physical Examination\n T 99.3 BP 91/40 HR 108 RR 21 O2 93% 3L\n GENERAL: Pleasant, tired-appearing, alert, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Hyperactive BS. Soft, diffusely tender to palpation, no\n rebound or guarding, No HSM appreciate.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: Diffuse maculo-papular rash over entire body, sparing area\n surrounding lips, areas of confluence on face and back.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 276 K/uL\n 8.2 g/dL\n 108 mg/dL\n 0.4 mg/dL\n 15 mg/dL\n 32 mEq/L\n 106 mEq/L\n 3.8 mEq/L\n 143 mEq/L\n 23.7 %\n 13.8 K/uL\n [image002.jpg]\n \n 2:33 A3/26/ 06:13 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 13.8\n Hct\n 23.7\n Plt\n 276\n Cr\n 0.4\n Glucose\n 108\n Other labs: PT / PTT / INR:14.6/30.7/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:37/17, Alk Phos / T Bili:49/0.5, Amylase / Lipase:31/21,\n Albumin:2.9 g/dL, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR : small b/l effusions, possible LLL infiltrate\n .\n CTA : filling defects in pulmonary arteries to LUL. Aorta\n unremarkable. Small bilateral pleural effusions. Parenchymal\n consolidation at both lung bases with air bronchograms c/w pneumonia or\n atelectasis. Cyst in liver.\n .\n KUB : Extensive gas and feces in colon. No distal colonic gas\n noted. Several air filled small loops of bowel are seen in\n mid-abdomen. s/p CCY.\n .\n IMPRESSION: Findings suggestive of obstruction in mid descending colon.\n .\n CT head : Normal. No acute hemorrhage.\n .\n CT abdomen: per d/c summary (no report came with patient) showed\n inflammatory process in head of pancreas, positive free fluid in pelvis\n and abdomen, and ? of free air in abdomen\n Assessment and Plan\n 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis,\n abdominal pain, hypotension and concern for acute abdomen.\n .\n # Abdominal pain: Differential is broad including gastritis, PUD,\n perforated ulcer, pancreatitis, colitis, spontaneous bleed in setting\n of Arixtra. Abdominal pain is fairly diffuse, however her abdomen is\n soft. There was concern for free air at OSH, unfortunately we do not\n have the data here to confirm this. At OSH the patient's abdomen was\n reportedly rigid and there was concern for an acute process which\n prompted urgent transfer for possible surgery. At this point she is\n hemodynamically stable and her exam is not concerning for peritoneal\n signs. Surgery is following closely. Patient has been on high-dose\n steroids so an ulcer is possible, however was on GI ppx at OSH with\n Pepsid. KUB was also concerning for possible obstruction. Labs here\n show LFTs and pancreatic enzymes wnl making pancreatitis less likely.\n C. diff is of concern given recent long antibiotics course and\n leukocytosis, however was neg. x 1 at OSH.\n - Repeat abdominal CT now with oral/IV contrast to look for acute\n pathology, r/o free air and look for obstruction.\n - Surgery co-managing and appreciate their input\n - Will cont. cipro/flagyl and add vanco.\n - Serial abdominal exams\n - Pain control with IV morphine\n - Follow LFTs, pancreatic enzymes\n - PPI gtt for now\n - Consider GI consult for EGD if PUD and GIB remains high on\n differential\n - NPO for now\n .\n # Hypotension: Differential includes sepsis, bleeding, volume\n depletion. Given leukocytosis an infection is high on the\n differential. Hct here also lower (23.7 from 29.6 this morning at\n OSH). Given abdominal tenderness, this is concerning for bleed. BP\n stable with IVF currently.\n - Cont. IVF boluses to maintain MAP>60 and UOP>30\n - Consider pressors if unable to maintain with IVF\n - Trend serial Hct and transfuse if dropping or <21\n - CIS\n .\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8.\n Currently 13, however this is after abx since this am. Sources include\n abdomen, line-infection, urine, lungs. Cultures at OSH reportedly\n negative, however UA there showed 1+ bacteria and WBC. Given\n recent antibiotics, diarrhea and abdominal pain, c. diff is of\n concern. Was neg. x1 at OSH. CT at OSH also concerning for PNA,\n however patient does not have cough and lungs are clear. Has low grade\n fever here.\n - f/u OSH culture data\n - f/u CT read here for possible abdominal source\n - CIS\n - Cont. vanc/cipro/flagyl per surgery recommendation\n - Add on differential\n .\n # PE: CTA confirmed PE at OSH, was on Arixtra, last dose this morning.\n Unclear what precipitated this exept for risk factor of being\n hospitalized. No h/o malignancy, has been getting routine mom\n and Paps, has not had colonoscopy. No personal or fam hx. of clot, not\n on HRT.\n - Holding anticoagulation for now in setting of possible procedure\n - Obtain OSH CT films to confirm presence of PE\n - If no surgery imminantly planned, will start hep gtt\n - Check LENIs is am\n .\n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - Cont. to follow\n .\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Holding steroids in setting of possible bleed/infection\n - Benadryl prn\n .\n # Anxiety:\n - Cont. ativan and effexor once not NPO\n .\n FEN: NPO for now, IVF\n .\n PPX:\n -DVT ppx with , restart heparin if no surgery planned\n -Bowel regimen on hold\n -Pain management with morphine\n .\n ACCESS: RIJ placed at OSH\n .\n CODE STATUS: Full\n .\n EMERGENCY CONTACT: \n .\n DISPOSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:47 PM\n 20 Gauge - 05:06 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665476,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Pt fully oriented, pleasant, cooperative.\n Pain control (acute pain, chronic pain)\n Assessment:\n Assumed care of pt while she was in IR for filter placement, rec\n 1.5mg midaz and 50mcg Fent from IR RN pre-procedure. Back in MICU, had\n c/o abd and back pain @ 6/10 scale\n Action:\n Medicated w/ 2 mg MSO4 IV x1, pain @ so given additional 1mg IV\n Response:\n Pain relieved enough for pt to sleep most of noc and able to tolerate\n it with BP MAP >60 but c/o very active dreams\nrequesting non-narcotic\n pain control\n Plan:\n Continue to monitor pain level and medicate prn with non narcotic\n .\n Pulmonary Embolism (PE), Acute\n Assessment:\n Films reviewed from and confirmed that pt does have a PE\n Action:\n No change of action taken at this point\n Response:\n Pt has adequate O2 sats 98% on 1.5 L NC\n sats do drop to 91-92% on RA\n Plan:\n Continue to monitor resp status and support as necessary\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt has had no active sites of bleeding and Hct is stable. ST w/ HR in\n 100\ns, SBP in high 90\n Action:\n Endoscopy done by GI on day shift: no definitive sights located and no\n sign of active bleeding. PM and am Hct drawn\n Response:\n Hct pm =25+, am labs hct =28\n Plan:\n Continue to monitor Hct closely and treat as ordered\n Hypotension (not Shock)\n Assessment:\n Pt has been hemodynamically stable throughout shift\n Action:\n IVF at 125/hr continued\n Response:\n BP stable and UO> 100cc/hr\n Plan:\n Monitor closely for changes in BP and give fluid as tolerated.\n Pt has 2 close friends that were at bedside for several hours and plan\n on returning tomorrow. Also has husband and 4 children, all of whom\n have had Lyme Disease in the past (friends\n family members as well)\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665480,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Pt fully oriented, pleasant, cooperative.\n Febrile overnight to 101.2. Given Tylenol 650mg PO x1\n Pain control (acute pain, chronic pain)\n Assessment:\n Assumed care of pt while she was in IR for filter placement, rec\n 1.5mg midaz and 50mcg Fent from IR RN pre-procedure. Back in MICU, had\n c/o abd and back pain @ 6/10 scale\n Action:\n Medicated w/ 2 mg MSO4 IV x1, pain @ so given additional 1mg IV\n Response:\n Pain relieved enough for pt to sleep most of noc and able to tolerate\n it with BP MAP >60 but c/o very active dreams\nrequesting non-narcotic\n pain control\n Plan:\n Continue to monitor pain level and medicate prn with non narcotic\n .\n Pulmonary Embolism (PE), Acute\n Assessment:\n Films reviewed from and confirmed that pt does have a PE\n Action:\n No change of action taken at this point\n Response:\n Pt has adequate O2 sats 98% on 1.5 L NC\n sats do drop to 91-92% on RA\n Plan:\n Continue to monitor resp status and support as necessary\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt has had no active sites of bleeding and Hct is stable. ST w/ HR in\n 100\ns, SBP in high 90\n Action:\n Endoscopy done by GI on day shift: no definitive sights located and no\n sign of active bleeding. PM and am Hct drawn\n Response:\n Hct pm =26.5, am labs hct =28.5. Continues in ST w/ hr up to 117,\n ?anemia vs. fever vs pain\n Plan:\n Continue to monitor Hct closely and treat as ordered\n Hypotension (not Shock)\n Assessment:\n ST w/HR in 100\ns, SBP in 90\ns and MAP 62 or greater.\n Action:\n IVF at 125/hr continued\n Response:\n SBP\ns now 100\ns to 110\ns and MAP>65, UO> 100cc/hr\n Plan:\n Monitor closely for changes in BP and give fluid as tolerated.\n Pt has 2 close friends that were at bedside for several hours and plan\n on returning tomorrow. Also has husband and 4 children, all of whom\n have had Lyme Disease in the past (friends\n family members as well)\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665484,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Pt fully oriented, pleasant, cooperative.\n Febrile overnight to 101.2. Given Tylenol 650mg PO x1\n Full body rash still evident as documented.\n TLC to be d/c\nd today as placed in OSH.\n Pain control (acute pain, chronic pain)\n Assessment:\n Assumed care of pt while she was in IR for filter placement, rec\n 1.5mg midaz and 50mcg Fent from IR RN pre-procedure. Back in MICU, had\n c/o abd and back pain @ 6/10 scale\n Action:\n Medicated w/ 2 mg MSO4 IV x1, pain @ so given additional 1mg IV\n Response:\n Pain relieved enough for pt to sleep most of noc and able to tolerate\n it with BP MAP >60 but c/o very active dreams\nrequesting non-narcotic\n pain control\n Plan:\n Continue to monitor pain level and medicate prn with non narcotic\n .\n Pulmonary Embolism (PE), Acute\n Assessment:\n Films reviewed from and confirmed that pt does have a PE\n Action:\n No change of action taken at this point\n Response:\n Pt w/ O2sats 94% on 2L NC.\n Plan:\n Continue to monitor resp status and support as necessary\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt has had no active sites of bleeding and Hct is stable. ST w/ HR in\n 100\ns, SBP in high 90\ns. Abd CT yesterday revealed probable acute bled\n around 3^rd and 4^th portions of the duodenum--?spontaneous\n retroperiotineal bleed anticoagulation therapy vs vascular injury\n ulcer\n Action:\n Endoscopy done by GI on day shift: no definitive sights located and no\n sign of active bleeding. PM and am Hct drawn\n Response:\n Hct pm =26.5, am labs hct =28.5. Continues in ST w/ hr up to 117,\n ?anemia vs. fever vs pain\n Plan:\n Continue to monitor Hct closely and treat as ordered\n Hypotension (not Shock)\n Assessment:\n ST w/HR in 100\ns, SBP in 90\ns and MAP 62 or greater.\n Action:\n IVF at 125/hr continued\n Response:\n SBP\ns now 100\ns to 110\ns and MAP>65, UO> 100cc/hr\n Plan:\n Monitor closely for changes in BP and give fluid as tolerated.\n Pt has 2 close friends that were at bedside for several hours and plan\n on returning tomorrow. Also has husband and 4 children, all of whom\n have had Lyme Disease in the past (friends\n family members as well).\n"
},
{
"category": "Physician ",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 665492,
"text": "TITLE:\n Chief Complaint: 53 y/o F with PMH of CNS lyme who presents from OSH\n with leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen.\n 24 Hour Events:\n FEVER - 102.6\nF - 04:00 PM\n - Uploaded OSH scans, Confirmed PE\n - IVC filter placed\n - Hct stable\n - GI did EGD, diffuse edema in duodenum, no e/o fresh blood\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Hives;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:43 PM\n Metronidazole - 12:00 AM\n Ciprofloxacin - 03:46 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 10:03 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 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.6\n Tcurrent: 38.4\nC (101.2\n HR: 109 (78 - 109) bpm\n BP: 118/59(71) {79/40(56) - 118/74(77)} mmHg\n RR: 26 (14 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 15 (1 - 22)mmHg\n Total In:\n 4,934 mL\n 1,292 mL\n PO:\n 120 mL\n TF:\n IVF:\n 4,334 mL\n 1,172 mL\n Blood products:\n 600 mL\n Total out:\n 2,090 mL\n 965 mL\n Urine:\n 2,015 mL\n 965 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 2,844 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, tired-appearing, alert, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Hyperactive BS. Soft, diffusely tender to palpation, no\n rebound or guarding, No HSM appreciate.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: Diffuse maculo-papular rash over entire body, sparing area\n surrounding lips, areas of confluence on face and back.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 182 K/uL\n 9.7 g/dL\n 101 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 100 mEq/L\n 134 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 06:13 PM\n 11:15 PM\n 04:54 AM\n 11:36 AM\n 08:39 PM\n 03:09 AM\n WBC\n 13.8\n 10.5\n 10.6\n 10.0\n Hct\n 23.7\n 24.0\n 28.2\n 30.1\n 26.5\n 28.5\n Plt\n 82\n Cr\n 0.4\n 0.5\n 0.5\n Glucose\n 108\n 119\n 101\n Other labs: PT / PTT / INR:14.7/31.0/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:26/9, Alk Phos / T Bili:48/0.6, Amylase / Lipase:31/21,\n Differential-Neuts:45.0 %, Band:2.0 %, Lymph:32.0 %, Mono:4.0 %,\n Eos:16.0 %, Albumin:2.9 g/dL, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.3\n mg/dL\n Imaging: LENI read pending\n Uncomplicated IVC filter placement\n Microbiology: BC pending\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n .H/O ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n HYPOTENSION (NOT SHOCK)\n 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis,\n abdominal pain, hypotension and concern for acute abdomen.\n # Abdominal pain: Differential is broad including gastritis, PUD,\n perforated ulcer, pancreatitis, colitis. Abdominal pain is fairly\n diffuse, however her abdomen is soft. There was concern for free air\n at OSH, unfortunately we do not have the data here to confirm this. At\n OSH the patient's abdomen was reportedly rigid and there was concern\n for an acute process which prompted urgent transfer for possible\n surgery. At this point she is hemodynamically stable and her exam is\n not concerning for peritoneal signs. Surgery is following closely.\n Patient has been on high-dose steroids so an ulcer is possible, however\n was on GI ppx at OSH with Pepsid. KUB was also concerning for possible\n obstruction. Labs here show LFTs and pancreatic enzymes wnl making\n pancreatitis less likely. C. diff is of concern given recent long\n antibiotics course and leukocytosis, however was neg. x 1 at OSH.\n - Surgery wants GI to scope to provide evidence for/against\n intraluminal cause\n PUD, etc., such that if positive will proceed w/\n surgery, if negative will proceed with angiography for RP bleed\n - GI: scoping this AM\n - will discuss final management plan in coordination w/ GI and Surgery\n - continue serial abd exams\n - continue PPI gtt\n - Cipro/flagyl and Vanco ppx, day#2\n - obtain OSH records\n # Hypotension: Differential includes sepsis, bleeding, volume\n depletion, toxic shock. Given leukocytosis an infection is high on the\n differential. No no longer hypotensive after fluid resuscitaiton\n - Cont. IVF boluses to maintain MAP>60 and UOP>30\n - Consider pressors if unable to maintain with IVF\n - Hct q6\n - CIS\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8.\n Currently 13, however this is after abx since this am. Sources include\n abdomen, line-infection, urine, lungs. Cultures at OSH reportedly\n negative, however UA there showed 1+ bacteria and WBC. Given\n recent antibiotics, diarrhea and abdominal pain, c. diff is of\n concern. Was neg. x1 at OSH. CT at OSH also concerning for PNA,\n however patient does not have cough and lungs are clear. Has low grade\n fever here.\n - f/u OSH culture data\n - f/u CT read here for possible abdominal source\n - CIS\n - Cont. vanc/cipro/flagyl per surgery recommendation\n - Add on differential\n # PE: CTA confirmed PE at OSH, was on Arixtra, last dose this morning.\n Unclear what precipitated this exept for risk factor of being\n hospitalized. No h/o malignancy, has been getting routine mom\n and Paps, has not had colonoscopy. No personal or fam hx. of clot, not\n on HRT.\n - Holding anticoagulation for now in setting of possible procedure\n - Attempt to obtain OSH CT films to confirm PE\n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - follow as outpt\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Continue steroid taper once discussed with surgery\n # Anxiety:\n - Cont. ativan and effexor once not NPO\n FEN: NPO for now, IVF\n PPX:\n -DVT ppx with , restart heparin if no surgery planned\n -Bowel regimen on hold\n -Pain management with morphine\n ACCESS: will take out R IJ from OSH, likely need central access\n CODE STATUS: Full\n EMERGENCY CONTACT: \n OSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:47 PM\n 18 Gauge - 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": "Nursing",
"chartdate": "2186-03-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665304,
"text": "Pt is a 53 yo female who arrived to via ambulance at 1730.\n Pt tx from . SHe had been treated for 1 mos for\n Lyme Dz on ceftriaxone thru PICC. Went into OSH last Fri for increasing\n lethargy and rash all over body. She was admitted to ICU last Fri for\n observation and w/u of fever, lethargy. Tx to floor and this am, pt\n was found on floor after attempting to go to the BR for increase in abd\n pain. She was then brought to ICU. Received Cipro/Flagyl at 1600. K+\n also repleted for initial K+ of 3.2. Head CT --, Abd CT-? inflammatory\n mass at head of pancreas vs pancreatitis. KUB + for possible ileus.\n ON arrival to ICU, pt is slightly hypotensive 90\ns. Received\n 700 cc NS. Now on LR at 125 /hr.\n Pt has had her gastrograffin and will go down to CT scan around 8pm\n tonight.\n"
},
{
"category": "Physician ",
"chartdate": "2186-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 665628,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - STOP 09:55 AM\n - Hct dropped 3 points so transfused 1 unit but bumped appropriately as\n if drop was lab error. 28-> 25-> 1U-> 30\n - short episode of tachycardia, hypotension while sitting up, resolved\n spontaneously without intervention. Thought to be volume related.\n - restarted home ativan and effexor\n - rash is itchy, started Sarna\n - was irritated/agitated after albuterol, given 50mg PO benadryl\n - ECHO not done today\n - central line pulled\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Hives;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Metronidazole - 12:15 AM\n Ciprofloxacin - 04:00 AM\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 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 35.8\nC (96.4\n HR: 79 (78 - 129) bpm\n BP: 116/65(78) {98/49(64) - 116/71(80)} mmHg\n RR: 22 (16 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n Total In:\n 3,431 mL\n 577 mL\n PO:\n 120 mL\n 200 mL\n TF:\n IVF:\n 3,034 mL\n 377 mL\n Blood products:\n 277 mL\n Total out:\n 3,425 mL\n 570 mL\n Urine:\n 3,425 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6 mL\n 7 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///30/\n Physical Examination\n GENERAL: Pleasant, tired-appearing, alert, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Hyperactive BS. Soft, diffusely tender to palpation, no\n rebound or guarding, No HSM appreciate.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: Diffuse maculo-papular rash over entire body, sparing area\n surrounding lips, areas of confluence on face and back.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 187 K/uL\n 10.2 g/dL\n 182 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 101 mEq/L\n 136 mEq/L\n 29.2 %\n 12.2 K/uL\n [image002.jpg]\n 06:13 PM\n 11:15 PM\n 04:54 AM\n 11:36 AM\n 08:39 PM\n 03:09 AM\n 01:26 PM\n 05:40 PM\n 04:12 AM\n WBC\n 13.8\n 10.5\n 10.6\n 10.0\n 12.2\n Hct\n 23.7\n 24.0\n 28.2\n 30.1\n 26.5\n 28.5\n 25.6\n 30.4\n 29.2\n Plt\n 82\n 187\n Cr\n 0.4\n 0.5\n 0.5\n 0.5\n Glucose\n 108\n 119\n 101\n 182\n Other labs: PT / PTT / INR:29.7/36.7/3.0, CK / CKMB / Troponin-T:/2/,\n ALT / AST:26/9, Alk Phos / T Bili:48/0.6, Amylase / Lipase:31/21,\n Differential-Neuts:45.0 %, Band:2.0 %, Lymph:32.0 %, Mono:4.0 %,\n Eos:16.0 %, Lactic Acid:0.7 mmol/L, Albumin:2.9 g/dL, LDH:305 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis,\n abdominal pain, hypotension and concern for acute abdomen.\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n # Abdominal pain: likely due to compression of retroperitoneal hematoma\n on celiac plexus. Appears that this may have occurred in the setting of\n falling while on fondaparinux.\n - EGD did not reveal cause of bleeding\n - Surgery has no plan for intervention\n - continue serial abd exams, serial lactates\n - continue PPI\n - Cipro/flagyl and Vanco ppx, day#3\n # Hypotension resolved. Likely due to blood loss. Now with stable hct x\n several days.\n - hct check\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8.\n - F/u micro\n - f/u OSH culture data\n - f/u CT read here for possible abdominal source\n - CIS\n - Cont. vanc/cipro/flagyl per surgery recommendation\n - Add on differential\n # PE: CTA confirmed PE at OSH, was on , Unclear what\n precipitated this except for risk factor of being hospitalized. No h/o\n malignancy, has been getting routine mammogram and Paps, has not had\n colonoscopy. No personal or fam hx. of clot, not on HRT.\n - Holding anticoagulation for now in setting of bleeding\n - S/p IVC filter on \n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - follow as outpt\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Continue steroid taper once discussed with surgery\n # Anxiety:\n - Cont. ativan and effexor\n FEN: ADAT as no procedures planned.\n PPX:\n -DVT ppx with IVC filter.\n -Bowel regimen on hold\n -Pain management with ultram as pt getting GI upset and hallucinations\n on morphine\n ACCESS: will take out R IJ from OSH, likely need central access\n CODE STATUS: Full\n EMERGENCY CONTACT: \n OSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 12:00 AM\n 20 Gauge - 06:42 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": "2186-03-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 665614,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt presents on n/c satting well. BS clear left diminished on rt.\n Albuterol neb given with good effect increased aeration on right,\n however pt stated it made her feel jittery and did not want any more.\n Uneventful remainder of night.\n"
},
{
"category": "Physician ",
"chartdate": "2186-03-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 665349,
"text": "TITLE:\n Chief Complaint: 53 y/o F with PMH of CNS lyme who presents from OSH\n with leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen.\n 24 Hour Events:\n MULTI LUMEN - START 04:47 PM\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Metronidazole - 12:00 AM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 06:50 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.4\nC (99.4\n HR: 93 (75 - 108) bpm\n BP: 111/54(67) {81/40(52) - 111/72(77)} mmHg\n RR: 22 (15 - 29) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 3 (2 - 13)mmHg\n Total In:\n 2,128 mL\n 1,674 mL\n PO:\n TF:\n IVF:\n 2,128 mL\n 1,074 mL\n Blood products:\n 600 mL\n Total out:\n 215 mL\n 375 mL\n Urine:\n 215 mL\n 300 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 1,913 mL\n 1,299 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 225 K/uL\n 9.9 g/dL\n 119 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 11 mg/dL\n 107 mEq/L\n 140 mEq/L\n 28.2 %\n 10.5 K/uL\n [image002.jpg]\n 06:13 PM\n 11:15 PM\n 04:54 AM\n WBC\n 13.8\n 10.5\n Hct\n 23.7\n 24.0\n 28.2\n Plt\n 276\n 225\n Cr\n 0.4\n 0.5\n Glucose\n 108\n 119\n Other labs: PT / PTT / INR:14.7/31.0/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:37/17, Alk Phos / T Bili:49/0.5, Amylase / Lipase:31/21,\n Differential-Neuts:49.2 %, Lymph:39.6 %, Mono:3.6 %, Eos:7.0 %,\n Albumin:2.9 g/dL, Ca++:7.4 mg/dL, Mg++:1.8 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 53 y/o F with PMH of CNS lyme who presents from\n OSH with leukocytosis, abdominal pain, hypotension and concern for\n acute abdomen.\n .\n # Abdominal pain: Differential is broad including gastritis, PUD,\n perforated ulcer, pancreatitis, colitis. Abdominal pain is fairly\n diffuse, however her abdomen is soft. There was concern for free air\n at OSH, unfortunately we do not have the data here to confirm this. At\n OSH the patient's abdomen was reportedly rigid and there was concern\n for an acute process which prompted urgent transfer for possible\n surgery. At this point she is hemodynamically stable and her exam is\n not concerning for peritoneal signs. Surgery is following closely.\n Patient has been on high-dose steroids so an ulcer is possible, however\n was on GI ppx at OSH with Pepsid. KUB was also concerning for possible\n obstruction. Labs here show LFTs and pancreatic enzymes wnl making\n pancreatitis less likely. C. diff is of concern given recent long\n antibiotics course and leukocytosis, however was neg. x 1 at OSH.\n - Repeat abdominal CT now with oral/IV contrast to look for acute\n pathology, r/o free air and look for obstruction.\n - Surgery co-managing and appreciate their input\n - Will cont. cipro/flagyl and add vanco.\n - Serial abdominal exams\n - Pain control with IV morphine\n - Follow LFTs, pancreatic enzymes\n - PPI gtt for now\n - Consider GI consult for EGD if PUD remains high on differential\n - NPO for now\n .\n # Hypotension: Differential includes sepsis, bleeding, volume\n depletion, toxic shock. Given leukocytosis an infection is high on the\n differential. Hct here also lower (23.7 from 29.6 this morning at\n OSH). Given abdominal tenderness, this is concerning for bleed. BP\n stable with IVF currently.\n - Cont. IVF boluses to maintain MAP>60 and UOP>30\n - Consider pressors if unable to maintain with IVF\n - Trend serial Hct and transfuse if dropping or <21\n - CIS\n .\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8.\n Currently 13, however this is after abx since this am. Sources include\n abdomen, line-infection, urine, lungs. Cultures at OSH reportedly\n negative, however UA there showed 1+ bacteria and WBC. Given\n recent antibiotics, diarrhea and abdominal pain, c. diff is of\n concern. Was neg. x1 at OSH. CT at OSH also concerning for PNA,\n however patient does not have cough and lungs are clear. Has low grade\n fever here.\n - f/u OSH culture data\n - f/u CT read here for possible abdominal source\n - CIS\n - Cont. vanc/cipro/flagyl per surgery recommendation\n - Add on differential\n .\n # PE: CTA confirmed PE at OSH, was on Arixtra, last dose this morning.\n Unclear what precipitated this exept for risk factor of being\n hospitalized. No h/o malignancy, has been getting routine mom\n and Paps, has not had colonoscopy. No personal or fam hx. of clot, not\n on HRT.\n - Holding anticoagulation for now in setting of possible procedure\n - Attempt to obtain OSH CT films to confirm PE\n .\n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - Cont. to follow\n .\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Continue steroid taper once discussed with surgery\n .\n # Anxiety:\n - Cont. ativan and effexor once not NPO\n .\n FEN: NPO for now, IVF\n .\n PPX:\n -DVT ppx with , restart heparin if no surgery planned\n -Bowel regimen on hold\n -Pain management with morphine\n .\n ACCESS: RIJ placed at OSH\n .\n CODE STATUS: Full\n .\n EMERGENCY CONTACT: \n .\n DISPOSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:47 PM\n 18 Gauge - 05:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665334,
"text": "Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Retroperitoneal (Duodenal) Hemmorhage\n Assessment:\n Abd. Soft, distended with hypoactive BS\ns. Pt. with diffuse rebound\n tenderness as well as tenderness to palpation. No BM, no flatus.\n Action:\n CT torso done last eve. NGT placed by surgical team, presently to ILWS\n with minimal bilious output. Pt. in protonix gtt.\n Response:\n CT revealed bleeding duodenal ulcer, ? steroid related vs. spontaneous.\n Plan:\n Continue to follow abd. Exam closely. Close hemodynamic monitoring.\n GI consulted, possible scope today. To OR if becomes unstable.\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct. Last eve and night to 24, down significantly from a.m. hct. Pt.\n hypotensive as documented, SBP largely in 80\ns last eve, once noted to\n drop into 60\ns en route to CT. CVP 3-4.\n Action:\n 2 units PRBC\ns transfused overnight without incident.\n Response:\n A.m. labs pending. SBP mid 90\ns-100\ns since receiving blood. CVP\n remains low/unchanged.\n Plan:\n Serial hcts per team. Close hemodynamic monitoring.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. in NAD, no pulmonary complaints. Sats stable.\n Action:\n None, cannot be anticoagulated at this time due to RP bleed.\n Response:\n No change in respiratory function.\n Plan:\n LENI\ns today. SCD boots after LENI\ns if appropriate. Long term plan\n pending above.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. with abd. Pain as documented.\n Action:\n Morphine administered x 3 doses.\n Response:\n Good pain relief per pt.\n Plan:\n Continue to monitor and treat as indicated.\n"
},
{
"category": "Physician ",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 665518,
"text": "TITLE:\n Chief Complaint: 53 y/o F with PMH of CNS lyme who presents from OSH\n with leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen.\n 24 Hour Events:\n FEVER - 102.6\nF - 04:00 PM\n - Uploaded OSH scans, Confirmed PE\n - IVC filter placed\n - Hct stable\n - GI did EGD, diffuse edema in duodenum, no e/o fresh blood\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Hives;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:43 PM\n Metronidazole - 12:00 AM\n Ciprofloxacin - 03:46 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 10:03 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 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.6\n Tcurrent: 38.4\nC (101.2\n HR: 109 (78 - 109) bpm\n BP: 118/59(71) {79/40(56) - 118/74(77)} mmHg\n RR: 26 (14 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 15 (1 - 22)mmHg\n Total In:\n 4,934 mL\n 1,292 mL\n PO:\n 120 mL\n TF:\n IVF:\n 4,334 mL\n 1,172 mL\n Blood products:\n 600 mL\n Total out:\n 2,090 mL\n 965 mL\n Urine:\n 2,015 mL\n 965 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 2,844 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, tired-appearing, alert, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Hyperactive BS. Soft, diffusely tender to palpation, no\n rebound or guarding, No HSM appreciate.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: Diffuse maculo-papular rash over entire body, sparing area\n surrounding lips, areas of confluence on face and back.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 182 K/uL\n 9.7 g/dL\n 101 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 100 mEq/L\n 134 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 06:13 PM\n 11:15 PM\n 04:54 AM\n 11:36 AM\n 08:39 PM\n 03:09 AM\n WBC\n 13.8\n 10.5\n 10.6\n 10.0\n Hct\n 23.7\n 24.0\n 28.2\n 30.1\n 26.5\n 28.5\n Plt\n 82\n Cr\n 0.4\n 0.5\n 0.5\n Glucose\n 108\n 119\n 101\n Other labs: PT / PTT / INR:14.7/31.0/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:26/9, Alk Phos / T Bili:48/0.6, Amylase / Lipase:31/21,\n Differential-Neuts:45.0 %, Band:2.0 %, Lymph:32.0 %, Mono:4.0 %,\n Eos:16.0 %, Albumin:2.9 g/dL, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.3\n mg/dL\n Imaging: LENI read pending\n Uncomplicated IVC filter placement\n Microbiology: BC pending\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n .H/O ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n HYPOTENSION (NOT SHOCK)\n 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis,\n abdominal pain, hypotension and concern for acute abdomen.\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n # Abdominal pain: likely due to compression of retroperitoneal hematoma\n on celiac plexus. Appears that this may have occurred in the setting of\n falling while on fondaparinux.\n - EGD did not reveal cause of bleeding\n - Surgery has no plan for intervention\n - continue serial abd exams, serial lactates\n - continue PPI\n - Cipro/flagyl and Vanco ppx, day#3\n # Hypotension resolved. Likely due to blood loss. Now with stable hct x\n several days.\n - hct check\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8.\n - F/u micro\n - f/u OSH culture data\n - f/u CT read here for possible abdominal source\n - CIS\n - Cont. vanc/cipro/flagyl per surgery recommendation\n - Add on differential\n # PE: CTA confirmed PE at OSH, was on , Unclear what\n precipitated this except for risk factor of being hospitalized. No h/o\n malignancy, has been getting routine mammogram and Paps, has not had\n colonoscopy. No personal or fam hx. of clot, not on HRT.\n - Holding anticoagulation for now in setting of bleeding\n - S/p IVC filter on \n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - follow as outpt\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Continue steroid taper once discussed with surgery\n # Anxiety:\n - Cont. ativan and effexor\n FEN: ADAT as no procedures planned.\n PPX:\n -DVT ppx with IVC filter.\n -Bowel regimen on hold\n -Pain management with ultram as pt getting GI upset and hallucinations\n on morphine\n ACCESS: will take out R IJ from OSH, likely need central access\n CODE STATUS: Full\n EMERGENCY CONTACT: \n OSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:47 PM\n 18 Gauge - 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": "2186-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 665520,
"text": "TITLE:\n Chief Complaint: 53 y/o F with PMH of CNS lyme who presents from OSH\n with leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen.\n 24 Hour Events:\n FEVER - 102.6\nF - 04:00 PM\n - Uploaded OSH scans, Confirmed PE\n - IVC filter placed\n - Hct stable\n - GI did EGD, diffuse edema in duodenum, no e/o fresh blood\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Hives;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 08:43 PM\n Metronidazole - 12:00 AM\n Ciprofloxacin - 03:46 AM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Morphine Sulfate - 10:03 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 06:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.2\nC (102.6\n Tcurrent: 38.4\nC (101.2\n HR: 109 (78 - 109) bpm\n BP: 118/59(71) {79/40(56) - 118/74(77)} mmHg\n RR: 26 (14 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 65 Inch\n CVP: 15 (1 - 22)mmHg\n Total In:\n 4,934 mL\n 1,292 mL\n PO:\n 120 mL\n TF:\n IVF:\n 4,334 mL\n 1,172 mL\n Blood products:\n 600 mL\n Total out:\n 2,090 mL\n 965 mL\n Urine:\n 2,015 mL\n 965 mL\n NG:\n 75 mL\n Stool:\n Drains:\n Balance:\n 2,844 mL\n 327 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///28/\n Physical Examination\n GENERAL: Pleasant, tired-appearing, alert, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Hyperactive BS. Soft, diffusely tender to palpation, no\n rebound or guarding, No HSM appreciate.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: Diffuse maculo-papular rash over entire body, sparing area\n surrounding lips, areas of confluence on face and back.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 182 K/uL\n 9.7 g/dL\n 101 mg/dL\n 0.5 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 100 mEq/L\n 134 mEq/L\n 28.5 %\n 10.0 K/uL\n [image002.jpg]\n 06:13 PM\n 11:15 PM\n 04:54 AM\n 11:36 AM\n 08:39 PM\n 03:09 AM\n WBC\n 13.8\n 10.5\n 10.6\n 10.0\n Hct\n 23.7\n 24.0\n 28.2\n 30.1\n 26.5\n 28.5\n Plt\n 82\n Cr\n 0.4\n 0.5\n 0.5\n Glucose\n 108\n 119\n 101\n Other labs: PT / PTT / INR:14.7/31.0/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:26/9, Alk Phos / T Bili:48/0.6, Amylase / Lipase:31/21,\n Differential-Neuts:45.0 %, Band:2.0 %, Lymph:32.0 %, Mono:4.0 %,\n Eos:16.0 %, Albumin:2.9 g/dL, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL, PO4:3.3\n mg/dL\n Imaging: LENI read pending\n Uncomplicated IVC filter placement\n Microbiology: BC pending\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n .H/O ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n ANEMIA, ACUTE, SECONDARY TO BLOOD LOSS (HEMORRHAGE, BLEEDING)\n HYPOTENSION (NOT SHOCK)\n 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis,\n abdominal pain, hypotension and concern for acute abdomen.\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n # Abdominal pain: likely due to compression of retroperitoneal hematoma\n on celiac plexus. Appears that this may have occurred in the setting of\n falling while on fondaparinux.\n - EGD did not reveal cause of bleeding\n - Surgery has no plan for intervention\n - continue serial abd exams, serial lactates\n - continue PPI\n - Cipro/flagyl and Vanco ppx, day#3\n # Hypotension resolved. Likely due to blood loss. Now with stable hct x\n several days.\n - hct check\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8.\n - F/u micro\n - f/u OSH culture data\n - f/u CT read here for possible abdominal source\n - CIS\n - Cont. vanc/cipro/flagyl per surgery recommendation\n - Add on differential\n # PE: CTA confirmed PE at OSH, was on , Unclear what\n precipitated this except for risk factor of being hospitalized. No h/o\n malignancy, has been getting routine mammogram and Paps, has not had\n colonoscopy. No personal or fam hx. of clot, not on HRT.\n - Holding anticoagulation for now in setting of bleeding\n - S/p IVC filter on \n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - follow as outpt\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Continue steroid taper once discussed with surgery\n # Anxiety:\n - Cont. ativan and effexor\n FEN: ADAT as no procedures planned.\n PPX:\n -DVT ppx with IVC filter.\n -Bowel regimen on hold\n -Pain management with ultram as pt getting GI upset and hallucinations\n on morphine\n ACCESS: will take out R IJ from OSH, likely need central access\n CODE STATUS: Full\n EMERGENCY CONTACT: \n OSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:47 PM\n 18 Gauge - 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 ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined Mrs , and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n Mrs has had an IVC filter placed without difficulty and has had\n stabilization of her Hct without further transfusion. her rash appeart\n to be responding to prednisone and she still complains of abdominal\n pain. CT scan has shown significant intra-peritoneal\n bleed around duodenum and into both paracolic gutters and pelvis.\n Exam notable for Tmof 102.6 BP118/59 HR of 103 RR of 22 with sats of\n 96% on 3lpm O2 . She has a diffuse maculopapular rash that appears to\n be resolving. her abdomen is still tender to touch.\n Labs notable for WBC of 10K, HCTof 28.5 , K+of 4 , Crof 0.5 , LDH of\n 305, lactate of less than 2. CXR with bilateral small effusions but no\n infiltrate.\n Agree with plan to advance diet slowly as tolerated, discontinue Rt IJ\n line ( per ICU policy) and check caloric counts. She may need short\n term TPN until PO intake has improved. Prednisone will be continued\n till rash has resolved and Eos have decreased.\n IV PPI to be continued on a basis and she will be transitioned to a\n chair today. if she has no setback over next 24 hrs, we will consider\n transfer to surgical service on regular floor in am \n Remainder of plan as outlined above.\n Patient is ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n ------ Protected Section Addendum Entered By: , MD\n on: 01:17 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665447,
"text": "FULL CODE\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665448,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Pt fully oriented, pleasant, cooperative.\n Pain control (acute pain, chronic pain)\n Assessment:\n Assumed care of pt while she was in IR for filter placement, rec\n 1.5mg midaz and 50mcg Fent from IR RN pre-procedure. Back in MICU, had\n c/o abd and back pain @ 6/10 scale\n Action:\n Medicated w/ 2 mg MSO4 IV x1, pain @ so given additional 1mg IV\n Response:\n Pain relieved enough for pt to sleep most of noc and able to tolerate\n it with BP MAP >60\n Plan:\n Continue to monitor pain level and medicate prn.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Films reviewed from and confirmed that pt does have a PE\n Action:\n No change of action taken at this point\n Response:\n Pt has adequate O2 sats 98% on 1.5 L NC\n sats do drop to 91-92% on RA\n Plan:\n Continue to monitor resp status and support as necessary\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt has had no active sites of bleeding and Hct is stable\n Action:\n Endoscopy done by GI on day shift: no definitive sights located and no\n sign of active bleeding\n Response:\n NGT dc\nd during scope. Pt is passing flatus but no stool. No further\n blood transfusions required at this point\n Plan:\n Continue to monitor Hct closely and treat as ordered\n Hypotension (not Shock)\n Assessment:\n Pt has been hemodynamically stable throughout shift\n Action:\n IVF at 125/hr continued\n Response:\n BP stable and UO> 100cc/hr\n Plan:\n Monitor closely for changes in BP and give fluid as tolerated.\n Pt has 2 close friends that were at bedside for several hours and plan\n on returning tomorrow. Also has husband and 4 children, all of whom\n have had Lyme Disease in the past (friends\n family members as well)\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665534,
"text": "FULL CODE\n Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Significant Events:\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct stable over night. HR 80\ns-low 100\ns, NBP 100-110/50-60\ns. Skin\n warm with resolving macular rash from abx rxn, (+) pedal pulses.\n Abdomen soft but diffusely tender, hypoactive bowel sounds, (+) flatus\n but no bowel movement. Foley draining clear yellow urine, 100-200\n cc/hr.\n Action:\n Pt OOB with nurse assist, HR increased to 120\ns r/t pain with\n activity\npt settled down and VSS stable until after an hour when HR\n increased to\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665428,
"text": "Pt. with recent treatment for Lyme\ns disease admitted to OSH last\n Friday with lethargy and full body rash. Rash improved with steroids,\n pt. remained inpatient for monitoring. She developed a small PE while\n inpatient and was treated with arixtra. Yesterday a.m. pt. was found\n on floor near bed with no recollection of incident (unwitnessed). Pt.\n hypotensive with signs of acute abdomen and transferred to for\n management.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abd and back pain\n 8/10 scale\n Action:\n Med q 2-3 hours with 2 mg MSO4 IV\n Response:\n Pain is fairly well relieved and able to tolerate it with BP MAP >60\n Plan:\n Continue to monitor pain level and medicate as needed.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Films reviewed from and confirmed that pt does have a PE\n Action:\n No change of action taken at this point\n Response:\n Pt has adequate O2 sats 98% on 1.5 L NC\n sats do drop to 91-92% on RA\n Plan:\n Continue to monitor resp status and support as necessary\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Pt has had no active sites of bleeding and Hct is stable\n Action:\n Endoscopy done by GI and no definitive sights located and no sign of\n active bleeding\n Response:\n NGT dc\nd during scope. Pt is passing flatus but no stool. No further\n blood transfusions required at this point\n Plan:\n Continue to monitor Hct closely and treat as ordered\n Hypotension (not Shock)\n Assessment:\n Pt has been hemodynamically stable throughout the day\n Action:\n IVF at 125/hr continued\n Response:\n BP stable and UO more than adequate.\n Plan:\n Monitor closely for changes in BP and give fluid as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2186-03-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 665671,
"text": "53 y/o female with PMH of CNS Lyme who presented from OSH with\n Leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen. OSH scans ~ + PE, IVC filter placed , GI performed\n EGD\n diffuse edema in duodenum, no fresh blood.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 3 L NC with Sp02 low 90\ns. SOB with exertion ie.\n Transfer to chair otherwise pt states no difficulty with breathing at\n rest. RR 18-22 and also increases to low 30\ns with exertion. IVC\n filter in place- site WNL. Lungs clear, diminished at bases.\n Action:\n Encouraged pt to CDB and IS use. OOB to chair- VSS during transfer.\n Dropped 02 to 2 L NC. Pneumo boots\n Response:\n Pt remains on 2 L NC with SP02 mid 90\ns. Pt in chair for 4 hours.\n Plan:\n Wean 02 as tolerated. Encourage CDB and IS. Pneumo boots\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Hct stable overnight. Currently Hct 29.2- last PRBC given yesterday.\n Abdomen soft and still slightly distended and tender but improving. (+)\n bowel sounds and flatus. Urine yellow and clear, adequate amounts- body\n balance even. Hemodynamically stable, SBP 100-110, NSR 80\n Action:\n Advanced diet to full- tolerating but states she does not really have\n an appetite. Started bowel regimen due to no bowel movement since\n admission\n Response:\n Pt continues to be hemodynamically stable. Abdominal assessment\n improving.\n Plan:\n Monitor hemodynamics. Tranfuse PRN\n Pain control (acute pain, chronic pain)\n Assessment:\n Mid abdominal and back pain initially being treated with morphine PRN\n but stated she did not like how it made her feel and therefore switched\n to Ultram q4h. Pain has been managed well today with c/o and a\n after being in chair. Pt also restarted on Effexor and Ativan PRN\n for anxiety which she was on prior to admission\n Action:\n Ultram PRN for abdominal and back pain.\n Response:\n Pt\ns pain is well controlled with Ultram and states she feels much\n better than yesterday\n Plan:\n Continue frequent pain assessments. Ultram for pain PRN. Standing\n effexor and PRN Ativan for anxiety.\n Endo: Pt on sliding scale due to elevated BS r/t predisone taper\n Skin: Prednisone taper due to macular rash from ceftriaxone, rash\n improving\n Demographics\n Attending MD:\n T.\n Admit diagnosis:\n PERFORATED DUODENUM\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 73 kg\n Daily weight:\n Allergies/Reactions:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Hives;\n Ceftriaxone\n Rash;\n Precautions:\n PMH:\n CV-PMH:\n Additional history: C-section x2. Lap Choley.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:57\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 91 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 923 mL\n 24h total out:\n 1,720 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:12 AM\n Potassium:\n 4.0 mEq/L\n 04:12 AM\n Chloride:\n 101 mEq/L\n 04:12 AM\n CO2:\n 30 mEq/L\n 04:12 AM\n BUN:\n 7 mg/dL\n 04:12 AM\n Creatinine:\n 0.5 mg/dL\n 04:12 AM\n Glucose:\n 182 mg/dL\n 04:12 AM\n Hematocrit:\n 29.2 %\n 04:12 AM\n Finger Stick Glucose:\n 199\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: 12 R\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2186-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 665580,
"text": "53 y/o female with PMH of CNS Lyme who presented from OSH with\n Leukocytosis, abdominal pain, hypotension and concern for acute\n abdomen. OSH scans - + PE, IVC filter placed , GI\n performed EGD\n diffuse edema in duodenum, no fresh blood.\n Rash - ?reaction to ceftriaxone. Pt on steroid taper\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o abd pain with turning, pt states is on Ativan and\n Effexor at home , c/o itching\n Action:\n Medicated with q 4 hrs prn. Pt received .5 mg po Ativan\n and 75 mg Effexor. Also received 50 mg po Benadryl for her itching -\n Response:\n Abd pain somewhat relieved by , pt able to sleep in short naps\n Plan:\n Continue with \n Pulmonary Embolism (PE), Acute\n Assessment:\n On 2 l n/p, rr 20\ns, resp increase with activity\n lungs with\n decreased breath sounds\n.. filter placed , site WNL\n Action:\n Supplemental O2, assessed filter site\n Response:\n Pt remains dependent on 2 liters n/c\n Plan:\n Continue to monitor pt closely\n.. follow O2 sats\n Anemia, acute, secondary to blood loss (Hemorrhage, Bleeding)\n Assessment:\n Bp stable HR 90\ns SR no vea noted. Skin warm with\n resolving macular rash from abx rxn, + pedal pulses. Pt on PPI\n Action:\n Response:\n Plan:\n Continue to monitor Hcts.\n ID: afebrile WBC pt remains on Flagyl, Cipro, Vanco.\n GU: good urine output via foley\n"
},
{
"category": "Physician ",
"chartdate": "2186-03-03 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 665317,
"text": "Chief Complaint: Transfer from OSH with abdominal pain\n HPI:\n Patient is a 53 y/o F with PMH of CNS lyme who presents from OSH for\n evaluation of possible acute abdomen. Of note, the patient recently\n completed 28 days of IV Ceftriaxone for CNS lyme on . She\n initially presented to an OSH on with rash and fever. She also\n had chills, nausea and vomiting. In the OSH ED she was found to be\n tachy with HR 133 and temp 101. Her BP was as low as 90 and responded\n to IVF. WBC was 11.9 with 22% bands. CXR showed a R hilar\n infiltrate. A RIJ was placed and she was admitted to the ICU for\n presumed line sepsis from her PICC. She was given vanc/levo. Blood\n cultures were checked x3 and were NGTD. Her levo was discontinued and\n her vanco was continued for 3 days. Dermatology was consulted for ? of\n , however drug rxn was felt to be more likely. She was\n started on solumedrol 80mg q8hr which has been tapered down to 60mg\n q12. On the patient was noted to be hypoxic to 88% with\n ambulation. CTA confirmed LUL PE and she was started on Arixtra 7.5mg\n daily. CT also showed bilateral lower lobe PNA and pleural effusions.\n .\n At 3am on the morning of transfer the patient developed sudden onset,\n severe abdominal pain and cramps. She describes it as a severe gas\n pain. She then had 4-5 episodes of emesis of greenish material, denies\n blood. At 7am she was found on the floor with a BP of 73/53 and O2 sat\n 88%. She was placed on NRB and given 250cc NS and BP improved to\n 90/50. CT neck was neg. for fracture. Exam showed diffusely tender\n abdomen with guarding and rebound. CT abdomen showed an inflammatory\n mass in the pancreas, free fluid and ? free air. WBC at that time was\n 20.8. The patient does not recall the events leading up to the fall\n and remembers waking up on the floor.\n .\n Currently, the patient reports that her abdominal pain is improved\n after she received morphine. She reports that the pain is diffuse,\n continues to feel like bad gas. Up until yesterday she was passing\n gas, however she has not today. She also reports having diarrhea 3\n days ago with 4-5 loose stools/day. She has had some SOB since her\n admission and reports that her breathing is improved today. She denies\n cough. She reports having low grade fevers at OSH. She feels that her\n rash is significantly improved. ROS is otherwise negative.\n Patient admitted from: Transfer from other hospital\n History obtained from Medical records\n Allergies:\n Vicodin (Oral) (Hydrocodone Bit/Acetaminophen)\n Unknown;\n Ceftriaxone\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 08:00 PM\n Other medications:\n MEDICATIONS AT HOME:\n Ativan 0.5mg q6hr prn\n Effexor 75mg \n .\n MEDICATIONS ON TRANSFER:\n Nystatin swish and swallow 5cc qid\n Effexor 75mg \n Solumedrol 60mg IV q12\n Arixtra 7.5 SQ daily\n Humalog SS\n Morphine 1-2 mg IV q4hr prn\n Flagyl 500mg IV q8hr\n Cipro 400mg IV q12\n Protonix gtt\n Past medical history:\n Family history:\n Social History:\n Lyme disease with neurologic manifestations\n Mitral valve prolapse\n NC, no family h/o blood clots\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Works as pharmacist technician at Wallgreens. Lives with her\n husband and children. Denies tobacco use. Drinks wine occasionally.\n Review of systems:\n Constitutional: Fatigue, Fever\n Gastrointestinal: Abdominal pain, Nausea, Emesis, Diarrhea\n Integumentary (skin): Rash\n Neurologic: Numbness / tingling\n Flowsheet Data as of 10:23 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 98 (91 - 108) bpm\n BP: 93/45(55) {83/40(52) - 96/52(62)} mmHg\n RR: 29 (18 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 65 Inch\n CVP: 13 (4 - 13)mmHg\n Total In:\n 1,846 mL\n PO:\n TF:\n IVF:\n 1,846 mL\n Blood products:\n Total out:\n 0 mL\n 130 mL\n Urine:\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,716 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///32/\n Physical Examination\n T 99.3 BP 91/40 HR 108 RR 21 O2 93% 3L\n GENERAL: Pleasant, tired-appearing, alert, in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Hyperactive BS. Soft, diffusely tender to palpation, no\n rebound or guarding, No HSM appreciate.\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: Diffuse maculo-papular rash over entire body, sparing area\n surrounding lips, areas of confluence on face and back.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Gait\n assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 276 K/uL\n 8.2 g/dL\n 108 mg/dL\n 0.4 mg/dL\n 15 mg/dL\n 32 mEq/L\n 106 mEq/L\n 3.8 mEq/L\n 143 mEq/L\n 23.7 %\n 13.8 K/uL\n [image002.jpg]\n \n 2:33 A3/26/ 06:13 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 13.8\n Hct\n 23.7\n Plt\n 276\n Cr\n 0.4\n Glucose\n 108\n Other labs: PT / PTT / INR:14.6/30.7/1.3, CK / CKMB / Troponin-T:/2/,\n ALT / AST:37/17, Alk Phos / T Bili:49/0.5, Amylase / Lipase:31/21,\n Albumin:2.9 g/dL, Ca++:7.1 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR : small b/l effusions, possible LLL infiltrate\n .\n CTA : filling defects in pulmonary arteries to LUL. Aorta\n unremarkable. Small bilateral pleural effusions. Parenchymal\n consolidation at both lung bases with air bronchograms c/w pneumonia or\n atelectasis. Cyst in liver.\n .\n KUB : Extensive gas and feces in colon. No distal colonic gas\n noted. Several air filled small loops of bowel are seen in\n mid-abdomen. s/p CCY.\n .\n IMPRESSION: Findings suggestive of obstruction in mid descending colon.\n .\n CT head : Normal. No acute hemorrhage.\n .\n CT abdomen: per d/c summary (no report came with patient) showed\n inflammatory process in head of pancreas, positive free fluid in pelvis\n and abdomen, and ? of free air in abdomen\n Assessment and Plan\n 53 y/o F with PMH of CNS lyme who presents from OSH with leukocytosis,\n abdominal pain, hypotension and concern for acute abdomen.\n .\n # Abdominal pain: Differential is broad including gastritis, PUD,\n perforated ulcer, pancreatitis, colitis, spontaneous bleed in setting\n of Arixtra. Abdominal pain is fairly diffuse, however her abdomen is\n soft. There was concern for free air at OSH, unfortunately we do not\n have the data here to confirm this. At OSH the patient's abdomen was\n reportedly rigid and there was concern for an acute process which\n prompted urgent transfer for possible surgery. At this point she is\n hemodynamically stable and her exam is not concerning for peritoneal\n signs. Surgery is following closely. Patient has been on high-dose\n steroids so an ulcer is possible, however was on GI ppx at OSH with\n Pepsid. KUB was also concerning for possible obstruction. Labs here\n show LFTs and pancreatic enzymes wnl making pancreatitis less likely.\n C. diff is of concern given recent long antibiotics course and\n leukocytosis, however was neg. x 1 at OSH.\n - Repeat abdominal CT now with oral/IV contrast to look for acute\n pathology, r/o free air and look for obstruction.\n - Surgery co-managing and appreciate their input\n - Will cont. cipro/flagyl and add vanco.\n - Serial abdominal exams\n - Pain control with IV morphine\n - Follow LFTs, pancreatic enzymes\n - PPI gtt for now\n - Consider GI consult for EGD if PUD and GIB remains high on\n differential\n - NPO for now\n .\n # Hypotension: Differential includes sepsis, bleeding, volume\n depletion. Given leukocytosis an infection is high on the\n differential. Hct here also lower (23.7 from 29.6 this morning at\n OSH). Given abdominal tenderness, this is concerning for bleed. BP\n stable with IVF currently.\n - Cont. IVF boluses to maintain MAP>60 and UOP>30\n - Consider pressors if unable to maintain with IVF\n - Trend serial Hct and transfuse if dropping or <21\n - CIS\n .\n # Leukocytosis: Improving. Peaked at OSH this morning at 20.8.\n Currently 13, however this is after abx since this am. Sources include\n abdomen, line-infection, urine, lungs. Cultures at OSH reportedly\n negative, however UA there showed 1+ bacteria and WBC. Given\n recent antibiotics, diarrhea and abdominal pain, c. diff is of\n concern. Was neg. x1 at OSH. CT at OSH also concerning for PNA,\n however patient does not have cough and lungs are clear. Has low grade\n fever here.\n - f/u OSH culture data\n - f/u CT read here for possible abdominal source\n - CIS\n - Cont. vanc/cipro/flagyl per surgery recommendation\n - Add on differential\n - send c diff if stools\n .\n # PE: CTA confirmed PE at OSH, was on Arixtra, last dose this morning.\n Unclear what precipitated this exept for risk factor of being\n hospitalized. No h/o malignancy, has been getting routine mom\n and Paps, has not had colonoscopy. No personal or fam hx. of clot, not\n on HRT.\n - Holding anticoagulation for now in setting of possible procedure and\n concern for bleed\n - Obtain OSH CT films to confirm presence of PE\n - Check LENIs is am\n .\n #. CNS Lyme: Received 4 weeks of ceftriaxone for this per her\n Neurologist Dr. . Per notes from ID consult at OSH, the diagnosis\n of this is in question based on her CSF results. Reports a history of\n neuropathy in her hand and feet which is improved and stable.\n - Cont. to follow\n .\n # Rash: Possible reaction to ceftriaxone. Dermatology was consulted at\n OSH due to concern for . Started on solumedrol which\n was being tapered. Rash improving.\n - Holding steroids in setting of possible bleed/infection\n - Benadryl prn\n .\n # Anxiety:\n - Cont. ativan and effexor once not NPO\n .\n FEN: NPO for now, IVF\n .\n PPX:\n -DVT ppx, holding pneumoboots in setting of possible DVT, holding\n heparin in setting of possible bleed, received arixtra this am so\n covered today.\n -Bowel regimen on hold\n -Pain management with morphine\n .\n ACCESS: RIJ placed at OSH, PIV\n .\n CODE STATUS: Full\n .\n EMERGENCY CONTACT: \n .\n DISPOSITION: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 04:47 PM\n 20 Gauge - 05:06 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nutrition",
"chartdate": "2186-03-03 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 665384,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 73 kg\n 26.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 129\n 61kg\n Diagnosis: perforated duodenum\n PMH : ? CNS lyme dz, MV prolapse\n Food allergies and intolerances: none noted.\n Pertinent medications: protonix, vanco, cipro, RISS.\n Labs:\n Value\n Date\n Glucose\n 119 mg/dL\n 04:54 AM\n Glucose Finger Stick\n 146\n 01:00 AM\n BUN\n 11 mg/dL\n 04:54 AM\n Creatinine\n 0.5 mg/dL\n 04:54 AM\n Sodium\n 140 mEq/L\n 04:54 AM\n Potassium\n 3.6 mEq/L\n 04:54 AM\n Chloride\n 107 mEq/L\n 04:54 AM\n TCO2\n 29 mEq/L\n 04:54 AM\n Albumin\n 2.9 g/dL\n 06:13 PM\n Calcium non-ionized\n 7.4 mg/dL\n 04:54 AM\n Phosphorus\n 3.5 mg/dL\n 04:54 AM\n Magnesium\n 1.8 mg/dL\n 04:54 AM\n ALT\n 37 IU/L\n 06:13 PM\n Alkaline Phosphate\n 49 IU/L\n 06:13 PM\n AST\n 17 IU/L\n 06:13 PM\n Amylase\n 31 IU/L\n 06:13 PM\n Total Bilirubin\n 0.5 mg/dL\n 06:13 PM\n WBC\n 10.5 K/uL\n 04:54 AM\n Hgb\n 9.9 g/dL\n 04:54 AM\n Hematocrit\n 28.2 %\n 04:54 AM\n Current diet order / nutrition support: NPO\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: Low protein stores, may need nutrition support.\n Estimated Nutritional Needs\n Calories: 1525-1830 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate.\n Specifics:\n 53 YO female w/ hx of ?presumed CMS lyme dz & blood loss anemia who\n presents from OSH with Leukocytosis, abd pain, hypotension with concern\n for acute abd d/t ?gastritis/PUD/perf ulcer/pancreatitis or colitis.\n KUB with ?obstruction, abd CT with fluid collection around the 3^rd 7\n 4^th portion of the duodenum\nconcerning for acute bleed, no free air.\n Remains NPO with ongoing work-up. If remains NPO for the next 24-48hrs,\n consider TPN (will need central access) Goal TPN would be STD 3-in 1\n for 60kg feeding weight; 1500mL(255g Dex/90g AA/30g Fat) providing\n 1500kcals. Check triglycerides; lipids contraindicated if TG is\n >400mg/dl.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If remains NPO in the next 24-48hrs, obtain central access &\n start TPN; start with Day /starter STD & adjust lytes per am labs\n 2. Check triglycerides w/ am labs; check chem. 10 daily. Replete\n lytes PRN\n 3. continue with RISS\n 4. Advance TPN towards goal per FS\n 5. Goal TPN: 3-in-1 for 60kg if TG is <400mg/kg, otherwise 2-in-1\n for 60kg if TG >400mg/dl\n"
},
{
"category": "Nutrition",
"chartdate": "2186-03-03 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 665386,
"text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 73 kg\n 26.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 129\n 61kg\n Diagnosis: perforated duodenum\n PMH : ? CNS lyme dz, MV prolapse\n Food allergies and intolerances: none noted.\n Pertinent medications: protonix, vanco, cipro, RISS.\n Labs:\n Value\n Date\n Glucose\n 119 mg/dL\n 04:54 AM\n Glucose Finger Stick\n 146\n 01:00 AM\n BUN\n 11 mg/dL\n 04:54 AM\n Creatinine\n 0.5 mg/dL\n 04:54 AM\n Sodium\n 140 mEq/L\n 04:54 AM\n Potassium\n 3.6 mEq/L\n 04:54 AM\n Chloride\n 107 mEq/L\n 04:54 AM\n TCO2\n 29 mEq/L\n 04:54 AM\n Albumin\n 2.9 g/dL\n 06:13 PM\n Calcium non-ionized\n 7.4 mg/dL\n 04:54 AM\n Phosphorus\n 3.5 mg/dL\n 04:54 AM\n Magnesium\n 1.8 mg/dL\n 04:54 AM\n ALT\n 37 IU/L\n 06:13 PM\n Alkaline Phosphate\n 49 IU/L\n 06:13 PM\n AST\n 17 IU/L\n 06:13 PM\n Amylase\n 31 IU/L\n 06:13 PM\n Total Bilirubin\n 0.5 mg/dL\n 06:13 PM\n WBC\n 10.5 K/uL\n 04:54 AM\n Hgb\n 9.9 g/dL\n 04:54 AM\n Hematocrit\n 28.2 %\n 04:54 AM\n Current diet order / nutrition support: NPO\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: Low protein stores, may need nutrition support.\n Estimated Nutritional Needs\n Calories: 1525-1830 (BEE x or / 25-30 cal/kg)\n Protein: 73-92 (1.2-1.5 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate.\n Specifics:\n 53 YO female w/ hx of ?presumed CMS lyme dz & blood loss anemia who\n presents from OSH with Leukocytosis, abd pain, hypotension with concern\n for acute abd d/t ?gastritis/PUD/perf ulcer/pancreatitis or colitis.\n KUB with ?obstruction, abd CT with fluid collection around the 3^rd 7\n 4^th portion of the duodenum\nconcerning for acute bleed, no free air.\n Remains NPO with ongoing work-up. If remains NPO for the next 24-48hrs,\n consider TPN (will need central access) Goal TPN would be STD 3-in 1\n for 60kg feeding weight; 1500mL(255g Dex/90g AA/30g Fat) providing\n 1500kcals. Check triglycerides; lipids contraindicated if TG is\n >400mg/dl.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. If remains NPO in the next 24-48hrs, obtain central access &\n start TPN; start with Day /starter STD & adjust lytes per am labs\n 2. Check triglycerides w/ am labs; check chem. 10 daily. Replete\n lytes PRN\n 3. continue with RISS\n 4. Advance TPN towards goal per FS\n 5. Goal TPN: 3-in-1 for 60kg if TG is <400mg/kg, otherwise 2-in-1\n for 60kg if TG >400mg/dl\n Will follow plan.\n"
},
{
"category": "Echo",
"chartdate": "2186-03-06 00:00:00.000",
"description": "Report",
"row_id": 89053,
"text": "PATIENT/TEST INFORMATION:\nIndication: R/O Endocarditis. PCC line sepsis.\nHeight: (in) 65\nWeight (lb): 147\nBSA (m2): 1.74 m2\nBP (mm Hg): 110/60\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 11:49\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Aneurysmal interatrial septum.\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. No 2D\nor 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. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Left pleural effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). Right ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve appears structurally\nnormal with trivial mitral regurgitation. The estimated pulmonary artery\nsystolic pressure is high normal. There is no pericardial effusion.\n\nIMPRESSION: No valvular pathology or pathologic flow identified.\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": "Radiology",
"chartdate": "2186-03-03 00:00:00.000",
"description": "INTERUP IVC",
"row_id": 1070105,
"text": " 6:45 PM\n IVC GRAM/FILTER Clip # \n Reason: Place IVC filter\n Admitting Diagnosis: PERFORATED DUODENUM\n Contrast: OPTIRAY Amt: 35\n ********************************* CPT Codes ********************************\n * INTERUP IVC PERC PLCMT IVC FILTER *\n * MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with PE\n REASON FOR THIS EXAMINATION:\n Place IVC filter\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBCa FRI 8:28 PM\n Uncomplicated IVC filter placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman presenting with PE and intraperitoneal bleed.\n\n RADIOLOGISTS: The procedure was performed by Drs. , and ,\n the attending radiologist, who was present and supervising throughout.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiography table and the right groin was prepped and draped in\n standard sterile fashion. A preprocedure timeout was performed.\n\n Using sterile technique, fluoroscopic and palpatory guidance, the right common\n femoral vein was punctured and a 0.018 guidewire was advanced through the\n needle into the IVC under fluoroscopic guidance. The micropuncture needle was\n then exchanged for a micropuncture sheath. The wire and the inner dilator of\n the sheath were removed and a 0.035 wire was advanced through the\n sheath into the IVC under fluoroscopic guidance. The micropuncture sheath was\n then exchanged for -Tip vascular sheath. An Omniflush catheter was\n advanced through the sheath over the wire and positioned within the\n contralateral iliac vein crossing the bifurcation. A venogram was performed\n demonstrating a single and patent IVC. The level of the renal veins was\n determined.\n\n A G2 retrievable IVC filter was deployed below the level of the origin of the\n renal veins.\n\n The sheath was removed and manual compression was held until hemostasis was\n achieved.\n\n The patient tolerated the procedure well without immediate complications.\n\n Moderate sedation was provided by administering divided doses of 50 mcg of\n fentanyl and 1.5 mg of Versed throughout the total intra-service time of 30\n minutes during which the patient's hemodynamic parameters were continuously\n monitored.\n (Over)\n\n 6:45 PM\n IVC GRAM/FILTER Clip # \n Reason: Place IVC filter\n Admitting Diagnosis: PERFORATED DUODENUM\n Contrast: OPTIRAY Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION: Uncomplicated placement of a G2 retrievable IVC filter below the\n level of the origin of the renal veins. The filter can be retrieved within\n the next few weeks.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-03-03 00:00:00.000",
"description": "INTERUP IVC",
"row_id": 1070106,
"text": ", T. 6:45 PM\n IVC GRAM/FILTER Clip # \n Reason: Place IVC filter\n Admitting Diagnosis: PERFORATED DUODENUM\n Contrast: OPTIRAY Amt: 35\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with PE\n REASON FOR THIS EXAMINATION:\n Place IVC filter\n ______________________________________________________________________________\n PFI REPORT\n Uncomplicated IVC filter placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-03-03 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1070075,
"text": " 4:44 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: evaluate for DVT\n Admitting Diagnosis: PERFORATED DUODENUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with ? PE at OSH\n REASON FOR THIS EXAMINATION:\n evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman with question PE at an outside hospital.\n Evaluate for DVT.\n\n COMPARISON: None.\n\n FINDINGS: scale and Doppler evaluation of bilateral common femoral,\n superficial femoral, popliteal veins demonstrate normal compressibility, flow,\n augmentation. There is no evidence of intraluminal thrombus. Prominent right\n inguinal region nodes that measure 1.5 x 0.6 cm are noted.\n\n IMPRESSION: No evidence of DVT in bilateral lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-03-02 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1069877,
"text": " 8:46 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: FEVER, COUGH, ABD PAIN\n Admitting Diagnosis: PERFORATED DUODENUM\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53F w/ fevers, cough, abd pain\n REASON FOR THIS EXAMINATION:\n assess for pneumonia, intr-abd process ***Pt started po prep at 1730\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST WITH CONTRAST, CT OF THE ABDOMEN WITH CONTRAST, CT OF THE\n PELVIS WITH CONTRAST, , AT 2108 HOURS\n\n HISTORY: 53-year-old female with fever, cough, and abdominal pain. The\n patient presented to outside hospital with abdominal pain and hypotension.\n\n TECHNIQUE: Serial transverse images were acquired sequentially through the\n chest, abdomen, and pelvis following the uneventful administration of 130 mL\n of Optiray 350. Oral contrast was also administered. Multiplanar reformatted\n images were generated.\n\n COMPARISON: None.\n\n FINDINGS:\n\n CHEST: There are small bilateral simple effusions with adjacent relaxation\n atelectasis. No pneumonia or superimposed edema identified. No pulmonary\n nodules or masses seen. The mediastinum is unremarkable. The heart is normal\n in size with no pericardial effusion. The major airways are widely patent.\n\n ABDOMEN/PELVIS: There is a simple cyst anteriorly in the dome of the right\n liver. Numerous other small hypodensities are noted throughout the liver\n which are too small to further characterize. There is minimal prominence of\n the central intrahepatic biliary ducts. However, the patient is post-\n cholecystectomy with clips seen in the gallbladder fossa. The kidneys,\n adrenal glands, and spleen are unremarkable. There is a small amount of\n perisplenic and perihepatic ascites.\n\n The pancreas itself is grossly unremarkable. However, there is a large amount\n of relative high-attenuation (60 Hounsfield units) fluid surrounding the third\n and fourth portions of the duodenum. This high-attenuation fluid flows into\n the right paracolic gutter. There is a large amount similar high-attenuation\n fluid layering within the pelvis both anterior and posterior to the uterus.\n This fluid has somewhat intermediate density between 25 and 40 Hounsfield\n units; however, there are confluent areas of higher attenuation noted tracking\n along the left adnexa and in focal areas in the left paracolic gutter. These\n are closer again to 60 Hounsfield units. There is no free air.\n\n No definite extravasated oral contrast is noted, although contrast does reach\n (Over)\n\n 8:46 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: FEVER, COUGH, ABD PAIN\n Admitting Diagnosis: PERFORATED DUODENUM\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the distal small bowel and colon. The colon itself is otherwise unremarkable.\n No small bowel dilatation is noted. Scattered stool is seen throughout the\n colon with no diverticular disease. An appendix is not discretely identified.\n The bladder is collapsed around a Foley catheter balloon.\n\n The uterus is grossly unremarkable. Ovaries cannot be evaluated secondary to\n the intra- abdominal fluid/hemorrhage. Numerous prominent bilateral inguinal\n lymph nodes are identified. No pathologic lymphadenopathy is seen within the\n abdomen or pelvis. The abdominopelvic vascular structures are grossly\n unremarkable. Please note, CT angiography was not requested or performed.\n Minimal fluid is noted within the superficial flanks likely due to third\n spacing.\n\n The osseous structures are grossly unremarkable with no suspicious osseous\n lesions. Thoracolumbar spinal alignment is maintained.\n\n IMPRESSION:\n\n There is a high attenuation, presumably hemorrhage centered around the third\n and fourth portions of the duodenum in the retroperitoneum. This does not\n appear to be arising from the pancreas. There is contact of this high-\n attenuation fluid with the uncinate process, but otherwise, the remainder and\n majority of the pancreas is uninvolved and normal. It is presumed that this\n extensive hemorrhage extends into the intraperitoneal space and the pelvis\n where the high-attenuation foci along the left paracolic gutter are presumed\n clots. No obstruction is identified. There is no free air. This case was\n discussed at length with Dr. , general surgery, in person and with Dr.\n , general surgery, over the phone. Diagnostic considerations\n include a vascular injury (gastroduodenal artery) secondary to ulcer in the\n distal duodenum (atypical). Diagnostic considerations also may center around\n a spontaneous retroperitoneal hemorrhage as further history obtained revealed\n recent anticoagulation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1069952,
"text": " 9:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for consolidation, pulmonary edema\n Admitting Diagnosis: PERFORATED DUODENUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with known PE.\n REASON FOR THIS EXAMINATION:\n Evaluate for consolidation, pulmonary edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 2:04 PM\n Low lung volumes. Bibasilar opacities, mostly on the right, could be\n atelectasis or multifocal pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 53-year-old woman with known PE, rule out consolidation or\n edema.\n\n No prior study for comparison.\n\n A nasogastric tube ends in the stomach and a right internal jugular catheter\n ends in the mid to low SVC.\n\n Lung volumes are low. Bibasilar opacities increased, mostly on the left,\n could be atelectasis, or less likely pneumonia, in correlation with recent\n chest CT. There is no pleural effusion. The cardiomediastinal silhouette and\n hilar contours are otherwise normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-03-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1069953,
"text": ", T. 9:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for consolidation, pulmonary edema\n Admitting Diagnosis: PERFORATED DUODENUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with known PE.\n REASON FOR THIS EXAMINATION:\n Evaluate for consolidation, pulmonary edema\n ______________________________________________________________________________\n PFI REPORT\n Low lung volumes. Bibasilar opacities, mostly on the right, could be\n atelectasis or multifocal pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1070161,
"text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for consolidation\n Admitting Diagnosis: PERFORATED DUODENUM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with PE\n REASON FOR THIS EXAMINATION:\n Evaluate for consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with pulmonary embolism. Assess for consolidation.\n\n COMPARISON: .\n\n SEMI-UPRIGHT AP CHEST: A right internal jugular approach central venous\n catheter is in place, the tip of which is difficult to visualize in the region\n of the cavoatrial junction. Cardiac and mediastinal contours are stable. Lung\n volumes remain quite low. Retrocardiac opacity may reflect consolidation\n and/or atelectasis. Blunting of the left costophrenic angle is consistent\n with a small pleural effusion seen on CT.\n\n In the abdomen, a new IVC filter is present, and there are cholecystectomy\n clips in the right upper quadrant. Oral contrast remains within the colon.\n There is a small amount of radiodense material is seen in the linear\n configuration just superior to the IVC filter which is indeterminant in\n nature.\n\n IMPRESSION:\n 1. Unchanged retrocardiac opacity and adjacent small left effusion.\n 2. Indeterminate radiodensity of the upper abdomen as above. Please\n correlate clinically. This could be better evaluated with dedicated abdominal\n radiographs if indicated.\n\n Findings were discussed with Dr. on the morning of .\n\n"
}
] |
1,344 | 190,827 | Admitted to on for heparinization/normalization of INR off Coumadin pre-op. She was taken tot he OR on for left thoracoscopic pericardial window. POst-op, she was taken to the CSRU, extubated & weaned of phenylephrine gtt by POD #1. Thoracic surgery consult was obtained on for pleural effusion. On , she underwent doxycycline pleurodesis for her right pleural effusion. She was transferred to teh telemetry floor on . Her Coumadin was resumed, she began to progress with physical therapy and ambulation. Over the next few days, she continued to have a large amount of serous drainage from her chest tube, and re-dosing of doxycycline was considered. On , her drainage had decreased, and her chest tube was ultimately removed on . Follow-up chest x-ray on showed small, stable biapical pneumothoraces. She is ready to be discharged from the hospital, but still requiring assistance to ambulate. She will be sent to rehab to progress with physical therapy. | Incidental note of mitral anular calcifications. afebrile.resp: bilateral upper ls clr, bases are dim. Resolving biapical pneumothoraces. FINAL REPORT INDICATION: Status post pericardial window, now status post right chest tube. + pulses to lower ext. Foley w qs huop. ABGs WNL, weaned to CPAP/PS. extremities w/d. a-line dc'd. neuro: pt is a&ox3-appropriate. There is a right middle lobe bleb. Prior inferiormyocardial infarction. Left anteriorfascicular block. Small pericardial effusion. REASON FOR THIS EXAMINATION: s/p ct d/c FINAL REPORT INDICATION: Status post right chest tube D/C. Resp CarePost Op vented orig with SIMV/PS. There is a small pericardial effusion. compression sleeves on for dvt prophylaxis. compression sleeves on for dvt prophylaxis. Mg: 1.6-repleated. Rt radial aline intact, dsg changed. There is a small foci of air within the anterior mediastinum likely secondary to the patient's recent pericardial window. Slight increase in right pleural effusion with loculated intrafissural component. There is a large-sized right- sided pleural effusion with Hounsfield attenuation units consistent with simple fluid. A right-sided chest tube tip is in the inferomedial aspect of the pleural space. s/p L CT removal with small apical PTX, now d/c right Ct REASON FOR THIS EXAMINATION: accumulation of ptx? compression boot on. Bilateral chest tubes have been removed. There is a moderate right-sided pleural effusion with associated atelectasis, increased. IMPRESSION: New small left apical and basilar pneumothorax status post chest tube removal. INDICATION: Pneumothorax. Prior anteroseptal myocardial infarction. HISTORY: Pericardial effusion. c/o pain from ct site treated w/percocet w/good effect. afebrile. afebrile. BS clear, extubated after repeat ABGs WNL. Large increasing right pleural effusion with Hounsfield attenuation consistent with simple fluid. FINAL REPORT TWO VIEW CHEST of COMPARISON: . +perrl.cv: af 80s-90s, bp 100s-130s by cuff, AM lopressor given; palpable pulses. Minimal edema noted. Atrial fibrillation with a controlled ventricular response. Admitting Diagnosis: CORONARY ARTERY DISEASE\PERICARDIAL WINDOW W/? Admitting Diagnosis: CORONARY ARTERY DISEASE\PERICARDIAL WINDOW W/? IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. A left-sided chest tube is seen coursing apically and medially. Coronary artery calcifications. serosang. FINDINGS: There is a small left apical pneumothorax including a small left basilar pneumothorax. Chest tube dsgs intact.Pt. There is a very small left- sided pleural effusion with associated atelectasis. AM ABG: 7.46/37/93/27.CV: Afib without ectopy. OF PLEURAL EFFUSION Field of view: 36 FINAL REPORT (Cont) 6. HR 80-110, SBP 85-130, titrated Neo as needed. palp pulses. Left-sided pneumothorax. REASON FOR THIS EXAMINATION: eval R pleural effusion for thoracic consult. COMPARISON: . Bp stable. OF PLEURAL EFFUSION Admitting Diagnosis: CORONARY ARTERY DISEASE\PERICARDIAL WINDOW W/? Moderate cardiomegaly and aortic calcifications are again noted. Stable small left pneumothorax. Partial improvement in right pleural effusion and right basilar opacity. recent L CT removal with small apical PTX. recent L CT removal with small apical PTX. recent L CT removal with small apical PTX. Stable small right pleural effusion. Unchanged moderate right pleural effusion. IMPRESSION: Stable small biapical pneumothoraces and small bilateral pleural effusions. IMPRESSION: Stable small biapical pneumothoraces, status post chest tube removal. FINDINGS: Right-sided chest tube has been removed. s/p L CT removal with small apical PTX, now d/c right Ct REASON FOR THIS EXAMINATION: eval for change, ptx FINAL REPORT INDICATION: Status post pericardial window. Small bipical pneumothoraces, right slightly greater than left, are unchanged in the interim. Small right pleural effusion is decreased in the interim. remains off neo gttresp: LS clear, dim on left side. ogt dc'd with extubation. CHEST: PA and lateral views. CHEST: PA and lateral views. Small right pleural effusion is unchanged. hct stable. Unchanged small left pleural effusion. The small left apical pneumothorax is unchanged. Trachea is midline. Bilateral chest tubes are in place. pp by doppler. New right pleural or parenchymal opacity of uncertain etiology. Right-sided pleural effusion remains unchanged. CT DRAINAGE MODEARTE SERO SANG, CHEST DSG CHANGED X1. CHEST: AP supine portable view. Ct to sx. Small bilateral pleural effusions with foci of loculated fluid remain unchanged. Small left pleural effusion is unchanged. Small bilateral pleural effusions are unchanged. REVERSED AT APPROX. A small apical pneumothorax remains unchanged. Right chest tube remains in place. IMPRESSION: Persistent right-sided pleural effusion. There is mild pulmonary edema and an unchanged right pleural effusion. Right chest tube for pleural effusion. BS WNL. post extubation abg wnl. Moderate height loss is again noted in several lower thoracic vertebra. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. Evaluation of the medial right lung apex is slightly limited by superimposition of the patient's chin. There is a new nasogastric tube, with tip in the proximal stomach and side port at or just beyond the gastroesophageal junction. Recent left chest tube removal with small pneumothorax. AP and lateral radiographs of the chest again demonstrated right-sided chest tube. REASON FOR THIS EXAMINATION: eval for interval change re: L apical PTX. There is evidence of right-sided volume loss. The right chest tube remains in place. Small left-sided effusion. There is probably a small left-sided effusion. PERRL. CHEST: AP upright portable view. 12:06 AM CHEST (PORTABLE AP) Clip # Reason: eval for interval change re: L apical PTX. | 21 | [
{
"category": "ECG",
"chartdate": "2110-07-07 00:00:00.000",
"description": "Report",
"row_id": 117443,
"text": "Atrial fibrillation with a controlled ventricular response. Left anterior\nfascicular block. Prior anteroseptal myocardial infarction. Prior inferior\nmyocardial infarction. Compared to the previous tracing of there is\nvariation in precordial lead placement. No diagnostic interim change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-08 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 916786,
"text": " 5:58 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval R pleural effusion for thoracic consult. NO IV contrast\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with recurrent pericardial and pleural effusion, now s/p\n pericardial drainage/window.\n REASON FOR THIS EXAMINATION:\n eval R pleural effusion for thoracic consult. NO IV contrast needed.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 86-year-old female with recurrent pericardial and pleural\n effusions, now status post pericardial window, evaluate for right pleural\n effusion.\n\n Note is made of chest x-ray of .\n\n TECHNIQUE: MDCT axial images of the chest were obtained without IV contrast.\n\n CT CHEST WITHOUT IV CONTRAST: Lack of IV contrast limits evaluation of the\n vessels and solid organs. There is a small pericardial effusion. There is\n cardiomegaly. There is coronary artery as well as aortic calcifications.\n Otherwise, the great vessels appear to be unremarkable. The bronchi are\n patent bilaterally. There are scattered mediastinal and axillary lymph nodes,\n which do not meet the CT criteria for pathologic enlargement. The largest\n precarinal lymph node measures 9 mm.\n\n There is a large-sized right- sided pleural effusion with Hounsfield\n attenuation units consistent with simple fluid. There is associated\n atelectasis. There is a very small left- sided pleural effusion with\n associated atelectasis. A left-sided chest tube is seen coursing apically and\n medially. There is a very small left-sided hydropneumothorax. There is a\n small foci of air within the anterior mediastinum likely secondary to the\n patient's recent pericardial window. There are scattered 4-mm pulmonary\n nodules in the left lower lung as well as one in the right middle lobe. There\n is a right middle lobe bleb.\n\n The visualized portions of the upper abdomen appear unremarkable.\n\n The osseous structures are unremarkable.\n\n IMPRESSION:\n 1. Large increasing right pleural effusion with Hounsfield attenuation\n consistent with simple fluid.\n 2. Small pericardial effusion.\n 3. Left-sided pneumothorax. Note is made of a left-sided chest tube.\n 4. Small amount of anterior mediastinal free air likely secondary to\n patient's recent intervention.\n 5. Scattered pulmonary nodules for which continued surveillance is\n recommended.\n (Over)\n\n 5:58 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval R pleural effusion for thoracic consult. NO IV contrast\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 6. Coronary artery calcifications.\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 (Over)\n\n 5:58 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval R pleural effusion for thoracic consult. NO IV contrast\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\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": "2110-07-06 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 916397,
"text": " 10:02 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with\n REASON FOR THIS EXAMINATION:\n pericardial effusion\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, .\n\n HISTORY: Pericardial effusion.\n\n IMPRESSION: PA and lateral chest compared to :\n\n The cardiac silhouette is enlarged but not as large as it was on . There is no mediastinal vascular engorgement to suggest elevated\n central venous pressure due to pericardial tamponade, constricted\n pericarditis, or right heart failure. Cardiac configuration suggests\n substantial left atrial enlargement. Moderate right pleural effusion is\n slightly larger today. Tiny left pleural effusion is unchanged. Lungs are\n essentially clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 917123,
"text": " 8:00 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: s/p ct d/c\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with s/p Pericardial Window via Left Thorascopy, now s/p\n right chest tube.\n REASON FOR THIS EXAMINATION:\n s/p ct d/c\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right chest tube D/C.\n\n COMPARISON: .\n\n FINDINGS: There is a small left apical pneumothorax including a small left\n basilar pneumothorax. Bilateral chest tubes have been removed. Small right\n pleural effusion is unchanged. Small bibasilar atelectasis is unchanged.\n Small left pleural effusion is unchanged. Pulmonary vasculature is normal.\n The cardiac and mediastinal silhouettes are stable.\n\n IMPRESSION: New small left apical and basilar pneumothorax status post chest\n tube removal. These findings were communicated with Dr. at 9:00 p.m.\n on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-15 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 917691,
"text": " 9:00 AM\n CHEST (PA & LAT) Clip # \n Reason: accumulation of ptx?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p pericardial window, s/p R chest tube for pleural\n effusion. s/p L CT removal with small apical PTX, now d/c right Ct\n REASON FOR THIS EXAMINATION:\n accumulation of ptx?\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST of \n\n COMPARISON: .\n\n INDICATION: Pneumothorax.\n\n Very small biapical pneumothoraces, both of which have decreased since the\n recent radiograph. The heart is enlarged but unchanged in size. There are\n persistent bilateral pleural effusions. The right effusion has slightly\n increased in the interval with new areas of intrafissural loculation. A\n poorly defined focal opacity in the left midlung is without change and may\n also be due to focal partial loculated pleural fluid and adjacent atelectasis.\n\n IMPRESSION:\n\n 1. Resolving biapical pneumothoraces.\n\n 2. Slight increase in right pleural effusion with loculated intrafissural\n component.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916950,
"text": " 6:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for tube position, PTX.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with s/p Pericardial Window via Left Thorascopy, now s/p\n right chest tube.\n REASON FOR THIS EXAMINATION:\n Please assess for tube position, PTX.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pericardial window, now status post right chest tube.\n\n COMPARISON: CT of the chest from .\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: A left-sided chest tube tip is\n in the lung apex. A right-sided chest tube tip is in the inferomedial aspect\n of the pleural space. Small left-sided pneumothorax visualized on the CT is\n not seen on the current study. There is a moderate right-sided pleural\n effusion with associated atelectasis, increased. There may be a small left-\n sided pleural effusion. The cardiac silhouette is enlarged as compared to the\n prior study. There is pulmonary vascular congestion. Incidental note of\n mitral anular calcifications. Clips are seen in the right upper quadrant.\n There are air and stool filled loops of colon in the upper abdomen.\n\n IMPRESSION:\n 1. Increase in the cardiac silhouette as compared to the prior study, raising\n question of increasing pericardial effusion, and increase in the size of the\n right pleural effusion.\n 2. Borderline pulmonary edema.\n\n Findings discussed with Haughen, the nurse caring for the patient.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-10 00:00:00.000",
"description": "Report",
"row_id": 1279800,
"text": "neuro: pt is a&ox3, maes to command, oob->chair, ambulated w/pt; percocet for pain w/good effect. +perrl.\n\ncv: af 80s-90s, bp 100s-130s by cuff, AM lopressor given; palpable pulses. extremities w/d. compression sleeves on for dvt prophylaxis. afebrile.\n\nresp: bilateral upper ls clr, bases are dim. o2sats >98% on 4l nc-o2 weaned to 2l-sats remain >97%. resp rate 20s. I.S. up to 500; left & rt pleural ct's draining min serosang fluid qh. pt traveled for pa & lateral xray per .\n\ngi/gu: tolerates po intake & meds, no c/o nausea. +bs, no bm, abd soft, nt, nd. adequate huo-clr yellow, no sediment noted.\n\nendo: bs monitored per csru ss protocol-covered w/rssi and iv-see carevue.\n\nsocial: husband visited, son telephoned, plans visit in evening.\n\nplan: continue monitoring cardioresp status. pulm toilet, monitor labs, increase activity & po intake as tolerated. transfer to 2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-09 00:00:00.000",
"description": "Report",
"row_id": 1279797,
"text": "1900-0700\n\nNeuro: Pt awake, alert, oriented X3. Follows commands well. MAEs. Speech clear and appropriate. No neuro deficits noted.\n\nResp: Pt with 4 L NC on. Resp shallow at times, encouraged to practice deep breathing and coughing exercises. Weak congested cough. O2sat 94-98%, Lungs clear/diminished at the bases. Rt radial aline intact, dsg changed. AM ABG: 7.46/37/93/27.\n\nCV: Afib without ectopy. HR 80-110, SBP 85-130, titrated Neo as needed. afebrile. Medicated for incisional pain X1 percocet with good effect. + pulses to lower ext. compression boot on. Minimal edema noted. Skin warm/dry/intact. Mg: 1.6-repleated. WBC: 12.4. Received last dose of Vanco this am. Pericardial drain to pleurevac at -15cm suction draining minimal amounts of S/S fluid. Dsh to site D+I.\nPIV X1.\n\nGI/GU: Abd softly dist, + BS, no BM. Tolerating diet well. Foley to BSD draining clear yellow urine. Pt received IV lasix for minimal UO with good effect.\n\nEndo: RISS with oral \n\nPlan: Supportive care, resp support, DBC exercises.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-09 00:00:00.000",
"description": "Report",
"row_id": 1279798,
"text": "neuro: pt is a&ox3-appropriate. maes to command. oob->chair for 8hrs. c/o pain from ct site treated w/percocet w/good effect. +perrl.\n\ncv: af 80s-100s, bp tolerates 90s-140s w/maps >60. cuff pressure correlates w/a-line. palp pulses. extremities pink w/d. afebrile. compression sleeves on for dvt prophylaxis. a-line dc'd. rt ant piv placed by iv nurse.\n\nresp: upper ls clr, bases dim, o2sats >95% on 4l nc weak cough. L pleural ct draining min serous fluid this shift; rt pleural ct placed @1800 drained >1000cc serous fluid by 1900. cough much improved after rt pleural ct placed.\n\ngi/gu: tolerates po intake & meds, +bs, no bm, abd firm distended, but nontender. adequate clr yello huo most of shift with 1 marginal hr. ivp lasix in AM w/little diuresis.\n\nendo: bs monitored per ss protocol~covered w/metformin & rssi. ? consult.\n\nsocial: husband & son visited.\n\nplan: continue monitoring cardioresp status. monitor 02sats, bld sugars~? consult. monitor labs, treat as appropriate. increase activity & po intake as tolerated. transfer to 2.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-10 00:00:00.000",
"description": "Report",
"row_id": 1279799,
"text": "neuro: Alert and oriented. Pleasant and cooperative. Mae to command Med x 2 for c/o pain with percocet 1 tab= good effect. Slept well.\nCV/resp Afib started on lopresser. Bp stable. lungs clear. o2 sat wnl. new right chest tube drained 250cc. serosang. sample sent to lab.\nLeft chest tube 25cc serous fluid drained.\ngi/gu reg diet/no stools. Foley w qs huop. On iv lasix.\nInteg. Chest tube dsgs intact.\nPt. is stable. Called out to floor. Orders are written.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-07 00:00:00.000",
"description": "Report",
"row_id": 1279792,
"text": "Resp Care\nPost Op vented orig with SIMV/PS. ABGs WNL, weaned to CPAP/PS. BS clear, extubated after repeat ABGs WNL. Good cough. Placed on 4LPM .\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-07 00:00:00.000",
"description": "Report",
"row_id": 1279793,
"text": "PATIENT ADMITTED TO CSRU ON NEO/PROPOFOL, WEANED OFF NEO EASILY. REVERSED AT APPROX. 1245 PROPOFOL OFF BY 1300, TOO SLEEPY TO WEAN, EVENTUALLY PLACED ON CPAP5/5. CT DRAINAGE MODEARTE SERO SANG, CHEST DSG CHANGED X1. BS WNL. GU U/O DROPPED OFF AFTER A FEW HRS, 250CC LR BOLUS GIVEN. NP OF MINIMAL RESPONSE.. HUSBAND AT BEDSIDE UPDATE GIVEN. PLAN TO WEAN TO EXTUBATE. MEDICATED WITH NORPHINE 1MG X2 WITH GOOD RESULTS PER PATIENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-07 00:00:00.000",
"description": "Report",
"row_id": 1279794,
"text": "1400-1900 update\nneuro: pt woken and extubated ~ 1500. pt remains lethargic although easily arousable. PERRL. pt MAE and able to follow commands\n\nCv: pt remains in afib, HR 70-80's. SBP 100-130's. MAP 60-70's. hct stable. pp by doppler. remains off neo gtt\n\nresp: LS clear, dim on left side. pt extubated ~ 1500 and placed on 4 L nc, o2 sats > 98%. post extubation abg wnl. CT draining serousanginous fluid, no airleak noted\n\ngi/gu: BS absent. ogt dc'd with extubation. foley draining clear yellow urine. Uo boarderline.\n\nendo: started on insulin gtt for elvated bs. insulin gtt currently off d/t low BS. insulin gtt titrated per protocol\n\nplan: monitor lytes/bs/hct, pulm toleit, pain management, ? 2 in am, advance diet and activity as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-08 00:00:00.000",
"description": "Report",
"row_id": 1279795,
"text": "Pt. is s/p pericardial window via VAT procedure. Most recently experiencing worsening SOB.\n\nNeuro: pt. is alert and cooperative. MAE. lethargic at times but awakens easily.\n\nCV: neo for BP. Titrated to keep SBP >100 or MAP >60. HR afib >100 but came down to 80's after fluid bolus. aline waveform dampening; NBP cuff in place for BP readings.\n\nPulm: productive cough; swallowing. Ct to sx. drng serosang,\n\nGI/GU: no n/v. taking small amounts ice chips. Small amounts cl.yellow urine via foley.\n\nEndo: ssri for elevated bs[s.\n\nplan: med for pain prn. Pulm hygeine.monitor for increasing SOB. wean neo. transfer to floor when stable.advance DAT and activities as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-07-08 00:00:00.000",
"description": "Report",
"row_id": 1279796,
"text": "nursing note (7a-7p): NO BP/IV's in left arm (lumpectomy)\n\nneuro: a&ox3, mae's, oob x 1 and ambulated w/PT, percocet (1 tab) given for pain management\n\nresp: lungs sounds diminished, started on IS & reminded about CBD, on 4l/nc w/sats>94%, rr wnl\n\ncv: hr 70's a-fib w/no ectopy, sbp goal>90 still on small amount of neo, a-line slight damp and lower than nbp but flushed & draws well, CT's remain in w/minimal pericardial fluid drainage, 2 units of RBC's given, no drainage from site, plan for CAT scan either or being followed by Dr. \n\ngu/gi: diet increased to regular, foley w/moderate UO still positive fluid, +bs w/no bm\n\nendo: oral DM, meds given and covered by ssri\n\nplan/goal: con't w/pulmonary toilet, increase activity as tolerated, ?? possible transfer in am\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916534,
"text": " 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx, effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with s/p Pericardial Window via Left Thorascopy\n REASON FOR THIS EXAMINATION:\n ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post pericardial window.\n\n COMPARISON: .\n\n CHEST: AP supine portable view. There is a new endotracheal tube, with tip\n 2.5 cm above the carina. There is a new nasogastric tube, with tip in the\n proximal stomach and side port at or just beyond the gastroesophageal\n junction. There is a new left apical chest tube, with no evidence of a\n pneumothorax in supine position, and no left pleural effusion. No pericardial\n catheter is identified. The cardiac silhouette is slightly smaller than on\n the previous study. There is mild pulmonary edema and an unchanged right\n pleural effusion.\n\n IMPRESSION:\n 1. Slightly decreased cardiac silhouette likely due to decreased effusion.\n 2. Unchanged moderate right pleural effusion.\n 3. The nasogastric tube could be advanced further into the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 917142,
"text": " 12:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change re: L apical PTX. Please perform a\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p pericardial window, s/p R chest tube for pleural\n effusion. recent L CT removal with small apical PTX.\n REASON FOR THIS EXAMINATION:\n eval for interval change re: L apical PTX. Please perform at midnight tonight.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left apical pneumothorax, status post pericardial window and right\n chest tube for pleural effusion.\n\n COMPARISON: .\n\n CHEST: AP upright portable view. The small left apical pneumothorax is\n unchanged. There is no right pneumothorax. Small right pleural effusion is\n unchanged. Right chest tube remains in place. There is a new opacity\n projecting over the lateral lower aspect of the left hemithorax, which may be\n pleural or parenchymal. There is no pulmonary edema. Moderate cardiomegaly\n and aortic calcifications are again noted.\n\n IMPRESSION:\n\n 1. Stable small left pneumothorax.\n\n 2. Stable small right pleural effusion.\n\n 3. New right pleural or parenchymal opacity of uncertain etiology. Further\n evaluation by PA and lateral views is suggested.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-12 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 917333,
"text": " 1:34 PM\n CHEST (PA & LAT) Clip # \n Reason: check R pleural placque\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p pericardial window, s/p R chest tube for pleural\n effusion. recent L CT removal with small apical PTX.\n REASON FOR THIS EXAMINATION:\n check R pleural placque\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube placement.\n\n AP and lateral radiographs of the chest again demonstrated right-sided chest\n tube. There is evidence of right-sided volume loss. Right-sided pleural\n effusion remains unchanged. Trachea is midline. The previously described\n left apical pneumothorax is not evident on the current study. Increased\n opacity projecting over the left mid lung is a new finding. There is probably\n a small left-sided effusion. Cardiomediastinal contours are unchanged.\n\n IMPRESSION:\n\n Persistent right-sided pleural effusion. Small left-sided effusion.\n\n No pneumothorax detected in either hemithorax.\n\n Increased opacity in the left mid lung likely represents atelectasis. Early\n pneumonia is not excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 917076,
"text": " 2:09 PM\n CHEST (PA & LAT) Clip # \n Reason: eval position of chest tubes\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman with pericardial window\n\n REASON FOR THIS EXAMINATION:\n eval position of chest tubes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post pericardial window with multiple chest tubes.\n\n COMPARISON: .\n\n CHEST: PA and lateral views. Evaluation of the medial right lung apex is\n slightly limited by superimposition of the patient's chin. Small right\n pleural effusion is decreased in the interim. Right basilar opacity is nearly\n completely improved. Small left pleural effusion is unchanged. There is no\n pneumothorax. Bilateral chest tubes are in place. There is no pulmonary\n edema.\n\n IMPRESSION:\n 1. Partial improvement in right pleural effusion and right basilar opacity.\n 2. Unchanged small left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 917620,
"text": " 5:04 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for change, ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p pericardial window, s/p R chest tube for pleural\n effusion. s/p L CT removal with small apical PTX, now d/c right Ct\n REASON FOR THIS EXAMINATION:\n eval for change, ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pericardial window. Right chest tube for pleural\n effusion. Chest tube DC'd, eval for change.\n\n COMPARISON: at 8:56. (7 hours prior).\n\n FINDINGS: Right-sided chest tube has been removed. A small apical\n pneumothorax remains unchanged. There is also is a tiny left apical\n pneumothorax, unchanged. Small bilateral pleural effusions are unchanged.\n Cardiac and mediastinal contours are stable. Pulmonary vasculature is normal.\n Disc height loss of multiple lower thoracic vertebrae are unchanged.\n\n IMPRESSION: Stable small biapical pneumothoraces, status post chest tube\n removal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-07-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 917518,
"text": " 8:53 AM\n CHEST (PA & LAT) Clip # \n Reason: eval effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\PERICARDIAL WINDOW W/? OF PLEURAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old woman s/p pericardial window, s/p R chest tube for pleural\n effusion. recent L CT removal with small apical PTX.\n REASON FOR THIS EXAMINATION:\n eval effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post pericardial window and right chest tube for right\n pleural effusion. Recent left chest tube removal with small pneumothorax.\n\n COMPARISON: .\n\n CHEST: PA and lateral views. Small bipical pneumothoraces, right slightly\n greater than left, are unchanged in the interim. The right chest tube remains\n in place. Small bilateral pleural effusions with foci of loculated fluid\n remain unchanged. There is no pulmonary edema. Cardiac and mediastinal\n contours are stable. Moderate height loss is again noted in several lower\n thoracic vertebra.\n\n IMPRESSION: Stable small biapical pneumothoraces and small bilateral pleural\n effusions.\n\n\n"
}
] |
69,201 | 149,143 | Pt was seen in the ED for possible NSTEMI. He had been complaining of abdominal pain and back pain status post a syncopal episode while shaving. He he did hit his head and was out for seconds. He denied any headache neck pain chest pain or shortness of breath, he was having ongoing abdominal back pain. We were called to see the pt emergently. He had OSH imaging that demonstrated a ruptured 10cm AAA. We attempted to obtain a CTA torso as the OSH imaging was non contrasted. He lost his blood pressure while on the CT table and was brought emergently to the operative suite. He underwent an emergent EVAR with rapid transfusion protocol intstituted. Decompressive laparotomy performed with evacution of hematoma and noted ongoing exsanquination. He went into PEA arrest multiple times and responded to resuscitative efforts. Additional stent grafts placed proximally to obtain hemmorhage econtrol, covering the mesenertic vessels transiently. Ventricular thrombus and aortic thrombus noted on ECHO and angiogram despite aortic control. A decision was made to discontinue aggressive resuscitative efforts and the patient expired. His family was updated during the procedure and then again after his passing. | The pancreas is pushed anteriorly by retroperitoneal hematoma, but is otherwise unremarkable. Scattered calcifications are seen of the thoracic aorta as well as the aortic root. The right kidney is unremarkable. Probable prior inferior myocardial infarction of indeterminateage. Evaluate aorta with non-contrast CT. FINDINGS: CHEST: The thyroid is unremarkable. Loss of intervertebral disc space height of L5-S1 with large anterior osteophyte and endplate sclerosis. The gallbladder is unremarkable. Diffuse centrilobular emphysema without focal consolidation, pleural effusion, or pneumothorax. Bilateral internal iliac arteries are aneurysmal and measure 2.0 cm on the left and 2.2 cm on the right. The heart is otherwise unremarkable on this non-contrast exam. TECHNIQUE: MDCT images were obtained from the thoracic inlet to the pubic symphysis without the administration of IV contrast. IMPRESSION: Ruptured infrarenal fusiform abdominal aortic aneurysm measuring 10.4 x 9.7 cm, with acute hematoma within its lumen, large retroperitoneal hematoma and a small amount of hemoperitoneum. Bedside ultrasound demonstrates an enlarged aortic diameter. No hilar, mediastinal, or axillary lymphadenopathy meeting CT size criteria. 1.9 x 1.3 cm ground-glass opacity in the superior portion of left lower lobe (2:23) is noted. Left anterior descending coronary artery calcifications are present. PELVIS: The bladder is unremarkable. Large amount of mixed density complex fluid seen in the retroperitoneum on the left extending into the pelvis. Early R wave transition with generous R wave in leads V1-V2 suggestiveof possible prior posterior wall myocardial infarction of indeterminate age.Non-specific ST-T wave changes in the inferolateral leads with low QRS voltagein the limb leads. Sigmoid diverticulosis noted. No large pericardial effusion. please evaluate aorta with noncontrast CT No contraindications for IV contrast WET READ: EHAd FRI 12:11 PM 1. Nonspecific left lower lobe ground glass opacity, 1.9 cm. Airways are otherwise patent to subsegmental levels. Soft tissue stranding related to acute aortic rupture surrounds the left kidney and within the anterior and posterior pararenal space. Ruptured infrarenal abdominal aortic aneurysm measuring up to 10.4 x 9.7 cm, with complex left retroperitoneal fluid and stranding. ABDOMEN: A fusiform infrarenal abdominal aortic aneurysm begins 1.5 cm below the left renal artery, measures 10.4 x 9.7 cm (AP x LR) in maximal dimensions, and tapers at the aortic bifurcation to about 2.9 cm in diameter. Mucous plug within right mainstem bronchus. Bilateral common iliac arteries are also aneurysmal, measuring up to 2.7 cm on the right (2:93) and 2.4 cm on the left (2:92). The stomach is unremarkable. No pneumoperitoneum or abdominal wall hernia. Based on an unenhanced scan, the liver appears normal without focal or diffuse abnormality. Right main stem bronchus contains a mucus plug. A small amount of high density pelvic fluid is present. Cresent of hyperdensity is seen within the expanded lumen of the aneurysm compatible with acute hematoma and there is more focal bulge with interruption of mural (Over) 11:52 AM CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # Reason: aortic diameter appears on bedside ultrasound to be enlarged FINAL REPORT (Cont) calcification along the left superior anterolateral aspect of the aneurysm (2:73), suspected site of rupture. DLP: 447 mGy-cm. No mesenteric lymphadenopathy. OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for malignancy. The bilateral adrenal glands are normal. The small and large bowel are normal in course and caliber. 11:52 AM CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # Reason: aortic diameter appears on bedside ultrasound to be enlarged MEDICAL CONDITION: History: 83M with acute onset abdominal pain, syncope REASON FOR THIS EXAMINATION: aortic diameter appears on bedside ultrasound to be enlarged. Sinus rhythm. The spleen is normal. Axial images were interpreted in conjunction with coronal and sagittal reformats. COMPARISONS: None. The prostate gland is markedly enlarged, measuring a 6.4 x 4.8 cm (transverse x AP dimensions). No previous tracing available for comparison. 3. 2. WET READ VERSION #1 FINAL REPORT INDICATION: 83-year-old male with acute onset of abdominal pain and syncope. | 2 | [
{
"category": "Radiology",
"chartdate": "2107-07-08 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1245332,
"text": " 11:52 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: aortic diameter appears on bedside ultrasound to be enlarged\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 83M with acute onset abdominal pain, syncope\n REASON FOR THIS EXAMINATION:\n aortic diameter appears on bedside ultrasound to be enlarged. please evaluate\n aorta with noncontrast CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EHAd FRI 12:11 PM\n 1. Ruptured infrarenal abdominal aortic aneurysm measuring up to 10.4 x 9.7\n cm, with complex left retroperitoneal fluid and stranding.\n 2. Nonspecific left lower lobe ground glass opacity, 1.9 cm.\n 3. Mucous plug within right mainstem bronchus.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 83-year-old male with acute onset of abdominal pain and syncope.\n Bedside ultrasound demonstrates an enlarged aortic diameter. Evaluate aorta\n with non-contrast CT.\n\n COMPARISONS: None.\n\n TECHNIQUE: MDCT images were obtained from the thoracic inlet to the pubic\n symphysis without the administration of IV contrast. Axial images were\n interpreted in conjunction with coronal and sagittal reformats.\n\n DLP: 447 mGy-cm.\n\n FINDINGS:\n\n CHEST:\n\n The thyroid is unremarkable. No hilar, mediastinal, or axillary\n lymphadenopathy meeting CT size criteria. Scattered calcifications are seen\n of the thoracic aorta as well as the aortic root. Left anterior descending\n coronary artery calcifications are present. The heart is otherwise\n unremarkable on this non-contrast exam. No large pericardial effusion.\n\n 1.9 x 1.3 cm ground-glass opacity in the superior portion of left lower lobe\n (2:23) is noted. Diffuse centrilobular emphysema without focal consolidation,\n pleural effusion, or pneumothorax. Right main stem bronchus contains a mucus\n plug. Airways are otherwise patent to subsegmental levels.\n\n ABDOMEN:\n\n A fusiform infrarenal abdominal aortic aneurysm begins 1.5 cm below the left\n renal artery, measures 10.4 x 9.7 cm (AP x LR) in maximal dimensions, and\n tapers at the aortic bifurcation to about 2.9 cm in diameter. Cresent of\n hyperdensity is seen within the expanded lumen of the aneurysm compatible with\n acute hematoma and there is more focal bulge with interruption of mural\n (Over)\n\n 11:52 AM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: aortic diameter appears on bedside ultrasound to be enlarged\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n calcification along the left superior anterolateral aspect of the aneurysm\n (2:73), suspected site of rupture. Large amount of mixed density complex\n fluid seen in the retroperitoneum on the left extending into the pelvis.\n\n Bilateral common iliac arteries are also aneurysmal, measuring up to 2.7 cm on\n the right (2:93) and 2.4 cm on the left (2:92). Bilateral internal iliac\n arteries are aneurysmal and measure 2.0 cm on the left and 2.2 cm on the\n right.\n\n Based on an unenhanced scan, the liver appears normal without focal or diffuse\n abnormality. The gallbladder is unremarkable. The pancreas is pushed\n anteriorly by retroperitoneal hematoma, but is otherwise unremarkable. The\n spleen is normal. The bilateral adrenal glands are normal. The right kidney\n is unremarkable. Soft tissue stranding related to acute aortic rupture\n surrounds the left kidney and within the anterior and posterior pararenal\n space.\n\n The stomach is unremarkable. The small and large bowel are normal in course\n and caliber. Sigmoid diverticulosis noted.\n\n No mesenteric lymphadenopathy. No pneumoperitoneum or abdominal wall hernia.\n\n\n PELVIS: The bladder is unremarkable. The prostate gland is markedly\n enlarged, measuring a 6.4 x 4.8 cm (transverse x AP dimensions). A small\n amount of high density pelvic fluid is present.\n\n OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for\n malignancy. Loss of intervertebral disc space height of L5-S1 with large\n anterior osteophyte and endplate sclerosis.\n\n IMPRESSION:\n Ruptured infrarenal fusiform abdominal aortic aneurysm measuring 10.4 x 9.7\n cm, with acute hematoma within its lumen, large retroperitoneal hematoma and a\n small amount of hemoperitoneum.\n\n\n Findings were communicated in person by with the ED attending at\n the time of study.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-07-08 00:00:00.000",
"description": "Report",
"row_id": 305009,
"text": "Sinus rhythm. Probable prior inferior myocardial infarction of indeterminate\nage. Early R wave transition with generous R wave in leads V1-V2 suggestive\nof possible prior posterior wall myocardial infarction of indeterminate age.\nNon-specific ST-T wave changes in the inferolateral leads with low QRS voltage\nin the limb leads. No previous tracing available for comparison.\n\n"
}
] |
4,599 | 109,574 | his significant abdominal examination the patient was started on Ampicillin, Levofloxacin and Flagyl. The patient was made NPO and he was supported with intravenous fluids. On hospital day two the patient underwent a CT of the abdomen and pelvis, which showed an intraabdominal fluid collection with enhancing room throughout the peritoneal cavity, which was found to connect up with a small pocket of fluid adjacent to the ileocolic anastomotic site and mid pelvis. There was also gas noted within the small pocket of fluid and this was interpreted to be consistent with an intraabdominal abscess and a possible anastomotic leak. There was no evidence of bowel wall thickening and no evidence of obstruction at that time. The patient started developing a fever of a temperature max of 102.5 despite being on intravenous antibiotics with an unchanged abdominal examination. Therefore the patient underwent a CT guided drainage of the abscess on hospital day three removing approximately 10 cc of purulent substance on initial insertion and the patient received a pigtail catheter in the right lower quadrant. After the procedure the patient was continued on intravenous antibiotics Ampicillin, Levofloxacin and Flagyl and continued to receive intravenous fluids. The patient was noted to have declining urine output requiring more then 6 liters of intravenous fluid resuscitation. The patient became tachycardic and on laboratory examination the patient was found to have decrease in hematocrit from 32.4 to 21.8 over the course of 11 hours. The patient was also found to be thrombocytopenic with a platelet count down to 49 and a rise in creatinine to 2.3. Given these conditions the patient was thought to underwent an active intraabdominal bleeding or having sepsis with coagulopathy. The patient was urgently transferred to the Trauma Surgical Intensive Care Unit for close monitoring. The patient was monitored with serial hematocrit checks and was transfused packed red blood cells and platelets as needed. The patient underwent a repeat CAT scan of the abdomen and was found to have a new collection in the upper abdominal area, which contained air and extravasated barium. The pigtail catheter was inserted into this new area of abscess removing approximately 20 cc of thick viscous brown liquid. Subsequent to the second CT guided drainage the patient returned to the Surgical Intensive Care Unit, but progressively became dyspneic and was having respiratory difficulty. The patient was intubated on and was urgently taken to the Operating Room for exploratory laparotomy. On the patient successfully underwent drainage of the intraabdominal abscesses, lysis of adhesions and a creation of a loop ileostomy. Please see the operative report for further details. The patient left the Operating Room in critical condition, intubated and returned to the Trauma Surgical Intensive Care Unit with three JP drains and continued on intravenous antibiotics including Vancomycin, Ceftriaxone, Flagyl and Fluconazole. Preoperatively the patient's creatinine values were rising and by postoperative day one they were even higher to a value of 4.2. The patient was seen by Renal Consult Service, calculated fraction excretion of sodium (FENA) was 1.9%. The patient's urine was shown to have many granular and muddy brown casts with proteinuria and hematuria, all the finding, which were consistent with acute renal failure and acute tubular necrosis. For management of this intravascular and extravascular volume the patient underwent hemodialysis. Postoperatively, the patient was also started on total parenteral nutrition with minimal volume and a low protein given his acute renal failure. With respect to his respiratory system the patient was intubated and was on the ventilator machine and was able to tolerate a CPAP with pressure support by postoperative day three and was successfully extubated on postoperative day four. The patient was on Ampicillin and Levofloxacin preoperatively and postoperatively the patient was on Vancomycin and Ceftriaxone, Flagyl and Fluconazole. The abscess drainage from grew out pan sensitive enterococcus eventually. The second CT guided drainage of the abscess grew out Levofloxacin resistant enterococcus and Ceptaz and Cipro resistant Pseudomonas and staph aureus that was resistant to Levaquin and Penicillin, but sensitive to Vancomycin. Postoperatively, the patient also started developing infection of his pulmonary system with his sputum cultures growing out Pseudomonas. Ceftriaxone was changed to Meropenem and the patient was continued on Vancomycin, Meropenem, Flagyl and Fluconazole for treatment of his Pseudomonas pneumonia and intraabdominal infection. Unfortunately the sputum cultures subsequently grew out Pseudomonas, but became resistant to Meropenem. However, remained sensitive to Zosyn. When the sensitivities returned as previously mentioned the patient was taken off the Meropenem and started on Zosyn and continued on Vancomycin. Nutritionally the patient s continued on total parenteral nutrition, but was also started on tube _______ via Dobbhoff tube and was doing relatively well until postoperative day 14 when he was found to have respiratory distress requiring greater O2 to support him. There was a suspicion that the patient might have had an aspiration pneumonia and the patient was reintubated and was put on the ventilator machine. Sputum cultures taken again after reintubation showed moderate growth Pseudomonas with resistance to Cipro and Meropenem and sensitive to Zosyn. A bronchoscopy and bronchoalveolar lavage also revealed same Pseudomonas. Complicating this Pseudomonas ventilator related pneumonia was the fact the patient was fluid overloaded and was requiring diuresis. However, given his acute renal failure the patient was requiring hemodialysis with treatment with Zosyn for which the Pseudomonas was sensitive to and resolution of his congestive heart failure. The patient's respiratory status improved and the patient was successfully extubated on postoperative day 20. The patient continued to do well with gradual resolution of his acute renal failure and acute tubular necrosis and was transferred to the regular floor on postoperative day 23. The patient continued on intravenous Zosyn for completion of antibiotic treatment and was monitored for his renal functions. The patient underwent a speech and swallow evaluation given his risk for aspiration and was cleared to continue on his po intake and the patient's nutritional needs were assessed by caloric count and the patient was found to be taking adequate po and his nutritional intake was supplemented with Boost plus nutritional supplements three times a day. The patient was seen by physical therapy while he was on the floor regarding his deconditioning and was recommended to be discharged to rehab for improvement of his physical functioning. By postoperative day 28 the patient was ready for discharge. It should be noted that the patient should be followed up closely regarding his renal function given his creatinine volume of 1.4 on discharge. | A right subclavian vascular catheter has been removed and a feeding tube remains in place, now terminating in the region of the duodenojejunal junction. There is severe global rightventricular free wall hypokinesis.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are mildly thickened. CT ABODMEN WITHOUT IV CONTRAST: There are small bilateral pleural effusions with associated compressive lower lobe atelectasis. The estimatedpulmonary artery systolic pressure is normal.PERICARDIUM: There is a small pericardial effusion. A right CVL has been placed with tip in the SVC - no pneumothorax. Shortness of breath.BP (mm Hg): 141/73HR (bpm): 69Status: InpatientDate/Time: at 13:59Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. The right ventricular cavity ismarkedly dilated. (Over) 4:02 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: r/o undrained intra-abdominal collection vs rectus hematoma Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION FINAL REPORT (Cont) IMPRESSION: 1) There is a large amount of free air with leakage of oral contrast material into the peritoneal cavity. Diffuse haziness in the upper abdomen is noted and may relate to ascites. 1+ EDEMA NOTED TO EXTREM. There are right IJ and right subclavian central lines with tips over distal SVC. An endotracheal tube terminates just above the thoracic inlet level and has been withdrawn slightly in the interval. There remains vascular engorgement and perihilar haziness. AP UPRIGHT CHEST RADIOGRAPH: There are small bilateral effusions and bibasilar atelectasis, new in the interval. ILEOSTOMY WITH GOOD AMTS. Good ABG prior extubation. T/O SHIFT FOR MOD>COPIOUS AMTS. TO BE REPLETED PER PRN.GI/GU - PEDI. Allowing for differences in technique, the cardiac silhouette, mediastinal and hilar contours are stable. SINGLE VIEW, AP: There is a right-sided internal jugular Quinton catheter as well as a right-sided subclavian central venous line in satisfactory position. IMPRESSION: 1) Interval improvement in aeration in the right lower lobe with residual patchy atelectasis present. Intubated. ABP IN RIGHT RADIAL GOOD WAVE FORM, SYSTOLIC BP RANGES FROM 130S-140S, HR-80S TO LOW 100S. edema.GI: Abd softly distended. PEEP WEANED MD ORDER. INDWELLING FOLEY IN PLACE; PATENT, WITH ADEQUATE AMTS. Nasal cannula weaned off. Dilaudid PCA.VSS. Rhonchi clearing with sxing. Palpable DP?PT pulses bilaterally.GI: Tube feeding changed to nepro w/ promod. Currently being dialyzed.ID: Afebrile. CVP- . L subclavian placed today. AM ABG 7.41/42/131/20/2. Had CXR prior to extubation which showed baseline CHF. Vancomycin after dialyis. Retention sutures . Breath sounds course but immprove after sx. Cont on dilaudid PCA and prn ativan(1mg given this shift). DOES C/O INTERMITTENT ABD. CVP HAS BEEN . GIVEN X1 DILAUDID FOR PAIN; PT. Episode resolved when sats improved and pt settled w/o further distress. REMAINS ON Q6/HR IV LOPRESSOR. Residual checked and rate advanced accordingly. POST HCT 30.3. Protonix cont . AMTS. NGT to LCS with minimal >clear drainage. (PT. PT. PT. PT. PT. PT. PT. PT. IN PLACE; SITE WNL. TPN. BS with scattered rhonchi t/o. To be started on Nepro tube feeds. Abd firm tender w/active BS. O2 sats up with re-positioning O2 mask and/or C&DB. related to pain this am; Now dry....abd incision is open superficailly with retention sutures securing incision. EKG done. Re-taped EET. Pt grimaces easily to touch of abdomen.CVS- stable hemodynamics..see careview flow data. ETT repositioned and retaped.GI: sump in right nare, LCS returning bilios drainage. 3 JP drains to bulb suction returning moderate amt bloody output. Renal following- holding off on HD @ this time.Derm: D&I.Social: FULL CODE. w>d dsg changes /prn. Steri-strips in place on abd. CXR done. L radial aline with dgood waveform analysis and +csm noted. Pt remains on IV Lo0pressor Q6hr.RESP: LS coarse throughout with bibasilar cracklers noted. Spont breaths cont @ over vent/per min. RESP CAREPT. BP up, Lopressor q6hr. PCA providing adequate pain control.P: CHeck vanco level today. Will repleat a.m. lytes per prn orders. +BS noted. CXR pnd. Pt with peripheral edema.Abd firm and distended and very tender. NPO, PPI prophylaxis. Normal S1 S2 per auscultation. IVF ARE INFUSING AS ORDRED.DISPO: PT. DOSED PER LEVEL.GI/GU - DOPPOFF TUBE PLACED YEST. INTUBATION YEST. for repos.of ng-tube. Team feels pt in in pulm edema per CXR.GI: Abd soft and nontender. CXR done. +BS hypo noted. INR 1.4 Pt is afebrile, on Flagyl. REMAINS ON MEREPENUM, FLAGYL, AND VANC. REMAINS ON CAPTOPRIL 12.5 MG TID AND LOPRESSOR 2.5 QID. REFLECTIVE ABG 7.44/39/98/27/1. WITH WITH TMAX 100.5.C.V; PT. NPO, PPI prophylaxis. See flowsheet for rx times, and pt data.Plan: Wean as tolerated. TF ON OVER/ PER TEAM; PRESENTLY DELIVERING NEPRO. SPEECH/SWALLOW CONSULT YEST. Retention sutures . AM ABG 7.46/37/96/27/2 ON SAME. HAS LEFT RADIAL ALINE WHICH CORRELATES WITH CUFF, AND WAVEFORM WNL.I.D; PT. Received Metoprolol. MONITOR U/O, LYTES, BUN AND CRE. TUBE IN PLACE TO (L)NARE; . Administering Combivent ~Q4 thru . Pt remains on IV Lopressor Q6hr.RESP: LS coarse throughout with bibasilar crackles noted. PLAN TO EXTUBATE PT. HAS LEFT RADIAL ALINE WHICH REMAINS AND CORRELATES WITH CUFF PRESSURE. UPDATED ON PT. Protonix cont; carafate d/c'd. EKG done and SICU HO notified. REPEAT EKG DONE THIS AM. + EDEMA NOTED TO BILAT. Placed back on CPAP/PS. RESP CAREPT. +PERRLA noted. Stool sent for c-diff. Resp. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. PT HAD EPISODE CP LST PM. : afebrile Remains on flagyl, ceftiaxone. care note - Pt. SPUTUM WITH TF APPEARANCE; NGT NOTED TO BE IN (R)NARE. SKIN W+D. ON DILAUDID PCA FOR ADB. A/B BALANCE WITHIN NORMAL PARAMETERS, WELL OXYGENATED.,BS: COARSE @ TIMES 'D X3 FOR MODERATE AMTS. STOMA PINK.INDWELLING FOLEY IN PLACE; PATENT WITH ADEQUATE AMTS. TOL TF AT GOAL WITH MIN RESIDUALS. Pt to IR for Dobhoff placement with +confirmation. DESAT. +PP. REMAINS ON SCHEDULED DOSE CAPTOPRIL (INC. YEST. NEB. EXP. ENCOURAGE TO C&DB. PAN CX. HAD BEEN SWANED IN T/SICU.RESP - PT. 4+ EDEMA ON LOWER EXTREMITIES.A--STABLE. CVP 6-11. with 2+ ppe. Afebrile. RSC RE-SITED YEST TO LSC; OLD-LINE TIP SENT.GI/GU - PT. RECIEVED LOPRESSOR. Pt. Pt. | 111 | [
{
"category": "Radiology",
"chartdate": "2120-10-30 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 804321,
"text": " 2:25 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: R/O abdominal abscess, please administer po contrast\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n Field of view: 32 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p ileostomy take-down.\n REASON FOR THIS EXAMINATION:\n R/O abdominal abscess, please administer po contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 47 year old man status-post ileostomy take-down with an elevated\n white count. Evaluate for intra-abdominal abscess.\n\n TECHNIQUE: Axial images were performed from the lung bases through the pubic\n symphysis after the administration of oral and intravenous contrast. Coronal\n reformatted images were obtained.\n\n Contrast: 150cc of Optiray were administered due to patient debility.\n\n CT OF THE ABDOMEN WITH CONTRAST: There is minimal dependent atelectasis\n within the lung bases. The liver, spleen, adrenals, kidneys, pancreas and\n gallbladder are unremarkable.\n\n There is fluid within an enhancing rim throughout the peritoneal cavity. This\n connects up with a smaller pocket of fluid adjacent to the ileocolic\n anastomotic site in the mid-pelvis. Within this smaller pocket of fluid, there\n are gas bubbles. This is consistent with an abscess and possibly an\n anastomotic leak. Stool is seen throughout the sigmoid colon and rectum beyond\n the anastomosis. The fluid measures 25 to 55 Hounsfield units depending upon\n where the measurement is taken. Again there is an enhancing rim around the\n fluid in the abdomen suggestive of an abscess.\n\n CT OF THE PELVIS WITH CONTRAST: There is no evidence of bowel wall\n thickening. There is no obstruction. There are coarse abdominal vascular\n calcifications.\n\n Bone windows demonstrate no suspicious lytic or blastic lesion.\n\n Coronal reformatted images aid in the evaluation of the fluid collection and\n its relationship to the bowel loops.\n\n IMPRESSION: Large amount of free fluid throughout the abdomen connecting to a\n more focal pocket of fluid and air adjacent to the anastomotic site. Some of\n the fluid in the right paracolic gutter represents hematoma. However a\n leak cannot be excluded, in particular as there is a focal collection of\n extraluminal air immediately adjacent to the anastomosis.\n\n These findings were discussed with Dr. at approximately 3 a.m. on\n .\n (Over)\n\n 2:25 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: R/O abdominal abscess, please administer po contrast\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n Field of view: 32 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-10-31 00:00:00.000",
"description": "CT PERITONEAL DRAINAGE",
"row_id": 804467,
"text": " 12:37 PM\n CT PERITONEAL DRAINAGE; CT PELVIS W/O CONTRAST Clip # \n CT FINE NEEDLE ASP; CT GUIDANCE DRAINAGE\n Reason: PELVIC COLLECTION DRAINAGE TUBE PLACEMENT\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p reversal of ileostomy\n REASON FOR THIS EXAMINATION:\n Drain collection.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT GUIDANCE DRAINAGE\n\n INDICATION: Abscess. For CT guided drainage.\n\n CT PELVIS WITHOUT IV CONTRAST: Noncontrast images of the pelvis again reveal\n a large intraabdominal fluid collection anteriorly with exension into both\n paracolic gutters and pelvis. On the current scan, there are new pockets of\n air and increased density of the fluid within this collection relative to\n prior exam.\n\n CT GUIDED ABSCESS DRAINAGE: The risks and benefits of the procedure were\n explained to the patient and written informed consent was obtained. Conscious\n sedation was administered with the nursing staff present.\n\n CT GUIDED LOCALIZATION: CT fluoroscopy was used to localize a spot in the\n right lower quadrant for subsequent catheter insertion into patient's known\n collection.\n\n CT GUIDED NEEDLE INSERTION: An 18-gauge spinal needle catheter was inserted\n into the marked spot within the right lower quadrant, after the administration\n of 10 cc of local anesthetic of 1% Lidocaine. Approximately 10 cc of a bloody\n foul smelling collection were aspirated and obtained for culture and gram\n stain.\n\n CT GUIDED CATHETER INSERTION: A 12-gauge pigtail catheter was successfully\n inserted at the identical site of prior spinal needle insertion, guided\n successfully using CT fluoroscopy.\n\n The patient tolerated the procedure well and there were no complications.\n\n of the attending radiology staff was present and supervised\n the procedure in its entirety.\n\n IMPRESSION: Successful pigtail catheter placement in right lower quadrant\n within patient's known fluid collection.\n\n\n (Over)\n\n 12:37 PM\n CT PERITONEAL DRAINAGE; CT PELVIS W/O CONTRAST Clip # \n CT FINE NEEDLE ASP; CT GUIDANCE DRAINAGE\n Reason: PELVIC COLLECTION DRAINAGE TUBE PLACEMENT\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-12-05 00:00:00.000",
"description": "CVL/PICC",
"row_id": 807994,
"text": " 12:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC line for IV tx and blood draw ** requested\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with long hx of trauma, ARF/ATN, in recovery, with rising Cr\n and hyperkalemia / uncooperative and refuses blood draw / refuses PICC on floor\n REASON FOR THIS EXAMINATION:\n please place PICC line for IV tx and blood draw ** requested by Dr **\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of trauma. Acute renal failure, ATN. Please place PICC\n for IV antibiotics and blood draws.\n\n PHYSICIANS: Drs. and . Dr. , attending radiolosits,\n was supervising.\n\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. Brachial vein was patent and compressible. After local\n anesthesia with 2 mm of 1% Lidocaine, the brachial vein was entered under\n ultrasonographic guidance with a 21 gauge needle. A .018 guidwire was\n advanced under fluoroscopy into the superior vena cava. Based on the markers\n on the guidewire, it was determined that a length of 39 cm would be suitable.\n The PICC was trimmed to length and advanced over a 4-French introducer sheath\n under fluoroscopic guidance into the superior vena cava. The sheath was\n removed. The catheter was flushed. A final chest x-ray was obtained and the\n film demonstrates the tip to be in the superior vena cava just abvove the\n atrium. The line is ready for use.\n\n A statlock was applied and the line was heplocked.\n\n IMPRESSION: Successful placement of a 39 cm total length, 4-French single\n lumen PICC with tip in the superior vena cava, ready for use.\n\n"
},
{
"category": "Echo",
"chartdate": "2120-11-18 00:00:00.000",
"description": "Report",
"row_id": 74537,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Shortness of breath.\nBP (mm Hg): 141/73\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 13:59\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis severely depressed.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. The right\nventricular cavity is markedly dilated. There is severe global right\nventricular free wall hypokinesis.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nTRICUSPID VALVE: Physiologic tricuspid regurgitation is seen. The estimated\npulmonary artery systolic pressure is normal.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Bilateral pleural effusions are present.\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 severely depressed. The right ventricular cavity is\nmarkedly dilated. There is severe global right ventricular free wall\nhypokinesis. The aortic valve leaflets are mildly thickened. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. The\nestimated pulmonary artery systolic pressure is normal. There is a small\npericardial effusion. There are no echocardiographic signs of tamponade.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-22 00:00:00.000",
"description": "N-G TUBE PLACEMENT (W/ FLUORO)",
"row_id": 806656,
"text": " 10:46 AM\n N-G TUBE PLACEMENT (W/ FLUORO) Clip # \n Reason: pls place post pyloric feeding tube\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p ileostomy, washout, intubated for chf\n\n REASON FOR THIS EXAMINATION:\n pls place post pyloric feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old male status post ileostomy. Requires tube\n feedings.\n\n TECHNIQUE: feeding tube was advanced via the left nares\n and positioned under fluoroscopincrease guidance in the second portion of the\n duodenum. No immediate post-procedure complications were observed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804989,
"text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT movement\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n ETT movement\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Fever, status post abdominal abscess drainage. Evaluate ET tube\n placement.\n\n VIEWS: Semierect AP view compared with semierect AP view from .\n\n FINDINGS: Endotracheal tube is in satisfactory position with the tip\n approximately 7.5 cm from the carina. The Swan-Ganz catheter and nasogastric\n tube remain in stable and satisfactory positions. There has been interval\n improvement of the bilateral diffuse interstitial and alveolar opacities\n consistent with interval improvement of pulmonary edema. There is continued\n atelectasis in the right lower lobe. A small left pleural effusion persists.\n The cardiac and mediastinal contours remain stable. No pneumothorax is\n identified.\n\n IMPRESSION:\n 1. Satisfactory position of endotracheal tube.\n 2. Interval improvement in mild alveolar and interstitial pulmonary edema.\n 3. Persistent right lower lobe atelectasis with small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804850,
"text": " 10:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls check line and tube placement\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n pls check line and tube placement\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Fever, low oxygen saturation, abdominal abscess drainage. Evaluate\n line and tube placement.\n\n VIEWS: Single supine AP view compared with AP view from approximately 10 hours\n earlier, the same day.\n\n FINDINGS: The ETT is in satisfactory position with tip approximately 5 cm\n above the carina. A right internal jugular central venous line is seen\n terminating in the proximal superior vena cava. A right subclavian Swan- Ganz\n catheter is noted with the tip in the right pulmonary artery. An NG tube is\n present in satisfactory position with the tip in the fundus of the stomach.\n There is persistent left ventricular enlargement with slightly improved\n perihilar haziness and bilateral diffuse alveolar opacities consistent with\n slightly improving left ventricular heart failure. There is persistent left\n lower lobe collapse/consolidation with a moderate sized left pleural effusion.\n No pneumothorax is identified.\n\n IMPRESSION:\n 1) Satisfactory placement of all lines and tubes.\n 2) Slightly improved moderate left ventricular heart failure.\n 3) Persistent left lower lobe collapse/consolidation with a moderate left\n pleural effusion, not significantly changed from prior exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806864,
"text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sp line\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess\n drainage s/p intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n sp line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: History of abscess drainage versus intubation, line placement\n and fever.\n\n PORTABLE AP CHEST: Endotracheal tube is 3 cm above carina. Right subclavian\n CV line is in mid SVC. Left subclavian CV line is in proximal SVC. The\n feeding tube is in stomach with distal end not included on films. No\n pneumothorax. There are bilateral atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804737,
"text": " 12:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, low oxygen saturation, status post abdominal abscess\n drainage.\n\n VIEWS: Supine AP view compared with upright AP view from .\n\n FINDINGS: The right subclavian central venous line remains in stable and\n satisfactory position within the mid-superior vena cava. Again seen is\n moderate left ventricular enlargement. There has been interval worsening of\n bilateral diffuse alveolar opacities with perihilar haziness, consistent with\n worsening moderate left ventricular heart failure. Bilateral layering pleural\n effusions are also noted, left greater than right, which may have increased in\n size from the prior exam. There is persistent left lower lobe\n atelectasis/consolidation. No pneumothorax is identified.\n\n IMPRESSION:\n 1. Interval worsening of moderate left ventricular heart failure.\n 2. Bilateral layering pleural effusions, left greater than right.\n 3. Persistent left lower lobe collapse/consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806165,
"text": " 6:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: desat\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n s/p intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n desat\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n CLINICAL INDICATION: Oxygen desaturation.\n\n Comparison is made to previous study of 1 day earlier.\n\n An endotracheal tube, vascular catheters, and a feeding tube remain in place.\n The heart is enlarged but stable. There is persistent vascular engorgement,\n but there has been interval improvement in the degree of lung opacification\n with residual perihilar haziness remaining. Bilateral pleural effusions,\n right greater than left persists.\n\n IMPRESSION:\n\n Improving pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 805515,
"text": " 6:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47 year old man with fever and low oxygen saturation status post\n abscess drainage. Assess line placement.\n\n COMPARISON: Chest radiograph from earlier the same day.\n\n FINDINGS: A semi-upright AP portable chest radiograph demonstrates a right\n internal jugular catheter whose tip is in the mid SVC. Additionally, there is\n a right subclavian central venous catheter whose tip is in the distal SVC. A\n nasogastric tube tip is in the proximal portion of the stomach. The side hole\n is below the GE junction. There is persistent cardiomegaly and dense opacity\n in the left lung base. This most likely represents collapse/atelectasis,\n however an early pneumonia cannot be excluded. There are persistent bilateral\n pleural effusions and pulmonary edema. Overall there is no significant change\n from the prior study.\n\n IMPRESSION:\n\n 1) Lines and tubes in appropriate position.\n\n 2) Persistent bilateral pulmonary opacities and bilateral pleural effusions\n consistent with pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-03 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 804675,
"text": " 4:02 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o undrained intra-abdominal collection vs rectus hematoma\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p ileostomy take-down admitted w/ abdominal pain. Now s/p\n percutaneous drainage of large intra-abdominal collection with decreased\n HCT, hypotension, oliguria\n REASON FOR THIS EXAMINATION:\n r/o undrained intra-abdominal collection vs rectus hematoma\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P ileostomy take-down with abdominal pain, s/p percutaneous\n drainage of large intraabdominal collection . Decreased hematocrit,\n hypotension and oliguria.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases to the\n pubic symphysis without intravenous contrast.\n Coronal reformatted images were obtained.\n\n COMPARISON: .\n\n CT ABODMEN WITHOUT IV CONTRAST: There are small bilateral pleural effusions\n with associated compressive lower lobe atelectasis. This is new compared with\n the prior examination. The liver, pancreas, kidneys, adrenal glands and\n spleen are unremrkable. Evaluation is somewhat limited due to lack of\n intravenous contrast. There is no cholelithiasis. There is diffuse stranding\n throughout the mesentery.\n\n Anterior to the stomach, there is a large collection of free air. This is in\n the region of the previously demonstrated fluid collection. Posterior within\n this region of free air is layering, extravasated oral contrast material. The\n small bowel loops are mildly distended though contrast masses to the sigmoid.\n\n CT PELVIS WITHOUT IV CONTRAST: A pigtail catheter is present within the right\n lower quadrant. The hypodense fluid collection within the anterior portion of\n the pelvis is no longer present. In the anterior upper pelvis, there is free\n air and probable extraluminal oral contrast material. Tiny pockets of free\n air and fluid are noted tracking in the left lateral portion of the abdomen.\n Within the deep pelvis, there is a 7.6 x 7.5 cm fluid collection with several\n pockets of free air within the collection. This collection is posterior to the\n urinary bladder and anterior to the rectum.\n A Foley catheter is present within the urinary bladder. Contrast extends to\n the rectum. At the anastomotic site in the mid pelvis, there is no definite\n focal leak identified.\n\n The osseous structures are unremarkable.\n\n Coronal reformatted images confirm the above findings.\n\n (Over)\n\n 4:02 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o undrained intra-abdominal collection vs rectus hematoma\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1) There is a large amount of free air with leakage of oral contrast material\n into the peritoneal cavity. This is concerning for a leak at the anastomotic\n site or bowel perforation. This finding is new compared with the prior study.\n 2) There is an abscess within the deep pelvis anterior to the rectum and\n posterior to the urinary bladder. Though this collection was present on the\n prior examination, the air within the cavity is new.\n\n These findings were directly communicated to Dr. at the time of the\n examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-15 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 805963,
"text": " 4:12 PM\n PORTABLE ABDOMEN Clip # \n Reason: NG TUBE PLACEMENT\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with\n REASON FOR THIS EXAMINATION:\n NG TUBE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n PORTABLE ABDOMEN, SINGLE VIEW: Patient motion. An NG tube is present, the tip\n overlies the fundus. Due to motion, the tube is not traced contiguously\n through the lower esophagus and GE junction, but the tip and sideport overlie\n the gastric bubble. Several drains are seen in the left lower quadrant. Some\n contrast is present in the bladder. There is relative paucity of gas within\n the abdomen and there are changes at both lung bases.\n\n IMPRESSION: NG tube tip over gastric fundus. See comment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806938,
"text": " 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: follow up CHF\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess\n drainage s/p intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n follow up CHF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Congestive heart failure.\n\n Comparison is made to a previous study of one day earlier as well as two days\n earlier.\n\n A left subclavian vascular catheter remains in satisfactory position. A right\n subclavian vascular catheter has been removed and a feeding tube remains in\n place, now terminating in the region of the duodenojejunal junction. The\n cardiac and mediastinal contours are stable in the interval. There is\n interval improvement in the degree of perihilar and basilar opacification,\n with particular improvement in the right lower lobe. A right pleural effusion\n is no longer evident and there is a persistent small left pleural effusion.\n\n IMPRESSION:\n 1. Improving aeration, particularly at the right lung base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-03 00:00:00.000",
"description": "CT PERITONEAL DRAINAGE",
"row_id": 804689,
"text": " 8:45 AM\n CT PERITONEAL DRAINAGE; CT PERITONEAL DRAINAGE Clip # \n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE\n CT GUIDANCE DRAINAGE; -59 DISTINCT PROCEDURAL SERVICE\n CT LIMITED SCANS; -59 DISTINCT PROCEDURAL SERVICE\n Reason: please place drainage catheter in upper abdomen and pelvis\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p reversal of ileostomy with infected hematoma\n intraperitoneally, s/p drainage x 1 . Now with septic picture and CT\n evidence of free air and contrast extravasation.\n\n REASON FOR THIS EXAMINATION:\n please place drainage catheter in upper abdomen and pelvis\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47 year old man s/p reversal of ileostomy with infected\n intraperitoneal hematoma. Now with septic picture and CT evidence of free air\n and contrast extravasation. Please drain collections.\n\n CT ABDOMEN: An initial noncontrast CT abdomen of the abdomen was performed and\n compared with the next previous CT obtained approximately 5 hrs earlier. As on\n the earlier exam, there is a large collection in the upper abdomen anterior to\n the stomach which contains air and extravasated barium. There is a 2nd large\n collection which also contains air and barium which is located in the anterior\n portion of the low abdomen and extends into the deep pelvis.\n\n PROCEDURE: After explaining the risks vs benefits of the procedure, informed\n written consent was obtained from the patient. The upper abdomen was prepped\n and draped in the usual sterile fashion and anesthesia was obtained with 1%\n Lidocaine. Under direct CT guidance, a 14 French Flexima drainage catheter\n was advanced into the upper abdominal collection and approximately 10 cc of\n thick dark brown material aspirated. The pigtail was secured. Thereafter, a\n second suitable site for accessing the lower collection was chosen and again\n sterile technique was used for preparation and 1% Lidocaine for local\n anesthesia. A 2nd 14 French Flexima drainage catheter was advanced under\n direct CT guidance into this lower collection and approximately 20 cc of this\n same thick dark brown fluid was aspirated. Both samples sent to the lab for\n gram stain and culture. Subsequently, sterile saline was utilized to flush\n and aspirate through both catheters. The material inside both collections is\n very thickened viscus and, despite the large caliber of these catheters,\n aspiration was difficult.\n\n The patient tolerated the procedure well under conscious sedation administered\n by his SICU nurse with continuous hemodynamic monitoring. There were no\n immediate complications.\n\n Dr. , Staff Radiologist, was present and supervised the entire\n procedure.\n\n (Over)\n\n 8:45 AM\n CT PERITONEAL DRAINAGE; CT PERITONEAL DRAINAGE Clip # \n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE\n CT GUIDANCE DRAINAGE; -59 DISTINCT PROCEDURAL SERVICE\n CT LIMITED SCANS; -59 DISTINCT PROCEDURAL SERVICE\n Reason: please place drainage catheter in upper abdomen and pelvis\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION: Technically successful placement of two 14 French Flexima drainage\n catheters, one into the superior collection and the 2nd into the inferior\n abdominal collection which appears to extend into the deep pelvis. As\n described above, the material draining from these catheters is extreme\n thickened viscus, perhaps due to inspissated barium in these collections.\n\n The results of this procedure were discussed with both Drs. and\n at the time of the exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-20 00:00:00.000",
"description": "N-G TUBE PLACEMENT (W/ FLUORO)",
"row_id": 806427,
"text": " 11:34 AM\n N-G TUBE PLACEMENT (W/ FLUORO) Clip # \n Reason: please place post pyloric doffhuff tube.\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with\n REASON FOR THIS EXAMINATION:\n please place post pyloric doffhuff tube.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47 y/o surgical patient requiring tube feeds.\n\n TECHNIQUE: feeding tube was positioned under fluoroscopic\n guidance into the distal duodenum. No immediate post procedure complications\n were noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806443,
"text": " 1:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, copious secretions, chf/infiltrate\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n s/p intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n interval change, copious secretions, chf/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Abscess drainage with intubation and Swan-Ganz catheter placement.\n\n ETT is 4 cm above the carina. Right subclavian CV line is in distal SVC.\n Feeding tube extends into the duodenum but distal end of tube is not included\n on the film. No pneumothorax. There are persistent bilateral predominantly mid\n and lower zone air space opacities and small bilateral pleural effusions\n findings being consistent with pulmonary edema/consolidation and pleural\n effusion. Unchanged since prior film of .\n Impression:No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804673,
"text": " 1:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p central line placement R subclavian.\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n\n REASON FOR THIS EXAMINATION:\n s/p central line placement R subclavian.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, - 01:15:\n\n COMPARISON: at 13:05.\n\n FINDINGS: There is increased opacity at the left lung base with obscuration\n of the left hemidiaphragm. This is an interval change most consistent with\n developing pneumonia in this location. The pulmonary vascular markings are\n subtley more prominent than on the prior study. Right effusion is again\n noted. The heart size is stable and within normal limits.\n\n A right CVL has been placed with tip in the SVC - no pneumothorax.\n\n IMPRESSION:\n\n Interval development of left lower lobe consolidation suggesting pneumonia in\n the proper clinical context.\n\n Slight worsening in fluid status.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806817,
"text": " 7:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia, eval for inflitrate/failure\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess\n drainage s/p intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n hypoxia, eval for inflitrate/failure\n ______________________________________________________________________________\n FINAL REPORT\n History of fever with intubation and line placement.\n\n Endotracheal tube is 5 cm above carina. Right subclavian CV line is in distal\n SVC. Feeding tube extends beyond the region of the ligament of Treitz with\n distal end not included on film. No pneumothorax. Heart size is borderline for\n technique. There is pulmonary vascular engorgement with possible CHF and\n linear atelectasis at the right base. Previously noted left pleural effusions\n have largely resolved.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804559,
"text": " 1:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate?\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n REASON FOR THIS EXAMINATION:\n infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever. Status post abdominal abscess drainage.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST RADIOGRAPH: There are small bilateral effusions and bibasilar\n atelectasis, new in the interval. Allowing for differences in technique, the\n cardiac silhouette, mediastinal and hilar contours are stable. There is no\n consolidation. Soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: No evidence of pneumonia. There are new small bilateral effusions\n and patchy bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 805469,
"text": " 12:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Acute Respiratory Distress\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n Acute Respiratory Distress\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old male with fevers and low oxygen saturations. The\n patient is S/P abscess drainage and intubation.\n\n COMPARISONS: Single view, AP from .\n\n SINGLE VIEW, AP: There is a right-sided internal jugular Quinton catheter as\n well as a right-sided subclavian central venous line in satisfactory position.\n The endotracheal tube seen on the previous study is not seen on today's\n study, indicating extubation. An intra-abdominal drain is seen as well as an\n NG tube which terminates within the stomach. There has been interval\n development of bibasilar atelectasis and consolidation. There also appears to\n be bilateral pleural effusions. The pulmonary vasculature has increased in\n caliber when compared to the previous exam, consistent with pulmonary edema.\n There is also a mid-zone right-sided infiltrate which may represent atypical\n distribution of congestive heart failure or a consolidation.\n\n IMPRESSION: 1) Bibasilar atelectasis/consolidation, right greater than left.\n 2) Increased prominence of pulmonary vasculature consistent with pulmonary\n edema.\n 3) Right-sided mid-zone infiltrate which may represent atypical distribution\n of congestive heart failure or consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804904,
"text": " 9:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: WORSENING LUNG SOUNDS / RESP STATUS\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n WORSENING LUNG SOUNDS / RESP STATUS\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n Compared to 1 day earlier.\n\n CLINICAL INDICATION: Worsening lung sound and worsening respiratory status in\n a post operative patient.\n\n An endotracheal tube terminates just above the thoracic inlet level and has\n been withdrawn slightly in the interval. A Swan-Ganz catheter terminates in\n the proximal interlobar right pulmonary artery and a nasogastric tube\n terminates below the diaphragm. The heart size and mediastinal contours are\n stable allowing for patient rotation. There is a bilateral combined alveolar\n and interstitial pattern present. The alveolar opacities have changed\n distribution slightly and are now most prominent in the lower lung zones where\n they were previously more prominent in the perihilar/mid lung zone regions.\n This probably represents change in distribution of pulmonary edema related to\n differences in patient position. Bilateral pleural effusions are present and\n are unchanged.\n\n IMPRESSION: Change in distribution of alveolar opacities since recent\n radiograph, likely reflecting the effect of gravity on pulmonary edema\n distribution in response to changes in patient positioning. Overall no\n significant change in severity since recent radiograph but improvement is\n noted when compared to an earlier study of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 805145,
"text": " 4:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p right ij line change over wire, eval placement\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n s/p right ij line change over wire, eval placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Status post right internal jugular line change over wire,\n evaluate placement.\n\n FINDINGS: The patient remains intubated, ETT and NG tube in unchanged\n positions. A previously present Swan-Ganz catheter has been withdrawn through\n the right subclavian approach central venous line, the latter being in\n unchanged position and terminating in the lower SVC, not reaching the junction\n with the right atrium. The wide caliber central venous line approached via\n the right internal jugular vein is again noted and seen to terminate in the\n mid portion of the SVC approximately at the level of the carina. There is no\n pneumothorax or any other placement-related complication. Diffuse density in\n the left base again consistent with left-sided pleural effusion, however,\n presenting somewhat differently related to patient's now semi-upright\n position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 805117,
"text": " 11:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Temperature, low saturation, status post abdominal abscess\n drainage. Intubation and Swan-Ganz catheter in place, returns from OR.\n\n FINDINGS: The portable film is analyzed in direct comparison with the next\n preceeding portable chest examination obtained 2 1/2 hours earlier. The\n patient remains intubated the ETT in unchanged position. The same holds for\n the NG tube which reaches below the diaphragm. The right subclavian approach\n central venous line carries the Swan-Ganz catheter which reaches the central\n portion of the right PA. A right sided internal jugular approach sheath is\n seen and it has been advanced by approximately 10 cm now terminating in the\n mid portion of the SVC at the level of the carina. No pneumothorax is present.\n No new parenchymal densities have developed but the left sided diffuse density\n appears to have increased slightly and is interpreted as representing pleural\n effusion layering posteriorly in this patient is supine position. Quantitation\n of the pleural effusion on portable chest xray is difficult in particular\n since the patient's postural position appears to have changed significantly\n between the two examinations.\n\n IMPRESSION: Left sided pleural effusion layering posteriorly. Otherwise\n unremarkable findings of instrument position no new parenchymal infiltrates.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806521,
"text": " 11:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for CHF\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n s/p intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n please eval for CHF\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Intubation and Swan repositioning.\n\n Comparison is made to prior studies of and .\n\n An ET tube remains in satisfactory position. No SG catheter is identified.\n There is a right subclavian vascular catheter terminating in the lower SVC. A\n feeding tube is present, terminating in the distal duodenum near the\n duodenojejunal junction.\n\n Cardiac and mediastinal contours are stable in the interval. There remains\n vascular engorgement and perihilar haziness. A right pleural effusion appears\n less prominent in the interval and a left pleural effusion is unchanged.\n Diffuse haziness in the upper abdomen is noted and may relate to ascites.\n\n IMPRESSION: No recent change in degree of pulmonary edema but overall\n improvement is noted when compared to an older study of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806095,
"text": " 9:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt intubated for respiratory distress\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n Pt intubated for respiratory distress\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Temperature. Low sats. Status post abdominal abscess drainage.\n Intubation and swan. Intubated for respiratory distress.\n\n CHEST, SINGLE AP PORTABLE VIEW\n\n There has been interval placement of an ET tube with tip lying at the level of\n the clavicles, approximately 6.9 cm above the carina. There are diffuse\n alveolar opacities with small to moderate bilateral effusions and underlying\n collapse/consolidation. There is mild to moderate cardiomegaly. There are\n right IJ and right subclavian central lines with tips over distal SVC. No\n pneumothorax detected.\n\n IMPRESSION:\n\n 1) Dense bilateral alveolar opacities with bilateral effusions and underlying\n collapse/consolidation. Findings are more suggestive of CHF. Underlying\n infectious infiltrate would be difficult to exclude.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806301,
"text": " 9:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: EVALUATE FOR CHF\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n s/p intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n EVALUATE FOR CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and low sats. Status post abdominal abscess drainage.\n Intubated and has a Swan catheter. Evaluate for CHF.\n\n FINDINGS: Single AP semi-upright image. Comparison study dated . The ET tube, right IJ central line and right subclavian central line\n remain in good positions. The Dobhoff catheter tip is within the proximal\n portion of the stomach. The lungs appear slightly better inflated, but there\n are bilateral residual interstitial pulmonary infiltrates in both lower zones\n in the left mid zone. Small bilateral pleural effusions are noted with\n blunting of the CP angles.\n\n IMPRESSION: Improving lung inflation with reduced bibasilar pulmonary\n infiltrates. Further follow up images are recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 804784,
"text": " 11:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECK PA CATH, ETT\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest of compared to previous study of earlier the same\n date.\n\n CLINICAL INDICATION: Line placement.\n\n A Swan-Ganz catheter has been placed and terminates in the expected location\n of the main pulmonary artery proximal to its bifurcation. No pneumothorax is\n identified but the right costophrenic sulcus has been excluded from the study\n precluding assessment for a basilar pneumothorax on the supine study. An\n endotracheal tube has been placed in the interval terminating at the thoracic\n inlet level about 8 cm above the carina. There is a worsening combined\n alveolar and interstitial pattern within the lungs. A left pleural effusion\n is unchanged, moderate in size. A right pleural effusion cannot be assessed.\n A percutaneous catheter/tube is noted in the left upper quadrant of the\n abdomen.\n\n IMPRESSION:\n\n 1) Swan-Ganz catheter terminates in region of the main pulmonary artery. No\n pneumothorax on this limited study.\n\n 2) Worsening pulmonary edema pattern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806115,
"text": " 12:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please check for placement of Duphoff\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n please check for placement of Duphoff\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Temp., low sat, check Dobhoff.\n\n CHEST, 2 VIEWS:\n\n An O-G tube with radiopaque tip is present. The radiopaque tip lies\n immediately beyond the GE junction, overlying the gastric fundus and should be\n advanced. Otherwise, no significant change is detected. There is extensive\n alveolar opacity, compatible with severe CHF.\n\n IMPRESSION: Dobhoff tube tip lies just beyond GE junction and should be\n advanced.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-19 00:00:00.000",
"description": "N-G TUBE PLACEMENT (W/ FLUORO)",
"row_id": 806345,
"text": " 3:05 PM\n N-G TUBE PLACEMENT (W/ FLUORO) Clip # \n Reason: pls place post pyloric dobhoff\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p ileostomy, washout, intubated for chf\n REASON FOR THIS EXAMINATION:\n pls place post pyloric dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 47 y/o male status post ileostomy requring postpyloric tube for\n feedings.\n\n Under fluoroscopic guidance, an attempt was made to advance the present\n Dobhoff catheter into the duodenum. After multiple attempts, this could not\n be achieved. The tip of the catheter remains within the distal body/antrum of\n the stomach. It is recommended that the patient lie on his right side to\n allow for passive migration of the tube to the proper position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 805095,
"text": " 8:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pending extubation in presence of massive positive fluid bal\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n pending extubation in presence of massive positive fluid balance (18L+)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal abscess drainage, massive positive fluid balance.\n\n VIEWS: Upright AP view compared with semi-erect AP view from .\n\n FINDINGS: The ETT, Swan-Ganz catheter, and right internal jugular central\n venous line remain in stable and satisfactory positions. A NGT is seen with\n tip in the fundus of the stomach, in good position. The cardiac and\n mediastinal contours remain stable. There is continued retrocardiac\n collapse/consolidation with interval increase in size of the small layering\n pleural effusion. There is slight upper zone redistribution with perihilar\n haziness, not significantly changed from prior exam, and consistent with mild\n congestive heart failure. There has been interval improvement in the aeration\n of the right lung base with residual patchy atelectasis present in the right\n lower lobe.\n\n IMPRESSION:\n 1) Interval improvement in aeration in the right lower lobe with residual\n patchy atelectasis present.\n 2) Continued retrocardiac collapse/consolidation with layering small left\n pleural effusion, slightly increased in size from prior exam.\n 3) Continued mild congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806077,
"text": " 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT out, Increased coughing, desaturation, ? aspiration\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage s/p\n intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n NGT out, Increased coughing, desaturation, ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Temperature, low sats, status post abdominal abscess drainage,\n intubation and Swan, increased coughing and desaturation, ?aspiration.\n\n CHEST, SINGLE AP VIEW.\n\n There are extensive diffuse bilateral interstitial and alveolar opacities,\n with small bilateral pleural effusions. There is mild-to-moderate\n cardiomegaly. These have progressed compared with . Two central\n lines are seen, one a dual-lumen right IJ line with tip overlying distal SVC;\n the other a right subclavian line, with tip slightly more distal in the distal\n SVC. No pneumothorax was detected.\n\n IMPRESSION: Dense diffuse bilateral alveolar interstitial infiltrates, with\n sMALL bilateral effusions. Findings are most suggestive of severe CHF. The\n possibility of an underlying pneumonic infiltrate would be difficult to\n exclude.\n\n"
},
{
"category": "Radiology",
"chartdate": "2120-11-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 806366,
"text": " 7:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please check for feeding tube placement\n Admitting Diagnosis: METHICILLIN RESISTANT STAPH AUREUS;SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with temp, low sat s/p abd abscess drainage\n s/p intubation and swan, back from OR>\n REASON FOR THIS EXAMINATION:\n please check for feeding tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Low oxygen saturation S/P abdominal abscess drainage. Fever.\n Intubated. Swan-Ganz catheter. Check feeding tube placement.\n\n COMPARISON: .\n\n AP PORTABLE SUPINE CHEST: The feeding tube has been advanced since the prior\n study. Its tip is not visualized but it does course below the level of the\n diaphragm and lies over the expected position of the stomach. The\n endotracheal tube and right internal jugular central venous line are unchanged\n in position. Cardiac and mediastinal contours are stable. The appearance of\n the lungs is grossly unchanged with bibasilar opacities, more confluent on the\n left in the retrocardiac region.\n\n IMPRESSION: Tip of feeding tube not identified, but tube passes below the\n level of the diaphragm and projects over the expected region of the stomach.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-06 00:00:00.000",
"description": "Report",
"row_id": 1321619,
"text": "NPN0700-1900\nNEURO; ALERT PLEASANT AND COOPERATIVE GENTLEMAN WHO FOLLOWS COMMANDS PURPOSEFULLY. ABLE TO ANSWER Y/N QUESTIONS APPROPRIATELY AND MOUTHING WORD AROUND ETT. MOVES UPPER ARMS SPONTANEOUSLY. MOVES LOWER LEGS TO COMMAND EDEMATOUS 3PLUS.PROPOFOL OFF DURING DIALYSIS.\n\nRESP;A/C 40% 700X12 PEEP CHANGED FROM .LUNG SOUNDS CLEAR TO COARSE.WITH OCC EXP WHEEZE. SUCTIONED Q2 FOR MOD THICK YELLOW REQUIRES SALINE IRRIGATIONS,SATS 92-99% ABG SHOW IMPROVED OXYGENATION AFTER DIALYSIS.\n\nCVS; TEMP37-37.5 CORE. SR-ST UP TO 118 PRIOR TO LOPRESSOR. SOME RARE PAC'S NOTED.STABLE C,O, DOWN DURING DIALYISWITHLOW BP TRANSIENT LY ON NEO.37 MCGS/KG/MIN DURING MIDDLE OF DIALYSIS WEANED OFF BEFORE END OF DIALYSIS,CI GREATER THAN 3 THROUGHOUT.MV02 58-66PLEASE SEE CAREVUE FOR DETAILS.\n\nGU;ANURIC FOLEY FLUSHED FOR PATENCY.GIVEN LASIX 120MGS LASIXI.V. WITH NO RESPONSE THEREFORE DIALYSED FOR 4 HRS REQUIRED LOW DOSE NEO TRANSIENTLY. 2.5 L REMOVED POST DIALYSIS LABS PENDING.LT GROIN SITE .\n\nGI; NPO BS ABSENT. ILEOSTOMY STOMA RED WARM DRAINING SMALL AMOUNT THICK LIQUID STOOL.BAG REMAINS S/B STOMA NURSE.CONTINUES ON TPN\n\nENDO;COVERED WITH RISS.10 UNITS INSULIN IN TPN.\n\nHEME STABLE PLATS 84.\n\nSKIN EDAMATOUS HEELS WITH DRY CALOUSES ELEVATED OF BED.COCCYX PINK SCROTUM AND PENIS SEVERELY EDAEMATOUS WITH SEOUD DRAINAGE FROM SMALL SKINTEAR,\n\n WOUND RED AT BASE NSWTD DSD DONE AT 1600.JP DRAINED 60 MLS IN TOTAL OVER12 HOURS NGT TO LCS DRAINED 50 MLS ? SOME FRESH BLOOD FLECKS.\n\nPAIN CONTROL WITH DILAUDID IMG Q1-2 HOURS WITH GOOD EFFECT.\n\nSOC; SISTERS CALLED AND UPDATED WITH CURRENT CONDITION AND PLAN OF CARE.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-07 00:00:00.000",
"description": "Report",
"row_id": 1321620,
"text": "REVIEW OF SYSTEMS:\n\nNEURO: PT AWAKE MOST OF SHIFT, ALERT, CONSISTENTLY FOLLOWS COMMANDS, PURPOSEFUL MOVEMENTS, NODS HEAD APPROPRIATELY AND WRITES ON BOARD LEGIBLY. PERRL, 3MM/, X 4, GRIPS ARE EQUAL BILATERALLY. PERIODIC DILAUDID REQUIRED FOR PAIN, 2 MG Q1-2 HOURS HAS GOOD EFFECT.\n\nCV: SR-ST, NO ECTOPY NOTED. ABP IN RIGHT RADIAL GOOD WAVE FORM, SYSTOLIC BP RANGES FROM 130S-140S, HR-80S TO LOW 100S. CCO , SVO2 70S, CVP 13-15, PA 40S/20S. DP/PT PULSES ARE PRESENT AND EASILY PALPABLE. RECEIVES METOPROPLOL.\n\nPULM: PT CONTINUES TO BE VENTED, GOOD THIS AM, ABGS SHOW ADEQUATE OXYGENATION, PEEP DECREASED TO 5, PT ON PS 5, 40% O2, RR 20. LUNG SOUNDS ARE COARSE, MORE ON LEFT SIDE. SUCTIONOING RETURND THICK WHITE SECRETIONS.\n\nGI: ILEOSTOMY PUTTING OUT BROWN/LIQUID STOOL, - BS, BELLY SOFT/DISTENDED. PPI PROPHYLAXIS.\n\nGU: NO .\n\nID: AFEBRILE, RECEIVING ANTIBIOTICS\n\nHEME: CRIT 24.8, RECEIVED 2 UNITS PRBCS\n\nSKIN: MIDLINE ABD INCISION W-D DRESSING CHANGED, GRANULATING, SS OOZE SMALL IN AMT. DRAINS JP X 3 PUUTING OUT SMALL SS DRAINAGE. SKIN CARE DONE, PT CHANGED POSITION AND PASSIVE/ACTIVE ROM.\n\nSOCIAL: NO FAMILY CONTACT THIS SHIFT.\n\nPLAN: EXTUBATION? CONT TO FOLLOW CRIT, DRS , FOLLOW , CONTINUE TO SUPPORT PT AND ANSWER QUESTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-24 00:00:00.000",
"description": "Report",
"row_id": 1321675,
"text": "MICU-B NPN 1900-0700\nNEURO - PT. REMAINS INTUBATED AND OFF SEDATION SINCE YEST. A.M. RECEIVING PRN. ATIVAN FOR RESTLESSNESS X2 OVER/. C/O ABD. PAIN INTERMITTENTLY; MOSTLY WITH POSITIONING. TX. X2 WITH PRN DILAUDID WITH GOOD EFFECT. PT. ALERT, FOLLOWING COMMANDS, COMMUNICATING NEEDS WELL VIA NON-VERBAL GESTURING; MOUTHING WORDS. +MAE. PERRLA 3MM/3MM WITH BRISK RESPONSE.\n\nC/V - HR 80'S-100'S, NSR>ST, WITH NO ECTOPY NOTED. ABP 140'S-200'S/70'S-100'S, HYPERTENSIVE T/O SHIFT, DENIED CP; TEAM NOTIFIED; PT. TX. WITH PRN HYDRALAZINE X1, GIVEN X2 LOPRESSOR 5MG WITH TRANSIENT EFFECT. REMAINS ON CAPTOPRIL 6.25 QID, AND LOPRESSOR 2.5 QID. ? NEED TO INC. LOPRESSOR DOSE; HAD BEEN ON 10MG. QID. PERIPHERAL PULSES PALPABLE. 1+ EDEMA NOTED TO EXTREM. CVP 1-3. NO FURTHER DIURESIS OVER/.\n\nRESP - NO VENT CHANGES OVER/. PT. REMAINS ON CPAP+PS 5/PEEP 0/ .30/ VTS 400'S-500'S/O2SATS 92-97%. AM ABG 7.42/38/98/0/25. SX. T/O SHIFT FOR MOD>COPIOUS AMTS. THICK WHITE >YELLOW SECRETIONS. DECREASING THIS AM. CXRAY AT CHANGE OF SHIFT WITH NO SIGNIFICANT CHANGES. LS COARSE T/O. PT. WITH STRONG COUGH; +GAG. PLAN FOR & SBT THIS AM WITH GOAL OF EXTUBATION.\n\nID - TMAX 101.6. PAN CX.; RESULTS PENDING. WBC 10.1. REMAINS ON MEREPENUM FOR ABX. COVERAGE.\n\nHEME/LYTES - HCT STABLE @ 32.9. K+ REPLETED LAST EVE. FOR EVE. K+ 3.8 WITH 20MEQ. KCL. AM K+ 3.3. TO BE REPLETED PER PRN.\n\nGI/GU - PEDI. TUBE IN PLACE; PATENT. TF DELIVERING @ GOAL RATE 40/HR. ABD. SOFT, ND, TENDER WITH MOVEMENT AND PALPATION. +BS. ILEOSTOMY WITH GOOD AMTS. LIQUID, BROWN STOOL OVER/. STOMA CARE PERFORMED AS ADHESIVE HAD COME UNDONE. STOMA PINK. ABD. INCISION DRESSING CHANGED AS WELL WITH WET >DRY STERILE DRESSING. WOUND, HEALING NICELY. INDWELLING FOLEY IN PLACE; PATENT, AS ABOVE, NO FURTHER DIURESIS OVER/. GOOD AMTS. CLEAR, YELLOW URINE OUT.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-24 00:00:00.000",
"description": "Report",
"row_id": 1321676,
"text": "REspiratory Care Note\nPt continues on PSV5. Decreased FiO2 to 30%. Still has copious amounts of secretions. ETT in good position and secure. ABG this am shows good oxygenation and ventilation. BLBS= coarse rhonchi.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-24 00:00:00.000",
"description": "Report",
"row_id": 1321677,
"text": "Respiratory Care Note:\nPt remain mostly on SBT during shift with stable VS. Clearing mod to copious thick yellowish secretions. Elective extubation attempted this evening. Good ABG prior extubation. Will follow sats, IS and post ext ABG later.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-24 00:00:00.000",
"description": "Report",
"row_id": 1321678,
"text": "NPN MICU 7a-7p\nNeuro: Alert and oriented. Receiving prn Ativan and Dilautid for pain and anxiety.\nCV: BP 150-170 in NSR. BP elevated with anxiety. Captopril increased to 12.5mg TID.\nResp: Extubated at 4:40pm. Maintaining 02 sats 94-95%. Continues to have fair amounts of secretions but able to cough them out. Had CXR prior to extubation which showed baseline CHF. Was diuresed with 60 of lasix at 2pm-diuresed approx 1 liter.\nID: Meropenem d/c'd (completed 14d course). Awaiting ID approval for Pipercillin. Sputum growing resistant pseudomonas. tmax 100 today. Was pan cx last night. L subclavian placed today. R line d/c'd and tip sent for cx.\nGI: Iliostomy draining well.\nskin: abdominal incision clean and dry, no drainage, no redness.\nSocial: family in to visit today.\nA/P: Extubated today\n-monitor ABG-most recent one post extubation pnd.\n-? PT consult to help improve pt. strength.\n-pain management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-14 00:00:00.000",
"description": "Report",
"row_id": 1321641,
"text": "NPN: REview of Systems\nNeuro: Pt has been awake. Oriented to person/place and time. Moans alot and c/o generalized discomfort. Hurts to touch. Pt encouraged and instructed how to use dilaudid PCA. Moves well w/ assistance. Follows commands. Periodically agitated w/ nursing care, but subsides when activity is done and he is allowed to rest.\n\nResp: Breathing is labored. Pt continues on 4L NC and 95% high flow. Pt has strong productive cough for thick yellow secretions. He uses incentive spirometer independently. Sao2 up to 99% when O2 on, but drops to 80s when off.\n\nCV: SR. NO ectopy. BP has been stable. Please see flowsheet for data and assessment. Skin warm. Palpable DP?PT pulses bilaterally.\n\nGI: Tube feeding changed to nepro w/ promod. Rate started at 20cchr. Residual checked and rate advanced accordingly. Currently on 30cc/hr. Goal rate is 40cchr. Ileostomy appliace . Stoma is pink. Liquid brown stool present. Abdominal dressing changed. Retention sutures . Open area of wound clean w/ granulating tissue. No purulent drainage present.\n\nGU: Foley to gravity. UO=505cc 8am-2pm. Currently being dialyzed.\n\nID: Afebrile. Pt to receive vancomycin after dialysis since level was < 15 today.\n\nActivity: OOB w/ use of walker and 2 assist. Pt took a few steps to chair. Did well. Weaker going back to bed.\n\nSocial: Sister called. Anticipate being here tomorrow.\n\nA: Tenuous respiratory status. Hemodynamics stable.\n\nP: Dialysis as ordered. Continue encouraging Pt to use PCA. Vancomycin after dialyis. Advacne tubefeedings as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-14 00:00:00.000",
"description": "Report",
"row_id": 1321642,
"text": "addendum to above note.\n\ndialysed for 3 hours 3.5 l removed.tolerated well respiratory status improved slightly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-15 00:00:00.000",
"description": "Report",
"row_id": 1321643,
"text": "ROS (1900-0700):\n\nNeuro: AAOx3, appropriately answering questions and following commands. Using PCA appropriately for pain, though needs encouragement. IV ativan given x1 for restlessness/anxiety.\n\nResp: LS course and dm at bases. SaO2=98-100% on 95 % hi flow mask. Nasal cannula weaned off. ABG adequate. +PC for thich white/yellow sputum. Using Incentive spirometry.\n\nCV: NSR c hr=70-80s, no ectopy. SBP=120-130s. IV lopressor continues. Color pink, skin warm and dry. edema.\n\nGI: Abd softly distended. +BS. Nepro with promod at goal of 40cc hr and residuals=5cc. Illeostomy draining liquid brown stool, illeostomy pink. IV protonis and po carafate continue.\n\nGU: Indwlleing foley, draining amber urine.\n\nID: Abebrile. IV antibiotics continue. Contact precautions.\n\nEndo: no coverage needed per RISS.\n\nSkin: Abd dressing W-D changed.\n\nPlan: Continue support. Wean O2.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-20 00:00:00.000",
"description": "Report",
"row_id": 1321659,
"text": "Respiratory Care:\n\nPatient remains intubated/sedated on Psv. Vent settings unchanged. Current settings Psv 12, Cpap 5, Fio2 40%. Spont vols 500's with RR high teen. Increased secretions since yesterday. Sx'd for moderate amounts of thick white and yellow sputum. ETT retaped at 25cm. Bs equal bilaterally. Rhonchi clearing with sxing. No further changes made. Will repeat later in am. Continue with Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-20 00:00:00.000",
"description": "Report",
"row_id": 1321660,
"text": "NEURO; PT. REMAINS LIGHTLY SEDATED ON 70MCG/KG/MIN OF PROPOFOL. PT. EASILY AWAKES TO VERBAL STIMULI AND MOUTHS WORDS, PT ALSO FOLLOWS SIMPLT COMMANDS. PT. DOES MAE'S AND HAS REMAINED AFEBRILE DURING THIS SHIFT. PT. DOES C/O INTERMITTENT ABD. PAIN, BUT HE QUICKLY FALLS BACK TO SLEEP FOLLOWING THIS COMPLAINT.\n\nC.V; PT. HAS REMAINED NSR 70-80'S WITH NO NOTED ECTOPY DURING THIS SHIFT. B/P HAS BEEN SLIGHTLY ELEVATED BUT CONTROLLED. LOPRESSOR DOSAGE HAS BEEN DECREASED AND PRN NITRO PASTE AND HYDRALAZINE ORDERED FOR B/P CONTROL.\n\nRESP; PT. IS INTUBATED WITH NO VENT SETTINGS CHANGED DURING THS SHIFT, SEE CAREVUE FOR SETTINGS. PT. HAS BEEN SUCTIONED FOR MODERATE AMT'S OF THICK YELLOW/TAN SPUTUM. PT. HAS BEEN LAVAGED WITH EACH TREATMENT. O2 SATS READ 100% WITH RESP RATE CONTROLLED. SPUTUM CULTURE SENT YESTERDAY WITH RESULTS PENDING AT THIS TIME.\n\nG.I; PT. IS NPO AT PRESENT FOLLOWING INSERTION OF POST PYLORIC FEEDING TUBE PLACEMENT. NEPRO WILL BE STARTED TODAY AT SOME POINT. ABD. IS ROUND, SOFT. 3 J/P DRAINS REMAIN , WHILE DRAINING SCANT TO SMALL AMT'S OF PUS/SEROUS DRAINAGE. BLOOD SUGARS HAVE BEEN WNL'S.\n\nG.U; PT. HAS FOLEY CATHETER DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE. CVP HAS BEEN . NO ADDITIONAL LASIX GIVEN DURING THIS SHIFT.\n\nI.V; PT. HAS TLC WITH ALL PORTS PATENT, SECURED, AND FUNCTIONING WELL. A-LINE IS FUNCTIONING WELL AND CORRELATING WITH CUFF PRESSURES.\n\nI.D; PT. CONTINUES MEROPENUM FOR MRSA AT WOUND SITE.\n\nDISPO; PT'S B/P IS TO BE CLOSELY MONITORED AND TREATED UTILIZING PRN ORDERS.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Report",
"row_id": 1321633,
"text": "t-sicu nsg note:\nneuro- alert and oriented, anxious, and panics at times d/t pain level. fc,mae's.\n\nresp- sao2 drops to 88% when face tent off ,95% w/ 70% fio2 via tent.\nstrong cough productive for very tenacious yellow secretions in copious amts. bs coarse, using incentive spirometer.\n\ncvs- hr 90's-105ns, no ectopy, afeb, sbp 140's-160's. k+ and ca++ repleted. no insulin requirements.\n\ngi- abd sl distended, ileostomy patent for thick dk green bile, stoma pink.\n\ngu- uo ~45-60cc/hr amber urine.\n\nskin- dependent edema to arms and legs. wound w/ granulation tissue.\n\na: inc pain, inc anxiety panics easily.\n\np: monitor vs per routine, follow abg's, abd ct, anti-anxiety .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-12 00:00:00.000",
"description": "Report",
"row_id": 1321634,
"text": "T/SICU NSG PROGRESS NOTE\n0700>>\n\nEVENTS- RESP DISTRESS>> DESATURATION>>RIGORS THIS AM\n HD TODAY FOR 3L\n\nNEURO- REMAINS ALERT & COOPERATIVE WITH CONT ONGOING PAIN(AS PREVIOUSLY DESCRIBED; NOT NEW); OCC MILD ANXIETY. Cont on dilaudid PCA and prn ativan(1mg given this shift). Pt rates pain at when using PCA regularly, but elevates to 7 with activites.\n\nCVS- nsr, stable BP ..see careview. No new hemodynamic issues. Tolerated 4 hrs HD with 3L taken off. CVP mid-low teens.\n\nRESP- Acute episode of desaturation to low 80's with elevated BP and onset of rigors this am. Required NRB support with NC @8L to improve sats. (PaO2 to ~60). Blood culture x1 sent. Episode resolved when sats improved and pt settled w/o further distress. O2 support weaned to FT @ 70% with NC @ 2L..sats maintained >96% as long as FT remains in place; if o2 contact lost..sats drop to 85-90. ABG returning to baseline this afternoon; no c/o resp distress by pt.\n..cont to clear mod amt thick brown> bloody secretions.\n..breath sounds are coarse to clear anteriorly with bronchial sounds posteriorly and crackles at bases.\n\nRenal- cont steady u/o q1-2/hrs with daily utput ~400-500cc\n\nID- temp dropped to 96.8 with rigors this am and returned to 98-99 baseline range the rest of the day. WBC down to 17 today. Cont on antibiotic therapy w/o changes. Awaiting vanco level <15 to dose vanco\n..abd wound is slightly red at incision edges with yellow fibrinous tissue at base of wound distally. scant s/s drainage\n..Jp drains with scant s/s drainage.\n\nGI- abd remains tense & tender. NGT to LCS with minimal >clear drainage. Carafate cont q6/hr\n..ileostomy drainage is minimal today; remains black in color & is thick. Stoma care by ET rn today; stoma remains pink. Protonix cont .\n***Planned CT with contrast planned but deferred today per DR . Pt will be reasses tomorrow. If pt needs CT with contrast, plan may be to intubate to protect airway during flat lying position with full GI tract..this is per ICU team.\n...TPN ongoing at goal rate\n\nHeme- stable, no issues\n\nEndo- ssri coverage x1 during am rigors for glucose of 135. Isulin remains in TPN.\n\nSkin- no new issues. Pt without breakdown on back/buttocks but with pre-existing ruddy appearance of coccyx with 'old' evidence of pressure area. Anasarca slowly resolving with cont Ultrafiltration/HD.\nWill cont to monitor for need to change to air mattress support.\n\nAssess- resp distress/desat with rigors x1 today- resolved with increased o2 support, HD, rest.\n persistent mod abd pain..PCA ongoing\n New onset rigors ?? ongoing abd process.\n\nPlan- cont with current mngmnt\n ? ABD CT tomorrow; may require elective intubation for airway protection.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-13 00:00:00.000",
"description": "Report",
"row_id": 1321638,
"text": "T/SICU NPN\nREVIEW OF SYSTEMS:\n\nNEURO- ALERT THIS AM,BUT HAD RECIEVED ATIVAN EARLIER IN TH MORNING AND BECAME CONFUSED, ORIENTED X 1 ONLY.CLEARED LATER IN THE MORNING.NOW SLIGHTLY CONFUSED AT TIMES REQUIRING REORIENTATION.CONTINUES ON A DILAUDID PCA.SISTERS CALLED.\n\nCARDIAC SR-ST,NO ECTOPY.BP STABLE.ALINE DAMPENS FREQUANTLY.LRG AMT LOWER EXTREMITY EDEMA.PT WEAK,TOTAL SLIDE INTO A RECLINER TODAY.TOLERATED WELL.\n\nRESP- NC 4L AND FACE TENT AT 70% FIO2,SATS 92-96%.DROPS DOWN TO LOW 80'S WHEN HE TAKES HIS MASK OFF.LS COURSE,DECREASED IN BASES,LT WORSE THEN RIGHT.\n\nGI- TPN CONTINUES,STARTED ON IMPACT WITH FIBER AT 20CC/HR,TOLERATED WELL.ILEOSTOMY DRAINING BLK/GREEN STOOL,SLTLY OB +\n\nGU-UO 15-60CC/HR.PLAN FOR DIALYSIS TOMORROW.\n\nSKIN- ABD INCISION W-D DSNG .JPX3 TO BULB SX,SM TO MODERATE AMT OUT.JP #3 ALSO PUT OUT QUARTER SIZE THICK,PURULENT DRAINAGE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-13 00:00:00.000",
"description": "Report",
"row_id": 1321639,
"text": " 1900-2300\n\nAlert Orient X's 3. Requests ativan for anxiety. Appears calm and restful. When left alone drifts off to sleep.\n\nLungsounds coarse and diminished in the bases. O2 70% facetent + 4L np. SaO2 95-99% Coughs up thick tan to yellow phlemg. IS done. Gross edema in arms, sacral, hips, and legs.\n\nSinus Rhythm rate 90's no ectopy noted. Right radial art line positional. CVP=14's. Peripheral pulses present.\n\n sump w/tube feedings. No residuals. Abd firm tender w/active BS. 3 jp drains to abd w/ S/S scant drainage. Ileostomy w/dark green to black liquid draining small amt. Abd. dressing clean dry and .\n\nFoley draining clear yellow urine upto 120cc/hr\n\nFingerstick 115 no coverage\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-14 00:00:00.000",
"description": "Report",
"row_id": 1321640,
"text": "S/P GI Surgery\n\nPt is alert and oriented, slept very little. Frequently moaning loudly due to resp. issues. Dilaudid PCA.\n\nVSS. Aline positional. HCT 27.6. WBC^15.2. Pneumoboots on.\n\nHigh neb on due to low sats. Pt has strong cough-expectorates thick yellow sputum.\n\nTube feeds at 20cc/hr, no residuals. TPN. Abd. soft-incision unchanged. JP drains in place. Ileostomy with brown liquid out.\n\nLasix 40mg with increased urine out. Cr 4.7. Anasacra.\n\nRed coccyx.\n\nNo calls from family.\n\nPlan: Dialysis today with ultrafiltration. Continue with antibiotics.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-19 00:00:00.000",
"description": "Report",
"row_id": 1321656,
"text": "MICU-B NPN 1900-0700\nNEURO - PT. REMAINS INTUBATED AND LIGHTLY SEDATED ON PROPOFOL GTT. @ 60MCG/KG/MIN. OPENING EYES SPONT. FOLLOWING COMMANDS. +MAE. PERRLA 3MM/3MM WITH BRISK RESPONSE. NODDING HEAD; GESTURING TO COMMUNICATE NEEDS. GIVEN X1 DILAUDID FOR PAIN; PT. WITH INC. ABP AND GRIMACING (NO SIGNIF. EFFECT NOTED).\n\nRESP - NO VENT CHANGES OVER/. PT. REMAINS ON CPAP+PS 10/5 .50/VT 300'S-500'S, RR 10-20/ O2SATS. 96-99%. AM ABG 7.41/42/131/20/2. 18. LS COARSE T/O WITH CRACKLES NOTED TO LLL. GOOD COUGH & GAG. SX. T/O SHIFT FOR MOD. AMTS. THICK, WHITE SECRETIONS. COPIOUS AMTS. ORAL SECRETIONS AS WELL.\n\nC/V - HR 60'S-70'S, NSR WITH NO ECTOPY NOTED. ABP 140'S-150'S/60'S-80'S. + PITTING EDEMA TO EXTREM. PERIPHERAL PULSES PALPABLE. REMAINS ON Q6/HR IV LOPRESSOR. (PT. WITH EF 25% ? NEED FOR ACE; THOUGH PT. WITH RESOLVING ATN WHICH REQUIRED DIALYSIS). CVP 6-8.\n\nHEME - PT. S/P TRANSFUSION 2U PRBCS FOR AM HCT YEST. 24. POST HCT 30.3. AM LABS PENDING.\n\nGI/GU - PEDI-TUBE IN PLACE; PATENT; PLACEMENT VERFIFIED PER CXRAY; CLAMPED; TF OFF OVER/. PT. TO GO TO IR FOR POST PYLORIC TUBE PLACEMENT TODAY. ABDOMINAL DRESSING DRY AND . JP DRAINS X3 TO BULB SX. WITH MINIMAL OUTPUT OVER/. SMALL AMTS. LIQUID,BROWN STOOL FROM ILEOSTOMY; STOMA PINK. INDWELLING FOLEY IN PLACE; PATENT, WITH ADEQUATE AMTS. CLEAR, YELLOW, URINE OUT OVER/.\n\nID - AFEBRILE.\n\nACCESS - RIJ DIALYSIS CATH. IN PLACE; SITE WNL. RSC MULTI-LUMEN IN PLACE; PATENT, ALL PORTS PATENT, SITE WNL. (L)RADIAL A-LINE IN PLACE; PATENT, WITH SHARP WAVE-FORM, +FLUSH, +DRAW, SITE WNL.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-19 00:00:00.000",
"description": "Report",
"row_id": 1321657,
"text": "Respiratory Care Note:\n Patient remains intubated and sedated on propofol. Suctioned today for coopious amounts of clear yellow-tan streaked sputum. BS with scattered rhonchi t/o. Taken to IRV this afternoon to verify placement of pej tube without incident. Plan to maintain on PSV at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-19 00:00:00.000",
"description": "Report",
"row_id": 1321658,
"text": "NPN MICU 7a-7p\nNeuro: Remains lightly sedated on Propofol 70mcg. Able to mouth words and follow commands.\nCV: Had cardiology consult today to evaluate increased BP and poor EF. SBP remains 160-170 with HR in 70's-80's. CVP- . Cardiology recommends adding ACE inhibitor and decreasing beta blocker for mild CHF.\nResp: Remains on 40% CPAP 10 and 5 PEEP, minute volumes 9-10L. Sx frequently for large amounts of thin, white sputum. Breath sounds course but immprove after sx. Possible plan for extubation tomorrow.\nGI: Went to IR for post pyloric placement of feeding tube. To be started on Nepro tube feeds. Passing moderate amounts of liquid brown stool. Will intermittently c/o abdominal pain but has not required Dilautid.\nRenal: Had dose of lasix this am with good response. need more lasix tonight as CVP has increased from from this am to this afternoon. Quinton catheter d/c'd this afternoon, tip sent for cx.\nF & E: Repleted with K this afternoon. Has set of lytes PND.\nSocial: No visitors, no phone calls.\nA/P:\n-Possible extubation tomorrow although still has moderate amount of sputum.\n-Needs sputum cx sent.\n-Monitor lytes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-13 00:00:00.000",
"description": "Report",
"row_id": 1321635,
"text": "T/SICU Nursing progress note\nS/\n\nO/ neuro , ongoing abdominal pain, reporting good effect with dilaudid PCA, assisting with repositioning, independent with IS/ yankauer, SpO2 90-92% with 4L NP in place, requires FT 70% humidified mist in addition to maintain SpO2 96-100%, minimal reserve, pt tachypneic, tachycardiac with desturations 85-89% with activity, recovers with rest, cough strong, pt independent with pulmonary hygiene, mobilizing moderate amounts thick tan secretions, remains afebrile on multiple , decreasing WBC, note purulent output from JP #3 in small amounts, dressing with mild erythema at wound edges, retention sutures , no drainage, decreasing weight with ongoing UF, improving \n\nA/ desaturations with activity, minimal reserve\n improved pain control overnoc\n purulent d/c from JP #3\n\nP/ cont to assess pain regimen\n monitor resp status\n follow temp curve\n monitor JP output\n consider UF again today\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-13 00:00:00.000",
"description": "Report",
"row_id": 1321636,
"text": "T/SICU NPN 7A-7P\nREVIEW OF SYSTEMS:\n\nNEURO- ALERT AND ORIENTED X 3,MAE EQUALLY.C/O MODERATE TO SEVERE HA MUCH OF THE DAY,MEDICATED WITH FENTYNALIV PRN, THEN PERCOCET PO PRN WITH SOME RELIEF.TO RADIOLOGY FOR REPEAT HEAD CT,THEN NECK FILMS FLEXSION AND EXTENTION AFTER C/O PAIN IN CERVICAL SPINE ON CLINICAL EXAM.PT VOMITED IN RADIOLOGY LRG AMOUNT X ONE.AWAITING RESULTS OF SCAN/FILMS. IN TO VISIT.\n\nCARDIAC- SR-ST W/O ECTOPY.SBP 120-150'S MOST OF THE DAY,OCASIONALLY UP TO 160'S BREIFLY WITH COUGHING/VOMOTING.\n\nRESP- ON ROOM AIR.LUNG SOUNDS CLEAR.STRONG,PRODUCTIVE COUGH.\n\nGI- INTERMITTENTLY C/O STOMACH DISCOMFORT,PEPCID GIVEN.LIQUIDS TAKEN WELL,ON STRICT 1.5 LITER FLUID RESTRICTION.NO FREE WATER.PASSING FLATUS.\n\nGU- FOLEY , UO MORE CONCENTRATED THROUGHOUT THE DAY DT FLUID RESTRICTION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-13 00:00:00.000",
"description": "Report",
"row_id": 1321637,
"text": "ADDENDUM\nAPPOVE NOTE WRITTEN ON WRONG PATIENT,PLEASE DISREGARD\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-18 00:00:00.000",
"description": "Report",
"row_id": 1321651,
"text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED IN SIMV/PS MODE. PEEP WEANED MD ORDER. TOL WELL BY PT, 2 97%. BS GROSSLY CTA BILAT, FOR LG AMT BROWN THICK SEC. AM ABG REFLECTS NORMAL ACID-BASE W/NORMOXIA, HCT 56. NO SBT PER TEAM PENDING FURTHER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-18 00:00:00.000",
"description": "Report",
"row_id": 1321652,
"text": "NEURO: Pt remains lightly sedated on propophol @ 70 mcg\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-18 00:00:00.000",
"description": "Report",
"row_id": 1321653,
"text": "RESP CARE\nPT. REMAINS INTUBATED/SEDATED ON MECHANICAL VENTILATION. CHANGED MODES FROM SIMV TO PSV WITH GOOD EFFECT. NO ABGS DONE ON CURRENT SETTINGS, SPO2 99%, VT'S 500'S RR>20 TOLERATING WELL.\nBS: COARSE BILAT. 'D X1 FOR SM. YELLOW THICK.\nPLAN: CONTINUE TO WEAN AS TOLERATED\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-05 00:00:00.000",
"description": "Report",
"row_id": 1321612,
"text": "Review of systems:\n\n2045-0700\n\nPt received from the OR s/p exploratory lap, lysis of adhesions, drainage of intra abdominal abscess, loop ileostomy, jp drain placement X 3.\n\nIV/invasive line access: RIJ trauma line, RSC swan with CCO/introducer, LL arm PIV # 18g, R Radial A line.\n\nNeuro: Pt sedated on propofol at 15 mcg/kg/min. PERRl 2-3 mm/bsk. When propofol lightened: No spontaneous movement noted, Pt does not withdraw or respond to deep pain, - gag reflex, - cough reflex, - pupil reflexes.\n\nCV: ST with occasional PVCs 100-115. Art line in right radial, waveform has a whip and is corrected for - correlates with NBP. Systolic Bp trends 120s-140s. Normal S1 S2 per auscultation. DP/PT pulses are present and easily palpable bilaterally. CVP 11-15, PA pressures running 40s/30s, PAWP 14-19, CCO 6.6, SVO@ 76 % and calibrated this shift. Receives Metoprolol.\n\nPulmonary: When initially received from OR, Pt sats decreased to 70s with good wave form, oxygenation oon the vent was increased to 100%, ABG drawn and showed worsening acidosis. PEEP increased to 12 and repeat ABGS showed improving acidosis. See carevue for trend. Current VEnt settings: CMV mode, 700 X 12, 70 % FIO2, 12 PEEP. Breath sounds are clear to coarse bilaterally, suctioning returns thin/scant secretions.\n\nGI: sump in right nare to Low intermediate suctioning returning thick green secretions. Belly is soft/distended, absent BS. - Colostomy had minimal S/S drainage in bag, Stoma is bright Red and dusky. Pt receiving TPN. PPI prophylaxis.\n\nGU: Foley patent to gravity, 15 cc out for shift yellow/cloudy. Creat increasing, see labs. MIVF NS at 150/hour. Replenished 2 gm Mag this shift.\n\nENDO: RISS.\n\nID: afebrile, on multiple antibiotics and fluconazole. VANCO level to be drawn prior to each dose.\n\nHEME: Crit stable, see labs for details.\n\nSKIN/drains: MId line abdominal incision wet to Dry from OR. DSD with slight s/s ooze. 3 JP drains to bulb suction returning moderate amt bloody output. Compressin sleeves on/. Pt rolled side to side, skin on back/peri area . Pink, warm, diaphoretic. Skin care and oral care done.\n\nSocial: Per Dr. , Surgeon, message left on home phone for sister of pt after surgery completed. No family contact this shift.\n\nPlan: Continue to follow ABGs, CRit/COAgs, assess pt's alertness. Update sister and provide support, change abdominal dressing , monitor output from JPs, monitor skin.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-05 00:00:00.000",
"description": "Report",
"row_id": 1321613,
"text": "addendum:\n 0600: propofol turned completely off, pt does not open eyes to command but will wiggle toes/feet to command, very slightly, weak.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-05 00:00:00.000",
"description": "Report",
"row_id": 1321614,
"text": "T/Sicu Nsg Progress Note\n0700>>1500\n\nS-intubated\nO\nNeuro- off propofol since 0600; prolonged waking time. Pt now responding to voice briskly- will follow weakly with all extremities, nods head in response to questions/comments. Minimal spontaneous activitiy noted. perrl initialy @ 5-6m>> now @ 3mm/brisk.\n pt consistently nods 'yes' to 'do you have pain?' Receiving ivp dilaudid @ .5mg increments ~ q1/hr. Per pt..pain persists. Pt grimaces easily to touch of abdomen.\n\nCVS- stable hemodynamics..see careview flow data.\n IVF have been reduced to kvo status to restrict intake.\n electrolytes wnl\n\nRESP- fio2 weaned to 50% with improved PaO2..no other vent changes. abg within acceptable range at present time..base deficit stable at -5 and ph at 7.37. Breath sounds are clear & decreased at bases. Spont breaths cont @ over vent/per min. Secretions are small amts thick brown/blood tinged sputum. Impaired cough/gag response.\n\nRenal- no u/o and NO response to lasix 100mg ivp x1 today. Renal consult with recommendation for dialysis; catheter to be placed by team. Family to be consented for line placement; probable dialysis in am. Creat to >4 today(adm creat 0.9).\n..iv intake restricted\n..all meds renal dosed\n\nHeme- stable...no issues\n\nID- afebrile; cont on antibiotics x3, antifungal x1\n\nGI- TPN ongoing @45cc/hr\n maintenance at kvo rate\n ngt to lcs with THICK draiange; protonix qd\n ..ileostomy patent with brown liquid stool in bag; stoma pink/moist\n ostomy RN to assess area and reapply ostomy appliance.\n\nendo- ssri with scale tightened to rpovide improived coverage for blood sugars >160\n\nskin- edematous, warm & dry with palpable peripheral pulses. Initially diaphoretic skin in facial area..? related to pain this am; Now dry.\n\n...abd incision is open superficailly with retention sutures securing incision. w>d dsg changes /prn. small amt s/s drainage from wound.\n..3 JP drains in abd with s/s drainage.\n\nsocial- sisters visiting this afternoon. Both have been provided with pt condition update with explanation of renal issues and plans for dialysis. Family in agreement & support of this treatment at this time. Per family , pt is prone to 'panis attacks' and will extubate self if not restrained when he is able to move more independently. Also, pt does not want prolonged life supportive measures or a significant change in his quality of life: ie does not want to end up in nursing home or on chronic dialysis etc. His sisters are aware and support pt's wishes and will advocate for pt if his clinical situation worsens or does not indicate significant recovery in a reasonablely expected amount of time.\n\nAssess- s/p abd abcess/sepsis complicated by renal failure\n s/p exp lap for lysis of adhesions and drain placement into abcess sites. Loop ileostomy formation.\n\nPlan- cont with current plan of care: fluid restriction, pain mngmnt, vent support, dialysis.\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": "2120-11-05 00:00:00.000",
"description": "Report",
"row_id": 1321615,
"text": "NURSING PROGRESS NOTE\nS/ PT HEMODYNAMICALLY STABLE, PT HAD CATH PLACED IN LEFT GROIN, SITE IS WNL. NEURO STATUS IS UNCHANGED , HE IS SLEEPY BUT EASILY AROUED, ASKING FOR PAIN MED, DILAUDID GIVEN .5-1MG Q1 WITH SOME RELIEF. PT FOLLOWING COMMANDS WITH ALL EXTREMITIES. BOTH HANDS ARE RESTRAINED AT THIS TIME. RESP - NO CHANGES REMAINS ON AC PT C/O FEELING LIKE HE COULDN'T BREATH AFTER TURNING AND SUCTIONING, PAIN MED GIVEN AND PT FELL ASLEEP. GU- CONT TO HAVE NO URINE OUTPUT, IVF AT 5CC HR. NUTRITION, PT CONT ON TPN AT 45CC HR. GI- ABD FIRM , NG TO SUCTION, DRAINING THICK BILE. DSG ON ABD , DRAINS DRAINING SMALL AMT OF .SOCIAL, PT FAMILY SPOKE WITH DR IN DEPTH ABOUT THE PLAN OF CARE.\nA/ PT TO BE DIALYSED IN AM, CONT WITH PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Report",
"row_id": 1321631,
"text": "T-SICU Nsg Note\n Neuro - anxious/agitated about 2100, asking for \"advil - you know to help my stress.\" Medicated with 1mg ativan IV with calming effects. Slept well, awaking several times to cough & Deep breathe.\n HR 90- 110 even with 10mg metoprolol IV q 6.\n Resp - desats to 80% when face tent slips down. O2 sats up with re-positioning O2 mask and/or C&DB.\n GU - u/o has increased, lots of sediment in urine.\n GI - dk brown/black liquid from ileostomy. Abd swollen, retention sutures are tight to skin. Abd incision is pink, clean, granulating.\nPt often c/o sharp abd pains, as thought something is poking him. Dilaudid PCA with good effect.\n Heme - Hct > 30 after transfusions on \nID - Meropenam started for resistant gram - rods finally growing from swab taken in OR on . Ceft. DC'd. Vanco level 23, so no dose given .\n ENDO - no extra insulin required, TPN with insulin has kept BS under good control.\n Remains very edematous. ? dialysis today.\nA: Stable, able to comminicate needs. PCA providing adequate pain control.\nP: CHeck vanco level today. Encourage C & DB and turning in bed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-11 00:00:00.000",
"description": "Report",
"row_id": 1321632,
"text": "T/SICU NPN 7A-7P\nPT WITH INCREASING RESP DISTRESS REQUIRING EMERGENT DIALYSIS.\n\nREVIEW OF SYSTEMS:\n\n PT ALERT AND ORIENTED X 3,MAE,FOLLOWS COMMANDS.ON DILAUDID GTT WITH FAIR PAIN CONTROLL,MODERATE TO SEVERE ADB PAIN WITH ANY MOVEMENT.\n\nCARDIAC- ST W/O ECTOPY.BP ELEVATED MUCH OF THE DAY WITH HIS RESP DISTRESS/PAIN,SBP DOWN TO HIGH 90'S AT TIMES AFTER DIALYSIS,1800 LOPERESSOR HELD.RT SUBCLAVIAN TRIPLE LUMEN CHANGED OVER A WIRE,TIP SENT FOR CULTURE.\n\n PT ON A FACE TENT AT 70% FIO2 WITH RR OF ,SATS 94-98%.THROUGH OUT THE DAY,PT DEVELOPED RESP DISTRESS,SOB WITH RR UP TO 30.PLACED ON 100% FACE TENT WITH PO2 59,PLACED ON A NON-REBREATHER AT 100% WIT SATS UP TO 100%,BACK TO 100% FACE TENT AFTER DIALYSIS.GOOD COUGH,PRODUCTIVE OF THICK YELOW SPUTUM.\n\nGI- NGT TO LCS.ABD CT ORDERED,ATTEMPTED TO GIVE PT CONTRAST VIA NGT;PT DEVELOPED SEVERE ABD PAIN.DUE TO POOR RESP STATUS,CT SCAN HELD,ATTEMPTED TO DRAIN CONTRAST OUT VIA NGT WITH MOD AMT RETURNED.ILEOSTOMY PUT OUT APPROX. 400CC WATERY,BROWN STOOL.APPLIANCE LEAKED,REPLACED BY OSTOMY NURSE.\n\nGU- UO 10-50CC/HR.REMOVED 2.5 LITERS WITH DIALYSIS, PT NOW MUCH MORE COMFORTABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-27 00:00:00.000",
"description": "Report",
"row_id": 1321683,
"text": "Nursing Progress Note 1900-0700\nReview of Systems:\n\nNeuro: Pt has remained AAO x 3, MAEE. Sitting in chair for total of 6hrs today before requesting to go back to bed. Transfered from chair to bed with assist of one. Pt tiring very easily with exertion, C/O dizziness after transfer to bed. Pt received Dilaudid 2mg X 2 for abd pain, pt states Percocet has minimal effect on his abd pain. He also requested Ativan for anxiety, rec'd 1mg with good effect--able to sleep several hrs .\n\nResp: Sating 96-100% on 3l NC. RR 7-14 and easy. Lungs clear, diminished @ bases. Pt using inspirometer freq.\n\nCV: HR 60-88NSR without ectopy. BP 95/62-116/55.\n\nGI: Tol house diet well, no C/O nausea or increase in abd discomfort. Doboff tube clamped. draining small amt brown/loose stool, stoma pink. Abd dsg D&I. List of consumed food kept for calorie ct by nutritionist.\n\nGU: Urine output low to adequate per carevue. 24hr balance at MN -425ml; LOS balance -1954ml.\n\nPlan: AM labs pending. Cont to prep for D/C to Rehab. Cont to increase activity with PT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-18 00:00:00.000",
"description": "Report",
"row_id": 1321654,
"text": "NEURO: Pt remains lightly sedated on propophol @ 70 mcg/kg/min. Pt opens eyes to voice/stimuli and follows simple commands. Cough/gag .\nCV: Monitor shows NSR with rare pvc noted. L radial aline with dgood waveform analysis and +csm noted. CVP 9-13. Decreased from previous day (2+ PPE). Pt remains on IV Lo0pressor Q6hr.\nRESP: LS coarse throughout with bibasilar cracklers noted. Pt placed on PS 10 with PEEP 5 and fio2 .50. Pt tol well. mod amts thick brown secretions via ett and copious amts cl oral secretions.\nGI: Abd soft and nontender. +BS noted. TF's off in am for ? post pyloric tube this afternoon. Ileostomy stoma pink draining lg amts liquid brown stool heme -. Ostomy RN up yo change appliance.\nGU: Foley and patent draining yellow urine.\nHEME: K and mag repleted per scale, 1st of 2 U PRBC up and will need post transfusion Hct. Pleasee recheck lytes this evening.\nENDO: Remains on fingersticks Q6hr wit RISS coverage per scale.\nI-D: Cont with low grade temps. Pt remains on Meropenum all other Abx d/c'd this am.\nPSY-SOC: Sister called x1 and updated on status and plan of care. Plans to visit tomorrow per telephone conversation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-19 00:00:00.000",
"description": "Report",
"row_id": 1321655,
"text": "Respiratory Care:\n\nPatient remains intubated/sedated on Psv. Pt. weaned to Psv yesterday. Vent settings Psv 10, Cpap 5, Fio2 40%. Tolerating well maintaining vols of 500's. RR mid teens. Bs clear bilaterally. Sx'd for moderate amounts of thick white sputum. Sx'd for lg amounts of clear oral secretions. CXR improving pulmonary edema, bilateral effusions R > L. No further changes made. Plan: Repeat later in am. Continue with Psv and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-06 00:00:00.000",
"description": "Report",
"row_id": 1321616,
"text": "Review of systems:\n\nNeuro: Pt awake, altert, consistently follows commands. MAE X 4, weak. Pt nods appropriately to simple questions and mouths words. Pt C.O pain in the belly and requires 1 mg of Dilaudid ~QH with good effect.\n\nCV: SR to St 80s to 110, no ectopy noted. ABP in right radial with good waveform. Systolic BP ranging 120s-140s, CVP 12-15, PA 40s/20s, CO ~ 6.5, SVO2 70s. DP/PT pulses present and easily palpable bilaterally. edema in extremities. MIVF at KVO. Normal S1 S2 per auscultation.\n\nPulm: Pt vented on AC: 700 X 12, 40%, 12 PEEP, ABGs show adequate oxygenation. Lung sounds are coarse to clear bilaterally. Deep suctioning returns scant thin secretions. Lots of oral suctioning required, thick white. ETT adjusted by from 22 to 24 at the lip due to frequent air leak notation and pt appearing to tongue ETT. ETT repositioned and retaped.\n\nGI: sump in right nare, LCS returning bilios drainage. - BS, ileostomy has small brown/liquid stool output. Receiving TPN. NPO, PPI prophylaxis. Belly soft/distended.\n\nGU: No , pt to receive dialysis today.\n\nEndo: RISS\n\nID: Afebrile\n\nHEME: Crit stable\n\nSkin: midline abdominal incision with retention sutured, approximated, base red, wet to dry dressing changed. Slight/scant SS output. Compression sleeves on/. Skin edematous, no breakdown elsewhere noted. Full bed bath received, linens/gown changed.\n\nSocial: No family contact this shift.\n\nDrains: JP X 3 left abdominal area. Small output, SS drainage.\n\nPlan: Dialysis today, Wean down vent support/peep, follow crit/lytes, follow/monitor pain status, dressing changes. Continue to provide pt and family with support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-06 00:00:00.000",
"description": "Report",
"row_id": 1321617,
"text": "Respiratory Care:\nPatient remains on ventilatory support throughout the night with no parameter changes made. Morning ABG results are compatible with a compensated metabolic acidemia with good oxygenation on the current vent settings.\n\nNo done due to PEEP level currently needed by patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-06 00:00:00.000",
"description": "Report",
"row_id": 1321618,
"text": "Respiratory Care:\nAble to wean FIO2 to 40% and maintain good oxygenation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-23 00:00:00.000",
"description": "Report",
"row_id": 1321670,
"text": "Respiratory Care Note\nAS of 5:30 am, pt placed on SBT. =11.4. Continue to moderate to large amount thick yellow secretions. Re-taped EET. BLBS=coarse rhonchi. ABG shows good ventilation and oxygenation.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-04 00:00:00.000",
"description": "Report",
"row_id": 1321610,
"text": "Sepsis\n\nPt becoming lethargic, occ. confused. Pain med q3hr. Ativan x1 for anxiety.\n\nST 120s. EKG done. BP up, Lopressor q6hr. CVP 7-11. HCT down to 27 given 1uRBC. Repeat 28.4. Plts given for count 47-up to 101. Pneumoboots on.\n\nPt becoming tachypneic-sats falling to 86%. Non-rebreather on. RR 22, sats 93%. Becoming acidotic. CXR done. Breath sounds clear-diminished at bases. Pt coughs and deep breaths well. Very poor activity tolerance. Base deficit -5; Lactate 1.2\n\nUrine output low and icteric. No response to Lasix 40mg IV. BUN^82/Cr^3.5 IVF@ 150cc/hr. Wt up 20kg from dry wt. Pt with peripheral edema.\n\nAbd firm and distended and very tender. Drains flushed q4hr. Drain #1 with increasing output of maroon colored fluid, green fluid from #2, none from #3. Mod. amt. soft stool. Steri-strips in place on abd. incision. Protonix IV. Pt is NPO. TPN infusing.\n\nPt appears jaundiced. WBC up to 8. Remains on Levoflox, Vanco and Flagyl; Fluconazole started. Temp up to 100.4.\n\nCoccyx red.\n\nSister called.\n\nPlan: continue to monitor hemodynamics and respiratory status. Support; full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-23 00:00:00.000",
"description": "Report",
"row_id": 1321671,
"text": "MICU-B, NPN:\nNeuro: A&OX3, PERRLA @ 3mm, MAE independently. Propofol gtt @ 25mcg/kg/min throughout shift. Received total 8mg Dilaudid for abdominal pain this shift with + response.\n\nCV: HR 70's-80's NSR w/o ectopy. SBP 100's-130's- held BP meds this a.m. d/t SBP low 100's. Received 60mg IV Lasix @ 22:00- diuresed approx. 1100cc-1500cc. Easily palpable peripheral pulses. CVP 7-10 @ start of shift, down to 4 following diuresis.\n\nResp: CPap with PS 15, PEEP 5, FiO2 40%, RR 10-18, TV 400-500. Suxn'd q 1-2 hrs for copious amnts. thick yellow sputum. Lungs are coarse throughout. Bronch. done did not reveal pathological source for constant secretions.\n\nHeme/lytes/micro: ABG's WNL- please refer to Carevue. Will repleat a.m. lytes per prn orders. Afebrile. Pseudomonas/GNR to sputum- receives Meropenem.\n\nGI: PD NGT placed in IR yesterday. TF's Nephro @ goal/40cc hr. FSBG qid. Stooling liquid stool to colostomy. Team wrote for tincture of opium to TF's.\n\nGU: Foley to gravity draining clear yellow urine. Renal following- holding off on HD @ this time.\n\nDerm: D&I.\n\nSocial: FULL CODE. Family involved.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-23 00:00:00.000",
"description": "Report",
"row_id": 1321672,
"text": "the pt remained on cpap 0/5 all day without any disconforts.abg=\n7.38/43/109 .bs:scattered ronchi and wheezes.suctionned copious amt\nof yellow secretions. 11.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-23 00:00:00.000",
"description": "Report",
"row_id": 1321673,
"text": "MICU NPN 7a-7p\nNeuro: Alert and oriented. Propofol off this am. Receiving prn Ativan and Dilautid for pain.\nResp: Continues to be vented on PSVof 15 at 40% with acceptable ABG. RISBI this am 11 but continues to have copious secretions. Plan was to wean today but will hold off due to excess secretions. Pt. does have very strong cough and can cough out secretions. Attempted to sit pt. up in bed but fatigued quickly.\nCV: Started on captopril this afternoon with minimal change in BP-continues to run 140-170. Hydralazine changed to prn with goal of managing BP with Lopressor and captopril.\nID: Tmax 100.\nGI/GU: Tube feeds at goal. Given 60 of lasix this afternoon and dieuresed 1000cc.\nskin: Abdominal incision healing. c/o mild abdominal pain relieved with 1mg of dilautid and 1mg of Ativan.\nA/P\nNo significant change\n-? wean tomorrow depending on amt. of secretions\n-sx prn\n-pain management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-23 00:00:00.000",
"description": "Report",
"row_id": 1321674,
"text": "NPN addendum\nResp: 02 sat 87%, had increased secretions-thin white. ABG done-Pa02 140 but had only been off 100% for 7 min. CXR pnd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-04 00:00:00.000",
"description": "Report",
"row_id": 1321611,
"text": "NPN: Review of Systems\nEvents: Pt became increasingly labored w/ breathing. Sao2 decreased from 89-90% to 85% on 100% nonrebreather. SICU team notified. ABG sent with results as follows: 7.37/33/50 and 20/-4. Pt intubated w/#8 ETT by Dr. . F/U ABG=7.34/34/94 and 19/-6 on Fio2 100% and 10 of PEEP. Continuous cardiac output VIP swan placed. CXR obtained and then Pt sent to OR for abdominal surgery.\n\nNeuro: Pt currently sedated w/ propofol at 30mcg/kg/min. Receiving IV hydromorphone intermittently for discomfort.\n\nResp: As noted above Pt intubated w/ #8 ETT. AC 600X 14 w/ 10 PEEP. BS are CTA billateraly. Sao2 up 96%.\n\nCV: Sinus tachycardia. No ectopy. Free calcium =1.05 for which Pt was to receive 4amps calcium gluconate. However, prior to going to the OR pt recived 2 of the 4 amps d/t limited IV access while swan being placed. BP has been stable. 500cc fluid bolus once for SBP in the 80s when sedation started. CCO/ VIP swan placed. CXR done. Awaiting confirmation of line location.\n\nGI: NPO. TPN stopped prior to line placement and remained off while going to the OR per anesthesia. Abdomen distended/ firm/ tender. Abdominal incision OTA w/ steristrips in place. Old drainage present onn them. Drains in place. Flushed/ aspirated w/ ease. Drain #1 draining thick marroon fluid. BM today: Moderate amt of soft brown stool.\n\nGU: Foley to gravity. Decreased UO. Per team renal consult being obtained\n\nHeme: Plts=73k. Transfused w/ plts as ordered prior to going to OR> INR=1.4 from 1.3. FFP to be given in OR. HCT=29.8 from 28.4.\n\nID: Temp=101.1. Pt continues on antibiotics.\n\nSkin: Warm. Coccyx pink. No open lesions.\n\nFamily: Sisters in today. Saw Pt prior to going to OR. Spoke w/ physicians. Social work and case management following.\n\nA: Respiratory distress requiring intubation prior to going to OR.\n\nP: To OR for abdominal surgery.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-22 00:00:00.000",
"description": "Report",
"row_id": 1321666,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes overnight. This morning's =43, therefore pt left on spontaneous breathing trial. Currently stable. Pt having copious oral secretions thru , sxing mod amts thick light tan from ETT. Administering Combivent ~Q4 thru . See flowsheet for rx times, and pt data.\nPlan: Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Report",
"row_id": 1321625,
"text": "SOCIAL WORK\nSW met with pts sisters in waiting room. requested SW assistance in changing NOK in medical record, and in obtaining a copy of medical record. reports that they have concerns that pt was brought to the police station after he was stabbed in rather than directly to hospital, and are interested to see hospital documentation related to this incident.\n\nSisters state that they are very concerned about the brothers prognosis and concerned that he will receive services upon discharge. Pt is currently living with his sister , and she is eager for him to obtain SSDI and other services. Both sisters presented as anxious and expressed anger over their brothers treatment treatment by police.\n\nSW met with pt at bedside with sisters present. Pt consented to sisters having access to medical record and being listed as his NOK. SW contact admitting with info and provided consent form for medical records to pt to sign. SW to continue to follow. Pls pg prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Report",
"row_id": 1321626,
"text": "NSG NOTE\n\n PT HEMODYNAMICALLY,OCCASIONAL HYPERTENSIVE WHEN LOPRESSOR DUE.\nREMAINS IN NSR.\nUO ABOUT 40-45CC/4HRS,WILL BE DIALYZED SAT AND WILL PROBABLY RECEIVE 2U PCELLS AT THAT TIME.HCT AT 10AM WAS 27.2 AFTER 1U PCELLS AT 7AM.\nABD FIRM,TENDER.HE HAS HYPOACTIVE BS.ABD DSD CHANGED AT 5PM.\nPT EXTUBATED AT 10AM,IS NOW ON FT WITH SAT 98.HE HAS STRONG PROD COUGH,THICK TAN-YELLOW SPUTUM.USING YANKER TO SUCTION SELF.\nPT DILAUDID PCA WHICH HE IS USING APPROPIATELY.\nPT OOB AT 6PM WITH 2 PEOPLE ASSISTING.\nHE REMAINS AFEBRILE.ALERT,COOPERATIVE,QUITE PLEASANT.\n\nSISTERS IN TO VISIT---SEE SOCIAL SERVICE NOTE..\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Report",
"row_id": 1321627,
"text": "S/P GI Surgery\n\nPt is alert, remained OOB 6 hours. Using Dilaudid PCA well, pt slept.\n\nVSS. Afebrile. HCT 26.6 WBC up to 21.\n\nSats 96%, pt has strong cough and expectorating lg. amt. thick mucus.\n\nIleostomy functioning. Abd. firm. NGT clamped. JP drains with small amt. bloody drainage. TPN. Receiving Protonix. Sta-sutures -dsg clean.\n\nLow urine output, Cr up to 5.1. Anasarca.\n\nPt has pneumoboots on.\n\nNo calls from family.\n\nPlan: ?dialysis, continue to increase rehab.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-09 00:00:00.000",
"description": "Report",
"row_id": 1321628,
"text": "T/Sicu NSg Progress Note\n0700>>1900\n\nS- 'this pain; i can't stand it\"\n 'I just don't feel well today;i do not want to get OOB'\n\nNeuro- alert/appropriate/cooperative/uncomfortable d/t intermittent but persistent severe abd pain. Pt utilizing PCA appropriatley ..with effect; BUT experiences delay in pain relief after falling asleep- during which time he does not push pain button(varies from 30-45min). At these times, pt becomes frustrated and excitable; situation resolves with pain med, repositioning, patience, and verbal support.\n..Pt experiencing b;adder spasms this am; citing intense pressure/pain like when bladder is full & need to urinate. Also cont to have generalized abd pain/tenderness.\n\n\nCVS- no issues..see careview\n tolerating lopressor 10mg ivp q6/hr\n\nResp- tolerating spontaneous ventilation with coarse diminished breath sounds. Does not c/o resp distress. Pt able to clear secretions effectively after premedication, coughing, IS use, & yankauer suction of mouth. Secretions remain tenacious brown/old bloody sputum.\nFT at 50% with occdrop in sats to low 90's when face tent slipping from face. Tried NC, but pt c/o dry nares, and cannulae do not stay positioned in nares. Currently on FT 50% and NC @ 2L. Sats geneerally >96%. RR mid teens.\n\nRenal- intermittent u/o..cloudy & yellow..no sludge.\n**HD X 3hours for 2L take off** No instability with HD\n\nHeme- hct 23.6 pre-dialysis. Team requests post dialysis hct and serial hct of q8/hr x3\n\nID- temp max to 99.9 with elevated wbc to 21. Antibiotic coverage unchanged. Pan cultured today. (except for urine c&s)\n**team wants vanco given tonight**\n\nendo- no issues\n\nGI- tpn cont\n ileostomy with black mucoid drainage **Quiac POSITIVE**. Decrease output amt noted today. NGT to LCS with min output. Protonix ongoing\n hypoactive bowel sounds.\n\nskin- no new issues. anasarca persists; with de crease edema appreciated in upper extremities and facial areas. warm, dry skin with palpable pulses.\n\nsocial- sister called & updated; will visist in am(sunday)\n\nassess- cont elevated WBC\n persistent abd pain\n managing airway & secretiosn effectiviely with occ desaturation\n\nplan- monitor ID status, cultures\n cont pain mngmnt/support\n cont pulm toileting\n ? HD tomorrow per renal\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Report",
"row_id": 1321629,
"text": "Review of systems:\n\nNeuro: Pt awake most of shift, difficulty in sleeping, pain control a problem, pt constantly moaning, grimacing in pain despite using PCA. Ativan given in attempt to relax pt X 2. Surgical resident notified of pain control issue. Pt A/O X 3, follows commands, MAE X 4, good/equal bilateral strength.\n\nCV: SR-ST, no ectopy noted. Received Metoprolol. ABP in Right radial with good wave form, BP ranging 140s-150s systolic. DP/PT pulses are present and easily palpable. + edema in arms/feet. CVP 2-6. Normal S1 S2.\n\nPulm : 50% 02 via face tent and 4l NC. O2 sats remain 96-100% most of the time, occasionially decreasing to 80s if O2 comes off or pt attempting to expectorate/ mucous plug. Secretions are moderate in amt and very thick, blood tinged. Pt able to use oral yankeur to suction orally. Pt C.O pain with coughing and not having good pain control, trouble with expectorating at times. Using a pillow to hug while coughing seems to help. Lung sounds are clear to coarse throughout. ABGS show adequate oxygenation. Pt denies SOB but does comp[lain of mucous in throat and lungs.\n\nGI: Belly is soft/distended. No BS heard per auscultation, Ileostomy site looks good/ stoma pink. Output is black liquid. NPO, PPI prophylaxis. Receiving TPN.\n\nGU: Foley is patent to gravity, is amber to yellow, cloudy. Pt putting out 15-40cc/hour of urine. K 3.4, H.O aware. MIVF at KVO\n\nID: low grade temp, 100.7 TMAX, receiving antibiotics, pt was cultured within 24 hours.\n\nHEME: Crit 26, H.O aware.\n\nSkin: Full bed bath, bruise noted on left forearm, under side. Legs and feet + edema, compression sleeves on and off. Midline abdominal incsion w-d dressing changed, slight/scant ss ooze. Retention sutures . JP X 3 in left abdominal area putting out small amt of ss drainage.\n\nSocial: , Pts sister phoned this evening and questions answered and support provided by this RN.\n\nPlan: Continue to encourage pt to cough and expectorate, follow abgs to ensure adequate oxygenation, pain control, change dressing and monitor for s/s of infection, follow WBCs and Crit. Provide pt and family with support/encouragement, and answer questions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-10 00:00:00.000",
"description": "Report",
"row_id": 1321630,
"text": "T/Sicu NSg Progress Note\n0700>>\n\nS- \"yes, the pain is better.\"\n\n pt having difficulty obtaining adequate pain relief overnigth and into early am. Pt with increased distress/frustration. Dilaudid dose increased to .5mg q6/min via PCA. Pt cont to utilize PCA appropriately and with effect with some 'light hours' d/t sleep. Pain at worst rated as at rest>>>now and tolerable per pt. Pt remains sensitive to abdominal procedures. No ativan required.\n\nCVS- stable vss\n\nResp- stable abg's, no c/o distess. BS's coarse/decreased at bases. Cont with adequate pulm toileting with encouragement. Occ drop in sats when asleep. Desat's to 89-90 with O2 out of place. Thick, brown- tan secretions.\n\nRenal- u/o cont to be steady with total o/p > 250cc for the day so far. No dialysis today; plan is for Tuesday with daily assessment.\n..low k+..(3.0).. repleted with 20meq kcl\n..mg 1.9..1gm mgso4 given\n..bun/creat stable elevated.\n\nGI- npo with TPN at goal rate ongoing\n.. NGT to lcs with minimal drainage.\n** d/t persistent heme positive stool and drifting hct/need for transfusion>>>> protonix changed to and carafate added to therapy.\n..absent to hyopoactive bowel sounds. Ileostomy drainage - large amt liquid black stool with decrease in amt this afternoon. Stoma pink/stable.\n\nID- WBC persistent at 21; temp max 99.8\n abd incision errythematous with scant s/s drainage. W>D dsg ..wound bed dry with skin edges sticking together..?increase dsg change to tid.\n*** new antibiotic coverage added tonight for + resistent psuedomonas reported in peritoneal swab from ...meropenum started. Other antibiotics ongoing.\n\nHeme- transfused 2u prbc's for hct 24..post-tx hct pnd\n\nEndo- no insulin required; TPN with 10u insulin/qd..blood sugars <120.\n\n pt moving about independently in bed with great effort..but able to after pre-medication. Pt oob to chair with minimal assistance.\nReturned to bed with minimal assisstance as well.\n..Peristent lower body & lower extremity edema which adds to pt's difficulty in moving independently. Weight remains ~ 25kg over pre-op status.\n\nAssess- improved pain control\n stable pulm status\n increasing u/o\nPlan- cont with current mngmnt.\n asses readiness to transfer from ICU care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-17 00:00:00.000",
"description": "Report",
"row_id": 1321649,
"text": "NEURO: Initially A+OX3, now sedated on propophol gtt @ 30 mcg/kg/min. Cough/gag . Pt received etomidate and succ for intubation.\nCV: Monitor shows NSR with no ectopy noted. Gross pitting edema of . CVP 17-26. Pt remains on IV Lopressor Q6hr.\nRESP: LS coarse throughout with bibasilar crackles noted. Pt with increased Fio2 requirements and placed on 100% NRB and continued with ^ resp distress. Pt tacypneic with RR 30's and Sao2 86-90. T/SICU team spoke with pt and intubated for resp failure. Pt on A/C 650x12x100 PS 10 and PEEP 8. Most recent ABG 7.40-42-119. for mod amts pink tinged frothy secretions. Team feels pt in in pulm edema per CXR.\nGI: Abd soft and nontender. +BS hypo noted. Pedi tube placed by Dr. and confirmed with Xray. TF's (Nepro with promod) started in afternoon and to be advanced Q6hr as tolerated to goal of 40 cc/hr. Ileostomy pink and patent draining mod amts loose brown stool. Pt had sm smear from below and team notified. JPx3 to self with scant output.\nGU: Foley and patent draining yellow urine with sm amt sedimentation noted. Pt received lasix 40 mg this am. New order for Lasix 80 mg X3 and diuresing well.\nHEME: K 3.3 this am and repleted as ordered. Will recheck lytes @ 1800 and replete as needed.\nI-D: Pt with low grade temps. Tylenol given X1. Pt remains on flagyl, meropenum and fluconazole.\nENDO: Pt remains on fingersticks Q6hr with RISS coverage per scale.\nPAIN: PCA d/c'd and prn dilaudid given with +effect.\nPSY-SOC: Sister called x1 and updated on status and plan of care. No visitors this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-18 00:00:00.000",
"description": "Report",
"row_id": 1321650,
"text": "MICU-B NPN 1900-0700\nNEURO - PT. REMAINS INTUBATED AND VERY LIGHTLY SEDATED ON 60MCG/PROPOFOL. INC. FROM 30 MCG. @ START OF SHIFT. PT. FOLLOWING COMMANDS. +MAE. MILD PAIN NOTED TO ABD. @ START OF SHIFT. APPEARS COMFORTABLE ON PROPOFOL.\n\nRESP - RECEIVED ON SIMV +PS 10/PEEP 8/.50/VT 650/RR TEENS. PEEP DECREASED TO 5 @ 2200. REFLECTIVE ABG 7.44/39/98/27/1. AM ABG 7.46/37/96/27/2 ON SAME. LS COARSE WITH CRACKLES TO BILAT. BASES. DIURESED WITH LAST TWO DOSES 80MG. IV LASIX. WITH >3L OUT OVER/. O2SATS. 95-99%. SX. T/O SHIFT FOR MOD. AMTS. BROWN, FROTHY, THICK, SECRETIONS REQUIRING OCCAS. LAVAGE.\n\nC/V - HR 70'S-80'S, NSR WITH NO ECTOPY NOTED. ABP 120'S-140'S/60'S-70'S. CONT. ON Q6 /HR IV LOPRESSOR 10 MG. + PITTING EDEMA TO EXTREM. PERIPHERAL PULSES PALPABLE.\n\nLYTES - 20MEQ K+ GIVEN OVER/ WITH LASIX. AM K+3.3. 20 MEQ K+ TO BE GIVEN.\n\nID - TMAX 100.6. REMAINS ON MEREPENUM, FLAGYL, AND VANC. DOSED PER LEVEL.\n\nGI/GU - DOPPOFF TUBE PLACED YEST. PATENT AND PLACEMENT VERIFIED PER CXRAY. TF. (NEPRO WITH PROMODE) RUNNING @ 30/HR, TO BE ADVANCED Q6/HR TO GOAL 40/HR. ABD, SOFT, DISTENDED, TENDER, WITH +BS. ILEOSTOMY PATENT WITH STOMA PINK, SM. AMT. LIQUID BROWN STOOL OUT OVER/. JP DRAINS TO BULB SX. WITH MINIMAL OUTPUT THIS SHIFT. ABD. DRESSING DRY & . INDWELLING FOLEY IN PLACE; PATENT WITH >3L OUT OVER/ OF CLEAR, YELLOW URINE.\n\nSOCIAL - PT. SISTER IN OVER/. UPDATED ON PT. STATUS AND CONT. PLAN OF CARE. SISTER EXPRESSED BEING VERY UPSET WITH MANAGEMENT OF CARE BY TEAM. VERY CONCERNED THAT THEY WERE NOT PER PT. INTUBATION YEST. GIVEN REASSURANCE AND DETAILED COURSE OF TX. WITH PTS. SISTER FEELING MUCH RELIEF.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-03 00:00:00.000",
"description": "Report",
"row_id": 1321608,
"text": "T/SICU Nursing Admission Note\n\nPt is 47 year old transfer to T/SICU at 11:30pm from floor with increased abd. pain, decreased HCT, decreased u/o. Aline placed, right subclavian triple lumen; 4u RBC, 2uFFP, 2bags platelets given. Pt to CT (Baricat contrast).\n\nPMHx: In T/SICU s/p stab wounds to chest and back; exp. lap with colostomy for ischemic bowel; reexplored for more ischemic colon; pt did well in rehab; reversal of colostomy; did well until to OSH- with ^^abd. pain. Pt is homeless. +smoker. +ETOH abuse.\n\nNo known allergies.\n\nMeds: Oxycontin, Ativan, Combivent, Ibuprofen, Tylenol.\n\nPt is alert and oriented. VERY tender abd. to touch. Pt requests Dilaudid exactly every 2 hours. Able to nap in between.\n\nST 106, BP 104/79 CVP 13. HCT 31.1 after transfusion. Plt 94 after transfusion. INR 1.4 Pt is afebrile, on Flagyl. IVF@150/hr. Pneumoboots on.\n\n4L NP with sats 96%, no cough, lungs clear.\n\nAbd. incision with steri-strips . Sm. amt. serous drainage from lower part of incision. Pig tail drain with dark (old blood) fluid. Abd. CT done. Pt NPO except for Baricat.\n\nUrine output low. Cr 25/BUN 55.\n\nNo contact with family.\n\nPlan: Continue to monitor hemodynamics; provide pain relief.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-22 00:00:00.000",
"description": "Report",
"row_id": 1321667,
"text": "NEURO; PT. IS A/A/O AND REMAINS LIGHTLY SEDATED ON 50MCG/HR OF PROPOFOL. PT. HAS ONLY C/O LEFT SIDED PAIN THIS AM WITH .5MG I.V. DILAUDID GIVEN WITH DESIRED EFFECT REACHED. PT. HAS LOW GRADE TEMP. WITH WITH TMAX 100.5.\n\nC.V; PT. HAS BEEN NSR IN THE 70-90'S WITH NO NOTED ECTOPY. B/P HAS BEEN STABLE WITH NO NEED FOR SUPPORTIVE MEASURES. MAP'S HAVE BEEN IN THE 70-80'S. +2 PITTING PEDAL EDEMA NOTED.CVP HAS RANGED 5-8.\n\nRESP; PT. REMAINS INTUBATED WITH NO CHANGE TO VENT SETTING THROUGHOUT THIS SHIFT. PT. HAS BEEN SUCTIONED FOR MODERATE AMT'S OF YELLOWISH SECRETIONS AND MOD. AMT'S OF ORAL SECRETIONS, THIS IS AN IMPROVEMENT FROM PREVIOUS SHIFT. O2 SATS HAVE BEEN 98-100% AND RESP RATE IS CONTROLLED. ABG IS PENDING THIS AM.\n\nG.I; PT. PRESENTLY HAS TUBE FEEDS SHUT OFF, DUE TO PEDI TUBE COILED IN BACK OF THROAT. PT. SUCTIONED WITH NO EVIDENCE OF TUBE FEEDS. BLOOD SUGARS HAVE BEEN WNL WITH NO COVERAGE REQUIRED. PT. HAS FECAL INCONTINENT SYSTEM IN PLACE WITH MODERATE AMT'S OF LIQUID BROWN STOOL NOTED. CDIFF SPECIMEN PENDING.\n\nG.U; PT. HAS AMPLE AMT'S OF CLEAR YELLOW URINE VIA FOLEY. PT. C/O SLIGHT IRRITATION AT GLANDS. LIDOCAINE JELLY APPPLIED WITH DESIRED EFFECTS REACHED.\n\nI.V; PT. HAS LEFT RADIAL ALINE WHICH REMAINS AND CORRELATES WITH CUFF PRESSURE. PT. ALSO HAS RIGHT TLC WITH ALL PORTS SECURED, , AND PATENT. IVF ARE INFUSING AS ORDRED.\n\nDISPO: PT. IS FOR AGAIN POSSIBLE EXTUBATION THIS AM. PT. HAS BLOOD AND SPUTUM CULTURES PENDING, WITH ANTIBOITICS RX; REASSESSED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-22 00:00:00.000",
"description": "Report",
"row_id": 1321668,
"text": "respiratory care\npt. remains intubated. suctioning thick yellow, recieving combivent as ordered. weaning vent as tolerated abgs pending , to fluro. for repos.\nof ng-tube. tolerated transfer well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-22 00:00:00.000",
"description": "Report",
"row_id": 1321669,
"text": "NPN MICU-B 7AM-7PM\nS/O: RESPIR: Remains intubated on PS-15, peep-5 with O2sats 93-96%. Failed Spon breathing trial this AM RR up to 38 very umcomfortable, O2 sats 91%, placed back on PS-15,peep-5, with O2 sats 94-99% with ABG-7.43/40/106/27/1, able to wean PS- to 10, O2sats 94-98%. Continues with constant suctioning in the AM of thick yellow sputum, did decrease somewhat over the course of the day, but still suctioning lrge amts q2-3hr. L/S course bilat.\n\nC/V: BP-110-140/70, HR 70-80's SR with no ectopy noted, K+ 3.5 rec'd 20mEq KCL IV. Remains on Lopressor and Hydralazine IV q6hr.\n\nGU: U/O 50-70cchr BUN/CRE-36/1.6, Mag 1.9, rec'd Mag 2GM IV repletion.\n\nGI: TF's were off in the AM due to ?ing of placement with, new Post-pyloric tube placed in Rad. TF's were restarted Nepro with Promod @ 40cchr. Having mod amts brown OB neg liquidy stool noted from Colostomy.\n\nID: Afebrile remains on IV Meropenum.\n\nNeuro: Was on Propofol Gtt @ 50mcq/hr which was d/c'd, is alert and interactive mouthing words, rec'ing Dialudid IV 1-2mg PRN with good response.\n\nA/P: Continue with aggressive pulmon toilet, monitor O2 sats and ABG's. Assess I&O's, and BP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-26 00:00:00.000",
"description": "Report",
"row_id": 1321681,
"text": "MICU-B NPN 1900-0700\nNEURO - PT. AXOX3. PLEASANT. +MAE, THOUGH WEAK. PT CONSULT. YEST. PT. OOB LAST EVE. FOR 5 HOURS, WELL. TOL. UNSTEADY GAIT. SPEECH/SWALLOW CONSULT YEST. WITH NO DEFICITS NOTED. SPEECH CLEAR. PERRLA 3MM/3MM WITH BRISK RESPONSE. TX. X2 FOR ABD. PAIN WITH PRN DILAUDID WITH IMPROVEMENT NOTED.\n\nRESP - PT. S/P EXTUBATION ; NOW ON 3L NC WITH O2SATS 96-99%. RR TEENS-20'S. LS CLEAR UPPER WITH COARSE BILAT. BASES. STRONG, PROD. COUGH. AM ABG 7.41/41/88/27/0. I.S. @ BEDSIDE.\n\nC/V - HR 60'S-90'S, NSR WITH NO ECTOPY NOTED. ABP 100'S-140'S/50'S-90'S WITH NO HYPER/HYPOTENSIVE EPISODES OVER/. REMAINS ON CAPTOPRIL 12.5 MG TID AND LOPRESSOR 2.5 QID. TRACE EDEMA TO EXTREMITIES. PERIPHERAL PULSES PALPABLE.\n\nID - TMAX 99.8 OVER/. STARTED ON PIPPERICILLIN FOR PSEUDOMONAS IN SPUTUM.\n\nGI/GU - DIET ADVANCED YEST. AFTER SPEECH/SWALLOW CONSULT CLEARED TO HOUSE WITH SODIUM RESTRICTION; WELL TOL.PT. WITH PEDI. TUBE IN PLACE TO (L)NARE; . TF ON OVER/ PER TEAM; PRESENTLY DELIVERING NEPRO. @ 20/HR TO ADVANCE TO GOAL 40/HR. ABD. SOFT, ND, TENDER TO PALPATION. +BS. PINK; OSTOMY CARE DONE YEST. BY ET NURSE. AND DRAINING LIQUID,BROWN STOOL. INCISIONAL DRESSING CLEAN, DRY AND . INDWELLING FOLEY IN PLACE; AND DRAINING ADEQUATE AMTS. CLEAR, YELLOW URINE OVER/.\n\nACCESS - LSC MULTI-LUMEN IN PLACE; , SITE WNL. (L)RADIAL A-LINE IN PLACE; POSITIONAL WAVE FROM, +DRAW, +FLUSH, SITE WNL.\n\nSOCIAL - NO CONTACT FROM FAMILY THIS SHIFT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-26 00:00:00.000",
"description": "Report",
"row_id": 1321682,
"text": "nursing progress note seew careview for details.\n\nneuro:awake,alert,orientedx3.speech clear and understanable.follows commands and moves all extremites with appears equal strenght.pt was able to stand and ambulate to chair,was weak.\n\ncv:remains in nsr without ectopy,bp systolic 92 to 117 dr is aware of systolic bp .pt started on carvedilol,lisinopril and lasix.both feet warm with palpable dp and pt pulses present.\n\nresp:breath sounds clear but diminished resp rate 16 to 18,spo2 96% to 100%.coughing and raising moderate amount of thick yellow secretions.\n\ngi:abd soft with positive bowel sounds present.feeding tube clampped.tolerating full diet with calorie count being done. draining moderate amount of liquid brown stool,stoma pink.\n\npain:medicated with percocet and hydromorphone for pain with good effect.\n\ngu:foley to cd draining moderate amount of clear yellow urine,had good response to lasix po this am.\n\nsocial:sister has called and has been update on pts condition.\n\naccess:left sc was dcd and tip sent for culture,aline was dcd.has peripheral in right hand wnl.\n\nplan:surgical attending will decide if pt will be sent to floor or remain in unit .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-03 00:00:00.000",
"description": "Report",
"row_id": 1321609,
"text": "TRAUMA SICU NPN\nO:\nNEURO: PT ALERT AND ORIENTED, MAE AND FOLLOWS COMMANDS. C/O LGE AMT ABD PAIN AND GENERAL DISCOMFORT. DILAUDID 4MG Q2HRS FAITHFULLY AND GIVEN PRN ATIVAN W/ GD EFFECT.\n\nCV: EPISODE OF HTN DURING DRAIN PLACEMENT AT CT SCAN. 10MG LOPRESSOR GIVEN X1 W/ MODERATE EFFECT. HR 100-120NST, NO ECTOPY AND BP NOW 130-150/70. LOPRESSOR ORDERED 5MG Q6HRS.\n\nRESP: 4LNP W/ STABLE 02SATS. SRR 20'S. LS CLEAR. INTERMITTENT PRODUCTIVE COUGH.\n\nRENAL: U/O CONSISTENTLY LOW. RECEIVED FLUID BOLUS X2 W/ SL RESPONSE OVER 2HRS AND THEN DECREASED U/O <20CC/HR. CRE UP TO 3.2. CVP 13-8.\n\nGI:ABD FIRM AND VERY TENDER. PT TAKEN TO CT SCAN FOR DRAIN PLACEMENT UNDER FLUORO. 2 NEW PIGTAIL DRAINS PLACED AND FLUSHED IN CT. PURULENT DNGE SENT FOR CULTURE. NO DNGE SINCE CT SCAN. DRAIN #2 AND #3 FLUSHED W/ RESISTANCE (5CC INSTILLED AND ASPIRATED). NO STOOL TODAY.\n\nHEME: HCT AND COAGS STABLE. PLT COUNT DOWN TO 37. 1 BAGF PLTS ORDERED\nHIT TITER SENT.\n\nID: TMAX 101.2 POST PROCEDURE. CONT ON IV ABX: VANCO, FLAGYL AND LEVOFLOX.\n\nSKIN: ABD INCISION STERISTRIPPED W/ OLD DRY BLD UNDER INCISION. DRAIN SITES CLEAN. COCCYX REDDENED.\n\nSH: SISTER CALLED AND CONCERNED ABT PT'S ANXIETY LEVEL. ASKING APPROPRIATE QUESTIONS. WILL CALL AGAIN THIS EVE.\n\nA: INFECTION S/P COLOSTOMY REVERSAL. ACUTE RENAL FAILURE\n\nP: CONT TO MONITOR AND CONT ABX. FLUSH DRAINS AND MONITOR OUTPUT Q4HRS. CONT ABX AND MONITOR TEMP. MONITOR U/O, LYTES, BUN AND CRE. FLUID BOLUS AS NEEDED. PLT TRANSFUSION. MONITOR CBC, COAGS, PLTS Q6HRS. PAIN CONTROL. PT AND FAMILY SUPPORT. RE-EVALUATE SUCCESS OF DRAINS IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-21 00:00:00.000",
"description": "Report",
"row_id": 1321664,
"text": "NEURO; PT. IS MUCH MORE AWAKE DURING THIS SHIFT. PT. REMAINS ON 70MCG OF PROPOFOL WITH LITTLE SEDATIVE EFFECT. PT. MAES, AND HAS BEEN AFEBRILE DURING THIS SHIFT.\n\nC.V; PT. HAS BEEN NSR 80-90'S WITH B/P STABLE AND NOT REQUIRING PRN DOSING FOR HTN. NO TRACE EDEMA NOTED WITH PT. RECEIVING 80MG I.V. LASIX AND 2.5 LITERS DRAINED PER CATHETER. CVP HAS RANGED 6-9.\n\nRESP; PT. REMAINS ON PSV WITH NO CHANGES MADE DURING THIS SHIFT. PT. IS SUCTIONED FOR COPIOUS AMT'S OF THICK YELLOWISH SECRETIONS AS WELL, ORAL SECRETIONS. RESP RATE HAS BEEN CONTROLLED. O2 SATS 100%. PLAN TO EXTUBATE PT. IN AM PENDING .\n\nG.I; PT. HAS POST PYLORIC TUBE PLACED, AND NEPRO PRESENTLY INFUSING AT GOAL OF 40CC/HR. PT. HAS FECAL INCONTINENT BAG INPLACE WITH MODERATE AMT'S OF LIQUID BROWN STOOL NOTED. BLOOD SUGARS HAVE BEEN WNL.\n\nG.U; PT. HAS FOLEY CATHETER AND CONTINUES TO DRAIN AMPLE AMT'S OF CLEAR YELLOW URINE. PT. HAS REMAINED NEGATIVE DURING THIS SHIFT.\n\nI.V; PT. HAS RIGHT TLC WITH ALL PORTS PATENT, SECURED, WITH IVF INFUSING AS ORDERED. PT. HAS LEFT RADIAL ALINE WHICH CORRELATES WITH CUFF, AND WAVEFORM WNL.\n\nI.D; PT. CONTINUES ON MEROPENUM FOR MRSA AT WOUND SITE.\n\nDISPO; PT. IS FOR PLANNED EXTUBATION THIS AM. TEAM IS AWARE OF AMT'S OF SECRETIONS. PT. DOES HAVE A VERY STRONG COUGH EFFORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-21 00:00:00.000",
"description": "Report",
"row_id": 1321665,
"text": "NPN MICU-B 7A-7PM\nS/O: RESPIR: Did attempt a Spon Breathing trial this AM, went into respir distress with RR 35-40, became diaphoretic, decreased spon VT's to 100's, HR-90's, very anxious, placed back on PS-10, Peep-5, FIO2-40%, appeared more comfortable but desated to 91% ABG- 7.52/32/57/3/27, decision made to perform a Bronch. Bronch showed copious amts white frothy sputum, that was being suctioned before bronch q30min-1hr. S/P Bronch was placed on PS-15, Peep-8 40%, repeat ABG- 7/50/34/78/3/21, peep increased again to 10, with ABG- 7.44/42/131/4/29, Peep- decreased back down to 8 with O2 sats 94-98% repeat ABG to be drawn. Suctioning q2hr s/p bronch, for lrge amts thick yellow sputum.\n\nC/V: BP98-130/70, when anxious this AM BP 170's, still on IV Lopressor and Hydralazine, last dose of Hydralazine was held for BP 100/70. HR-80-95 SR with no ectopy noted.\n\nGU: U/O was>100cchr in the AM now is 40-70cc/hr, no Lasix given, was started on Diamox 250mq IV q6hr, due to Met. Alkalosis noted on ABG's. BUN/CRE- 44/1.9. Total I&O's 700cc's neg.\n\nGI: TF's were on hold due to possible extubation, but were restarted s/p Bronch Nepro with Promod @40cc/hr. Appears to be tolerating well, having lrge amts brown liquidy OB neg stool via colostomy. Colostomy bag changed by Ostomy RN.\n\nNeuro: Alert even on Propofol Gtt @70mcq/kq/min, able to mouth words, and obey commands, Gtt was decreased to 50mcq/kq/min, when became hypotensive. Occ request Dialudid 1mg IV, with good response.\n\nSkin: wounds healing well, wet/dry NS dsg changed. No coccyx decub breakdowns noted.\n\nA/P: Continue with aggressive Pulmon toliet, assess O2 sats and ABG's adjust vent as needed. Monitor VS, and assess I&O's duiresis as needed. Assess Neuro status adjust Propofol Gtt as needed and IV Dialudid as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-07 00:00:00.000",
"description": "Report",
"row_id": 1321621,
"text": "Respiratory Care:\nPatient progressed to CPAP/PSV after morning ABG results demonstrated good oxygenation and a slight respiratory alkalosis. Patient still has a moderate amount of thick secretions to deal with.\n\n = 39.2 on 0-PEEP and 0-PSV with 100% ATC.\n\nPlan is to continue bronchial hygeine while weaning to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-07 00:00:00.000",
"description": "Report",
"row_id": 1321622,
"text": "Resp. care note - Pt. remaines intubated and vented, suctioned for sm. yellow, bs coares.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-07 00:00:00.000",
"description": "Report",
"row_id": 1321623,
"text": "npn 7a-7p\nEVENT:hd today.fem quinton cath kinked-d/c'd.trauma line rewired to quinton cath.during hd,sats dropped,pao2 60s,hypertensive,anxiety r/t pain,lying flat,line changes.increased peep,ps,and fio2.given ativan. status improved.3L removed from hd.rsc rewired.\nNEURO:.dilaudid pca managing pain adequately.\nCV:b/p to 120s after hd.metoprolol given w/ good effect.cvp from 11 to 5 after hd.ivf kvo.\nRESP:planned to extubate after hd but plan for tomorrow.fio2 returned to 40%.lg amt thick yellow sputum suctioned frequently.very weak cough.\nGI:firm distended tender abd.neg bs.brown liquid/mucous stool from ileostomy.stoma pink.tpn changed-see med record.ngt to lws, drg.\nGU:scant u/o to f/c.creat 4.7 before hd.\nSKIN:midline abd incision w/ retention sutures,clear.open,w->d dsg.no drg.\nHEME:hct improved.\nID:increased wbc.low-grade temps.\nENDO:no coverage.\nSOCIAL:sister,,called and updated.to see pt tomorrow am.\nPLAN:monitor hct.pan culture if rise in temps.wean vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-08 00:00:00.000",
"description": "Report",
"row_id": 1321624,
"text": "FULL CODE NKDA MRSA precautions\n\n\nNeuro: AAOx3, MAEx4 spont/command. Communicates well by mouthing, gesturing and writing.\n\nCardiac: HR=80-90s, NSR, no ectopy. BP=120-140/70s. Lopressor 10mg IV q 6hr. CVP after dialysis , but has crept up to just prior to recieving a unit of blood and is 18-19 after the blood. To be dialyzed this am. +periph pulses, extrems warm, +edema.\n\nResp: 40% CPAP/PS during the night. Placed on spont breathig trial early this am and did well for about 1 1/2 hrs and then go a bit anxious. Placed back on CPAP/PS. Will proably extubate today. Suctioning thick tan secretions via ETT - lavaged ETT. Lungs clear bilat. Weak cough even when suction cath placed down ETT. ABG at 1130pm WNL.\n\nGI/GU: Abd firm/distended, no BS. Ileostomy w/ 100cc brown liquid stool. TPN for nutrition. Foley cath w/ no u/o. Was dialyzed yesterday and to be dialyzed again today. Yesterday, 3 liters were removed.\n\nSkin: Abd dressings changed this am by surgical team. Midline incision - stay sutures. W-D NS dressing placed under sutures in wound. Small amt drainage. JP x3 w/ small amt fluid (25/10/30). Generalized edema noted.\n\nPain: Dilaudid PCA - using it effectively. Dose increased to .37 mg q 6 min from .25mg.\n\n: afebrile Remains on flagyl, ceftiaxone. diflucan and Vanco, altho Vanco level was 21 and dose was not given (hold for level >15).\n\nLabs: K=3.2 at 1130p - given 20 KCL IV and repeat at 3p was 3.5. No rx ordered at that time. Mg=1.5 - 2gms MgS04 given IV. HCT=25.9 down from 26.8 - one unit RBCs given.\n\nPlan: Monitor labs, vs, wounds, drains. Extubate today if ready. Maintain Dilaudid PCA for comfort.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-25 00:00:00.000",
"description": "Report",
"row_id": 1321679,
"text": "MICU-B NPN 1900-0700\nNEURO - PT. AXOX3. PLEASANT. +MAE. PERRLA 3MM/3MM WITH BRISK RESPONSE. RECEIVING PRN ATIVAN AND DILAUDID T/O SHIFT FOR ABD. PAIN AND ANXIETY WITH GOOD EFFECT.\n\nRESP - PT. S/P EXTUBATION YEST LATE AFTERNOON. REMAINS ON COOL NEB. 15L, WITH O2SATS 94-98%. LS COARSE T/O. PT. WITH STRONG, PRODUCTIVE COUGH. IS @ BEDSIDE. AM ABG 7.44/37/77/26/0.\n\nC/V - HR 90'S-ONE-TEENS, NSR>ST WITH NO ECTOPY NOTED. ABP 140'S-190'S/60'S-90'S. CONT. TO HAVE DIFFICULTY CONTROLLING BP. GIVEN X1 5MG IV LOPRESSOR AND PRN HYDRALAZINE WITH TRANSIENT EFFECT. REMAINS ON SCHEDULED DOSE CAPTOPRIL (INC. YEST. TO 12.5 TID) AND QID 2.5MG. LOPRESSOR. PER TEAM, GOAL SBP 160 SECONDARY TO PT. LOW EF (25%). NEED TO AFTERLOAD REDUCE TO PREVENT CHF. PERIPHERAL PULSES PALPABLE.\n\nID - LOW GRADE TEMP. OVER/. TMAX. 100.0. PAN CX. . SPUTUM WITH RESISTANT PSEUDOMONAS. COMPLETED 14 DAY COARSE MEREPENUM. RSC RE-SITED YEST TO LSC; OLD-LINE TIP SENT.\n\nGI/GU - PT. NPO OVER/ EXCEPT ICE CHIPS. PEDI-TUBE IN PLACE TO (R)NARE; CLAMPED T/O EVE. ABD. SOFT, ND, TENDER WITH DRESSING CLEAN, DRY , & . ILEOSTOMY PATENT WITH LIQUID, BROWN STOOL OUT OVER/. STOMA PINK.INDWELLING FOLEY IN PLACE; PATENT WITH ADEQUATE AMTS. CLEAR, YELLOW URINE OUT THIS SHIFT.\n\nACCESS - LSC TRIPLE-LUMEN IN PLACE; PATENT, SITE WNL. (L)RADIAL A-LINE IN PLACE; PATENT WITH POSITIONAL WAVE FORM, +DRAW,+FLUSH, SITE WNL.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-25 00:00:00.000",
"description": "Report",
"row_id": 1321680,
"text": "Nsg Progress Note 0700-1900\n\nCV - BP better controlled today. Required hydralazine x1 at 10am and has been stable since then. Afebrile. NSR - no ectopy noted.\n\nResp - Able to switch to 2L NC without problem. BS course to right upper airway - otherwise clear. No c/o SOB\n\nGI - Began TF again at 20cc/ hr. Tolerated well. Swallow study done and ok'd to start po's. Taking cl liqs all day and advance to full liqs this pm. Very happy to be eating! Ileostomy appliance changed by stoma nurse. Site is red and moist - draining mod amt liq brown stool. Abd soft - incisional dsg changed x1.\n\nGU - Given lasix x1 with excellent response. Foley cath draining cl yellow urine.\n\nPain - med x2 with pain med with good relief.\n\nNeuro - Pt a&o x3. Very pleasant and cooperative. Pt OOB to chair with physical therapy. Tolerated very well. Has been sitting up for 3 hours.\n\nSocial - 2 sisters in to visit. Pt happy to see them. They are pleased that he is making such good progress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-15 00:00:00.000",
"description": "Report",
"row_id": 1321644,
"text": "NURSING PROGRESS NOTE 0700-1500\nNEURO--CONFUSED AT TIMES BUT REORIENTS EASILY. MAE SPONT AND TO COMMAND. OOB TO CHAIR WITH WALKER AND MIN ASSIST. CONVERSANT. PEARL AT 3-4 MM.\n\nRESP--LUNGS COARSE IN ALL FIELDS. STRONG PRODUCTIVE COUGH. WEANING HI FLOW O2 PRESENTLY ON 40% WITH GOOD SAO2 >98%. RR 18-28. NO ABG'S DRAWN. ART LINE D/CED.\n\nCARDIAC--BP AND HR STABLE. NO OBSERVED VEA. RECIEVED LOPRESSOR. CVP 4-10.\n\nGI--RECIEVING TUBE FEEDS OF NEPRO AT 40 CC HR WHICH IS GOAL. ILEOSTOMY DRAINING ~200 CC OF GOLDEN STOOL. ABD INCISION WITH STAY SUTURES IS CLEAN. LOWER ASPECT OF WOUND WITH DSD. GOOD GRANULATION TISSUE. STARTING ON <30 CC HR OF CLEAR LIQS. TOL. OK.\n\nGU--UO ~40 CCHR OF AMBER URINE.\n\nENDO--BS 127. COVERED WITH 2 U REG INSULIN SQ.\n\nPAIN--C/O ABD PAIN. ABD SOFT BUT DISTENDED. USING PCA NOT OFTEN ENOUGH. HE FORGETS TO USE IT AND NEEDS ENCOURAGEMENT. HE HAS USED ~4MG IV DILAUDED THIS SHIFT.\n\nCOPING--SISTERS IN TO VISIT. THEY ARE HAPPY WITH HIS PROGRESS. APPEAR TO BE VERY SUPPORTIVE. PT WANTS TO GO HOME.\n\nSKIN--. 4+ EDEMA ON LOWER EXTREMITIES.\n\nA--STABLE. WEANING O2.\n\nP--CON'T TO MONITOR. CHECK BS. ENCOURAGE TO C&DB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-16 00:00:00.000",
"description": "Report",
"row_id": 1321645,
"text": "T/SICU NSG UPDATE\n1900>>0000\n\nS- \"WHERE ARE WE NOW..?\"\n\nO-PT /DISORIENTED..AND KNOWS HE IS: \"I'VE FELT CONFUSED\" EASILY REORIENTED.\n\nCvs- Cont on iv lopressor w/effect; HR 90's to 110 w/o ectopy\n ***pt with acute loud moaning..with hand over left chest. Pt c/o chest pain- sharp w/o radiation to arm. Oxygen found off with sats down to 80's. Pt tachypneic, ashen colored. O2 reapplied, PCA activated for pain med. EKG done and SICU HO notified. Episode resolved within 20min. ??ekg changes from most recent ekg of . 12 lead in chart. No repeat episode.\n..cvp 12-17\n\nResp- desaturation with O2 out of place; quick recovery with O2 in place. Breath sounds clear-coarse with basilar crackles. Cough remains strong but now NP. RR remains in teens when not uncomfortable.\nCont to utilize IS.\n\nPain- except for above episode of acute pain, pt states overall pain level has improved to . Usage of PCA cont; less frequency noted. Pt needs reminders to use PCA if having pain. Usage encouraged prior to dsg cahnges and physical activities.\n\nRenal- steady u/o cont; amber & cloudy\n BUN/Creat levels cont on downward trend\n electrolytes repleted carefully for low levels\n ...weight 75kg tonight (-5kg)\n\nGI- ngt pulled out earlier today; tf's on hold pnd CXR confirmation of new NGT. Feedings restarted @ 2100. Protonix cont; carafate d/c'd. TPN off since yest(?).\nAbd is less distended; bowel sounds remain quiet. Ileostomy remains patent with golden liquid stool. Stoma is pink; appliance .\n**tolerating clear fluid(w/o straw>>chocking noted w/ straw)\n\nID- temp 99.5 ax. WBC cont on downward trend since start of meropenum.\n..Vanco level 20...so NO dosing today.\n\nHeme- no issues\n\nEndo- No issues\n\nSkin- no new issues; cont with lower body edema. Warm extremites with palpable pulses.\n..abd incision is healing with distal aspect remaining open with granulation tissues evident. Some erythema at skin edges and around retention sutures. Scant s/s drainage from wound. W>D dsg changes cont.\n\nASsess- cont with easy desaturation\n periods of confusion/disorientation ? r/t hypoxia and prolonged hospital/ICU stay.\n improving pain\n ?CP\n resolving ATN\n\nPlan- review ekg; monitor for cont c/o CP\n cont with current mngmnt\n maintain adequate oxygen delivery.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-16 00:00:00.000",
"description": "Report",
"row_id": 1321646,
"text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PT A+OX3 MOST OF DAY. PT SL CONFUSED AND PULLING OFF O2 THIS PM. EASILY REDIRECTED AND REORIENTS WHEN O2 BACK ON. ATIVAN X1 FOR C/O ANXIETY.\n\nCV-AFEB. HR/BP STABLE. SKIN W+D. +PP. PBOOTS ON. CON'T WITH PITTING EDEMA. DENIES CARDIAC COMPLAINTS. PT HAD EPISODE CP LST PM. SEE RN NOTE. REPEAT EKG DONE THIS AM. ? ISCHEMIC CHANGES. TO HAVE CPK'S CYCLED AND R/O MI.\n\nRESP-O2 SAT 97% ON 60% FACE TENT. O2 SAT DOWN TO 88% WHEN O2 OFF. LS COARSE, DECREASED AT BASES. C+DB ENC. USING IS.\n\nGI-ABD SOFT, APPROP TENDER. +BS. TOL TF AT GOAL WITH MIN RESIDUALS. TOL SIPS. ILEOSTOMY PINK WITH LIQ BROWN STOOL. JP WITH SCANT THICK BROWN DRG. ABD DSG CHANGED AS ORDERED. WOUND WITH PINK GRANULATION TISSUE AND SOME FIBRINOUS TISSUE. RETENTION SUTURES IN PLACE. CON'T ON ABX.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS CLOUDY AMBER URINE. NO HD TODAY.\n\nCOMFORT-DILAUDID PCA WITH ADEQ STATED EFFECT.\n\nENDO-SSRI.\n\nPLAN-CON'T WITH CURRENT PLAN., CON'T R/O MI\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-17 00:00:00.000",
"description": "Report",
"row_id": 1321647,
"text": "MICU-B NPN 1900-0700\nPLEASE SEE FHP/ICU UPDATE FOR FURTHER HX. PT. ADMIT TO MICU-B FROM T/SICU @ FOR FURTHER MANAGEMENT.\nPT. 47 Y/O MALE S/P ILEOSTOMY REVERSAL; DOING WELL @ HOME. PASSING STOOL. RAN OUT OF DILAUDID AND WENT TO LOCAL ED WHERE HE WAS NOTED TO HAVE ACUTE ABD. PAIN IN SETTING OF INC. WBC; SO TRANSFERRED TO . AT PT. WITH INTRA-ABDOMINAL COLLECTION DRAINAGE (3 JP'S IN PLACE) NEWLY PLACED ILEOSTOMY. COARSE COMPLICATED BY ATN REQUIRING DIALYSIS (HALTED AS OF ).\n\nNEURO - PT. AXOX3. PLEASANT. VERY APPROPRIATE. +MAE. ON DILAUDID PCA FOR ADB. INC. PAIN WHICH IS CONSTANT AT REST. PCA HAS .5 DOSING WITH 6 MIN. LOCKOUT FOR TOTAL 5MG/HR. PT. RECEIVED TOTAL OF 8 MG THUS FAR THIS SHIFT. ALSO GIVEN X1 PRN ATIVAN 1MG FOR RESTLESSNESS WITH GOOD EFFECT.\n\nC/V - HR 70'S-100'S, NSR WITH NO ECTOPY NOTED. NBP 130'S-160'S/70'S-90'S. ON QID 10MG IV LOPRESSOR. CVP 18. + EDEMA NOTED TO BILAT. LOWER EXTREM. MILD FAILURE PER TEAM POST CHF W/U. HAD BEEN SWANED IN T/SICU.\n\nRESP - PT. RECEIVED ON HI- FACE TENT 15.0/60% WITH RR 8-20'S (NON-PRODUCTIVE COUGH) O2SATS. 90-100% WITH SPONT. DESAT. WHEN MASK OFF. AT 0400 PT. WITH INC. COUGHING; PRODUCTIVE WITH MUCOUS PLUG NOTED. SPUTUM WITH TF APPEARANCE; NGT NOTED TO BE IN (R)NARE. PT. WITH INC. WOB; REQUIRING NC 4.0 IN ADDITION TO HI-. NEB. O2SATS. TO AS LOW AS 79%. PRESENTLY LOW-MID-90'S. TEAM NOTIFIED. CXRAY TO BE OBTAINED. LS REMAIN AS INITIAL ASSESSMENT ON ADMIT TO UNIT WITH RHONCHI >CRACKLES TO BILAT.BASES. CONT. TO HAVE GOOD PROD. COUGH. EXP. LARGE AMTS. THICK, TAN SECRETIONS.\n\nGI/GU - AS ABOVE NGT FOUND TO BE IN (R) NARE THIS EVE. TF (NEPRO WITH PROMODE) HALTED @ 0400. HAD BEEN DELIVERING GOAL RATE 40/HR. ABD. SOFT, ND, TENDER WITH DRESSING IN PLACE, D & . 3 JP DRAINS TO BULB SX. NO OUTPUT THIS SHIFT. ILEOSTOMY WITH PINK STOMA; PATENT WITH LOOSE, BROWN STOOL OUT. INDWELLING FOLEY IN PLACE; PATENT WITH GOOD AMTS. CLEAR, YELLOW URINE OUT OVER/.\n\nACCESS - RIJ (DIALYSIS CATH), SITE WNL. (? DC). RSC MULTI-LUMEN IN PLACE; PATENT, GOOD DRAW, GOOD FLUSH, SITE WNL.\n\nSOCIAL - NO CONTACT FROM FAMILY OVER/.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-17 00:00:00.000",
"description": "Report",
"row_id": 1321648,
"text": "RESP CARE\nPT. RE-INTUBATED TODAY FOR RESP. DISTRESS/?ASPIRATION. OXYGENATION MARGINAL INITIALLY. PEEP LEVEL INCREASED, FIO2 WEANED. A/B BALANCE WITHIN NORMAL PARAMETERS, WELL OXYGENATED.,\nBS: COARSE @ TIMES 'D X3 FOR MODERATE AMTS. OF FROTHY PINK SPUTUM.\nCONTNIUE CURRENT SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-20 00:00:00.000",
"description": "Report",
"row_id": 1321661,
"text": "NEURO: Pt remains lightly sedated on propophol @ 70 mcg/kg/min. Pt opens eyes to voice and follows simple commands. +PERRLA noted. Cough/gag .\nCV: Monitor shows NSR with no ectopy noted. L radial aline with good waveform analysis and +csm noted. CVP 6-11. with 2+ ppe. Pt cont on Lopressor IV q 6hr.\nRESP: LS coarse throughout with bibasilar crackles noted. Pt on CPAP 5/5 x.40 with RR 10-18 and TV's 400-600. mod amts thick tan secretions via ett and lg amts clear oral secretions (slightly blood tinged after feeding tube replaced in IR).\nGI: Abd softwith +BS noted. Pt to IR for Dobhoff placement with +confirmation. TF's restarted this afternoon and to be advanced as tolerated to goal of 40 cc/hr. Plan for TF's to be shut off @ 0400 for probable extubation in am. Ileostomy stoma pink and draining liquid brown stool. Stool sent for c-diff. Pt remains on free water boluses Q6hr.\nGU: Foley and patent draining yellow urine.\nI-D: Afebrile. Pt remains on Meropenum. Bld cx sent off CVL and pending. MRSA precautions maintained.\nSKIN: Surgery up to eval and drains x3 removed by MD. Exit sites washed with NS and DSD applied X3. Abd wound incision pink with sutures and sm amt ss drainage. Wash with NS and W-D dsg applied as ordered.\nHEME: Lytes to be rechecked this afternoon and repleted as needed. Mag repleted this am and K was repleted early am.\nENDO: Pt remains on fingersticks Q6hr with no coverage per scale.\nPSY-SOC: Sister in to visit and updated on status and plan of care. Cont to provide emotional support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-20 00:00:00.000",
"description": "Report",
"row_id": 1321662,
"text": "Respiratory Care Note:\n Patient remains intubated and ventilated. Sedated on propofol and is on MMV due to apneic epsisodes today. Transported to IRV without incident. Suctioned for mod-large amounts of thick yellow sputum today. Plan for possible extubation tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2120-11-21 00:00:00.000",
"description": "Report",
"row_id": 1321663,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Pt. more awake, no apneic episodes noted during this shift. Pt. taken off MMV. Vent settings Psv 10, Cpap 5, Fio2 40%. Sedated with propofol. Pt. maintaining good vols of 500-600's with RR 12-mid teens. Bs rhonchi bilaterally. Copious amounts of secretions. Sx'd for moderate-large amounts of thick yellow secretions. Adequate O2 sats. No further changes made. Continue with mechanical support.\n"
},
{
"category": "ECG",
"chartdate": "2120-12-02 00:00:00.000",
"description": "Report",
"row_id": 178154,
"text": "Sinus rhythm. Vertical axis. Anterior T wave inversions. Inferior and lateral\nJ point and ST segment elevation. Since the previous tracing of \nthe inferolateral ST segment elevations are more marked, the rate has decreased\nand anterior T wave inversions are more prominent. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2120-11-15 00:00:00.000",
"description": "Report",
"row_id": 178155,
"text": "Sinus rhythm\nPoor R wave progression - probable normal variant\nLateral T wave changes are nonspecific\nSince last ECG, no significant change\n\n"
}
] |
5,259 | 146,768 | CCU NSG PROGRESS NOTE 7P-7A/ S/P BRADYCARDIA/FUOS- INTUBATEDO-CV= PT REMAINS ON LEVO/DOPA- ABLE TO SLIGHTLY WEAN LEVO TO 0.01 MCG FROM 0.029 MCG/KG- DOPA REMAINS AT 2 MCG.BP- 107/50- 112/46 WITH HR- V PACED- 90.SITE WITH SLIGHT OOZE- EXTERNAL PACER PRESENT UNDER TEGEDERM.HEPARIN AT 900U- PTT- 81. PT REMAINS WITH LABILE BP ON PRESSOR X 1LEVO GTT 0.025- 0.01 WITH BP- 92/48- 120/56 - SOME DIPPING TO 70'S WHILE ASLEEP - REQUIRING INCREASE BACK UP TO 0.02MCG/KGUNABLE TO WEAN OFF TOTALLY THIS SHIFT.HR- 90'S VPACED - 100'S AFIB- LOADING WITH DIG FOR RATE CONTROL- 0.5 MCG X 1 AND 0.25MCG X 2 DOSES TO FOLLOW.HEPARIN REMAINS AT 900U- AM LABS/COAGS PENDING.DOPA REMAINS D/C - OFF. CCU NSG PROGRESS NOTE 7P-7A/ S/P BRADY; SEPSISS- INUTBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA.. PT REMAINS ON LEVO GTT- 0.04 MCG/KG- ATTEMPTED TO DECREASE, BUT DROPPED BP TO 80/40. A .018 guidewire was advanced under fluoroscopy into the superior vena cava. PT REMAINS ON VENT SUPPORT- 40/500/10 A/C.SUCTIONED FOR THICK WHITISH SPUTUM.DIMINISHED BREATH SOUNDS AT BASE/RHONCHOROUS.+ COUGH/ + GAG.SPONTANEOUS BREATHS OVER SET RATETO CHANGE MODE TO PRESSURE SUPPORT FOR TEST THIS AM.PAD- 19- 23/ CVP - 12- 16. NPNCCU7 PM - 7 AMBRADYCARDIC/HYPOTENSIVES/O ORALLY INTUBATED AND SEDATEDPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATACV ..2300..TRANSVENOUS PACER ON STANDBY TO ASSESS UNDERLYING RHYTHM....SINUS ARREST /BRADYCARDIA ..RATE OF 29-32...PLACED BACK ON RATEOF 80..MA OF 3 ..WITH 100% CAPTURE...0330..PT WITH FREQUENT INTRINSIC BEATS NOTED ....AGAIN ..PACER PLACED ON STANDBY..PT FOUND TO BE IN AFIB ..RATE OF 110-120..WITH SBP 130-150'S/60'S...BUT UNABLE TO WEAN LEVO/DOPA WITHOUT DRAMATIC DROP IN SBP....0415...RHYTHM CHANGED TO SINUS BRADYCARDIA AT RATE OF 28-36...PLACED ON PACER AT RATE OF 80..WITH 100% CAPTURE ....CONTINUES ON 15 MCGS DOPA...1MCG/KG OF LEVO...WITH SBP 130-150'S...DIURESIS WITH 20MG/40MG OF IV LASIX IN CONJUNCTION WITH HIGHER SBP WITH BRISK URINE OUTPUT NOTED ..APPROX 300-400 CC Q2 ...RESP ON AC MODE ..RATE INCREASED TO 14..D/T PH OF 7.28...TV 500 ..5 PEEP..40%..LUNGS CLEAR ...WITH SMALL AMOUNT OF YELLOW ET SXNS...GI ..TUBE FEEDINGS HELD DUE TO PERSISTENT HIGH RESIDUALS ...DULC SUPP GIVEN ..WITHOUT RESULTS ..GU ..BRISK DIURESIS BEGUN WITH HIGHER SBP/DIURESIS COMBINATIN ..APPROX 10 L POSITIVE..SEDATION ..ON PROPOFOL GTT ...WRISTS LIGHTLY RESTRAINED ..GRIMACING WHEN SUCTIONED ...PERLA ..ENDOCRINE ...INSULIN GTT WEANED TO OFF..D/T FINGER STICK OF 81...AND CONTINUED HIGH RESIDUALS ...ID TEMP 101.6...TYLENOL TIMES 2..AM WBC PNDG...LEVO/FLAGYL/VANCOA HEMODYN INSTABILITY CONTINUES WITH PACER/PRESSOR DEPENDENCEP CONTINUE TO FOLLOW CLOSELY Remains on Digoxin 0.125po qod. Cont to wean as tol.GI/GU: +BS, abd soft, distended this AM. ABP 97-130/47-63. V PACED TO AFIB.BP STABLE.HEPARIN 800U /PTT 65.SAT 97 2LNP. Recheck Hct, K, BS. CXR after placement. remains on LEVO @ 0.1mcg/k/min and DOPA @ 10mcg/k/min. pan cultured last noc.GI/GU: foley patent. Repeat PTT 87.9 (therapeutic). Pulses palpable.ID: Pt afebril. Received Atropine X3, dopa and levo gtt started. Posttransfusion HCT and K+ sent. abg: 180/42/7.43/29/3. BS CL TO DIMINISHED.E/D WELL . Question restart Heparin. Heparin gtt cont t/b off, will restart with am PTT level according to PTT protocol. Palpable pulses bilaterally.Resp: ETT. then back down to .1 mcgs/kg/min. RR 12-26, last ABG 7.36/41/120/24/-1. Check HCT. ABG's = 7.43 33 121 23 0 slightrespiratory alkalosis. PROBLEM C .BS COVERED C SSRI . Tmax today 99.8 post transfusion. Levo continues at .1 mcgs/kg/min. Cont to wean vent as tol. Resp. Levo weaned from 0.078 to 0.053. Aline intact R radial. Covered with 4-10 u RISS. cont on heparin 800u/hr. Experienced single episode of hypertension and converted to underlying rhythm of Afib returned to on own. PERRLA. BUN/ CR 48/1.3.ENDO: BS 150 - 200. Head CT done.G.I. HR 87-120. +695/24hrs and + 11 Liters for LOS. Monitor vent and sxn prn. TEE done which was normal with no vegatation and normal EF. Continues on Valpoic acid. Remains on abx regimen of Vanco, Flagyl and Levofloxacin. encourage DB+C, monitor u/o. Rhoncerous lung sounds.Id: Spiked yesterday. Restart Temp pacer intact to LSC. Confirmed placement by auscultation. creat. + BS. +BS. +BS. Pt has PRN ativan order for sedation. REACHES FOR ETT AND LINES WHEN RESTRAINTS OFF. monitor u/o, ?another fluid bolus later tonite if u/o drops. Opens eyes to sternal rub. At 0400- pt overrided pacer, rhythm afib HR 110's with , MD aware. Triple lumen placed in left IJ. AM HCT 26.8. In EW experienced hypotensive episode received 1L NS accompanied with a # of episodes of SB. Very involved with pt's care.A/P: VSS except with changes in position. Mild(1+) mitral regurgitation is seen. Mild (1+)mitral regurgitation is seen. Mild (1+)mitral regurgitation is seen. Mild (1+) aorticregurgitation is seen. Mild (1+) aortic regurgitation is seen. There is a minimally increasedgradient consistent with minimal aortic valve stenosis. There is a minimally increasedgradient consistent with minimal aortic valve stenosis. There is moderate mitral annularcalcification. Mild (1+) aortic regurgitation isseen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+)mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. There is moderate symmetric leftventricular hypertrophy. Mild to moderate [+] tricuspid regurgitation isseen. The aortic valve leaflets are moderately thickened withoutevidence of vegations. The tricuspid valve leaflets are mildlythickened. Relativelylow limb lead and precordial voltage. Mild (1+) aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are moderately thickened. Compared to the previous tracing of ventriculiar pacingis no longer seen and atrial fibrillation is now present, with the otherfindings as previously resportedn. There is nomitral valve prolapse. Currently, well sedated and synchronous with mechanical ventilation. Right ventricularsystolic function is normal.AORTIC VALVE: The aortic valve leaflets are mildly thickened. There is mild pulmonic valve stenosis. The aortic valve leaflets are mildly thickened and displaysomewhat reduced mobility and excursion. Views areinadequate for assessment of systolic function. Hypotension.BP (mm Hg): 105/60HR (bpm): 80Status: InpatientDate/Time: at 13:45Test: Portable TTE(Focused views)Doppler: Focused pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.LEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.RIGHT VENTRICLE: The right ventricular cavity is dilated. Non-specific ST-T wave changesconsistent with ischemia, post-pacemaker T wave changes, etc. PT ON PROPOFOL GTT.DIFFICULT TO AROUSE CURRENTLY. Moderate to severe spontaneous echocontrast is seen in the body of the left atrium. There is mild thickening of the mitral valve chordae. The right ventricular cavityis dilated. PERL, sluggish, Moves all ext.ID: afebrile. The tips of the papillarymuscles are calcified. is well sedated. Mild tricuspid [1+]regurgitation is seen.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: A transesophageal echocardiogram was performed in thelocation listed above. | 60 | [
{
"category": "Radiology",
"chartdate": "2145-09-03 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 769959,
"text": " 5:31 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION\n Reason: please evaluate for abscess or focus of infection\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with infection and syncope of unknown etiology\n REASON FOR THIS EXAMINATION:\n please evaluate for abscess or focus of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infection of unknown origin.\n\n TECHNIQUE: Contrast-enhanced CT of the chest, abdomen, and pelvis. 150 cc of\n Optiray were used.\n\n COMPARISON: Chest CT and abdominal and pelvic CT obtained .\n\n CT CHEST WITH INTRAVENOUS CONTRAST: Right ventricular pacer wire and Swann-\n Ganz catheter are noted. Coronary artery calcifications are present. The\n aortic arch is densely calcified. The pulmonary arteries are grossly normal.\n there is no pericardial effusion. No mediastinal, hilar, or axillary\n adenopathy is present. A large left pleural effusion is seen with associated\n atelectasis of the adjacent left lung. This has increased in size since the\n prior study. Thickened septal lines with associated nodularity are noted in\n the right lower lobe, which has increased in its extent since the prior study.\n There are new pleural-based nodules at the posterior right upper lobe\n measuring approximately 18 mm x 7 mm and in the posterior right upper lobe\n measuring approximately 4.3 cm x 1.0 cm. A trace right pleural effusion is\n noted. The airways are grossly patent. An endotracheal tube is noted. The\n patient is status post right mastectomy.\n\n CT ABDOMEN WITH IV CONTRAST: The liver, spleen, and adrenal glands are normal.\n The pancreas demonstrates several foci of fluid density, particularly in the\n body and anterior to the head of the pancreas. This appearance was present in\n the prior study from and is unchanged. Multiple simple cysts are noted\n in the kidneys bilaterally which are stable. The kidneys enhance and excrete\n contrast symmetrically. A large stone measuring approximately 1.2 cm is seen\n near the gallbladder neck. There is no gallbladder wall thickening to suggest\n cholecystitis. The small bowel loops are normal. Innumerable diverticula are\n noted in the sigmoid colon with no evidence of inflammatory change to suggest\n diverticulitis. A trace amount of fluid is noted tracking along the liver and\n in the pelvis. There is no retroperitoneal or mesenteric lymphadenopathy and\n no free fluid. Several coarse calcifications in the left mesentery are\n unchanged from the prior study. Surgical clips are noted along the stomach.\n There are no fluid collections to suggest an abscess.\n\n CT PELVIS WITH IV CONTRAST: Limited visualization due to artifact from left\n hip prosthesis. A 3.0 cm x 7.5 cm pocket of air is noted superior to the\n pubic symphysis adjacent to the abdominal wall and is surrounded on three\n (Over)\n\n 5:31 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION\n Reason: please evaluate for abscess or focus of infection\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n sides by contrast-opacified small-bowel loops. This does not appear to\n connect to the bladder. The bladder is decompressed with a Foley catheter.\n There is no lymphadenopathy. Note that in the gluteal cleft there is a region\n of relative with multiple tiny air bubbles, which appears to\n be within the skin. It also appears to connect with the stool in the rectum.\n This may represent an infected decubitus ulcer.\n\n IMPRESSION:\n 1. Large air pocket with no fluid level in the anterior pelvis. This does not\n definitely connect with the bowel or with the bladder and could represent an\n unusual abscess cavity. A repeat study has been recommended and is currently\n scheduled to assess for interval passage of bowel contrast into the structure\n and to assess for fluid infusion via Foley catheter to enter this structure.\n\n 2. Apparent infected decubitus ulcer in the gluteal cleft. Clinical\n correlation is suggested.\n\n 3. Interval increase in left pleural effusion.\n\n 4. Interval increase in extent of thickened septal lines and bronchovascular\n bundle in the right lower lobe, consistent with progression of lymphangitic\n carcinomatosis. Also new pleural-based nodules posteriorly in the right mid\n lung, also concerning for progression of disease.\n\n 5. Trace ascites.\n\n 6. Stable gallstone with no evidence of cholelithiasis.\n\n 7. Stable appearance of multiple bilateral simple renal cysts.\n\n 8. Diverticulosis with no evidence of diverticulitis.\n\n 9. Stable multicystic structure within and anterior to the pancreatic head.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-09-09 00:00:00.000",
"description": "UD GUID FOR NEEDLE PLACMENT",
"row_id": 770494,
"text": " 3:17 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC line placement: eval by nurse, needs placement under fl\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with above\n REASON FOR THIS EXAMINATION:\n PICC line placement: eval by nurse, needs placement under fluoro\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85 year old woman with malnutrition and atrial fibrillation.\n\n PROCEDURE: The procedure was performed by Dr. and , with Dr.\n , Attending Radiologist, being present and supervising the entire\n procedure. The right upper arm was prepped and draped in the usual sterile\n fashion. Since no suitable superficial veins were visible, ultrasound was used\n for localization of a suitable vein. The brachial vein was patent and\n compressible. After local anesthesia with 2 cc of 1% Lidocaine, the brachial\n vein was entered under ultrasonographic guidance with a 21 g. needle. A .018\n guidewire was advanced under fluoroscopy into the superior vena cava. Based\n on markers on the guidewire it was determined that a length of 48 cm would be\n appropriate. The PICC line was trimmed to length and advanced through a 4\n French introducer sheath into the superior vena cava. The sheath was removed\n and the catheter was flushed. A final chest x-ray demonstrates the tip to be\n at the SVC/right atrial junction. The line is ready for use.\n\n A statlock was applied and the line was heplocked.\n\n IMPRESSION: Successful placement of a 48 cm total length double lumen, 5\n French PICC line with tip in the superior vena cava, ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 769385,
"text": " 9:59 PM\n CHEST FLUORO WITHOUT RADIOLOGIST PORT; CHEST (PORTABLE AP) Clip # \n Reason: Pacer Wire Insertion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with symptomatic bradycardia\n REASON FOR THIS EXAMINATION:\n Pacer Wire Insertion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pacing wire insertion. Bradycardia.\n\n Chest fluoroscopy was provided to Dr. . 3 fluoroscopic images\n from the procedure were obtained. No radiologists were involved in the\n procedure. 3 fluoroscopic images demonstrate pacing wire in the expected\n location of the right ventricle. The spot fluoroscopic nature of the images\n precludes assessment for complications such as pneumothorax.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-31 00:00:00.000",
"description": "Report",
"row_id": 1331620,
"text": "CV: Patient is intermittently Vpaced at a rate of 90 MA 3. Underlying rhythm is AF with Vent response in the 100's. MAP is higher while patient is in AF. IV Heparin started at 1000u/hr/. Patient continues to experience periods of hypotension when pressors are weaned. Dopa at 8mcgs/kg/min and Levo at .078mcgs/kg/min.Pacer reset to rate 80 5pm\nCardiac echo done; nl EF and normal valves.\n\nResp: Patient remains on A/C 500, 40%,14. ABGS 7.40 33 140 21. Suctioned for moderate amount of tan sputum. Desats when placed on right side. CXR shows pleural effusions on both sides but worse on the left. ET tube advanced to level 22.\n\nNeuro: IV Propofol DC'd after patient was seen by neuro. Tolerating well. Able to respond to verbal stimuli and limited comands, continues to be sleepy. Pupils are 3-4mm,equal & brisk. Ativan prn for sedation.\n\n\nGI: Tolerating tube feeding at goal 50cc/hr with minimal residuals and good bowel sounds. Small amount of quiac negative stool. FIB applied. Blood sugars covered with SS.\n\nGU: Creat 1.8. Seen by Renal. Vanco dose decreased.: Hourly urine output 30-100cc/hr.\n\nID: T max 101R.\n\nAssessment: Patient continues to be pacer and pressor dependent.\n\nPlan: Wean Neo as tolerated. Evaluate pacer setting of 80. IV Ativan for sedation. Avoid placement of patient on right side.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-01 00:00:00.000",
"description": "Report",
"row_id": 1331621,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ SEPSIS/ CONDUCTION FX\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS ON DOPA/LEVO WITHOUT CHANGE IN DOSES THIS SHIFT\nFOR THE MOST PART- BP- 110-130/50-70 WITH HR 80-85 PACED- UP TO 110'S AFIB. NO VEA, ALL AM LYTES PENDING.\nHEPARIN AT 1000U- HELD 1 HOUR AND DECREASED TO 900 U FOR PTT>150.\nONE EPISODE OF SPONTANEOUS DROP IN BP TO 80/30 WITH HR 80 PACED.\nTEAM AWARE= INCREASED PACER RATE TO 85 WITH SLIGHT IMPROVEMENT OF BP.\nAWOKEN WITH SUCTIONING/STIMULTATION AND INCREASE IN HR TO 110'S AFIB AND BP INCREASED AS WELL.\nNO FURTHER LABILE EPISODES AS OF 4AM.\n\n PT REMAINS INTUBATED ON VENT SUPPORT- A/C 40/500/14.\nBREATHING IN SYNCH WITH VENT WHEN ADEQUATELY SEDATED.\nSUCTIONED FOR THIN WHITISH SECRETIONS Q 3 HOURS.\nRHONCHOROUS, DIM AT RT BASE OTHERWISE CL.\nO2 SATS- 99-100% .\nAWAIT AM ABG RESULTS.\n\nID- AFEBRILE THIS SHIFT.LAST TEMP YESTERDAY DAY SHIFT TO 101; WHITE COUNT REMAINS ELEVATED.\nUNABLE TO OBTAIN RECTAL TEMP D/T RECTAL BAG\nPO TEMPS- 97.\nREMAINS ON ANTIBX X 3- VANCO/LEVO/FLAGYL.\nALL CULTURES PENDING/ OR (-).\nTEAM PHONED ID TONITE- WILL FORMALLY CONSULT IN THE AM.\n\nGU- GOOD UO- NO DIURESIS CURRENTLY-\n50-80CC/HOUR VIA FOLEY CATH.\nI/O (+) 700CC FOR THE DAY AND (+) 10 LITERS OVERALL.\n\nGI- TUBE FEEDS AT 50CC / PROMOTE - MINIMAL RESIDUALS, NO STOOL - RECTAL BAG IN PLACE.\n(+) BOWEL SOUNDS.\nABD SOFT.\n\nDM- BS<200- REMAINS ON SS INSULIN\nNO COVERAGE THIS SHIFT.\n\nSKIN- NO ISSUES CURRENTLY- SKIN LOOKS GOOD, NO SIGNS OF BREAKDOWN.\n\nMS- D/C PROPOFOL GTT THIS AFTERNOON TO TRY TO INCREASE BP , IF SEDATION IS ADDING TO HYPOTENSIVE PROBLEM.\nCURRENTLY GIVEN 1 MG ATIVAN Q 4HOUR. APPEARS TO BE KEEPING PT COMFORTABLE.\nPT ALERT, EASILY AWAKENED.\nSQUEEZING BOTH HANDS TO COMMAND, NEURO SIGNS STABLE.\nSON IN LAW AND BROTHER OF SON IN LAW IN- SPOKE AT LENGTH WITH THEM REGARDING CURRENT PROGRESS/PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-06 00:00:00.000",
"description": "Report",
"row_id": 1331640,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P BRADY; SEPSIS\n\nS- INUTBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA..\n\n PT REMAINS ON LEVO GTT- 0.04 MCG/KG- ATTEMPTED TO DECREASE, BUT DROPPED BP TO 80/40. PT PACED AT RATE 90. NO ISSUES WITH HR- SOME BREAK INTO AFIB 100'S- STARTED ON DIGOXIN QOD.\n\n PT SWITCHED FROM PS 10/5 TO A/C 10/500/40% TO REST OVERNITE.\nSUCTIONED Q 2 HOUR FOR THICK WHITISH SPUTUM. COARSE BREATH SOUNDS.\nI/O - 800CC AS OF 12AM. STILL (+) 14L LOS.\nGIVEN MORE LASIX- 40 MG THEN 80 MG WITH FAIR DIURETIC RESPSONSE.\nABG WNL/SATS 99%.\n\nID- AFEBRILE- D/C FLAGYL- REMAINS ON VANCO AND CEFTRIAX\n\nGU- SEE ABOVE RE: I/O/UO/LASIX DOSES.\n\n PT NPO FOR POSSIBLE WEAN TODAY\nMIN RESIDUAL- HOLDING REGLAN D/T LOOSE STOOL - RECTAL BAG.\n(+) BOWEL SOUNDS. G (-) STOOL.\n\n PT ALERT/ORIENTED X 3, GESTURING/MOUTHING APPROPRIATE WORDS .\nDAUGHTER IN TO VISIT, OTHER DAUGHTER CALLED.\nGIVEN 1 ATIVAN FOR SLEEP- WIDE AWAKE THIS AM.\nAPPEARS COMFORTABLE.\n\nA/ PT S/P BRADY/HYPOTENSION REMAINS WITH LABILE BP.\nPACER WORKING WITHOUT PROBLEM.\nAWAIT WEAN/'EXTUBATION.\n\nRESUME PS 10 THIS AM FOR EXERCISE/WEAN.\nRESUME NUTRITION ONCE WEANED OR IF RESTING AGAIN.\nSKIN CARE/COMFORT.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\nDISCUSS PLAN FOR PRESSOR WEAN/D/C PA LINE AS WELL.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-06 00:00:00.000",
"description": "Report",
"row_id": 1331641,
"text": "NPN\nCV: Patient remains in VVI paced rhythm at 90. No AF noted. Hemo's stable. SBP > 100 and PAD's 18-22. IV Levophed weaned very slowly to off. Tolerated well. Digoxin to be started tomorrow. Check level tomorrow am.\n\nRESP: Patient placed on pressure support of 10 early this am. Tolerated well TV 200-250. O2 Sats 96-98. Respirations remain unlabored. 1230 patient extubated without problem by respiratory therapist. Good cough, raising moderate amounts of white sputum placed on 40% face mask. No stridor present. Respirations are even and unlabored.\n\nGU: Given 80mg IV Lasix to keep hourly urine output > 100cc/per hour.\nUrine output 60-120/hr. Check creat in am.\n\nNeuro: Patient is awake and alert, responding to commands. Calm and cooperative. PT consult placed.\n\nGI: Patient has remained NPO for extubation. Will begin liquid\ndiet this pm. Bowel sounds present. Small amount of liquid stool. Quiac neg. Hct 30.\n\nSuccessful extubation. Continue to assess respiratory status. Monitor O2 Sats, encourage coughing and deep breathing. Monitor hourly urine output. Check creat in am. Advance diet as tolerated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-30 00:00:00.000",
"description": "Report",
"row_id": 1331617,
"text": "NPN\nCCU\n7 PM - 7 AM\nBRADYCARDIC/HYPOTENSIVE\nS/O ORALLY INTUBATED AND SEDATED\nPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV ..2300..TRANSVENOUS PACER ON STANDBY TO ASSESS UNDERLYING RHYTHM....SINUS ARREST /BRADYCARDIA ..RATE OF 29-32...PLACED BACK ON RATEOF 80..MA OF 3 ..WITH 100% CAPTURE...0330..PT WITH FREQUENT INTRINSIC BEATS NOTED ....AGAIN ..PACER PLACED ON STANDBY..PT FOUND TO BE IN AFIB ..RATE OF 110-120..WITH SBP 130-150'S/60'S...BUT UNABLE TO WEAN LEVO/DOPA WITHOUT DRAMATIC DROP IN SBP....0415...RHYTHM CHANGED TO SINUS BRADYCARDIA AT RATE OF 28-36...PLACED ON PACER AT RATE OF 80..WITH 100% CAPTURE ....CONTINUES ON 15 MCGS DOPA...1MCG/KG OF LEVO...WITH SBP 130-150'S...DIURESIS WITH 20MG/40MG OF IV LASIX IN CONJUNCTION WITH HIGHER SBP WITH BRISK URINE OUTPUT NOTED ..APPROX 300-400 CC Q2 ...\nRESP ON AC MODE ..RATE INCREASED TO 14..D/T PH OF 7.28...TV 500 ..5 PEEP..40%..LUNGS CLEAR ...WITH SMALL AMOUNT OF YELLOW ET SXNS...\nGI ..TUBE FEEDINGS HELD DUE TO PERSISTENT HIGH RESIDUALS ...DULC SUPP GIVEN ..WITHOUT RESULTS ..\nGU ..BRISK DIURESIS BEGUN WITH HIGHER SBP/DIURESIS COMBINATIN ..APPROX 10 L POSITIVE..\nSEDATION ..ON PROPOFOL GTT ...WRISTS LIGHTLY RESTRAINED ..GRIMACING WHEN SUCTIONED ...PERLA ..\nENDOCRINE ...INSULIN GTT WEANED TO OFF..D/T FINGER STICK OF 81...AND CONTINUED HIGH RESIDUALS ...\nID TEMP 101.6...TYLENOL TIMES 2..AM WBC PNDG...LEVO/FLAGYL/VANCO\nA HEMODYN INSTABILITY CONTINUES WITH PACER/PRESSOR DEPENDENCE\nP CONTINUE TO FOLLOW CLOSELY\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-30 00:00:00.000",
"description": "Report",
"row_id": 1331618,
"text": "BRADYCARDIC,HYPOTENSIVE ,POSSIBLY SEPTIC\n\nV PACED AT 80, AT 430 PT WENT INTO AFIB RATE 110.PACER RESET TO RATE 90. BP DRIFTING TO 80S THROUGHOUT THE DAY REQUIRING TITRATION OF DOPAMINE AND LEVOPHED TO KEEP MAP > 60.BP FAIRS BETTER WHEN PT IN AFIB. CA REPLETED .\n\nSX TAN.CXR SHOWS NEW LL INFILTRATE .AC 500/40/5/14. ABG 7.34/32/88/18.\n\nTF RESTARTED.TOL 20CC/HR. PASSING BR FORMED TO LIQUID STOOL .COVERED C SSRI\n\nHUO 30 TO 200CC.\n\nT MAX 100,8 SPUTUM SPEC SENT\n\nPT NON RESPONSIVE, PROPOFOL OFF FOR NEURO EXAM ,PT GRIMACES ,PROPOFOL CURRENTLY 10 MICS\n\nWEAN PRESSERS AS TOL\nADVANCE TF\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-31 00:00:00.000",
"description": "Report",
"row_id": 1331619,
"text": "Review of systems:\n\nNeuro: Pt remains sedated on propofol gtt. gtt currently running at 10/mcg/kg/min. pt pupils are 3-4mm equal and brisk. pt has no response to painful stimuli, but will grimis to suctioning.\n\nCV: pt is at 90, and MA is set at 3. pt is currently on a levo gtt @ 10cc and a dopa gtt @ 22 cc to maintain MAP of 60. Was unable to titrate Dopa gtt b/c when pt's pacer is fireing, pt MAP is low, but when PT is in , pt BP is higher. Pt not tolerating tiration of vasopressors.\n\nResp: Pt remains on vent AC/500/40/5/14. pt sao2 is > 96%. pt requires q 2-4 hour suctioning for small amounts of tan secreations. pt Lungs are clear in the uppers and diminished in the lowers.\n\nGI/GU: Pt has not had a BM. Pt urine output has been > 30 cc/ hr but has slowed down as the night has gone on. pt urine in clear and yellow.\n\nLines: pt L IJ TLC has no blood return but flushes well. all other lines WNL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-05 00:00:00.000",
"description": "Report",
"row_id": 1331637,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P BRADY/SEPSIS\n\nS- INTUBATED\nNODDING HEAD YES/NO\n\nO-SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS WITH LABILE BP ON PRESSOR X 1\nLEVO GTT 0.025- 0.01 WITH BP- 92/48- 120/56 - SOME DIPPING TO 70'S WHILE ASLEEP - REQUIRING INCREASE BACK UP TO 0.02MCG/KG\nUNABLE TO WEAN OFF TOTALLY THIS SHIFT.\nHR- 90'S VPACED - 100'S AFIB- LOADING WITH DIG FOR RATE CONTROL- 0.5 MCG X 1 AND 0.25MCG X 2 DOSES TO FOLLOW.\nHEPARIN REMAINS AT 900U- AM LABS/COAGS PENDING.\nDOPA REMAINS D/C - OFF.\n\n PT REMAINS ON A/C OVERNITE TO REST IN ANTICIPATION OF WEANING AGAIN TODAY.\n40/500/10- BREATHING OVER RATE OF VENT.\nSUCTIONED FOR THICK WHITISH SPUTU/TAN MODERATE TO SMALL AMT.\nCOARSE TO DIM BREATH SOUNDS .\nPAD-18-22/ CVP - 16-18, UNABLE TO WEDGE PA LINE.\n\nID- AFEBRILE THIS SHIFT- REMAINS ON ANTIBX X 3.\n\nGU- FAIR UO- 30-50/HOUR.\n\nGI- TUBE FEEDS D/C AT 12 AM - PROMOTE AT 50/CC HOUR.\nMINIMAL RESIDUALS- STOOL VIA RECTAL BAG.\n(+) BOWEL SOUNDS.\nREGLAN ON HOLD.\n\nMS- ATIVAN 1 MG X 1 - QHS- WIDE AWAKE- ENCOURAGED TO SLEEP\nSON IN LAW IN TO VISIT.\nPT ANSWERING QUESTIONS APPROPRIATELY BY GESTURES\n\nSKIN- TURNING SIDE TO SIDE- EXTREMITIES WITH (+) EDEMA.\n\nA/ PT CURRENTLY REQUIRING PRESSOR/VENT SUPPORT\n\nCONTINUE TO MONITOR PT HEMODYNAMICS - ATTEMPT TO WEAN LEVO AS TOLERATED.\nCONTINUE TO ATTEMPT TO WEAN VENT- AM PRESSURE SUPPORT THIS AM.\nANTIBX AS ORDERED- WATCH FOR FEVER.\nCOMFORT/KEEP PT INFORMED AS TO PLAN OF CARE/AS WELL AS FAMILY.\nRESTART NUTRITION ONCE WEAN PLAN FOR THE DAY DISCUSSED.\nSKIN CARE/DECREASE PT .\nCONTINUE DIG LOAD.\n? D/C PA LINE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-05 00:00:00.000",
"description": "Report",
"row_id": 1331638,
"text": "RESP CARE NOTE\nPT REMAINS INTUBATED, MECH VENTED VIA PB7200 VENT, A/C 500 X 10, 40%, 5PEEP. AM ABG ON THESE SETTINGS 7.43/36/101/25/0. PT COMFORTABLE, IN SYNCH W/VENT OCCAS OVERBREATHING VENT RATE. BS OCCAS RHONCHI, SXN SM THICK YEL. PLAN TO ATTEMPT PSV WEAN IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-05 00:00:00.000",
"description": "Report",
"row_id": 1331639,
"text": "DIURESES BEGUN TO FACILITATE VENT WEAN. LEVOPHED ADJUSTED TO MAINTAIN BP .PACED TO AFIB ,LESS TACHY P DIG. PAD 18.MV SAT 77,CI 4.33,SVR 898.\nHEPARIN 800 PTT 86,TEMP OFF FOR GROIN LINE DC.\n\nTOL PS ALL DAY ,ABG 7.42/37/154/25,SX FOR TAN .\n\nTF HELD .BR STOOL\n\nDIURESING WELL ,IF UO UNDER 100CC HR CALL FOR LASIX DOSE\n\nALERT,ORIENTED ,NO CO PAIN, SEEMS MORE RESTFUL TODAY\n\n CONTINUE VIGOROUS DIURESIS\nSUPPORT BP AS NECESSARY\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-03 00:00:00.000",
"description": "Report",
"row_id": 1331633,
"text": "Went to EP Lab for temp pacing wire change. Had episodes of AF during procedure. Now patient is in paced rhytm. TEE normal,plan to go to CT Scan for head and Abdomen films.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-08 00:00:00.000",
"description": "Report",
"row_id": 1331646,
"text": "ADDENDUM PACED R 60 BEATS, HAD BEEN SEEN BY EPS TODAY ,PACER INTEREGATED AND RATE CHANGED .BP 95/31. PT AWAKE .HO NOTIFIED\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-03 00:00:00.000",
"description": "Report",
"row_id": 1331634,
"text": "CCU NPN 1500-1900\nco/ci done at 1500-> 3.8/2.53/1368. bp has remained w/ MAPS >70 and levo weaned and is currently .029 mcg/kg, dopamine at 2 mcg/kg. Heparin was restarted at 1600 at 900u/hr.\n\nCT scan of chest, abdomen and pelvis done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-04 00:00:00.000",
"description": "Report",
"row_id": 1331635,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P BRADYCARDIA/FUO\n\nS- INTUBATED\n\nO-\n\nCV= PT REMAINS ON LEVO/DOPA- ABLE TO SLIGHTLY WEAN LEVO TO 0.01 MCG FROM 0.029 MCG/KG- DOPA REMAINS AT 2 MCG.\nBP- 107/50- 112/46 WITH HR- V PACED- 90.\nSITE WITH SLIGHT OOZE- EXTERNAL PACER PRESENT UNDER TEGEDERM.\nHEPARIN AT 900U- PTT- 81.\n\n PT REMAINS ON VENT SUPPORT- 40/500/10 A/C.\nSUCTIONED FOR THICK WHITISH SPUTUM.\nDIMINISHED BREATH SOUNDS AT BASE/RHONCHOROUS.\n+ COUGH/ + GAG.\nSPONTANEOUS BREATHS OVER SET RATE\nTO CHANGE MODE TO PRESSURE SUPPORT FOR TEST THIS AM.\nPAD- 19- 23/ CVP - 12- 16. UNABLE TO PCW.\n\nID- AFEBRILE-\nREMAINS ON ANTIBX X 3. STARTED WITH VANCO 750 Q 18 HOURS.\nFLAGYL/CEFTRIAX.\nWENT FOR REPEAT CT SCAN OF PELVIS- (-).\n\nGU- GOOD UO- 40-60/HOUR VIA FOLEY CATH.\nNO DUIRESIS THIS SHIFT.\n\n PT MUCH LOOSE STOOL G (+).\nRECTAL BAG IN PLACE.\nHOLDING REGLAN.\nNPO FOR POSSIBLE EXTUBATION TODAY.\n\nDM- BS < 180- SS REG INSULIN.\n\n PT ALERT, ATIVAN 1 MG X 2.\nGAGGING ON ETT/COUGHING- REQUIRING SEDATION FOR CT SCAN.\nEYES OPEN/ PURPOSEFUL AND OBEY COMMANDS.\n\nLINES- NEW RT RADIAL ALINE- D/C LEFT BRACHIAL ALINE D/T INFILTRATION.\n\nSOCIAL- DAUGHTER CALLED FOR UPDATE.\n\nA/ PT S/P LONG COURSE OF LABILE HEMODYNAMICS/TEMP WIRE/FUO CURRENTLY WITH STABLE HEMODYNAMICS /AFEBRILE.\n\nCONTINUE TO CLOSELY WATCH HEMODYNAMICS- CONTINUE TO WEAN LEVO GTT TO OFF. WEAN DOPA AS ABLE AS WELL. KEEP HEPARIN AT THERAPEUTIC DOSES.\nREPLETE LYTES AS NEEDED.\nCONTINUE ANTIBX THERAPY-WATCH FOR FEVER.\nSWITCH MODE TO PRESSURE SUPPORT THIS AM.\nCOMFORT FOR PT.DECREASE ANXIETY FOR PT.\nKEEP PT AND FAMILY AWARE OF PT CONDITION.\nCLOSELY ASSESS PT'S RESP STATUS. CONTINUE TO WEAN/EXERCISE -EXTUBATE ONCE MEDICALLY APPROPRIATE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-04 00:00:00.000",
"description": "Report",
"row_id": 1331636,
"text": "PRESSERS STILL REQUIRED, DOPAMINE AT 2 MIC,GOAL TO DC AND USE LEVOPHED WHICH IS .029 MICS.AFIB TO V PACED .CI > 2,SVR 1069. PAD 23.\n\n\nTOL CPAP TRIAL FOR SEVERAL HRS . ABG 7.43/33/118/23. BECAME TIRED C TV < 200, REQUIRED FIO2 TO 50 % ON AC .SX FOR TAN TO BLOOD TINGED .\n\nTF RESTARTED. SOFT BR NEG STOOL\n\nHUO 20 TO 60 ,PT POS AND EDEMATOUS\n\nALERT, FOLLOWS COMMANDS ,DENIES CP BUT IS DISCOURAGED\n\nAFEBRILE\n\nPLAN TO DC DOPAMINE, GO C LEVOPHED, BE STARTED ON DIG\nREST OVERNITE, WEAN IN AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-09 00:00:00.000",
"description": "Report",
"row_id": 1331647,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P BRADY/SEPSIS\n\nS- \" THANK YOU..\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT CURRENTLY WITH LOW NML BP- MAPS < 60 - 52-58 BY AUSC/CUFF.\nHR 60 PACED FOR THE MOST PART WITH SOME SR- 70'S. NO VEA.\nOF NOTE= PACER TURNED DOWN TO 60 ON DAYS AND PT LEFT WITH SUBSEQUENT BORDERLINE HYPOTENSION- 90/40 .\nGIVEN 250 NS X 3 DOSES FROM 12-4A.\nALSO WITH LOW BP/MAP , UO DECREASED TO 10CC/HOUR.\nNOT MUCH IMPROVEMENT IN EITHER UO OR MAPS,\nTEAM AWARE.\nPT TOTALLY ALERT AND MENTATING WITH LOWER BP.\nTO CALL EP TODAY TO INCREASE PACER RATE.\n\nRESP- BASE DIM- O2 SATS- MID 90'S ON 2 L NP.\nAPPEARS COMFORTABLE.\nNO ISSUES CURRENTLY.\nDIURESED ON DAYS- I/O - 1700CC ON DAYS.\nNO DISTRESS.\n\nID- AFEBRILE- REMAINS ON VANCO/CEFTRIAX.\n\nGU- SEE ABOVE- UO- 10/HOUR\nAM LYTES/CREAT/BUN PENDING.\n\nGI- TAKING SMALL AMT DINNER/FOOD.SMALL SOFT STOOL G (-)\nASKED FOR BEDPAN\n\nMS- VERY ALERT AND ORIENTED- SLEEPING WELL THIS SHIFT.\nVERY TIRED.\nBEDREST THIS SHIFT.\n\nSOCIAL - FAMILY CALLED THIS EVE TO CHECK IN .\n\nA/ PT S/P LONG COURSE OF PRESSOR/VENT SUPPORT FOR HYPOTENSION/SEPSIS/BRADYCARDIA- CURRENTLY WITH SOME HYPOTENSION ON LOWER PACER RATE AND S/P DIURESIS.\n\n\nDISCUSS MORE FLUID? PRESSOR FOR BP/UO.\nAWAIT AM CHEMISTRIES.\nKEEP HEP AT THERAPEUTIC AM PTT.\nCALL EP FOR ? INCREASE PACER RATE AGAIN FOR ASSIST IMPROVING HEMODYNAMICS.\nCONTINUE ANTIBX AS ORDERED UNTIL COURSE IS OVER.\nNPO AFTER MN FOR POSSIBLE PICC LINE.\nCONTINUE TO INCREASE ACTIVITY/REHAB AS PT TOLERATES WITH PT.\nCOMFORT/SUPPORT.\nC/O TO FLOOR ONCE BP/UO IMPROVED AND ONCE INTRODUCER D/C AND PICC LINE IN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-09 00:00:00.000",
"description": "Report",
"row_id": 1331648,
"text": "CCU NPN 7A-7P\nNeuro: Alert & oriented x 3, HOH. C/O L shoulder pain w/ movement. treated w/ tylenol and hot packs w/ good effect\n\nCV: Tele-Afib this morning, HR 90s-120s. External pacer in L SC, C/D/I. Pacer rate increased from 60 to 80, now 100% Vpaced @ 80. BP 100s-120s/30s-60s, MAPs 60-70s, no significant increase in BP w/ pacing. Double lumen PICC line placed under IR in R brachial, TLC d/c from neck. Heparin gtt restarted @700u/hr, last PTT 79.1, no changes. Recheck @2230. Palp DP/PT pulses. K 3.9, repleted w/ 20mEq KCl.\n\nPulm: LS CTA but diminished at the bases. Coughing up sm amt yellowish sputum, using IS Q1-2 hrs. Sats 95-98% on 2L NC.\n\nGI/GU: +BS, abd. soft, non-tender. Loose BM x 2, guiac neg. Tol sm amt POs w/o difficulty. Creat 1.3, HUO 15-120/hr, +785cc today. HO aware, may give lasix later this evening if U/O remains low.\n\nID: Afebrile, cont on for more day, last doses of ceftriaxone and vancomycin tomorrow at 0400. Blood cultures to be drawn after , have permanent pacer placed on Monday if negative.\n\nHeme: S/P 2uPRBC, Hct 29.3 today, no transfusion.\n\nSocial: Pt's 2 daughters present throughout day. Updated by RN and team.\n\nPlan: C/O to tele floor, waiting for bed. Cont to enc po intake, monitor u/o, give lasix as necessary. D/C after tomorrow morning's dose, draw cultures, pacer Monday. Start coumadin after pacer placement. D/C to rehab when stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-01 00:00:00.000",
"description": "Report",
"row_id": 1331622,
"text": "Respiratory Care:\nPt. remained on CMV all noc rarely over breathing. Vent settings:\nA/C 500 14/14 40% 5peep. ABG's = 7.43 33 121 23 0 slight\nrespiratory alkalosis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-01 00:00:00.000",
"description": "Report",
"row_id": 1331623,
"text": "CCU NURSING PROGRESS NOTE\n83 yr old woman experienced syncopal episode with LOC. In EW experienced hypotensive episode received 1L NS accompanied with a # of episodes of SB. Received Atropine X3, dopa and levo gtt started. ETT to CCU for temporary pacemaker wire placement.\n\nS: Intubated\n\nO: Neuro: Pt off all sedation. Has order for Ativan prn for any apparent discomfort. Last dose given last shift. Easily aroused by voice. Follows simple commands appropriately (opens eyes, squeezes hands and wiggles toes). Not much purposeful movement of extremeties in bed. Continues on Valpoic acid. No seizure activity noted. Denies any pain.\n\nCV: Vpaced. Temporary pacer wire remains in place. VSS. HR 87-120. ABP 97-130/47-63. Experienced single episode of hypertension and converted to underlying rhythm of Afib returned to on own. Became hypotensive with position changes and coughing/suctioning. Resolved without intervention. Dopamine gtt unsuccessfully weaned and remains unchanged at 8.0 mcg. Levo weaned from 0.078 to 0.053. Started on heparin yesterday for underlying Afib. AM PTT >110 heparin decreased to 800u. Repeat PTT 87.9 (therapeutic). Heparin on hold at 1500 until all lines are changed by the team. AM HCT 26.8. Given 1UPRBC's completed at 1400. K+ 3.4 repleted with 4meq KCL. Posttransfusion HCT and K+ sent. Palpable pulses bilaterally.\n\nResp: ETT. Current Mode of Ventilation AC 40% Fio2/ Vt 500/ RR 14 with a peep of 5. Overbreathing the vent by 1-4 breaths. O2 sats 100%. Suctioned scant to moderate amounts of white to yellow secretions. Chest pt performed with some effect. Rhoncerous lung sounds.\n\nId: Spiked yesterday. Tmax today 99.8 post transfusion. Remains on abx regimen of Vanco, Flagyl and Levofloxacin. Id consult today. Resent cultures of Aline, Triple Lumen and sputum. Unsuccessfully recultured pacing wire transducer. No stool this shift therfore unable to send Cdiff specimen. WBC 16.3\n\nGI/GU: TF. Promote with Fiber at goal of 50 cc/hr. Minimal residuals. Confirmed placement by auscultation. + BS. No BM this shift. Rectal bag in place. (Loose stool last night) Foley catheter patent. Draining 40 CC+ yellow urine. No diuresis this shift. +695/24hrs and + 11 Liters for LOS. BUN/ CR 48/1.3.\n\nENDO: BS 150 - 200. Covered with 4-10 u RISS. Insulin gtt to be started this evening if necessary.\n\nACCESS: L radial aline, L triple lumen and pacing wire transducer due to be changed by the team per ID request.\n\nSkin: No breakdown noted. Third spacing edema present in upper extremeties. Some weeping observed. Remain elevated with minimal effect.\n\nSOCIAL: Daughters remain at bedside. Asking appropriate questions answered by MDs and RN. Very involved with pt's care.\n\nA/P: VSS except with changes in position. Unable to wean off pressors. More alert today, following simple commands. Neuro concluded that pt status is improving. ID recommending that all lines be recultured and changed to identify and eliminate infection source. Continue to wean pt from pressors as tolerated. Restart\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-01 00:00:00.000",
"description": "Report",
"row_id": 1331624,
"text": "CCU NURSING PROGRESS NOTE\n(Continued)\n Heparin for AFIB once central/ arterial lines are changed. Continue aggressive antibiotic treatment. Ordered for additional dose of Vancomycin awaiting its arrival from pharmacy. Follow HCT and electrolytes. Replete as needed. Continue to support patient and family as indicated\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-01 00:00:00.000",
"description": "Report",
"row_id": 1331625,
"text": "Pt remains mechanically vented: A/C 500 14 40% 5peep. No new abg's drawn, Sat's remain 99-100%. Comfortable day, no distress noted. View flowsheet for further info.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-03 00:00:00.000",
"description": "Report",
"row_id": 1331631,
"text": "NURSING\nNUERO--AROUSABLE WITH STIMULATION.+EXT MVT X4 FINE MVT ONLY TO SPECEFIC COMMANDS X4 EXT.NO GROSS MVT ONLY ON BED VERY FINE.PERRLA BRISK.+REFLEXES.ATIVAN 1MG X1 PRN > RESP RATE.NO RESTRAINTS IN USE.\nCV----100% VPACED MA3 SENS2 UNTIL 0300 PT INTO AF RAPID RESPONSE POST BATH.CCU STAFF DR INFORMED STATES \"WE WONT TREAT UNLESS MAJOR DROP IN DP\"LEVOPHED > TO 0.078MCG/KG/MN AND DOPA <TO3MCG/KG/MN TO ATTEMPT TO < HR.HR 110'S TO LOW 120'S.+PULSES X4 EXT.AFEBRILE.R IJ EXT PACER SITE NEGATIVE.+2 GENERAL EDEMA PITTING WITH OOZING FROM LINE SITES\nRESP---CPAP 50% PS +15 PEEP 5 UNTIL 0200 THEN BACK TO RATE AC/14/50%/PEEP5 FOR RESP RATE 30'S AND TV DEOP TO 200-300'S.+ AIR EXCHANGE ALL LO9BES ADVANED ET TUBE FROM 22>24 AT THE LIP PER CCU ORDERS.ETS FOR SM TO MOD TAN TO LIGHT BLOODY.> ORAL SECRETIONS CLEAR\nGI---TO OFF AT 0000 OER ORDERS.TOL WELL.ABD DIST +BS X4.SM LIQ BM\nGU---ADEQUATE OUTPUT ,NEGATIVE FOR THIS SHIFT.>30CC QHR WITH SEDIMANT.\nSKIN---PALE AND INTACT.WULT OOZING SITES.NO BREAKDOWN.DIGITS SLIGHTLY MOTTLED.\nCARE---COMPLETE BATH 0200.SKIN INTACT.\nTURN AND POSITION Q2.FRQ ORAL AND ET CARE R/T > SECRETIONS.RETAPE ET TUBE AND POSITION CHANGED.COMPRESSION HOSE REMOVED 1HR.\nPLAN----CT HEAD/ABD TODAY.TEE THIS AM OFF PTT 85 THIS AM TO D/C 0600 PER CCU FOR TEE.\nDRIPS...LEVO TITRATED FOR SBP > 100 AND MAP >65 EFFECTIVE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-03 00:00:00.000",
"description": "Report",
"row_id": 1331632,
"text": "CCU NPN\nCV: patient in paced rhythm for most of the day. To the EP lab to have her temp pacing wire changed. New wire placed in L subclavian, screwdown lead. VVI at rate of 90. CXR after placement. In af during the procedure. Heomodynamically stable. MAP < 65. Returned from lab in AF, then back in paced rhythm. Swan placed in RIJ PAD 20-25. CVP 15. TEE done which was normal with no vegatation and normal EF. Dopa to be left at 2 mcgs/kg/min and Levophed to be weaned as tolerated currently at .068mcgs/kg/min.\n\nResp: Vent settings unchanged while patient undergoing mutilpe procedures and receiving sedation. Continues to be suctioned for moderate amount of tan sputum.\n\nNeuro: Patient is sleepy but arousable. Responding appropriately to verbal commands. Very sleepy post procedure.\n\nGI: Patient is NPO for testing. Abdomen is distended but soft. Bowel sounds are present. HCT after PRBC's is 33 this am. Pm HCT pending.\n\nID: Patient is afebrile today. Cultures pending. Temp wire changed.\nScheduled to go to CT scan for ABD and Head CT.\n\nGU: I & O is + 350. Foley continues to drain clear yellow urine.\n\nPlan: Check ABG's this afternoon and attempt wean if patient is more awake. Check HCT. Continue to wean Levophed as BP tolerates. Resume Tube feedings after CT scan. Check cultures. Question restart Heparin.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-06 00:00:00.000",
"description": "Report",
"row_id": 1331642,
"text": "CCU NPN 1500-1900\nneuro: alert and oriented x2, cooperative, following commands, MAE\ncv: hemodynamically stable off levophed w/ bp 105-115/50-60, hr 90 v paced no a fib. cont on heparin 800u/hr. PAD 14-16\nresp: SATS 97-99% on 40% cool neb, rr 16-22, unlabored, strong cough\ngu: continues to make >100cc urine/hr, currently ~ 1l neg.\ngi: taking cl liqs w/o difficulty, will advance diet.\nid: afebrile\nskin: intact, 3+ edema,\nsocial: daughter in to visit\nA: sucessful extubation, hemodynamically stable of levophed\nP: monitor resp status, follow hemodynamics, monitor i/o, increase diet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-02 00:00:00.000",
"description": "Report",
"row_id": 1331626,
"text": "7p-7a Nursing Note:\n\nNeuro: Pt alert at times, obeys commands. Not MAE. Pt has PRN ativan order for sedation. During TLC insertion, pt medicated with 2mg IV ativan x3, total of 6mg. Pt temporally hypotensive with sedation. Family phoned last night, update given.\n\nPulm: Pt maintained on mech vent. CMV 14/40%/500/peep 5. Pt sxn'd for mod amt clear-white thick secreations. BS course-Rh, SPO2 98%.\n\nCV: Tele: Vpaced with temporary pacer wire via R IJ at 87. At 0400- pt overrided pacer, rhythm afib HR 110's with , MD aware. L ABP 90-110'/50-80's. Pt on IV levo @ .053mcg and IV dopa decreased to 6mcg/kg/min. Heparin gtt cont t/b off, will restart with am PTT level according to PTT protocol. L IJ TLC infiltrated and unable to use. L femoral TLC inserted for IV access. Pulses palpable.\n\nID: Pt afebril. On several abx, see .\n\nSkin: No breakdown noted, generalized edema noted throughout.\n\nGI/GU: Pt on TF @ 50cc/hr with minimal residual. TF off during line insertion and restarted at 0400. BS , pt not started on insulin gtt. Foley in place and draining amber color urine, 40cc/hr. Rectal pouch in place.\n\nPlan: Monitor VS, pulm and neuro status, Titrate pressors as tol. Monitor vent and sxn prn. Monitor pending am labs. Turn Q2hrs. Update family on plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-02 00:00:00.000",
"description": "Report",
"row_id": 1331627,
"text": "Respiratory Care:\nPt. has had a quiet noc. the doctors did replace a groin line. No\nABG's.. the O2 sat. = 100%. see Carevue for details.\nVentilator set @\nCMV 500cc x 14 40% and 5peep Ve = 7.0L\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-02 00:00:00.000",
"description": "Report",
"row_id": 1331628,
"text": "CCU NPN 7A-7P\nNeuro: Pt not requiring any sedation since last night. Opens eyes to voice, able squeeze hands and wiggle toes, unable to nod yes or no to answer questions. Not moving any , , +gag. Has PRN ativan order if needed.\n\nCV: Tele-Afib this AM w/ intermittent paced beats, HR 120s, converted completely to Vpacing @1230. Dopamine titrated down to 6mcg/min, [email protected]/min, unable to titrate pressors down more. Temp pacing wires in R IJ cordis, mA 3.0, sensitivity 2.0. Hep@900u/hr, PTT due at .\n\nPulm: LS coarse at times, diminished at bases. Sxn copious amt yellow blood tinged sputum this AM but have not been able to Sxn much sputum since. Changed from AC to PS 15 PEEP 5 FiO2 40% TV 500-600, tol well. RR 12-26, last ABG 7.36/41/120/24/-1. Cont to wean as tol.\n\nGI/GU: +BS, abd soft, distended this AM. Promote w/ fiber @50/hr, residual 85cc this AM. Reglan started, now has minimal residuals. Rectal bag on, sm amt stool in bag. U/O down to 15-25/hr for 4 hrs, received 20mg IV lasix w/ good effect. K repleted this morning, 4.5 this afternoon.\n\nID: Afebrile, no culture growth yet. Cont on flagyl/vanco, levo changed to ceftriaxone, waiting for ID approval.\n\nAccess: L radial Aline changed to L brachial Aline. TLC in L groin w/ sl ooze, now C/D/I. L TLC infiltrated, d/c.\n\nSkin: + pitting edema in all , LUE skin weeping.\n\nHeme: Hct 27.6, 2nd unit of PRBC infusing.\n\nSocial: 2 daughters in throughout day, updated by RN and team.\n\nEndo: Came in this AM, found 100u/100cc bag of regular insulin empty and piggybacked into KVO IVF. BS 71, gave total 2amps D50. BS now stable, 136@1800. To be covered by SSRI, no insulin gtt.\n\nPlan: NPO after MN for TEE to R/O SBE. To have temp wires changed to external box tomorrow, d/c heparin at 0600. To have total CT scan tomorrow if possible. Cont emotional support for pt and family. Cont to wean vent as tol. Recheck Hct, K, BS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-03 00:00:00.000",
"description": "Report",
"row_id": 1331629,
"text": "PT HR 110-130'S POST COMPLETE BATH.AND IV TUBING CHANGE OF DOPAMINE.SEPERATED DOPA AND LEVO GTTS.DR AWARE OF > HR STATES \"AS LONG AS PT MAINTAINS BP NO TREATMENT NEEDED FOR HR\" DOPA < 3MCG/KG/MN AND LEVOPHED > 6MCG/KG/MN TO ATTEMPT TO < HR.INFORMED CCU TEAM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-03 00:00:00.000",
"description": "Report",
"row_id": 1331630,
"text": "AMENDMENT TO NOTE LEVOPHED AT 0.078 MCG/KG/MN OR 8CC/HR\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-07 00:00:00.000",
"description": "Report",
"row_id": 1331643,
"text": "CCU progress note 7a-7p\nUneventful day. VSS.\n\nCARDIAC: Vpaced 90 w/ break-thru AFIB 90s-100s. EP to come in sometime today to assess underlying rhythm and ?decrease rate on pacer. Plan for permanent pacemaker insertion in future. HEPARIN gtt @ 800u, held since 4pm for line placement. Aline intact R radial. To have Swan in LIJ removed today. Temp pacer intact to LSC. Remains on Digoxin 0.125po qod. no c/o CP or discomfort.\n\nNEURO: alert and oriented x 3. calm. procedures explained to pt and family. emotional support given. MAE. gen weakness. PT in to work w/ patient. sat up on side of bed w/ support - very tired post sitting up.\n\nRESP: LS clear, dim to bases. poor air entry. congested occasionally productive cough, thick yellow/tan sputum. O2 2L n/c. sats 96%. no SOB. no resp distress.\n\nGI/GU/ENDO: foley patent. fair urine output, sediment noted. Lasix 80mg ivp given. abd soft. +BS. having small amts loose stool. taking po well. small amts regular diet. remains on FS BS 100-130s. on RISS.\n\nPLAN: con't to monitor vitals/resp status. PA line to be removed this evening. encourage DB+C, monitor u/o. plan for future perm pacer insertion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-08 00:00:00.000",
"description": "Report",
"row_id": 1331644,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P BRADY/SEPSIS\n\nS- \" I AM COLD\"\n\nSEE FLOWSHEET FOR OBJECTIVE DATA..\n\nCV= PT REMAINS HEMODYNAMICALLY STABLE OFF ALL PRESSORS.\nBP- 110-130/60'S WITH HR- 90 PACED- 100'S AFIB.\nREMAINS ON HEPARIN GTT 800- RESTART AFTER D/C PA LINE AND REPLACED WITH TLC VIA INTRODUCER.\nREMAINS ON DIG FOR RATE CONTROL AND TRANVENOUS PACER.\nAWAIT PERMANENT PLACEMENT OF PACER ? TODAY.\nNO ISSUES CURRENTLY.\n\nRESP- STRONG NONPRODUCTIVE COUGH.\n02 SATS > 96% ON 2 L NP.\n\nID- AFBRILE-\nREMAINS ON VANCO- PEAK/TROUGH SENT. AS WELL AS CEFTRIAXONE.\nALMOST AT END OF COURSE.\n\nGU- GOOD UO VIA FOLEY CATH- 60-100/HOUR .\n\nGI- TAKING MEDS OK- NEEDS EXTRA TIME/SUPPORT WITH DRINKING LIX WITH MEDS - SOME COUGHING.\nLOOSE STOOL G (-).\n\n PT ALERT/ORIENTED X 3- AWAKE- GIVEN SOME ATIVAN FOR LINE REPLACEMENT- SLEEPING CURRENTLY.\n\nA/ PT STABLE CURRENTLY S/P LONG COURSE OF RESP FX/PRESSORS FOR HYPOTENSION.\n\nPLAN FOR PERM PACER TODAY?\nCONTINUE INCREASE ACTIVITY WITH PT.\nHEPARIN WHILE IN/OUT AFIB.\nCONTINUE RATE CONTROL WITH DIG PO.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE.\nMONITOR CLOSELY FOR ANY S/SX FEVER/HYPOTENSION/HEMODYNAMIC ISSUES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-09-08 00:00:00.000",
"description": "Report",
"row_id": 1331645,
"text": "V PACED TO AFIB.BP STABLE.HEPARIN 800U /PTT 65.\n\nSAT 97 2LNP. BS CL TO DIMINISHED.\n\nE/D WELL . PROBLEM C .BS COVERED C SSRI . SOFT BR STOOL NEG\n\nDIURESED C 80 MG LASIX\n\nALERT/COOPERATIVE CO PAIN IN L ARM, EXAMINED BY HO, PAIN DIMINISHED THIS PM .STOOD C PT\n\nPERM PACER NEXT WEEK\nPICC BY IR ,NPO P MIDNOC\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-27 00:00:00.000",
"description": "Report",
"row_id": 1331608,
"text": "CCU progress note 7a-7p\nNEURO: remains sedated on PROPOFOL @ 20mcg/k/min. gimmaces to pain. PERLA 3mm.\n\nCV: 100% VPACED via temp wire in RIJ. remains on LEVO @ 0.1mcg/k/min and DOPA @ 10mcg/k/min. EP in to assess pacer since needed increase in MA from 4 to 10 to capture this evening. threshold is <.4MA, placed back on 3MA. wire advanced very slightly by EP. need CXR to confirm placement. pacer wires intact. palpable pulses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-27 00:00:00.000",
"description": "Report",
"row_id": 1331609,
"text": "RESP: AC 500x10 5 peep 40%. scant secretions. abg: 180/42/7.43/29/3. LS clear, dim.\n\nID: febrile today tmax 101.7. to be started on LEVO this evening. pan cultured last noc.\n\nGI/GU: foley patent. poor urine output during the day, given total of 1L NS fluid bolus w/ improvement. started in IVF D5.45NS@125cc/hr. abd soft. +BS. no BM. OGT intact. NPO x/ meds.\n\n\nPLAN: monitor neuros ?CT again in future. emotional support to family. monitor u/o, ?another fluid bolus later tonite if u/o drops. tylenol for temp. monitor Pacer + hemodynamics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-28 00:00:00.000",
"description": "Report",
"row_id": 1331610,
"text": "nursing progress note 7p-7a\nNEURO: SEDATED ON PROPOFOL GTT 10 MCG/KG/MIN. WILL OPEN EYES SPONTANEOUSLY. MOVES UPPER EXTREMITIES. REACHES FOR ETT AND LINES WHEN RESTRAINTS OFF. WRISTS RESTRAINTS ON TO PREVENT PULLING AT LINES. NO PURPOSEFUL MOVEMENT, DOES NOT FOLLOW COMMANDS.\n\nCV: REMAINS ON DOPA GTT AT 10 MCG/KG/MIN AND LEVO 0.1 MCG/KG/MIN. BP STABLE. SEE FLOWSHEET FOR VS. HR 80 VPACED NO VEA NOTED. PACER MA 3 SENSING AND CAPTURING APPROPRIATELY. EXTERNAL PADS ON.\n\nRESP: VENT SEE FLOWSHEET FOR VENT SETTINGS. SUCTIONING FOR THIN WHITE SPUTUM. THICK YELLOW ORAL AND NASAL SECRETIONS. LUNGS CLEAR.\n\nGI: OGT IN PLACE. CLAMPED EXCEPT FOR MEDS. HYPOACTIVE BOWEL SOUNDS.\n\nGU: U/O 25-40 CC/HR. IV D5 1/2 NS @ 75 CC/HR. URINE CLEAR YELLOW.\n\nSKIN INTACT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-28 00:00:00.000",
"description": "Report",
"row_id": 1331611,
"text": "Resp. Care Note\nPt remains intubated and vented on current settings AC 500x 10x 40% peep 5. No vent changes made this shift. pt transported to CT scan of head this afternoon without incident. Cont vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-28 00:00:00.000",
"description": "Report",
"row_id": 1331612,
"text": "CCU NPN 7am - 7pm\nS/O: Resp.: Vent settings remain unchanged. Pt. suctioned every 4 hours for small amounts of yellow thick secretions. O2 sats are 98 - 100%.\nCVS: Pt. is pacer dependent. Rate is 80, MA is 3. Occasional intrinsic beats noted. External pacer is on standby. Levo continues at .1 mcgs/kg/min. Dopamine continues at 10 mcgs/kg/min. Attempted to wean levo this morning and the pt.'s SBP dropped to 70's within 5 minutes. Levo was titrated up to .2 mcgs/kg/min. then back down to .1 mcgs/kg/min. Triple lumen placed in left IJ. Proximal port transduced and CVP is estimated at 25. Pedal pulses dopplerable\nNeuro: Pt. sedated on 20 mcgs of propofol. Opens eyes to sternal rub. Moving all extremities. PERRLA. Head CT done.\nG.I.: Promote with fiber started at 10cc/hr and advanced to 20 cc/hr. Residuals are less than 10 cc's. Bowel sounds present. HOB remains at 30 degrees.\nG.U.: U/O 15 - 60 cc/hr. creat. slightly high.\nA: s/p syncope/ arrest.\nP: assess neuro status, continue dopa, levo, wean if possible, may swan tomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-26 00:00:00.000",
"description": "Report",
"row_id": 1331606,
"text": "CCU NPN 9PM-11PM\nSee FHPA\n\nCV: Pt arrived from EW on Levo gtt at .175ug/kg/min, Dopa at 19ug/kg/min, BP 120's/60, HR 59 SB. New cortis placed over wire and temp pacing wire placed successfully under fluro. Rate set at 80, Ma at 4, good capture. CK's to be cycled. K+ 5.3 grossly hemolyzed. Weaning pressors as tolerated.\n\nResp: on vent, AC, 50% 600x 16 5 PEEP. LS clear. ABG on vent in ew: 170/43/7.41/28/2\n\nNeuro: sedated on propofol, grimaces with care. PERL, sluggish, Moves all ext.\n\nID: afebrile. WBC 10. Urine C&S sent.\n\nSoc: 2 daughters, involved, lives with , susans # in chart. Both in this eve, went home for the night.\n\nA/P: 83 yr old admitted after syncopal episode, now with bradycardia, hypotension requiring pressors and placement of temp wire. To be ruled out for MI, monitored in CCU.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-27 00:00:00.000",
"description": "Report",
"row_id": 1331607,
"text": "CCU NSG PROGRESS NOTE 11P-7A/ S/P BRADY ARREST\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE ON LEVO/DOPA.\nREMAINS AT 10 MCG DOPA- VERY SLOWLY DECREASING LEVO GTT IN 0.05 MCG/KG INCREMENTS- CURRENTLY TOLERATING.\nHR- 80 V PACED- (+) SENSITIVITY/(+) CAPTURING- NO ISSUES WITH TEMP WIRE.\nCPK'S (-)- CURRENTLY R/O- NO SIGN OF ISCHEMIA.\n\n PT ON 50/600/16 - PH CHECKED WITH AM LABS- 7.67- RATE DECREASED RATE TO 12 AND PH- 7.60- JUST DECREASED TV TO 500 AND RATE TO 10. TO RECHECK ABG THIS AM.\nSUCTIONED FOR MINIMAL THIN WHITE SECRETIONS.\nCLEAR LUNG.\nO2 SATS 99%.\n\nID- TEMP SPIKE TO 101.6- TYLENOL X 2 DOSES. PAN CULTURED- TO ? START LEVOFLOXACIN THIS AM.\nINITIAL RESP CULTURE GM (+) COCCI.\n\nGU- FAIR TO POOR UO- 20-30/HOUR.\n\nGI- NPO- OG TUBE IN PLACE-\nMEDS VIA TUBE- NO STOOL (+) BOWEL SOUNDS.\n\n PT ON PROPOFOL GTT.\nDIFFICULT TO AROUSE CURRENTLY. PEERL. RESPOND TO PAIN.\nSEE FLOWSHEET FOR DETAILS.\n(+) MOVING ALL EXTREMITIES WITH SL AGITATION/DISTRESS.\n\nSOCIAL- DAUGHTER CALLED TO CHECK IN.INFORMED AS TO CURRENT STATUS.\n\nA/ PT ADMITTED TO CCU S/P BRADY/HYPOTENSION ARREST\nCURRENTLY HEMODYNAMICALLY STABLE ON PRESSORS X 2 AND MAINTAINING PATENT AIRWAY ON VENT SUPPORT\nFEVER- AWAIT CULTURES RESULTS AND ? START OF ANTIBX.\nKEEP FAMILY AWARE OF PLAN OF CARE.\n? WEAN OFF VENT AS MENTAL/NEURO STATUS ALLOWS\nSLOW WEAN OF LEVO GTT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-29 00:00:00.000",
"description": "Report",
"row_id": 1331613,
"text": "NPN\nCCU\n7 PM - 7 AM\nBRADYCARDIA/HYPOTENSION\nS/O SEDATED/INTUBATED\nPLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nID T MAX 100 R ..AM WBC'S PNDG...VANCO/LEVOQUIN/FLAGYL CONTINUE\nCV TVP WIRE IN PLACE .. CAPTURING/SENSING APPROPRIATLEY...RATE OF 80..MA 3 ..EXTERNAL PADS ON STANDBY....RARE INTRINIC BEAT SEEN\nRESP AC MODE/ RATE OF 10..MINIMAL OVERBREATING SEEN...40% FIO2....5 PEEP...LUNGS DIMINISHED AT THE BASES ..MINIMAL ETT SXNS...THICK YELLOW DRAINAGE FROM NARES ....\nNEURO FACIAL GRIMACING WITH ETT/NASAL SUCTIONING ..TURNING HEAD AWAY FROM NOXIOUS STIMLUI..AM DEPAKOTE PNDG\nGI PROMOTE AT 80 CC/HR ( GOAL ) ....MINIMAL ASPIRATES ..NO STOOL\nLEFT IJ CENTRAL LINE PORTS FLUSHED\nTURNED Q3 ....\nA PACER/PRESSOR DEPENDENT\n? SWAN IN AM\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-29 00:00:00.000",
"description": "Report",
"row_id": 1331614,
"text": "Respiratory Care:\nPt. remains on A/C settings. ABG's well oxygenated with a fully compensated metabolic acidosis. Pt. continues to be febrile, with increased WBC count. Remains pressor dependent, and V-paced. Currently, well sedated and synchronous with mechanical ventilation. ? swan ;ine placement, and/or ABD. CT for ? source of fevers. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-29 00:00:00.000",
"description": "Report",
"row_id": 1331615,
"text": "RESP. CARE NOTE\nPT REMAINS INTUBATED AND VENTED ON SETTINGS AC 500X 10X 40% PEEP 5. NO VENT CHANGES MADE THIS SHIFT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-08-29 00:00:00.000",
"description": "Report",
"row_id": 1331616,
"text": "CCU NPN 7am - 7pm\nS/O: Resp.: Pt. remains intubated and sedated. Vent settings are unchanged. Suctioned for small amounts of yellow thick sputum via ETT and yellow secretions via left nare Q 4 hours. Overbreathing vent at a RR of 14 - 26. Lungs are clear.\nCVS: Dopamine is at 15 mcgs/kg/min. weaned from 20mcgs/kg. Levophed remains at .1mcg/kg/min. BP range from 80 - 120/40 - 50. Pt. remains completely pacer dependent with very rare intrinsic beats. Pacer rate is set at 80 and MA is at 3. Pacer site is dry and intact. Echo done today.\nG.U.: U/O very poor 15 - 20cc/hr. Pt. was given a 500cc NS bolus x2 without any improvement in u/o. creat. 1.6. Presently pt. is approx. 8 L positive length of stay.\nG.I.: Abd. distended and firmer than yesterday. no stool. KUB done and pending. At 5 pm tube feedings were put on hold for residuals of greater than 180.\nHeme: HCT 29\nNeuro: Pt. remains on propofol at 30mcgs/kg/min. Pt. is well sedated. Pupils are reactive to light. Grimaces to painful stimuli. gag and cough are weak. EEG done today results are pending.\nA: pacer dependent, pressor dependent\nP: attempt to wean pressors as tolerated, check labs drawn at 6 pm, check EEG and KUB results, monitor HR and pacer, propofol for sedation, follow temp., Tylenol prn.\n"
},
{
"category": "Echo",
"chartdate": "2145-09-03 00:00:00.000",
"description": "Report",
"row_id": 103458,
"text": "PATIENT/TEST INFORMATION:\nIndication: R/o endocarditis.\nBP (mm Hg): 130/80\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 09:57\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n0.2 mg of iv glycopyrrolate was given as an antisialagogue prior to TEE probe\ninsertion.\nLEFT ATRIUM: The left atrium is dilated. Moderate to severe spontaneous echo\ncontrast is seen in the body of the left atrium. Moderate to severe\nspontaneous echo contrast is present in the left atrial appendage. No thrombus\nis seen in the left atrial appendage.\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: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and systolic function (LVEF>55%).\n\nAORTA: There are complex (>4mm or mobile) atheroma in the descending thoracic\naorta.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. No masses or\nvegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is\nseen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. No mass or\nvegetation is seen on the mitral valve. There is moderate mitral annular\ncalcification. There is mild thickening of the mitral valve chordae. Mild (1+)\nmitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. There is\nno mass or vegetation detected on the tricuspid valve. Mild tricuspid [1+]\nregurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). Local anesthesia was provided by\nlidocaine spray. There were no TEE related complications. The patient is in a\nventricularly paced rhythm. The cardiology fellow involved with the patient's\ncare was notified by telephone. The results were personally reviewed with the\nphysician caring for the patient. The echocardiographic results were reviewed\nwith the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is dilated. Moderate to severe spontaneous echo contrast is\nseen in the body of the left atrium and left atrial appendage without evidence\nof thrombus. The right atrium is dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and systolic function\n(LVEF>55%). There are complex (>4mm or mobile) atheroma in the descending\nthoracic aorta. The aortic valve leaflets are moderately thickened without\nevidence of vegations. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened without evidence of vegetation. Mild (1+)\nmitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. There is no pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2145-08-31 00:00:00.000",
"description": "Report",
"row_id": 103459,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 130\nBSA (m2): 1.61 m2\nBP (mm Hg): 135/65\nStatus: Inpatient\nDate/Time: at 14:33\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 mildly 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. No atrial\nseptal defect is seen by 2D or color Doppler.\n\nLEFT VENTRICLE: There is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity is unusually small. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. The ascending aorta is normal in diameter. There are focal\ncalcifications in the ascending aorta.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are mildly thickened. There is a minimally increased\ngradient consistent with minimal aortic valve stenosis. Mild (1+) aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are moderately thickened. There is no\nmitral valve prolapse. There is severe mitral annular calcification. There is\nmoderate thickening of the mitral valve chordae. The tips of the papillary\nmuscles are calcified. There is no significant mitral stenosis. Mild (1+)\nmitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. There is\nno triscupid stenosis. Mild to moderate [+] tricuspid regurgitation is\nseen. There is borderline pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen. There is\nmild pulmonic valve stenosis.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\npatient is in a ventricularly paced rhythm.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is dilated. No atrial\nseptal defect is seen by 2D or color Doppler. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity is unusually small. Due\nto suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. Overall left ventricular systolic function appears normal\n(LVEF>55%), possibly hyperdynamic. Right ventricular chamber size and free\nwall motion are normal. The number of aortic valve leaflets cannot be\ndetermined. The aortic valve leaflets are mildly thickened and display\nsomewhat reduced mobility and excursion. There is a minimally increased\ngradient consistent with minimal aortic valve stenosis. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nThere is no mitral valve prolapse. There is severe mitral annular\ncalcification. There is moderate thickening of the mitral valve chordae. Mild\n(1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The tricuspid valve\nleaflets are mildly thickened. The supporting structures of the tricuspid\nvalve are thickened/fibrotic. There is borderline pulmonary artery systolic\nhypertension. There is mild pulmonic valve stenosis. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2145-08-29 00:00:00.000",
"description": "Report",
"row_id": 103460,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Hypotension.\nBP (mm Hg): 105/60\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 13:45\nTest: Portable TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses and cavity size are normal.\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated. Right ventricular\nsystolic function is normal.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened. Significant\naortic regurgitation is present, but cannot be quantified.\n\nTRICUSPID VALVE: Tricuspid regurgitation is present but cannot be quantified.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. Views are\ninadequate for assessment of systolic function. The right ventricular cavity\nis dilated. Right ventricular systolic function is normal. The aortic valve\nleaflets are mildly thickened. Significant aortic regurgitation is present\n(?mild) - but cannot be quantified. No significant pericardial effusion is\nseen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2145-09-16 00:00:00.000",
"description": "Report",
"row_id": 312659,
"text": "Taken with magnet\nA-V sequential pacing\nSince previous tracing, same date A-V pacing\n\n"
},
{
"category": "ECG",
"chartdate": "2145-09-16 00:00:00.000",
"description": "Report",
"row_id": 312660,
"text": "Taken without magnet\nVentricular paing with A-V sequential pacing last three complexes\nSince previous tracing, fully paced\n\n"
},
{
"category": "ECG",
"chartdate": "2145-09-14 00:00:00.000",
"description": "Report",
"row_id": 312661,
"text": "Taken with magnet\nPaced beats on first three complexes\nShort PR interval\nIncomplete right bundle branch block\nLateral ST-T changes are nonspecific\nLow QRS voltages in precordial leads\nSince previous tracing, same date pacer activity seen\n\n"
},
{
"category": "ECG",
"chartdate": "2145-09-14 00:00:00.000",
"description": "Report",
"row_id": 312662,
"text": "Taken without magnet\nSinus rhythm\nShort PR interval\nIncomplete right bundle branch block\nNonspecific lateral ST-T changes\nLow QRS voltages in precordial leads\nSince previous tracing, atrial fibrillation absent\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-31 00:00:00.000",
"description": "Report",
"row_id": 312881,
"text": "Atrial fibrillation with a relatively rapid ventricular response. Relatively\nlow limb lead and precordial voltage. Complete right bundle-branch block\nfollowed by inferior myocardial infarction. Non-specific ST-T wave changes\nconsistent with ischemia, post-pacemaker T wave changes, etc. Q-T interval\nprolongation. Compared to the previous tracing of ventriculiar pacing\nis no longer seen and atrial fibrillation is now present, with the other\nfindings as previously resportedn. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-31 00:00:00.000",
"description": "Report",
"row_id": 312882,
"text": "Ventricular pacing at a rate of about 90 per minute, with apparent retrograde\nP waves in the ST segments. Compared to the previous tracing of the\npacing rate is faster. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-29 00:00:00.000",
"description": "Report",
"row_id": 312883,
"text": "Ventricular pacing at a rate of 80 beats per minute with probable\nV-A conduction with an apparent retrograde P wave in the ST segments. Compared\nto the previous tracing of this finding is new with the previous\ntracing showing sinus rhythm, with other abnormalities as reported.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-26 00:00:00.000",
"description": "Report",
"row_id": 312884,
"text": "Sinus rhythm\nConduction defect of RBBB type\nProlonged QT-c\nNondiagnostic ST-T wave changes\nSince previous tracing, QT-c appears more prolonged and lateral T wave changes\nare more pronounced\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2145-08-26 00:00:00.000",
"description": "Report",
"row_id": 312885,
"text": "Sinus rhythm\nRight bundle branch block\nNondiagnostic ST-T abnormalities\nProlonged QT-c\nSince previous tracing, right bundle branch block noted\n\n"
},
{
"category": "ECG",
"chartdate": "2145-09-04 00:00:00.000",
"description": "Report",
"row_id": 312879,
"text": "Atrial fibrillation with an average ventricular response rate 127. Since the\nprevious tracing of no pacing beats are seen. No other comparison can\nbe made.\n\n"
},
{
"category": "ECG",
"chartdate": "2145-09-01 00:00:00.000",
"description": "Report",
"row_id": 312880,
"text": "Ventricular paced rhythm there may be ventricular atrial conduction or atrial\nfibrillation\nSince previous tracing, now ventricular paced\nClinical correlation is suggested\n\n"
}
] |
|
84,544 | 172,344 | HOSPITAL COURSE This is a 63-year old female w a history of congenital heart defects (s/p repair primum atrial septal defect, cleft mitral valve with an endocardial cushion defect), a/w worsening severe pHTN, hospital course c/b CCU stay for prolonged QT torsades and VT/VF arrest s/p pacemaker placement, diuresed with follow-up echocardiography demonstrating improved PA pressures. . ACTIVE # Pulmonary hypertension: Patient was admitted with worsening SOB and a TTE demonstrated pHTN. A R heart cath demonstrated PA pressures of 113/23, PCW 30 with V waves up to 60, moderately responsive to supplemental O2. Given elevated wedge with large V waves, there was the question of mitral valve disease versus L heart disease versus worsening primary process as the driving process for this worsening pHTN (prior TTE in had estimated pulm pressures in 30s). Patient was aggresively diuresed with torsemide and spironolactone. TEE did not demonstrate evidence of severe mitral valve disease, suggesting that large v waves were artifact. After diuresis of ~10kg, repeat TTE estimated PA systolic pressures in the low 40s, suggesting that exacerbation of pHTN was to L sided failure. Patient was discharged on lasix and spironolactone, with set-up for home O2. . # Torsades and VT/VF arrest: Patient developed torsades leading to VT/VF arrest on floor on . She had ROSC after ACLS. EP was consulted who felt that a rate related prolonged QT was responsible. A single chamber pacemaker was placed on with normalization of the QT. She was started on PO magnesium and metoprolol for treatment of persistant ectopy. . # ARF: During diuresis, Cr rose to 1.6 (baseline 0.9). Metformin was held. Diuresis was slowed and at discharge Cr was 1.4. Patient was instructed to discuss resuming metformin at future PCP . . #DM: Patient was continued on SS humalog, acarbose, glyburide, metformin, and pioglitazone, with holding of oral hyperglycemics in the setting of the cath and restarting afterwards. Home januvia was nonformulary and restarted at discharge. . #GI Bleed: Patient had a single episode of blood emesis in the setting of her torsades episode. She was started on PPI. At future outpatient follow-up, the patient could be evaluated for stopping this medication. . # Afib: Patient's coumadin regimen was continued, but patient's INR became subtherapeutic late in the admission. With consultation from the coumadin clinic, her coumadin was increased to 5mg daily and she was bridged with lovenox. She discharged with script for lovenox and instructed to have her INR checked by her VNA on and faxed to the coumadin clinic. . INACTIVE #HLD: Patient was continued on home simvastatin. . #HTN: The patient was continued on home lisinopril . #h/o atypical lobular hyperplasia: Patient was continued on home tamoxifen. . #Chronic Lymphedema: Patient was continued on home ultram. . TRANSITIONAL 1. Code status: Patient remained full code for the duration of this admission 2. Pending: No labs pending at time of discharge 3. Transition of Care: Details of this admission were discussed with PCP. was given follow-up appointments with PCP, , Pulmonary, and Device Clinic. Patient was arranged to have VNA and home O2. | Mild (1+) mitral regurgitationis seen. There is moderate pulmonary artery systolichypertension.IMPRESSION: Trivial mitral stenosis. Abnormal septal motion/position consistent with RV pressure/volumeoverload.AORTA: Normal aortic diameter at the sinus level. Moderate PAsystolic hypertension.Conclusions:There is mild symmetric left ventricular hypertrophy. Mild mitral regurgitation. No AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. No AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting bradycardia (HR<60bpm).Conclusions:The left atrium is moderately dilated. Moderatetricuspid regurgitation. Atrial fibrillation with a slow ventricular response. Atrial fibrillation with a slow ventricular response. The right atrialappendage ejection velocity is depressed (<0.2m/s). Normal ascending aortadiameter. Mild to moderate (+) mitral regurgitationis seen. Moderate pulmonary artery systolic hypertension. The tricuspid valve leaflets are mildlythickened. Atrial fibrillation with slow ventricular response. Noaortic regurgitation is seen. No MVP.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal aortic arch diameter. The right ventricular cavity is moderately dilated withdepressed free wall contractility. There is nomitral valve prolapse. The left atrial appendage emptying velocityis depressed (<0.2m/s). Mild spontaneous echo contrast in the LAA.Depressed LAA emptying velocity (<0.2m/s)RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast or thrombus inthe body of the RA or RAA. Normal interatrial septum. No thrombus/mass in the body of the LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Moderate [2+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Simple aortic atheroma in the arch and descending thoracic aorta. Minimally increasedgradient consistent with trivial MS. The mitral valve leaflets are moderatelythickened. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mildspontaneous echo contrast without thrombus in the left atrium and left atrialappendage. Mild thickening ofmitral valve chordae. Moderate baseline artifact in leads V4-V6. The right ventricular freewall is hypertrophied. ]TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The tricuspid valve leaflets are mildly thickened with moderate [2+]tricuspid regurgitation. ?degree of mitral regurgitation.Height: (in) 67Weight (lb): 185BSA (m2): 1.96 m2BP (mm Hg): 127/48HR (bpm): 72Status: InpatientDate/Time: at 10:00Test: TEE (Congenital)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:The GE junction was not crossed.LEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. There is moderatepulmonary artery systolic hypertension.Compared with the findings of the prior study (images reviewed) of , the apparent pulmonary artery pressure is significantly reduced. The tricuspid valve leaflets are mildly thickened.Moderate-to-severe [3+] tricuspid regurgitation is seen. A catheter or pacing wire is seen in the RA.Depressed RAA ejection velocity (<0.2m/s). The right atrium is moderately dilated. Moderately dilated RV cavity. No 2D or Doppler evidence of distalarch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There issevere pulmonary artery systolic hypertension. Nomass/thrombus in the LAA. There is mild functional mitralstenosis (mean gradient 6 mmHg) due to mitral annular calcification versusannular ring from prior repair. Mild to moderate (+)MR. [Due to acoustic shadowing, the severity of MR may be significantlyUNDERestimated. Moderate to severe [3+] tricuspid regurgitation is seen. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolicfunction (LVEF>55%). There is abnormal septal motion/positionconsistent with right ventricular pressure/volume overload. The left ventricularcavity size is normal. Clinical correlation is suggested.Compared to tracing #1 no change.TRACING #2 Incomplete right bundle-branch block.Anteroseptal ST-T wave changes may be due to myocardial ischemia. No ASDby 2D or color Doppler.AORTA: Simple atheroma in aortic arch. please assess pulmonary htnHeight: (in) 67Weight (lb): 200BSA (m2): 2.02 m2BP (mm Hg): 136/80HR (bpm): 45Status: OutpatientDate/Time: at 11:00Test: TTE (Congenital, complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Moderate LA enlargement. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , the RV appearsenlarged with evidence of pressure/volume overload. PATIENT/TEST INFORMATION:Indication: Focused study for pulmonary artery pressures s/p extensive diuresisHeight: (in) 67Weight (lb): 179BSA (m2): 1.93 m2BP (mm Hg): 112/45HR (bpm): 70Status: InpatientDate/Time: at 14:57Test: TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.LEFT VENTRICLE: Mild symmetric LVH. Moderate tosevere [3+] TR. There appears to be a ventricular pacer artifact in leads V4-V6. Prolonged Q-T interval.Left axis deviation. The aortic valveleaflets (3) are mildly thickened. The aortic valveleaflets (3) are mildly thickened. The mitralvalve leaflets are moderately thickened and there appears to be prostheticmaterial in the mitral valve annulus consistent prior surgery. Normal tricuspidvalve supporting structures. Normal LV cavity size. Moderate to severe [3+] TR. [Due to acoustic shadowing, the severity of mitral regurgitation maybe significantly UNDERestimated.] No VSD.RIGHT VENTRICLE: RV hypertrophy. Probable prolongedQ-T interval, although difficult to determine the end of the T wave segment inthe limb leads. Non-specific T wavechanges. Atria seem to be in atrialfibrillation. Incomplete right bundle-branch block.ST-T wave changes in the anterior precordial leads may be due to ischemia.Clinical correlation is suggested. There is a 3 mmHg mean gradient across the mitral valve, with an estimated valve area of 2.3cm2, consistent with trivial mitral stenosis. Leftventricular hypertrophy. There is mild symmetric leftventricular hypertrophy with normal cavity size and global systolic function(LVEF>55%). Severe PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Incomplete right bundle-branch block. ProlongedQ-T interval. Overall left ventricular systolic function is normal(LVEF 75%). Compared to tracing #1 no diagnostic interim change.TRACING #2 There are simple atheroma in the aortic arch anddescending thoracic aorta to 35 cm from the incisors. There are occasional ventricular premature beats.Intraventricular conduction delay with a QRS duration of 144 milliseconds.Compared to the previous tracing of the patient has gone from atrialfibrillation, average ventricular rate 46, to a ventricular paced rhythm with arate of 72 and occasional ventricular premature beats.TRACING #1 Overall normal LVEF(>55%).MITRAL VALVE: Moderately thickened mitral valve leaflets. RV functiondepressed. Q-T interval prolongation. No PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Left axis deviation. Left axis deviation. Mitral valveannuloplasty ring. Mild functional MS due to MAC. AnterolateralST-T wave changes may be due to ischemia. | 10 | [
{
"category": "Echo",
"chartdate": "2183-12-15 00:00:00.000",
"description": "Report",
"row_id": 100184,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/p repair of primum ASD and cleft mitral valve. Congestive heart failure. Severe pulmonary hypertension. ?degree of mitral regurgitation.\nHeight: (in) 67\nWeight (lb): 185\nBSA (m2): 1.96 m2\nBP (mm Hg): 127/48\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 10:00\nTest: TEE (Congenital)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe GE junction was not crossed.\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.\nDepressed LAA emptying velocity (<0.2m/s)\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast or thrombus in\nthe body of the RA or RAA. A catheter or pacing wire is seen in the RA.\nDepressed RAA ejection velocity (<0.2m/s). Normal interatrial septum. No ASD\nby 2D or color Doppler.\n\nAORTA: Simple atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Minimally increased\ngradient consistent with trivial MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. 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. 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. The patient is in a ventricularly paced rhythm.\nResults were personally reviewed with the MD caring for the patient.\n\nConclusions:\nMild spontaneous echo contrast but no thrombus is seen in the body of the left\natrium and left atrial appendage. The left atrial appendage emptying velocity\nis depressed (<0.2m/s). No spontaneous echo contrast or thrombus is seen in\nthe body of the right atrium or the right atrial appendage. The right atrial\nappendage ejection velocity is depressed (<0.2m/s). No atrial septal defect is\nseen by 2D or color Doppler. There are simple atheroma in the aortic arch and\ndescending thoracic aorta to 35 cm from the incisors. The aortic valve\nleaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral\nvalve leaflets are moderately thickened and there appears to be prosthetic\nmaterial in the mitral valve annulus consistent prior surgery. There is a 3 mm\nHg mean gradient across the mitral valve, with an estimated valve area of 2.3\ncm2, consistent with trivial mitral stenosis. Mild (1+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened with moderate [2+]\ntricuspid regurgitation. There is moderate pulmonary artery systolic\nhypertension.\n\nIMPRESSION: Trivial mitral stenosis. Mild mitral regurgitation. Moderate\ntricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Mild\nspontaneous echo contrast without thrombus in the left atrium and left atrial\nappendage. Simple aortic atheroma in the arch and descending thoracic aorta.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2183-12-04 00:00:00.000",
"description": "Report",
"row_id": 100185,
"text": "PATIENT/TEST INFORMATION:\nIndication: prior congenital heart disease repaired. please assess pulmonary htn\nHeight: (in) 67\nWeight (lb): 200\nBSA (m2): 2.02 m2\nBP (mm Hg): 136/80\nHR (bpm): 45\nStatus: Outpatient\nDate/Time: at 11:00\nTest: TTE (Congenital, complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement. No thrombus/mass in the body of the LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: RV hypertrophy. Moderately dilated RV cavity. RV function\ndepressed. Abnormal septal motion/position consistent with RV pressure/volume\noverload.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Mitral valve\nannuloplasty ring. Moderate mitral annular calcification. Mild thickening of\nmitral valve chordae. Mild functional MS due to MAC. Mild to moderate (+)\nMR. [Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate to\nsevere [3+] TR. Severe PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting bradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium is moderately dilated. No thrombus/mass is seen in the body of\nthe left atrium. The right atrium is moderately dilated. No atrial septal\ndefect is seen by 2D or color Doppler. There is mild symmetric left\nventricular hypertrophy with normal cavity size and global systolic function\n(LVEF>55%). There is no ventricular septal defect. The right ventricular free\nwall is hypertrophied. The right ventricular cavity is moderately dilated with\ndepressed free wall contractility. There is abnormal septal motion/position\nconsistent with right ventricular pressure/volume overload. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. There is no mitral valve prolapse. There is mild functional mitral\nstenosis (mean gradient 6 mmHg) due to mitral annular calcification versus\nannular ring from prior repair. Mild to moderate (+) mitral regurgitation\nis seen. [Due to acoustic shadowing, the severity of mitral regurgitation may\nbe significantly UNDERestimated.] The tricuspid valve leaflets are mildly\nthickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is\nsevere pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , the RV appears\nenlarged with evidence of pressure/volume overload. There is now severe\npulmonary hypertension and the degree of TR has increased. The mean\ntransmitral gradient is similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2183-12-16 00:00:00.000",
"description": "Report",
"row_id": 100245,
"text": "PATIENT/TEST INFORMATION:\nIndication: Focused study for pulmonary artery pressures s/p extensive diuresis\nHeight: (in) 67\nWeight (lb): 179\nBSA (m2): 1.93 m2\nBP (mm Hg): 112/45\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 14:57\nTest: TTE (Complete)\nDoppler: Limited 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.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate to severe [3+] TR. Moderate PA\nsystolic hypertension.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is normal\n(LVEF 75%). The mitral valve leaflets are moderately thickened. There is no\nmitral valve prolapse. The tricuspid valve leaflets are mildly thickened.\nModerate-to-severe [3+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension.\n\nCompared with the findings of the prior study (images reviewed) of , the apparent pulmonary artery pressure is significantly reduced.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2183-12-10 00:00:00.000",
"description": "Report",
"row_id": 274749,
"text": "There appears to be a ventricular pacer artifact in leads V4-V6. This\nthus appears to be a ventricular paced rhythm. Atria seem to be in atrial\nfibrillation. There are occasional ventricular premature beats.\nIntraventricular conduction delay with a QRS duration of 144 milliseconds.\nCompared to the previous tracing of the patient has gone from atrial\nfibrillation, average ventricular rate 46, to a ventricular paced rhythm with a\nrate of 72 and occasional ventricular premature beats.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2183-12-09 00:00:00.000",
"description": "Report",
"row_id": 274750,
"text": "Atrial fibrillation with a slow ventricular response. Prolonged\nQ-T interval. Left axis deviation. Incomplete right bundle-branch block.\nST-T wave changes in the anterior precordial leads may be due to ischemia.\nClinical correlation is suggested. Compared to tracing #2 the T waves are now\nupright in lead V2 although this may reflect lead placement.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2183-12-08 00:00:00.000",
"description": "Report",
"row_id": 274751,
"text": "Atrial fibrillation with slow ventricular response. Prolonged Q-T interval.\nLeft axis deviation. Incomplete right bundle-branch block. Anterolateral\nST-T wave changes may be due to ischemia. Clinical correlation is suggested.\nCompared to tracing #1 no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2183-12-08 00:00:00.000",
"description": "Report",
"row_id": 274980,
"text": "Atrial fibrillation with a slow ventricular response. Probable prolonged\nQ-T interval, although difficult to determine the end of the T wave segment in\nthe limb leads. Left axis deviation. Incomplete right bundle-branch block.\nAnteroseptal ST-T wave changes may be due to myocardial ischemia. Clinical\ncorrelation is suggested. Compared to the previous tracing of there\nare now more prominent ST segment depessions and T wave inversions in\nleads V1-V3. The other findings are similar.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2183-12-11 00:00:00.000",
"description": "Report",
"row_id": 274748,
"text": "Ventricular paced rhythm at a rate of 71 per minute with rate ventricular\npremature beats. Compared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2183-12-04 00:00:00.000",
"description": "Report",
"row_id": 274981,
"text": "Atrial fibrillation with a ventricular rate of 46 beats per minute. Left\nventricular hypertrophy. Q-T interval prolongation. Non-specific T wave\nchanges. Moderate baseline artifact in leads V4-V6. Compared to the previous\ntracing of the Q-T interval is more prolonged and there are more T wave\nchanges than noted previously. The rate has also slowed. Consider electrolyte\nabnormality, although ischemia is also possible.\n\n"
},
{
"category": "ECG",
"chartdate": "2183-12-04 00:00:00.000",
"description": "Report",
"row_id": 274982,
"text": "ECG interpreted by ordering physician.\n see corresponding office note for interpretation.\n\n"
}
] |
32,260 | 105,611 | The patient is a 49yoM with h/o of metastatic anorectal ca to spine, liver, lungs presents with worsening hypoxia in the setting of nonproductive cough. He was found to have probable lymphangitic spread of metastatic disease and transferred to for close respiratory monitoring and possible chemotherapy. Hospital course by problem is as follows: . # Hypoxic/hypercarbic respiratory distress: In review of chest CT, reticular pattern appears c/w lymphangitic spread of his disease and was likely the major precipitant in the decompensation of his respiratory status. Had been on face mask, but clinical evidence of increasing resp distress persisted(increased work of breathing, increased O2 requirement, tachycardia), and the patient was intubated on for worsening respiratory distress and hypercarbia. Broad spectrum antibiotic coverage with zosyn, vancomycin, and azithromycin was initiated on admission for a question of PNA on admission CXR with leukocytosis and left shift. . # Fever: The patient spiked temperatures to 101s-102s during hospital course. There was no clear source of fevers. Infectious etiology was a possibility (e.g. VAP), but it was difficult to assess for new infiltrate on CXR and the patient was on broad-spectrum antibiotics (zosyn, vancomycin, and azithromycin) for the duration of admission. All cultures were negative to date. DVT/PE was considered with LUE swelling on exam; however Doppler US was negative for DVT. Etiolgy may be related to fever of malignancy. . # Sinus tachycardia: The patient demonstrated sinus tachycardia for the duration of admission. Etiology was most likely physiologic (tachypnea, fever, profound hypoxemia) with stable hemodynamics. There was lack of response to IVF boluses, making hypovolemia less likely. This was monitored closely for concern for development of tachyarrythmia. . # Metastatic anorectal ca: Last chemo in 2/. With known metastatic disease to bone, liver, lungs (worsening liver mets on CT as well as hilar/mediastinal LNs). XRT in performed for back pain to his bony mets (low thoracic-lumbar spine). His cancer has previously been very chemosensitive, but since last treatment, appears to have rapid progression of disease given imaging as outlined above. The patient completed cycle of 5FU and G-CSF, which was tolerated well without significant side effects; however, there was little effect on metastatic disease during chemotherapy. During hospital course the patient developed a leukocytosis, most likely due to G-CSF treatment. Towards the end of his hospital course he developed a pancytopenia, likely related to the progression of his disease. . # Thrombocytopenia: The patient is chronically thrombocytopenic w/ platelet count 65K-154K in review of OMR labs, with evidence of declining platelets during admission. Heparin was held briefly for the question of HIT, but was restarted after HIT Ab panel was negative. Most likely etiology is either progression of metastatic disease versus 5FU treatment. . # ?DVT/PE: On admission the patient was started on a therapeutic heparin drip for concern of PE given hypercoagulable state, tachycardia, and tachypnea. He was unable to tolerate CTA per back pain from spinal metastases. Heparin drip was discontinued on after LE doppler US were negative for DVT. . # FEN: The patient had evidence of hypernatremia that responded well to free water repletion; this was likely hypovolemic hypernatremia given his poor po intake. He was maintained on TPN given the inability to take po during admission, and was started on tube feeds after intubation. . # During admission the patient was maintained on , IV PPI, and heparin (gtt or sq) for prophylaxis. . # Communication: Wife is patient's HCP . # Code: After discussion with the patient's oncologist and the ICU team regarding the lack of response to chemotherapy and the poor prognosis, the patient and his family decided to opt for comfort measures. On , while the family was present the patient was bolused with fentanyl and was extubated to room air with a respiratory rate of 10. He became asystolic and was pronounced dead at 9:35am. | Colostomy drained medium amt. BOLUS STOPPED CXR DONE WHICH LOOKED COMPARABLE TO YESTERDAY. EKG done. Given ativan 1mg X2 for tachypnea.CV: NBP 115-136/63-76; HR 117-154, ST no ectopy, HR progressively higher and staying in the 150's towards evening-> given lopressor 5mg IV X1 with HR now 120-130's. Bs course and wheezy. SATS 90-93% ON 100% COOL NEB.ABG UNCHANGED.MD REVIEWED POSSIBILITY OF INTUBATION AND PT AGREED TO IT ,IF IT WAS TO BECOME NECESSARY.ALTHOUGH CONT TO BE TACHYPNIEC RR WAS BACK TO BASELINE IN 30'S.C/V: ST NO ECTOPY, RECIEVED 5 MG LOPRESSOR W/ NO ,MARKED RESULTS. SATS ARE MAINTAINED @ 93-94%.C/V: ST NO ECTOPY, BP STABLE. PATIENT TACHYPENIC AND RECEIVED ATIVAN 2MG X1 W/ GOOD EFFECT. Pt improved after a few moments and fio2 titrated down. K+ 3.5 AND PHOS 1.8 THIS AM, WILL REPLEAT.RESP: PT BECAME SOB, C/O CONGESTION DURING FLUID BOLUS. 7.45/31/69/22/0/95%. MADE DNR. ST with HR in 120-130's, no ectopy noted; heparin gtt infusing at 1360units/hr via R SC portacath. ABGS 7.47/24/69/18/-3/93%. RR 28-51.NEURO: FLAT AFFECT. HO AWARE OF BP INTO 140-150'S NO AGGRESSIVE ACTION TAKEN AT THIS TIME.LENIS NEG AND HEPRIN GTT D/C'D . LUNGS HAD BIL RALES AT THAT TIME. SBP 95-110. MD informed. AWAITING CX RESULTS.SKIN INTEGRITY: DUODERM REAPPLIED. Received Kphos IV for phos of 1.8 and K of 3.5.GU: Voiding 100-200cc q 1-3 hrs; 24 hour fluid balance is +336, LOS +5836.ID: Tmax 100.4ax; continues on vanco, zosyn and azithromycin.Endo: FSBG 149 and 131, no insulin given.Skin: Coccyx has 1mm open area -> cleaned with soap and water and new duoderm applied.Plan: Monitor resp status, titrate O2 to keep sat >90%, RR <40, nebs prn; monitor HR, give beta blocker prn, ativan prn; TPN as ordered, check FSBG qid, follow SSI; monitor temp, follow cultures, continue abx. Current vent settings Vt 550, A/C 28, Fio2 90% and Peep 10. Current vent settings Vt 550, A/c 28, Fio2 90%, and Peep 10. Pt to have LENI's then d/c heparin gtt.Resp: O2 sat 92-97% on hi flow neb 80%-95%; recieved atrovent neb in eve for low sat with little effect so now on 100% NRB; RR 32-50's; lung sounds are clear to diminished upper lobes, crackles lower lobes.GI/FEN: Abdomen soft, ND, NT, +BS. AM LABS PENDING.RESP: RECEIVED THE PATIENT ON VENT AC/500/22/12/70%. NSR/ST WITH HR RNGING FROM 93-123, NO ECTOPY NOTED. CURRENTLY FENTAYL ^ 140MIC/HR AND MIDAZOLAM ^ 6MG/HR.CV: HR 140-150 THROUGH OUT NIGHT.SINUS TACHY, NO ECTOPY. CONT ON HEPARIN IN THERAPEUTIC RANGE. Increase Peep/wean Fio2 as tolerated. SMALL AMT OF STOOL IN COLOSTOMY.RENAL: ADEQUATE U/O'S.NEURO: SEDATED ON FENT AND VERSED. Resp CarePt given nebs for resp distress. UO > 50CC/HRSKIN: COCCYX DEODERM DRESSING INTACT.ID: T MAX 101.6 RECEIVED TYLENOL WITH NO EFFECT. REMAINS ON A/C. DESAT TO MID 80'S WHILE ATTEMPTING TO TURN.GI: ABD SOFT, BS SLUGGISH TUBE FEEDING 50CC/HR WITH MINIMAL RESIDUAL. SAO2 93-97% ON 100% NRB AND 6L N/C. Arrived on 100% NRB, RR in high 30's, sats low 90's. Heparin gtt remains at 1300units/hr, repeat PTT at 0800 was 100.8 so rate unchanged. "O:Neuro: pt is A&Ox3, flat affect, MAEW, denies pain at presentPulm: LS are diminished with fine rales at the bases, SpO2 90-98% on NRBFM and 6L NPCV: HR 115-128 ST with rare ectopy, BP 90-123/56-68, please see flow sheet for dataInteg: DSD over folds of buttocks C/D/IGI/GU: abd soft, NT/ND, BS present, NPO, voiding qs in urinalAccess: new left DL PICC, right SC POC, #20 angio right FASocial: meeting at bedside with pt family and ICU team and onclolgy team to discuss pt's condition, prognosis and goals of careA:altered breathing r/t acute on chronic inflammatory processimpaired gas exchange r/t acute on chronic inflammatory processrisk for infection r/t invasive linesP:continue to monitor hemodynamic/respiratory status, continue respiratory support as needed up to and including intubation, continue abx as ordered and follow micro data, continue weight based heparin and check next aPTT at 2330 "O:Neuro: pt is A&Ox3, anxious, flat/depressed affect, MAEW, denies painPulm: pt remains O2 dependent on NRBFM, SpO2 94-98% on NRBFM, SRR 23-35, LS coarse in the upper lobes and diminished at the basesCV: HR 80-110 SR/ST with rare ectopy, BP 113-132/60-68, please see flowsheet for dataGI/GU: abd soft, NT/ND, BS present, NPO, colostomy draining soft brown stool, pt voiding qS in urinalAccess: left brachial DL PICC day #2, #20 angio riggh FA, right SC POCA:altered breathing r/t acute on chronic inflammatory processimpaired gas exchange r/t acute on chronic inflammatory processrisk for infection r/t invasive linesP:continue to monitor hemodynamic/respiratory status, continue resp support as needed, continue abx as ordered and follow micro data oral care cause some bleeds.RESP: lungs clear to coarse, AC 90%, sats95%, no oral secretions, little ET secretions. Sedated since intubation w/ versed 2.5mg & fentanyl 75mcg now.Skin: Duoderm @ coccyx replaced. HIT antibody labs sent for progressively lower platelets.Resp: O2 at 95% hi flow neb and 6L NC with sats running 92-95%, RR 37-50; lung sounds are coarse upper lobes, crackles and expiratory wheezing RLL, coarse LLL. PT DID GET KCL 20MEQ PO.RESP: REMAINED ON NRB AND 6L N/C. Has approx 1cn bleeding decubitus ulcer @ coccyx. responds to increase pain and sedation by decreasing HR and RR.ACCESS: Port a cath accessed in right chest, PICC line in left arm, art line dampened, ecchymotic at site,SKIN: duoderm on coccyx. He tolerated turning partially on side fairly well, w/ O2 sats maintained @ 92%.Skin: Has bleeding decubitus ulcer @ coccyx. MAE's extremities and able to turn side to side with one assist but very dyspneic on exertion.CV: NBP 109-133/59-95; HR 141-150, ST no ectopy. ON 50% NEB W/ 6 L NC, SATS 90-93%.CONT TO REFUSE MASK VENTILATION.C/V: ST UP INTO 130'S RARE PVC'S , BP STABLE 1TEEN -130'S.F/E/N:UO @ 80-100HR, K+PHOS REPLETION , COLOSTOMY W/ LOOSE BROWN STOOL. RESP CARE NOTERECEIVED PT ON AC 14/500/+5/80%. DENIES PAIN OR FEELING OF WORSENING.RESP: TACHYPNEIA UNCHANGED, RR 30-40'S. asynchronous resp decreased with increase in meds.GU/GI: foley drk amber qs. Patient intubated yesterday for resp failure,hypoxemic othrwise ABG acceptable.Suctioned for minimal amount of thin bloody secretion.Status quo will continue to follow. | 32 | [
{
"category": "Nursing/other",
"chartdate": "2156-09-16 00:00:00.000",
"description": "Report",
"row_id": 1671307,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Worsening resp acidosis and hypoxia, over course of shift. Fio2 ^ 90% along ^ MV for PaCo2. Also ^ fever. Current vent settings Vt 550, A/c 28, Fio2 90%, and Peep 10. Sedation ^ via RN due to some dysynchrony with vent. Repeat ABG revealed partially compensated resp acidosis and much improved. BS coarse bilaterally. Sx'd minimal secretions. No further changes made.\nPlan: Continue with mechanical support. Increase Peep/wean Fio2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-16 00:00:00.000",
"description": "Report",
"row_id": 1671308,
"text": "MICU 7 RN REPORT 1900-0700\n\nEVENTS: VENT CHANGES, A LINE PLACEMENT, ABG.\n\nNEURO: RECEIVED THE PATIENT SEDATED ON FENTANYL 100MIC/KG/HR AND MIDAZOLAM 4MG/HR. PATIENT TACHYPENIC AND RECEIVED ATIVAN 2MG X1 W/ GOOD EFFECT. NO MOVEMENTS OF EXTREMITIES. PUPIL 3MM SLUGGISH. CURRENTLY FENTAYL ^ 140MIC/HR AND MIDAZOLAM ^ 6MG/HR.\n\nCV: HR 140-150 THROUGH OUT NIGHT.SINUS TACHY, NO ECTOPY. SBP 95-110. RECEIVED NS 500 BOLUS TO TREAT TACHYCARDIA W/ NO RESPONSE ON HR. VENT CHANGES MADE TO TREAT TACHYCARDIA BUT FAILED. RT RADIAL A LINE PLACED @ 0500 SHARP. AM LABS PENDING.\n\nRESP: RECEIVED THE PATIENT ON VENT AC/500/22/12/70%. @ PATINT CONTINUE TO BE TACHYCARDIC SO FIO2 ^ 80%,AND PEEP REDUCED TO 10. @ 2400 SPO2 REMAINED IN 91% FOR LONGER DURATION OF TIME AND FIO2 ^ 90% ABG @ 0400 7.23/75/101/0/33. VENT SETTINGS CHANGED TO AC/550/28/10/90%. SPO2 91-94%. LS COARSE, SUCTIONED FOR THIN SCANTY PINK SEC. DESAT TO MID 80'S WHILE ATTEMPTING TO TURN.\n\nGI: ABD SOFT, BS SLUGGISH TUBE FEEDING 50CC/HR WITH MINIMAL RESIDUAL. GOAL 55CC/HR. RECEIVED FREE WATER BOLUS 150CC Q4H.\n\nGU: FOLEY DRAINING YELLOW CLEAR URINE. UO > 50CC/HR\n\nSKIN: COCCYX DEODERM DRESSING INTACT.\n\nID: T MAX 101.6 RECEIVED TYLENOL WITH NO EFFECT. ABX VANCO, ZOSYN,AZITHROMYCIN.\n\nSOCIAL: FULL CODE.NO FAMILY CONTACT DURING THIS SHIFT.\n\nPLAN: PAN CULTURE.\n CONTIUE SAME MANAGEMENT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-16 00:00:00.000",
"description": "Report",
"row_id": 1671309,
"text": "Resp Care\n\nPt remains intubated and on full vent support. MV is being maintained the high teens. Bs are coarse and suctioning smal amts of sputum. Plan is for extubation in am\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-16 00:00:00.000",
"description": "Report",
"row_id": 1671310,
"text": "FAMILY MEETING TODAY. PT. MADE DNR. FAMILY IN AGREEMENT. MET WITH SOCIAL WORKER AS WELL.\nRESP: BS'S COARSE. REMAINS ON A/C. NO VENT CHANGES TODAY., ORAL SECRETIONS THIS AM WERE BLOODY, BUT THIS HAS CLEARED.\nGI: TPN D/C'ED. TF'INGS AT GOAL. WELL. SMALL AMT OF STOOL IN COLOSTOMY.\nRENAL: ADEQUATE U/O'S.\nNEURO: SEDATED ON FENT AND VERSED. NO ATTEMPT TO AROUSE D/T VENT INSTABILITY. UNRESPONSIVE.\nENDOC: NO SSI REQUIRED.\nID: CONT. ON ANTIBIOTICS. FEBRILE TO 102PO DESPITE TYLENOL AND ICE PACKS. AWAITING CX RESULTS.\nSKIN INTEGRITY: DUODERM REAPPLIED. NOTED BLEEDING FROM SMALL PUNCTURE TYPE SITE ON COCCYX. PACKING PLACED.\nSOCIAL: FAMILY INTO VISIT.\nPLAN: COMFORT MEASURES TOMORROW WITH EXTUBATION.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-17 00:00:00.000",
"description": "Report",
"row_id": 1671311,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Current vent settings Vt 550, A/C 28, Fio2 90% and Peep 10. Pt. breathing 2-3 breaths over the set rate. BS coarse bilaterally. Sx'd for no secretions. O2 sats 93-95%. Increased temp. Increased Fio2/Peep requirements. No further changes made.\nPlan: Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-13 00:00:00.000",
"description": "Report",
"row_id": 1671297,
"text": "NPN 1900-0700\n\nNEURO: SLEPT THROUGHOUT MOST OF THE NOC. AXOX3 WHEN AWAKE. ATIVAN IV FOR ANXIETY W/ GOOD RESULTS.\n\nRESP: CONT ON 100% HI NEB,DID NOT WANT MASK VENTILATION UNLESS HE BECAME MORE UNCOMFORTABLE. RR 30-40'S AND HAS BEEN AT THIS RATE FOR LAST 48 HR. SATS ARE MAINTAINED @ 93-94%.\n\nC/V: ST NO ECTOPY, BP STABLE. ON ARGATROBAN @ 1.5MCG/KG/MIN FOR HITT , W/ GOAL OF PTT 60-80.PTT DUE @ 0800\n\nF/E/N: RECIEVED 20 MG IV LASIX W/ BRISK RESPONSE OF ~ 800 CC.ON TPN FOR NUTRITION, COLOSTOMY W/ LOOSE BROWN STOOL.AM LYTES PENDING.NO COVERAGE REQUIRED FOR FSBS.\n\nPLAN: CONT TO MONITOR RESP STATUS,CONT AGATROBAN FOR HITT, PT WISHES TO BE INTUBATED IF NECESSARY, FEELS THAT WILL \"HELP\" HIM. CODE STATUS REVIEWED W/ WIFE AND ONCOLOGY ON CONTINUOUS BASIS.EMOTIONAL SUPPORT FOR PT AND FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-13 00:00:00.000",
"description": "Report",
"row_id": 1671298,
"text": "pt offered assistance via mask ventilation during shift but pt refusing at this time. MD informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-07 00:00:00.000",
"description": "Report",
"row_id": 1671283,
"text": "NPN\n\nPt admitted from to 4 ICU bed 5. See FHP for detailed hx. Arrived on 100% NRB, RR in high 30's, sats low 90's. Wife present at bedside. Pt denies pain. All procedures/POC explained to pt prior to initiation. ST with HR in 120-130's, no ectopy noted; heparin gtt infusing at 1360units/hr via R SC portacath. Afebrile. EKG done. Pt voiding in urinal cl/yellow urinal. Pt has colostomy bag to L abd with loose brown stool noted. Pt has area of skin breakdown on gluteal fold per wife-unable to assess at this time secondary to pt not wanting to lie down/turn due to SOB. Ativan given x2 for anxiety with fair results. Will cont to monitor resp status, VS, labs; cont to implement POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-08 00:00:00.000",
"description": "Report",
"row_id": 1671284,
"text": "impaired skin below coccyx,allevyn dressing present.(not on gluteal folds)\n\n20G PIV inserted on Rt ant forearm.blood c/s 2 samples sent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-11 00:00:00.000",
"description": "Report",
"row_id": 1671292,
"text": "Resp Care\nPt given nebs for resp distress. Bs course and wheezy. Sats low 90s. Pt improved after a few moments and fio2 titrated down.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-11 00:00:00.000",
"description": "Report",
"row_id": 1671293,
"text": "NPN 0700-1900\n\nNeuro: A&O X3 when awake. Dozing throughout the day but awakens easily. MAE's but not moving much in the bed due to SOBOE. Given ativan 1mg X2 for tachypnea.\n\nCV: NBP 115-136/63-76; HR 117-154, ST no ectopy, HR progressively higher and staying in the 150's towards evening-> given lopressor 5mg IV X1 with HR now 120-130's. Heparin gtt remains at 1300units/hr, repeat PTT at 0800 was 100.8 so rate unchanged. Pt to have LENI's then d/c heparin gtt.\n\nResp: O2 sat 92-97% on hi flow neb 80%-95%; recieved atrovent neb in eve for low sat with little effect so now on 100% NRB; RR 32-50's; lung sounds are clear to diminished upper lobes, crackles lower lobes.\n\nGI/FEN: Abdomen soft, ND, NT, +BS. Colostomy drained medium amt. liquid dark brown stool in am. Tolerating sips of water. Continues on TPN. Received Kphos IV for phos of 1.8 and K of 3.5.\n\nGU: Voiding 100-200cc q 1-3 hrs; 24 hour fluid balance is +336, LOS +5836.\n\nID: Tmax 100.4ax; continues on vanco, zosyn and azithromycin.\n\nEndo: FSBG 149 and 131, no insulin given.\n\nSkin: Coccyx has 1mm open area -> cleaned with soap and water and new duoderm applied.\n\nPlan: Monitor resp status, titrate O2 to keep sat >90%, RR <40, nebs prn; monitor HR, give beta blocker prn, ativan prn; TPN as ordered, check FSBG qid, follow SSI; monitor temp, follow cultures, continue abx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-12 00:00:00.000",
"description": "Report",
"row_id": 1671294,
"text": "NPN 1900 -\n\nNEURO: AXOX3, REQUIRED ATIVAN Q 4 HRS FOR ANXIETY,AND REQUESTED IT FOR SLEEP.\n\nRESP: TACHYPNEIC, RECIEVED LASIX 20MG FOR WORSENED CXR , AND NEB TX W/ MOD RESULTS. SATS 90-93% ON 100% COOL NEB.ABG UNCHANGED.MD REVIEWED POSSIBILITY OF INTUBATION AND PT AGREED TO IT ,IF IT WAS TO BECOME NECESSARY.ALTHOUGH CONT TO BE TACHYPNIEC RR WAS BACK TO BASELINE IN 30'S.\n\nC/V: ST NO ECTOPY, RECIEVED 5 MG LOPRESSOR W/ NO ,MARKED RESULTS. BP 100'S-120'S. HO AWARE OF BP INTO 140-150'S NO AGGRESSIVE ACTION TAKEN AT THIS TIME.LENIS NEG AND HEPRIN GTT D/C'D . PT IS NOW ON MINI HEP TID.\n\nF/E/N: VOIDS IN URINAL W/ RESPONSE TO LASIX OF ~ 800cc.AM LYTES PENDING, COLOSTOMY DRAINING LIQUID BROWN STOOL.\n\nPLAN: CONT TO MONITOR RESP STATUS , INTUBATE IF WORSENS. EMOTIONAL SUPPORT FOR PT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-12 00:00:00.000",
"description": "Report",
"row_id": 1671295,
"text": "Resp Care\nPt having episodes of resp distress that get relieved with nebs and lasix. Pt on 100% hi-. sats 85-93%. Pt agreed to intubation if it has to come to it.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-10 00:00:00.000",
"description": "Report",
"row_id": 1671290,
"text": "MICU/SICU NPN ICU DAY #4\nEvents: pt OOB to chair x2h today, pt unble to tolerate reduction in FiO2, he reports that he \"cannot get enough air\" with lower concentration oxygen delivery devices, bolused with 1.5L NS today for tachycadia\n\nS: \"\n\nO:\n\nNeruo: pt is A&Ox3, anxious, MAEW, denies pain\n\nPulm: remains on NRBFM with SpO2 93-100%, SRR 28-38, pt unbale to tolerate High-flow neb or SFM d/t subjective discomfort, LS are coarse in upper fields, diminished at the bases, occasional exp wheezes\n\nCV: HR 109-138 ST without appreciable ectopy, 116-139/65-76, pleae see flowsheet for data\n\nGI/GU: abd soft, NT/ND, BS present, tolerating sips of water without difficulty, voiding qS in urinal\n\nAccess: right SC POC, left brachial DL PICC day #3\n\nA:\n\naltered breathing r/t acute on chronic inflammatory process\nimpaired gas exchange r/t acute on chronic inflammatory process\nanxiety r/t diagnosis, hospitalization\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue resp support as needed, aggressive pulmonary toilet, activity progression, wean FiO2 as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-11 00:00:00.000",
"description": "Report",
"row_id": 1671291,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 107/65-136/77. ST WITH HR RNGING FROM 114-135 WITH SEVERAL EPISODES OF HR REACHING 140-150 RANGE. PT WAS GIVEN A FLUID BOLUS FOR TACHYCARDIA WITH 600CC OF 1000 INFUSED PT C/O SOB, BOLUS STOPPED. HR REMAINED INCREASED. PPP BILAT. REMAINS ON HEPARIN AT 1300 UNITS HR, PTT CURRENTLY PENDING. K+ 3.5 AND PHOS 1.8 THIS AM, WILL REPLEAT.\n\nRESP: PT BECAME SOB, C/O CONGESTION DURING FLUID BOLUS. BOLUS STOPPED CXR DONE WHICH LOOKED COMPARABLE TO YESTERDAY. LASIX 10MG IV GIVEN. PT WAS ON HIGH FLOW MASK 60%, INCREASED TO 80%. ABGS 7.47/24/69/18/-3/93%. LUNGS HAD BIL RALES AT THAT TIME. HAVE REMAINED COARSE WITH DIM BASES. PT HAS FINISHED HIS LAST EVENING. SAO2 92-100%. RR 28-51.\n\nNEURO: FLAT AFFECT. VERY COOPERATIVE WITH CARE. A&O, FOLLOWS COMMANDS.\n\nGU: VOIDS IN URINAL SM AMTS. URINE SENT FOR CULTURE. DIURESED SM AMTS AFTER LASIX.\n\nSKIN: PT HAS DSG ON COCCYX BUT REFUSES TO TURN WHILE IN BED. SPOKE WITH WIFE RE: PT NOT TURNING AND WIFE FELT THAT HE WAS AFRAID THAT HIS SPINE WOULD HURT IF TURNED AND THAT THE LUNGS WERE THE PRIMARY ISSUE AND NOT TO WORRY ABOUT HIS NOT TURNING.\n\nGI: HAS COLOSTOMY. ABD SOFT WITH POS BS.\n\nPLAN: CONT TO MONITOR RESP STATUS AND PROVIDE RESP SUPPORT AS NEEDED. MONITOR LABS AND HR AND REPLENISH LYTES AS NEEDED. CONT ON HEPARIN IN THERAPEUTIC RANGE. PROVIDE EMOTIONAL SUPP0ORT FOR PT AND WIFE WITH UPDATES ON ANY CHANGES IN PT CONDITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-09 00:00:00.000",
"description": "Report",
"row_id": 1671287,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 111/65-151/69. NSR/ST WITH HR RNGING FROM 93-123, NO ECTOPY NOTED. PPP BILAT. HCT AT MN 85, NO CHANGES IN HEPARIN GTT. THIS AM 82, NO CHANGES MADE, GTT REMAINS AT 1300 UNITS/HR.\n\nNEURO: A&O. NO C/O PAIN.\n\nRESP: HAS HAD NO RESP DISTRESS THROUGHOUT THE SHIFT. LUNGS ARE CLEAR BUT DIM IN THE BASES. SAO2 93-97% ON 100% NRB AND 6L N/C. 7.45/31/69/22/0/95%. RR 25-36.\n\nGU: VOIDING SM AMTS FREQUENTLY IN THE URINAL.\n\nGI: ABD SOFT WITH POS BS. TPN STARTED LAST EVENING AT 84CC/HR. NPO OTHER THAN MEDS.\n\nSKIN: PT REFUSES TO TURN BUT DOES HAVE A DSG ON FOLDS OF BUTTOCKS. LEFT PICC WITH WEIGHT ON IT TO ENSURE NO BLEEDING AT SITE.\n\nPLAN: CONT TO SUPPORT PT WITH RESP DISTRESS, PT WILL BE INTUBATED IF NEEDED. PT IS HOPING IS EFFECTIVE ENOUGH FOR HIM TO GO HOME. PROVIDE EMOTIONAL SUPPORT AS NEEDED FOR PT AND WIFE. MONITOR LYTES AND REPLENISH AS NEEDED.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-09 00:00:00.000",
"description": "Report",
"row_id": 1671288,
"text": "MICU/SICU NPN ICU day #3\nS: \" I feel better.\"\n\nO:\n\nNeuro: pt is A&Ox3, anxious, flat/depressed affect, MAEW, denies pain\n\nPulm: pt remains O2 dependent on NRBFM, SpO2 94-98% on NRBFM, SRR 23-35, LS coarse in the upper lobes and diminished at the bases\n\nCV: HR 80-110 SR/ST with rare ectopy, BP 113-132/60-68, please see flowsheet for data\n\nGI/GU: abd soft, NT/ND, BS present, NPO, colostomy draining soft brown stool, pt voiding qS in urinal\n\nAccess: left brachial DL PICC day #2, #20 angio riggh FA, right SC POC\n\nA:\n\naltered breathing r/t acute on chronic inflammatory process\nimpaired gas exchange r/t acute on chronic inflammatory process\nrisk for infection r/t invasive lines\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue resp support as needed, continue abx as ordered and follow micro data\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-10 00:00:00.000",
"description": "Report",
"row_id": 1671289,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 106/70-122/64. SR/ST WITH HR RANGING FROM 93-105. PPP BILAT. REMAINS ON HEPARIN GTT AT 1300 UNITS HR. PTT AT 2330 WAS 72.5, REPEAT THIS AM AT 0415 WAS 68.8, NO CHANGES MADE. PT DID GET KCL 20MEQ PO.\n\nRESP: REMAINED ON NRB AND 6L N/C. SAO2 95-97%. RR 25-34. NO RESP DISTRESS NOTED. LUNGS HAD INTERMITTENT WHEEZES BUT MOSTLY CLEAR IN UPPER LOBES AND DIM IN THE BASES.\n\nNEURO: NO CHANGES. A&O WITH FLAT AFFECT.\n\nGU: VOIDS SMALL FREQUENT AMTS IN URINAL. CLEAR YELLOW URINE.\n\nGI: COLOSTOMY INTACT. ABD SOFT WITH BS POS.\n\nSKIN: HAS DSG TO COCCYX. PT REFUSES TO TURN WHILE IN BED. STATES THT HIS BOTTOM DOES NOT HURT.\n\nPLAN: CONT WITH UNTIL TONIGHT. CONT TO MONITOR RESP STATUS AND PROBIDE THE RESP SUPPORT AS NEEDED. MONITOR LYTES AND REPLENISH AS NEEDED. CONT THE ATB. EMOTIONAL SUPPORT TO PT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-15 00:00:00.000",
"description": "Report",
"row_id": 1671303,
"text": "RESP CARE NOTE\nRECEIVED PT ON AC 14/500/+5/80%. CHANGES MADE FOLLOWING ABG AND FOR PT COMFORT. BREATH SOUNDS ARE WITH FINE CRACKLES. SUCTIONED SMALL TO MOD AMTS OF THICK BLOODY SECRETIONS. PT RECEIVING SEDATION FOR COMFORT AND TO CONTROL WOB. OETT ROTATED AND RETAPED AT 27 CM@LIP FOR BETTER PLACEMENT ON CXR. AMBU BAG AND MASK AT BEDSIDE.\nPLAN: CONT FULL VENT SUPPORT, TITRATE SEDATION TO KEEP PT COMFORTABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-15 00:00:00.000",
"description": "Report",
"row_id": 1671304,
"text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 93/60-112/69. ST WITH HR RANGING FROM 128-142, NO ECTOPY NOTED. PPP BILAT.\n\nRESP: LUNGS ARE COARSE THROUGHOUT WITH THICK BLOODY SECRETIONS. SAO2 91-96% ON AC 80%/500/22/5. RR 27-33. PT DID HAVE LG ORAL BLOOD CLOTS SX FROM ORAL CAVITY.\n\nNEURO: SEDATED ON FENTANYL 100MIC/HR AND VERSED 4MG HR. PT OPENS EYES TO VERBAL STIMULI. DOES NOT MOVE EXTREMITIES. DOES NOT FOLLOW COMMANDS BUT WILL OPEN EYES.\n\nGU: FOLEY CATH PATENT DRAINING AMBER URINE WITH ADEQUATE AMTS OF URINE.\n\nGI: TF NUTREN PULM STARTED AT 10CC HR AND IS NOW AT 20CC HR AND PT IS WELL. ALSO GETTING FREE WATER BOLUSES.\n\nPLAN: SUPPORT PT WITH RESP EFFERT. MONITOR LABS AND TEMPS AND REPLENISH LYTES AS NEEDED. PROVIDE EMOTIONAL SUPPORT FOR PT AND WIFE. UPDATE WIFE WITH ANY CHANGES WHICH OCCUR.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-15 00:00:00.000",
"description": "Report",
"row_id": 1671305,
"text": "NPN 0700-1900\n\nNeuro:Patient sedated on 100mcg/hr fentanyl & 4mg/hr versed. Opens eyes to turning & when his wife visited. movement of extremities.\n\nCV: HR slowly inched up from upper 120's ST to upper 140's. Resident aware. Cuff BP: 90's-110/systolic. HR increased from 130's to 140's after his vent settings were changed @ 1600. Attempted 500cc NS bolus @ 1830 to decrease HR.\n\nResp: Patient's O2 sats were 91-94% on A/C .80/500/RR22/PEEP5. ABG's on these settings were 7.35/65 pO2/57 FiO2 was decreased to .70 & his PEEP was increased to 10 @ 1600. His ABG's @ 1800 were 7.36/74 pO2/54 pCO2. Lungs are diminished @ L base,w/ bronchial(coarse) sounds @ R base & upper lungs. Patient tolerated turning poorly, desatting to 88-90% when turned to sides. He tolerated turning partially on side fairly well, w/ O2 sats maintained @ 92%.\n\nSkin: Has bleeding decubitus ulcer @ coccyx. Applied pressure to stop bleeding & then duoderm. Turned side to side only partially to maintain O2 sats.\n\nGI: Increased TF's (nutren pulmonary) to 40cc/hr. TF residual only 10-12cc. Given 150cc free H2O boluses q 4 hrs.\n\nGU: Foley draining 40-80cc/hr clear yellow urine.\n\nImmune: Tmax 99.6 ax WBC 7.4 Continues on neupogen. Urine Cx from : no growth. BC from : pending. If patient gets\n , it would be on (Tues).\n\nA/P: Patient doing poorly on vent, despite high FiO2 due to lung CA\nPatient has high HR most likely from not tolerating FiO2 70%\nPatient continues to be full code.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-15 00:00:00.000",
"description": "Report",
"row_id": 1671306,
"text": "Patient intubated yesterday for resp failure,hypoxemic othrwise ABG acceptable.Suctioned for minimal amount of thin bloody secretion.Status quo will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-17 00:00:00.000",
"description": "Report",
"row_id": 1671312,
"text": "NPN 1900-0700\nPt. is currently a DNR. Plan for determination of CMO this day\n\nNEURO: Non responsive. pupils pinpoint\n\nCV: maps 58-60. sinus 150 decreased to 120's. urine amber qs. pp intact, skin warm tmax 102.2 responsive to tylenol. pale. lab shows little white count and dropping platlets. oral care cause some bleeds.\n\nRESP: lungs clear to coarse, AC 90%, sats95%, no oral secretions, little ET secretions. RR initially 32+, now 27-30 with increase in versed and fentanyl increased. asynchronous resp decreased with increase in meds.\n\nGU/GI: foley drk amber qs. BUN rising, colostomy bag changed for mod at green black mucoid stool, BT hypoactive, abd firm no distention.\n\nENDO: BS 133, sliding scale coverage only. tf remains at goal 55 cc with 20-30 cc residuals.\n\nPAIN: using vs pt. responds to increase pain and sedation by decreasing HR and RR.\n\nACCESS: Port a cath accessed in right chest, PICC line in left arm, art line dampened, ecchymotic at site,\n\nSKIN: duoderm on coccyx. generalized dependant edema\n\nSOCIAL: no visits or calls.\n\nPLAN: comfort care planned for today, supportive care, maintain ventilation and sed/analgesia.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-08 00:00:00.000",
"description": "Report",
"row_id": 1671285,
"text": "Nsg.notes 1900-0700hrs\n\nAllergies :NKDA\n\nA case of CA rectum,mets to lungs,lymph nodes,T11 -L4 involvement,s/p radiation TX 1week ago admitted in with N/V,weakness,tachypoenic,tachcardiac and desats,PNA VS mets lungs.?PE On heparin gtt.admitted FN4 micu for observation and further management.\n\nNeuro:alert and oriented x3,denies any pain,comfortable on bed,back sleeper,refused to turn on sides for sleep,slept well .\n\nResp:on NRBM 100%,sats 93-95%,LS dimished .RR 30-40/min.sputum sample pending,not producing sputum.\n\nCVS:HR 120-130'ST.no ectopics noted.BP 100-110/50-60 mm of hg.on heparin GTT FOR ?PE.follow PTT.pottasium phosphate repleted.\n\nGU/GI:Taking sips of water and PO meds.adbomen soft,BS hypo.colostomy bag present,draining moderately.voided clear yellow urine.\n\nIV access:Rt SC porta cath,dressing intact.site looks clean.\n\nSocial:visited by wife early shift and updated.calm and co operative.full code.\n\nID:on vanco,azithromycin,zosyn.\n\nIntegu:skin brakedown on gluteal foldes,alllevyn dressing.back care given and positioned on back only per pt.T max 98.6\n\nPlan:chemo today.\n follow PTT Q6H\n MONITOR HR & RR.\n wean O2 when possible.\n emotional support to pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-08 00:00:00.000",
"description": "Report",
"row_id": 1671286,
"text": "MICU/SICU NPN ICU Day #2\nEvents: pt and family met with critical care and oncology fellows to discuss pt's current status, prognosis and plan of care, new left brachial DL PICC placed at bedside\n\nS: \"When will I get the chemo?\"\n\nO:\n\nNeuro: pt is A&Ox3, flat affect, MAEW, denies pain at present\n\nPulm: LS are diminished with fine rales at the bases, SpO2 90-98% on NRBFM and 6L NP\n\nCV: HR 115-128 ST with rare ectopy, BP 90-123/56-68, please see flow sheet for data\n\nInteg: DSD over folds of buttocks C/D/I\n\nGI/GU: abd soft, NT/ND, BS present, NPO, voiding qs in urinal\n\nAccess: new left DL PICC, right SC POC, #20 angio right FA\n\nSocial: meeting at bedside with pt family and ICU team and onclolgy team to discuss pt's condition, prognosis and goals of care\n\nA:\n\naltered breathing r/t acute on chronic inflammatory process\nimpaired gas exchange r/t acute on chronic inflammatory process\nrisk for infection r/t invasive lines\n\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue respiratory support as needed up to and including intubation, continue abx as ordered and follow micro data, continue weight based heparin and check next aPTT at 2330\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-13 00:00:00.000",
"description": "Report",
"row_id": 1671299,
"text": "MICU/SICU NPN ICU Day #7\nEvents: pt continues to be tachypneic with labored breathing pattern, additionally pt becomes SOB while speaking\n\nS: \"My mouth is dry\"\n\nO:\n\nNeuro: pt is A&Ox3, MAEW, denies pain, SOB while speaking\n\nPulm: LS coarse in upper fields, fine rales at bases, continues on high flow neb at 50% with 4L NP, SpO2 92-97%, pt denies distress but is using all accessory muscles to breathe\n\nCV; HR 132-136 ST with rare ectopy, BP 109-129/63-77, please see flowsheet for data\n\nInteg: Duoderm over upper legs\n\nGI/GU: pt is tolerating sips of clears without difficulty, abd is soft, NT/ND, BS are present, ileostomy draining soft stool, Foley draining adequate amts clear yellow urine\n\nAccess: left brachial DL PICC day #5, right SC POC\n\nA:\n\naltered breathing r/t acute on chronic inflammatory process\nimpaired gas exchange r/t acute on chronic inflammatory process\nanxiety, acute r/t diagnosis, hospitalization\nhigh risk for infection r/t invasive lines, indwelling catheter\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue resp support as needed including intubation and mechanical ventilation encourage aggressive pulmonary toilet, continue abx as ordered and follow micro data\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-14 00:00:00.000",
"description": "Report",
"row_id": 1671300,
"text": "NPN 1900 - 0700\n\nNEURO: REQUESTING ATIVAN FOR MOD ANXIETY. DOSE INCREASED TO 1-2 MG Q 4HR. AXOX3.EYES CLOSED AND DOSING MOST OF THE NOC. DENIES PAIN OR FEELING OF WORSENING.\n\nRESP: TACHYPNEIA UNCHANGED, RR 30-40'S. ON 50% NEB W/ 6 L NC, SATS 90-93%.CONT TO REFUSE MASK VENTILATION.\n\nC/V: ST UP INTO 130'S RARE PVC'S , BP STABLE 1TEEN -130'S.\n\nF/E/N:UO @ 80-100HR, K+PHOS REPLETION , COLOSTOMY W/ LOOSE BROWN STOOL. TPN FOR NUTRITION.\n\nPLAN: CONT TO MONITOR RESP STATUS , PT REFUSING MASK VENT BUT WILL ALLOW INTUBATION IF BECOMES NECESSARY. ATIVAN FOR ANXIETY, REPELTE LYTES PRN, CONT AB TX, EMOTIONAL SUPPORT FOR PT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-14 00:00:00.000",
"description": "Report",
"row_id": 1671301,
"text": "NPN 0700-1900\n\nNeuro: Patient only requested ativan 2mg X1 @0800. Did not move @ all. ABG's @ 1500 showed high pCO2 of 63. Mental status not easily assessed as patient did not speak more than 4 words all day.\n\nCV: HR:120's-130's ST BP 130's/sys until intubated & then dropped to 90's/. Pneumo boots for DVT prophylaxis on.\n\nResp: RR30's-40's, maintaining O2 sats @ 92-94% on 80% high flow O2 & 6L NP. At 1500, ABG's done: 7.31/79/63. Patient electively intubated @ 1600 after situation discussed w/wife & family. Patient's ET repositioned to 28cm @ lip. OGT placed before 2nd CXR to confirm placement. Now on .80/500/RR 14/5 PEEP. O2 sats 98%. Sedated since intubation w/ versed 2.5mg & fentanyl 75mcg now.\n\nSkin: Duoderm @ coccyx replaced. Has approx 1cn bleeding decubitus ulcer @ coccyx. Applied pressure & 2X2 to stop bleeding. PLT only 32,000 this am.\n\nPain: Denied.\n\nA/P: Patient much more comfortable w/breathing on vent, intubated.\nWill need new duoderm to bleeding decub ulcer.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-14 00:00:00.000",
"description": "Report",
"row_id": 1671302,
"text": "Rectal ca mets to lungs. Electively intubated due to poor oxygenation.# 8 ETT advanced to 28 cm @ the lip. Hypoxemic with resp acidosis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-09-12 00:00:00.000",
"description": "Report",
"row_id": 1671296,
"text": "NPN 0700-1900\n\nNeuro: More somnolent today, difficulty speaking d/t dyspnea but answers yes/no questions. Given ativan 1mg IV q 4-5hrs. Awakens easily and gives thumbs up when asked how he is doing. MAE's extremities and able to turn side to side with one assist but very dyspneic on exertion.\n\nCV: NBP 109-133/59-95; HR 141-150, ST no ectopy. + edema present BLE R>L -> LENI's done yesterday were negative and pt reports R leg has been bigger than L for awhile. HIT antibody labs sent for progressively lower platelets.\n\nResp: O2 at 95% hi flow neb and 6L NC with sats running 92-95%, RR 37-50; lung sounds are coarse upper lobes, crackles and expiratory wheezing RLL, coarse LLL. Lasix 20mg IV given with slight, transient improvement in O2sats. Attending talked with pt during rounds about non-invasive ventilation and intubation. Says he does not want mask ventilation but agrees to intubation if needed.\n\nGI/FEN: Abdomen soft, ND, NT, +BS, 150cc dark liquid stool drained from colostomy; receiving TPN, po intake very poor. Given Kphos IV for K 3.8, phos 2.1\n\nGU: Voided 100-200cc/hr, given lasix late morning with urine output 300cc for 1hr; pt agreed to having a catheter placed so foley inserted at 1600. 24hr fluid balance is -190, LOS +5412.\n\nID: Tmax 99.8, Tcurrent 99.3; continues on vanco, zosyn, azithromycin.\n\nEndo: FSBG at noon pending.\n\nPlan: ? convince pt to try mask ventilation overnight to rest; continue to monitor resp status; minimize activity to avoid increasing O2 demand; monitor fluid/electrolyte status; FSBG qid.\n"
},
{
"category": "ECG",
"chartdate": "2156-09-11 00:00:00.000",
"description": "Report",
"row_id": 162649,
"text": "Sinus tachycardia. Compared to tracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-09-07 00:00:00.000",
"description": "Report",
"row_id": 162650,
"text": "Sinus tachycardia. The P-R interval is 0.13. Compared to the prior tracing\nof there is left atrial abnormality. The rate has increased.\nOtherwise, no diagnostic interim change.\n\n"
}
] |
76,327 | 176,858 | 42 year old male with a history of end stage liver disease on the list, pulmonary hypertension who presents from home with fevers and hypotension. Sepsis with Group B strep and Enterococcus Avium: Unclear etiology. Patient presents with fevers, tachycardia, hypotension in the setting of end stage liver disease. WBC count of 12.0 with 14% bands. Urinalysis negative. No evidence of SBP on paracentesis. Urine culture negative. Blood cultures with 4/4 bottles GPC initially. He initially received 5 liters of normal saline for reuscitation and this was switched to albumin and blood in the MICU. He was started on vancomycin and ceftriaxone in the emergency room and this was switched to vancomycin and cefipime. He never required pressors or central line placement. His blood pressures improved to 100s systolic which is his baseline. He continued to have poor urine output 20-30 cc/hr and was treated with albumin. Lactate was initially elevated at 6.7 and this trended down to normal. When cultures grew Group B Streptococcus, cefipime was discontinued and he was receiving only vancomycin via PICC line. On , blood cultures were also preliminarily growing Enterococcus avium, a rare organism found predominantly in the GI tract. TEE was negative for vegitations. CT abdomen/pelvis was negative. Colonoscopy was negative and no source of GI etiology of bacteremia was found. Because the enterococcus organism had only intermediate sensitivity to vancomycin, Mr. was switched to linezolid 600mg for a one month course (until ). One month course was recommended by ID since no etiology of bacteremia had been found. He will follow up with ID on . Platelet counts must be followed as linezolid can cause thrombocytopenia after 2 weeks. He will have weekly CBC's checked. He will follow up in hepatology clinic on . | PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 67Weight (lb): 140BSA (m2): 1.74 m2BP (mm Hg): 105/64HR (bpm): 73Status: InpatientDate/Time: at 16:17Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Sepsis- GPC bacteremia of unclear source -continue vanco + cefepime; plan on narrowing when GPCs are speciated -Follow lactate -Albumin and fluids with good response Anemia- guaiac negative on this admission but hx of prior positive and w/ known varices -trend serial Hcts, transfuse for hct less than 21 ESLD- LFTs slightly elevated and coagulopathy worsened -vit K if elevated INR worsening -check fibrinogen to r/o infection-related DIC -inform Hepatology/ Transplant svce of admission -cont encephalopathy therapy -holding diuresis for volume resuscitation as above Acute Renal Failure- preexisting HRS plus prerenal w/ sepsis -fluids and colloid as above -cont octreotide and midodrine Pulm HTN- clinically stable -cont iloprost -maintain healthy RV preload with volume resuscitation as above Sleep disordered breathing- known hx of OSA based on PSG -CPAP w/ full-face mask pressure setting -will ensure this is resumed prior to discharge, as it may help w/ pulm HTN Remainder of plan as per housestaff note ICU Care Nutrition: Nutren 2.0 (Full) - 05:56 AM 15 mL/hour Glycemic Control: Lines: 18 Gauge - 11:37 PM Prophylaxis: DVT: boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition : To remain in ICU Total time spent: 45 minutes Plan: Follow Hct & s/s of hypovolemia. Plan: Follow Hct & s/s of hypovolemia. Sepsis- GPC bacteremia of unclear source -continue vanco + cefepime; plan on narrowing when GPCs are speciated -Albumin and fluids with good response in UOP and lactate Anemia- guaiac negative on this admission but hx of prior positive and w/ known varices -trend serial Hcts, transfuse for hct less than 21 ESLD- LFTs slightly elevated and coagulopathy worsened -vit K if elevated INR worsening -Hepatology following -cont encephalopathy therapy -holding diuresis for volume resuscitation as above Acute Renal Failure- preexisting HRS plus prerenal w/ sepsis -fluids and colloid as above -cont octreotide and midodrine Pulm HTN- clinically stable -cont iloprost -maintain healthy RV preload with volume resuscitation as above Sleep disordered breathing- known hx of OSA based on PSG -CPAP w/ full-face mask pressure setting -will ensure this is resumed prior to discharge, as it may help w/ pulm HTN Remainder of plan as per housestaff note ICU Care Nutrition: Nutren 2.0 (Full) - 05:56 AM 30 mL/hour Glycemic Control: Blood sugar well controlled Lines: 18 Gauge - 11:37 PM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition :Transfer to floor Total time spent: 30 minutes lactulose and rifaximin titrated to BM, and continue TF. lactulose and rifaximin titrated to BM, and continue TF. lactulose and rifaximin titrated to BM, and continue TF. lactulose and rifaximin titrated to BM, and continue TF. Directional flow of the main portal vein is appropriately hepatopetal, where it is noted that on the prior examination the main portal vein flow was reversed (hepatofugal). Sepsis- GPC bacteremia of unclear source -continue vanco + cefepime; plan on narrowing when GPCs are speciated -Albumin and fluids with good response in UOP and lactate Anemia- guaiac negative on this admission but hx of prior positive and w/ known varices -trend serial Hcts, transfuse for hct less than 21 ESLD- LFTs slightly elevated and coagulopathy worsened -vit K if elevated INR worsening -Hepatology following -cont encephalopathy therapy -holding diuresis for volume resuscitation as above Acute Renal Failure- preexisting HRS plus prerenal w/ sepsis -fluids and colloid as above -cont octreotide and midodrine Pulm HTN- clinically stable -cont iloprost -maintain healthy RV preload with volume resuscitation as above Sleep disordered breathing- known hx of OSA based on PSG -CPAP w/ full-face mask pressure setting -will ensure this is resumed prior to discharge, as it may help w/ pulm HTN Remainder of plan as per housestaff note ICU Care Nutrition: Nutren 2.0 (Full) - 05:56 AM 30 mL/hour Glycemic Control: Blood sugar well controlled Lines: 18 Gauge - 11:37 PM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition :Transfer to floor Total time spent: 30 minutes Admitting Diagnosis: ALTERED MENTAL STATUS FINAL REPORT (Cont) bladder (2:79) and would recommend correlation with prior Foley instrumentation. | 48 | [
{
"category": "Echo",
"chartdate": "2148-07-03 00:00:00.000",
"description": "Report",
"row_id": 84832,
"text": "PATIENT/TEST INFORMATION:\nIndication: Bacteremia, ?endocarditis.\nHeight: (in) 67\nWeight (lb): 140\nBSA (m2): 1.74 m2\nBP (mm Hg): 105/75\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 13:12\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe TEE probe was not advanced beyond 35 cm. from the incisors due to the\npatient's known esophageal varices in the distal of the esophagus.\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: No atheroma in aortic arch. No atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild (1+) 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 leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The posterior pharynx was anesthetized\nwith 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given as an\nantisialogogue prior to TEE probe insertion. No TEE related complications.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient. MD caring for the patient was notified of the\nechocardiographic results by e-mail.\n\nConclusions:\nThe left atrium is normal in cavity size. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium/left atrial appendage or the\nbody of the right atrium/right atrial appendage. No atrial septal defect is\nseen by 2D or color Doppler. Overall left ventricular systolic function is\nnormal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis\nis not present. No masses or vegetations are seen on the aortic valve. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nNo mass or vegetation is seen on the mitral valve. Mild (1+) mitral\nregurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There\nis no pericardial effusion.\n\nIMPRESSION: Mild mitral regurgitation with normal valve morphology.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Report",
"row_id": 84833,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 67\nWeight (lb): 140\nBSA (m2): 1.74 m2\nBP (mm Hg): 105/64\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 16:17\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. Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). False LV tendon (normal variant). No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTA: Mildly dilated aortic sinus. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. No mass or vegetation on\nmitral valve. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: Small 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 global systolic function (LVEF>55%).\nThe right ventricular cavity is mildly dilated with borderline normal free\nwall function. The aortic root is mildly dilated at the sinus level. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis. No masses or vegetations are seen on the\naortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets\nare structurally normal. There is no mitral valve prolapse. No mass or\nvegetation is seen on the mitral valve. Mild to moderate (+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nNo vegetation/mass is seen on the pulmonic valve. There is a small pericardial\neffusion.\n\nIMPRESSION: No valvular vegetations seen. Mild symmetric left ventricular\nhypertrophy with preserved global and regional systolic function. Borderline\nright ventricular systolic function. Mild to moderate mitral regurgitation.\nMild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , biventricular\nsystolic function has improved. The other findings are similar.\n\n\n"
},
{
"category": "Nutrition",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 470007,
"text": "Subjective: Unable to speak with patient, who is currently undering a\n bedside ultrasound.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 67.2 kg\n 68.1 kg ( 12:00 PM)\n 23.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4 kg\n 104%\n Diagnosis: altered mental status\n PMH : - End Stage Liver Disease alcohol and hepatitis C. Currently\n on the transplant list. Course complicated by recurrent ascites, SBP,\n pulmonary hypertension. Currently on the transplant list (s/p aborted\n liver transplant given elevated pulmonary pressures in OR )\n - Spontaneous bacterial peritonitis early on Cipro prophylaxis\n - Grade II esophageal varices\n - Recurrent hepatic encephalopathy on vegetarian diet\n - Pulmonary hypertension\n - Hypothyroidism\n - Anxiety disorder\n - History of alcohol and IVDU\n - Osteoporosis of hip and spine per pt\n - Anemia with history of guaiac positive stool\n Food allergies and intolerances: no known food allergies\n Pertinent medications: Lactulose, octreotide acetate, calcium\n carbonate, vitamin D, Zinc Sulfate, rifaximin, ABx, others noted\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 02:38 AM\n Glucose Finger Stick\n 146\n 12:00 PM\n BUN\n 26 mg/dL\n 02:38 AM\n Creatinine\n 1.8 mg/dL\n 02:38 AM\n Sodium\n 138 mEq/L\n 02:38 AM\n Potassium\n 2.8 mEq/L\n 03:26 AM\n Chloride\n 98 mEq/L\n 02:38 AM\n TCO2\n 23 mEq/L\n 02:38 AM\n PO2 (venous)\n 28 mm Hg\n 03:26 AM\n PCO2 (venous)\n 46 mm Hg\n 03:26 AM\n pH (venous)\n 7.37 units\n 03:26 AM\n CO2 (Calc) venous\n 26 mEq/L\n 03:26 AM\n Calcium non-ionized\n 8.3 mg/dL\n 02:38 AM\n Phosphorus\n 2.0 mg/dL\n 02:38 AM\n Magnesium\n 1.8 mg/dL\n 02:38 AM\n WBC\n 10.3 K/uL\n 02:38 AM\n Hgb\n 6.1 g/dL\n 02:38 AM\n Hematocrit\n 18.8 %\n 02:38 AM\n Current diet order / nutrition support: Diet: Regular, vegetarian, 60g\n protein restriction\n Tube Feeds: Nutren 2.0 @ 35cc/hr (1680kcals, 67g protein)\n GI: abd firm, distended, + bowel sounds, + golden liquid stool\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: ESLD, Tube Feed depnedence\n Estimated Nutritional Needs (based on adm wt)\n Calories: 1680- ( 25-30 cal/kg)\n Protein: 60-81 (0.9-1.2 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Adequate\n Specifics:\n 42 y.o. M with ESLD ETOH and Hep C, on transplant list, presents\n with left eye rash, fever of greater than 104 degrees, tachycadia and\n hypotension. Patient found to have GPC bacteremia of unclear source.\n Patient is tube feed dependent at baseline, receiving tube feeds at\n home that provide ~100% of estimated nutritional needs. Patient also\n takes a vegetarian diet. Will recommend to continue with tube feeds as\n ordered. Noted K and Phos low.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Continue with Nutren 2.0 @ 35cc/hr.\n 2) Replete lytes, namely K and Phos until WNL.\n 3) Encourage po intake as tolerated.\n Following, please page with questions. #\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 469991,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n No events\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Infusions:\n Other medications:\n Lactulose, Octreotide, Midodrine, omeprazole, CaHCO3, Vit D, Zinc,\n Rifamixin, Synthroid, ursodiol, vancomycin, SPA,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:18 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: 35.7\nC (96.2\n HR: 90 (90 - 118) bpm\n BP: 102/31(47) {81/31(47) - 107/69(86)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 97%\n Total In:\n 4,860 mL\n 1,685 mL\n PO:\n 730 mL\n TF:\n 50 mL\n IVF:\n 60 mL\n 375 mL\n Blood products:\n 530 mL\n Total out:\n 160 mL\n 255 mL\n Urine:\n 10 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,700 mL\n 1,430 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Gen: NAD\n HEENT: icteric\n Neck: no JVD\n Chest: CTA B\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice, chronic venous stasis changes in LE\n Rectal: Guaiac negative in emergency room\n Labs / Radiology\n 6.1 g/dL\n 37 K/uL\n 114 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 26 mg/dL\n 98 mEq/L\n 138 mEq/L\n 18.8 %\n 10.3 K/uL\n [image002.jpg]\n 02:38 AM\n WBC\n 10.3\n Hct\n 18.8\n Plt\n 37\n Cr\n 1.8\n Glucose\n 114\n Other labs: PT / PTT / INR:36.5/66.9/3.8, Differential-Neuts:69.0 %,\n Band:14.0 %, Lymph:3.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:5.1\n mmol/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Peritoneal fluid- 35 wbcs\n Micro: 4/4 bottles blood cx- GPCs\n ECG - unchanged compared to prior\n ECG pm- rate-realated TWI in V1-V2\n CXR - low lung volumes, elevated R hemidiaphragm elevated\n Assessment and Plan\n 42 yo male with ESLD due to EtOH and HCV (on tx list) as well as mild\n PHTN, admitted with sepsis due to GPC bacteremia. Source unclear at\n this point.\n Sepsis- GPC bacteremia of unclear source\n -continue vanco + cefepime; plan on narrowing when GPCs are speciated\n -Follow lactate\n -Albumin and fluids with good response\n Anemia- guaiac negative on this admission but hx of prior positive and\n w/ known varices\n -trend serial Hcts\n ESLD- LFTs slightly elevated and coagulopathy worsened\n -vit K if elevated INR worsening\n -check fibrinogen to r/o infection-related DIC\n -inform Hepatology/ Transplant svce of admission\n -cont encephalopathy therapy\n -holding diuresis for volume resuscitation as above\n Acute Renal Failure- preexisting HRS plus prerenal w/ sepsis\n -fluids and colloid as above\n -cont octreotide and midodrine\n Pulm HTN- clinically stable\n -cont iloprost\n -maintain healthy RV preload with volume resuscitation as above\n Sleep disordered breathing- known hx of OSA based on PSG\n -CPAP w/ full-face mask pressure setting \n -will ensure this is resumed prior to discharge, as it may help w/ pulm\n HTN\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:56 AM 15 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : To remain in ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 469998,
"text": "Chief Complaint: Fever\n HPI: hepatic encephalopathy, Sepsis\n 24 Hour Events:\n bld cultures pos for GPC\ns, improving mentation\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Infusions:\n Other medications:\n Lactulose, Octreotide, Midodrine, omeprazole, CaHCO3, Vit D, Zinc,\n Rifamixin, Synthroid, ursodiol, vancomycin, SPA,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:18 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: 35.7\nC (96.2\n HR: 90 (90 - 118) bpm\n BP: 102/31(47) {81/31(47) - 107/69(86)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 97%\n Total In:\n 4,860 mL\n 1,685 mL\n PO:\n 730 mL\n TF:\n 50 mL\n IVF:\n 60 mL\n 375 mL\n Blood products:\n 530 mL\n Total out:\n 160 mL\n 255 mL\n Urine:\n 10 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,700 mL\n 1,430 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Gen: NAD\n HEENT: icteric\n Neck: no JVD\n Chest: CTA B\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice, chronic venous stasis changes in LE\n Rectal: Guaiac negative in emergency room\n Labs / Radiology\n 6.1 g/dL\n 37 K/uL\n 114 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 26 mg/dL\n 98 mEq/L\n 138 mEq/L\n 18.8 %\n 10.3 K/uL\n [image002.jpg]\n 02:38 AM\n WBC\n 10.3\n Hct\n 18.8\n Plt\n 37\n Cr\n 1.8\n Glucose\n 114\n Other labs: PT / PTT / INR:36.5/66.9/3.8, Differential-Neuts:69.0 %,\n Band:14.0 %, Lymph:3.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:5.1\n mmol/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Peritoneal fluid- 35 wbcs\n Micro: 4/4 bottles blood cx- GPCs\n ECG - unchanged compared to prior\n ECG pm- rate-realated TWI in V1-V2\n CXR - low lung volumes, elevated R hemidiaphragm elevated\n Assessment and Plan\n 42 yo male with ESLD due to EtOH and HCV (on tx list) as well as mild\n PHTN, admitted with sepsis due to GPC bacteremia. Source unclear at\n this point.\n Sepsis- GPC bacteremia of unclear source\n -continue vanco + cefepime; plan on narrowing when GPCs are speciated\n -Follow lactate\n -Albumin and fluids with good response\n Anemia- guaiac negative on this admission but hx of prior positive and\n w/ known varices\n -trend serial Hcts, transfuse for hct less than 21\n ESLD- LFTs slightly elevated and coagulopathy worsened\n -vit K if elevated INR worsening\n -check fibrinogen to r/o infection-related DIC\n -inform Hepatology/ Transplant svce of admission\n -cont encephalopathy therapy\n -holding diuresis for volume resuscitation as above\n Acute Renal Failure- preexisting HRS plus prerenal w/ sepsis\n -fluids and colloid as above\n -cont octreotide and midodrine\n Pulm HTN- clinically stable\n -cont iloprost\n -maintain healthy RV preload with volume resuscitation as above\n Sleep disordered breathing- known hx of OSA based on PSG\n -CPAP w/ full-face mask pressure setting \n -will ensure this is resumed prior to discharge, as it may help w/ pulm\n HTN\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:56 AM 15 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : To remain in ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 470130,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:00 AM\n BLOOD CULTURED - At 11:00 AM\n URINE CULTURE - At 01:47 PM\n - blood cx bottles with GPC in pairs and chains.\n - DIC labs with low fibrinogen to 92, but INR and PTT improved.\n - Patient's mental status returned to baseline per mother\n - She states his LE edema has been more persistant so ABD U/S and LENIs\n were ordered without evidence of portal venous thrombosis or DVT\n - CKs elevated with flat troponins\n - UOP remained poor despite 4.9 L positive\n - Liver: continue octreotide & midodrine. hold lasix. lactulose and\n rifaximin titrated to BM, and continue TF.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 69 (69 - 100) bpm\n BP: 103/70(78) {84/31(47) - 114/83(89)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 741 mL\n PO:\n 1,530 mL\n TF:\n 421 mL\n 179 mL\n IVF:\n 1,975 mL\n 562 mL\n Blood products:\n 800 mL\n Total out:\n 475 mL\n 130 mL\n Urine:\n 475 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Labs / Radiology\n 57 K/uL\n 8.5 g/dL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n ALT: 18\n AP: 163\n Tbili: 9.4\n Alb: 3.2\n AST: 77\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Ca: 8.3 Mg: 2.4 P: 1.6\n PT: 30.4\n PTT: 60.2\n INR: 3.0\n Fibrinogen: 97\n Vanco: 33.9\n LIVER U/S\n IMPRESSION:\n 1. Hepatopetal and patent main portal vein.\n 2. Cirrhotic liver with gallbladder wall edema and distention. This\n might be\n related to third spacing, chronic liver disease, and enteric\n status--please\n correlate clinically as to whether there is abdominal pain which may be\n attributable to the gallbladder.\n LENIs\n 1) No DVT.\n 2) Left-sided medial popliteal fossa () cyst.\n Microbiology:\n \n 4/4 bottles of gram positive cocci in pairs and chains\n \n peritoneal fluid cultures negative to date\n \n blood and urine cultures no growth to date\n Assessment and Plan\n 42 year old male with a history of end stage liver disease on the\n transplant list, pulmonary hypertension who presents from home with\n fevers and hypotension.\n Sepsis: Patient presents with fevers, tachycardia, hypotension in the\n setting of end stage liver disease. WBC count of 12.0 on presentation\n with 14% bands. Urinalysis negative. No evidence of SBP on\n paracentesis. Blood cultures with 4/4 GPC in pairs and chains, likely\n streptococcus species. He is now on vancomycin and cefepime. He has\n now been resuscitated with IVF, blood and albumin with stabilization of\n his blood pressures but persistently low urine output.\n - continue albumin and NS for resuscitation as needed for UOP < 30\n cc/hr, SBP < 80\n - lactate improved to 3.0\n - vancomycin, cefepime for empiric coverage (tolerating cephalosporin\n despite penicillin allergy) with plans to discontinue cefepime once\n cultures are speciated\n - f/u speciation and sensistivities of blood cultures\n - urine, peritoneal cultures pending\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension. CKs elevated on presentation with flat CKs.\n - continue to trend CKs\n - repeat EKG improved\n - Would hold off on ASA given portal hypertensive gastropathy and no\n statin liver disease.\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - will give additional dose of albumin today\n - continue ocreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine, octreotide and albumin for hepatorenal syndrome\n - holding diuretics given hypotension\n Anemia: Baseline hematocrit in mid 20s. Received 2 U PRBC for hct of\n 18 with hct now back to baseline of 25. Guaiac negative in the ER,\n athough kknown grade I varices and portal hypertensive gastropathy.\n - continue home PPI\n - active type and screen\n - transfusion threshold 21\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - continue iloprost\n Hypothroidism:\n - continue synthroid\n FEN: Low sodium diet, vegetarian diet, tube feeds via dobhoff, replete\n lytes, continue vitamin supplements\n Prophylaxis: Pneumoboots, lactulose, home PPI\n Code Status: Full.\n Communication: (mother, health care proxy) ,\n \n Disposition: pending clinical improvement\n ICU Care\n Nutrition: Tube feeds\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 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": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470143,
"text": "42 yr old male with ESLD well known to by liver & transplant\n services who returns today for mental status changes and rash noted to\n LLE by mother who is primary caretaker and HCP. Pt was ill appearing,\n cachectic and febrile to 104.8R. In the ED, he was noted to have a\n lactate of 6.7, an elevated white count and a 14% bandemia. He received\n 5L IVF, IV abx, diagnostic peritoneal tap, and was pan cultured. He\n was transferred to MICU for further management.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n (past abortion of transplant in Or in d/t elevated\n pulm pressures)\n Action:\n Lactulose as ordered. IV antibx. Cont supportive measures for\n transplant candidacy.\n Response:\n Large liquid stool, guaiac negative. Afebrile.\n Plan:\n Await cx data. Cont. lactulose for 6BM/day. Call out to 10 today.\n .H/O anxiety\n Assessment:\n At times patient is agitated, constantly picking at gown and sheets.\n A&Ox3, easily distracted.\n Action:\n Bedrest, frequent checks. Lactulose given 60ml q6hrs\n Response:\n Easily reoriented and follows commands\n Plan:\n Keep siderails up for safety. Bed alarm on. Cont. lactulose.\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 469970,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 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 09:18 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: 35.7\nC (96.2\n HR: 90 (90 - 118) bpm\n BP: 102/31(47) {81/31(47) - 107/69(86)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 97%\n Total In:\n 4,860 mL\n 1,685 mL\n PO:\n 730 mL\n TF:\n 50 mL\n IVF:\n 60 mL\n 375 mL\n Blood products:\n 530 mL\n Total out:\n 160 mL\n 255 mL\n Urine:\n 10 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,700 mL\n 1,430 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 6.1 g/dL\n 37 K/uL\n 114 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 26 mg/dL\n 98 mEq/L\n 138 mEq/L\n 18.8 %\n 10.3 K/uL\n [image002.jpg]\n 02:38 AM\n WBC\n 10.3\n Hct\n 18.8\n Plt\n 37\n Cr\n 1.8\n Glucose\n 114\n Other labs: PT / PTT / INR:36.5/66.9/3.8, Differential-Neuts:69.0 %,\n Band:14.0 %, Lymph:3.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:5.1\n mmol/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 42 yo male with history of cirrhosis now presenting with significant\n fever and findings consistent with SIRS and multiple suspected sources\n of infection consistent with sepsis. The source remains to be defined,\n however.\n 1)Sepsis-remaining sources are certainly bacteremia with skin source,\n viral illness is possible but less likely and will need to await final\n culture results.\n -Continue ABX\n -Follow lactate\n -Albumin and fluids with good response\n -Repeat CXR\n -Peripheral IV's appear adequate\n -All catheters out\n -Will send stool as possible\n 2)Acute Renal Failure-\n -Likely pre-renal source in addition to exising hepato-renal syndrome\n -Will check FeNa\n -Continue with fluids as needed and albumin with lasix held\n -COntinue Midodrine\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:56 AM 15 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 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": "2148-06-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 469972,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n No events\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Infusions:\n Other medications:\n Lactulose, Octreotide, Midodrine, omeprazole, CaHCO3, Vit D, Zinc,\n Rifamixin, Synthroid, ursodiol, vancomycin, SPA,\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:18 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: 35.7\nC (96.2\n HR: 90 (90 - 118) bpm\n BP: 102/31(47) {81/31(47) - 107/69(86)} mmHg\n RR: 16 (13 - 19) insp/min\n SpO2: 97%\n Total In:\n 4,860 mL\n 1,685 mL\n PO:\n 730 mL\n TF:\n 50 mL\n IVF:\n 60 mL\n 375 mL\n Blood products:\n 530 mL\n Total out:\n 160 mL\n 255 mL\n Urine:\n 10 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,700 mL\n 1,430 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n Gen: NAD\n HEENT: icteric\n Neck: no JVD\n Chest: CTA B\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice, chronic venous stasis changes in LE\n Rectal: Guaiac negative in emergency room\n Labs / Radiology\n 6.1 g/dL\n 37 K/uL\n 114 mg/dL\n 1.8 mg/dL\n 23 mEq/L\n 2.8 mEq/L\n 26 mg/dL\n 98 mEq/L\n 138 mEq/L\n 18.8 %\n 10.3 K/uL\n [image002.jpg]\n 02:38 AM\n WBC\n 10.3\n Hct\n 18.8\n Plt\n 37\n Cr\n 1.8\n Glucose\n 114\n Other labs: PT / PTT / INR:36.5/66.9/3.8, Differential-Neuts:69.0 %,\n Band:14.0 %, Lymph:3.0 %, Mono:4.0 %, Eos:0.0 %, Lactic Acid:5.1\n mmol/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Peritoneal fluid- 35 wbcs\n Micro: 4/4 bottles blood cx- GPCs\n ECG - unchanged compared to prior\n ECG pm- rate-realated TWI in V1-V2\n CXR - low lung volumes, elevated R hemidiaphragm elevated\n Assessment and Plan\n 42 yo male with ESLD due to EtOH and HCV (on tx list) as well as mild\n PHTN, admitted with sepsis due to GPC bacteremia. Source unclear at\n this point.\n Sepsis- GPC bacteremia of unclear source\n -continue vanco + cefepime; plan on narrowing when GPCs are speciated\n -Follow lactate\n -Albumin and fluids with good response\n Anemia- guaiac negative on this admission but hx of prior positive and\n w/ known varices\n -trend serial Hcts\n ESLD- LFTs slightly elevated and coagulopathy worsened\n -vit K if elevated INR worsening\n -check fibrinogen to r/o infection-related DIC\n -inform Hepatology/ Transplant svce of admission\n -cont encephalopathy therapy\n -holding diuresis for volume resuscitation as above\n Acute Renal Failure- preexisting HRS plus prerenal w/ sepsis\n -fluids and colloid as above\n -cont octreotide and midodrine\n Pulm HTN- clinically stable\n -cont iloprost\n -maintain healthy RV preload with volume resuscitation as above\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:56 AM 15 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : To remain in ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 469973,
"text": "Chief Complaint: Fevers\n HPI:\n Mr. is a 42 year old male with a history of end stage liver\n disease on the transplant list, pulmonary hypertension who presents\n from home with fevers and hypotension. Per his mother he was in his\n usual state of health until the afternoon of presentation. He walked\n around the house this afternoon and watched tv. She noticed that his\n forhead was hot at around noon and took his temperature and it was\n elevated at 103. He did not have any specific complaints. Since his\n most recent hospitalization for hepatorenal syndrome his only\n medication change has been restarting lasix. He had a therapeutic\n paracentesis on with removal of 8.5 liters of fluid. He has\n been taking his lactulose as schedule although he had fewer than normal\n bowel movements yesterday and so his dose was increased with good\n effect today. He has continued on his tube feeds for supplemental\n nutrition. He has not had any other fevers. He has not been\n complaining of cough, shortness of breath, nausea, vomiting, abdominal\n pain, dysuria, hematuria or leg pain. His lower extremity edema is at\n baseline. All other review fo systems negative in detail.\n In the ED, initial vs were: T: 103.0 P: 140 BP: not detectable R: 26 O2\n sat 93% on RA. He received 4 liters of normal saline for\n resuscitation. Lacatate was elevated at 6.7 with normal pH. His\n creatinine was 1.8 from baseline of 1.4. WBC count was 12.0 with 14%\n bands. Total bilirubin was slightly elevated from baseline at 12.2.\n He had a CXR which showed very small lung volumes but no definite acute\n process. He had a diagnostic paracentesis without evidence of SBP. He\n received vancomycin and ceftriaxone. He received 60 meq of potassium.\n He had blood and urine cultures sent. He was transferred to the MICU\n for further management.\n On arrival to the MICU he is confused but has no complaints. He is\n alert and talkative.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Clotrimazole 10 mg Troche 5X/DAY (5 Times a Day).\n Ursodiol 600 mg daily\n Miconazole Nitrate powder TID\n Levothyroxine 88 mcg daily\n Rifaximin 400 mg TID\n Simethicone 80 mg QID\n Zinc Sulfate 220 mg daily\n Cholecalciferol 800 mg daily\n Calcium Carbonate 1250 mg daily\n Omeprazole 20 mg daily\n Iloprost 10 mcg/mL nebulization Q4H\n Ciprofloxacin 500 mg daily\n Midodrine 10mg TID\n Lactulose 30-60mL QID (> 6 BMs per day)\n Octreotide 100 mcg Q8H\n Codeine Sulfate 15-30 mg PO Q12H:PRN\n Lasix 40 mg daily\n Magnesium Oxide 400 mg \n Past medical history:\n Family history:\n Social History:\n - End Stage Liver Disease alcohol and hepatitis C. Currently on\n the transplant list. Course complicated by recurrent ascites, SBP,\n pulmonary hypertension. Currently on the transplant list (s/p aborted\n liver transplant given elevated pulmonary pressures in OR )\n - Spontaneous bacterial peritonitis early on Cipro prophylaxis\n - Grade II esophageal varices\n - Recurrent hepatic encephalopathy on vegetarian diet\n - Pulmonary hypertension\n - Hypothyroidism\n - Anxiety disorder\n - History of alcohol and IVDU\n - Osteoporosis of hip and spine per pt\n - Anemia with history of guaiac positive stool\n Mother with diabetes and hypertension. Father with rheumatic heart\n disease.\n Occupation: Unemployed\n Drugs: History of IVDU as teenager\n Tobacco: Remote history\n Alcohol: Previous alcoholism, last drink 11 years ago\n Other: Lives with his mother who provides 24 hour care\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: Tube feeds\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: No(t) Headache\n Psychiatric / Sleep: Delirious\n Allergy / Immunology: No(t) Immunocompromised\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:54 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: 98 (98 - 118) bpm\n BP: 81/57(63) {81/41(51) - 107/66(70)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 97%\n Total In:\n 4,860 mL\n 851 mL\n PO:\n 390 mL\n TF:\n IVF:\n 60 mL\n 211 mL\n Blood products:\n 250 mL\n Total out:\n 160 mL\n 120 mL\n Urine:\n 10 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,700 mL\n 731 mL\n Respiratory\n SpO2: 97%\n Physical Examination\n Vitals: T: 98.3 BP: 88/41 P: 118 R: 18 O2: 98% on RA\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Rectal: Guaiac negative in emergency room\n Labs / Radiology\n 64\n 8.6\n 100\n 1.8\n 28\n 25\n 95\n 2.9\n 137\n 25.9\n 12.0\n [image002.jpg]\n Other labs: PT / PTT / INR:27.5/48.6/2.7, ALT / AST:17/78, Alk Phos / T\n Bili:131/12.2, Amylase / Lipase:/80, Differential-Neuts:72, Band:14,\n Lymph:2, Mono:12, Eos:0, Lactic Acid:6.7, Albumin:3.3\n Fluid analysis / Other labs: Peritoneal Fluid - 38 WBCs\n Imaging: CXR Portable (wet read): low lung volumes, no clear\n infiltrates or volume overload\n Microbiology: Blood, urine and peritoneal cultures pending\n ECG: sinus tachycardia at 136, normal axis, normal itnervals, TWI in\n V1-V4 which are new compared to priors.\n Assessment and Plan\n Assessment and Plan: 42 year old male with a history of end stage\n liver disease on the transplant list, pulmonary hypertension who\n presents from home with fevers and hypotension.\n Sepsis: Unclear etiology. Patient presents with fevers, tachycardia,\n hypotension in the setting of end stage liver disease. WBC count of\n 12.0 with 14% bands. Urinalysis negative. No evidence of SBP on\n paracentesis. Blood and urine cultures are pending. CXR without clear\n evidence of infection. He received vancomycin and ceftriaxone in the\n emergency room. He has now been fluid resuscitated with improvement in\n his blood pressures.\n - favor albumin for resuscitation\n - trend lactate\n - vancomycin, cefepime for empiric coverage (tolerated cephalosporin in\n the emergency room despite penicillin allergy)\n - IVF for MAP < 60, UOP < 30 cc/hr\n - blood, urine, peritoneal cultures\n - repeat CXR in AM\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension.\n - r/o myocardial infarction with serial cardiac enzymes\n - repeat EKG in AM\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - albumin 1 gram/kg x 48 hours\n - continue ocreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - continue iloprost\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine and octreotide for hepatorenal syndrome\n - holding diuretics given hypotension\n Anemia: Baseline hematocrit in mid 20s. Currently stable at Hct stable\n at 25.9. Guaiac negative in the ER, athough kknown grade I varices and\n portal hypertensive gastropathy.\n - continue home PPI\n - trend hct\n - active type and screen\n - consider blood for resusication fluid if necessary\n Hypothroidism:\n - continue synthroid\n FEN: Low sodium diet, vegetarian diet, tube feeds via dobhoff, replete\n lytes, continue vitamin supplements\n Prophylaxis: Pneumoboots, lactulose, home PPI\n Code Status: Full.\n Communication: (mother, health care proxy) ,\n \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Comments: Low protein, vegetarian, low sodium diet and tube feeds\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 PM\n Prophylaxis:\n DVT: Boots(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: ICU\n ------ Protected Section ------\n Micro showed GPC in blood cx.\n Repeat ECG improved with rate control\n 42 year old male with a history of end stage liver disease on the\n transplant list, pulmonary hypertension who presents from home with\n fevers and hypotension.\n Sepsis: Patient presents with fevers, tachycardia, hypotension in the\n setting of end stage liver disease. WBC count of 12.0 with 14% bands.\n Urinalysis negative. No evidence of SBP on paracentesis. Blood\n cultures with 4/4 GPC in clusters. He received vancomycin and\n ceftriaxone in the emergency room. He has now been fluid resuscitated\n with improvement in his blood pressures.\n - giving albumin for resuscitation\n - trend lactate\n - vancomycin, cefepime for empiric coverage (tolerated cephalosporin in\n the emergency room despite penicillin allergy)\n - IVF for MAP < 60, UOP < 30 cc/hr\n - f/u speciation and sensistivities of blood cultures\n - urine, peritoneal cultures pending\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension.\n - r/o myocardial infarction with serial cardiac enzymes\n - repeat EKG improved\n - Would hold off on ASA given portal hypertensive gastropathy and no\n statin liver disease.\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - albumin 1 gram/kg x 48 hours\n - continue ocreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine and octreotide for hepatorenal syndrome\n - holding diuretics given hypotension\n Anemia: Baseline hematocrit in mid 20s. Receiving 2 U PRBC for hct of\n 18. Guaiac negative in the ER, athough kknown grade I varices and\n portal hypertensive gastropathy.\n - continue home PPI\n - post-transfusion hct\n - active type and screen\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - continue iloprost\n Hypothroidism:\n - continue synthroid\n FEN: Low sodium diet, vegetarian diet, tube feeds via dobhoff, replete\n lytes, continue vitamin supplements\n Prophylaxis: Pneumoboots, lactulose, home PPI\n Code Status: Full.\n Communication: (mother, health care proxy) ,\n \n Disposition: pending clinical improvement\n ------ Protected Section Addendum Entered By: , MD\n on: 09:52 ------\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 470126,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:00 AM\n BLOOD CULTURED - At 11:00 AM\n URINE CULTURE - At 01:47 PM\n - blood cx bottles with GPC in pairs and chains.\n - DIC labs with low fibrinogen to 92, but INR and PTT improved.\n - Patient's mental status returned to baseline per mother\n - She states his LE edema has been more persistant so ABD U/S and LENIs\n were ordered without evidence of portal venous thrombosis or DVT\n - CKs elevated with flat troponins\n - UOP remained poor despite 4.9 L positive\n - Liver: continue octreotide & midodrine. hold lasix. lactulose and\n rifaximin titrated to BM, and continue TF.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 69 (69 - 100) bpm\n BP: 103/70(78) {84/31(47) - 114/83(89)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 741 mL\n PO:\n 1,530 mL\n TF:\n 421 mL\n 179 mL\n IVF:\n 1,975 mL\n 562 mL\n Blood products:\n 800 mL\n Total out:\n 475 mL\n 130 mL\n Urine:\n 475 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Labs / Radiology\n 57 K/uL\n 8.5 g/dL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n ALT: 18\n AP: 163\n Tbili: 9.4\n Alb: 3.2\n AST: 77\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Ca: 8.3 Mg: 2.4 P: 1.6\n PT: 30.4\n PTT: 60.2\n INR: 3.0\n Fibrinogen: 97\n Vanco: 33.9\n LIVER U/S\n IMPRESSION:\n 1. Hepatopetal and patent main portal vein.\n 2. Cirrhotic liver with gallbladder wall edema and distention. This\n might be\n related to third spacing, chronic liver disease, and enteric\n status--please\n correlate clinically as to whether there is abdominal pain which may be\n attributable to the gallbladder.\n LENIs\n 1) No DVT.\n 2) Left-sided medial popliteal fossa () cyst.\n Microbiology:\n \n 4/4 bottles of gram positive cocci in pairs and chains\n \n peritoneal fluid cultures negative to date\n \n blood and urine cultures no growth to date\n Assessment and Plan\n 42 year old male with a history of end stage liver disease on the\n transplant list, pulmonary hypertension who presents from home with\n fevers and hypotension.\n Sepsis: Patient presents with fevers, tachycardia, hypotension in the\n setting of end stage liver disease. WBC count of 12.0 on presentation\n with 14% bands. Urinalysis negative. No evidence of SBP on\n paracentesis. Blood cultures with 4/4 GPC in pairs and chains, likely\n streptococcus species. He is now on vancomycin and cefepime. He has\n now been resuscitated with IVF, blood and albumin with stabilization of\n his blood pressures but persistently low urine output.\n - continue albumin and NS for resuscitation as needed for UOP < 30\n cc/hr, SBP < 80\n - lactate improved to 3.0\n - vancomycin, cefepime for empiric coverage (tolerating cephalosporin\n despite penicillin allergy) with plans to discontinue cefepime once\n cultures are speciated\n - f/u speciation and sensistivities of blood cultures\n - urine, peritoneal cultures pending\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension. CKs elevated on presentation with flat CKs.\n - continue to trend CKs\n - repeat EKG improved\n - Would hold off on ASA given portal hypertensive gastropathy and no\n statin liver disease.\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - will give additional dose of albumin today\n - continue ocreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine, octreotide and albumin for hepatorenal syndrome\n - holding diuretics given hypotension\n Anemia: Baseline hematocrit in mid 20s. Received 2 U PRBC for hct of\n 18 with hct now back to baseline of 25. Guaiac negative in the ER,\n athough kknown grade I varices and portal hypertensive gastropathy.\n - continue home PPI\n - active type and screen\n - transfusion threshold 21\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - continue iloprost\n Hypothroidism:\n - continue synthroid\n FEN: Low sodium diet, vegetarian diet, tube feeds via dobhoff, replete\n lytes, continue vitamin supplements\n Prophylaxis: Pneumoboots, lactulose, home PPI\n Code Status: Full.\n Communication: (mother, health care proxy) ,\n \n Disposition: pending clinical improvement\n ICU Care\n Nutrition: Tube feeds\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 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": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 470114,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:00 AM\n BLOOD CULTURED - At 11:00 AM\n URINE CULTURE - At 01:47 PM\n - blood cx bottles with GPC in pairs and chains.\n - DIC labs with low fibrinogen to 92, but INR and PTT improved.\n - Patient's mental status returned to baseline per mother\n - She states his LE edema has been more persistant so ABD U/S and LENIs\n were ordered without evidence of portal venous thrombosis or DVT\n - CK and trops flat\n - UOP remained poor despite 4.9 L positive\n - Liver: continue octreotide & midodrine. hold lasix. lactulose and\n rifaximin titrated to BM, and continue TF.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 69 (69 - 100) bpm\n BP: 103/70(78) {84/31(47) - 114/83(89)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 741 mL\n PO:\n 1,530 mL\n TF:\n 421 mL\n 179 mL\n IVF:\n 1,975 mL\n 562 mL\n Blood products:\n 800 mL\n Total out:\n 475 mL\n 130 mL\n Urine:\n 475 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Labs / Radiology\n 57 K/uL\n 8.5 g/dL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n ALT: 18\n AP: 163\n Tbili: 9.4\n Alb: 3.2\n AST: 77\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Ca: 8.3 Mg: 2.4 P: 1.6\n PT: 30.4\n PTT: 60.2\n INR: 3.0\n Fibrinogen: 97\n Vanco: 33.9\n LIVER U/S\n IMPRESSION:\n 1. Hepatopetal and patent main portal vein.\n 2. Cirrhotic liver with gallbladder wall edema and distention. This\n might be\n related to third spacing, chronic liver disease, and enteric\n status--please\n correlate clinically as to whether there is abdominal pain which may be\n attributable to the gallbladder.\n LENIs\n 1) No DVT.\n 2) Left-sided medial popliteal fossa () cyst.\n Assessment and Plan\n 42 year old male with a history of end stage liver disease on the\n transplant list, pulmonary hypertension who presents from home with\n fevers and hypotension.\n Sepsis: Patient presents with fevers, tachycardia, hypotension in the\n setting of end stage liver disease. WBC count of 12.0 with 14% bands.\n Urinalysis negative. No evidence of SBP on paracentesis. Blood\n cultures with 4/4 GPC in clusters. He received vancomycin and\n ceftriaxone in the emergency room. He has now been fluid resuscitated\n with improvement in his blood pressures.\n - giving albumin for resuscitation\n - trend lactate\n - vancomycin, cefepime for empiric coverage (tolerated cephalosporin in\n the emergency room despite penicillin allergy)\n - IVF for MAP < 60, UOP < 30 cc/hr\n - f/u speciation and sensistivities of blood cultures\n - urine, peritoneal cultures pending\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension.\n - r/o myocardial infarction with serial cardiac enzymes\n - repeat EKG improved\n - Would hold off on ASA given portal hypertensive gastropathy and no\n statin liver disease.\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - albumin 1 gram/kg x 48 hours\n - continue ocreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine and octreotide for hepatorenal syndrome\n - holding diuretics given hypotension\n Anemia: Baseline hematocrit in mid 20s. Receiving 2 U PRBC for hct of\n 18. Guaiac negative in the ER, athough kknown grade I varices and\n portal hypertensive gastropathy.\n - continue home PPI\n - post-transfusion hct\n - active type and screen\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - continue iloprost\n Hypothroidism:\n - continue synthroid\n FEN: Low sodium diet, vegetarian diet, tube feeds via dobhoff, replete\n lytes, continue vitamin supplements\n Prophylaxis: Pneumoboots, lactulose, home PPI\n Code Status: Full.\n Communication: (mother, health care proxy) ,\n \n Disposition: pending clinical improvement\n ICU Care\n Nutrition: Tube feeds\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 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": "Physician ",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 469886,
"text": "Chief Complaint: Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Today-->\n Patient with fever noted at home with T=103 and patient to ED with\n increasing lethargy.\n in ED-\n T=103, HR-130\n 4 liters NS given\n WBC=12 (was 8), 14% bands\n Patient then admitted to ICU for futher care with sepsis and source yet\n to be defined.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hep C and EtOH driven cirrhosis-on transplant list\n Hepato-Renal Syndrome\n Pulmonary Hypertension-mean PAP-33\n Non-contributory\n Occupation: Unemp\n Drugs: none now\n Tobacco: remote\n Alcohol: quit 11 yrs ago\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: Tachycardia\n Heme / Lymph: Anemia\n Flowsheet Data as of 02:34 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: 98 (98 - 118) bpm\n BP: 81/57(63) {81/41(51) - 107/66(70)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 97%\n Total In:\n 4,860 mL\n 780 mL\n PO:\n 390 mL\n TF:\n IVF:\n 60 mL\n 180 mL\n Blood products:\n 210 mL\n Total out:\n 160 mL\n 120 mL\n Urine:\n 10 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,700 mL\n 660 mL\n Respiratory\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 3+, Left: 3+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 64\n 25.9\n 1.8\n 2.9\n 12\n [image002.jpg]\n Other labs: ALT / AST:17/78, Alk Phos / T Bili:/12.8, Band:14\n Fluid analysis / Other labs: Para-minimal WBC\n U/A-no active infection\n Imaging: CXR--No focal infiltrates\n ECG: -New anterior T-wave inversions in the setting of elevated rate\n Assessment and Plan\n 42 yo male with history of cirrhosis now presenting with significant\n fever and findings consistent with SIRS and multiple suspected sources\n of infection consistent with sepsis. The source remains to be defined,\n however.\n 1)Sepsis-remaining sources are certainly bacteremia with skin source,\n viral illness is possible but less likely and will need to await final\n culture results.\n -Continue ABX\n -Follow lactate\n -Albumin and fluids with good response\n -Repeat CXR\n -Peripheral IV's appear adequate\n -All catheters out\n -Will send stool as possible\n 2)Acute Renal Failure-\n -Likely pre-renal source in addition to exising hepato-renal syndrome\n -Will check FeNa\n -Continue with fluids as needed and albumin with lasix held\n -COntinue Midodrine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 11:37 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 469892,
"text": "Chief Complaint: Fevers\n HPI:\n Mr. is a 42 year old male with a history of end stage liver\n disease on the transplant list, pulmonary hypertension who presents\n from home with fevers and hypotension. Per his mother he was in his\n usual state of health until the afternoon of presentation. He walked\n around the house this afternoon and watched tv. She noticed that his\n forhead was hot at around noon and took his temperature and it was\n elevated at 103. He did not have any specific complaints. Since his\n most recent hospitalization for hepatorenal syndrome his only\n medication change has been restarting lasix. He had a therapeutic\n paracentesis on with removal of 8.5 liters of fluid. He has\n been taking his lactulose as schedule although he had fewer than normal\n bowel movements yesterday and so his dose was increased with good\n effect today. He has continued on his tube feeds for supplemental\n nutrition. He has not had any other fevers. He has not been\n complaining of cough, shortness of breath, nausea, vomiting, abdominal\n pain, dysuria, hematuria or leg pain. His lower extremity edema is at\n baseline. All other review fo systems negative in detail.\n In the ED, initial vs were: T: 103.0 P: 140 BP: not detectable R: 26 O2\n sat 93% on RA. He received 4 liters of normal saline for\n resuscitation. Lacatate was elevated at 6.7 with normal pH. His\n creatinine was 1.8 from baseline of 1.4. WBC count was 12.0 with 14%\n bands. Total bilirubin was slightly elevated from baseline at 12.2.\n He had a CXR which showed very small lung volumes but no definite acute\n process. He had a diagnostic paracentesis without evidence of SBP. He\n received vancomycin and ceftriaxone. He received 60 meq of potassium.\n He had blood and urine cultures sent. He was transferred to the MICU\n for further management.\n On arrival to the MICU he is confused but has no complaints. He is\n alert and talkative.\n Patient admitted from: ER\n History obtained from Patient, Family / Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Clotrimazole 10 mg Troche 5X/DAY (5 Times a Day).\n Ursodiol 600 mg daily\n Miconazole Nitrate powder TID\n Levothyroxine 88 mcg daily\n Rifaximin 400 mg TID\n Simethicone 80 mg QID\n Zinc Sulfate 220 mg daily\n Cholecalciferol 800 mg daily\n Calcium Carbonate 1250 mg daily\n Omeprazole 20 mg daily\n Iloprost 10 mcg/mL nebulization Q4H\n Ciprofloxacin 500 mg daily\n Midodrine 10mg TID\n Lactulose 30-60mL QID (> 6 BMs per day)\n Octreotide 100 mcg Q8H\n Codeine Sulfate 15-30 mg PO Q12H:PRN\n Lasix 40 mg daily\n Magnesium Oxide 400 mg \n Past medical history:\n Family history:\n Social History:\n - End Stage Liver Disease alcohol and hepatitis C. Currently on\n the transplant list. Course complicated by recurrent ascites, SBP,\n pulmonary hypertension. Currently on the transplant list (s/p aborted\n liver transplant given elevated pulmonary pressures in OR )\n - Spontaneous bacterial peritonitis early on Cipro prophylaxis\n - Grade II esophageal varices\n - Recurrent hepatic encephalopathy on vegetarian diet\n - Pulmonary hypertension\n - Hypothyroidism\n - Anxiety disorder\n - History of alcohol and IVDU\n - Osteoporosis of hip and spine per pt\n - Anemia with history of guaiac positive stool\n Mother with diabetes and hypertension. Father with rheumatic heart\n disease.\n Occupation: Unemployed\n Drugs: History of IVDU as teenager\n Tobacco: Remote history\n Alcohol: Previous alcoholism, last drink 11 years ago\n Other: Lives with his mother who provides 24 hour care\n Review of systems:\n Constitutional: Fatigue, Fever\n Ear, Nose, Throat: Dry mouth, OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: Tube feeds\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, No(t) Foley\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: Anemia, Coagulopathy\n Neurologic: No(t) Headache\n Psychiatric / Sleep: Delirious\n Allergy / Immunology: No(t) Immunocompromised\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:54 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: 98 (98 - 118) bpm\n BP: 81/57(63) {81/41(51) - 107/66(70)} mmHg\n RR: 13 (13 - 19) insp/min\n SpO2: 97%\n Total In:\n 4,860 mL\n 851 mL\n PO:\n 390 mL\n TF:\n IVF:\n 60 mL\n 211 mL\n Blood products:\n 250 mL\n Total out:\n 160 mL\n 120 mL\n Urine:\n 10 mL\n 120 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,700 mL\n 731 mL\n Respiratory\n SpO2: 97%\n Physical Examination\n Vitals: T: 98.3 BP: 88/41 P: 118 R: 18 O2: 98% on RA\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Rectal: Guaiac negative in emergency room\n Labs / Radiology\n 64\n 8.6\n 100\n 1.8\n 28\n 25\n 95\n 2.9\n 137\n 25.9\n 12.0\n [image002.jpg]\n Other labs: PT / PTT / INR:27.5/48.6/2.7, ALT / AST:17/78, Alk Phos / T\n Bili:131/12.2, Amylase / Lipase:/80, Differential-Neuts:72, Band:14,\n Lymph:2, Mono:12, Eos:0, Lactic Acid:6.7, Albumin:3.3\n Fluid analysis / Other labs: Peritoneal Fluid - 38 WBCs\n Imaging: CXR Portable (wet read): low lung volumes, no clear\n infiltrates or volume overload\n Microbiology: Blood, urine and peritoneal cultures pending\n ECG: sinus tachycardia at 136, normal axis, normal itnervals, TWI in\n V1-V4 which are new compared to priors.\n Assessment and Plan\n Assessment and Plan: 42 year old male with a history of end stage\n liver disease on the transplant list, pulmonary hypertension who\n presents from home with fevers and hypotension.\n Sepsis: Unclear etiology. Patient presents with fevers, tachycardia,\n hypotension in the setting of end stage liver disease. WBC count of\n 12.0 with 14% bands. Urinalysis negative. No evidence of SBP on\n paracentesis. Blood and urine cultures are pending. CXR without clear\n evidence of infection. He received vancomycin and ceftriaxone in the\n emergency room. He has now been fluid resuscitated with improvement in\n his blood pressures.\n - favor albumin for resuscitation\n - trend lactate\n - vancomycin, cefepime for empiric coverage (tolerated cephalosporin in\n the emergency room despite penicillin allergy)\n - IVF for MAP < 60, UOP < 30 cc/hr\n - blood, urine, peritoneal cultures\n - repeat CXR in AM\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension.\n - r/o myocardial infarction with serial cardiac enzymes\n - repeat EKG in AM\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - albumin 1 gram/kg x 48 hours\n - continue ocreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - continue iloprost\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine and octreotide for hepatorenal syndrome\n - holding diuretics given hypotension\n Anemia: Baseline hematocrit in mid 20s. Currently stable at Hct stable\n at 25.9. Guaiac negative in the ER, athough kknown grade I varices and\n portal hypertensive gastropathy.\n - continue home PPI\n - trend hct\n - active type and screen\n - consider blood for resusication fluid if necessary\n Hypothroidism:\n - continue synthroid\n FEN: Low sodium diet, vegetarian diet, tube feeds via dobhoff, replete\n lytes, continue vitamin supplements\n Prophylaxis: Pneumoboots, lactulose, home PPI\n Code Status: Full.\n Communication: (mother, health care proxy) ,\n \n Disposition: pending clinical improvement\n ICU Care\n Nutrition:\n Comments: Low protein, vegetarian, low sodium diet and tube feeds\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 PM\n Prophylaxis:\n DVT: Boots(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: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 469968,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n (past abortion of transplant in Or d/t elevated pulm pressures)\n Action:\n Lactulose as ordered. IV antibx. Cont supportive measures for\n transplant candidacy\n Response:\n No stool. afebrile\n Plan:\n Await cx data. Cont. lactulose for 6BM/day. Stool needs to be sent for\n c/diff.\n Anemia, chronic\n Assessment:\n Hx of anemia & esophageal varices. Follows vegetarian diet. Hct 25.9 &\n BP 90-100/40-50\n Action:\n Gave 1 unit of PRBC\ns over 3 hours this am. Albumin X2 (last dose\n tonight) Midodrine 10mg given PO for hypotension. Octeotide 100mcg give\n IVP.\n Response:\n Post-PRBC\ns Hct pending. BP stable 100/60\n Plan:\n Follow Hct & s/s of hypovolemia. 1/2NS @ 75ml/hr when blood not\n infusing. Guaiac stools.\n .H/O anxiety\n Assessment:\n At times patient is agitated, constantly picking at gown and sheets.\n A&Ox3, easily distracted.\n Action:\n Bedrest, frequent checks. Lactulose given 60ml q6hrs\n Response:\n Easily reoriented and follows commands\n Plan:\n Keep siderails up for safety. Bed alarm on. Cont. lactulose.\n RN CCRN\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 469943,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n .H/O anxiety\n Assessment:\n Pt arrived mod agitated, restless, and pulling at garments/lines. Hx\n hepatic encephalopathy\n Action:\n Pt maintained in bed and freq reassurance/reorientation given\n throughout night; mitten restraints applied for line safety of dobhoff;\n lactulose given\n Response:\n Pt responsive to low, non-accusatory tone; mittens soon removed as pt\n not attempting to pull at lines. Pt orientated to person, month, and\n reason for admission as of 0500hrs. cont to talk aloud and escalating\n easily at times.\n Plan:\n SIderails elevated to maintain safety. Mother to arrive this am and\n provide assistance with pt\ns emotional needs. Orient prn. Lactulose\n around the clock\n Anemia, chronic\n Assessment:\n Hx of anemia in past with hct from high teens to high 20\ns; follows\n vegetarian diet. Hx of esophageal varices; Hct 25.9 in EW. Pt oral\n mucosa very dry, drinking large amts g.ale; hypotensive\n Action:\n Received total of 5L IVF and 60 G of albumin; Am labs drawn; ordered\n for midodrine. Ocreotide given.\n Response:\n Am hct 18.8; so signs of bleeding, no stool this shift. Remains\n hypotensive to low-mid 80\ns, resident notified.\n Plan:\n Follow Hcts; repeat hct late am/early afternoon. GAS. Enc po\n transfuse one unit PRBC\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n ; aborted tx in Or d/t elevated pulm pressures\n Action:\n Lactulose as ordered. Begun on IV antibx. Cont supportive measures for\n transplant candidacy\n Response:\n No stool. afebrile\n Plan:\n Await cx data. Lactulose, dose by # Bms.\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 469944,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n .H/O anxiety\n Assessment:\n Pt arrived mod agitated, restless, and pulling at garments/lines. Hx\n hepatic encephalopathy\n Action:\n Pt maintained in bed and freq reassurance/reorientation given\n throughout night; mitten restraints applied for line safety of dobhoff;\n lactulose given\n Response:\n Pt responsive to low, non-accusatory tone; mittens soon removed as pt\n not attempting to pull at lines. Pt orientated to person, month, and\n reason for admission as of 0500hrs. cont to talk aloud and escalating\n easily at times.\n Plan:\n SIderails elevated to maintain safety. Mother to arrive this am and\n provide assistance with pt\ns emotional needs. Orient prn. Lactulose\n around the clock\n Anemia, chronic\n Assessment:\n Hx of anemia in past with hct from high teens to high 20\ns; follows\n vegetarian diet. Hx of esophageal varices; Hct 25.9 in EW. Pt oral\n mucosa very dry, drinking large amts g.ale; hypotensive\n Action:\n Received total of 5L IVF and 60 G of albumin; Am labs drawn; ordered\n for midodrine. Ocreotide given.\n Response:\n Am hct 18.8; so signs of bleeding, no stool this shift. Remains\n hypotensive to low-mid 80\ns, resident notified.\n Plan:\n Follow Hcts; repeat hct late am/early afternoon. GAS. Enc po\n transfuse one unit PRBC\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n ; aborted tx in Or d/t elevated pulm pressures\n Action:\n Lactulose as ordered. Begun on IV antibx. Cont supportive measures for\n transplant candidacy\n Response:\n No stool. afebrile\n Plan:\n Await cx data. Lactulose, dose by # Bms.\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 469945,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n .H/O anxiety\n Assessment:\n Pt arrived mod agitated, restless, and pulling at garments/lines. Hx\n hepatic encephalopathy\n Action:\n Pt maintained in bed and freq reassurance/reorientation given\n throughout night; mitten restraints applied for line safety of dobhoff;\n lactulose given\n Response:\n Pt responsive to low, non-accusatory tone; mittens soon removed as pt\n not attempting to pull at lines. Pt orientated to person, month, and\n reason for admission as of 0500hrs. cont to talk aloud and escalating\n easily at times.\n Plan:\n SIderails elevated to maintain safety. Mother to arrive this am and\n provide assistance with pt\ns emotional needs. Orient prn. Lactulose\n around the clock\n Anemia, chronic\n Assessment:\n Hx of anemia in past with hct from high teens to high 20\ns; follows\n vegetarian diet. Hx of esophageal varices; Hct 25.9 in EW. Pt oral\n mucosa very dry, drinking large amts g.ale; hypotensive\n Action:\n Received total of 5L IVF and 60 G of albumin; Am labs drawn; ordered\n for midodrine. Ocreotide given.\n Response:\n Am hct 18.8; so signs of bleeding, no stool this shift. Remains\n hypotensive to low-mid 80\ns, resident notified.\n Plan:\n Follow Hcts; repeat hct late am/early afternoon. GAS. Enc po\n transfuse one unit PRBC\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n ; aborted tx in Or d/t elevated pulm pressures\n Action:\n Lactulose as ordered. Begun on IV antibx. Cont supportive measures for\n transplant candidacy\n Response:\n No stool. afebrile\n Plan:\n Await cx data. Lactulose, dose by # Bms.\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 470104,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:00 AM\n BLOOD CULTURED - At 11:00 AM\n URINE CULTURE - At 01:47 PM\n - blood cx bottles with GPC in pairs and chains.\n - DIC labs with low fibrinogen to 92, but INR and PTT improved.\n - Patient's mental status returned to baseline per mother\n - She states his LE edema has been more persistant so ABD U/S and LENIs\n were ordered without evidence of portal venous thrombosis or DVT\n - CK and trops flat\n - UOP remained poor despite 4.9 L positive\n - Liver: continue octreotide & midodrine. hold lasix. lactulose and\n rifaximin titrated to BM, and continue TF.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 69 (69 - 100) bpm\n BP: 103/70(78) {84/31(47) - 114/83(89)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 741 mL\n PO:\n 1,530 mL\n TF:\n 421 mL\n 179 mL\n IVF:\n 1,975 mL\n 562 mL\n Blood products:\n 800 mL\n Total out:\n 475 mL\n 130 mL\n Urine:\n 475 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Labs / Radiology\n 57 K/uL\n 8.5 g/dL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n ALT: 18\n AP: 163\n Tbili: 9.4\n Alb: 3.2\n AST: 77\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Ca: 8.3 Mg: 2.4 P: 1.6\n PT: 30.4\n PTT: 60.2\n INR: 3.0\n Fibrinogen: 97\n Vanco: 33.9\n Assessment and Plan\n .H/O ANXIETY\n ANEMIA, CHRONIC\n CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition: Tube feeds\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 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": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 470105,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:00 AM\n BLOOD CULTURED - At 11:00 AM\n URINE CULTURE - At 01:47 PM\n - blood cx bottles with GPC in pairs and chains.\n - DIC labs with low fibrinogen to 92, but INR and PTT improved.\n - Patient's mental status returned to baseline per mother\n - She states his LE edema has been more persistant so ABD U/S and LENIs\n were ordered without evidence of portal venous thrombosis or DVT\n - CK and trops flat\n - UOP remained poor despite 4.9 L positive\n - Liver: continue octreotide & midodrine. hold lasix. lactulose and\n rifaximin titrated to BM, and continue TF.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 69 (69 - 100) bpm\n BP: 103/70(78) {84/31(47) - 114/83(89)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 741 mL\n PO:\n 1,530 mL\n TF:\n 421 mL\n 179 mL\n IVF:\n 1,975 mL\n 562 mL\n Blood products:\n 800 mL\n Total out:\n 475 mL\n 130 mL\n Urine:\n 475 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Labs / Radiology\n 57 K/uL\n 8.5 g/dL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n ALT: 18\n AP: 163\n Tbili: 9.4\n Alb: 3.2\n AST: 77\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Ca: 8.3 Mg: 2.4 P: 1.6\n PT: 30.4\n PTT: 60.2\n INR: 3.0\n Fibrinogen: 97\n Vanco: 33.9\n Assessment and Plan\n 42 year old male with a history of end stage liver disease on the\n transplant list, pulmonary hypertension who presents from home with\n fevers and hypotension.\n Sepsis: Patient presents with fevers, tachycardia, hypotension in the\n setting of end stage liver disease. WBC count of 12.0 with 14% bands.\n Urinalysis negative. No evidence of SBP on paracentesis. Blood\n cultures with 4/4 GPC in clusters. He received vancomycin and\n ceftriaxone in the emergency room. He has now been fluid resuscitated\n with improvement in his blood pressures.\n - giving albumin for resuscitation\n - trend lactate\n - vancomycin, cefepime for empiric coverage (tolerated cephalosporin in\n the emergency room despite penicillin allergy)\n - IVF for MAP < 60, UOP < 30 cc/hr\n - f/u speciation and sensistivities of blood cultures\n - urine, peritoneal cultures pending\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension.\n - r/o myocardial infarction with serial cardiac enzymes\n - repeat EKG improved\n - Would hold off on ASA given portal hypertensive gastropathy and no\n statin liver disease.\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - albumin 1 gram/kg x 48 hours\n - continue ocreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine and octreotide for hepatorenal syndrome\n - holding diuretics given hypotension\n Anemia: Baseline hematocrit in mid 20s. Receiving 2 U PRBC for hct of\n 18. Guaiac negative in the ER, athough kknown grade I varices and\n portal hypertensive gastropathy.\n - continue home PPI\n - post-transfusion hct\n - active type and screen\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - continue iloprost\n Hypothroidism:\n - continue synthroid\n FEN: Low sodium diet, vegetarian diet, tube feeds via dobhoff, replete\n lytes, continue vitamin supplements\n Prophylaxis: Pneumoboots, lactulose, home PPI\n Code Status: Full.\n Communication: (mother, health care proxy) ,\n \n Disposition: pending clinical improvement\n ICU Care\n Nutrition: Tube feeds\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 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": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 470102,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:00 AM\n BLOOD CULTURED - At 11:00 AM\n URINE CULTURE - At 01:47 PM\n - blood cx bottles with GPC in pairs and chains.\n - DIC labs with low fibrinogen to 92, but INR and PTT improved.\n - Patient's mental status returned to baseline per mother\n - She states his LE edema has been more persistant so ABD U/S and LENIs\n were ordered without evidence of portal venous thrombosis or DVT\n - CK and trops flat\n - UOP remained poor despite 4.9 L positive\n - Liver: continue octreotide & midodrine. hold lasix. lactulose and\n rifaximin titrated to BM, and continue TF.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 69 (69 - 100) bpm\n BP: 103/70(78) {84/31(47) - 114/83(89)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 741 mL\n PO:\n 1,530 mL\n TF:\n 421 mL\n 179 mL\n IVF:\n 1,975 mL\n 562 mL\n Blood products:\n 800 mL\n Total out:\n 475 mL\n 130 mL\n Urine:\n 475 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 57 K/uL\n 8.5 g/dL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n ALT: 18\n AP: 163\n Tbili: 9.4\n Alb: 3.2\n AST: 77\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Ca: 8.3 Mg: 2.4 P: 1.6\n PT: 30.4\n PTT: 60.2\n INR: 3.0\n Fibrinogen: 97\n Vanco: 33.9\n Assessment and Plan\n .H/O ANXIETY\n ANEMIA, CHRONIC\n CIRRHOSIS OF LIVER, ALCOHOLIC\n ICU Care\n Nutrition: Tube feeds\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 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": "Nursing",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470015,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n (past abortion of transplant in Or in d/t elevated\n pulm pressures)\n Action:\n Lactulose as ordered. IV antibx. Cont supportive measures for\n transplant candidacy. Ultrasound done on abdomen & LE.\n Response:\n Large liquid stool, guaiac negative. Afebrile.\n Plan:\n Await cx data. Cont. lactulose for 6BM/day. Stool needs to be sent for\n c/diff.\n Anemia, chronic\n Assessment:\n Hx of anemia & esophageal varices. Follows vegetarian diet. Hct 25.9 &\n BP 90-100/40-50\n Action:\n Gave 1 unit of PRBC\ns over 3 hours this am. Albumin X2 (last dose\n tonight) Midodrine 10mg given PO for hypotension. Octeotide 100mcg give\n IVP.\n Response:\n Post-PRBC\ns Hct 25.8. BP stable 100/60\n Plan:\n Follow Hct & s/s of hypovolemia. 1/2NS @ 75ml/hr when blood not\n infusing. Guaiac stools.\n .H/O anxiety\n Assessment:\n At times patient is agitated, constantly picking at gown and sheets.\n A&Ox3, easily distracted.\n Action:\n Bedrest, frequent checks. Lactulose given 60ml q6hrs\n Response:\n Easily reoriented and follows commands\n Plan:\n Keep siderails up for safety. Bed alarm on. Cont. lactulose.\n RN CCRN\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 469916,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n .H/O anxiety\n Assessment:\n Pt arrived mod agitated, restless, and pulling at garments/lines. Hx\n hepatic encephalopathy\n Action:\n Pt maintained in bed and freq reassurance/reorientation given\n throughout night; mitten restraints applied for line safety of dobhoff;\n lactulose given\n Response:\n Pt responsive to low, non-accusatory tone; mittens soon removed as pt\n not attempting to pull at lines. Pt orientated to person, month, and\n reason for admission as of 0500hrs. cont to talk aloud and escalating\n easily at times.\n Plan:\n SIderails elevated to maintain safety. Mother to arrive this am and\n provide assistance with pt\ns emotional needs. Orient prn. Lactulose\n around the clock\n Anemia, chronic\n Assessment:\n Hx of anemia in past with hct from high teens to high 20\ns; follows\n vegetarian diet. Hx of esophageal varices; Hct 25.9 in EW. Pt oral\n mucosa very dry, drinking large amts g.ale; hypotensive\n Action:\n Received total of 5L IVF and 60 G of albumin; Am labs drawn; ordered\n for midodrine. Ocreotide given.\n Response:\n Am hct 18.8; so signs of bleeding, no stool this shift. Remains\n hypotensive to low-mid 80\ns, resident notified.\n Plan:\n Follow Hcts; repeat hct late am/early afternoon. GAS. Enc po\n transfuse one unit PRBC\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n ; aborted tx in Or d/t elevated pulm pressures\n Action:\n Lactulose as ordered. Begun on IV antibx. Cont supportive measures for\n transplant candidacy\n Response:\n No stool. afebrile\n Plan:\n Await cx data. Lactulose, dose by # Bms.\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470080,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n (past abortion of transplant in Or in d/t elevated\n pulm pressures)\n Action:\n Lactulose as ordered. IV antibx. Cont supportive measures for\n transplant candidacy.\n Response:\n Large liquid stool, guaiac negative. Afebrile.\n Plan:\n Await cx data. Cont. lactulose for 6BM/day. Call out to 10 today.\n .H/O anxiety\n Assessment:\n At times patient is agitated, constantly picking at gown and sheets.\n A&Ox3, easily distracted.\n Action:\n Bedrest, frequent checks. Lactulose given 60ml q6hrs\n Response:\n Easily reoriented and follows commands\n Plan:\n Keep siderails up for safety. Bed alarm on. Cont. lactulose.\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 470152,
"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 afebrile overnight. remains oliguric\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:30 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 09:00 AM\n Other medications:\n lactulose, rifaximin, octreotide, midodrine, omeprazole, CaHCO3,\n synthroid, ursodiol, iloprost, 25% albumin qd\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.2\nC (95.3\n HR: 80 (69 - 100) bpm\n BP: 111/72(80) {91/51(63) - 114/74(84)} mmHg\n RR: 15 (10 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 1,719 mL\n PO:\n 1,530 mL\n 360 mL\n TF:\n 421 mL\n 307 mL\n IVF:\n 1,975 mL\n 802 mL\n Blood products:\n 800 mL\n 250 mL\n Total out:\n 475 mL\n 210 mL\n Urine:\n 475 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 1,509 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: B bases)\n Abdominal: Soft, Bowel sounds present, Distended, shifting dullness and\n fluid wave\n Extremities: Right: 3+, Left: 3+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Not assessed, Tone: Not assessed, + asterixis\n Labs / Radiology\n 8.5 g/dL\n 57 K/uL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n Other labs: PT / PTT / INR:30.4/60.2/3.0, CK / CKMB /\n Troponin-T:802/7/0.03, ALT / AST:18/77, Alk Phos / T Bili:163/9.4,\n Differential-Neuts:69.0 %, Band:14.0 %, Lymph:3.0 %, Mono:4.0 %,\n Eos:0.0 %, Fibrinogen:97 mg/dL, Lactic Acid:3.0 mmol/L, Albumin:3.2\n g/dL, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:1.6 mg/dL\n Imaging: B LENIs- no DVT\n RUQ US- no clot, cirrhotic liver\n Microbiology: blood- 4/4 bottles GPCs\n blood- pending\n Assessment and Plan\n 42 yo male with ESLD due to EtOH and HCV (on tx list) as well as mild\n PHTN, admitted with sepsis due to GPC bacteremia. Source unclear at\n this point.\n Sepsis- GPC bacteremia of unclear source\n -continue vanco + cefepime; plan on narrowing when GPCs are speciated\n -Albumin and fluids with good response in UOP and lactate\n Anemia- guaiac negative on this admission but hx of prior positive and\n w/ known varices\n -trend serial Hcts, transfuse for hct less than 21\n ESLD- LFTs slightly elevated and coagulopathy worsened\n -vit K if elevated INR worsening\n -Hepatology following\n -cont encephalopathy therapy\n -holding diuresis for volume resuscitation as above\n Acute Renal Failure- preexisting HRS plus prerenal w/ sepsis\n -fluids and colloid as above\n -cont octreotide and midodrine\n Pulm HTN- clinically stable\n -cont iloprost\n -maintain healthy RV preload with volume resuscitation as above\n Sleep disordered breathing- known hx of OSA based on PSG\n -CPAP w/ full-face mask pressure setting \n -will ensure this is resumed prior to discharge, as it may help w/ pulm\n HTN\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:56 AM 30 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 11:37 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 Total time spent: 30 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 470153,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:00 AM\n BLOOD CULTURED - At 11:00 AM\n URINE CULTURE - At 01:47 PM\n - blood cx bottles with GPC in pairs and chains.\n - DIC labs with low fibrinogen to 92, but INR and PTT improved.\n - Patient's mental status returned to baseline per mother.\n - LE edema persistant per mother so abd U/S and LENIs were ordered\n without evidence of portal venous thrombosis or DVT\n - CKs elevated with flat troponins\n - UOP remained poor despite 4.9 L positive\n - Liver: continue octreotide & midodrine. hold lasix. lactulose and\n rifaximin titrated to BM, and continue TF.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 69 (69 - 100) bpm\n BP: 103/70(78) {84/31(47) - 114/83(89)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 741 mL\n PO:\n 1,530 mL\n TF:\n 421 mL\n 179 mL\n IVF:\n 1,975 mL\n 562 mL\n Blood products:\n 800 mL\n Total out:\n 475 mL\n 130 mL\n Urine:\n 475 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Labs / Radiology\n 57 K/uL\n 8.5 g/dL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n PT: 30.4\n PTT: 60.2\n INR: 3.0\n Ca: 8.3 Mg: 2.4 P: 1.6\n ALT: 18\n AP: 163\n Tbili: 9.4\n Alb: 3.2\n AST: 77\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Fibrinogen: 97\n Vanco: 33.9\n Liver U/S\n 1. Hepatopetal and patent main portal vein.\n 2. Cirrhotic liver with gallbladder wall edema and distention. This\n might be related to third spacing, chronic liver disease, and enteric\n status--please correlate clinically as to whether there is abdominal\n pain which may be attributable to the gallbladder.\n LENIs\n 1) No DVT.\n 2) Left-sided medial popliteal fossa () cyst.\n Microbiology:\n \n 4/4 bottles of gram positive cocci in pairs and chains\n \n peritoneal fluid cultures negative to date\n \n blood and urine cultures no growth to date\n Assessment and Plan\n 42 year old male with a history of end stage liver disease on the\n transplant list, pulmonary hypertension who presents from home with\n fevers and hypotension.\n Sepsis: Patient presents with fevers, tachycardia, hypotension in the\n setting of end stage liver disease. WBC count of 12.0 on presentation\n with 14% bands. Urinalysis negative. No evidence of SBP on\n paracentesis. Blood cultures with 4/4 GPC in pairs and chains;\n currently on vancomycin and cefepime; source unclear but may have had\n translocation of gut bacteria. He has now been resuscitated with IVF,\n blood and albumin with stabilization of his blood pressures but\n persistently low urine output.\n - continue albumin and NS for resuscitation conservatively as needed\n for UOP < 30 cc/hr, SBP < 80\n - lactate improved to 3.0\n - cont vancomycin, cefepime for empiric coverage pending speciation\n - f/u speciation and sensistivities of blood cultures\n - urine, peritoneal cultures pending\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension. CKs elevated on presentation with flat trop.\n - continue to trend CKs\n - repeat EKG improved\n - Would hold off on ASA given portal hypertensive gastropathy and no\n statin liver disease.\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - will give additional dose of albumin today\n - continue octreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine, octreotide and albumin for hepatorenal syndrome\n - holding diuretics given hypotension\n - no need to paracentesis for now\n Anemia: Baseline hematocrit in mid 20s. Received 2 U PRBC for hct of\n 18 with hct now back to baseline of 25. Guaiac negative in the ER,\n athough kknown grade I varices and portal hypertensive gastropathy.\n - continue home PPI\n - active type and screen\n - transfusion threshold of 21\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - O2 for comfort\n - continue iloprost\n Hypothroidism:\n - continue synthroid\n ICU Care\n Nutrition: Low sodium diet, vegetarian diet, tube feeds via dobhoff,\n replete lytes, continue vitamin supplements\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: (mother, health care proxy)\n , \n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 470154,
"text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 09:00 AM\n BLOOD CULTURED - At 11:00 AM\n URINE CULTURE - At 01:47 PM\n - blood cx bottles with GPC in pairs and chains.\n - DIC labs with low fibrinogen to 92, but INR and PTT improved.\n - Patient's mental status returned to baseline per mother.\n - LE edema persistant per mother so abd U/S and LENIs were ordered\n without evidence of portal venous thrombosis or DVT\n - CKs elevated with flat troponins\n - UOP remained poor despite 4.9 L positive\n - Liver: continue octreotide & midodrine. hold lasix. lactulose and\n rifaximin titrated to BM, and continue TF.\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 69 (69 - 100) bpm\n BP: 103/70(78) {84/31(47) - 114/83(89)} mmHg\n RR: 11 (11 - 18) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 741 mL\n PO:\n 1,530 mL\n TF:\n 421 mL\n 179 mL\n IVF:\n 1,975 mL\n 562 mL\n Blood products:\n 800 mL\n Total out:\n 475 mL\n 130 mL\n Urine:\n 475 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 611 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///25/\n Physical Examination\n General: Alert, oriented to , not time\n HEENT: Sclera icteric, MM dry, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi\n CV: Tachycardic, regular rhythm, + RV heave, s1 + s2, no murmurs, rubs,\n gallops\n Abdomen: soft, non-tender, distended, + fluid wave, no rebound\n tenderness or guarding\n GU: foley draining dark urine\n Ext: warm, well perfused, unable to appreciate pulses, 3+ lower\n extremity edema, + clubbing, no cyanosis\n Neurologic: + asterixis\n Skin: + jaundice\n Labs / Radiology\n 57 K/uL\n 8.5 g/dL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n PT: 30.4\n PTT: 60.2\n INR: 3.0\n Ca: 8.3 Mg: 2.4 P: 1.6\n ALT: 18\n AP: 163\n Tbili: 9.4\n Alb: 3.2\n AST: 77\n LDH:\n Dbili:\n TProt:\n :\n Lip:\n Fibrinogen: 97\n Vanco: 33.9\n Liver U/S\n 1. Hepatopetal and patent main portal vein.\n 2. Cirrhotic liver with gallbladder wall edema and distention. This\n might be related to third spacing, chronic liver disease, and enteric\n status--please correlate clinically as to whether there is abdominal\n pain which may be attributable to the gallbladder.\n LENIs\n 1) No DVT.\n 2) Left-sided medial popliteal fossa () cyst.\n Microbiology:\n \n 4/4 bottles of gram positive cocci in pairs and chains\n \n peritoneal fluid cultures negative to date\n \n blood and urine cultures no growth to date\n Assessment and Plan\n 42 year old male with a history of end stage liver disease on the\n transplant list, pulmonary hypertension who presents from home with\n fevers and hypotension.\n Sepsis: Patient presents with fevers, tachycardia, hypotension in the\n setting of end stage liver disease. WBC count of 12.0 on presentation\n with 14% bands. Urinalysis negative. No evidence of SBP on\n paracentesis. Blood cultures with 4/4 GPC in pairs and chains;\n currently on vancomycin and cefepime; source unclear but may have had\n translocation of gut bacteria. He has now been resuscitated with IVF,\n blood and albumin with stabilization of his blood pressures but\n persistently low urine output.\n - continue albumin and NS for resuscitation conservatively as needed\n for UOP < 30 cc/hr, SBP < 80\n - lactate improved to 3.0\n - cont vancomycin, cefepime for empiric coverage pending speciation\n - f/u speciation and sensistivities of blood cultures\n - urine, peritoneal cultures pending\n - stool for c. diff\n EKG Changes: No complaints of chest pain or shortness of breath.\n Likely related to demand in the setting of profound tachycardia and\n hypotension. CKs elevated on presentation with flat trop.\n - continue to trend CKs\n - repeat EKG improved\n - Would hold off on ASA given portal hypertensive gastropathy and no\n statin liver disease.\n Hepatorenal Syndrome: Recent admission for acceleration of hepatorenal\n syndrome requiring octreotide and midodrine. Currently creatinine is\n 1.8 from 1.4 on last discharge. Mild worsening creatine likely\n secondary to hyperperfusion in the setting of infection. No evidence\n of GI bleeding or peritonitis.\n - will give additional dose of albumin today\n - continue octreotide and midodrine\n - trend creatinine\n - renally dose medications\n - hold diuretics\n Cirrhosis/End Stage Liver Disease: Secondary to alcohol abuse and\n hepatitis C. Currently on transplant list. No evidence of SBP on\n paracentesis from emergency room. He was encephalopathic on arrival\n but this has improved with IV hydration.\n - holding ciprofloxacin while on broad spectrum empiric antibiotics\n - continue lactulose and rifaximin\n - continue midodrine, octreotide and albumin for hepatorenal syndrome\n - holding diuretics given hypotension\n - no need to paracentesis for now\n Anemia: Baseline hematocrit in mid 20s. Received 2 U PRBC for hct of\n 18 with hct now back to baseline of 25. Guaiac negative in the ER,\n athough kknown grade I varices and portal hypertensive gastropathy.\n - continue home PPI\n - active type and screen\n - transfusion threshold of 21\n Pulmonary Hypertension: Pulmonary artery pressures on recent TTE were\n 35 mmHg but recent right heart catherization with mean PA pressures of\n 33 with PCWP 16. Of concern was the finding of mild RV dilitation.\n His case was considered carefully by the transplant committee and he is\n currently listed for transplant.\n - O2 for comfort\n - continue iloprost\n Hypothroidism:\n - continue synthroid\n ICU Care\n Nutrition: Low sodium diet, vegetarian diet, tube feeds via dobhoff,\n replete lytes, continue vitamin supplements\n Glycemic Control:\n Lines:\n 18 Gauge - 11:37 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: (mother, health care proxy)\n , \n Code status: Full code\n Disposition:Transfer to floor\n ------ Protected Section ------\n Addendum to Sepsis: Given positive blood cultures, will need TTE in\n next few days to evaluate valves as pt on transplant list. Hold off for\n now while optimizing fluid status given borderline pulmonary\n hypertension.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:32 ------\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470019,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n (past abortion of transplant in Or in d/t elevated\n pulm pressures)\n Action:\n Lactulose as ordered. IV antibx. Cont supportive measures for\n transplant candidacy. Ultrasound done on abdomen & LE.\n Response:\n Large liquid stool, guaiac negative. Afebrile.\n Plan:\n Await cx data. Cont. lactulose for 6BM/day. Stool needs to be sent for\n c/diff. f/u with u/s results.\n Anemia, chronic\n Assessment:\n Hx of anemia & esophageal varices. Follows vegetarian diet. Hct 25.9 &\n BP 90-100/40-50\n Action:\n Gave 1 unit of PRBC\ns over 3 hours this am. Albumin X2 (last dose\n tonight) Midodrine 10mg given PO for hypotension. Octeotide 100mcg give\n IVP.\n Response:\n Post-PRBC\ns Hct 25.8. BP stable 100/60\ns. U/o low 10-20ml/hr- team\n aware.\n Plan:\n Follow Hct & s/s of hypovolemia. 1/2NS @ 75ml/hr when blood not\n infusing. Guaiac stools.\n .H/O anxiety\n Assessment:\n At times patient is agitated, constantly picking at gown and sheets.\n A&Ox3, easily distracted.\n Action:\n Bedrest, frequent checks. Lactulose given 60ml q6hrs\n Response:\n Easily reoriented and follows commands\n Plan:\n Keep siderails up for safety. Bed alarm on. Cont. lactulose.\n RN CCRN\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470186,
"text": "42 yr old male with ESLD well known to by liver & transplant\n services who returns today for mental status changes and rash noted to\n LLE by mother who is primary caretaker and HCP. Pt was ill appearing,\n cachectic and febrile to 104.8R. In the ED, he was noted to have a\n lactate of 6.7, an elevated white count and a 14% bandemia. He received\n 5L IVF, IV abx, diagnostic peritoneal tap, and was pan cultured. He\n was transferred to MICU for further management.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA. Pt active on transplant list, known\n to Dr. (past abortion of transplant in OR in d/t\n elevated pulmonary pressures).\n Action:\n Pt receiving lactulose, rifaximin, albumin, midodrine, octreotide.\n Response:\n Pt with liquid stools, afebrile. A&Ox3.\n Plan:\n Cont lactulose for 6BM/day, and rifaximin. To receive 2 more days of\n albumin. Diagnostic paracentesis with no growth to date on cultures.\n Call out to 10 today.\n .H/O anxiety\n Assessment:\n Pt A&Ox3, anxious and tearful this AM. Very apprehensive about\n treatments/medication. C/O pain and insisting on receiving pain\n medication. Refusing to take PO meds until after eating breakfast.\n Action:\n Pt given pain medication. PO meds held until after breakfast per\n patient request. Mother in room at all times to help make pt feel safe,\n help him with anxious feelings. Safety maintained.\n Response:\n Pt much calmer by noon assessment. No further tearing/agitation noted\n this shift.\n Plan:\n Cont to reassure patient, maintain safety.\n Bacteremia\n Assessment:\n Pt admitted with temp up to 104.8 rectally and 14% bandemia with\n elevated white count. Blood cultures now with 4/4 bottles growing GPCs\n in pairs and clusters.\n Action:\n Pt receiving IV vanc and cefepime.\n Response:\n Pt afebrile but white count trending up to 17.6 from 10 yesterday.\n Awaiting speciation of cultures to determine more appropriate abx\n coverage.\n Plan:\n Cont with IV abx. F/U speciation of cultures.\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470190,
"text": "42 yr old male with ESLD well known to by liver & transplant\n services who returns today for mental status changes and rash noted to\n LLE by mother who is primary caretaker and HCP. Pt was ill appearing,\n cachectic and febrile to 104.8R. In the ED, he was noted to have a\n lactate of 6.7, an elevated white count and a 14% bandemia. He received\n 5L IVF, IV abx, diagnostic peritoneal tap, and was pan cultured. He\n was transferred to MICU for further management.\n * Pt self DCd his foley @ 1515, DTV 2115-2315\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA. Pt active on transplant list, known\n to Dr. (past abortion of transplant in OR in d/t\n elevated pulmonary pressures).\n Action:\n Pt receiving lactulose, rifaximin, albumin, midodrine, octreotide.\n Response:\n Pt with liquid stools, afebrile. A&Ox3.\n Plan:\n Cont lactulose for 6BM/day, and rifaximin. To receive 2 more days of\n albumin. Diagnostic paracentesis with no growth to date on cultures.\n Call out to 10 today.\n .H/O anxiety\n Assessment:\n Pt A&Ox3, anxious and tearful this AM. Very apprehensive about\n treatments/medication. C/O pain and insisting on receiving pain\n medication. Refusing to take PO meds until after eating breakfast.\n Action:\n Pt given pain medication. PO meds held until after breakfast per\n patient request. Mother in room at all times to help make pt feel safe,\n help him with anxious feelings. Safety maintained.\n Response:\n Pt much calmer by noon assessment. No further tearing/agitation noted\n this shift.\n Plan:\n Cont to reassure patient, maintain safety.\n Bacteremia\n Assessment:\n Pt admitted with temp up to 104.8 rectally and 14% bandemia with\n elevated white count. Blood cultures now with 4/4 bottles growing GPCs\n in pairs and clusters.\n Action:\n Pt receiving IV vanc and cefepime.\n Response:\n Pt afebrile but white count trending up to 17.6 from 10 yesterday.\n Awaiting speciation of cultures to determine more appropriate abx\n coverage.\n Plan:\n Cont with IV abx. F/U speciation of cultures.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 67.2 kg\n Daily weight:\n 68.1 kg\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Precautions:\n PMH: Anemia, Liver Failure\n CV-PMH:\n Additional history: IVDA as teenager, ETOH- quit 11yrs ago; smoker,\n quit. biventricular diastolic dysfunction by cardiac cath, pulm\n HTN, aborted liver tx in OR d/t pulm HTn found in OR; SBP ; grade\n II esophageal varices, recurrent hepatic encephalopathy, anxity, osteo\n of hip and spine per pt; cirrhosis +HCV, ETOH; severe diuretic\n refractory ascites.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:64\n Temperature:\n 97.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 67 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 90% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,475 mL\n 24h total out:\n 322 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:28 AM\n Potassium:\n 3.7 mEq/L\n 04:28 AM\n Chloride:\n 102 mEq/L\n 04:28 AM\n CO2:\n 25 mEq/L\n 04:28 AM\n BUN:\n 34 mg/dL\n 04:28 AM\n Creatinine:\n 1.8 mg/dL\n 04:28 AM\n Glucose:\n 130 mg/dL\n 04:28 AM\n Hematocrit:\n 25.6 %\n 04:28 AM\n Finger Stick Glucose:\n 160\n 06:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 783\n Transferred to: 1024\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470191,
"text": "42 yr old male with ESLD well known to by liver & transplant\n services who returns today for mental status changes and rash noted to\n LLE by mother who is primary caretaker and HCP. Pt was ill appearing,\n cachectic and febrile to 104.8R. In the ED, he was noted to have a\n lactate of 6.7, an elevated white count and a 14% bandemia. He received\n 5L IVF, IV abx, diagnostic peritoneal tap, and was pan cultured. He\n was transferred to MICU for further management.\n * Pt self DCd his foley @ 1515, DTV 2115-2315\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA. Pt active on transplant list, known\n to Dr. (past abortion of transplant in OR in d/t\n elevated pulmonary pressures).\n Action:\n Pt receiving lactulose, rifaximin, albumin, midodrine, octreotide.\n Response:\n Pt with liquid stools, afebrile. A&Ox3.\n Plan:\n Cont lactulose for 6BM/day, and rifaximin. To receive 2 more days of\n albumin. Diagnostic paracentesis with no growth to date on cultures.\n Call out to 10 today.\n .H/O anxiety\n Assessment:\n Pt A&Ox3, anxious and tearful this AM. Very apprehensive about\n treatments/medication. C/O pain and insisting on receiving pain\n medication. Refusing to take PO meds until after eating breakfast.\n Action:\n Pt given pain medication. PO meds held until after breakfast per\n patient request. Mother in room at all times to help make pt feel safe,\n help him with anxious feelings. Safety maintained.\n Response:\n Pt much calmer by noon assessment. No further tearing/agitation noted\n this shift.\n Plan:\n Cont to reassure patient, maintain safety.\n Bacteremia\n Assessment:\n Pt admitted with temp up to 104.8 rectally and 14% bandemia with\n elevated white count. Blood cultures now with 4/4 bottles growing GPCs\n in pairs and clusters.\n Action:\n Pt receiving IV vanc and cefepime.\n Response:\n Pt afebrile but white count trending up to 17.6 from 10 yesterday.\n Awaiting speciation of cultures to determine more appropriate abx\n coverage.\n Plan:\n Cont with IV abx. F/U speciation of cultures.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n ALTERED MENTAL STATUS\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 67.2 kg\n Daily weight:\n 68.1 kg\n Allergies/Reactions:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Precautions:\n PMH: Anemia, Liver Failure\n CV-PMH:\n Additional history: IVDA as teenager, ETOH- quit 11yrs ago; smoker,\n quit. biventricular diastolic dysfunction by cardiac cath, pulm\n HTN, aborted liver tx in OR d/t pulm HTn found in OR; SBP ; grade\n II esophageal varices, recurrent hepatic encephalopathy, anxity, osteo\n of hip and spine per pt; cirrhosis +HCV, ETOH; severe diuretic\n refractory ascites.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:64\n Temperature:\n 97.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 67 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 90% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,475 mL\n 24h total out:\n 322 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:28 AM\n Potassium:\n 3.7 mEq/L\n 04:28 AM\n Chloride:\n 102 mEq/L\n 04:28 AM\n CO2:\n 25 mEq/L\n 04:28 AM\n BUN:\n 34 mg/dL\n 04:28 AM\n Creatinine:\n 1.8 mg/dL\n 04:28 AM\n Glucose:\n 130 mg/dL\n 04:28 AM\n Hematocrit:\n 25.6 %\n 04:28 AM\n Finger Stick Glucose:\n 160\n 06:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 783\n Transferred to: 1024\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 470073,
"text": "42 yr old male known to by liver transplant service who returns\n today for mental status changes and rash noted to LLE by mother who is\n also pt\ns primary caretaker and HCP. Pt was ill appearing, cachectic\n and febrile to 104.8R . Pt received 5L IVF, Iv antibx, and peritoneal\n tap performed for diagnostic purposes only. Pan cx done and brought to\n MICU 7 for closer monitoring.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA; on transplant list, known to Dr.\n (past abortion of transplant in Or in d/t elevated\n pulm pressures)\n Action:\n Lactulose as ordered. IV antibx. Cont supportive measures for\n transplant candidacy. Ultrasound done on abdomen & LE.\n Response:\n Large liquid stool, guaiac negative. Afebrile.\n Plan:\n Await cx data. Cont. lactulose for 6BM/day. Stool needs to be sent for\n c/diff. f/u with u/s results.\n Anemia, chronic\n Assessment:\n Hx of anemia & esophageal varices. Follows vegetarian diet. Hct 25.9 &\n BP 90-100/40-50\n Action:\n Gave 1 unit of PRBC\ns over 3 hours this am. Albumin X2 (last dose\n tonight) Midodrine 10mg given PO for hypotension. Octeotide 100mcg give\n IVP.\n Response:\n Post-PRBC\ns Hct 25.8. BP stable 100/60\ns. U/o low 10-20ml/hr- team\n aware.\n Plan:\n Follow Hct & s/s of hypovolemia. 1/2NS @ 75ml/hr when blood not\n infusing. Guaiac stools.\n .H/O anxiety\n Assessment:\n At times patient is agitated, constantly picking at gown and sheets.\n A&Ox3, easily distracted.\n Action:\n Bedrest, frequent checks. Lactulose given 60ml q6hrs\n Response:\n Easily reoriented and follows commands\n Plan:\n Keep siderails up for safety. Bed alarm on. Cont. lactulose.\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470150,
"text": "42 yr old male with ESLD well known to by liver & transplant\n services who returns today for mental status changes and rash noted to\n LLE by mother who is primary caretaker and HCP. Pt was ill appearing,\n cachectic and febrile to 104.8R. In the ED, he was noted to have a\n lactate of 6.7, an elevated white count and a 14% bandemia. He received\n 5L IVF, IV abx, diagnostic peritoneal tap, and was pan cultured. He\n was transferred to MICU for further management.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA. Pt active on transplant list, known\n to Dr. (past abortion of transplant in OR in d/t\n elevated pulmonary pressures).\n Action:\n Pt receiving lactulose, rifaximin, lactulose. Being treated empirically\n with IV abx for possible SBP.\n Response:\n Pt with liquid stools, afebrile. A&Ox3.\n Plan:\n Cont lactulose for 6BM/day, and rifaximin. To receive 2 more days of\n albumin. Await culture results of diagnostic paracentesis. Call out to\n 10 today.\n .H/O anxiety\n Assessment:\n Pt A&Ox3\n Action:\n Bedrest, frequent checks. Lactulose given 60ml q6hrs\n Response:\n Easily reoriented and follows commands\n Plan:\n Keep siderails up for safety. Bed alarm on. Cont. lactulose.\n"
},
{
"category": "Physician ",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 470172,
"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: Cirrhosis, GPC Sepsis\n 24 Hour Events:\n afebrile overnight. remains oliguric\n Allergies:\n Amoxicillin\n Rash;\n Adhesive Bandage (Topical)\n Rash;\n Dicloxacillin\n Unknown;\n Last dose of Antibiotics:\n Cefipime - 04:08 AM\n Vancomycin - 08:30 AM\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 09:00 AM\n Other medications:\n lactulose, rifaximin, octreotide, midodrine, omeprazole, CaHCO3,\n synthroid, ursodiol, iloprost, 25% albumin qd\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.2\nC (95.3\n HR: 80 (69 - 100) bpm\n BP: 111/72(80) {91/51(63) - 114/74(84)} mmHg\n RR: 15 (10 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 67.2 kg\n Height: 66 Inch\n Total In:\n 5,116 mL\n 1,719 mL\n PO:\n 1,530 mL\n 360 mL\n TF:\n 421 mL\n 307 mL\n IVF:\n 1,975 mL\n 802 mL\n Blood products:\n 800 mL\n 250 mL\n Total out:\n 475 mL\n 210 mL\n Urine:\n 475 mL\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,641 mL\n 1,509 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: B bases)\n Abdominal: Soft, Bowel sounds present, Distended, shifting dullness and\n fluid wave\n Extremities: Right: 3+, Left: 3+\n Musculoskeletal: Muscle wasting\n Skin: Not assessed, Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Not assessed, Tone: Not assessed, + asterixis\n Labs / Radiology\n 8.5 g/dL\n 57 K/uL\n 130 mg/dL\n 1.8 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 34 mg/dL\n 102 mEq/L\n 136 mEq/L\n 25.6 %\n 17.6 K/uL\n [image002.jpg]\n 02:38 AM\n 03:25 PM\n 04:28 AM\n WBC\n 10.3\n 15.0\n 17.6\n Hct\n 18.8\n 25.8\n 25.6\n Plt\n 37\n 42\n 57\n Cr\n 1.8\n 1.7\n 1.8\n TropT\n 0.04\n 0.03\n Glucose\n 114\n 146\n 130\n Other labs: PT / PTT / INR:30.4/60.2/3.0, CK / CKMB /\n Troponin-T:802/7/0.03, ALT / AST:18/77, Alk Phos / T Bili:163/9.4,\n Differential-Neuts:69.0 %, Band:14.0 %, Lymph:3.0 %, Mono:4.0 %,\n Eos:0.0 %, Fibrinogen:97 mg/dL, Lactic Acid:3.0 mmol/L, Albumin:3.2\n g/dL, Ca++:8.3 mg/dL, Mg++:2.4 mg/dL, PO4:1.6 mg/dL\n Imaging: B LENIs- no DVT\n RUQ US- no clot, cirrhotic liver\n Microbiology: blood- 4/4 bottles GPCs\n blood- pending\n Assessment and Plan\n 42 yo male with ESLD due to EtOH and HCV (on tx list) as well as mild\n PHTN, admitted with sepsis due to GPC bacteremia. Source unclear at\n this point.\n Sepsis- GPC bacteremia of unclear source\n -continue vanco + cefepime; plan on narrowing when GPCs are speciated\n -Albumin and fluids with good response in UOP and lactate\n Anemia- guaiac negative on this admission but hx of prior positive and\n w/ known varices\n -trend serial Hcts, transfuse for hct less than 21\n ESLD- LFTs slightly elevated and coagulopathy worsened\n -vit K if elevated INR worsening\n -Hepatology following\n -cont encephalopathy therapy\n -holding diuresis for volume resuscitation as above\n Acute Renal Failure- preexisting HRS plus prerenal w/ sepsis\n -fluids and colloid as above\n -cont octreotide and midodrine\n Pulm HTN- clinically stable\n -cont iloprost\n -maintain healthy RV preload with volume resuscitation as above\n Sleep disordered breathing- known hx of OSA based on PSG\n -CPAP w/ full-face mask pressure setting \n -will ensure this is resumed prior to discharge, as it may help w/ pulm\n HTN\n Remainder of plan as per housestaff note\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:56 AM 30 mL/hour\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 11:37 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 Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470182,
"text": "42 yr old male with ESLD well known to by liver & transplant\n services who returns today for mental status changes and rash noted to\n LLE by mother who is primary caretaker and HCP. Pt was ill appearing,\n cachectic and febrile to 104.8R. In the ED, he was noted to have a\n lactate of 6.7, an elevated white count and a 14% bandemia. He received\n 5L IVF, IV abx, diagnostic peritoneal tap, and was pan cultured. He\n was transferred to MICU for further management.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA. Pt active on transplant list, known\n to Dr. (past abortion of transplant in OR in d/t\n elevated pulmonary pressures).\n Action:\n Pt receiving lactulose, rifaximin, lactulose. Being treated empirically\n with IV abx for possible SBP.\n Response:\n Pt with liquid stools, afebrile. A&Ox3.\n Plan:\n Cont lactulose for 6BM/day, and rifaximin. To receive 2 more days of\n albumin. Await culture results of diagnostic paracentesis. Call out to\n 10 today.\n .H/O anxiety\n Assessment:\n Pt A&Ox3, anxious and tearful this AM. Very apprehensive about\n treatments/medication. C/O pain and insisting on receiving pain\n medication. Refusing to take PO meds until after eating breakfast.\n Action:\n Pt given pain medication. PO meds held until after breakfast per\n patient request. Mother in room at all times to help make pt feel safe,\n help him with anxious feelings. Safety maintained.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2148-06-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 470183,
"text": "42 yr old male with ESLD well known to by liver & transplant\n services who returns today for mental status changes and rash noted to\n LLE by mother who is primary caretaker and HCP. Pt was ill appearing,\n cachectic and febrile to 104.8R. In the ED, he was noted to have a\n lactate of 6.7, an elevated white count and a 14% bandemia. He received\n 5L IVF, IV abx, diagnostic peritoneal tap, and was pan cultured. He\n was transferred to MICU for further management.\n Cirrhosis of liver, alcoholic\n Assessment:\n Cirrhosis ETOH, HCV, hx IVDA. Pt active on transplant list, known\n to Dr. (past abortion of transplant in OR in d/t\n elevated pulmonary pressures).\n Action:\n Pt receiving lactulose, rifaximin, albumin, midodrine, octreotide.\n Response:\n Pt with liquid stools, afebrile. A&Ox3.\n Plan:\n Cont lactulose for 6BM/day, and rifaximin. To receive 2 more days of\n albumin. Diagnostic paracentesis with no growth to date on cultures.\n Call out to 10 today.\n .H/O anxiety\n Assessment:\n Pt A&Ox3, anxious and tearful this AM. Very apprehensive about\n treatments/medication. C/O pain and insisting on receiving pain\n medication. Refusing to take PO meds until after eating breakfast.\n Action:\n Pt given pain medication. PO meds held until after breakfast per\n patient request. Mother in room at all times to help make pt feel safe,\n help him with anxious feelings. Safety maintained.\n Response:\n Pt much calmer by noon assessment. No further tearing/agitation noted\n this shift.\n Plan:\n Cont to reassure patient, maintain safety.\n"
},
{
"category": "ECG",
"chartdate": "2148-06-27 00:00:00.000",
"description": "Report",
"row_id": 216948,
"text": "Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing the heart rate is reduced. Otherwise, no major change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2148-06-26 00:00:00.000",
"description": "Report",
"row_id": 216949,
"text": "Sinus tachycardia. Non-diagnostic repolarization abnormalities. Compared to\nthe previous tracing of the heart rate is increased with increasing\nrepolarization abnormalities.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1087497,
"text": " 7:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with fever, tachycardia\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH\n\n Compared with a prior study from .\n\n CLINICAL HISTORY: Fever and tachycardia. Evaluate for pneumonia. The\n patient has end-stage liver disease.\n\n FINDINGS: AP semi-upright portable chest radiograph is obtained. There is an\n NG tube again noted with its tip extending into the upper abdomen. Evaluation\n of the lungs is quite limited given the extremely low lung volumes and the\n overlying chin obscuring view of the apices. There is crowding of\n bronchovasculature which likely accounts for the increased perihilar\n densities. There is no definite evidence of pneumonia or CHF. No large\n pleural effusions or pneumothorax is seen. Cardiomediastinal silhouette is\n difficult to assess.\n\n IMPRESSION:\n\n Low lung volumes without definite acute process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-06-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1087533,
"text": " 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with ESLD, leukocytosis, fevers. Film yesterday with very poor\n inspiratory effort.\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:53 AM\n Improvement in low lung volumes. No consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 42-year-old male with end-stage liver disease, leukocytosis and\n fever\n\n An AP portable supine chest radiograph is compared to . Nasogastric\n tube terminates within the stomach, as before. The lung volumes are overall\n improved, but remain low. The cardiomediastinal contours are stable. There\n are no focal areas of consolidation\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-06-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1087534,
"text": ", MED MICU-7 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with ESLD, leukocytosis, fevers. Film yesterday with very poor\n inspiratory effort.\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Improvement in low lung volumes. No consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-06-27 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1087627,
"text": ", MED MICU-7 2:20 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Eval for DVT\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with end stage liver disease here with bacteremic sepsis and LE\n swelling\n REASON FOR THIS EXAMINATION:\n Eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n 1) no dvt.\n 2) left medial popliteal fossa cyst.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-06-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1087964,
"text": " 3:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 51 cm Picc placed in right basilic vein, need Picc tip place\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 51 cm Picc placed in right basilic vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: New PICC line placement.\n\n Portable AP chest radiograph was compared to obtained at 04:26\n a.m.\n\n The right PICC line tip is at the level of mid SVC. The feeding tube tip is\n below the inferior margin of the film. Cardiomediastinal silhouette is\n unchanged. Bibasilar opacities are consistent with atelectasis. Note is made\n that the study was obtained in lordotic projection which might exaggerate the\n cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-06-27 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1087624,
"text": " 2:20 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please do US with dopplers to eval for portal venous thrombo\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with end stage liver disease here with bacteremic sepsis and LE\n swelling\n REASON FOR THIS EXAMINATION:\n Please do US with dopplers to eval for portal venous thrombosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:05 PM\n 1) cirrhotic liver\n 2) patent portal vein, hepatopetal flow.\n 3) gallbladder distention and wall edema, may be related to third spacing and\n chronic liver disease, correlate clinically.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND\n\n CLINICAL HISTORY: End-stage liver disease, with bacterial sepsis. Evaluate\n with Dopplers in order to evaluate for portal vein thrombosis.\n\n ABDOMINAL ULTRASOUND:\n\n Evaluation of the liver demonstrates a diffusely nodular contour and coarsened\n echotexture, consistent with known cirrhosis. Gallbladder wall is somewhat\n thickened and distended, and multiple gallstones are seen dependently within\n the gallbladder. No intra- or extra-hepatic biliary ductal dilatation is\n evident. Directional flow of the main portal vein is appropriately\n hepatopetal, where it is noted that on the prior examination the main portal\n vein flow was reversed (hepatofugal). No evidence of portal vein thrombosis.\n Moderate ascites is noted.\n\n IMPRESSION:\n 1. Hepatopetal and patent main portal vein.\n 2. Cirrhotic liver with gallbladder wall edema and distention. This might be\n related to third spacing, chronic liver disease, and enteric status--please\n correlate clinically as to whether there is abdominal pain which may be\n attributable to the gallbladder.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-07-03 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1088681,
"text": " 5:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Abscess/source for bacteremia in GI tract?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with ESLD, initially presenting with sepsis, now w/ bacteremia\n growing two enteric pathogens\n REASON FOR THIS EXAMINATION:\n Abscess/source for bacteremia in GI tract?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 7:55 PM\n 1. Minimally dilated loops of small bowel without evidence for obstruction\n likely secondary to ileus. Large volume abdominal ascites, similar in\n appearance to study from .\n 2. Mildly distended gallbladder containing innumerable stones, but no\n gallbladder wall thickening to suggest cholecystitis.\n 3. Air in the nondependent portion of the bladder, would recommend\n correlation with recent Foley instrumentation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old man with end-stage liver disease presenting with sepsis,\n now with bacteremia growing two enteric pathogens. Evaluate for abscess or\n source of bacteremia in the GI tract.\n\n CT ABDOMEN AND PELVIS: Helical imaging was performed from the lung bases\n through the pubic symphysis after uneventful administration of IV contrast.\n Oral contrast was also administered.\n\n COMPARISON: Liver ultrasound , CT abdomen .\n\n CT ABDOMEN: The partially visualized lung bases demonstrate atelectasis at\n the bilateral lung bases. There are no pleural effusions. The heart appears\n unremarkable.\n\n There is large volume simple fluid throughout the abdomen and pelvis, similar\n in appearance to study from . The spleen is enlarged measuring\n 15 cm (2:24) with significant splenic varices, apparently unchanged. The\n pancreas appears unremarkable. The adrenals appear normal. There are\n numerous sub-5-mm sized gallstones throughout the gallbladder and the\n gallbladder is mildly distended, but there is no abnormal gallbladder wall\n thickening or abnormal gallbladder wall enhancement, to suggest cholecystitis.\n The liver is shrunken with a diffuse nodular appearance, unchanged. The\n appearance of the hepatic vasculature is stable. The kidneys enhance and\n excrete contrast symmetrically without masses or hydronephrosis. The\n abdominal aorta and its branches appear widely patent. There is a feeding\n tube coursing through the stomach and into the proximal jejunum. Small bowel\n loops are mildly dilated to only really where there is oral contrast. There\n is no free air in the abdomen. There is no significant lymphadenopathy.\n\n CT PELVIS: Simple fluid tracks into the patient's pelvis in significant\n volume. There are small locules of air in the nondependent portion of the\n (Over)\n\n 5:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Abscess/source for bacteremia in GI tract?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bladder (2:79) and would recommend correlation with prior Foley\n instrumentation. The rectum, sigmoid colon and remaining pelvic loops of\n small and large bowel appear grossly normal with fluid appearing stool\n throughout the colon. There is no abnormal enhancement to the bowel wall.\n\n BONE AND SOFT TISSUE WINDOWS: There are no suspicious sclerotic or lytic\n lesions. There is diffuse soft tissue anasarca.\n\n IMPRESSION:\n 1. Large volume abdominal ascites, similar in appearance to study from , 09.\n\n 2. Mildly distended gallbladder containing innumerable stones, but no\n gallbladder wall thickening to suggest acute cholecystitis. If this is a\n concern nuclear medicine hepatobiliary scan would likely be the best test.\n\n 3. Air in the nondependent portion of the bladder, would recommend\n correlation with recent Foley instrumentation.\n\n 4. No bowel obstruction or small bowel abnormality. Mild colonic ileus with\n fluid, which could reflect diarrhea.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-07-03 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1088682,
"text": ", MED FA10 5:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Abscess/source for bacteremia in GI tract?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with ESLD, initially presenting with sepsis, now w/ bacteremia\n growing two enteric pathogens\n REASON FOR THIS EXAMINATION:\n Abscess/source for bacteremia in GI tract?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Minimally dilated loops of small bowel without evidence for obstruction\n likely secondary to ileus. Large volume abdominal ascites, similar in\n appearance to study from .\n 2. Mildly distended gallbladder containing innumerable stones, but no\n gallbladder wall thickening to suggest cholecystitis.\n 3. Air in the nondependent portion of the bladder, would recommend\n correlation with recent Foley instrumentation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-06-27 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1087625,
"text": ", MED MICU-7 2:20 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Please do US with dopplers to eval for portal venous thrombo\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with end stage liver disease here with bacteremic sepsis and LE\n swelling\n REASON FOR THIS EXAMINATION:\n Please do US with dopplers to eval for portal venous thrombosis\n ______________________________________________________________________________\n PFI REPORT\n 1) cirrhotic liver\n 2) patent portal vein, hepatopetal flow.\n 3) gallbladder distention and wall edema, may be related to third spacing and\n chronic liver disease, correlate clinically.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-06-27 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1087626,
"text": " 2:20 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Eval for DVT\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with end stage liver disease here with bacteremic sepsis and LE\n swelling\n REASON FOR THIS EXAMINATION:\n Eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:00 PM\n 1) no dvt.\n 2) left medial popliteal fossa cyst.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral extremity venous ultrasound.\n\n CLINICAL HISTORY: Bacterial sepsis, lower extremity swelling.\n\n Bilateral lower extremity venous ultrasound was performed with color and pulse\n wave Doppler.\n\n Bilateral common femoral veins, superficial femoral veins, popliteal veins\n demonstrate appropriate compressibility and flow with augmentation. Veins of\n the calves on both the right and left demonstrate appropriate color flow.\n Note is made of a cystic structure in the left popliteal fossa measuring 2.5 x\n 1.5 x 3.1 cm, consistent with medial popliteal fossa () cyst.\n\n IMPRESSION:\n\n 1) No DVT.\n\n 2) Left-sided medial popliteal fossa () cyst.\n\n"
}
] |
78,879 | 136,071 | There is a trivial/physiologic pericardial effusion.IMPRESSION: Mild left ventricular systolic dysfunction consistent withcoronary artery disease. Hazy opacity in the left hemithorax is consistent with moderate-to-large layering pleural effusion. There is mildregional left ventricular systolic dysfunction with anterior and anterolateralhypokinesis. Mild (1+) mitral regurgitation is seen. Right lung is grossly clear except for a small linear focus of atelectasis in the right perihilar region. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Physiologic TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:The left atrium is elongated. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anterolateral - hypo; mid anterolateral -hypo; anterior apex - hypo; septal apex - hypo; lateral apex - hypo; apex -hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. The mitral valve leaflets are mildlythickened. The right lung is relatively clear with some volume loss and patchy areas of volume loss versus infiltrate in the right lower lung. If any, there is a small left pleural effusion. There is some free fluid in the mesentery and retroperitoneum, due to soft tissue edema and general anasarca. This lesion is isointense to duodenal wall on T1-weighted images and slightly hyperintense to the pancreas head on T2-weighted images. There is moderate pulmonary artery systolichypertension. Based on pre-contrast T1-weighted images, there is abnormal contour of the inferior aspect of the pancreatic head. There is a small right pleural effusion, linear atelectasis in the right base unchanged. Inadequately characterized 2 x 4 cm ill-defined mass involving the junction of second and third part of duodenum with mass effect on the pancreatic head and compression of the duodenal lumen resulting in mild upstream gastric distention. Mild regional LVsystolic dysfunction. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild prominence of the pulmonary markings is consistent with some vascular congestion. Moderate estimated pulmonary artery systolichypertension. Persistent opacification at the left base is consistent with lower lobe volume loss and pleural effusion. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 63Weight (lb): 180BSA (m2): 1.85 m2BP (mm Hg): 145/118HR (bpm): 86Status: InpatientDate/Time: at 09:49Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. IMPRESSION: Moderate to large layering left pleural effusion. Cardiomegaly is accentuated by low lung volumes. NG tube with its tip out of view, right subclavian catheter with its tip in distal SVC are appropriate. Small left pleural effusion, left lower lobe atelectasis. There is mild prominence of pulmonary vascular markings, consistent with some congestion. There is mild vascular congestion. There is a relatively moderate amount of fluid in the stomach which may represent a gastric outlet obstruction. Residual barium is seen in the bowel. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. There is an ill-defined mass lesion compressing the inferior aspect of the head and appears in continuity with the second and third portion of the duodenal wall. Mildly depressed LVEF. Left lower lobe retrocardiac opacity is consistent with an area of large atelectasis. Patient with shortness of breath and low saturations. Overall left ventricular systolic function is mildly depressed(LVEF= 45 %). Mild thickening ofmitral valve chordae. Right supraclavicular catheter tip is in the distal SVC. There is also a small amount of free fluid in the abdomen as well as bilateral pleural effusions that degrade the MRCP images. Contrast noted in the bowel. Normal IVC diameter (<2.1cm)with >55% decrease during respiration (estimated RA pressure (0-5mmHg).LEFT VENTRICLE: Normal LV wall thickness and cavity size. NG tube tip is out of view below the diaphragm. NG tube tip is out of view below the diaphragm. There are low lung volumes. There are low lung volumes. No 2D or Doppler evidence of distal archcoarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). While this lesion may possibly arise from the pancreatic head, this is considered less likely given the morphology of the lesion and apparent mass effect on the pancreatic head. The estimated right atrial pressure is 0-5 mmHg.Left ventricular wall thicknesses and cavity size are normal. FINDINGS: The study is limited due to motion artifact as well as lack of intravenous and oral contrast. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess NG tube. There is again dense opacification at the left base consistent with a combination of substantial volume loss in the left lower lobe and pleural effusion. IMPRESSION: Very limited study due to motion artifact and lack of intravenous contrast as well as lack of oral contrast. There is an oblique line of opacification in the retrocardiac region consistent with substantial left lower lobe collapse, most likely associated with pleural effusion. Central catheter and nasogastric tube remain in place. Right ventricular chamber size and free wall motion are normal.The diameters of aorta at the sinus, ascending and arch levels are normal. There is an exophytic 2.8 cm duodenal diverticulum originating from the lateral aspect of the mid D2, filled with fluid. Mild atelectatic streaks are seen at both bases. FINDINGS: In comparison with the study of , there is an endotracheal tube in place with the tip approximately 4 cm above the carina. The patient has bilateral pleural effusions, larger on the left. Nasogastric tube may be coiled in the mouth or in the esophagus because it is not seen in the stomach or in the distal esophagus. Left lower lobe opacity is unchanged. The tricuspid valveleaflets are mildly thickened. FINDINGS: Layering moderate to large left pleural effusion is present as well as increased opacity in the adjacent lingula and left lower lobe. Sinus rhythm with prominent voltage in leads I and aVL for left ventricularhypertrophy. This lesion may represent an intrinsic duodenal intramural mass, or extramural lesion. | 14 | [
{
"category": "Radiology",
"chartdate": "2150-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1157470,
"text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung volumes\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with post-op resp insufficiency\n REASON FOR THIS EXAMINATION:\n lung volumes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Postop respiratory insufficiency.\n\n REFERENCE EXAM: \n\n FINDINGS: Compared to the study from the prior day, the left effusion is\n slightly larger. There continues to be pulmonary vascular redistribution and\n alveolar infiltrate on the left. The right lung is relatively clear with some\n volume loss and patchy areas of volume loss versus infiltrate in the right\n lower lung. The NG tube is unchanged. Right IJ line is unchanged. Right\n Port-A-Cath is again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1157558,
"text": " 4:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval eval\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with\n REASON FOR THIS EXAMINATION:\n interval eval\n ______________________________________________________________________________\n FINAL REPORT\n\n \n\n COMPARISON: .\n\n FINDINGS: Layering moderate to large left pleural effusion is present as well\n as increased opacity in the adjacent lingula and left lower lobe. Right lung\n is grossly clear except for a small linear focus of atelectasis in the right\n perihilar region.\n\n IMPRESSION: Moderate to large layering left pleural effusion. Adjacent\n opacities in the left lung could be due to atelectasis or infectious\n pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1155377,
"text": " 3:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: for ng-tube placement\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n nausea/vomitting\n REASON FOR THIS EXAMINATION:\n for ng-tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Nausea and vomiting, NG tube placement.\n\n Frontal view of the chest demonstrates Port-A-Catheter with access needle.\n Small left pleural effusion, left lower lobe atelectasis. Nasogastric tube\n may be coiled in the mouth or in the esophagus because it is not seen in the\n stomach or in the distal esophagus. Re-positioning should occur.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1155559,
"text": " 4:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for ng tube, also for infiltrate\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SBO, ng tube replaced, also before tube placed had low\n 02 sat and crackles on left\n REASON FOR THIS EXAMINATION:\n please eval for ng tube, also for infiltrate\n ______________________________________________________________________________\n WET READ: ASpf MON 6:04 PM\n Persistent left lower lobe opacity likely represents atelectasis although\n overlying pneumonia cannot be excluded. NG tube with its tip out of view,\n right subclavian catheter with its tip in distal SVC are appropriate. Contrast\n noted in the bowel. \n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess NG tube. Patient with shortness of breath and low\n saturations.\n\n Comparison is made with prior study performed a day earlier.\n\n NG tube tip is out of view below the diaphragm. Right supraclavicular\n catheter tip is in the distal SVC. Left lower lobe opacity is unchanged. It\n could represent atelectasis but pneumonia cannot be totally excluded. There\n is no evident pneumothorax. If any, there is a small left pleural effusion.\n Cardiac size is top normal. Residual barium is seen in the bowel.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1155879,
"text": " 1:06 PM\n CHEST (PA & LAT) Clip # \n Reason: R/O aspiration pneumonia; R/O heart failure\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with h/o diastolic heart failure, met breast CA, now SBO with\n NGT in place c/o non-productive cough x 24 hrs and has mild wheezing on exam\n REASON FOR THIS EXAMINATION:\n R/O aspiration pneumonia; R/O heart failure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic breast cancer with SBO and NGT and nonproductive cough.\n\n FINDINGS: In comparison with study of , the patient has taken a somewhat\n better inspiration. Nasogastric tube remains in place. Persistent\n opacification at the left base is consistent with lower lobe volume loss and\n pleural effusion. Streaks of atelectasis are also seen. In the appropriate\n clinical setting, supervening pneumonia could be considered.\n\n There is mild prominence of pulmonary vascular markings, consistent with some\n congestion. Central catheter remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-26 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1156951,
"text": " 2:18 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: UNCINATE MASS\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with diastolic heart failure, pulm congestion on prior films\n REASON FOR THIS EXAMINATION:\n preop for duodenal mass excision\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preoperative.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Monitoring and support devices remain in place. There is an oblique\n line of opacification in the retrocardiac region consistent with substantial\n left lower lobe collapse, most likely associated with pleural effusion. Mild\n atelectatic streaks are seen at both bases. Mild prominence of the pulmonary\n markings is consistent with some vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1157308,
"text": ", S. FA9A 4:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for acute intracranial process\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p gastrojejunostomy w/ acute MS changes/MS top\n REASON FOR THIS EXAMINATION:\n Eval for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No evidence of acute intracranial abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1157358,
"text": " 4:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman immediately s/p gastrojejunostomy with hypotension and\n unresponsiveness in the immediate post-op period.\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Immediate SP gastrojejunostomy with hypertension and\n unresponsiveness\n\n Comparison is made with prior study performed a day earlier.\n\n There are low lung volumes. ET tube is in standard position. NG tube tip is\n out of view below the diaphragm. Right central catheter remains in place.\n There is no evident pneumothorax. There are low lung volumes. Cardiomegaly\n is accentuated by low lung volumes. Hazy opacity in the left hemithorax is\n consistent with moderate-to-large layering pleural effusion. There is a small\n right pleural effusion, linear atelectasis in the right base unchanged. Left\n lower lobe retrocardiac opacity is consistent with an area of large\n atelectasis. There is mild vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1157307,
"text": " 4:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for acute intracranial process\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p gastrojejunostomy w/ acute MS changes/MS top\n REASON FOR THIS EXAMINATION:\n Eval for acute intracranial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 7:22 PM\n No evidence of acute intracranial abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with status post gastrojejunostomy with acute\n mental status changes.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n\n FINDINGS: There is no hemorrhage, mass effect, midline shift or\n hydrocephalus. The -white matter differentiation is maintained.\n\n IMPRESSION: No evidence of acute intracranial abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1157304,
"text": " 4:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o aspiration\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with sudden loc after anesthesia nad difficulty breathing and\n maintaining sats/\n REASON FOR THIS EXAMINATION:\n r/o aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Loss of consciousness after anesthesia with difficulty breathing.\n\n FINDINGS: In comparison with the study of , there is an endotracheal\n tube in place with the tip approximately 4 cm above the carina. Central\n catheter and nasogastric tube remain in place.\n\n There is again dense opacification at the left base consistent with a\n combination of substantial volume loss in the left lower lobe and pleural\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-08-16 00:00:00.000",
"description": "MRI ABDOMEN W/O CONTRAST",
"row_id": 1155322,
"text": " 8:21 AM\n MRI ABDOMEN W/O CONTRAST Clip # \n Reason: DUODENAL OBSTRUCTION\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with duoenal obstruction, ?uncinate mass\n REASON FOR THIS EXAMINATION:\n ? etiology of duodenal obstruction, ? pancreatic mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE ABDOMEN, \n\n STUDY INDICATION: 60-year-old woman with duodenal obstruction. Query\n uncinate process mass.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet. The patient's estimated glomerular filtration rate was 25,\n accordingly, gadolinium contrast was withheld. The patient was unable\n to tolerate oral contrast due to nausea and vomiting.\n\n No previous for comparison.\n\n FINDINGS:\n\n The study is limited due to motion artifact as well as lack of intravenous and\n oral contrast. There is also a small amount of free fluid in the abdomen as\n well as bilateral pleural effusions that degrade the MRCP images. The stomach\n is also distended with fluid, further contributing to degradation of the MRCP\n images.\n\n Based on pre-contrast T1-weighted images, there is abnormal contour of the\n inferior aspect of the pancreatic head. There is an ill-defined mass lesion\n compressing the inferior aspect of the head and appears in continuity with the\n second and third portion of the duodenal wall. It measures about 2 x 4 cm in\n transverse dimensions, but this also incorporates the duodenal wall which\n cannot be separated from this lesion. This lesion is isointense to duodenal\n wall on T1-weighted images and slightly hyperintense to the pancreas head on\n T2-weighted images. It does not cause pancreatic or common bile duct\n dilation. The wall of the duodenum at the junction of second and third part\n of the duodenum distal to this mass appears slightly thickened, but this may\n be due to underdistention and compression from this mass.\n\n There is a relatively moderate amount of fluid in the stomach which may\n represent a gastric outlet obstruction. The duodenal bulb and proximal D2 are\n filled with fluid. There is an exophytic 2.8 cm duodenal diverticulum\n originating from the lateral aspect of the mid D2, filled with fluid.\n\n There is loss of signal in liver, spleen and bone marrow on in-phase\n T1-weighted images, consitent with hemosiderosis, to be correlated with\n clinical history. The patient is post-cholecystectomy.\n\n (Over)\n\n 8:21 AM\n MRI ABDOMEN W/O CONTRAST Clip # \n Reason: DUODENAL OBSTRUCTION\n Admitting Diagnosis: UNCINATE MASS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Both kidneys demonstrate moderate dilation of colelcting system up to the\n ureteropelvic junctions. Adrenals are unremarkable.\n\n There is no adenopathy.\n\n There is some free fluid in the mesentery and retroperitoneum, due to soft\n tissue edema and general anasarca. The patient has bilateral pleural\n effusions, larger on the left.\n\n IMPRESSION:\n\n Very limited study due to motion artifact and lack of intravenous contrast as\n well as lack of oral contrast.\n\n Inadequately characterized 2 x 4 cm ill-defined mass involving the junction of\n second and third part of duodenum with mass effect on the pancreatic head and\n compression of the duodenal lumen resulting in mild upstream gastric\n distention. This lesion may represent an intrinsic duodenal intramural mass,\n or extramural lesion. While this lesion may possibly arise from the pancreatic\n head, this is considered less likely given the morphology of the lesion and\n apparent mass effect on the pancreatic head.\n\n Options for further investigation include contrast-enhanced CT scan if the\n patient's GFR can be improved, versus endoscopic evaluation.\n\n A preliminary report was entered into PACS by the body imaging fellow on call,\n concordant with the current final interpretation.\n\n"
},
{
"category": "Echo",
"chartdate": "2150-08-25 00:00:00.000",
"description": "Report",
"row_id": 90116,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 180\nBSA (m2): 1.85 m2\nBP (mm Hg): 145/118\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 09:49\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<2.1cm)\nwith >55% decrease during respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. Mildly depressed LVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anterolateral - hypo; mid anterolateral -\nhypo; anterior apex - hypo; septal apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Focal\ncalcifications in aortic root. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg.\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with anterior and anterolateral\nhypokinesis. Overall left ventricular systolic function is mildly depressed\n(LVEF= 45 %). Right ventricular chamber size and free wall motion are normal.\nThe diameters of aorta at the sinus, ascending and arch levels are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. No aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Mild left ventricular systolic dysfunction consistent with\ncoronary artery disease. Moderate estimated pulmonary artery systolic\nhypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2150-08-26 00:00:00.000",
"description": "Report",
"row_id": 238312,
"text": "Sinus rhythm. The previously mentioned abnormalities recorded on \npersist without diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2150-08-25 00:00:00.000",
"description": "Report",
"row_id": 238313,
"text": "Sinus rhythm with prominent voltage in leads I and aVL for left ventricular\nhypertrophy. Delayed precordial R wave transition and lateral ST-T wave\nflattening. No previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
|
24,683 | 192,030 | The patient was admitted to the neuro-ICU with the new diagnosis of myasthenia . He did well and was transferred to the neurology floor, where he was started on mestinon, which led to improvement in fatigable weakness. He was started on low-dose prednisone, with the plan on not increasing the dose, for fear of exacerbating his diabetes. It should be kept at the current dose for the next few months, while cellcept achieves immunosuppression; cellcept will be kept on indefinitely for long-term immunosuppression instead. He should be monitored carefully for side effects of this medication - namely, severe diarrhea which could impede absorption of mestinon. was consulted for management of his diabetes. They started glipizide, in addition to the patient's regimen of metformin. He should be followed closely on a humalog sliding scale (with the lunch dosing increased by 2 units over the rest, as steroids generally cause elevated blood sugar in the evening). He will see them as an outpatient as well. Extensive time was spent daily with patient education both for diabetes teaching and management of his myasthenia. This will need to continue, intensively, as he has demonstrated difficulty with retaining this information. He will need close neurology follow-up, every 2-4 weeks until his myasthenia stabilizes. It should be reiterated that any changes in his medication regimen (outside of his diabetes) should be approved by neurology. The following medications can exacerbate myasthenia: Antibiotics (eg, aminoglycosides, ciprofloxacin, erythromycin, ampicillin) Beta-adrenergic receptor blocking agents (eg, propranolol, oxprenolol) Lithium Magnesium Procainamide Verapamil Quinidine Chloroquine Prednisone Timolol (ie, a topical beta-blocking used for glaucoma) Anticholinergics (eg, trihexyphenidyl) Neuromuscular blocking agents, including vecuronium and curare, should be used cautiously in myasthenics to avoid prolonged neuromuscular blockade. | Denies dyspnea, rate WNL. Small right pleural effusion of unknown etiology. There is a small right pleural effusion. Minimal subsegmental atelectasis is seen in the right lung base. PIVx2, right radial arterial line transduces sharply and correlates well with NBP.GI: Abd soft and non-tender. FINDINGS: There is a very subtle hazy opacity in the lingula. Noprevious tracing available for comparison. While residual thymic tissue may be present at this age, the amount of tissue noted is slightly more than typical, and there is minimal convexity along the right margin of the mediastinum. HISTORY: Shortness of breath. There is minimal convexity along the right margin and slightly more residual thymus than is anticipating given the patient's stated age. There is adenopathy in the limited imaging through the included upper abdomen, of unknown etiology. thymoma (please check creat first as pt has hx of DM) No contraindications for IV contrast FINAL REPORT HISTORY: New onset myasthenia . Non-specific T wave flattening in leads aVL and V2-V3. The thoracic aorta is unremarkable. Transfused IVIG per protocol without incident, well tolerated.Pain: DeniesResp: Lungs clear and equal bilaterally, slightly diminished at the bases. The airway is patent with no endoluminal lesions identified. There is a heterogeneous rounded mass anterior and superior to the splenic hilum. A thymic mass cannot be entirely excluded. The visualized osseous structures are unremarkable. The visualized osseous structures are unremarkable. ABG's reveal compensated metabolic acidosis, latest PaCO2 within normal limits.CV: Sinus rhythm without ectopy, rate 80's-90's. No significant coronary calcifications are seen. Sinus tachycardia. There is anterior mediastinal soft tissue attenuation. There is bilateral gynecomastia. No pericardial effusion is evident. There was uneventful administration of 75 ml Optiray 350. He has no known allergies. Two small approximately 4 mm cardiophrenic lymph nodes are identified. thymoma (please check creat first as pt has hx of DM) Contrast: OPTIRAY Amt: 75 FINAL REPORT (Cont) Bilateral gynecomastia. The mediastinum is unremarkable. No pneumothorax is evident. His home medications inculde glyburide and lisinopril (questionable compliance). FINDINGS: There is no mediastinal or axillary lymphadenopathy. Generalized weakness. There is no pneumomediastinum. COMPARISON: None. IMPRESSION: 1. No effusion or pneumothorax is seen. T/SICU Nursing Admission NoteError in prior note: ABG's reveal compensated *respiratory* acidosis. There are no pulmonary masses. Microatelectasis is noted in the inferior lingular segment and correlates with that seen on recent chest x-ray. The heart size is normal. Judgement intact. Gait steady. The remaining lungs are clear. PERRL. 5:54 PM CT CHEST W/CONTRAST Clip # Reason: ? There is a regional focus of soft tissue attenuation with interspersed fat centrally in the anterior mediastinum likely reflective of residual thymic tissue. MAE with fair strength. IMPRESSION: Subtle opacity in the lingula, which may represent atelectasis or an early developing pneumonia. Coronal reformatted images were generated. (Over) 5:54 PM CT CHEST W/CONTRAST Clip # Reason: ? Strong palpable distal pulses. The heterogeneous enhancing nodule in the left upper quadrant adjacent to the spleen in demonstrating typical arterial phase heterogeneous enhancement. Hypertensive with SBP as high as 200, refractory to metoprolol and hydralazine, now requiring labetalol drip at just 0.5mg/min to maintain SBP <160. 3. His fiance is his health care proxy.Neuro: A&Ox3, anxious, cooperative. 2. COMPARISON: Chest x-ray performed earlier, same day. Numerous enlarged lymph nodes are noted in the porta hepatis and the gastrohepatic ligament. NPO as reports signs of aspiration at home. thymoma (please check creat first as pt has hx of DM) Contrast: OPTIRAY Amt: 75 MEDICAL CONDITION: 34 year old man with new onset MG REASON FOR THIS EXAMINATION: ? TECHNIQUE: Serial transverse images were acquired sequentially through the chest and reconstructed at stacked 5 mm increments. Family appropriate and asking many good questions about the disease and plan of care.Plan:Maintain safetyMonitor for signs of respiratory compromiseIVIG x4 more dosesPatient/family education Other PMHx includes diabetes diagnosed 4 yrs ago, hypercholesterolemia, pancreatitis 4 yrs ago, and a cyst removal. 4:46 PM CHEST (PA & LAT) Clip # Reason: eval pna, effusion, edema, ptx MEDICAL CONDITION: 34 year old man with sob REASON FOR THIS EXAMINATION: eval pna, effusion, edema, ptx FINAL REPORT PA AND LATERAL CHEST, , AT 16:47 HOURS. Had 2 loose BM's - states he ate bad chinese food a couple days ago.GU: Voids clear yellow urine qs.Endo: RISS with no coverage required.Lytes: Repleted magnesium and potassium.Social: Pt has large family and no clear next-of-; he was willing to fill out a health care proxy document naming his fiance as his HCP and spokesperson. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2155-01-03 00:00:00.000",
"description": "Report",
"row_id": 1583046,
"text": "T/SICU Nursing Admission Note\n34 year old male with month-long worsening complaints of diplopia, neck/arm/generalized weakness, difficulty breathing and swallowing who presents to the ER from the neurology clinic with probable diagnosis of myasthenia . Other PMHx includes diabetes diagnosed 4 yrs ago, hypercholesterolemia, pancreatitis 4 yrs ago, and a cyst removal. His home medications inculde glyburide and lisinopril (questionable compliance). He has no known allergies. His fiance is his health care proxy.\n\nNeuro: A&Ox3, anxious, cooperative. MAE with fair strength. Gait steady. Judgement intact. Generalized weakness. PERRL. Transfused IVIG per protocol without incident, well tolerated.\n\nPain: Denies\n\nResp: Lungs clear and equal bilaterally, slightly diminished at the bases. Denies dyspnea, rate WNL. ABG's reveal compensated metabolic acidosis, latest PaCO2 within normal limits.\n\nCV: Sinus rhythm without ectopy, rate 80's-90's. Hypertensive with SBP as high as 200, refractory to metoprolol and hydralazine, now requiring labetalol drip at just 0.5mg/min to maintain SBP <160. Strong palpable distal pulses. PIVx2, right radial arterial line transduces sharply and correlates well with NBP.\n\nGI: Abd soft and non-tender. NPO as reports signs of aspiration at home. Had 2 loose BM's - states he ate bad chinese food a couple days ago.\n\nGU: Voids clear yellow urine qs.\n\nEndo: RISS with no coverage required.\n\nLytes: Repleted magnesium and potassium.\n\nSocial: Pt has large family and no clear next-of-; he was willing to fill out a health care proxy document naming his fiance as his HCP and spokesperson. It was filed in his chart, POE, and copies were given to his fiance . Family appropriate and asking many good questions about the disease and plan of care.\n\nPlan:\nMaintain safety\nMonitor for signs of respiratory compromise\nIVIG x4 more doses\nPatient/family education\n"
},
{
"category": "Nursing/other",
"chartdate": "2155-01-03 00:00:00.000",
"description": "Report",
"row_id": 1583047,
"text": "T/SICU Nursing Admission Note\nError in prior note: ABG's reveal compensated *respiratory* acidosis.\n"
},
{
"category": "ECG",
"chartdate": "2155-01-04 00:00:00.000",
"description": "Report",
"row_id": 207610,
"text": "Sinus tachycardia. Non-specific T wave flattening in leads aVL and V2-V3. No\nprevious tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-01-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 945591,
"text": " 4:46 PM\n CHEST (PA & LAT) Clip # \n Reason: eval pna, effusion, edema, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with sob\n REASON FOR THIS EXAMINATION:\n eval pna, effusion, edema, ptx\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, , AT 16:47 HOURS.\n\n HISTORY: Shortness of breath.\n\n COMPARISON: None.\n\n FINDINGS: There is a very subtle hazy opacity in the lingula. The remaining\n lungs are clear. The mediastinum is unremarkable. There is a small right\n pleural effusion. No pneumothorax is evident. The visualized osseous\n structures are unremarkable.\n\n IMPRESSION: Subtle opacity in the lingula, which may represent atelectasis or\n an early developing pneumonia. Small right pleural effusion of unknown\n etiology.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2155-01-02 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 945598,
"text": " 5:54 PM\n CT CHEST W/CONTRAST Clip # \n Reason: ? thymoma (please check creat first as pt has hx of DM)\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 34 year old man with new onset MG\n REASON FOR THIS EXAMINATION:\n ? thymoma (please check creat first as pt has hx of DM)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New onset myasthenia .\n\n TECHNIQUE: Serial transverse images were acquired sequentially through the\n chest and reconstructed at stacked 5 mm increments. Coronal reformatted\n images were generated. There was uneventful administration of 75 ml Optiray\n 350.\n\n COMPARISON: Chest x-ray performed earlier, same day.\n\n FINDINGS: There is no mediastinal or axillary lymphadenopathy. There is a\n regional focus of soft tissue attenuation with interspersed fat centrally in\n the anterior mediastinum likely reflective of residual thymic tissue. There\n is minimal convexity along the right margin and slightly more residual thymus\n than is anticipating given the patient's stated age. Two small approximately\n 4 mm cardiophrenic lymph nodes are identified. There is no pneumomediastinum.\n The heart size is normal. No pericardial effusion is evident. No significant\n coronary calcifications are seen. The thoracic aorta is unremarkable.\n\n The airway is patent with no endoluminal lesions identified. Minimal\n subsegmental atelectasis is seen in the right lung base. Microatelectasis is\n noted in the inferior lingular segment and correlates with that seen on recent\n chest x-ray. No effusion or pneumothorax is seen. There are no pulmonary\n masses.\n\n There is a heterogeneous rounded mass anterior and superior to the splenic\n hilum. Numerous enlarged lymph nodes are noted in the porta hepatis and the\n gastrohepatic ligament.\n\n The visualized osseous structures are unremarkable. There is bilateral\n gynecomastia.\n\n IMPRESSION:\n 1. There is anterior mediastinal soft tissue attenuation. While residual\n thymic tissue may be present at this age, the amount of tissue noted is\n slightly more than typical, and there is minimal convexity along the right\n margin of the mediastinum. A thymic mass cannot be entirely excluded.\n 2. There is adenopathy in the limited imaging through the included upper\n abdomen, of unknown etiology. The heterogeneous enhancing nodule in the left\n upper quadrant adjacent to the spleen in demonstrating typical arterial phase\n heterogeneous enhancement.\n 3. Bilateral gynecomastia.\n (Over)\n\n 5:54 PM\n CT CHEST W/CONTRAST Clip # \n Reason: ? thymoma (please check creat first as pt has hx of DM)\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
}
] |
56,187 | 186,529 | # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR infiltrate is most likely acute pneumonia - typical vs atypical. Given ceftriaxone and azithromycin, and monitored INR, as azithromycin has a coumadin interaction. The patient remained hemodynamically stable, and no IVF were needed as not septic. Was transferred to General Medicine floor on HOD 2. Cont'd on abx with completed course of Azithromycin in house and 2 addt'l days of Cefoxitime at d/c. Symptomatically improved at d/c. . # COPD exascerbation: likely precipitated by acute pneumonia as evidenced by marked dyspnea and wheezing and increased O2 requirement. Was given SoluMedrol 125mg q8hr x2 doses and was transitioned to po prednisone burst (60mg -> 50mg -> 40mg -> 30mg). Weaned O2 as tolerated, with permissive O2 sats in low 90s. On the floor pt recv'd nebs ATC which eventually tarnsitioned to as needed as O2 requirment decreased to baseline. Prednisone burst cont'd with slow month long taper back instituted on d/c. Eval'd by PT with pt at baseline on d/c. . # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely unchanged from prior and 2 sets CE negative. . # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib. Was continued on dofetilide 375 mcg and diltiazem 180 mg daily with good control of ventricular rate. No issues during hospitalization . | # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2 . # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2 . # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2 . # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2 . # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2 . # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely unchanged from prior and first set CE negative - Second set CE trended down 0.04->0.02 . # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely unchanged from prior and first set CE negative - Second set CE trended down 0.04->0.02 . Hx: severe COPD (has home oxygen and has required steroid therepy in past), Asthma, PNA, atrial arrhythmias (A-fib), status post AVJ ablation, dual-chamber Medronic pacemaker, aoritic stenosis, left brachiocephalic vein clot, Hematuria. # Prophylaxis: Therapeutic on coumadin, H2 . # Prophylaxis: Therapeutic on coumadin, H2 . # Prophylaxis: Therapeutic on coumadin, H2 . # Prophylaxis: Therapeutic on coumadin, H2 . Recent URI treated with Augmentin, course completed. Recent URI treated with Augmentin, course completed. Recent URI treated with Augmentin, course completed. Recent URI treated with Augmentin, course completed. Recent URI treated with Augmentin, course completed. Recent URI treated with Augmentin, course completed. Recent URI treated with Augmentin, course completed. Chief Complaint: 24 Hour Events: No overnight events patient subjectively feels like he is breathing better Allergies: Amiodarone worsening COPD; Proscar (Oral) (Finasteride) breast sensitiv Sotalol Unknown; Last dose of Antibiotics: Ceftriaxone - 11:45 PM Infusions: Other ICU medications: Heparin Sodium (Prophylaxis) - 04:00 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 06:31 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.9C (98.4 Tcurrent: 36.1C (97 HR: 85 (70 - 102) bpm BP: 119/72(82) {112/69(82) - 126/78(87)} mmHg RR: 13 (13 - 26) insp/min SpO2: 99% Heart rhythm: AV Paced Total In: 325 mL PO: TF: IVF: 85 mL Blood products: Total out: 525 mL 213 mL Urine: 525 mL 213 mL NG: Stool: Drains: Balance: -200 mL -213 mL Respiratory support O2 Delivery Device: Nasal cannula SpO2: 99% ABG: 7.45/47/114/35/8 Physical Examination General: Alert, oriented, mild SOB HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Diminished throughout R>L with scattered wheezes and rales on R CV: Irreg rhythm with skipped beats, normal S1 + S2, SEM at RSB Abdomen: soft, non-tender, protuberant, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Labs / Radiology 176 K/uL 11.4 g/dL 162 mg/dL 0.8 mg/dL 35 mEq/L 3.9 mEq/L 20 mg/dL 100 mEq/L 141 mEq/L 33.8 % 15.3 K/uL [image002.jpg] 05:17 PM 09:59 PM 02:02 AM 05:00 AM WBC 15.3 Hct 33.8 Plt 176 Cr 0.8 TropT 0.02 TCO2 32 34 Glucose 162 Other labs: PT / PTT / INR:23.8/33.3/2.3, CK / CKMB / Troponin-T:120/5/0.02, Lactic Acid:1.7 mmol/L, Ca++:8.9 mg/dL, Mg++:2.4 mg/dL, PO4:2.6 mg/dL Assessment and Plan This is a 70 yo male with known Stage IV COPD with home O2 requirement and chronic prednisone, AS, and cardiac pacer, who presents with acute shortness of breath, fever, and productive cough for 2 days. | 19 | [
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 560696,
"text": "Chief Complaint: Shortness of breath\n HPI:\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath for the past 2 days. He states that on Sunday\n morning he was out in the cold weather and also decreased his\n prednisone dose from 40mg to 20mg, per his Pulmonologist. During the\n day he reports dyspnea on exertion, feverishness, sore throat decreased\n appetite and general malaise. He also reports cough with occasional\n whitish sputum. Yesterday he noted increased DOE, as he was not able to\n walk up stairs wihtout becoming acutely short of breath. He used\n nebulized albuterol with minimal effect. Tmax at home was 101.7F.\n Recent URI treated with Augmentin, course completed.\n .\n In the ED, initial vs were: T 99.3 P 59 BP 142/87 R 28 O2 sat 99%/NRB.\n Patient was given Solu-Medrol 125mg IV, ceftriaxone 1g IV, azithromycin\n 500mg IV and combivent nebs x2. The patient had subjective improvement\n in his breathing, but endorsed R-sided pleuritic CP. EKG showed AV\n pacing at 109bpm. CXR showed R-sided infiltrate.\n .\n On the floor, he was speaking in full sentences, but remained SOB with\n audible wheeze. He still complains of mild R-sided pleuritic CP. He\n denies any increase in LE edema; he has chronic LUE edema following\n pacer placement. He denies any nausea, vomiting, difficulty swallowing,\n abdominal pain, diarrhea, or constipation. He also denies urinary\n symptoms. He did not take his PO lasix dose earlier today.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n * Stage IV COPD requiring home oxygen (2 L NC during day, 4 L\n with bipap at night)\n * h/o pulmonary nodules\n * atrial fibrillation s/p AV junction ablation & dual\n chamber pacer placement in , on coumadin\n * aortic stenosis (valve area 1.0 on cath )\n * h/o arthritis\n * h/o basal cell carcinoma\n * h/o migraines\n * h/o hemoptysis in s/p bronchoscopy at (nonTB\n mycobacteria per report)\n Father with CAD, mother with CVA\n Occupation: Works as a travel .\n Drugs: Denies\n Tobacco: Prior smoker, but quit in .\n Alcohol: Denies\n Other:\n Review of systems:\n Flowsheet Data as of 12:59 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: 36.3\nC (97.3\n HR: 87 (87 - 102) bpm\n BP: 120/78(87) {115/69(82) - 126/78(87)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 60 mL\n Urine:\n 525 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -60 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.42/47/143//5\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), (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: Crackles :\n R base, Wheezes : scattered throughout, Diminished: R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 222\n 13.3\n 131\n 1.0\n 20\n 34\n 97\n 4.5\n 140\n 39.0\n 22.0\n [image002.jpg]\n \n 2:33 A3/3/ 05:17 PM\n \n 10:20 P3/3/ 09:59 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n 0.02\n TC02\n 32\n Other labs: CK / CKMB / Troponin-T:120/5/0.02, Lactic Acid:3.3 mmol/L\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - F/u lactate\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n - Wean O2 as tolerated\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - F/u second set CE\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n .\n # FEN: No IVF, replete electrolytes, NPO until clinical improvement\n .\n # Prophylaxis: Therapeutic on coumadin, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: Likely to floor in AM\n .\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 06:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 560628,
"text": "Chief Complaint: Shortness of breath\n HPI:\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath for the past 2 days. He states that on Sunday\n morning he was out in the cold weather and also decreased his\n prednisone dose from 40mg to 20mg, per his Pulmonologist. During the\n day he reports dyspnea on exertion, feverishness, sore throat decreased\n appetite and general malaise. He also reports cough with occasional\n whitish sputum. Yesterday he noted increased DOE, as he was not able to\n walk up stairs wihtout becoming acutely short of breath. He used\n nebulized albuterol with minimal effect. Tmax at home was 101.7F.\n Recent URI treated with Augmentin, course completed.\n .\n In the ED, initial vs were: T 99.3 P 59 BP 142/87 R 28 O2 sat 99%/NRB.\n Patient was given Solu-Medrol 125mg IV, ceftriaxone 1g IV, azithromycin\n 500mg IV and combivent nebs x2. The patient had subjective improvement\n in his breathing, but endorsed R-sided pleuritic CP. EKG showed AV\n pacing at 109bpm. CXR showed R-sided infiltrate.\n .\n On the floor, he was speaking in full sentences, but remained SOB with\n audible wheeze. He still complains of mild R-sided pleuritic CP. He\n denies any increase in LE edema; he has chronic LUE edema following\n pacer placement. He denies any nausea, vomiting, difficulty swallowing,\n abdominal pain, diarrhea, or constipation. He also denies urinary\n symptoms. He did not take his PO lasix dose earlier today.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n * Stage IV COPD requiring home oxygen (2 L NC during day, 4 L\n with bipap at night)\n * h/o pulmonary nodules\n * atrial fibrillation s/p AV junction ablation & dual\n chamber pacer placement in , on coumadin\n * aortic stenosis (valve area 1.0 on cath )\n * h/o arthritis\n * h/o basal cell carcinoma\n * h/o migraines\n * h/o hemoptysis in s/p bronchoscopy at (nonTB\n mycobacteria per report)\n Father with CAD, mother with CVA\n Occupation: Works as a travel .\n Drugs: Denies\n Tobacco: Prior smoker, but quit in .\n Alcohol: Denies\n Other:\n Review of systems:\n Flowsheet Data as of 12:59 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: 36.3\nC (97.3\n HR: 87 (87 - 102) bpm\n BP: 120/78(87) {115/69(82) - 126/78(87)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 60 mL\n Urine:\n 525 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -60 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.42/47/143//5\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), (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: Crackles :\n R base, Wheezes : scattered throughout, Diminished: R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 222\n 13.3\n 131\n 1.0\n 20\n 34\n 97\n 4.5\n 140\n 39.0\n 22.0\n [image002.jpg]\n \n 2:33 A3/3/ 05:17 PM\n \n 10:20 P3/3/ 09:59 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n 0.02\n TC02\n 32\n Other labs: CK / CKMB / Troponin-T:120/5/0.02, Lactic Acid:3.3 mmol/L\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - F/u lactate\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n - Wean O2 as tolerated\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - F/u second set CE\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n .\n # FEN: No IVF, replete electrolytes, NPO until clinical improvement\n .\n # Prophylaxis: Therapeutic on coumadin, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: Likely to floor in AM\n .\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 06:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 560686,
"text": "Chief Complaint:\n 24 Hour Events:\n No overnight events\n patient subjectively feels like he is breathing\n better\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:31 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: 36.1\nC (97\n HR: 85 (70 - 102) bpm\n BP: 119/72(82) {112/69(82) - 126/78(87)} mmHg\n RR: 13 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 213 mL\n Urine:\n 525 mL\n 213 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.45/47/114/35/8\n Physical Examination\n General: Alert, oriented, mild SOB\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated\n Lungs: Diminished throughout R>L with scattered wheezes and rales on R\n CV: Irreg rhythm with skipped beats, normal S1 + S2, SEM at RSB\n Abdomen: soft, non-tender, protuberant, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 176 K/uL\n 11.4 g/dL\n 162 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 100 mEq/L\n 141 mEq/L\n 33.8 %\n 15.3 K/uL\n [image002.jpg]\n 05:17 PM\n 09:59 PM\n 02:02 AM\n 05:00 AM\n WBC\n 15.3\n Hct\n 33.8\n Plt\n 176\n Cr\n 0.8\n TropT\n 0.02\n TCO2\n 32\n 34\n Glucose\n 162\n Other labs: PT / PTT / INR:23.8/33.3/2.3, CK / CKMB /\n Troponin-T:120/5/0.02, Lactic Acid:1.7 mmol/L, Ca++:8.9 mg/dL, Mg++:2.4\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - F/u lactate\n trending down 3.3 -> 1.7\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n - Wean O2 as tolerated\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - F/u second set CE\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n - Cont coumadin and monitor INR for drug interactions\n .\n # FEN: No IVF, replete electrolytes, reg diet\n .\n # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: likely transfer to the floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 560723,
"text": "HPI:\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath for the past 2 days. He states that on Sunday\n morning he was out in the cold weather and also decreased his\n prednisone dose from 40mg to 20mg, per his Pulmonologist. During the\n day he reports dyspnea on exertion, feverishness, sore throat decreased\n appetite and general malaise. He also reports cough with occasional\n whitish sputum. Yesterday he noted increased DOE, as he was not able to\n walk up stairs wihtout becoming acutely short of breath. He used\n nebulized albuterol with minimal effect. Tmax at home was 101.7F.\n Recent URI treated with Augmentin, course completed.\n .\n In the ED, initial vs were: T 99.3 P 59 BP 142/87 R 28 O2 sat 99%/NRB.\n Patient was given Solu-Medrol 125mg IV, ceftriaxone 1g IV, azithromycin\n 500mg IV and combivent nebs x2. The patient had subjective improvement\n in his breathing, but endorsed R-sided pleuritic CP. EKG showed AV\n pacing at 109bpm. CXR showed R-sided infiltrate.\n .\n On the floor, he was speaking in full sentences, but remained SOB with\n audible wheeze. He still complains of mild R-sided pleuritic CP. He\n denies any increase in LE edema; he has chronic LUE edema following\n pacer placement. He denies any nausea, vomiting, difficulty swallowing,\n abdominal pain, diarrhea, or constipation. He also denies urinary\n symptoms. He did not take his PO lasix dose earlier today.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Past medical history:\n * Stage IV COPD requiring home oxygen (2 L NC during day, 4 L\n with bipap at night)\n * h/o pulmonary nodules\n * atrial fibrillation s/p AV junction ablation & dual\n chamber pacer placement in , on coumadin\n * aortic stenosis (valve area 1.0 on cath )\n * h/o arthritis\n * h/o basal cell carcinoma\n * h/o migraines\n * h/o hemoptysis in s/p bronchoscopy at (nonTB\n mycobacteria per report)\n Pneumonia, other\n Assessment:\n Pt alert and oriented. Reports no CP/pain.\n Positive dyspnea on exertion. LS diminished w/ rhonchi to\n RUL/RML\n O2 saturation on 5 Liters 96%/. Goal per team to keep >95%\n Non-productive cough. Afebrile. WBC down 15.3. VS stable in\n Paced AV rhythm\n BCx/UCx/ Urine for Legionella pending\n Action:\n Atrovent/Albuterol nebs Q3hrs ATC\n Encourage po\ns for sputum production\n Received total of 2 doses of Solumedrol 125mg IV per order\n Ceftriaxone IV Q24hrs\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 560728,
"text": "Chief Complaint:\n 24 Hour Events:\n No overnight events\n patient subjectively feels like he is breathing\n better\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:31 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: 36.1\nC (97\n HR: 85 (70 - 102) bpm\n BP: 119/72(82) {112/69(82) - 126/78(87)} mmHg\n RR: 13 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 213 mL\n Urine:\n 525 mL\n 213 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.45/47/114/35/8\n Physical Examination\n General: Alert, oriented, mild SOB\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated\n Lungs: Diminished throughout R>L with scattered wheezes and rales on R\n CV: Irreg rhythm with skipped beats, normal S1 + S2, SEM at RSB\n Abdomen: soft, non-tender, protuberant, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 176 K/uL\n 11.4 g/dL\n 162 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 100 mEq/L\n 141 mEq/L\n 33.8 %\n 15.3 K/uL\n [image002.jpg]\n 05:17 PM\n 09:59 PM\n 02:02 AM\n 05:00 AM\n WBC\n 15.3\n Hct\n 33.8\n Plt\n 176\n Cr\n 0.8\n TropT\n 0.02\n TCO2\n 32\n 34\n Glucose\n 162\n Other labs: PT / PTT / INR:23.8/33.3/2.3, CK / CKMB /\n Troponin-T:120/5/0.02, Lactic Acid:1.7 mmol/L, Ca++:8.9 mg/dL, Mg++:2.4\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - Lactate\n trending down 3.3 -> 1.7\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n start 60mg, weaned down to\n 30mg\n - Wean O2 as tolerated, SaO2 >90%, OK to remain in low 90s\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - Second set CE trended down 0.04->0.02, no need for third troponin\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n - Cont coumadin and monitor INR for drug interactions\n .\n # FEN: No IVF, replete electrolytes, reg diet\n .\n # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: likely transfer to the floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 560690,
"text": "Chief Complaint:\n 24 Hour Events:\n No overnight events\n patient subjectively feels like he is breathing\n better\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:31 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: 36.1\nC (97\n HR: 85 (70 - 102) bpm\n BP: 119/72(82) {112/69(82) - 126/78(87)} mmHg\n RR: 13 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 213 mL\n Urine:\n 525 mL\n 213 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.45/47/114/35/8\n Physical Examination\n General: Alert, oriented, mild SOB\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated\n Lungs: Diminished throughout R>L with scattered wheezes and rales on R\n CV: Irreg rhythm with skipped beats, normal S1 + S2, SEM at RSB\n Abdomen: soft, non-tender, protuberant, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 176 K/uL\n 11.4 g/dL\n 162 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 100 mEq/L\n 141 mEq/L\n 33.8 %\n 15.3 K/uL\n [image002.jpg]\n 05:17 PM\n 09:59 PM\n 02:02 AM\n 05:00 AM\n WBC\n 15.3\n Hct\n 33.8\n Plt\n 176\n Cr\n 0.8\n TropT\n 0.02\n TCO2\n 32\n 34\n Glucose\n 162\n Other labs: PT / PTT / INR:23.8/33.3/2.3, CK / CKMB /\n Troponin-T:120/5/0.02, Lactic Acid:1.7 mmol/L, Ca++:8.9 mg/dL, Mg++:2.4\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - F/u lactate\n trending down 3.3 -> 1.7\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n - Wean O2 as tolerated\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - Second set CE trended down 0.04->0.02\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n - Cont coumadin and monitor INR for drug interactions\n .\n # FEN: No IVF, replete electrolytes, reg diet\n .\n # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: likely transfer to the floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 560694,
"text": "Chief Complaint:\n 24 Hour Events:\n No overnight events\n patient subjectively feels like he is breathing\n better\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:31 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: 36.1\nC (97\n HR: 85 (70 - 102) bpm\n BP: 119/72(82) {112/69(82) - 126/78(87)} mmHg\n RR: 13 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 213 mL\n Urine:\n 525 mL\n 213 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.45/47/114/35/8\n Physical Examination\n General: Alert, oriented, mild SOB\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated\n Lungs: Diminished throughout R>L with scattered wheezes and rales on R\n CV: Irreg rhythm with skipped beats, normal S1 + S2, SEM at RSB\n Abdomen: soft, non-tender, protuberant, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 176 K/uL\n 11.4 g/dL\n 162 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 100 mEq/L\n 141 mEq/L\n 33.8 %\n 15.3 K/uL\n [image002.jpg]\n 05:17 PM\n 09:59 PM\n 02:02 AM\n 05:00 AM\n WBC\n 15.3\n Hct\n 33.8\n Plt\n 176\n Cr\n 0.8\n TropT\n 0.02\n TCO2\n 32\n 34\n Glucose\n 162\n Other labs: PT / PTT / INR:23.8/33.3/2.3, CK / CKMB /\n Troponin-T:120/5/0.02, Lactic Acid:1.7 mmol/L, Ca++:8.9 mg/dL, Mg++:2.4\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - F/u lactate\n trending down 3.3 -> 1.7\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n - Wean O2 as tolerated\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - Second set CE trended down 0.04->0.02\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n - Cont coumadin and monitor INR for drug interactions\n .\n # FEN: No IVF, replete electrolytes, reg diet\n .\n # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: likely transfer to the floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 560695,
"text": "Chief Complaint: Shortness of breath\n HPI:\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath for the past 2 days. He states that on Sunday\n morning he was out in the cold weather and also decreased his\n prednisone dose from 40mg to 20mg, per his Pulmonologist. During the\n day he reports dyspnea on exertion, feverishness, sore throat decreased\n appetite and general malaise. He also reports cough with occasional\n whitish sputum. Yesterday he noted increased DOE, as he was not able to\n walk up stairs wihtout becoming acutely short of breath. He used\n nebulized albuterol with minimal effect. Tmax at home was 101.7F.\n Recent URI treated with Augmentin, course completed.\n .\n In the ED, initial vs were: T 99.3 P 59 BP 142/87 R 28 O2 sat 99%/NRB.\n Patient was given Solu-Medrol 125mg IV, ceftriaxone 1g IV, azithromycin\n 500mg IV and combivent nebs x2. The patient had subjective improvement\n in his breathing, but endorsed R-sided pleuritic CP. EKG showed AV\n pacing at 109bpm. CXR showed R-sided infiltrate.\n .\n On the floor, he was speaking in full sentences, but remained SOB with\n audible wheeze. He still complains of mild R-sided pleuritic CP. He\n denies any increase in LE edema; he has chronic LUE edema following\n pacer placement. He denies any nausea, vomiting, difficulty swallowing,\n abdominal pain, diarrhea, or constipation. He also denies urinary\n symptoms. He did not take his PO lasix dose earlier today.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n * Stage IV COPD requiring home oxygen (2 L NC during day, 4 L\n with bipap at night)\n * h/o pulmonary nodules\n * atrial fibrillation s/p AV junction ablation & dual\n chamber pacer placement in , on coumadin\n * aortic stenosis (valve area 1.0 on cath )\n * h/o arthritis\n * h/o basal cell carcinoma\n * h/o migraines\n * h/o hemoptysis in s/p bronchoscopy at (nonTB\n mycobacteria per report)\n Father with CAD, mother with CVA\n Occupation: Works as a travel .\n Drugs: Denies\n Tobacco: Prior smoker, but quit in .\n Alcohol: Denies\n Other:\n Review of systems:\n Flowsheet Data as of 12:59 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: 36.3\nC (97.3\n HR: 87 (87 - 102) bpm\n BP: 120/78(87) {115/69(82) - 126/78(87)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 60 mL\n Urine:\n 525 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -60 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.42/47/143//5\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), (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: Crackles :\n R base, Wheezes : scattered throughout, Diminished: R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 222\n 13.3\n 131\n 1.0\n 20\n 34\n 97\n 4.5\n 140\n 39.0\n 22.0\n [image002.jpg]\n \n 2:33 A3/3/ 05:17 PM\n \n 10:20 P3/3/ 09:59 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n 0.02\n TC02\n 32\n Other labs: CK / CKMB / Troponin-T:120/5/0.02, Lactic Acid:3.3 mmol/L\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - F/u lactate\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n - Wean O2 as tolerated\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - F/u second set CE\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n .\n # FEN: No IVF, replete electrolytes, NPO until clinical improvement\n .\n # Prophylaxis: Therapeutic on coumadin, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: Likely to floor in AM\n .\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 06:26 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 560680,
"text": "Pneumonia, .H/O chronic obstructive pulmonary disease (COPD,\n Bronchitis, Emphysema) with Acute Exacerbation\n Assessment:\n LSCTA throughout the night. No cough. Afebrile. WBC 15.3. ABG WNL.\n Action:\n Neb txs Q3 hours as ordered. Ceftriaxone as ordered.\n Response:\n Tolerated neb txs. No c/o of SOB. No c/o chest pain.\n Plan:\n Continue neb txs, antibiotics.\n Edema, peripheral\n Assessment:\n Pt with hx of LUE swelling following pacer placement.\n Action:\n No BP cuffs, no IV\n Response:\n Pt reports no increase in LE edema.\n Plan:\n Posted sign in pt\ns room with restrictions to LUE.\n .H/O atrial fibrillation (Afib)\n Assessment:\n Pt cardiovascular stable.\n Action:\n Q1 vital signs. Home cardiac meds ordered.\n Response:\n Plan:\n Continue to monitor closely and administer home meds as directed.\n Aortic stenosis\n Assessment:\n Per MICU team, pt with severe aortic stenosis. Limiting amount of\n IVF. Pt did not receive daily Lasix.\n Action:\n Pt u/o decreased to <30cc/hr ON.\n Response:\n MICU Team aware.\n Plan:\n Encourage increase in PO intake.\n"
},
{
"category": "Nursing",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 560671,
"text": "Pneumonia, .H/O chronic obstructive pulmonary disease (COPD,\n Bronchitis, Emphysema) with Acute Exacerbation\n Assessment:\n LSCTA throughout the night. No cough. Afebrile. WBC\n Action:\n Neb txs Q3 hours as ordered. Ceftriaxone as ordered.\n Response:\n Tolerated well.\n Plan:\n Continue neb txs.\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 560677,
"text": "Pneumonia, .H/O chronic obstructive pulmonary disease (COPD,\n Bronchitis, Emphysema) with Acute Exacerbation\n Assessment:\n LSCTA throughout the night. No cough. Afebrile. WBC 15.3. ABG WNL.\n Action:\n Neb txs Q3 hours as ordered. Ceftriaxone as ordered.\n Response:\n Tolerated neb txs. No c/o of SOB. No c/o chest pain.\n Plan:\n Continue neb txs, antibiotics.\n Edema, peripheral\n Assessment:\n Pt with hx of LUE swelling following pacer placement.\n Action:\n No BP cuffs, no IV\n Response:\n Pt reports no increase in LE edema.\n Plan:\n Posted sign in pt\ns room with restrictions to LUE.\n .H/O atrial fibrillation (Afib)\n Assessment:\n Pt cardiovascular stable.\n Action:\n Q1 vital signs. Home cardiac meds ordered.\n Response:\n Plan:\n Continue to monitor closely and administer home meds as directed.\n"
},
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 560759,
"text": "Chief Complaint:\n 24 Hour Events:\n No overnight events\n patient subjectively feels like he is breathing\n better\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:31 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: 36.1\nC (97\n HR: 85 (70 - 102) bpm\n BP: 119/72(82) {112/69(82) - 126/78(87)} mmHg\n RR: 13 (13 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 213 mL\n Urine:\n 525 mL\n 213 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -213 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.45/47/114/35/8\n Physical Examination\n General: Alert, oriented, mild SOB\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated\n Lungs: Diminished throughout R>L with scattered wheezes and rales on R\n CV: Irreg rhythm with skipped beats, normal S1 + S2, SEM at RSB\n Abdomen: soft, non-tender, protuberant, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 176 K/uL\n 11.4 g/dL\n 162 mg/dL\n 0.8 mg/dL\n 35 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 100 mEq/L\n 141 mEq/L\n 33.8 %\n 15.3 K/uL\n [image002.jpg]\n 05:17 PM\n 09:59 PM\n 02:02 AM\n 05:00 AM\n WBC\n 15.3\n Hct\n 33.8\n Plt\n 176\n Cr\n 0.8\n TropT\n 0.02\n TCO2\n 32\n 34\n Glucose\n 162\n Other labs: PT / PTT / INR:23.8/33.3/2.3, CK / CKMB /\n Troponin-T:120/5/0.02, Lactic Acid:1.7 mmol/L, Ca++:8.9 mg/dL, Mg++:2.4\n mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - Lactate\n trending down 3.3 -> 1.7\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n start 60mg, weaned down to\n 30mg\n - Wean O2 as tolerated, SaO2 >90%, OK to remain in low 90s\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - Second set CE trended down 0.04->0.02, no need for third troponin\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n - Cont coumadin and monitor INR for drug interactions\n .\n # FEN: No IVF, replete electrolytes, reg diet\n .\n # Prophylaxis: Therapeutic on coumadin, pneumoboots, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: likely transfer to the floor today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:26 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 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: 70M COPD, 2-4L home oxygen; nocturnal BiPAP,\n , chronic prednisone, AF s/p PPM, AS p/w flare.\n Exam notable for Tm 98.3 BP 116/48 HR 96 (paced) RR 18 with sat 98 on\n 6LNC 7.45/47/114. JVD 8cm. Distant BS B. RRR s1s2. Soft, distended.\n +BS. Trace edema. Labs notable for WBC 15K, HCT 34, K+ 3.8, Cr 0.8. CXR\n with subtle RML infiltrate, COPD changes.\n Agree with plan to manage COPD flare / pneumonia with transition to\n prednisone 60, CTX / azithro, MDI rx and oxygen titration for sat\n 90-92%. Will notify Drs. and of admission. Will\n continue coumadin for AF, with attention to INR on antibiotics.\n Continue dofetilide and dilt for rate control. OOB / PT eval. Remainder\n of plan as outlined above.\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:47 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 560760,
"text": "Chief Complaint: Shortness of breath\n HPI:\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath for the past 2 days. He states that on Sunday\n morning he was out in the cold weather and also decreased his\n prednisone dose from 40mg to 20mg, per his Pulmonologist. During the\n day he reports dyspnea on exertion, feverishness, sore throat decreased\n appetite and general malaise. He also reports cough with occasional\n whitish sputum. Yesterday he noted increased DOE, as he was not able to\n walk up stairs wihtout becoming acutely short of breath. He used\n nebulized albuterol with minimal effect. Tmax at home was 101.7F.\n Recent URI treated with Augmentin, course completed.\n .\n In the ED, initial vs were: T 99.3 P 59 BP 142/87 R 28 O2 sat 99%/NRB.\n Patient was given Solu-Medrol 125mg IV, ceftriaxone 1g IV, azithromycin\n 500mg IV and combivent nebs x2. The patient had subjective improvement\n in his breathing, but endorsed R-sided pleuritic CP. EKG showed AV\n pacing at 109bpm. CXR showed R-sided infiltrate.\n .\n On the floor, he was speaking in full sentences, but remained SOB with\n audible wheeze. He still complains of mild R-sided pleuritic CP. He\n denies any increase in LE edema; he has chronic LUE edema following\n pacer placement. He denies any nausea, vomiting, difficulty swallowing,\n abdominal pain, diarrhea, or constipation. He also denies urinary\n symptoms. He did not take his PO lasix dose earlier today.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Last dose of Antibiotics:\n Ceftriaxone - 11:45 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n * Stage IV COPD requiring home oxygen (2 L NC during day, 4 L\n with bipap at night)\n * h/o pulmonary nodules\n * atrial fibrillation s/p AV junction ablation & dual\n chamber pacer placement in , on coumadin\n * aortic stenosis (valve area 1.0 on cath )\n * h/o arthritis\n * h/o basal cell carcinoma\n * h/o migraines\n * h/o hemoptysis in s/p bronchoscopy at (nonTB\n mycobacteria per report)\n Father with CAD, mother with CVA\n Occupation: Works as a travel .\n Drugs: Denies\n Tobacco: Prior smoker, but quit in .\n Alcohol: Denies\n Other:\n Review of systems:\n Flowsheet Data as of 12:59 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: 36.3\nC (97.3\n HR: 87 (87 - 102) bpm\n BP: 120/78(87) {115/69(82) - 126/78(87)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 99%\n Heart rhythm: AV Paced\n Total In:\n 325 mL\n PO:\n TF:\n IVF:\n 85 mL\n Blood products:\n Total out:\n 525 mL\n 60 mL\n Urine:\n 525 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -60 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.42/47/143//5\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), (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: Crackles :\n R base, Wheezes : scattered throughout, Diminished: R>L)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, No(t) Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 222\n 13.3\n 131\n 1.0\n 20\n 34\n 97\n 4.5\n 140\n 39.0\n 22.0\n [image002.jpg]\n \n 2:33 A3/3/ 05:17 PM\n \n 10:20 P3/3/ 09:59 PM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n TropT\n 0.02\n TC02\n 32\n Other labs: CK / CKMB / Troponin-T:120/5/0.02, Lactic Acid:3.3 mmol/L\n Assessment and Plan\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath, fever, and productive cough for 2 days.\n --------------------------------------\n # Pneumonia: Acute onset fever, cough and dyspnea in setting of CXR\n infiltrate is most likely acute pneumonia - typical vs atypical.\n - Cont Ceftriaxone and azithromycin (monitor INR, coumadin\n interaction). Low threshold for CTA to look for PE, which also can\n cause fever, if not responding to tx\n - F/u Legionella Ag\n - F/u lactate\n - Will allow po fluids as known AS could precipitate pulmonary edema\n with fluid boluses\n - Cont Mepron for PCP \n .\n # COPD exascerbation: likely precipitated by acute pneumonia as\n evidenced by marked dyspnea and wheezing and increased O2 requirement\n - SoluMedrol 125mg q8hr x2 doses\n - transition to po prednisone burst in AM\n - Wean O2 as tolerated\n .\n # ROMI: R-sided pleuritic CP suspicious for AMI, but EKG largely\n unchanged from prior and first set CE negative\n - F/u second set CE\n .\n # Cardiac arrhythmia: Known AV pacer s/p ablation for a-fib\n - Cont dofetilide 375 mcg and diltiazem 180 mg daily\n .\n # FEN: No IVF, replete electrolytes, NPO until clinical improvement\n .\n # Prophylaxis: Therapeutic on coumadin, H2\n .\n # Access: PIV x1\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: Likely to floor in AM\n .\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n 18 Gauge - 06:26 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 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: 70M COPD, 2-4L home oxygen; nocturnal BiPAP,\n , chronic prednisone, AF s/p PPM, AS p/w flare.\n Exam notable for Tm 98.3 BP 116/48 HR 96 (paced) RR 18 with sat 98 on\n 6LNC 7.45/47/114. JVD 8cm. Distant BS B. RRR s1s2. Soft, distended.\n +BS. Trace edema. Labs as noted above. CXR with subtle RML infiltrate,\n COPD changes.\n Agree with plan to manage COPD flare / pneumonia with transition to IV\n solumedrol 125 q8h, CTX / azithro, MDI rx and oxygen titration for sat\n 90-92%. Will continue coumadin for AF, with attention to INR on\n antibiotics. Continue dofetilide and dilt for rate control. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:49 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 560743,
"text": "HPI:\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath for the past 2 days. He states that on Sunday\n morning he was out in the cold weather and also decreased his\n prednisone dose from 40mg to 20mg, per his Pulmonologist. During the\n day he reports dyspnea on exertion, feverishness, sore throat decreased\n appetite and general malaise. He also reports cough with occasional\n whitish sputum. Yesterday he noted increased DOE, as he was not able to\n walk up stairs wihtout becoming acutely short of breath. He used\n nebulized albuterol with minimal effect. Tmax at home was 101.7F.\n Recent URI treated with Augmentin, course completed.\n .\n In the ED, initial vs were: T 99.3 P 59 BP 142/87 R 28 O2 sat 99%/NRB.\n Patient was given Solu-Medrol 125mg IV, ceftriaxone 1g IV, azithromycin\n 500mg IV and combivent nebs x2. The patient had subjective improvement\n in his breathing, but endorsed R-sided pleuritic CP. EKG showed AV\n pacing at 109bpm. CXR showed R-sided infiltrate.\n .\n On the floor, he was speaking in full sentences, but remained SOB with\n audible wheeze. He still complains of mild R-sided pleuritic CP. He\n denies any increase in LE edema; he has chronic LUE edema following\n pacer placement. He denies any nausea, vomiting, difficulty swallowing,\n abdominal pain, diarrhea, or constipation. He also denies urinary\n symptoms. He did not take his PO lasix dose earlier today.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Past medical history:\n * Stage IV COPD requiring home oxygen (2 L NC during day, 4 L\n with bipap at night)\n * h/o pulmonary nodules\n * atrial fibrillation s/p AV junction ablation & dual\n chamber pacer placement in , on coumadin\n * aortic stenosis (valve area 1.0 on cath )\n * h/o arthritis\n * h/o basal cell carcinoma\n * h/o migraines\n * h/o hemoptysis in s/p bronchoscopy at (nonTB\n mycobacteria per report)\n Pneumonia, other\n Assessment:\n Pt alert and oriented. Reports no CP/pain.\n Positive dyspnea on exertion. LS diminished w/ rhonchi to\n RUL/RML\n O2 saturation on 5 Liters 96%/. Goal per team to keep\n >92-94%%\n Non-productive cough. Afebrile. WBC down 15.3. VS stable in\n Paced AV rhythm\n BCx/UCx/ Urine for Legionella pending\n Action:\n Atrovent/Albuterol nebs Q3hrs ATC\n Encourage po\ns for sputum production\n Received total of 2 doses of Solumedrol 125mg IV per order\n and now on day one of Prednisone taper\n Ceftriaxone IV Q24hrs\n Response:\n Still c/o SOB w/ exertion. O2 saturation >96% on 5Liters\n Responds well to Neb tx\n Still no sputum production\n Plan:\n Monitor LS admin Meds per order\n Encourage po\ns. Monitor U/O to eval hydration\n ? f/u with team when to restart Lasix po\n"
},
{
"category": "Nursing",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 560744,
"text": "HPI:\n This is a 70 yo male with known Stage IV COPD with home O2 requirement\n and chronic prednisone, AS, and cardiac pacer, who presents with acute\n shortness of breath for the past 2 days. He states that on Sunday\n morning he was out in the cold weather and also decreased his\n prednisone dose from 40mg to 20mg, per his Pulmonologist. During the\n day he reports dyspnea on exertion, feverishness, sore throat decreased\n appetite and general malaise. He also reports cough with occasional\n whitish sputum. Yesterday he noted increased DOE, as he was not able to\n walk up stairs wihtout becoming acutely short of breath. He used\n nebulized albuterol with minimal effect. Tmax at home was 101.7F.\n Recent URI treated with Augmentin, course completed.\n .\n In the ED, initial vs were: T 99.3 P 59 BP 142/87 R 28 O2 sat 99%/NRB.\n Patient was given Solu-Medrol 125mg IV, ceftriaxone 1g IV, azithromycin\n 500mg IV and combivent nebs x2. The patient had subjective improvement\n in his breathing, but endorsed R-sided pleuritic CP. EKG showed AV\n pacing at 109bpm. CXR showed R-sided infiltrate.\n .\n On the floor, he was speaking in full sentences, but remained SOB with\n audible wheeze. He still complains of mild R-sided pleuritic CP. He\n denies any increase in LE edema; he has chronic LUE edema following\n pacer placement. He denies any nausea, vomiting, difficulty swallowing,\n abdominal pain, diarrhea, or constipation. He also denies urinary\n symptoms. He did not take his PO lasix dose earlier today.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Past medical history:\n * Stage IV COPD requiring home oxygen (2 L NC during day, 4 L\n with bipap at night)\n * h/o pulmonary nodules\n * atrial fibrillation s/p AV junction ablation & dual\n chamber pacer placement in , on coumadin\n * aortic stenosis (valve area 1.0 on cath )\n * h/o arthritis\n * h/o basal cell carcinoma\n * h/o migraines\n * h/o hemoptysis in s/p bronchoscopy at (nonTB\n mycobacteria per report)\n Pneumonia, other\n Assessment:\n Pt alert and oriented. Reports no CP/pain.\n Positive dyspnea on exertion. LS diminished w/ rhonchi to\n RUL/RML\n O2 saturation on 5 Liters 96%/. Goal per team to keep\n >92-94%%\n Non-productive cough. Afebrile. WBC down 15.3. VS stable in\n Paced AV rhythm\n BCx/UCx/ Urine for Legionella pending\n Action:\n Atrovent/Albuterol nebs Q3hrs ATC\n Encourage po\ns for sputum production\n Received total of 2 doses of Solumedrol 125mg IV per order\n and now on day one of Prednisone taper\n Ceftriaxone IV Q24hrs\n Response:\n Still c/o SOB w/ exertion. O2 saturation >96% on 5Liters\n Responds well to Neb tx\n Still no sputum production\n Plan:\n Monitor LS admin Meds per order\n Encourage po\ns. Monitor U/O to eval hydration\n ? f/u with team when to restart Lasix po\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n PNEUMONIA;TELEMETRY\n Code status:\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n Amiodarone\n worsening COPD;\n Proscar (Oral) (Finasteride)\n breast sensitiv\n Sotalol\n Unknown;\n Precautions:\n PMH: COPD\n CV-PMH: Arrhythmias, Pacemaker\n Additional history: * Stage IV COPD requiring home oxygen (2 L NC\n during day, 4 L\n with bipap at night)\n * h/o pulmonary nodules\n * atrial fibrillation s/p AV junction ablation & dual\n chamber pacer placement in , on coumadin\n * aortic stenosis (valve area 1.0 on cath )\n * h/o arthritis\n * h/o basal cell carcinoma\n * h/o migraines\n * h/o hemoptysis in s/p bronchoscopy at (nonTB\n mycobacteria per report)\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:80\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 101 bpm\n Heart rhythm:\n AV Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 5 L/min\n FiO2 set:\n 24h total in:\n 480 mL\n 24h total out:\n 421 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 05:00 AM\n Potassium:\n 3.9 mEq/L\n 05:00 AM\n Chloride:\n 100 mEq/L\n 05:00 AM\n CO2:\n 35 mEq/L\n 05:00 AM\n BUN:\n 20 mg/dL\n 05:00 AM\n Creatinine:\n 0.8 mg/dL\n 05:00 AM\n Glucose:\n 162 mg/dL\n 05:00 AM\n Hematocrit:\n 33.8 %\n 05:00 AM\n Finger Stick Glucose:\n 191\n 04:00 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": "General",
"chartdate": "2159-02-20 00:00:00.000",
"description": "Generic Note",
"row_id": 560607,
"text": "TITLE: Nurse Admit Note:\n Pt is 70y/o male who presented to ED on 3/309 w/ worsening SOB and\n temps noted day previous. CXR revealing RML PNA, 02 saturation 84-86%\n on RA in ED and up to 96% on 2-3liters via NC. Hx: severe COPD (has\n home oxygen and has required steroid therepy in past), Asthma, PNA,\n atrial arrhythmias (A-fib), status post AVJ ablation, dual-chamber\n Medronic pacemaker, aoritic stenosis, left brachiocephalic vein clot,\n Hematuria. Arrived to SICU accompanied by wife, alert and oriented x3,\n positive dyspnea w/ exertion and insp/exp wheezing noted post activity.\n Combivent neb admin by RT. NS at TKO via Left AC #18 . Oriented to\n room and surroundings. MICU made aware of arrive. FULL CODE. Wife-\n is HCP.\n"
},
{
"category": "Nursing",
"chartdate": "2159-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 560664,
"text": ".H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n Action:\n Response:\n Plan:\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Edema, peripheral\n Assessment:\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "ECG",
"chartdate": "2159-02-22 00:00:00.000",
"description": "Report",
"row_id": 309258,
"text": "Electronic ventricular pacing with underlying sinus rhythm. Left atrial\nabnormality. Compared to the previous tracing of heart rate is\nlower. Otherwise, no major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2159-02-20 00:00:00.000",
"description": "Report",
"row_id": 309259,
"text": "Sinus tachycardia with atrial sensed and ventricular paced rhythm. Left\natrial enlargement. There is occasional atrial ectopy and occasional\nA-V sequential paced rhythm. Compared to the previous tracing of \nthe atrial rate has increased. There is atrial ectopy and occasional\nA-V sequential paced rhythm.\n\n"
}
] |
7,303 | 115,721 | He was referred to Dr. for aortic valve replacement. On , he underwent a coronary artery bypass graft times two with a right internal mammary artery to the posterior descending artery a left radial artery to the obtuse marginal. He had an aortic valve replacement with a 20-mm Homograft, and he had repair of his atrial septal defect. Please refer to the Operative Report. He was transferred to the Cardiothoracic Intensive Care Unit in stable condition. On postoperative day one, he was in a sinus rhythm with a blood pressure of 94/54. He was on a propofol drip, and nitroglycerin at 0.5 for his radial artery coverage, Fentanyl, and Neo-Synephrine at 0.5. He remained intubated with coarse breath sounds. He extremities had trace edema. The plan was to wean his sedation. His postoperative laboratories revealed white blood cell count was 9.3, hematocrit was 27.1, and platelets were 242,000. Sodium was 141, potassium was 4, chloride was 107, bicarbonate was 22, blood urea nitrogen was 11, creatinine was 0.8, and blood glucose was 119. His chest x-ray showed decreased lung volumes with no effusions of pneumothorax, and no congestive heart failure. An aggressive pulmonary toilet was started. The patient remained stable on his perioperative antibiotics. He had a bronchoscopy done; also done on , on postoperative day one, which showed clean airways by Dr. . He was seen by Case Management and Physical Therapy when he was transferred out to the floor. He also had an Electrophysiology consultation on postoperative day two. He had already been started on Lopressor and amiodarone for runs of tachycardia. He also had some late night episodes which were asymptomatic but responded to 5 mg of intravenous Lopressor. Some were self-limiting. His tracing showed atrial fibrillation. They recommended continuing his Lopressor and amiodarone and starting him on a intravenous heparin, off anticoagulation without a bolus if he could tolerate that. This was confirmed and reviewed by Dr. . A-wire tracing did confirm atrial fibrillation and atrial flutter. On postoperative day two, he was in a sinus rhythm in the 80s with a blood pressure of 101/56. His oxygen saturations were 97% on face mask and nasal cannula. He was continued on amiodarone, Imdur for his radial artery, albuterol, Colace, Zantac, and aspirin, as well as Percocet for pain. His hematocrit was stable at 28.7. Blood urea nitrogen was 11 and creatinine was 0.9. He was comfortable. His incision was clean, dry, and intact. Amiodarone was increased to 400 mg three times per day as per recommendations, and he began to auto diurese; putting out 3.5 liters of urine in a 24-hour period. He was alert, awake, and oriented. He started his rehabilitation with Physical Therapy on the floor on postoperative day two. He continued to diurese on the floor. He received an amiodarone bolus in addition to his routine dosing for supraventricular tachycardia which converted him back to a sinus rhythm. On postoperative day three, his blood pressure was 107/70; in a normal sinus rhythm at 67. His diet was advanced. He also started his Zantac. His creatinine rose slightly to 0.9. On postoperative day three, his chest tubes were removed. He remained on Lopressor, amiodarone, and Imdur, as well as his aspirin. He was comfortable. His lungs were clear bilaterally. His hematocrit rose to 30.5, and his creatinine dropped back down to 0.7. He had some trace peripheral edema and was continued with a pulmonary toilet and diuresis. His heparin drip continued. The decision was made to hold the Coumadin for now, and the patient was transferred out to the floor. He continued to receive Percocet for his incisional pain. He was followed by Electrophysiology who suggested possibly getting an Endocrine consultation given his radiation therapy and elevated thyroid-stimulating hormone with amiodarone. He was continued on his Lopressor and insulin sliding-scale. His creatinine remained stable at 0.8. He was started on 3 mg of Coumadin on postoperative day five while he continued his baseline intravenous heparin for anticoagulation for atrial fibrillation and atrial flutter, in addition to amiodarone boluses. Endocrine recommended starting him on Levoxyl 50 mcg p.o. once per day and following up with Dr. as an outpatient. They also recommended that he get a yearly thyroid examination and to recheck his thyroid function tests is approximately eight weeks given his history of radiation therapy. He was seen again by Case Management. On postoperative day five, he continued with his anticoagulation with heparin and Coumadin. His pacing wires were discontinued. He remained in atrial flutter and atrial fibrillation. His lungs were clear. His heart was regular in rate and rhythm. He had trace peripheral edema. He was in a sinus rhythm at 89 at the time of examination in the morning with a blood pressure of 126/75. On postoperative day six, he had some more bursts of atrial fibrillation in the evening and rapid atrial fibrillation in the morning which was rate controlled with Lopressor. The patient was totally asymptomatic. He had a blood pressure of 134/81. Temperature maximum was 100.6. His lungs were clear. He continued his anticoagulation and continued to ambulate with Physical Therapy. Since all of the recommendations had been followed, over the next day, the patient continued to ambulate on the floor awaiting therapeutic anticoagulation. His creatinine remained stable at 0.9. His INR on postoperative day six rose to 1.2. He continued to receive Percocet for pain and occasional Ambien for sleep with good effect. The patient remained in house awaiting a therapeutic INR. On postoperative day seven, the patient had no events overnight. He was in a sinus rhythm at a rate of 77. His blood pressure was 94/53. Oxygen saturation was 94% on room air. His heart was regular in rate and rhythm. His lungs were clear. He had trace pedal edema. His INR was 1.3, and he continued to ambulate. On postoperative day eight, the patient went back into intermittent atrial fibrillation and atrial flutter alternating with his sinus rhythm but with no complaints. His examination was unremarkable. On the day of discharge, his INR rose to 1.6. His prothrombin time was 15.8, and his partial thromboplastin time was 81.8 on heparin. | PT PLACED ON CPAP AND APPEARS VERY COMF ON CPAP. RESP: PT WITH LOW PO2 THIS AM -62. PT LAVAGED AND SX FOR SCANT AMTS SPUTUM. CXR DONE THAT SHOWED ATELECTASIS. PT HAS RECEIVED CPT Q2HR. foley d/c this am at 0500. lungs clear bilat. Heme: CTs serosang. wakeful from o.r. tol po meds. GI: Tol H2O. nsr w/ brief self limiting episodes afib. ID: T38.2, on kefzol. MOD CT DRG. pt continues on lopressor and amio PO. GI: OGT-LCWS. pt using IS.gi/gu: pt with + BS. WILL RECHECK ABG. pt update PT IS S/P AVR HOMOGRAFT, ASD REPAIR AND XX2 FROM YEST. MAE, follows commands.CV: Heartrate 80's to 90's NSR to short bursts of A-fib. Renal: Good diuresis to lasix. pt with 2 episodes nausea -> treated with reglan. sleeper given w/ fair effect. ace intact,elevated on pillow.hemodynamics as per flow sheet. temp pacer off. FINAL REPORT HISTORY: Status post AVR and CABG, now with chest tube removed, ? Pt able to expectorate small amt of thick tan sputum.GI: Pt tolerating clr liquids, hypoactive BS, abd soft NT.GU: Pt has f/c with marginal u/o, it decreased to zero at one point and pt given 20mg IV lasix, with good response.Access: Pt has R IJ cordis and PIV.ID: Low grade temp, and current afebrile. O2 sat 98%.GI: Abd large, slightly distended,slightly firm and quiet. sedated w midazolam & propofol increased. Pt taughtuse of IS getting to 1200, Lungs clear upper lobes and dim lower lobesOcc productive cough. k+ repleted. w variable bp,hypothermia. control rate and assymptomatic. BS clear and decreased in the bases bilaterally. There is mild perihilar haziness and a small left pleural effusion. LAB: K, CA REPLETED. csru updatept aaox3. He had reglan for N/V with good effect.GU: Foley to gravity draining clear yel urine Skin: Intact.A: Much improved.P: DC SG, OOB, diurese, cont lopressor, F2 in am. volume given,midazolam,mso4 & propfol bolused,a paced @ 90 w immed. CV: CI>3, stable off drips. pt remains on 2 L nc, o2 sats 94-97%. cordis d/c. IF ACCEPTABLE ABG. Pt still has A&V pacer wires connected to box, pacer off.Resp: Pt remains on .5% FT and 3L via NC, with O2 sat 96-100%. percocet 2 tabs x2 for c/o pain. pneumothorax. WITH ETT. BP stable 120-130/70-80. 1:01 PM CHEST (PORTABLE AP) Clip # Reason: s/p chest tube removal; is there a PTX? ecg w only slight changes from pre-op,low dose dilt. There is an expected degree of post surgical prominence of the cardiomediastinal silhouette. using is independently.assess: stable pm. Chest tube output minimal SS drainage.A & V wires secure to temp pacer, set at A demand rate of 70. plan to attempt vent weaning in a.m.lt. Resp: Weaned and extubated easily. Neuro: Pt sedated with propofol and Fent. Small left pleural effusion with associated atelectasis. tol liquids. Pt ambualted x 2 today. IMPRESSION: 1. Pt has CT in R pleural space to sxn, draining serous fluid, Mediasteinal CT's pulled. PT WAS HYPERTENSIVE AND TACHYCARDIC WHEN FIRST AWOKE. PT HAS GOOD CSM LT ARRM. Pt has had less bursts of A-fib with rate of 90's. oral airway inserted & fentanyl started for sedation. NEURO: PT SEDATED ON PROPOFOL AND FENTANYL THIS AM. When O2 completely off O2 sat decreases to 80's. PT required pain med x1.Cardiac: Pt currently in AF vs A-flutter (from EP) 80-110 HR. 150mg bolusof Amiodarone given at 23:30 and 400mg po given at 23;45. OGT to LCWSdraining minimal bilious drainage.GU: Foley to gravity draining clear yel urine. LAST PO2 WAS 66 (BEFORE PEEP INCREASED). delined.plan: transfer 2 when bed avail. The ET tube has been withdrawn. UO adequate. BS 100 RANGE. HR 60-80's. k+ & mg++ repleted,ntg continued @ .5 for radial condiut. CI>2PAD 15 to 20, CVP 15 to 17 MAP 60 to 70. SBP 100-140's. 2 units of PRBC give for low Hct of 22. Pt encouraged to cough and deep breath, along wiht IS. CV: PT HAVING FREQUENT PVC'S THIS AM (EVEN WITH LYTES REPLETED). PT GIVEN 20 LASIX WITH GOOD DIURESIS. There is density at the left base, which most likely represents postop changes. Chest tube with minimal drainage.A & V wires secure to temp pacer, wires do not sense and capture appropiately.RESP: When the pt was in Afib, and having pain, his O2 sats on NC and OFM were 94%, in NSR and without pain his O2 sats with just NC have been 96 to 97 %. PT MANY SECRETIONS. Endo: Glu 127, not treated. GIVEN 5MG IV LOPRESSOR WITH GOOD EFFECT. and coarse lower lobes bilatsuctioned for small amt of thick tan secretions. rise in bp. L arm remains in ace wrap -> fingers warm to touch -> + o2 pleth with good wave form on left fingersResp: LS clear with dim bases bil. CSRU Progress UpdateS/O: Neuro: Oriented, med with percocet and mso4. AP PORTABLE UPRIGHT CHEST, AT 13:30: Compared to prior study on , the SG catheter has been placed with a right IJ central venous line line with its tip in the SVC. Art line out.CI > 2.5 Swan DC'd. ALL DSG'S D&I. wires to pacer-> off. started for spasm prevention.turned w sudden waking despite high dose propofol,tight clamp w teeth on ett w hypotension into the 60's & bradycardia into the 40's w transient inability to pace. able to follow commandsCv: pt remains NSR, no ectopy noted. pt with strong cough. BS-DECREASED IN BASES. NEO/NTG TITRATED THIS PT ON NO GTTS. some st depression w increased vea noted on bedside monitor w waking. Neuro: Pt awake, alert & oriented x3. | 12 | [
{
"category": "Radiology",
"chartdate": "2153-01-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 781393,
"text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with s/p avr/cabg\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for effusion. Status post aortic valve replacement and\n coronary bypass.\n\n PORTABLE CHEST: Comparison is made to pre-operative study of . The\n endotracheal tube is 4.5 cm above the carina. The nasogastric tube below the\n view of the study. There is a swan ganz catheter placed via right internal\n jugular vein. The catheter tip is likely in the main pulmonary artery cannot\n be identified with certainty. There is an expected degree of post surgical\n prominence of the cardiomediastinal silhouette. There is mild perihilar\n haziness and a small left pleural effusion.\n\n IMPRESSION:\n\n 1. Post surgical changes as detailed above. Small left pleural effusion with\n associated atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-01-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 781606,
"text": " 1:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal; is there a PTX?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with s/p avr/cabg\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal; is there a PTX?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post AVR and CABG, now with chest tube removed, ?\n pneumothorax.\n\n AP PORTABLE UPRIGHT CHEST, AT 13:30:\n\n Compared to prior study on , the SG catheter has been placed with a\n right IJ central venous line line with its tip in the SVC. The ET tube has\n been withdrawn. There is no evidence of pneumothorax. Lung fields appear\n clear. There is density at the left base, which most likely represents postop\n changes.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-27 00:00:00.000",
"description": "Report",
"row_id": 1359865,
"text": "Neuro: Pt awake, alert & oriented x3. MAE, and follows commands. He is\nvery nervous about his A-fib, and was in pain at the begining of the night. he had percocet and tylenol q4hrs during the night for discomfort and a temp of 101.\n\nCV: Heartrate was 90's A-fib, his MAP 70's SBP was 130's until about an hour after his 2400 dose of amiodarone and then he converted to NSR\nwith a rate of 60's with MAP 70's. Chest tube with minimal drainage.\nA & V wires secure to temp pacer, wires do not sense and capture appropiately.\n\nRESP: When the pt was in Afib, and having pain, his O2 sats on NC and OFM were 94%, in NSR and without pain his O2 sats with just NC have been 96 to 97 %. His lungs are clear upper lobes and dim lower lobes.\n\nGI: Abd soft, +BS, tolerating water fairly well, vomited small amt of water shortly after taking 4 am percocet. He had reglan for N/V with good effect.\n\nGU: Foley to gravity draining clear yel urine\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-27 00:00:00.000",
"description": "Report",
"row_id": 1359866,
"text": "7am-7pm update\nNeuro: pt alert and orienated x3. MAE. able to follow commands\n\nCv: pt remains NSR, no ectopy noted. HR 60-80's. SBP 100-140's. pt continues on lopressor and amio PO. pt with 2 a wires and 2 wires. temp pacer off. PP weak although palpable. L arm remains in ace wrap -> fingers warm to touch -> + o2 pleth with good wave form on left fingers\n\nResp: LS clear with dim bases bil. pt remains on 2 L nc, o2 sats 94-97%. pt with strong cough. pt using IS.\n\ngi/gu: pt with + BS. no stool. pt with 2 episodes nausea -> treated with reglan. pt tolerated toast for dinner. foley to gravity draining clear yellow urine. UO adequate. pt recieved lasix 20 mg x 1 today -> diuresed well\n\nendo: BS at noon 155 -> treated with 6 units reg insulin. BS proir to dinner 124\n\nactivity/comfort: Pt OOB to chair with 1 person assist. Pt ambualted x 2 today. pt recieving percocets for pain control ~ q4h\n\nplan: monitor rhythm, monitor lytes/bs, increased activity and diet as tolerated, pulm toleit, pain control\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-28 00:00:00.000",
"description": "Report",
"row_id": 1359867,
"text": "csru update\npt aaox3. no neuro issues. nsr w/ brief self limiting episodes afib. control rate and assymptomatic. wires to pacer-> off. tol po meds. cordis d/c. k+ repleted. percocet 2 tabs x2 for c/o pain. sleeper given w/ fair effect. tol liquids. foley d/c this am at 0500. lungs clear bilat. strong cough productive of tan secretions. using is independently.\nassess: stable pm. delined.\nplan: transfer 2 when bed avail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-25 00:00:00.000",
"description": "Report",
"row_id": 1359862,
"text": "CSRU Progress Update\nS/O: Neuro: Oriented, med with percocet and mso4.\n CV: CI>3, stable off drips.\n Resp: Weaned and extubated easily. SAO2 96% on 2lNP and 100% face tent. Strong prod cough.\n Renal: Good diuresis to lasix.\n Heme: CTs serosang.\n ID: T38.2, on kefzol.\n GI: Tol H2O.\n Endo: Glu 127, not treated.\n Skin: Intact.\nA: Much improved.\nP: DC SG, OOB, diurese, cont lopressor, F2 in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-26 00:00:00.000",
"description": "Report",
"row_id": 1359863,
"text": "neuro: Pt awake, alert and oriented x3. MAE, follows commands.\n\nCV: Heartrate 80's to 90's NSR to short bursts of A-fib. 150mg bolus\nof Amiodarone given at 23:30 and 400mg po given at 23;45. Pt has had less bursts of A-fib with rate of 90's. SBP 100 to 90. Art line out.\nCI > 2.5 Swan DC'd. Pacing wires to temp pacer which is off. Chest tubes with mod amt of S/S drainage during the night.\n\nRESP: Pt has NC at 4l with OFM at 50% and O2 sats 97 to 96%. Pt taught\nuse of IS getting to 1200, Lungs clear upper lobes and dim lower lobes\nOcc productive cough. He is deep breathing and coughing and taking\npercocet for pain control.\n\nGI: Abd soft, +BS, tolerating clear liqs during the night.\n\nGU: Foley to gravity draining clear yel urine\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-26 00:00:00.000",
"description": "Report",
"row_id": 1359864,
"text": "CSRU Nursing Progress Note\nNeuro: Pt A&O x3, MAE, however painful. Pt remains in bed. PT required pain med x1.\n\nCardiac: Pt currently in AF vs A-flutter (from EP) 80-110 HR. Pt initially in SR with bouts of what is believed to be atrial tach as a precursor to A-fib/A-flutter, when pt having these tachycardic episodes pt felt chest tightness, Pt given total of 20mg lopressor IVP for HR in 120; when pts rhythm and rate broke, pt in SB and slightly hypotensive with MAP> 60 at all times. Pts rhythm changed to Af around 1630. Pt will con't on PO amio at 400mg , po lopressor increased to 25 , and given an additional bolus of 150mg amio. BP stable 120-130/70-80. Pt still has A&V pacer wires connected to box, pacer off.\n\nResp: Pt remains on .5% FT and 3L via NC, with O2 sat 96-100%. BS clear and decreased in the bases bilaterally. Pt encouraged to cough and deep breath, along wiht IS. Decrease O2 as tolerated, FT decreased from .7 to .5%, tolerated well. When O2 completely off O2 sat decreases to 80's. Pt has CT in R pleural space to sxn, draining serous fluid, Mediasteinal CT's pulled. Pt able to expectorate small amt of thick tan sputum.\n\nGI: Pt tolerating clr liquids, hypoactive BS, abd soft NT.\n\nGU: Pt has f/c with marginal u/o, it decreased to zero at one point and pt given 20mg IV lasix, with good response.\n\nAccess: Pt has R IJ cordis and PIV.\n\nID: Low grade temp, and current afebrile.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-24 00:00:00.000",
"description": "Report",
"row_id": 1359859,
"text": "wakeful from o.r. w variable bp,hypothermia. sedated w midazolam & propofol increased. ? some st depression w increased vea noted on bedside monitor w waking. k+ & mg++ repleted,ntg continued @ .5 for radial condiut. ecg w only slight changes from pre-op,low dose dilt. started for spasm prevention.turned w sudden waking despite high dose propofol,tight clamp w teeth on ett w hypotension into the 60's & bradycardia into the 40's w transient inability to pace. volume given,midazolam,mso4 & propfol bolused,a paced @ 90 w immed. rise in bp. oral airway inserted & fentanyl started for sedation. plan to attempt vent weaning in a.m.lt. hand warm w normal pleth wave. ace intact,elevated on pillow.hemodynamics as per flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-25 00:00:00.000",
"description": "Report",
"row_id": 1359860,
"text": "Neuro: Pt sedated with propofol and Fent. for pain. Pt wakes occ to\nloud noises or movement or painful stimuli, he does not follow commands, he does move all extremities.\n\nCV: Heartrate 90's to 70's NSR with Freq PVC's, rare PAC's. CI>2\nPAD 15 to 20, CVP 15 to 17 MAP 60 to 70. 2 units of PRBC give for low Hct of 22. 1000cc of LR bolus during the night for low PAD and MAP\nNeo titrating to keep MAP > 60. Chest tube output minimal SS drainage.\nA & V wires secure to temp pacer, set at A demand rate of 70. When he has freq vent ectopy SBP drops to 80's.\n\nRESP: Pt remains intubated, on full vent support as he is uncooperative when awake & agitated requiring sedation during the night.Lungs clear upper lobes bilat. and coarse lower lobes bilat\nsuctioned for small amt of thick tan secretions. O2 sat 98%.\n\nGI: Abd large, slightly distended,slightly firm and quiet. OGT to LCWS\ndraining minimal bilious drainage.\n\nGU: Foley to gravity draining clear yel urine.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-01-25 00:00:00.000",
"description": "Report",
"row_id": 1359861,
"text": "pt update\n PT IS S/P AVR HOMOGRAFT, ASD REPAIR AND XX2 FROM YEST.\n\n NEURO: PT SEDATED ON PROPOFOL AND FENTANYL THIS AM. BOTH WEANED OFF AND PT NOW COMPLETELY APPROPRIATE, FOLLOWING COMMANDS AND MAE. PT VERY CALM.\n\n RESP: PT WITH LOW PO2 THIS AM -62. PT MANY SECRETIONS. CXR DONE THAT SHOWED ATELECTASIS. PT HAS RECEIVED CPT Q2HR. PT LAVAGED AND SX FOR SCANT AMTS SPUTUM. FIO2 UP TO 60% AND PEEP UP TO 15. PT PLACED ON CPAP AND APPEARS VERY COMF ON CPAP. SATS NOW 98-SO FIO2 BACK DOWN TO 50%. RR 12. PT REMAINS VERY CALM AND COOPERATIVE-JUST WANTS ETT OUT. LAST PO2 WAS 66 (BEFORE PEEP INCREASED). WILL RECHECK ABG. BS-DECREASED IN BASES.\n\n CV: PT HAVING FREQUENT PVC'S THIS AM (EVEN WITH LYTES REPLETED). VENT ECTOPY MUCH DIMINISHED NOW-HAVE NOT SEEN PVC'S FOR SEVERAL HOURS. PT WAS HYPERTENSIVE AND TACHYCARDIC WHEN FIRST AWOKE. NEO/NTG TITRATED THIS PT ON NO GTTS. GIVEN 5MG IV LOPRESSOR WITH GOOD EFFECT. CI REMAINS EXCELLENT.\n\n GU: WEIGHT UP 14KG THIS AM. PT GIVEN 20 LASIX WITH GOOD DIURESIS. U/O REMAINS ADEQUATE.\n\n GI: OGT-LCWS.\n\n LAB: K, CA REPLETED. HAS NOT NEEDED INSULIN COVERAGE. BS 100 RANGE. HCT UP TO 27 AFTER RECEIVING 2 PC ON NOCS.\n\n OTHER: PT DENIES UNCOMF. WITH ETT. PT HAS GOOD CSM LT ARRM. ALL DSG'S D&I. MOD CT DRG.\n\n PLAN: TO CONT PULM TOILET AND ATTEMPT TO EXTUB. IF ACCEPTABLE ABG.\n"
},
{
"category": "ECG",
"chartdate": "2153-01-26 00:00:00.000",
"description": "Report",
"row_id": 168065,
"text": "Probable accelerated junctional rhythm\nPremature ventricular contractions\nExtensive ST-T changes may be due to myocardial ischemia\nSince previous tracing of , rhythm change and increased rate and less\nsuggestive of left ventricular hypertrophy\n\n"
}
] |
17,333 | 179,648 | Patient admitted to the trauma service. Orthopedics, Urology, Plastics and Vascular surgery were all consulted: He was taken to the operating room for repair of his pelvic and left tibial fractures on and . Postoperatively he did well; he did however experience pain control issues. He was initially placed on PCA which was not effective and so was changed to long acting narcotics, OxyContin with Oxycodone for breakthrough pain which has seemed to help. He is on Lovenox for DVT prophylaxis. Vascular surgery was consulted for IVC filter placement; a Gunther tulip filter was placed on without complication. This filter is a removable type. Urology was consulted early on because of his pelvic fractures to rule out any bladder injury; a cystogram was performed and did not reveal any injuries. A Foley catheter was placed during the initial trauma resuscitation phase; it was discontinued and then replaced because of failed voiding trial. The Foley remains in place at time of discharge. Once patient's mobility is increased another voiding trial should be attempted. Plastics was consulted for his orbital fracture; sinus mandible and maxillofacial CT scan was recommended. Non operative intervention for these injuries was recommended. Physical therapy was consulted, his weight bearing status has been upgraded to weight bearing as tolerated RLE and touch down weight bearing LLE. He is being recommended for short term rehab to improve his functional mobility. | There is nondisplaced oblique fracture of the proximal fibular diaphysis. There is a tiny fracture of the anterior aspect of the right acetabulum. There is a tiny right pneumothorax at the anterior costophrenic angle. There remains small bilateral pleural effusions. Small right pneumothorax. Small right pneumothorax. Small right pneumothorax. There is a comminuted fracture of the distal tibial diaphysis, with cortical width posterior displacement of the major distal fragment and minimal lateral apex angulation. There is a low attenuation area with the posterior aspect of the pancreatic head which likely represents a pancreatic laceration. There is a low attenuation area with the posterior aspect of the pancreatic head which likely represents a pancreatic laceration. Superior mediastinum is prominent on these views and the aortic knob is obscured. FINDINGS: There are bilateral pleural effusions, small on the left and moderate on the right. Left sacral ala fracture. Left sacral ala fracture. Left sacral ala fracture. Bilateral pleural effusions and atelectasis. There is some patchy retrocardiac opacity, which may represent atelectasis in supine position. SEMI-ERECT CHEST RADIOGRAPH: Cardiomediastinal silhouette is within normal limits. Right superficial femoral, popliteal, superficial femoral veins are patent and compressible and demonstrate normal augmentation. An area of decreased enhancement in the area of the branch point of the right main pulmonary artery into lobar branches is shown to be located outside of the pulmonary vessels on the reformations. There is a low attenuation area within the region of the pancreatic head and duodenum, which is concerning for an injury at this location, with tracking of blood around the liver, anterior to the right kidney, and within the right paracolic gutter. There is mesenteric fluid in the RLQ which is consistent with a small amount of blood and is concerning for a small mesenteric laceration. Minimal right convex curvature of the thoracic spine may be positional. There is an area of low attenuation within the pancreatic head, immediately adjacent to the distal common bile duct (series 2, image 59), which may represent a small amount of blood, from an injury in the pancreaticoduodenal region. The left common femoral, superficial femoral, saphenous, deep femoral, and gluteal veins are patient and compressible and demonstrate normal augmentation. Bilateral comminuted pubic rami fractures. Bilateral comminuted pubic rami fractures. Bilateral comminuted pubic rami fractures. There is a small amount of contrast within the membranous and penile urethra. A small right anterior pneumothorax seen on the prior CT is not seen on today's study. The right femoral vein is not well seen. Note is made of the CT torso of . This finding is concerning for a small mesenteric laceration at this location. Fracture of the anterior margin of the right acetabulum. Fracture of the anterior margin of the right acetabulum. Fracture of the anterior margin of the right acetabulum. There is a small amount of fluid around the inferior portion of the liver, and fluid along the paracolic gutter and posterior to the cecum (series 2, image 89). TECHNIQUE: MDCT of the sinuses with coronal reconstructions were obtained. left eye with bruising and s/s drainage. scrotal and groin edema and hematoma noted. There is a small amount of blood tracking along the right inguinal canal into the scrotum. There is a small amount of stranding and fluid along the root of the mesentery (series 2, image 86). Fracture of the medial wall of the left orbit, small amount of prolapsed orbital fat. Sinus disease as described above. There is limited evaluation of intrathecal contents on CT, however, the outline of the thecal sac is within normal limits. PELVIS, SINGLE AP VIEW. Right popliteal vein demonstrates respiratory motion transmission, suggesting that there is no proximal occlusion. There is a small amount of fluid noted within the maxillary sinuses. The radiograph taken after retrograde injection of urethral contrast demonstrates opacification of the membranous, prostatic and penile urethra without evidence of intra- or extraperitoneal extravasation. oriented x3, +CSM, denies numbness/tingling to feet/hands. There is considerable overlying trauma board artifact and portions of the pelvis are obscured. These demonstrate steps related to intramedullary rod placement traversing a comminuted fracture of the distal tibial diaphysis, side not indicated on these views. FINDINGS: Duplex Doppler ultrasound of the bilateral lower extremity venous system was performed on . Small hematoma within the fracture cavity. There is fracture of the medial wall of the left orbit, with prolapse of a small amount of intra-orbital fat. Bilateral pleural effusions, right greater than left. CHEST, SINGLE AP SUPINE PORTABLE VIEW. Patchy opacities throughout both lungs, which may represent lung contusion/edema. The heart and great vessels appear unremarkable. There is associated compressive atelectasis dependently bilaterally. Subcutaneous emphysema and retroperitoneal gas are again demonstrated. Again demonstrated are bilateral superior and inferior pubic rami fractures with diastasis of the pubic symphysis and right sacroiliac joint. Allowing for this, there is poor visualization of the right superior pubic ramus, suspicious for fracture. lytes repleted as indicated.ID: tmax 99.9, IV ancef as ordered.SKIN: left lower leg with primary ace wrap intact. There are hazy and patchy opacities throughout both lungs, more prominent posteriorly and in the periphery which may represent areas of contusion or pulmonary edema. COMPARISON: CT torso . The spleen, adrenal glands, and gallbladder are within normal limits. There is overlying trauma board artifact. There are lobulated soft tissue density lesions within the maxillary sinuses bilaterally, which likely represent retention cysts. FINAL REPORT INDICATION: Shortness of breath and decreased saturation. As a result, aortic injury and superior mediastinal hematoma cannot be excluded. The mediastinal and hilar contours are unremarkable. There is opacification of the ethmoid air cells. IMPRESSION: Mild pulmonary edema. There is a small amount of air within the liver peripherally, which is concerning for portal venous gas. The source of this may be the pancreatic laceration, though an tiny liver laceration is not excluded. | 16 | [
{
"category": "ECG",
"chartdate": "2183-07-05 00:00:00.000",
"description": "Report",
"row_id": 198643,
"text": "Sinus tachycardia\nNormal ECG except for rate\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-08 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 920575,
"text": " 10:06 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: CP, SOB.\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMcd TUE 11:59 PM\n 1. No evidence of PE. Technically limites study. 2. Bilateral pleural\n effusions and atelectasis. 3. Patchy opacities throughout both lungs, which\n may represent lung contusion/edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and decreased saturation.\n\n CTA OF THE CHEST WITH MULTIPLANAR REFORMATIONS:\n\n COMPARISONS: Trauma torso of .\n\n FINDINGS: There are bilateral pleural effusions, small on the left and\n moderate on the right. There is associated compressive atelectasis\n dependently bilaterally. There are hazy and patchy opacities throughout both\n lungs, more prominent posteriorly and in the periphery which may represent\n areas of contusion or pulmonary edema. The evaluation of pulmonary emboli is\n limited due to suboptimal contrast opacification which limits the assessment\n of segmental and subsegmental branches. Within the limitations, no filling\n defect is seen to suggest the presence of pulmonary embolism. An area of\n decreased enhancement in the area of the branch point of the right main\n pulmonary artery into lobar branches is shown to be located outside of the\n pulmonary vessels on the reformations. The heart and great vessels appear\n unremarkable. No pericardial effusion is seen. The airways are patent to the\n subsegmental bronchi. A small right anterior pneumothorax seen on the prior\n CT is not seen on today's study.\n\n No acute pathology is seen within the visualized upper abdominal organs.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions or fractures are seen.\n\n IMPRESSION:\n 1. Evaluation for small peripheral pulmonary artery branches is limited due\n to suboptimal contrast opacification. Within the limitations, no evidence for\n pulmonary embolism is seen.\n 2. Bilateral pleural effusions, right greater than left. Associated\n compressive atelectasis.\n 3. Hazy and patchy opacities throughout both lungs which may represent\n sequelae of lung contusion and/or pulmonary edema.\n\n Pertinent findings have been discussed with the resident taking care of the\n patient after completion of the study.\n (Over)\n\n 10:06 PM\n CTA CHEST W&W/O C &RECONS Clip # \n Reason: CP, SOB.\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-08 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 920576,
"text": " 10:08 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: TRAUMA TO FACE\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with\n REASON FOR THIS EXAMINATION:\n please assess for further facial fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SINUS\n\n HISTORY: 26-year-old man with trauma.\n\n TECHNIQUE: MDCT of the sinuses with coronal reconstructions were obtained.\n\n FINDINGS: Comparison is made to CT of the head dated .\n\n Again seen is a large left orbital medial wall blowout fracture with\n herniation of orbital fat and the medial rectus muscle. Within the fracture,\n there is a small approximately 5 mm soft tissue density, which likely\n represents a small hematoma.\n\n There is opacification of the ethmoid air cells. Mucosal thickening in the\n frontal and sphenoid sinuses are seen. There are lobulated soft tissue\n density lesions within the maxillary sinuses bilaterally, which likely\n represent retention cysts.\n\n IMPRESSION: Left orbital medial wall blowout fracture with herniation of\n orbital fat and the left medial rectus muscle. Small hematoma within the\n fracture cavity. Sinus disease as described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-05 00:00:00.000",
"description": "L TIB/FIB (AP & LAT) LEFT",
"row_id": 920200,
"text": " 7:15 PM\n TIB/FIB (AP & LAT) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: TIB/FIB RODDING\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Tib-fib rodding.\n\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Fluoro time not recorded on the electronic requisition.\n Eight spot views obtained. These demonstrate steps related to intramedullary\n rod placement traversing a comminuted fracture of the distal tibial diaphysis,\n side not indicated on these views.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-07 00:00:00.000",
"description": "O PELVIS (AP, INLET & OUTLET) IN O.R.",
"row_id": 920371,
"text": " 11:46 AM\n PELVIS (AP, INLET & OUTLET) IN O.R.; ABDOMINAL FLUORO WITHOUT RADIOLOGISTClip # \n Reason: ORIF RT PELVIC FX\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ORIF right pelvic fracture.\n\n Fluoroscopic assistance provided to the surgeon in the OR without the\n radiologist present. Three spot views obtained. These demonstrate steps\n related to external fixation procedure about the pelvis. Correlation with\n real-time findings is recommended for full assessment. Surgical tube or drain\n overlies the obdurator foramina.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920569,
"text": " 8:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PE\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with\n REASON FOR THIS EXAMINATION:\n r/o PE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man, evaluate for PE.\n\n Note is made of the CT torso of .\n\n SEMI-ERECT CHEST RADIOGRAPH: Cardiomediastinal silhouette is within normal\n limits. There is mild prominence of the pulmonary vasculature consistent with\n mild pulmonary edema. There is no pneumothorax. The osseous structures are\n unremarkable.\n\n IMPRESSION:\n\n Mild pulmonary edema. Please note that chest radiography is not sensitive for\n the detection of pulmonary embolus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-05 00:00:00.000",
"description": "RETRO UROGRAM (74450,51610)",
"row_id": 920181,
"text": " 4:29 PM\n RETRO UROGRAM (,) Clip # \n Reason: TRAUMA PED. VS SUV\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 26-year-old male struck by motor vehicle with concern for urethral\n injury.\n\n COMPARISON: CT torso .\n\n RETROGRADE URETHROGRAM:\n\n Two AP radiographs of the pelvis were obtained before and after retrograde\n injection of contrast into the urethra by the urologist. The first radiograph\n demonstrates contrast within the urinary bladder from prior IV contrast\n administration for CT study. There is a small amount of contrast within the\n membranous and penile urethra. Again demonstrated are bilateral superior and\n inferior pubic rami fractures with diastasis of the pubic symphysis and right\n sacroiliac joint. Subcutaneous emphysema and retroperitoneal gas seen on CT\n are noted to project over the right pelvis. The radiograph taken after\n retrograde injection of urethral contrast demonstrates opacification of the\n membranous, prostatic and penile urethra without evidence of intra- or\n extraperitoneal extravasation.\n\n IMPRESSION:\n\n 1. No evidence of urethral injury.\n 2. Bilateral superior and inferior pubic rami fractures with diastasis of the\n pubic symphysis and right sacroiliac joint.\n 3. Subcutaneous emphysema and retroperitoneal gas are again demonstrated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-05 00:00:00.000",
"description": "L TIB/FIB (AP & LAT) LEFT",
"row_id": 920182,
"text": " 4:30 PM\n TIB/FIB (AP & LAT) LEFT; ANKLE (2 VIEWS) LEFT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man with mvc\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for fracture.\n\n LEFT LOWER LEG, TWO VIEWS.\n\n There is a comminuted fracture of the distal tibial diaphysis, with cortical\n width posterior displacement of the major distal fragment and minimal lateral\n apex angulation. There is nondisplaced oblique fracture of the proximal\n fibular diaphysis. Limited assessment of the ankle joint is grossly\n unremarkable.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-05 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 920178,
"text": " 4:24 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: TRAUMA\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n assess for pathology, fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb SAT 6:37 PM\n 1. Small right pneumothorax.\n 2. Bilateral comminuted pubic rami fractures. Left sacral ala fracture.\n Widening of the right SI joint. Fracture of the anterior margin of the right\n acetabulum.\n 3. There is a large amount of extraperitoneal air extending from the\n laceration site in the right groin along the pelvic sidewall, around the\n bladder, and in the retroperitoneum.\n 4. There is a low attenuation area with the posterior aspect of the\n pancreatic head which likely represents a pancreatic laceration. This is\n adjacent to the common bile duct.\n 5. There is a small amount of blood near the inferior tip of the liver and\n anterior to the kidney extending along the ascending colon. The source of\n this may be the pancreatic laceration, though an tiny liver laceration is not\n excluded.\n 6. There is a small amount of air within the liver peripherally which is\n concerning for portal venous gas. No air is seen within the MPV/SMV/IMV. No\n free intraperitoneal air is seen.\n 7. There is blood within the scrotal sac, likely tracking from the right\n groin.\n 8. No bladder injury is identified.\n 9. There is mesenteric fluid in the RLQ which is consistent with a small\n amount of blood and is concerning for a small mesenteric laceration.\n WET READ VERSION #1 MAlb SAT 5:34 PM\n 1. Small right pneumothorax.\n 2. Bilateral comminuted pubic rami fractures. Left sacral ala fracture.\n Widening of the right SI joint. Fracture of the anterior margin of the right\n acetabulum.\n 3. There is a large amount of extraperitoneal air extending from the\n laceration site in the right groin along the pelvic sidewall, around the\n bladder, and in the retroperitoneum.\n 4. There is a low attenuation area with the posterior aspect of the\n pancreatic head which likely represents a pancreatic laceration. This is\n adjacent to the common bile duct.\n 5. There is a small amount of blood near the inferior tip of the liver and\n anterior to the kidney extending along the ascending colon. The source of\n this may be the pancreatic laceration, though an tiny liver laceration is not\n excluded.\n 6. There is a small amount of air within the liver peripherally which is\n concerning for portal venous gas. No air is seen within the MPV/SMV/IMV. No\n mesenteric free fluid is seen. No free intraperitoneal air is seen.\n 7. There is blood within the scrotal sac, likely tracking from the right\n groin.\n 8. No bladder injury is identified.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of trauma and MVC.\n (Over)\n\n 4:24 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: TRAUMA\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired contiguous axial images were obtained from the\n thoracic inlet to the pubic symphysis with multiplanar reconstructions.\n\n CONTRAST: 130 cc of IV Optiray contrast were administered. Images were\n obtained after contrast injection, and delayed images of the bladder were\n obtained after bladder filling.\n\n CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images demonstrate no\n mediastinal free fluid or lymphadenopathy. The trachea and airway is normal\n in appearance. There is no pneumomediastinum. The aorta and great vessels\n are normal in appearance, and caliber. There is no evidence of dissection. No\n pericardial or pleural effusions are seen. Lung window images demonstrate no\n parenchymal consolidation. There are several small pulmonary nodules\n bilaterally. There is a tiny right pneumothorax at the anterior costophrenic\n angle.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There are several foci of air within the\n periphery of the left liver lobes, which may represent portal venous gas or\n less likely biliary air. No other foci of air seen within the main portal\n vein, SMV, or IMV. No definite areas of focal defects or attenuation\n abnormalities are identified within the liver. The spleen, adrenal glands,\n and gallbladder are within normal limits.\n\n There is an area of low attenuation within the pancreatic head, immediately\n adjacent to the distal common bile duct (series 2, image 59), which may\n represent a small amount of blood, from an injury in the pancreaticoduodenal\n region. Additionally, in this region, there is dense fluid (attenuation values\n consistent with blood) anterior to the right kidney, and between the right\n kidney and liver. There is a small amount of fluid around the inferior\n portion of the liver, and fluid along the paracolic gutter and posterior to\n the cecum (series 2, image 89). The right kidney is intact. The ureters are\n intact. There is a small amount of stranding and fluid along the root of the\n mesentery (series 2, image 86). There is no free intraperitoneal air\n identified. There is no definite evidence of bowel wall thickening.\n\n There is a large laceration within the right groin. There is extensive amount\n of free air within the soft tissues in that location, extending along the\n right pelvic wall, around the bladder, and in the retroperitoneum. All of\n this air is extraperitoneal, and likely reflects air tracking from this\n laceration. The aorta is normal in caliber, without any filling defects or\n contour abnormalities.\n\n There is stranding within the root of the mesentery, as mentioned above.\n (Over)\n\n 4:24 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: TRAUMA\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Additionally, within mesentery of several loops of bowel within the right\n lower quadrant, there is fluid (series 105B, image 20), which demonstrates\n increased density consistent with blood. Additionally, on delayed images,\n slightly increased density, measuring 98 Hounsfield units (series 109B, image\n 26). This finding is concerning for a small mesenteric laceration at this\n location. There is no evidence of an aortic or IVC injury.\n\n CT OF THE PELVIS WITH IV CONTRAST: The bladder is normal in contour, and on\n delayed images demonstrates no contour abnormality or contrast extravasation.\n Additionally, the extraperitoneal fat around the bladder is preserved, and\n there are no pelvic free fluid collection/bladder injury. There is extensive\n free air within the pelvis in extraperitoneal locations, extending from the\n laceration within the right groin. The perirectal fat is preserved, without\n any evidence of definite connection to free air or fluid collections. The\n common iliac veins are preserved. There is a central line within the left\n common iliac vein. There is a small amount of blood tracking along the right\n inguinal canal into the scrotum.\n\n BONE WINDOWS: There are comminuted fractures of the superior pubic rami\n bilaterally. There is a vertical fracture through the left sacrum, and\n widening of the right SI joint. No definite femoral fractures are identified.\n There is a tiny fracture of the anterior aspect of the right acetabulum. There\n is no evidence of a hip dislocation. Reconstructed images of the thoracic and\n lumbar spine demonstrate no compression deformities or rib fractures. The\n thoracic and lumbar spine are well preserved, without any evidence of\n listhesis.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating\n the anatomy and pathology.\n\n IMPRESSION:\n 1. Small right pneumothorax.\n 2. Bilateral comminuted pubic rami fractures. Left sacral ala fracture.\n Widening of the right SI joint. Fracture of the anterior margin of the right\n acetabulum.\n 3. There is a large amount of extraperitoneal air extending from the\n laceration site in the groin along the pelvic side wall, around the bladder,\n and in the retroperitoneum.\n 4. There is a low attenuation area within the region of the pancreatic head\n and duodenum, which is concerning for an injury at this location, with\n tracking of blood around the liver, anterior to the right kidney, and within\n the right paracolic gutter.\n 5. There is a small amount of air within the liver peripherally, which is\n concerning for portal venous gas. No air is seen within the main portal vein,\n SMV, or IMV. There is no free intraperitoneal air. Additionally, there is\n (Over)\n\n 4:24 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: TRAUMA\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fluid within the mesentery, which demonstrates increased density on delayed\n images, and is concerning for a small mesenteric laceration within the\n mesentery of loops of small bowel in the right lower quadrant.\n 7. There is blood within the scrotal sac, which may be tracking from the\n right inguinal laceration.\n\n These findings were discussed immediately at the time of study completion with\n Dr. , followed by further discussion with Dr. at 6:15\n p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-08 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 920541,
"text": " 3:28 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: please eval for DVT and aid in planning IVC filter placement\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with polytrauma, L tib-fib fx, R pelvic fx; for IVC filter in\n next 24 hours\n REASON FOR THIS EXAMINATION:\n please eval for DVT and aid in planning IVC filter placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Bilateral lower extremity venous Doppler ultrasound.\n\n INDICATION: 26-year-old man with trauma, right pelvic fracture, left\n tibia/fibula fracture. Evaluate for DVT to aid in planning for IVC filter\n placement.\n\n FINDINGS: Duplex Doppler ultrasound of the bilateral lower extremity venous\n system was performed on . No prior studies were available.\n\n Limited study as presence of orthopedic hardware and bandages limits\n visualization. The right femoral vein is not well seen. Right superficial\n femoral, popliteal, superficial femoral veins are patent and compressible and\n demonstrate normal augmentation. Right popliteal vein demonstrates respiratory\n motion transmission, suggesting that there is no proximal occlusion.\n\n The left common femoral, superficial femoral, saphenous, deep femoral, and\n gluteal veins are patient and compressible and demonstrate normal\n augmentation. Left calf veins are not seen secondary to presence of bandages\n associated with prior tibia/fibula fracture.\n\n IMPRESSION: Limited study. No evidence of deep venous thrombosis, although\n right femoral vein is not visualized.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 920176,
"text": " 4:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed, injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man s/p high speed MVC, + LOC\n REASON FOR THIS EXAMINATION:\n ? bleed, injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb SAT 5:09 PM\n No intracranial hemorrhage. Fracture of the medial wall of the left orbit,\n small amount of prolapsed orbital fat. The left medial rectus muscle is\n slightly enlarged, and this may reflect injury.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of trauma.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD WITHOUT IV CONTRAST: No intracranial hemorrhage is identified. The\n ventricles are symmetric, there is no shift of normally midline structures.\n The -white white matter differentiation is preserved. No intracranial\n mass effect is seen. The density of the brain parenchyma is within normal\n limits.\n\n There is a defect involving the medial wall of the left orbit, and there\n appears to be a slight prolapse of fat into this, suggesting a fracture in\n this location. Additionally, there is slight asymmetric enlargement of the\n belly of the medial rectus, which may reflect injury at this location. No\n other fractures are identified. There is a small amount of opacification of\n several ethmoid air cells in that location. There is a small amount of fluid\n noted within the maxillary sinuses. There is slight soft tissue swelling\n overlying the left maxillary sinus as well.\n\n IMPRESSION:\n\n 1. No intracranial hemorrhage or mass effect.\n\n 2. There is fracture of the medial wall of the left orbit, with prolapse of a\n small amount of intra-orbital fat. Additionally, there is slight asymmetry of\n the belly of the medial rectus muscle, which may reflect injury at this\n location.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-05 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 920177,
"text": " 4:22 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: assess for fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 29 year old man s/p high speed MVC, + LOC\n REASON FOR THIS EXAMINATION:\n assess for fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb SAT 5:10 PM\n No fracture or spondylolisthesis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained of the cervical spine with\n coronal and sagittal reconstructions.\n\n CT C-SPINE: No fractures are identified. No spondylolisthesis is seen. The\n prevertebral soft tissue space is normal. No soft tissue abnormalities, or\n hematomas are identified. There is limited evaluation of intrathecal contents\n on CT, however, the outline of the thecal sac is within normal limits.\n\n IMPRESSION: No fracture or subluxation is identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920862,
"text": " 7:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate lung parenchyma - previously congested\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p MCC with difficulty breathing, improved after Lasix\n\n REASON FOR THIS EXAMINATION:\n Evaluate lung parenchyma - previously congested\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old status post MCC with difficulty breathing improved\n after Lasix, question fluid overload.\n\n SINGLE AP PORTABLE CHEST: Compared to , twelve hours prior. The heart\n size is normal. The mediastinal and hilar contours are unremarkable. There\n has been significant interval clearing of the lungs compared to the prior\n chest radiograph, likely consistent with resolving fluid overload. There\n remains small bilateral pleural effusions. No focal consolidation. No\n pneumothorax or evidence of traumatic bony injury.\n\n IMPRESSION: Interval clearing of the lungs, likely representing resolving\n fluid overload.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-05 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 920174,
"text": " 3:47 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n TRAUMA SERIES.\n\n CHEST, SINGLE AP SUPINE PORTABLE VIEW. There is overlying trauma board\n artifact. Superior mediastinum is prominent on these views and the aortic\n knob is obscured. As a result, aortic injury and superior mediastinal\n hematoma cannot be excluded. The heart is not enlarged. There is no CHF,\n focal infiltrate, or gross effusion. No supine film evidence of pneumothorax\n is detected. There is some patchy retrocardiac opacity, which may represent\n atelectasis in supine position. Minimal right convex curvature of the\n thoracic spine may be positional.\n\n PELVIS, SINGLE AP VIEW. There is considerable overlying trauma board artifact\n and portions of the pelvis are obscured. The lateral aspect of the left\n proximal femur is excluded from the film. The right proximal femur is rotated\n so as to obscure the femoral neck. Allowing for this, there is poor\n visualization of the right superior pubic ramus, suspicious for fracture.\n There is air tracking there as well raising the question of an open fracture\n or perforated viscus. No definite SI joint or pubic symphysis diastasis is\n detected, though these areas are quite obscured. No obvious proximal femur\n fracture is identified.\n\n IMPRESSION:\n\n 1. Prominent superior mediastinum. CT is recommended to further assess this\n area and exclude aortic injury/mediastinal hematoma.\n\n 2. Poor visualization of the right superior pubic ramus is highly suggestive\n of fracture. Further evaluation by CT scan is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920732,
"text": " 6:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate lung parenchyma - previously congested\n Admitting Diagnosis: MOTOR VEHICLE ACCIDENT\\INJURIES\n ______________________________________________________________________________\n FINAL REPORT\n\n REASON FOR EXAMINATION: Evaluation of patient with pulmonary edema clinically\n improved after diuretic therapy.\n\n Portable AP chest radiograph compared to the previous film from .\n\n IMPRESSION: The heart size is normal. The mediastinal contours are\n unremarkable. There is some decrease in bilateral interstitial and alveolar\n opacities representing improved on the pulmonary edema but still there are\n interstitial opacities seen bilaterally especially in the right lower lung.\n Further close follow up is recommended for documentation of complete clearance\n of the findings to exclude the possibility of underlying infection.There is no\n sizeable pleural effusion. The IVC filter has been inserted in the meantime\n interval.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-07-06 00:00:00.000",
"description": "Report",
"row_id": 1489063,
"text": "T/Sicu Admit Note\nPatient admitted to T/sicu s/p motorcycle vs. truck crash. +helmet, +brief LOC, ?thrown 15 feet, hypotensive at scene and fluid resuscitated. tx to via .\n\nInjuries include:\n\nPelvic Fractures: bilateral pubic rami fractures, left sacral fracture with widening of SI joint, fracture of anterior margin of the right acetabulum. Open area right groin: with large amount of extraperitoneal air from the laceration along the pelvic side wall, bladder and peritoneum.\nRight Tibial fracture > to OR for IM rodding\n?Pancreatic laceration\nleft orbital fracture\nblood within sacral sac, ? if tracking from groin lac\n\nPMH: allergic rhinitis.\n\nNPN: ROS>see carevue for details.\n\nPatient admitted from operating room s/p I&D of pelvic wound and IM rodding of left tibia. Extubated in OR without difficulty.\n\nNEURO: patient dozing off and on, but arouses easily and follows all commands. oriented x3, +CSM, denies numbness/tingling to feet/hands. morphine PCA for pain with fair effect. PERLA , briskly reactive. c-collar on and intact\n\nCV: HR 90-100s, SR, BP stable. hypotensive briefly this am 80s/40s, recieved 500 cc NS bolus with +effect. +pp, left toes cool. pboots on. lovenox to start in am.\n\nHEME: HCT stable overnoc\n\nRESP: LS clear, diminished, O2 sat 99-100% on 4L NC. coughing & deep breathing encouraged\n\nGI: remains NPO, abd softly distended, rare bowel sounds, denies flatus.\n\nGU: foley catheter with adequate urine out. clear yellow. lytes repleted as indicated.\n\nID: tmax 99.9, IV ancef as ordered.\n\nSKIN: left lower leg with primary ace wrap intact. right groin with incision/lac stapled with penrose drain. draining large amounts of sanguinous fluid, dressing changed x1. scrotal and groin edema and hematoma noted. left eye with bruising and s/s drainage. abrasion to left shoulder irrigated and bacitracin applied\n\nsocial: family all in . girlfriend and friends into visit and updated on plan and status.\n\nPLAN: monitor HCTs as ordered. pain control. monitor for CSM and pp. IVABX as ordered. encourage cough & deep breathing. PT consult. ? OR later this week for pelvic fixation. monitor & support as indicated\n\n\n\n"
}
] |
11,318 | 116,974 | 71 yo F with severe diastolic dysfuntion, a-fib on coumadin, CAD, pulmonary fibrosis, severe PVD with chronic LE ulcer who presented with septic shock likely from LE ulcers secondarily infected. . MICU course: subclavian line placed and briefly on Dopamine gtt from . She was presumed to be in septic shock secondary to L shifted elevated WBC. Other etiology would be over-diuresis and hypovolemia (but elev WBC does not fit this etiology). The source of sepsis was unclear but felt to be LE ulcers, as blood cx, CXR and UA were not revealing. She received 2.5 L of IVF in the ICU. She was continued on Vanco/Ceftaz/Flagyl for her presumed sepsis from LE cellulitis/questionable osteomyeltis. No Blood Cx or Urine Cx grew an organism. . 1)Foot ulcer/infection: Pt likely had re-infection of the LE wound after completing a 14 day course of Vanc/Levo/Flagyl. Pt got a non-invasive art studies this hospitalization with sigfnificant SFA and tibial dz. and surgery followed in house. Recommendations were for local wound care, with systemic antibiotics, and outpatient follow-up for continued discussions of re-vascularization/angiogram. Swabs of L and R heel and L great toe and tibial wounds revealed MRSA and Proteus species (sensitive to 3rd/4th gen cephalosporins, but resistant to FQ, gent). was unable to probe to bone on their exam. An x-ray of the L foot showed no evidence of osteomyelitis. An MRI was also obtained which showed possible intraosseus bone infarct of L calcaneus but no clear evidence for osteomyelitis. A follow-up xray should be obtained after patient finishes course of antibiotics. -- patient will finish 2 week course of Vanc/Ceftaz/Flagyl, PICC line placed. -- Vanc trough sl elevated (25), changed to 750 mg q24. -- all blood cx were NGTD. . 2)Hemodynamics: Pt was briefly (< 36hrs) on pressors (dopamine) for BP support in MICU. She remained basically euvolemic on the medical requiring no pressors and just her maintenance diuresis. -- In the past, she required Lasix gtt for diuresis as she is very sensitive to lasix. . 3)Cardiovascular: Pump: Pt with severe diastolic dysfunction and very sensitve to lasix bolus. Goal was BP/HR control. -- Patient did not require IV lasix in and was restarted on her oupatient dose prior to discharge. She was euvolemic on physical exam. -- Her lisinopril 5 mg po daily was also restarted prior to discharge for optimum BP control. -- Metoprolol was titrated up throughout her stay for better HR control (see below) . Ischemia: -- She was continued on BB, ASA, simvastatin. . Rhythm: -- Afib throughout stay. -- Her dose of metoprolol was titrated up for better HR control, she was d/c'd on 37.5 mg tid with HR in 80's. -- For anti-coag the patient was placed on warfarin 5 mg po qhs (goal INR ), she should have INR checked in days after discharge. -- amiodarone has been discontinued during the last admission for concern of pulmonary toxicity. . 5)Pulm: Pt h/o COPD//pulmonary fibrosis. Some wheezing noted in ICU but was treated successfully withn Albuterol and Ipratropium nebs PRN . 6)DM: The patient's glargine 14 units was stopped and she was switched to NPH 14 units in AM as she had low sugars in AM and high at night. She was maintained on HISS prior to meals and at bedtime. . 7)Pain: The patient had escalating pain on medical and her doses of fentanyl patch was increased to 75mcg/q72hrs and her neurontin was also changed back to her dosing during her most recent hospital stay ). She was receiving oxycodone 10mg every 4hrs prn for breakthrough pain and standing tylenol 1g tid. The patient was not somnolent or lethargic on this regimen. She should be monitored closely as she has had changes in her mental status before due to over-sedation with narcotics. . 8)Psych: Continue citalopram, methylphenadate, Topamax. . 9)Anemia: Anemia of chronic illness. Hct low but at baseline throughout stay (28-30). -- She was continued on iron supplements. . 10)Hypothyroid: -- Continued Levoxyl at outpatient dosing. TSH 1.1. | Pt receiving Vanco, Flagyl, Ceftazidime per prophylaxsis. OF DEPENDENT EDEMA TO EXTS. of dependent edema noted. RR REGULAR AND UNLABORED.CV: AFIB WITH HR 97-114 WITH OCCAS. RSVC CENTRAL LINE PRE- CATH IN PLACE.GI/GU: + BS NOTED. AFEBRILESKIN: ADVANCED PVD TO LOWER EXTS. Applied adaptic & Kerlex. Applied Adaptic & Kerlex. Applied Adaptic & Kerlex. Still needs MRI of lower exts. Foley in place with adequate UO.Skin: Numerous pressure ulcers to lower exts. Plan: Monitor respiratory status q4hr.CV: Pt demonstrates A. Fib, with occasional PVCs. Lung sounds CTA with occass. Drsg. NEEDS ROUTINE MRI OF LOWER EXTS. ULCERATIONS NOTED. ON OXYCODONE PRN. open areas/ulcers to lower exts. BP LABILE TO SYSTOLIC 80'S. Admitting Dx: sepsis. FOLEY IN PLACE WITH POOR UO.ID: CONTS. Pt receiving PPI prophylaxsis & Colace for stool management. MOVES UPPER EXTS. DRESSING TO BE CHANGED (WET TO DRY) WITH ADAPTEC OR XEROFORM USED.PLAN: CONT. with current plan of care. WITH CURRENT PLAN OF CARE. IV sites RSC, Lwrist, Rforearm are WNL. LUNG SOUNDS CTA. need to be address in AM.Endo: Conts. assist x 2.pulm:2L O2 via NC with adequate sats. Afebrile. AFEBRILE. AFTER PRESEP. Plan: continue to monitor adb status q4hr.PV: cool, mottled lower extemities bilaterally, pedal pulses very difficult to palpate. + bs x 4Q. HX. chngec.Plan: Continue current tx, needs routine MRI for LE, con't po's at tolerated, Follow am electrolytes. TX'ED TO EITHER FLOOR OR BACK TO REHAB ONCE MORE STABLE. prob will return to coumadin after mri done. amt. AMT. Insp wheezing cleared with coughing.cv:AFib with HR 99-127. HAS H/O CHRONIC BILAT LOWER EXT ULCER PAIN. 71 yr olad pt with fever ?sepsis on protocol and improving. on oxycodone prn with good effect. Bilateral heel ulcers are approx. 24 hr balance = -178, LOS = +2403.8. great toe outer aspect dime size dry ulcer and toenail red and serous drainage requires dry portective dsg bet and on toe. Transfuse for HCT <25. recieved pt on dopamine, iv insulin gtt and iv hep. GIVEN 2 DOSES WITH SOME EFFECT.PULM: 2L NC WITH ADEQUATE SATS. NPN 1900-0700Neuro: A&Ox 3, c/o pain to r and l heel d/t ulcers, gv can lift lower extremities to raise on pillow.Resp: Lungs CTA bilat., O2 at 2L NC, RR 16-22, O2 sats 99-100%, no cough.CV: HR 97-122 A-FIB with occasional PVC's, BP's 80-120's/40-60's, CVP 10-12, T max 98.2.GI: BS (+) x 4 quad., x 1 lrg brown soft BM quaiac (-)GU: Foley cath intact draining clear yellow urine in adequate amts.Skin: Lower extremities with severe PVD, wed to dry drsg. Monitor per protocol. MONITOR PER PROTOCOL. Presently using Fentanyl patch & Oxycodone q4-6hr prn for pain management. m/sicu npn for 7a-7p: full code numerous allergies please see flowsheet for more details Contact Precautions for VRE/MRSAneuro:aaox3. Abd obese, soft, NT, ND. REPLETING ELECTROLYTES AS NEEDED.TRANSFER NOTE COMPLETE. tolerance even after extra dose of pain med. with dressing changed this AM. Pt receiving NS @ 10ml/hr for KVO & fluid replacement. pt was initially having glucoses in 60-70n for first hrs of shift and was lethargic with low glucoses.neuro: pt is now mae, a&o, follows all commandscard: hx afib and in afib with tacycardia 95-115, irregular hr. Remains on Heparin gtt at 800 units with therapeutic PTT x 3. PLEASE FHP FOR MORE DETAILS OF PAST MED. PERLA. CATHETER IS REMOVED. EFFECT. ON COURSE OF IV ANTIBIOTICS. D/c'ed Right SVC central line intact with good hemostasis obtained.gi/gu:+ Bs noted. Replete electrolytes as needed. Min. MIN. BP stable. svo@ 85-92%gi: advanced diet and taking po well, pos bs on bed pan presently.gu/fluid status: foley in place adequate output. Please consult skin consultant for Ulcerations to both R and L foot. TOLERATING DIABETIC PO DIET WELL. Left great toenail dried serous drainage, placed gauze between grt toe & second toe, keeping MD order. RR 10-18. SOFT, NT, ND. STABLIZE BP WITH FLUID BOLUSES OVERNIGHT FOR POSSIBLE TX OUT TO REGULAR FLOOR IN AM. Placement confirmed by Chest x-ray. Episode while in chair of incont. with low blood glucose in AM. (130-140's this AM). c/o pain in lower exts on chronic basis. ABD. Continue to administer meds MD order.Labs: PTT 70.5 (goal range is 80-100. as of 0000 PTT was 64.1, so no change needed for Heparin drip), Hct 28.8, WBC 8.8, INR 1.4, Na 142, K 3.1, Co2 29, BUN 15, Creat 0.7, Ca 8.5, Mg 1.8, Phos 2.6, Cl 106.A: which may be related to sepsisPain related to peripheral vascular insufficiency as evidenced by pt verbalization, reluctance to move extremities. currently on kvo via rt triple sepsis cath.skin: pt has multiple wounds below kenns with poor vascular flow. Plan: Pt scheduled for MRI on to rule out osteomyelitis. PVC'S. cvp this am up to 14 and thought to be a bit hypervolemic with jugular vein distention. MULTI. pt was on rehab but not theraputic and started on hep gtt. pt had xray and flow studies today and to have mri to r/o osteomelitis {3 hr study} tommorrow.id: poss sources of fever pic line pulled in ew and tip sent, ft/leg ulcers,or resp with sputum pending. needs one more set blood culture.one triple antibx coverage.endo: insulin gtt stopped 1315 and recieved glargene 18 unit at 1730 and reg ssi 6 units reg insulin at 1800. iv steroids stopped at 1400 last dose.plan: monitor temp, resp, iv anticoagulation, glucose control, leg wounds. off dopamine at 1630 with sys bp 130resp: cough and raising sputum, thick tan/green. last ptt 115 and dose decreased from 1000 units/hr to 800/ units/hr at 1315. needs ptt at . | 9 | [
{
"category": "ECG",
"chartdate": "2123-04-23 00:00:00.000",
"description": "Report",
"row_id": 293726,
"text": "Atrial fibrillation with rapid ventricular response\nNonspecific extensive ST-T changes\nSince previous tracing, heart rate faster; ST-T wave changes more pronounced\n\n"
},
{
"category": "ECG",
"chartdate": "2123-04-22 00:00:00.000",
"description": "Report",
"row_id": 293727,
"text": "Atrial fibrillation with rapid ventricular response\nNonspecific T wave changes\nSince previous tracing, no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-04-24 00:00:00.000",
"description": "Report",
"row_id": 1410998,
"text": "M/SICU NPN FOR 7A-7P: FULL CODE\n\nALLERGIES TO PCN, BEEF/PORK INSULIN, TEGRETOL, ZAROXOLYN\n\n PLEASE SEE FLOWSHEET FOR MORE DETAILS\n\nNEURO: AAOX3. PERLA. MOVES UPPER EXTS. INDEPENDENTLY. NO MOVEMENT OF RLE, BUT WEAK MOVEMENT OF LLE. HAS H/O CHRONIC BILAT LOWER EXT ULCER PAIN. ON OXYCODONE PRN. GIVEN 2 DOSES WITH SOME EFFECT.\n\nPULM: 2L NC WITH ADEQUATE SATS. LUNG SOUNDS CTA. NO COUGH NOTED. RR REGULAR AND UNLABORED.\n\nCV: AFIB WITH HR 97-114 WITH OCCAS. PVC'S. BP LABILE TO SYSTOLIC 80'S. REC'ED A TOTAL OF 750 CC NS BOLUS WITH MIN. EFFECT. MICU TEAM IS AWARE. AFEBRILE. MIN. AMT. OF DEPENDENT EDEMA TO EXTS. RSVC CENTRAL LINE PRE- CATH IN PLACE.\n\nGI/GU: + BS NOTED. TOLERATING DIABETIC PO DIET WELL. ABD. SOFT, NT, ND. NO BM FOR MY TIME. FOLEY IN PLACE WITH POOR UO.\n\nID: CONTS. ON COURSE OF IV ANTIBIOTICS. AFEBRILE\n\nSKIN: ADVANCED PVD TO LOWER EXTS. MULTI. ULCERATIONS NOTED. DRESSING TO BE CHANGED (WET TO DRY) WITH ADAPTEC OR XEROFORM USED.\n\nPLAN: CONT. WITH CURRENT PLAN OF CARE. MONITOR PER PROTOCOL. STABLIZE BP WITH FLUID BOLUSES OVERNIGHT FOR POSSIBLE TX OUT TO REGULAR FLOOR IN AM. NEEDS ROUTINE MRI OF LOWER EXTS. AFTER PRESEP. CATHETER IS REMOVED. PLAN IS TO PLACE NEW PICC LINE UNDER FLUROSCOPY ON MONDAY AND HAVE PT. TX'ED TO EITHER FLOOR OR BACK TO REHAB ONCE MORE STABLE. REPLETING ELECTROLYTES AS NEEDED.\n\nTRANSFER NOTE COMPLETE. PLEASE FHP FOR MORE DETAILS OF PAST MED. HX.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-04-25 00:00:00.000",
"description": "Report",
"row_id": 1410999,
"text": "NPN 1900-0700\nNeuro: A&Ox 3, c/o pain to r and l heel d/t ulcers, gv can lift lower extremities to raise on pillow.\n\nResp: Lungs CTA bilat., O2 at 2L NC, RR 16-22, O2 sats 99-100%, no cough.\n\nCV: HR 97-122 A-FIB with occasional PVC's, BP's 80-120's/40-60's, CVP 10-12, T max 98.2.\n\nGI: BS (+) x 4 quad., x 1 lrg brown soft BM quaiac (-)\n\nGU: Foley cath intact draining clear yellow urine in adequate amts.\n\nSkin: Lower extremities with severe PVD, wed to dry drsg. chngec.\n\nPlan: Continue current tx, needs routine MRI for LE, con't po's at tolerated, Follow am electrolytes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-04-25 00:00:00.000",
"description": "Report",
"row_id": 1411000,
"text": "m/sicu npn for 7a-7p: full code numerous allergies\n\n please see flowsheet for more details\n\n Contact Precautions for VRE/MRSA\nneuro:\naaox3. c/o pain in lower exts on chronic basis. on oxycodone prn with good effect. OOB to chair with max. assist x 2.\n\npulm:\n2L O2 via NC with adequate sats. RR 10-18. Regular and unlabored. Lung sounds CTA with occass. Insp wheezing cleared with coughing.\n\ncv:\nAFib with HR 99-127. (130-140's this AM). Started on TID lopressor 12.5mg with good effect from first dose. Afebrile. Min. amt. of dependent edema noted. BP stable. Remains on Heparin gtt at 800 units with therapeutic PTT x 3. Will check PTT with pm labs.\n\nLines: Bedside DL PICC placed by IV RN today. Placement confirmed by Chest x-ray. D/c'ed Right SVC central line intact with good hemostasis obtained.\n\ngi/gu:\n+ Bs noted. Tolerating PO diet well. Abd obese, soft, NT, ND. Episode while in chair of incont. stool in large amts. A total of 2 Bm's for my time. Foley in place with adequate UO.\n\nSkin: Numerous pressure ulcers to lower exts. with dressing changed this AM. Difficult to change dressing due to poor pt. tolerance even after extra dose of pain med. need to be address in AM.\n\nEndo: Conts. with low blood glucose in AM. New insulin orders in place and scheduled to start in AM. NPH 14 units SC with now sliding scale.\n\nplan:\nCont. with current plan of care. Monitor per protocol. Replete electrolytes as needed. Hct to be sent at 1800. Transfuse is < 25. Still needs MRI of lower exts. Please contact Skin therapy RN in am to evaluate appropriate treatment of multi. open areas/ulcers to lower exts. transfer to regular private room when bed becomes available. Transfer note needs to be updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-04-26 00:00:00.000",
"description": "Report",
"row_id": 1411001,
"text": "NPN 1900-0700\nGeneral: Pt A&Ox 3, @ 0400 c/o pain to lower extremities, given Oxycodone 10mg po x 1, no pain since 1730 last night. Drsg. change done x 1 to lower extremity wounds d/t c/o discomfort.\n\nNeuro: Moves all extremities well in bed, up to chair x 1 last night, able to get into bed with heavy assist, uses call-bell, SR up x 4 in bed for safety overnight.\n\nResp: Lungs CTA throughout, no cough noted, O2 at 2L NC intact, RR 8-15, with O2 sats 100%.\n\nCV: HR 94-105 A-fib, Bp's 94-127/30-50's, T max 99.3, pedal pulses palpable bilat., lower extremities dusky/brownish and skin leathery in appearance, Heparin gtt increased to 900u/hr.\n\nGI: BS (+) x 4 quad, abd obese, non-distended, non-tender, X1 very large liquidy brown stool, on diet, tolerates 40% of diet.\n\nGU: Foley cath intact draining clear yellow urine.\n\nPlan: Continue to montior VS, monitor UO, BP occasionally drops below MAP 60 and is being tx with fluid boluses, to floor when bed available. Transfuse for HCT <25. Please consult skin consultant for Ulcerations to both R and L foot.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-04-23 00:00:00.000",
"description": "Report",
"row_id": 1410995,
"text": "71 yr olad pt with fever ?sepsis on protocol and improving. recieved pt on dopamine, iv insulin gtt and iv hep. pt was initially having glucoses in 60-70n for first hrs of shift and was lethargic with low glucoses.\n\nneuro: pt is now mae, a&o, follows all commands\n\ncard: hx afib and in afib with tacycardia 95-115, irregular hr. pt was on rehab but not theraputic and started on hep gtt. last ptt 115 and dose decreased from 1000 units/hr to 800/ units/hr at 1315. needs ptt at . off dopamine at 1630 with sys bp 130\n\nresp: cough and raising sputum, thick tan/green. 98-100% sat on 2l nc. svo@ 85-92%\n\ngi: advanced diet and taking po well, pos bs on bed pan presently.\n\ngu/fluid status: foley in place adequate output. cvp this am up to 14 and thought to be a bit hypervolemic with jugular vein distention. pt did recieve 3 liters in ew prior to coming to icu. currently on kvo via rt triple sepsis cath.\n\nskin: pt has multiple wounds below kenns with poor vascular flow. all to be dressed with adaptic and kerlix wraps. rt leg ant with 2 lesions 1x1 inch, post rt leg with 2 wounds 3inx1in open and draining slightly, rt heel 1 diameter black with slight drainage, lt leg no open areas on leg but foot with 3 sites. great toe outer aspect dime size dry ulcer and toenail red and serous drainage requires dry portective dsg bet and on toe. red/purple blister not open on lt great tor knuckle, lt heel 1 1/2in diameter dry black base ulcer. all sites cultured. pt had xray and flow studies today and to have mri to r/o osteomelitis {3 hr study} tommorrow.\n\nid: poss sources of fever pic line pulled in ew and tip sent, ft/leg ulcers,or resp with sputum pending. needs one more set blood culture.\none triple antibx coverage.\n\nendo: insulin gtt stopped 1315 and recieved glargene 18 unit at 1730 and reg ssi 6 units reg insulin at 1800. iv steroids stopped at 1400 last dose.\n\nplan: monitor temp, resp, iv anticoagulation, glucose control, leg wounds. prob will return to coumadin after mri done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-04-24 00:00:00.000",
"description": "Report",
"row_id": 1410996,
"text": "d: Pt is 71 y.o female (allergies to beef, pork insulin, penicillins, Tegretol, Zaroxolyn) admitted on after vomiting food at her residence, Rehab & onset of confusion & lethargy. Admitting Dx: sepsis. Pt is cooperative this shift, has frequent complaints of pain, esp. in both heels that she describes as constant. Pt states pain is relieved by feet dangling over edge of bed (consistent with hx of PVD). Heels wrapped with adaptic & kerlex dsg, waffle boots in place bilaterally & feet elevated on pillows. Pt had quiet night, tolerated meds well, appeared to be resting comfortably. Presently using Fentanyl patch & Oxycodone q4-6hr prn for pain management. Pt states Oxycodone decreases pain from 10 to 4 on scale of . Pt tolerates movement of lower extremities poorly, frequently requiring assiatance with movement. D/C'ed IV insulin drip & SvO2 monitor today MD order.\nI&O: Foley catheter in place draining clear yellow urine. 24 hr balance = -178, LOS = +2403.8. U/O varies. Plan: continue to monitor I&O, fluid status.\nSkin: Nurse on day shift bathed pt, not noted in Careview. Lower extremities are in color, skin is cracked & scaly, multiple lesions bilateral lower extremities. Bilateral heel ulcers are approx. 2cm x 2cm, black, open to air, no exudate. Applied Adaptic & Kerlex. Right lower extremity 2 wounds on anterior, 1cm x 1cm, 2 wounds on posterior, 3cm x 1cm, all have red/black base minimal exudate. Applied adaptic & Kerlex. Left lower extremity 3 wounds, 1cm x 1cm, all with red/black base, minimal exudate. Applied Adaptic & Kerlex. Left great toenail dried serous drainage, placed gauze between grt toe & second toe, keeping MD order. Applied Waffle boots bilaterally. IV sites RSC, Lwrist, Rforearm are WNL. Plan: monitor wound sites, change dressing as ordered, keep heels free of pressure, elevated with pillows, allow pt to dangle in order to relieve pain.\nResp: lung sounds clear bilaterally, bases to apices. No use of accessory muscles. RR over last 24 hours range 10-18, O2 sats 87-100%. Plan: Monitor respiratory status q4hr.\nCV: Pt demonstrates A. Fib, with occasional PVCs. HR over last 24 hours range 75-119. BP over last 24 hours range 85-135/31-59. Pt receiving NS @ 10ml/hr for KVO & fluid replacement. Pt receiving Heparin @ 800units/hr Plan: Continue to monitor HR, BP, CVP\nAbd: no bowel movements today, although pt requested bedpan frequently. + bs x 4Q. Pt receiving PPI prophylaxsis & Colace for stool management. Plan: continue to monitor adb status q4hr.\nPV: cool, mottled lower extemities bilaterally, pedal pulses very difficult to palpate. Plan: monitor PV status.\nEndo: Pt has hx of DMII uses oral agents & insulin @ home. 2200 bs was 341, covered with 6u regular insulin. 0000 bs was 198, covered with 6u regular insulin. 0500 labs bs was 44 pt give n4 oz juice. Plan: continue to monitor bs until pt within goal range.\nID: Cultures from wound sites\n"
},
{
"category": "Nursing/other",
"chartdate": "2123-04-24 00:00:00.000",
"description": "Report",
"row_id": 1410997,
"text": "(Continued)\npending. Pt receiving Vanco, Flagyl, Ceftazidime per prophylaxsis. Plan: Pt scheduled for MRI on to rule out osteomyelitis. Continue to administer meds MD order.\nLabs: PTT 70.5 (goal range is 80-100. as of 0000 PTT was 64.1, so no change needed for Heparin drip), Hct 28.8, WBC 8.8, INR 1.4, Na 142, K 3.1, Co2 29, BUN 15, Creat 0.7, Ca 8.5, Mg 1.8, Phos 2.6, Cl 106.\nA: which may be related to sepsis\nPain related to peripheral vascular insufficiency as evidenced by pt verbalization, reluctance to move extremities.\n\n"
}
] |
22,914 | 171,899 | 82 yo man who during pre-op for knee surgery was found to have a positive ETT. He then underwent cardiac cath which revealed multi-vessel coronary disease (80% LAD, 70% mLAD, 80% pLCx, 60% pRCA, 60-70% mRCA, 80-90% dRCA). He was then referred for surgical re-vascularization. The pt went to the OR for CABG x3 (LIMA-LAD, SVG-OM, SVG-RCA). For more detailed account please see operative report. Post-op, he was transferred to the CSRU where he was extubated on POD 0 and vasopressors were off by POD 1. He went into rapid atrial fibrillation on POD 1, which was treated with lopressor and amiodarone, and he converted to sinus rhythm. Chest tubes and wires were removed on POD 2. He was also transferred to the floor on POD 2. His floor course was unremarkable. | MIN CT DRG. C&DB well. PT UPDATE PT IS S/P CABG X3 YEST. ?d/c ct'd in am. GIVEN CA REPLACEMENT. OGT DC'D WITH EXTUBATION. Left atrialabnormality. +pp bilat. DSGS D+I. POST-EXT. K+CA REPLACED . P-R interval 0.19. Pt. Pt. Pt. Pt. Pt. Portable AP view of the chest dated . Left mid lung zone atelectasis. EXTREMITIES WARM, DOPP PP. IMPRESSION: Status post median sternotomy and CABG with lines and tubes as described above. CVP 14-6 RECIEVED 1 L LR. RESP: PT WEANED AND EXTUB. lytes repleated.resp: lungs clear but diminished in bases. HCT 31. All a.m. care performed then. ABG GOOD. PT REMAINS IN AFIB; WITH CONT SAME RATE. Sinus rhythm with baseline artifact. PT WILL PROBABLY TOLERATE LOPRESSOR IN AM. encouraged to cdb & use is.gi/gu: +bs. reglan given w/poor effect. Will wean per protical when indicated. A/P: BREATHING APPEARS COMF. started on amio & lopressor po. sbp stable. Small left pleural effusion. SATS 96-97 ON OFM AND CHANGED TO NP; WITH STILL GOOD SATS. BS CLEAR. BP MUCH IMPROVED NOW; WILL ATTEMPT TO WEAN NEO OFF. Resp CarePt received from OR and placed on current settings. Equivocal right pleural effusion. pacer attached & set for ademand at rate of 60. ct w/minimal amt drainage. PT REMAINS ON LOW DOSE NEO .25. BS bilateral but diminished on left. There is linear atelectasis in the left mid lung zone. DR. CALLED; AND PT GIVEN 150MG IV AMIODARONE BOLUS. percocet given x1 w/good effect but switched back to mso4 d/t n/v.cardiac: afib->nsr after lytes repleated. First abg with adequate acid base but a Pao2 of 82. To CSRU intubated, placed on vent support. Retrocardiac opacity, likely postoperative changes and/or atelectasis. AS PER ORDERS. Advance DAT. mso4 given prn pain. GI: HAS REMAINED NPO . cont cardiac rehab. SMALL AMOUNT OF SANGUINOUS DRAINAGE FROM EPICARDIAL WIRES. NEEDS ENCOURAGEMENT TO COUGH, USE I.S. DID NOT TOLERATE AFIB-NEEDS ATRIAL KICK; BUT BP STABLE ON LOW DOSE NEO; REMAINS IN AFIB. The endotracheal tube is in appropriate position. MED WITH IV MSO4 WITH MIN. RELIEF. difficulty.Plan: d/c chest tubes, D/C foley. TO LOW U/O. NEURO: REVERSED AND PROPOFOL OFF PT AWOKE CALM, MAE, FOLLOWING COMMANDS, PUPILS WITH CATARACT BUT BRISK REACTION. mae. Slow R wave progression, a non-diagnostic finding. The right jugular IV catheter terminates in the distal SVC. GU: U/O ADEQUATE 30-40/HR. NEURO: PT IS A&O X3. The patient is status post CABG and median sternotomy. n/v throughout day. THEN MED WITH SC MSO4 WITH GOOD RELIEF. shift update:neuro: a&o x3. CT DRAINAGE MINIMAL. CXR DONE AND NO ISSUES. asked to get OOB at 0400. s/p cabg x 3S: "IT'S ABOUT A 6"O: CARDIAC: SR-SB 59 THEREFORE A PACED AT 80. ABD SOFT NONTENDER. BP MUCH IMPROVED AFTER FLUID. requested Tylenol with good relief.Labs wnl. There is continued cardiomegaly. DENIES N/V. The left costodiaphragmatic angle is slightly blunted, indicating a likely small pleural effusion. Pt currently resting comfortably, vent pulled. CV: PT AP 80 UNTIL 0150; PT INTO AFIB RATE 90-100; BUT BECAME VERY HYPOTENSIVE-SBP TO 69. PT STARTED ON NEO; AND GIVEN 500 LR. A+V WIRES SENSE AND CAPTURE. INCREASE ACTIVITY; GET PT OOB IN AM. Patchy atelectasis is seen in the left lung base. VSS stable with no arrythmias or resp. LAB: K 3.8-GIVEN BOLUS (10MEQ) ONLY SECOND. There are 2 left-sided chest tubes. oob->chair x2 tolerated well. The patient has been extubated and the chest tube and mediastinal drain have been removed. SBP 100-110 REQUIRING .25MCQ TO KEEP MAP 60-90. There is a right internal jugular central venous catheter, terminating in the superior vena cava. Please call for further RT intervention. IMPRESSION: No pneumothorax. Vent support weaned without event, and pt extubated without difficulty. GU: ADEQUATE UO ENDO: PRESENTLY ON INSULIN GTT AT 3 UNITS/HR. ?transfer to 2 in am. Obtain peripheral IV if possible and D/C CVL, Continue to manage pain prn and Activities as tol. BS 80-100; CURRENTLY ON 2U REG INSULIN GTT. Placed on nasal cannula, 4L/m-> SaO2=96%. And increase peep if necessary LATE LAST EVE. TO PAIN. No c/o of n/v. sat's>95% on 4l nc. dolasetron given x1 w/effect pending.endo: fs covered w/ssri per protocol.social: wife & daughter into visit.plan: pain management. RESPIRATORY CARE:Pt is an 82 yo male, s/p CABG x3. WEIGHT THIS AM 93.2-UP ABOUT 5 KG. There is an NG tube coursing below the diaphragm and coiling in the stomach. Otherwise, there are no focal opacities to suggest consolidation. GI: PT HAS HAD VERY SM AMTS EMESIS (AFTER COUGHING) 25CC CLEAR FLUID. There is increased density in the retrocardiac space, which could represent atelectasis, and/or postoperative changes. No previoustracing available for comparison. COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with the previous study of . very pleasant and cooperative. VERY PLEASANT AND COOPERATIVE. NO CHEST TUBE LEAK, EXTUBATED AT 2145 WITHOUT INCIDENT. PT HAS GOOD STRONG COUGH; BUT NEEDS ENCOURAGEMENT TO DO SO SECOND. TAKING ONLY SM AMTS WATER DURING NIGHT. The right costodiaphragmatic angle was cut off the film, however, no large pleural effusion exists on the right. There is no pneumothorax. RESP: PO2 OUT OF OR 82 PEEP INCREASED TO 10 WITH PO2 TO 170'S. SLEPT LITTLE-IN SHORT NAPS. Pain precipitated by coughing and turning. No pneumothorax is seen. comfortable in the chair. REASON FOR THIS EXAMINATION: check for pneumo FINAL REPORT INDICATION: A 82-year-old man status post CABG. ID: KEFZOL 2 GM AT PAIN: 2 MG IV MORPHINE SULPHATE X1 WITH GOOD EFFECT SOCIAL: WIFE AND DAUGHTER INTO VISIT AND UPDATEDA: STABLE POST CABG X 3P: MONITOR COMFORT, HR AND RYTHYM-MONITOR UNDERLYING RYTHYM, SBP-WEAN NTG AS TOLERATED, CT DRAINAGE, DSGS, PP, RESP STATUS-PULM TOILET, NEURO STATUS, I+O, LABS. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2133-05-02 00:00:00.000",
"description": "Report",
"row_id": 1562151,
"text": "shift update:\n\nneuro: a&o x3. mae. oob->chair x2 tolerated well. mso4 given prn pain. percocet given x1 w/good effect but switched back to mso4 d/t n/v.\n\ncardiac: afib->nsr after lytes repleated. sbp stable. started on amio & lopressor po. pacer attached & set for ademand at rate of 60. ct w/minimal amt drainage. +pp bilat. lytes repleated.\n\nresp: lungs clear but diminished in bases. sat's>95% on 4l nc. encouraged to cdb & use is.\n\ngi/gu: +bs. n/v throughout day. reglan given w/poor effect. dolasetron given x1 w/effect pending.\n\nendo: fs covered w/ssri per protocol.\n\nsocial: wife & daughter into visit.\n\nplan: pain management. cont cardiac rehab. ?d/c ct'd in am. ?transfer to 2 in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-05-03 00:00:00.000",
"description": "Report",
"row_id": 1562152,
"text": "Pt. very pleasant and cooperative. Slept most of the night in short intervals q1-2 hrs. Pt. C&DB well. No c/o of n/v. Pain precipitated by coughing and turning. Pt. requested Tylenol with good relief.\nLabs wnl. Pt. asked to get OOB at 0400. All a.m. care performed then. Pt. comfortable in the chair. VSS stable with no arrythmias or resp. difficulty.\nPlan: d/c chest tubes, D/C foley. Obtain peripheral IV if possible and D/C CVL, Continue to manage pain prn and Activities as tol. Advance DAT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-05-01 00:00:00.000",
"description": "Report",
"row_id": 1562147,
"text": "Resp Care\n\n\nPt received from OR and placed on current settings. First abg with adequate acid base but a Pao2 of 82. BS bilateral but diminished on left. Will wean per protical when indicated. And increase peep if necessary\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-05-01 00:00:00.000",
"description": "Report",
"row_id": 1562148,
"text": "s/p cabg x 3\nS: \"IT'S ABOUT A 6\"\nO: CARDIAC: SR-SB 59 THEREFORE A PACED AT 80. SBP 100-110 REQUIRING .25MCQ TO KEEP MAP 60-90. CVP 14-6 RECIEVED 1 L LR. CT DRAINAGE MINIMAL. EXTREMITIES WARM, DOPP PP. DSGS D+I. SMALL AMOUNT OF SANGUINOUS DRAINAGE FROM EPICARDIAL WIRES. A+V WIRES SENSE AND CAPTURE. HCT 31. K+CA REPLACED .\n RESP: PO2 OUT OF OR 82 PEEP INCREASED TO 10 WITH PO2 TO 170'S. CXR DONE AND NO ISSUES. NO CHEST TUBE LEAK, EXTUBATED AT 2145 WITHOUT INCIDENT. OPEN FACE TENT@ 50 % WITH O2 SAT >97%. RR HIGH TEENS, IS 500 COUGHING WITHOUT RAISING.\n NEURO: REVERSED AND PROPOFOL OFF PT AWOKE CALM, MAE, FOLLOWING COMMANDS, PUPILS WITH CATARACT BUT BRISK REACTION.\n GI: HAS REMAINED NPO . OGT DC'D WITH EXTUBATION. ABD SOFT NONTENDER.\n GU: ADEQUATE UO\n ENDO: PRESENTLY ON INSULIN GTT AT 3 UNITS/HR.\n ID: KEFZOL 2 GM AT \n PAIN: 2 MG IV MORPHINE SULPHATE X1 WITH GOOD EFFECT\n SOCIAL: WIFE AND DAUGHTER INTO VISIT AND UPDATED\nA: STABLE POST CABG X 3\nP: MONITOR COMFORT, HR AND RYTHYM-MONITOR UNDERLYING RYTHYM, SBP-WEAN NTG AS TOLERATED, CT DRAINAGE, DSGS, PP, RESP STATUS-PULM TOILET, NEURO STATUS, I+O, LABS. AS PER ORDERS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-05-02 00:00:00.000",
"description": "Report",
"row_id": 1562149,
"text": "RESPIRATORY CARE:\n\nPt is an 82 yo male, s/p CABG x3. To CSRU intubated, placed on vent support. Vent support weaned without event, and pt extubated without difficulty. Placed on nasal cannula, 4L/m-> SaO2=96%. Pt currently resting comfortably, vent pulled. Please call for further RT intervention.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-05-02 00:00:00.000",
"description": "Report",
"row_id": 1562150,
"text": "PT UPDATE\n PT IS S/P CABG X3 YEST.\n\n NEURO: PT IS A&O X3. VERY PLEASANT AND COOPERATIVE.\n\n RESP: PT WEANED AND EXTUB. LATE LAST EVE. POST-EXT. ABG GOOD. SATS 96-97 ON OFM AND CHANGED TO NP; WITH STILL GOOD SATS. BS CLEAR. PT HAS GOOD STRONG COUGH; BUT NEEDS ENCOURAGEMENT TO DO SO SECOND. TO PAIN.\n\n CV: PT AP 80 UNTIL 0150; PT INTO AFIB RATE 90-100; BUT BECAME VERY HYPOTENSIVE-SBP TO 69. PT STARTED ON NEO; AND GIVEN 500 LR. DR. CALLED; AND PT GIVEN 150MG IV AMIODARONE BOLUS. PT REMAINS IN AFIB; WITH CONT SAME RATE. BP MUCH IMPROVED AFTER FLUID. PT REMAINS ON LOW DOSE NEO .25.\n\n GU: U/O ADEQUATE 30-40/HR. WEIGHT THIS AM 93.2-UP ABOUT 5 KG.\n\n GI: PT HAS HAD VERY SM AMTS EMESIS (AFTER COUGHING) 25CC CLEAR FLUID. DENIES N/V. TAKING ONLY SM AMTS WATER DURING NIGHT.\n\n OTHER: PT TURNED FREQUENTLY DURING NIGHT-PT HAD A HARD TIME GETTING COMF. MED WITH IV MSO4 WITH MIN. RELIEF. THEN MED WITH SC MSO4 WITH GOOD RELIEF. MIN CT DRG.\n\n LAB: K 3.8-GIVEN BOLUS (10MEQ) ONLY SECOND. TO LOW U/O. GIVEN CA REPLACEMENT. BS 80-100; CURRENTLY ON 2U REG INSULIN GTT.\n\n\n A/P: BREATHING APPEARS COMF. NEEDS ENCOURAGEMENT TO COUGH, USE I.S. SLEPT LITTLE-IN SHORT NAPS. DID NOT TOLERATE AFIB-NEEDS ATRIAL KICK; BUT BP STABLE ON LOW DOSE NEO; REMAINS IN AFIB. BP MUCH IMPROVED NOW; WILL ATTEMPT TO WEAN NEO OFF. PT WILL PROBABLY TOLERATE LOPRESSOR IN AM. INCREASE ACTIVITY; GET PT OOB IN AM.\n"
},
{
"category": "Radiology",
"chartdate": "2133-05-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 860630,
"text": " 11:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check for pneumo\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man s/p cabg x3 and now chest tubes removed.\n REASON FOR THIS EXAMINATION:\n check for pneumo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 82-year-old man status post CABG.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study of .\n\n The patient has been extubated and the chest tube and mediastinal drain have\n been removed. The right jugular IV catheter terminates in the distal SVC. No\n pneumothorax is seen. The patient is status post CABG and median sternotomy.\n\n Patchy atelectasis is seen in the left lung base. There is continued\n cardiomegaly. No evidence for congestive heart failure is seen.\n\n IMPRESSION: No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-05-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 860468,
"text": " 5:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man s/p cabg x3\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 82-year-old man status post CABG, with CAD.\n\n Portable AP view of the chest dated . The endotracheal tube is in\n appropriate position. There is a right internal jugular central venous\n catheter, terminating in the superior vena cava. There are 2 left-sided chest\n tubes. There is an NG tube coursing below the diaphragm and coiling in the\n stomach. There is no pneumothorax. There is linear atelectasis in the left\n mid lung zone. There is increased density in the retrocardiac space, which\n could represent atelectasis, and/or postoperative changes. Otherwise, there\n are no focal opacities to suggest consolidation. The right costodiaphragmatic\n angle was cut off the film, however, no large pleural effusion exists on the\n right. The left costodiaphragmatic angle is slightly blunted, indicating a\n likely small pleural effusion. There is no prominence of the pulmonary\n vasculature to suggest congestive heart failure.\n\n IMPRESSION: Status post median sternotomy and CABG with lines and tubes as\n described above. Left mid lung zone atelectasis. Retrocardiac opacity,\n likely postoperative changes and/or atelectasis. Small left pleural effusion.\n Equivocal right pleural effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2133-05-01 00:00:00.000",
"description": "Report",
"row_id": 189926,
"text": "Sinus rhythm with baseline artifact. P-R interval 0.19. Left atrial\nabnormality. Slow R wave progression, a non-diagnostic finding. No previous\ntracing available for comparison.\n\n"
}
] |
31,021 | 117,284 | Patient electively admitted on for evacuation of chronic left subdural hematoma complicated by subarachnoid hemmorhage. : EEG performed: IMPRESSION: Markedly abnormal portable EEG due to the slow and disorganized background rhythm and due to the prominent focal sharp waves in the left fronto-temporal region and, less frequently, in the right frontal area. A slow background indicates a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. This should not come from a subdural hematoma alone in most cases. There were very frequent sharp waves, mostly in the left anterior quadrant (and occasionally right frontally), but there were no repetitive discharges to indicate ongoing seizures at the time. Finally, there was no prominent voltage asymmetry : IV antibiotics started secondary to gram negative rods in the sputum. : CT performed: IMPRESSION: Compared to the prior study dated , there has been interval improvement of the pneumocephalus. There is a persistent left-sided subdural collection causing mass effect upon the left cerebral hemisphere and 6 mm midline shift, which is unchanged. Persistent widespread subarachnoid hemorrhage. Stable focal intraparenchymal hemorrhage in the left frontal region. Left subclavian line placed for continued antibiotic treatment. : Portable chest x-ray to follow up temp spike to 102: IMPRESSION: 1. Pulmonary edema with superimposed right middle lobe/right lower lobe infection and/or aspiration. 2. Left retrocardiac atelectasis, however, pneumonia cannot be excluded. 3. Lines, tubes and catheters are in satisfactory location. : Trach placed in OR, PEG postponed due to fevers. : IMPRESSION: 1. Compared to the prior CT, there is slight increased size of the left-sided subdural CSF intensity collection with midline shift which has slightly increased with subfalcine herniation. The right temporal is more dilated compared to the previous study. Extensive subarachnoid hemorrhage and hemorrhagic contusions are again identified without new hemorrhage. 2. No definite aneurysm is identified but the vascular structures are less distinctly visualized which could be due to mild non-occlusive spasm. Proximal basilar artery demonstrates narrowing which could be due to stenosis as described previously. : Staples removed from cranial wound. : Patient received 2U PRBC's for black tarry stool(guiac negative) : Percutaneous Gastrostomy Tube placed. : Tube feeds begun without incident. | FINDINGS: Again demonstrated is a left craniotomy defect with extra-axial subdural collection which is low density and of similar size compared to prior study. COMPARISON: Non-contrast head CT and CT angiogram head, . Slight atelectasis per am CXR as read by Dr. . Hypodensity of the subcortical regions of the left frontal and parietal lobes are similar to the prior study consistent with edema or infarction. COMPARISON: non-contrast head CT and . There is a persistent left-sided subdural collection causing mass effect upon the left cerebral hemisphere and 6 mm midline shift, which is unchanged. IMPRESSION: Overall similar appearing diffuse subarachnoid hemorrhage and left frontal, parietal, and occipital intraparenchymal hemorrhages, right lateral intraventricular hemorrhage, and left subdural hematoma evacuation. Stable focal intraparenchymal hemorrhage in the left frontal region. Extensive subarachnoid hemorrhage and hemorrhagic contusions are again identified without new hemorrhage. Mild overinflation of endotracheal tube cuff. FINDINGS: The cardiac silhouette is within normal limits and there are atelectatic changes especially at the left base in the retrocardiac region. Also seen is the left frontal intraparenchymal hemorrhage with surrounding edema, without significant change. TECHNIQUE: Noncontrast head CT. The cuff of the endotracheal tube appears slightly over- distended. Mouth care done with difficulty.NGT placed and verified per CXR, no drainage noted.Plan:Continue to assess neurological status closely. FINDINGS: Again identified is diffuse subarachnoid hemorrhage. SAH and Large pneumocephalus with possible mild tension component. TECHNIQUE: Non-contrast head CT. There remains pneumocephalus layering along the left frontal convexity with a small amount of pneumocephalus also along the right frontal lobe. Discrete foci of intraparenchymal hemorrhage of the left frontoparietal region, not significantly changed. RSBI of 79 this am but continues to have impaired cough/gag although appears to be improving.NGT with /bilious drainage.Plan:Continue close neurological assessments Q1hr. CONCLUSION: Status post evacuation of left chronic subdural fluid collection. Stable rightward subfalcine herniation by about 9 mm with intraventricular blood as before. Unchanged left retrocardiac density, atelectasis or alternatively multifocal pneumonia. + EDEMA.RESP: LS CLEAR TO COARSE. LYTES WNL.ENDO: FS QID. Resp CarePt. Resp CarePt. Abgs reveal resp. CONTINUES ON DILANTIN. GOAL SBP < 160 MET WITH NIPRIDE GTT WHICH WAS WEANED OFF AFTER PO LOPRESSOR GIVEN. Vanco level pending for AM. SPUTUM SPEC SENT.GI: NPO. Tol procedure well, maint sats and trach placement verified by bronch. Continue Vancomycin and Cefepime, ? LABETALOL GTT TRITRATED TO OFF. Abdomen soft, distended, +BS, TF at goal w/minimal residuals. HAD MINI-CRANI. Cont to tol trach collar w/acceptable ABG this am. PERRLA. tinged.abgs:adequately oxygenated with resp. TITRATE SUPPLEMENTAL VENT SUPPORT AS TOLERATED. Freq repostioning. Labetolol infusion remaining off. +RADIAL, FEMORAL,, PT AND DP X2. Based on latest ABG. CA repleted.Skin w/d. CSL ON. Pt had bronch and perc trach 8.0 @ bedside tol well. alkalosis with adequate oxygenation.Bs:ess. DP/PT pulses palpable. TF held. PAIN MAINAGEMENT PRN. Resp CareTrached with #8 portex perfit. REPOSITION Q 2. Hydralazine PRN x 1. T101.3 this am, pan cultured and tylenol given. +cough reflex. PERL. PERL. Keep SBP <160. LS: R+LUL COARSE-CLEAR,DIMINISHED BIBASILAR. Dilantin level remains low, dilantin d/c'd andf kepra dose increased. PRN HYDRALAZINE, LOPRESSOR, AND DILAUDID GIVEN WITH FAIR EFFECT, JUST MEETING GOAL OF < 160. PPP. TF infusing via NGT at goal rate; no residual noted. Good paO2 (113). Dosed per SICU resident on call. SURVAILLENCE LABS PRN. POSSIBLE TRACH-PEG ON . + COUGH. Dilaudid 0.5mg IV x1 given d/t pt grimacing. Pt opens eyes to voice. PERLA. source of treatment. TOLERATING TF AT GOAL. Pt needs PEG when no longer febrile. ABP: 137-155/66-70. ADMITTED FOR BURR HOLES ON , HOWEVER INTRA-OP HAD SAH AND IPH. BAL was sent. Abdomen was firmly distended at beginning of shift, but is now softly distended. CONTINUE DILATIN AND KEPPRA. COVERAGE PER REGUALR INSULIN SS. + GAG.CV: HR 70'S-80'S NSR. Foley draining clear amber, TF remains on hold pending PEG/trach. Mild alkolisis. PLAN CT OF HEAD TONIGHT.CARDIAC: HCT: STABLE. Resp CarePt remains on PSV. Neuro exam q2hr. Respiratory care note:Pt received on current setting, SIMV . Resp Care Note, Pt remains on current vent settings. resp careremains intubated/vented in psv/cpap mode. resp careremains intub/vented in psv/cpap mode. infection No contraindications for IV contrast FINAL REPORT INDICATION: Left STH/SAH/IPH. Again noted is partial opacification of both mastoid air cells. tube re-taped and repositioned, bilat bs clear dimn lower bases maintains good sats. Respiratory CarePt maintained on mech vent, tol well with some improvment, wean started and tol well, PS weaned down. Morning rsbi 34.2.BS: CEB, secreations minimal.Plan: Cont. d/t neuro responxe to head bleeds;on labetelol gtt, received pt on 1 mg/min, now on 2.5 mg/min;NSR, no ectopy;vent settings unchanged, remains on PS/CPAP 5/5, FIO2 0.35, O2 sats remain in hi 90's;suctioned approx q 3 hrs for mod amt whitish/opaquish thick return;oral care received;abd somewhat distended; is having stools, some soft, some regular formed, brown, gu neg; is on goal tube feed rate, tolerating well;low grade febrile this night at most; remains on IV Abx of vanco and cefepime;though WBC is up again slightly this a.m.;hct slightly down, however some of decrease ?dilutional--pt w/ weight gain, likely body fluid;PLAN:1) cont current POC2) follow exam3) MD team to bring up issues of trach and PEG for this pt reportedly today Mon 4) ?pt needs increase in anti-hypertensives to be able to wean off labetelol gtt5) ?add dilantin level to a.m. labs STAPLES C-D-I. Resp CarePt. Pt was restarted on Nipride gtt, persently @ 1.3 with good effect.Resp: Pt still on Cpap @ 0.35 5 and 5, suctioned yellow think secretions throught out shift.Plan: Monitor BP goal < 160; Titrate Nipride gtt for desire BP Goal <160; Monitor Pt temps, Monitor Q2hr Neuro checks tolerating mode with vt 400-600,rr around 20. transported to ctscan with stable ventilatory status t/out. | 55 | [
{
"category": "Radiology",
"chartdate": "2102-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 999133,
"text": " 9:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man with history of IPH1 and fever spikes and a\n probable area of consolidation in the retrocardiac region for evaluation of\n infiltrate.\n\n COMPARISON: .\n\n SINGLE VIEW, CHEST: NG tube in standard location. Right subclavian venous\n access device in upper SVC. Worsening consolidation in the right lower lung\n fields. Left retrocardiac opacification, unchanged. Mild interstitial edema,\n unchanged. Hilar contour, heart size is within normal limits.\n\n IMPRESSION: Worsening RLL opacification, could be atelectasis, aspiration or\n pneumonia. Unchanged left retrocardiac density, atelectasis or\n alternatively multifocal pneumonia. Unchanged mild interstitial edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 998061,
"text": " 2:33 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: size of SDH, vent size, new bleed\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with L SDH, s/p crani\n REASON FOR THIS EXAMINATION:\n size of SDH, vent size, new bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT SCAN\n\n TECHNIQUE: 5-mm axial images from the skull base to the vertex without\n intravenous contrast administration.\n\n Comparison made to prior study dated .\n\n FINDINGS: Again seen is the diffuse subarachnoid hemorrhage along the sylvian\n fissures and cerebral convexities bilaterally. There is a left subdural fluid\n collection. The pneumocephalus has significantly decreased, although there is\n persistent residual. There is stable mass effect with a 6 mm left to right\n shift of the midline structures. Also seen is the left frontal\n intraparenchymal hemorrhage with surrounding edema, without significant\n change.\n\n Stable appearance of the left middle cranial fossa arachnoid cyst.\n\n There is complete opacification of the ethmoid and sphenoid air cells. There\n is mucosal thickening of the visualized maxillary sinuses.\n\n IMPRESSION: Compared to the prior study dated , there has been\n interval improvement of the pneumocephalus. There is a persistent left-sided\n subdural collection causing mass effect upon the left cerebral hemisphere and\n 6 mm midline shift, which is unchanged. Persistent widespread subarachnoid\n hemorrhage. Stable focal intraparenchymal hemorrhage in the left frontal\n region.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997324,
"text": " 9:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess placement of NGT, ETT\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p craniotomy, s/p NGT, ETT placement\n REASON FOR THIS EXAMINATION:\n assess placement of NGT, ETT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post craniotomy, to assess placement of nasogastric and\n endotracheal tubes.\n\n FINDINGS: The cardiac silhouette is within normal limits and there are\n atelectatic changes especially at the left base in the retrocardiac region.\n Specifically, the tip of the endotracheal tube lies approximately 5 cm above\n the carina and the nasogastric tube extends to the upper stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-01-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 999640,
"text": " 5:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for progression of bleed, hydrocephalus, any\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with SDH intraop bleeding and SAH distant to operative site.\n Continued unresponsiveness. will Be going to Rehab soon and we want a\n baseline.\n REASON FOR THIS EXAMINATION:\n Please evaluate for progression of bleed, hydrocephalus, any new intracranial\n processes.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male with subarachnoid and subdural hemorrhage after\n evacuation.\n\n COMPARISON: Non-contrast head CT and CT angiogram head, .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Overall, the appearance of the brain is similar to .\n Again demonstrated are multiple areas of parenchymal hemorrhage and\n subarachnoid hemorrhage involving the bilateral frontal, temporal and parietal\n lobes. A subdural CSF-density collection remains layering around the left\n convexity not appreciably changed, measuring about 2.0 cm in maximal\n thickness. Shift of the septum pellucidum to the right by about 9 mm is\n stable. There are postoperative changes of the left frontal and temporal\n regions. No definite new sites of intracranial hemorrhage are identified.\n Hypodensity of the subcortical regions of the left frontal and parietal lobes\n are similar to the prior study consistent with edema or infarction. The\n ventricular system is stable in size and configuration with asymmetric large\n size of the right temporal again demonstrated, possibly secondary to\n subfalcine herniation. Blood is again noted within the occipital \n of the right lateral ventricle.\n\n Mucosal thickening is noted of the visualized paranasal sinuses. A few of the\n bilateral mastoid air cells are opacified.\n\n IMPRESSION:\n\n 1. No significant change compared to the most recent head CT of .\n\n 2. Widespread foci of parenchymal and subarachnoid hemorrhage redemonstrated.\n\n 3. No significant change in CSF-density subdural collection of the left\n convexity.\n\n 4. Stable rightward subfalcine herniation by about 9 mm with\n intraventricular blood as before.\n\n\n (Over)\n\n 5:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for progression of bleed, hydrocephalus, any\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 998535,
"text": " 8:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man IPH s/p craniotomy\n REASON FOR THIS EXAMINATION:\n assess for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 67-year-old man with left subdural hematoma status post\n evacuation. Followup study.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast CT of the head.\n\n FINDINGS: Again demonstrated is a left craniotomy defect with extra-axial\n subdural collection which is low density and of similar size compared to prior\n study. There has been interval reduction in extent of pneumocephalus. The\n diffuse subarachnoid and left frontal, parietal, and occipital\n intraparenchymal hemorrhages are evolved appearing with no evidence of new\n intracranial hemorrhage. Blood within the occipital of the right\n lateral ventricle is again noted. The amount of mass effect is similar\n compared to prior study with 7 mm of rightward shift of the midline.\n\n IMPRESSION: Overall similar appearing diffuse subarachnoid hemorrhage and\n left frontal, parietal, and occipital intraparenchymal hemorrhages, right\n lateral intraventricular hemorrhage, and left subdural hematoma evacuation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-18 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 997290,
"text": " 4:39 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: CT AND CTA NOW PER DR - R/O UNDERLYING AVM VS\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with BURR HOLES FOR SUBDRUAL WITH INTRAOP SWELLING - OPENED TO\n MINI CRANI - SAH AND IPH NOTED DISTANT TO OPERATIVE SITE.\n REASON FOR THIS EXAMINATION:\n CT AND CTA NOW PER DR - R/O UNDERLYING AVM VS ANEURYSM\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRCi 11:30 PM\n No aneurism or AVM identified. SAH and Large pneumocephalus with possible\n mild tension component. Subdural collection present which appears new from\n recent comparision 2 hrs previous approximately 8mm width. discussed\n with at 11:25pm the day of exam.\n WET READ VERSION #1 JRCi 11:26 PM\n No aneurism or AVM identified. SAH and Large pneumocephalus without definite\n tension component. Subdural collection present which appears new from recent\n comparision 2 hrs previous approximately 8mm width. discussed with \n at 11:25pm the day of exam.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD AND CT ANGIOGRAPHY, \n\n HISTORY: Subarachnoid hemorrhage after surgery for subdural drainage.\n\n CTA was performed with rapid intravenous infusion of contrast during helical\n scanning through the brain. Comparison to a prior head CT of earlier , . Three-dimensional volume-rendered images were reconstructed on a\n separate workstation.\n\n FINDINGS: Again identified is diffuse subarachnoid hemorrhage. There is no\n evidence of new hemorrhage since the prior recent CT scan.\n\n The CT angiogram demonstrates no evidence of aneurysm, vascular malformation,\n or other vascular abnormality to explain the subarachnoid blood. There is\n severe narrowing of the proximal basilar artery, just distal to the\n vertebrobasilar junction. However, the artery remains patent. This appears\n most likely due to atheromatous disease. The vessels of the anterior\n circulation appear normal.\n\n CONCLUSION:\n 1. No findings to explain subarachnoid hemorrhage.\n 2. Severe stenosis of the basilar artery just distal to the vertebrobasilar\n junction.\n\n (Over)\n\n 4:39 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: CT AND CTA NOW PER DR - R/O UNDERLYING AVM VS\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 997357,
"text": " 5:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P CRANI., ? RT SIDED PARESIS, EVAL FOR INERVAL CHANGES.\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with s/p craniotomy, now with ? Right sided paresis\n REASON FOR THIS EXAMINATION:\n assess for interval change s/p L. craniotomy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old male status post craniotomy, now with right-sided\n paresis.\n\n COMPARISON: non-contrast head CT and .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Redemonstrated is the left subdural collection, which is similar in\n thickness to the prior CTA head at 16:56 measuring about 9 mm maximal\n thickness. There remains pneumocephalus layering along the left frontal\n convexity with a small amount of pneumocephalus also along the right frontal\n lobe. Redemonstrated is extensive subarachnoid hemorrhage within the sylvian\n fissures and sulci of the convexities bilaterally as well as within the\n ambient cistern. Parenchymal hemorrhage of the left frontoparietal region has\n not appreciably changed. The septum pellucidum remains shifted to the right\n by approximately 5 mm, not appreciably changed going back to head CT .\n The ventricular system is stable in size and configuration. A few of the\n ethmoid air cells are opacified. Mild mucosal thickening is noted of the\n maxillary sinuses. Mastoid air cells are clear. Left middle cranial fossa\n arachnoid cyst, unchanged.\n\n IMPRESSION: No significant short interval change compared to prior study\n at 16:56. Persistent left subdural collection. Widespread\n subarachnoid hemorrhage. Discrete foci of intraparenchymal hemorrhage of the\n left frontoparietal region, not significantly changed. Rightward shift of the\n septum pellucidum by approximately 5 mm is stable.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 997264,
"text": " 2:43 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post-op\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with known SDH, post-op\n REASON FOR THIS EXAMINATION:\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST, \n\n HISTORY: Hemorrhage after drainage of subdural hematoma.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. The most recent prior head CT was from .\n\n FINDINGS: The patient is status post a left frontal craniotomy for evacuation\n of a chronic subdural fluid collection. There is postoperative air at the\n surgical site.\n\n There is diffuse subarachnoid hemorrhage in the sylvian fissures and\n convexities sulci bilaterally. In addition, there is subarachnoid blood in\n the ambient cistern. This has filled the sulci with isodense material, making\n them appear smaller. There is evidence of mass effect, and the lateral\n ventricles appear smaller than on the study of . The cause of this\n mass effect is not apparent.\n\n CONCLUSION: Status post evacuation of left chronic subdural fluid collection.\n Now with extensive subarachnoid hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 997649,
"text": " 12:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p OGT placement, pls assess position\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p L SDH evacuation converted to mini craniotomy with intra-op\n SAH and IPH and post-op seizures x2\n REASON FOR THIS EXAMINATION:\n s/p OGT placement, pls assess position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man with intracranial hemorrhage and seizure, for\n assessment of orogastric tube placement.\n\n CHEST, SEMI-UPRIGHT AP: Comparison is made to two days earlier. The patient\n remains intubated. The cuff of the endotracheal tube appears slightly over-\n distended. A feeding tube courses into the stomach, its inferior extent not\n visualized.\n\n Cardiac and mediastinal contours are unchanged. There are new opacities in\n the right mid lung and superior segment of the left lower lobe, probably\n consolidations. No pneumothorax or effusion is demonstrated. The lateral\n aspect of the right hemithorax is excluded from this view.\n\n IMPRESSION:\n 1. Feeding tube passing into the stomach, its distal extent not visualized.\n\n 2. Mild overinflation of endotracheal tube cuff.\n\n 3. New bilateral opacities, probably consolidations, of rapid onset in the\n setting of normal pulmonary vascularity. Differential considerations include\n aspiration.\n\n Discussed with Dr. on the same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-30 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 999294,
"text": " 9:40 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: r/o aneurysm\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with SAH distant to surgical site from subdural evacuation\n REASON FOR THIS EXAMINATION:\n r/o aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CTA of the head.\n\n CLINICAL INFORMATION: Patient with subarachnoid hemorrhage and evacuation of\n subdural hematoma, rule out aneurysm.\n\n TECHNIQUE: Axial images of the head were obtained without contrast. Following\n this, using departmental protocol, CT angiography of the head was acquired.\n Sagittal, axial, and coronal reformatted images were obtained.\n\n FINDINGS:\n\n CT HEAD:\n Comparison was made with the previous CT examination of . Again\n multiple areas of brain contusions and subarachnoid hemorrhage are identified.\n There are post-operative changes seen within the left temporal region with\n evacuation of the subdural hematoma. A subdural CSF intensity collection is\n now identified along the left frontoparietal region with maximum width of\n about 2 cm, slightly increased from previous study. There are hypodensities\n identified at the left subcortical and cortical region which are slightly more\n prominent from prior study. There is no new hemorrhage identified. There is\n some midline shift identified. There is prominence of ventricles particularly\n the right temporal which appears to be secondary to subfalcine herniation\n and has increased from previous study.\n\n CT ANGIOGRAPHY OF THE HEAD:\n The CT angiography of the head again demonstrates some irregularity and\n narrowing of the basilar artery which could be due to intrinsic disease. The\n vascular structures in the anterior circulation are otherwise well visualized.\n However, compared to the prior study, the middle cerebral arteries appear\n slightly decreased in caliber which could be due to mild non-occlusive spasm.\n No other significant abnormalities are seen.\n\n IMPRESSION:\n 1. Compared to the prior CT, there is slight increased size of the left-sided\n subdural CSF intensity collection with midline shift which has slightly\n increased with subfalcine herniation. The right temporal is more dilated\n compared to the previous study. Extensive subarachnoid hemorrhage and\n hemorrhagic contusions are again identified without new hemorrhage.\n 2. No definite aneurysm is identified but the vascular structures are less\n distinctly visualized which could be due to mild non-occlusive spasm. Proximal\n basilar artery demonstrates narrowing which could be due to stenosis as\n (Over)\n\n 9:40 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: r/o aneurysm\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n described previously.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 998047,
"text": " 1:36 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval R subclavian line placement.\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with subarachnoid bleed.\n REASON FOR THIS EXAMINATION:\n Please eval R subclavian line placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Right subclavian line placement.\n\n Right subclavian catheter terminates at junction of superior vena cava and\n right atrium with no evidence of pneumothorax. Nasogastric tube and\n endotracheal tube are in standard position. Cardiac and mediastinal contours\n are stable in appearance. Persistent patchy opacity in the right lung, just\n above the minor fissure is noted as well as an improving opacity in the left\n retrocardiac region.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-19 00:00:00.000",
"description": "Report",
"row_id": 1659399,
"text": "Focus: Status Update\nData:\nSedated on Propofol drip and woken up off sedation q4hrs for neurological assessment per Dr. . When patient off sedation his whole body shakes rhythmically and stiffly, he does no open eyes or follow commands. He does move all extremities in bed when stimulated and lifts left leg slightly off bed. Pupils are equal and briskly reactive to light from 1mm when sedated and 2-3mm when off sedation. 0500 exam revealed unilateral shaking on right only with continued withdrawal to nailbed pressure on right. Dr. asked to evaluate. Head CT done at this time to r/o neuro change. Formal read pending but stable with slight improvement per Dr. . Wife in earlier and stated that pt. has not taken his usual Parkinson meds and this is typical for him.\n\nLungs clear bilaterally. Continues ventilated on SIMV 600x14, , decreased to 40% after PO2 of 185. Bite block applied d/t rigorous biting of ETT particularly when pt. stiffly shaking. Mouth care done with difficulty.\n\nNGT placed and verified per CXR, no drainage noted.\n\nPlan:\nContinue to assess neurological status closely. EEG today to r/o seizures. Dilantin bolus for Dilantin level=8. Continue to keep intubated and sedated today and perform neurological exams q4hrs.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-20 00:00:00.000",
"description": "Report",
"row_id": 1659405,
"text": "addendum\nPt off Nipride gtt , but still not maintaining BP goal <160, Pt received Hydralazine 10mg Prn with little effect. Dr. aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-21 00:00:00.000",
"description": "Report",
"row_id": 1659406,
"text": "Respiratory care note:\nPt currently on PS 5/5 with 35 FiO2. tolerated well setting, no changes made. Sx for small amt of tan secretion. Clear BS throughout.\nRSBI done =36\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-21 00:00:00.000",
"description": "Report",
"row_id": 1659407,
"text": "Focus: Status Update\nData:\nOpening eyes to aggressive stimulation or sternal rub. Not following commands. PERL. Moving all extremities.\n\nBP maintained <160 systolic with Lopressor and PRN hydralazine.\n\nLungs bilaterally clear. No vent changes overnight. Suctioned for thick tan secretions. Low grade temp, started on abx today.\n\nTube feeds at goal rate of 80ml/hr with no residuals.\n\nPlan:\nContinue to monitor neurological status closely. Maintain BP<160sys. Stop IVF this am w/tf at goal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-21 00:00:00.000",
"description": "Report",
"row_id": 1659408,
"text": "Resp Care\n\nPt remains intubated and currently vented on PSV/CPAP 5/5 tol well with Vt arounf 400-500cc and MV 8-9L. BS clear to course sxing for small to mod amts of thick tan secretions. Will cont to monitor and cont with vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-21 00:00:00.000",
"description": "Report",
"row_id": 1659409,
"text": "see careVue for specifics:\n\nNeuro: Pt arousable to pain, but will open eyes now to stimuli(rubbing of chest); Nonpurposeful movement, withdraws,, Impaired gag and cough.\n\nResp: Pt still on Cpap at 5&5, suctioned thick tan secretions throughout shift.\n\nCV: max temp 99.9, HR 70s-80s, Bp 140s-160s, BP goal < 160, Pt requried Lopressor 10mg IV X1, Hydralazine 10mg X2 to maintain a BP < 160 with little effect, Dr. aware, Changed Lopressor PO to 75 mg from 50mg TID.\n\nFen: Pt at tube Feed goal 80cc/hr, No residuals.\n\nPlan: Cont to monitor BP goal of < 160, Hydralazine PRN, Watch secretions, suctions when needed, Monitor Q2hr Neuro checks.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-19 00:00:00.000",
"description": "Report",
"row_id": 1659400,
"text": "See CareVue for specific:\n\nNeuro: Pt weaned off propofol this am @0830, Pt aroused only by stimuli, very lethargic, posturing on the left , withdrawing on the right, recieved 1mg of ativan @0830 per neuromed exam to treat pt right arm shaking. Pt is schedule for EEG tomorrow. Dr was into see the pt @ 1800, was able to stimulate pt to open eyes.\n\nCV: Max temp 101.1, neuro med aware, pt recieved tylenol X2 with ice packs; HR 70s-80s, BP 140-150s, BP goal <160 systolic, Pt prsently on Nipride @ 1.2mg.\n\nResp: Lung sounds clear, diminished at bases, conts on Vent on SIMV.\n\nGI: Pt tolerates Meds down Ngtube.\n\nPlan: cont to monitor temps, Montior BP to amintain goal < 160 systolic, EEG tomorrow, Cont to monitor Neuro status Q1hr checks.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-20 00:00:00.000",
"description": "Report",
"row_id": 1659401,
"text": "Focus: Status Update\nData:\nNo sedation administered overnight. Arousable only to painful stimuli. Opened eyes only x1 to pain. Withdraws upper extremities to nailbed pressure and lower extremities are hypersensitive to the touch. He does non-purposefully move all extremities in bed. Whole body continues to be very stiff, particularly when stimulated as in turning. Does not follow any commands. Pupils equal and briskly reactive to light at 2mm. No seizure activity or shaking noted.\n\nNipride weaned as able to maintain SBP<150.\n\nCopious amounts of tan/yellow thick secretions suctioned, sputum cx sent d/t low grade temps. WBC improved this am. Frequent turning, oral care and CPT performed overnight. Slight atelectasis per am CXR as read by Dr. . RSBI of 79 this am but continues to have impaired cough/gag although appears to be improving.\n\nNGT with /bilious drainage.\n\nPlan:\nContinue close neurological assessments Q1hr. Possible EEG today per neuro. F/u sputum cx and assess secretions before weaning to extubate. Frequent turning and application of lotion for skin care d/t rigidity and lack of self repositioning. Assess NGT drainage for adequate absorption of Parkinson meds.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-25 00:00:00.000",
"description": "Report",
"row_id": 1659425,
"text": "NURSING PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS.\n\n67 Y/O MALE WITH PHH OF AND RECATAL CA. ADMITTED FOR BURR HOLES ON , HOWEVER INTRA-OP HAD SAH AND IPH. HAD MINI-CRANI. PRESENTLY POD #7.\n\nNEURO: AROUSES TO VOICE. ,BRISK. NO MAE. +GAG/COUGH. NO SEIZURE ACTIVITY NOTED. CONTINUES ON DILANTIN. PLAN CT OF HEAD TONIGHT.\n\nCARDIAC: HCT: STABLE. NSR. HR: 69-79. ABP: 137-155/66-70. LABETALOL GTT TRITRATED TO OFF. GOAL BP LESS THAN 160. +RADIAL, FEMORAL,, PT AND DP X2. CSL ON. SC HEPARIN.\n\nPULM: INTUBATED ON CPAP+PS/35%/. POX: 95-98%. LS: R+LUL COARSE-CLEAR,DIMINISHED BIBASILAR. SX FOR SM AMTS OF THICK TAN SPUTUM. SPUTUM SPEC SENT.\n\nGI: NPO. TOLERATING TF AT GOAL. ABD:OBESE,+BSX4,S,NT. MED FORMED BROWN STOOLS X3, TODAY.\n\nGU: FOLEY WITH QS URINE. HUO: 50-120. LYTES WNL.\n\nENDO: FS QID. COVERAGE PER REGUALR INSULIN SS. NPH TO START TONIGHT.\n\nIVL'S: R-TRIPLE LUMEN SC AND R-RADIAL A-LINE SITES WNL'S AND DRESSINGS CDI.\n\nPSYCH/SOCIAL: WIFE IN TO VISIT ALL DAY. MET WITH NEURO TEAM AND MD CRITLOW TO DISCUSS POC. SUPPORTIVE CARE PROVIDE.\n\nPLAN: Q 2 HOUR NEURO CHECKS. CONTINUE DILATIN AND KEPPRA. PAIN MAINAGEMENT PRN. HEAD CT TONIGHT. AGGRESSIVE PULM HYGIENE. TITRATE SUPPLEMENTAL VENT SUPPORT AS TOLERATED. POSSIBLE TRACH-PEG ON . SURVAILLENCE LABS PRN. REPOSITION Q 2. PROVIDE SUPPORTIVE CARE TO PT AND FAMILY.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-26 00:00:00.000",
"description": "Report",
"row_id": 1659426,
"text": "SICU NPN\nS-Intubated.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Neuro exam as documented. Routine CT of head performed with results pending. Dilantin level low. Discussed with SICU resident on call and holding off on further load as pt on Keppra and Dilantin. Labetolol infusion remaining off. Goal SBP < 160. Hydralazine PRN x 1. Continue PO antihypertensives with good results. CPAP 5/5 with good Mv and good Spont Tvs. Breathing even non-labored on settings. Tachypenic post suctioning, RR low 30s but recovering with minutes of suctioning. Secretions thick yellow, small to moderate amounts. HUO adequate. TF held. NPO for peg/trach this morning. Low grade temps. Continue Vancomycin and Cefepime, ? source of treatment. Vanco level 19.3 evening. Dosed per SICU resident on call. Vanco level pending for AM. No phone calls or visitors overnight.\n\nA/P: s/p crani secondary to SDH, uneventful shift. Peg and trach today.\nKeep SBP < 160\nContinue q2H neuro exams\nNPO for trach/peg this morning\nVanco level pending this morning\nContinue emotional support to family\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-26 00:00:00.000",
"description": "Report",
"row_id": 1659427,
"text": "Resp Care\nPt. remains intubated/ on minimal vent support.TV 600-750cc MV 11-13L. Abgs reveal resp. alkalosis with adequate oxygenation.\nBs:ess. clear minimal sxn.\nBrought for repeat head CT overnight.\nPlan:Trach/peg today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-26 00:00:00.000",
"description": "Report",
"row_id": 1659428,
"text": "Nursing Progress Note\n Please see carevue for details of care. Pupils remain equal and reactive @ 2-3mm. W/D upper and lower extrem to pain. Sometimes opens eyes to name being called but inconsistently. Dilantin level remains low, dilantin d/c'd andf kepra dose increased. T101.3 this am, pan cultured and tylenol given. SBP maint <160 this shift, captopril dose increased and hydralazine prn x1 w/good effect.\n Remains on CPAP 5/5 this am, sats 94-97, desat after bronch this am, sats slowly returned to baseline. Suctions for small thick white-yellow secretions, vanco dose as ordered post vanco level this am. Foley draining clear amber, TF remains on hold pending PEG/trach.\n Wife at bedside this pm, update given.\n\nPLAN: Cont to provide vent support/TF as needed. Trach/PEG insertion pending this pm, Cont to monitor neuro status, labs. Maint SBP <160, emotional support to wife.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-26 00:00:00.000",
"description": "Report",
"row_id": 1659429,
"text": "Resp Care\nPt remains on PSV. Pt had bronch and perc trach 8.0 @ bedside tol well. BAL was sent. Plan to continue with current tx wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-27 00:00:00.000",
"description": "Report",
"row_id": 1659432,
"text": "Resp Care\nPt. trached yesterday with #8 Portex. Remains on PSV with 500-700/10-11.5.\nBS: coarse at times sxn'd x3 for copious thick bld. tinged.\nabgs:adequately oxygenated with resp. alkalosis.\nPlan:Possibly attempt trach collar.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-19 00:00:00.000",
"description": "Report",
"row_id": 1659398,
"text": "Pt remains on SIMV. Clear bil BS. Based on latest ABG. FiO2 was decreased to 40. Routine EEG in the morning if pt does't wake up when propofol is weaned, also wean PS\nRSBI=20\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-26 00:00:00.000",
"description": "Report",
"row_id": 1659430,
"text": "Percutaneous trach insertion\n PEG tube insertion deferred due to temp spike. Percutaneous trach inserted #8 Portex after vecuronium 5mg IV x2, fentanyl 200mcg in divided doses over procedure and propofol 50mcg infusion. Tol procedure well, maint sats and trach placement verified by bronch. Adequate tidal volumes post procedure w/sats >96%.\n Nuero status unchanged after procedure. PERL, cont to w/d only to pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-27 00:00:00.000",
"description": "Report",
"row_id": 1659431,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Neuro exam q2hr. Pt opens eyes to voice. PERRLA. Pt does not follow commands. No spontaneous movement noted. Pt withdraws extremities to nailbed pressure. Impaired gag and corneal reflex. +cough reflex. Dilaudid 0.5mg IV x1 given d/t pt grimacing. Tmax 101.2; Tylenol 650mg given via NGT. HR 70s-80s (NSR; no ectopy noted). Goal SBP <160. ABP 100s-170s/40s-60s. Metoprolol and hydralazine IV given for hypertension without much effect. SBP decreased after hydromorphone given. CVP 6-12. DP/PT pulses palpable. Venodyne boots on BLE. Lungs clear. CPAP 35%, PEEP 5, PS 5. ABG showed respiratory alkalosis. Suctioned for blood-tinged secretions. Mouth care performed per VAP prevention protocol. Abdomen was firmly distended at beginning of shift, but is now softly distended. BM x1; soft brown stool. TF infusing via NGT at goal rate; no residual noted. FS q6hr; treated with regular insulin sliding scale. NPH 5units given as ordered. Foley intact with clear, yellow urine. UO >/= 60cc/hr. No pressure sore noted. Pt turned and repositioned frequently to maintain skin integrity. Right and left upper arm with skin tears; Aquacel intact. No calls/visit from family overnight.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Notify HO with any changes in neuro exam. Per Chip , NP perform neuro exam q2hr. Keep SBP <160. Pt needs PEG when no longer febrile. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-27 00:00:00.000",
"description": "Report",
"row_id": 1659433,
"text": "please see carevue for details of care\n\nT max= 101.9, 650 mg tylenol given via NGT x2\n. pt non-verbal, trach collar in place, responds to verbal stimuli at times, withdraws to painful stimuli. No spontaneous movement of bilat extremities noted. Pupils 2 mm equal and reactive. pt OOB to chair with lift today. Grimace scale/change in vitals used to assess pain level, dilaudid 0.5 mg given prn with grimace/increase in BP. HR 70s-80s, SR, no ectopy. BP 160s/80s, 10 mg lopressor IV given as ordered with some effect. PT returned to bed, 0.5 mg dilaudid given, BP remained elevated, 10 mg hydralazine IV given as ordered. BP later afternoon 120s/50s. +3 edema noted bilat hands and feet. Lungs CTA upper lobes anteriorly, decreased at bases. Trach trial today, 35% FiO2 infusing via trach collar, O2 sats > 95%. No SOB, no respiratory distress noted. Post-extubation ABGs without change from previous. Abdomen soft, distended, +BS, TF at goal w/minimal residuals. BMx1 noted. Foley catheter draining adequate amounts of clear yellow urine. L skull with staples open to air, C/D/I. Skin tears L upper arm, R shoulder open to air, no drainage.\n\nPlan: continue to assess neuro status, maintain BP < 160, assess pain level, assess respiratory status, maintain skin integrity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-27 00:00:00.000",
"description": "Report",
"row_id": 1659434,
"text": "Resp Care\nPt started TM trial today tol well. Pt has good cough sx for mod thick white. Plan to continue with trach mask as tolerated and prepare for rehab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-28 00:00:00.000",
"description": "Report",
"row_id": 1659435,
"text": "NPN 1900-0700\n\nNo Events overnight.\n\nNeuro- Unchanged. Withdraws all extremeties very weakly to pain stimuli. PERLA. Opens eyes spont at times, consistently to voice.\n\nResp- Tolerating trach collar overnight. Mild alkolisis. Good paO2 (113). Productive cough with thick blood tinged secretions, trachial suction q4h. RR in 20s, sats>94%.\n\nCV- SBP > 160 last evening and treated with hydralazine PRN and lopressor dose given. Later pt again hypertensive > 160 and given dose of dilaudid to r/o discomfort as cause, good effect. CA repleted.\nSkin w/d. 2 areas skin tears on LUE OTA. Coccyx light pink.\n\nGI/GU- ABd soft, +BS. TF at goal. No residual. Foley patent with >100cc/h UO. Small formed BM x 1.\n\nPlan- Maintain safety. Freq repostioning. Pt stable on trach collar x 24h, team may wish to transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-28 00:00:00.000",
"description": "Report",
"row_id": 1659436,
"text": "Nursing Progress Note\n Please see carevue for details of care. Neuro asses essentially unchange but continues to wax and wane. Does not w/d to pain thias am but some slight spontaneous movement noted in L arm late am. PERL. Opens eyes consistently to voice. Cont to tol trach collar w/acceptable ABG this am. Suctioned Q3-4 hrs for small amt thick tan secretions occasionally blood tinged. RR 20's, sats 96-100% on 35% trach collar.\n Cont to be hypertensive at times, responds best to dilaudid 0.5mg. SBP maint <160.\n Skin tears on LUE open to air, dry and nondraining. ABD soft, BOS soft, TF at goal, no stools this am, dulcolax and colace given. Foley draining clear yellow. First dose of diamox at 1400.\n\nPLAN: Monitor neuro status, resp status and GI status. Transfer to floor when bed avail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-28 00:00:00.000",
"description": "Report",
"row_id": 1659437,
"text": "Continues on 35% trach collar. BS few coarse crackles. transfer to floors.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-29 00:00:00.000",
"description": "Report",
"row_id": 1659438,
"text": "Update\nSee careview for details...\nNeuro: assessment unchanged, withdraws to pain on LE's and LUE, no movement to RUE noted, pupils 2-3mm bilat and brisk, opens eyes to verbal but does not track, does not follow commands, impaired gag, strong cough, appears to be comfortable\n\nCV: VSS, NSR 60-70's, electrolytes WNL's\n\nresp: tol O2 35% TC, sats 97-99%, sx for thick bld tinged secretions, lungs slightly coarse bilat\n\nGI: TF changed to replete with fiber FS, goal 80cc/hr, tol increase Q4hrs, low residuals, incont loose brown stool x2, abd soft\n\nGU: clear urine via foley\n\nSkin: staples to head dry and intact, OTA, blistered area to R upper arm oozing sersang, cleaned and DSD applied\n\nPlan: Neuro assessment, ? transfer to floor\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-29 00:00:00.000",
"description": "Report",
"row_id": 1659439,
"text": "Resp Care\nTrached with #8 portex perfit. Suctioned for mod amt of blood-tinged secretions. On 35% trach mask.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-23 00:00:00.000",
"description": "Report",
"row_id": 1659417,
"text": "CONDITION UPDATE:\nD/A: T MAX 102.6, SPUTUM CULTURE SENT PER DR. AS ALL OTHER CULTURES ARE WITHIN 24 HOURS.\n\nNEURO: UNCHANGED. PT OPENS EYES TO VOICE OR STIMULI, DOES NOT FOLLOW COMMANDS, DOES NOT TRACK, DOES NOT ATTMEPT TO TALK. PERL. ALL EXTREMITIES WITHDRAW TO PAINFUL STIMULI. + COUGH. + GAG.\n\nCV: HR 70'S-80'S NSR. GOAL SBP < 160 MET WITH NIPRIDE GTT WHICH WAS WEANED OFF AFTER PO LOPRESSOR GIVEN. ~ 2-3 HOUR AFTER LOPRESSOR PO GIVEN, BP BEGAN TO RISE. PRN HYDRALAZINE, LOPRESSOR, AND DILAUDID GIVEN WITH FAIR EFFECT, JUST MEETING GOAL OF < 160. BY 1800, PT AGAIN > 160, LOPRESSOR IV GIVEN WITH NO EFFECT, HYDRALAZINE INFUSING WITH EFFECT PENDING. CVP ~ 10. FLUID BALANCE MN-1900 + 1500 CC'S. PPP. + EDEMA.\n\nRESP: LS CLEAR TO COARSE. NO VENT CHANGES MADE, PT REMAINS ON CPAP + PS, 40%. 5 PEEP, 5 PS WITH O2 SATS ~ 98 %. SPUTUM SAMPLE SENT.\n\nGI: TOLERATING TUBE FEEDS AT GOAL. COLACE AND BISACODYL GIVEN, NO STOOL THIS SHIFT. ABDOMEN SOFTLY DISTENDED, + BS.\n\nGU: FOLEY-BSD WITH URINE, SEDIMENT PRESENT. DR. AWARE, URINE CULTURE PENDING.\n\nSX: WIFE AND FAMILY MEMBERS VISITED THROUGHOUT THE DAY.\n\nR: FEBRILE, DIFFICULT TO MEET SBP GOAL < 160 WITHOUT NIPRIDE GTT.\n\nP: CONTINUE GOAL OF SBP < 160, UTILIZE NIPRIDE AS NEEDED. ? INCREASE FREQUENCY OF LOPRESSOR? TUBE FEEDS AT GOAL. NEURO CHECKS. ? FAMILY DISCUSSION ABOUT TRACH AND PEG IF PRIMARY AND SICU TEAMS AGREE. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-22 00:00:00.000",
"description": "Report",
"row_id": 1659410,
"text": "Update\nSee careview for details...\nNeuro: Pt opens eyes to verbal but does not focus or track, pupils 3mm bilat and brisk, does not follow commands, withdraws to pain in all 4 extrems, + gag and cough, no seizures noted, dilantin level low, dilantin bolus given as ordered by Dr \n\nCV: hypertensive with little results from lopressor and hydralazine, med with dilauded x2 with good results, Dr aware, ? discomfort, hydralazine given x1 during shift for BP 170's, NSR 60-70's, T max 100.4 PO\n\nResp: Vent unchanged overnight, Lungs clear, sx for large amts tan secretions, CPT x2, sats 98-100%\n\nGI: tol TF at goal, med formed brown BM x1\n\nGU: foley dng yellow urine with sed.\n\nSkin: staples to head intact with no dng, open to air\n\nPlan: Neuro assessment, BP control\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-22 00:00:00.000",
"description": "Report",
"row_id": 1659411,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes made overnight. Sxing thick tan secretions from ETT. RSBI=27 this am. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-24 00:00:00.000",
"description": "Report",
"row_id": 1659418,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick white secretions. Temp 101.8.Increasing nipride for HTN.RSBI done on 0 peep 5 ips 16.2. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-24 00:00:00.000",
"description": "Report",
"row_id": 1659419,
"text": "NPN 7P-7A (please also see carevue flownotes for objective data)\n\ndx: Parkinson's Dz; hx rectal CA;\n\nAdmitted for neuro changes, dble vision, gait changes, change mental status; head CT showed increase in size of SDH; to OR for burr holes, however had SAH and IPH intraop, w/ sz's, receieved craniotomy; admitted to SICU post-op for closer monitoring;\n\nnow has crani incision on left side, patent w/ staples, clean, open to air;\n\nThis night:\npt seems to be very slightly more alert this night; almost seems to change vision to direction of voice at vocal stimuli;\n\nAble to keep from restarting Nipride gtt, however pt received maximum anti-hypertensives of prn IV hydralazine and IV lopressor ordered; Infrequent prn dilaudid received d/t presumed pain when anti-hypertensive did not work;\n\nT 101.8 Ax, therefore 1 set of blood cx's sent w/ a.m. labs;\na.m. WBC also slightly up;\n\na.m. serum K+ slightly low, however pt does not have K+ s.s., notable is pt's creatinine 1.3;\n\nreceived full bed bath at 22:00; slight redness noted on buttocks; pt w/ interstitial fluid, puffy hands, arms, extremities; allergy wrist band cut d/t tight around wrist, however still on wrist d/t bandage taping in area;\n\nPT's SBP remaining in 180's at 06:45, will try to resolve, or check w/ team re restarting Nipride gtt or other intervention;\n\nMD's to address wife with further plan of care.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-24 00:00:00.000",
"description": "Report",
"row_id": 1659420,
"text": "resp care - Pt remains intubated and on PSV. No changes were made in vent settings this shift. Slightly coarse BS cleared on suction of small amounts of white/tan secretions. Continued resp care planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-24 00:00:00.000",
"description": "Report",
"row_id": 1659421,
"text": "NEURO-SLEEPING ALL DAY EXCEPT WHEN STIMULATED WITH CARE.BITES DOWN ON ETT WITH ORAL CARE,BECOMES VERY RIGID WITH REPOSITIONING & OPENS EYES TO ALL ACTIVITY. INTERMITTENTLY TRACKED WIFES VOICE. WITHDREW TO NAIL BED PRESSURE. NO OTHER MOVEMENT SEEN.DOES NOT FOLLOW ANY COMMANDS. + COUGH -GAG.\n\nCV- NSR 65-86. HTN 165-185 MOST OF SHIFT. UNRELEIVED WITH SCHEDULED DOSES ON ANTIHTN MEDS &/OR PRN ANTIHTN. ESMOLOL GTT STARTED WITH GREAT EFFECT-> BP @140. ESMOLOL GTT TO BE CHANGED TO LABATOLOL GTT IN ORDER TO TRANSITION TO PO MEDS LATER. T-MAX=100.4 SKIN W/D. STAPLES C-D-I. GENERALIZED BODY EDEMA. +PP.\n\n\nRESP- REMAINED VENTED ON CPAP/PS NO CHANGE IN SETTNGS. LS CTA/DIM @ BASES. SXD THIN CLEAR-> TANNISH YELLOW SPUTUM.\n\nGI- ABD SOFTLY DISTENDED. + BS. TUBE FEED VIA OGT @ 85CC/HR. NO RESIDUAL. MED.SOFT STOOL X1.\n\nGU- FOLEY DRG CLEAR ( DISCOLORED FROM MEDICINE) URINE.\n\nENDO- FINGERSTICK GLUCOSE LEVELS COVERED WITH SCCI.\n\nPAIN- MEDICATED WITH 0.25MCG IVP DILAUDID X2.\n\n WIFE INTO VISIT THIS AFTERNOON AND SPOKE WITH MD IN REGARDS TO PLAN OF CARE.RE: TRACH & PEG LATER THIS WEEK. CT RESULTS.\n\nPLAN- MONITOR NEURO STATUS. HEMODYNAMICS.SBP GOAL <160.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-25 00:00:00.000",
"description": "Report",
"row_id": 1659422,
"text": "Resp Care\nPt. remains intubated w/o change overnight. Continues on minimal vent support with TV 550-600/MV . Morning rsbi 34.2.\nBS: CEB, secreations minimal.\nPlan: Cont. current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-25 00:00:00.000",
"description": "Report",
"row_id": 1659423,
"text": "npn 7p-7a (please also see carevue flownotes for objective data)\n\n67M w/ hx Parkinsons, also hx rectal CA;\n\ncame in for burr holes for evac SDH, converted to mini-craniotomy d/t intra-op SAH and IPH, w/ post-op sz's x2; now on IV dilantin;\n\n is POD 7;\n\nPt w/ vascilating neuro exam; yesterday did not move extrities, though did very slightly 24 hrs prior to that; this night again pt seemed slightly more awake, did visibly lift and hold left arm up when turned for cares; pt laying on opposite arm, therefore unable to see movt; no mvt observed in legs other than stiffness;\n\nhypertensive, ? d/t waking up, ? d/t neuro responxe to head bleeds;\non labetelol gtt, received pt on 1 mg/min, now on 2.5 mg/min;\nNSR, no ectopy;\n\nvent settings unchanged, remains on PS/CPAP 5/5, FIO2 0.35, O2 sats remain in hi 90's;\nsuctioned approx q 3 hrs for mod amt whitish/opaquish thick return;\noral care received;\n\nabd somewhat distended; is having stools, some soft, some regular formed, brown, gu neg; is on goal tube feed rate, tolerating well;\n\nlow grade febrile this night at most; remains on IV Abx of vanco and cefepime;\nthough WBC is up again slightly this a.m.;\n\nhct slightly down, however some of decrease ?dilutional--pt w/ weight gain, likely body fluid;\n\nPLAN:\n1) cont current POC\n2) follow exam\n3) MD team to bring up issues of trach and PEG for this pt reportedly today Mon \n4) ?pt needs increase in anti-hypertensives to be able to wean off labetelol gtt\n5) ?add dilantin level to a.m. labs\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-25 00:00:00.000",
"description": "Report",
"row_id": 1659424,
"text": "Resp Care\nPt remains intubated on PSV, no vent changes, no abg's. Stable shift, plan for trach.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-20 00:00:00.000",
"description": "Report",
"row_id": 1659402,
"text": "Respiratory care note:\nPt received on current setting, SIMV . Occasi sx for small amt of thick yellow secretions. Good gas\nRSBI done =39.5\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-20 00:00:00.000",
"description": "Report",
"row_id": 1659403,
"text": "Respiratory Care\nPt maintained on mech vent, tol well with some improvment, wean started and tol well, PS weaned down. tube re-taped and repositioned, bilat bs clear dimn lower bases maintains good sats. ABG done see flowsheet. plan to wean PS to facilitate a SBT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-20 00:00:00.000",
"description": "Report",
"row_id": 1659404,
"text": "See CareVue for Specifics:\n\nNeuro: Pt Aroused to Pain; opens eyes, nonpurposeful movements and withdraws from nail bed pressure, , Pt seems more arousable and sensitive than prior day, Pt had EEG done this afternoon still awaitng results.\n\nCV: Max Temp 100.7, neuromed aware, HR 80s-90s, BP 150-160s, pt on Nipride gtt but trying to wean off. Pt recieved lopressor 50mg and Hrydralazine PRN. Bp did come down to the 100s systolic but once nipride was d/c BP increased into the 170s again. Pt is presently back on Nipride at same dose of 0.5. Dr. aware.\n\nResp: Pt presently on Cpap + PS @ 0.40, suctioned pt, mod sputum tan and think.\n\nFen: Pt started on tube feed, replete with fiber @ 20cc/hr , Plans is to increase Q4hrs by 20cc/hr to reach goal of 80 cc/hr, as you increase also decrease Iv fluids by same amount. No residuals.\n\nPlan: Q1hr neuro checks, monitor Bp goal < 160 systolic, try and wean off nipride gtt, cont tube feeds to goal of 80cc/hr, Possible extubation tomorrow?\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-22 00:00:00.000",
"description": "Report",
"row_id": 1659412,
"text": "See CareVue for specifics:\n\nNeuro: Pt arousable to stimuli most of the day, @ 1400 pt became less arousable to stimuli and more so to pain, Was opening eyes , but became more lethargic, Less brisk withdrawing of extermities from nail bed pressure, SICU HO aware, also NeuroMed aware. Pt went for CT scan @ 1430, results are pending, , Impaired gag and cough.\n\nCV: Max temp 102.1, SICU HO Dr. aware, Blood and urine cultures X1 sent, HR 70s-80s, BP 120s-180s, Pt hypertensive most of the morning , Pt recieved lopressor 10mgX1, Hydralazine 20mg X1, Dilaudid 0.25 X1, all with minimal effect. Pt was restarted on Nipride gtt, persently @ 1.3 with good effect.\n\nResp: Pt still on Cpap @ 0.35 5 and 5, suctioned yellow think secretions throught out shift.\n\nPlan: Monitor BP goal < 160; Titrate Nipride gtt for desire BP Goal <160; Monitor Pt temps, Monitor Q2hr Neuro checks\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-22 00:00:00.000",
"description": "Report",
"row_id": 1659413,
"text": "resp care\nremains intubated/vented in psv/cpap mode. sxning thick yellowish sputum. tolerating mode with vt 400-600,rr around 20. transported to ctscan with stable ventilatory status t/out. no plans for extubation due to altered ms.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-23 00:00:00.000",
"description": "Report",
"row_id": 1659414,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes made overnight. BS's diminished and slightly coarse, sxing thick white secretions. RSBI=44 this am. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-23 00:00:00.000",
"description": "Report",
"row_id": 1659415,
"text": "febrile 101.9 was cx'd yesterday-tylenol given. on snp gtt .5-1mcg/kg/min to keep sb/p <160.\nneuro pt opens eyes to noxious stimuli-otherwise always closed. pupils equal react to light. moving extremies on bed while turning/bathing pt but does nothing to command.\nt. fdg @ goal-min resid. no bm this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-12-23 00:00:00.000",
"description": "Report",
"row_id": 1659416,
"text": "resp care\nremains intub/vented in psv/cpap mode. vt 550-650,rate 15-24. febrile. no plans for extubation due to altered ms. refer to flow sheet for data.\n"
},
{
"category": "Radiology",
"chartdate": "2103-01-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1000184,
"text": " 5:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: L SDH / SAH/ IPH/ vent size/ ? infection\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with L SDH, s/p crani\n REASON FOR THIS EXAMINATION:\n L SDH / SAH/ IPH/ vent size/ ? infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left STH/SAH/IPH.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISON: .\n\n FINDINGS: There is little change from comparison examination as\n multiple areas of intraparenchymal hemorrhage and subarachnoid hemorrhage are\n again demonstrated in the frontal, temporal, and parietal lobes of both\n cerebral hemispheres. The subdural CSF density collection that is layering\n about the left convexity is unchanged, and shift of the septum pellucidum is\n stable. Post-operative changes in the left frontal and temporal regions are\n again noted. Hypodense regions in the subcortical areas of the left frontal\n and parietal lobes are unchanged. Mass effect is stable, and note is again\n made of right temporal enlargement. Blood is no longer well appreciated\n within the ventricles. Partial opacification of the ethmoid and sphenoid\n sinuses along with mild thickening of the maxillary sinuses is unchanged.\n Again noted is partial opacification of both mastoid air cells.\n\n IMPRESSION: No significant interval change from with\n multiple intracranial hemorrhages, mass effect, and post-operative changes.\n\n Evaluation for intracranial infection is limtied due to lack of IV contrast.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1260624,
"text": " 10:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: H/O IPH, FEVER SPIKE, ASSESS INTERVAL CHANGE\n Admitting Diagnosis: PARKINSON'S DISEASE/SDA\n ______________________________________________________________________________\n FINAL REPORT\n\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: Patient with history of intraparenchymal hemorrhage, fever, chills\n assess for interval changes.\n\n FINDINGS: There is bilateral fairly symmetrical pulmonary edema. Superimposed\n on the pulmonary edema predominantly in the right middle lobe or right lower\n lobe are patchy areas of airspace disease that is worrisome for pneumonia\n and/or aspiration. The heart is not enlarged. A central subclavian line has\n been introduced from the right side with tip overlying the mid portion of the\n SVC. An endotracheal tube distal tip projects approximately 3 cm above the\n carinal bifurcation. A feeding tube projects over the thorax and abdomen with\n distal tip terminating in the left upper quadrant. A left retrocardiac\n opacity is again seen unchanged likely represent an atelectasis however\n infection cannot be excluded completely.\n\n IMPRESSION:\n 1. Pulmonary edema with superimposed right middle lobe/right lower lobe\n infection and/or aspiration.\n 2. Left retrocardiac atelectasis, however, pneumonia cannot be excluded.\n 3. Lines, tubes and catheters are in satisfactory location.\n\n\n\n\n"
}
] |
86,709 | 104,508 | ASSESSMENT AND PLAN: 54yoF with h/o HIV, fibromyalgia/spinal scoliosis and chronic pain who presented today to the ED with a cc of nausea and vomiting. She was found to have + cardiac enzymes in the ED with ST elevations on EKG and is now s/p cardiac catheterization. . # STEMI/CAD: Pt with no previous CAD hx presents with STEMI now s/p cath. The pt was Plavix loaded with 300 mg, was given ASA 325 mg, as well as a high dose statin, metoprolol 5 mg IV x 1, SLNTG, Integrillin. ASA 325 mg po daily and Plavix 75 mg po daily were continued throughout admission. Atorvastatin was decreased to 40 mg po QHS as HAART affects the cytP450 that metabolizes statins. She had an episode of CP responsive to SLNG and morphine after cath. She also had chest pain that varied with position and inpiration that responded to indomethacin; however, no pericardial effusion noted on Echo. She was started on metoprolol tartrate 12.5mg , which was titrated up to 25mg , and she was discharged on 50mg of metoprolol succinate. However, while she was bale to tolerate BBlockade well, her SBPs, which were in the 90s, did not tolerate addition of an ACEi. Pt developed a small inguinal hematoma after cath. Hct was closely followed. She received 1 unit pRBCs after which her Hct/Hgb bumped appropriately and was stable throughout the rest of admission. . # PUMP: Pt has no prior Dx of CHF. Echo showed EF 45-50% and mild regional LV systolic dysfunction. BBlocker started as noted above. ACEi held as noted above. . # RHYTHM: Pt monitored on tele throughout hospital stay. No arrhythmia noted. . # HIV: Home HAART regimen continued throughout admission: Lopinavir-Ritonavir 200-50 mg and Emtricitabine-Tenofovir 200-300 mg daily. Last known CD4 is 488 from . Atorvastatin dose adjusted as noted above. . # Gastric Ulcers: Pt is on omeprazole at home. Pt was initially started on pantoprazole 40 mg IV BID for now. She was switched to po ranitidine given the potential interaction between Plavix and PPIs. . # Bipolar Disorder: Home sertraline and bupropion continued throughout admission. | Normal ascending aortadiameter. Mild [1+] TR. Mild regionalLV systolic dysfunction. Right ventricular chamber size and free wall motion are normal.The aortic arch is mildly dilated. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. There is mild regionalleft ventricular systolic dysfunction with mid anterior/anterolateralhypokinesis. Left ventricular wall thicknesses arenormal. Non-specific ST-T wave changes. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Mildly dilated aortic arch.AORTIC VALVE: Normal aortic valve leaflets (3). No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. The left ventricular cavity size is normal. Compared to the previous tracingof there is no change.TRACING #1 Normal LV cavity size. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic regurgitation.The mitral valve appears structurally normal with trivial mitralregurgitation. Clinical correlation issuggested. Clinical correlation issuggested. Since the previous tracing of the same date ST-T wave changes areslightly less prominent.TRACING #2 The estimated pulmonary artery systolic pressure is normal.There is no pericardial effusion. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -hypo; basal anterolateral - hypo; mid anterolateral - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Since theprevious tracing of findings as outlined are now present.TRACING #1 Probable posterolateral myocardial infarction with ST-T waveconfiguration consistent with acute process. Probable posterolateral myocardial infarction with ST-T waveconfiguration consistent with acute process. Compared to prior there is no definite change.TRACING #2 There is an early transition which is non-specific. Probable posterolateral myocardial infarction with ST-T wave configurationconsistent wtih acute process. Clinical correlation is suggested.Since the previous tracing of the same date no significant change.TRACING #3 Compared tothe previous tracing there is no signifciant change. Probable posterolateral myocardial infarction with ST-T waveconfiguration suggesting acute process. No AS. Since the previous tracing of no significant change.TRACING #4 Clinical correlation is suggested. | 8 | [
{
"category": "Echo",
"chartdate": "2140-08-02 00:00:00.000",
"description": "Report",
"row_id": 95569,
"text": "PATIENT/TEST INFORMATION:\nIndication: HIV + s/p stemi w/ bms to circ\nHeight: (in) 65\nWeight (lb): 170\nBSA (m2): 1.85 m2\nBP (mm Hg): 84/52\nStatus: Inpatient\nDate/Time: at 12:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild regional\nLV systolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Mildly dilated aortic arch.\n\nAORTIC VALVE: 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. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. There is mild regional\nleft ventricular systolic dysfunction with mid anterior/anterolateral\nhypokinesis. Right ventricular chamber size and free wall motion are normal.\nThe aortic arch is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-08-04 00:00:00.000",
"description": "Report",
"row_id": 253462,
"text": "Sinus rhythm. There is an early transition which is non-specific. Compared to\nthe previous tracing there is no signifciant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-08-03 00:00:00.000",
"description": "Report",
"row_id": 253463,
"text": "Sinus rhythm. Compared to prior there is no definite change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-08-02 00:00:00.000",
"description": "Report",
"row_id": 253464,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing\nof there is no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2140-08-01 00:00:00.000",
"description": "Report",
"row_id": 253465,
"text": "Sinus rhythm. Probable posterolateral myocardial infarction with ST-T wave\nconfiguration consistent with acute process. Clinical correlation is\nsuggested. Since the previous tracing of no significant change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2140-07-31 00:00:00.000",
"description": "Report",
"row_id": 253466,
"text": "Sinus rhythm. Probable posterolateral myocardial infarction with ST-T wave\nconfiguration suggesting acute process. Clinical correlation is suggested.\nSince the previous tracing of the same date no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2140-07-31 00:00:00.000",
"description": "Report",
"row_id": 253467,
"text": "Sinus rhythm. Probable posterolateral myocardial infarction with ST-T wave\nconfiguration consistent with acute process. Clinical correlation is\nsuggested. Since the previous tracing of the same date ST-T wave changes are\nslightly less prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2140-07-31 00:00:00.000",
"description": "Report",
"row_id": 253468,
"text": "Probable posterolateral myocardial infarction with ST-T wave configuration\nconsistent wtih acute process. Clinical correlation is suggested. Since the\nprevious tracing of findings as outlined are now present.\nTRACING #1\n\n"
}
] |
15,668 | 198,554 | Spoke with MD and social worker..all in agreement to send pt back to Rehab.Pt seen by screener and arrangements being made to send back to HR for end of life care. With pts attending MD and Dr and rest of house staff..pt made comfort care. Morphine ordered but pt states she is comfortable at this time.VSS..Later in afternoon..pt pulled of CPAP..placed on 6l nc..sats down to 80's..added 100% NRB..sats mid 90's. Treated with antibiotics,antihypertensives and CPAP in EW. Pt easily arousable, but sleepy..ABG done..co2 92..placed on CPAP. Pt rr 18-24.. Had conversation with Rehab..were sending Pts husband over to visit with his social worker and care taker. Sent to ICU for further treatment. 4 ICU nursing admit/progress note: 76 y/o woman admitted from Rehab with respiratory distress/pneumonia. Pt with significant past med hx of lung ca since , and HTN. Conversation had with patient who appears to understand plan. Sinus tachycardiaModest nonspecific low amplitude T wavesSince previous tracing of , sinus tachycardia now present and T waveamplitude lower Given her severe lung disease with pneumonia prognosis very poor. Sats in 90's. | 2 | [
{
"category": "ECG",
"chartdate": "2127-11-18 00:00:00.000",
"description": "Report",
"row_id": 283132,
"text": "Sinus tachycardia\nModest nonspecific low amplitude T waves\nSince previous tracing of , sinus tachycardia now present and T wave\namplitude lower\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-11-18 00:00:00.000",
"description": "Report",
"row_id": 1465419,
"text": " 4 ICU nursing admit/progress note:\n 76 y/o woman admitted from Rehab with respiratory distress/pneumonia. Pt with significant past med hx of lung ca since , and HTN. Treated with antibiotics,antihypertensives and CPAP in EW. Sent to ICU for further treatment.\n Pt admitted on 100% NRB..rr 20's. Sats in 90's. Pt easily arousable, but sleepy..ABG done..co2 92..placed on CPAP. With pts attending MD and Dr and rest of house staff..pt made comfort care. Given her severe lung disease with pneumonia prognosis very poor. Conversation had with patient who appears to understand plan.\n Morphine ordered but pt states she is comfortable at this time.\nVSS..Later in afternoon..pt pulled of CPAP..placed on 6l nc..sats down to 80's..added 100% NRB..sats mid 90's. Pt rr 18-24..\n Had conversation with Rehab..were sending Pts husband over to visit with his social worker and care taker. Spoke with MD and social worker..all in agreement to send pt back to Rehab.\nPt seen by screener and arrangements being made to send back to HR for end of life care.\n"
}
] |
|
8,105 | 190,751 | will be dictated in a separate discharge summary addendum. HOSPITAL COURSE: The patient was initially admitted cardiology medicine, subsequently transferred to the CCU and then transferred back out to cardiology medicine floor on . Hospital course leading up to then will be dictated in a separate discharge summary. Hospital course on C-MED from until discharge on with no new events. For cardiomyopathy the patient was continued on aspirin and lisinopril, digoxin, bumetanide, Coreg. For alcohol abuse he had outpatient followup with a therapist and folate and thiamine were continued. He was discharged to for one night with subsequent discharge to his mother in her new apartment. | Shortness of breath.Height: (in) 71Weight (lb): 157BSA (m2): 1.90 m2BP (mm Hg): 113/82HR (bpm): 125Status: InpatientDate/Time: at 16:45Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. The estimatedpulmonary artery systolic pressure is normal.PERICARDIUM: There is a trivial/physiologic pericardial effusion.GENERAL COMMENTS: A left pleural effusion is present.Conclusions:The left atrium is mildly dilated. wnl.a:improved #'s after captopril dose. Moderate tosevere (3+) mitral regurgitation is seen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. Overall left ventricular systolic function isseverely depressed.RIGHT VENTRICLE: The right ventricular wall thickness is normal. There is a trivial/physiologic pericardial effusion. The hepatic veins are distended, but show appropriate direction of flow. 4:46 PM CHEST (PORTABLE AP) Clip # Reason: PLACEMENT OF CENTRAL LINE Admitting Diagnosis: DILATED CARDIOMYOPATHY FINAL REPORT INDICATION: Placement of central line. 3) Slight cardiomegaly with left atrial swan ganz. 12:59 PM LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # Reason: ? Comparison with the next previous study shows some regression of central pulmonary edema. Again noted is slight cardiomegaly with prominent left atrium. CCU NPN 3-11PMCV: HR 115-130 ST, BP 90-105/60, cont on .5ug/kg/min of milrinone. Central pulmonary edema has regressed in comparison with the next previous film of . IMPRESSION: 1) Tip of left subclavian IV catheter is in the superior vena cava. Interval slight decrease in prominence of pulmonary vasculature. ?further diuresis verse after load reduction. There is severe global rightventricular free wall hypokinesis.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are structurally normal. Received serax 20mg po x1 with good effect, took a nap.CV-VSS milrinone at .625mcg/kg/min and captopril at 75mg TID. Question obstructive cholangiopathy. TOLERATING WELL.CV: HR 100S TO 119S. IMPRESSION: 1) Findings compatible with passive congestion of the liver. slept.p:discuss w pt-antidepressent. Decreased milrinone at .5mcg/kg/min at 1200 and 2 hrs after CO/CI decreased 4.2/2.11/1219. Moderate to severe (3+)mitral regurgitation is seen. There is severe global rightventricular free wall hypokinesis. It is noted that the previous pulmonary arterial Swan-Ganz catheter was approached from below and has been substituted by a catheter approached from the left subclavian approach. GIVEN AMBIEN FOR SLEEP AND ON PRIOR SHIFT SERAX FOR ANXIETY. PAD 27-29 with poor waveform PWP 22 with small V wave.Resp-LS clear O2 sats 97-99%, Occ NPC this am.ID afebrileGU- voiding well moderate amt. Compared to the previoustracing of ST segment elevations in the anterior leads with loss ofR waves persist. Initial CO/CI/SVR 3.6/1.81/1400 received lisinopril this am and captopril 12.5mg at 12noon. Pedal edema is decreasing.RESP: Pt sating 93-99% on RA. Inferior ST-T wave changes persist. Left atrial enlargement. Repeat # CO/CI/SVR 5.3/2.6/850. change foley to condom cath.FOllow elctrolytesRestrict po intake 1.5liters. One millimeterST segment depression in leads II, III and aVF. CO/CI/SVR 3.2/1.61/1375. He was K+ replaced and repeat K+ was 4.3. CCU progress note 11p-7aFailed Natrecor trial - started on Milrinone overnite.NEURO: A+Ox3. BUN/CREAT WNLS. CCU NSG NOTE: ALT IN CV/CARDIOMYOPATHYS: "I feel better than before I came in"O: For complete VS see CCU flow sheet.ID: T-max 99 po.CV: Pt continues on milrinone at .5mic/kilo/min. OCCASSIONAL MULTIFOCAL PVC NOTED. # AFTER MILRINONE INCREASE 4.5/2.26/1156. PULSES BY DOP .NATRECOR .01 .BS COARSE THROUHOUT ,HAS DRY COUGH ,SOUNDS HAORSETAKING PO ,BS PRESENTHUO 50 CC VIA FOLEYMONITOR RESPONSE TO NATRECORMONITOR CHANGES IN MS CO/CI/SVR PRIOR TO INCREASE IN CAPTOPRIL 4.2/2.11/1143. FOUND TO HAVE CARDIOMYOPATHY PROBABLY DUE TO ETOH.NOT DIURESING WELL ,SWAN PLACED IN CATH LAB ,NATRECOR STARTED AND DIURESED 1L P BUMEX . CO/CI/SVR AFTER CAPTOPRIL LITTLE TO NO IMPROVEMENT. Consider right ventricular hypertrophy. 1.5L/DAY.HEME: HCT STABLE AT 41 AS OF AM WITH AM PENDING.ID: TM 99.6 AND TC 98.6. PAP 30-40/22-26 and RA . CL BS. Probable left atrial abnormality. One to two millimeterST segment elevation in leads VI-V5. CAPTOPRIL AND BUMEX ADDED WITH SIGNFICANT IMPROVEMT IN PADS AND CI'SCONTINUE TO TITRATE CAPTOPRILDIURESE ACCORDING TO PAD'SCONTINUE EMOTIONAL SUPPORT DR NOTIFIED. no abx.RESP: LS dim bases. NEEDS REINFORCMENT REGARDING FLUID RESTRICTIONS AND LOW NA FOOD CHOICES.. + BS LAST BM . SERAX GIVEN WITH GOOD EFFECT.SKIN: INTACTLABS: MG 1.6 MAG REPLACED.ID: WBC 6.7 NO ACTIVE ISSUESSOCIAL: MOTHER IN ON EVES. "O: CV: ST WITH HR 112-123. Q waves in leads VI-V3. He had BM.MS: Pt A & O times 3. monitor resp status + u/os. DENIES CPRESP: RA SATS 97-98%. Sinus tachycardiaPremature ventricular contractionLong QTc intervalPossible left atrial abnormalityRight axis deviationConsider biventricular hypertrophyLate precordial QRS transitionQS configuration in leads V1-V2 - could be due to left ventricular hypertrophybut consider prior ischemiaClinical correlation is suggestedSince previous tracing of : sinus tachycardia rate faster and precordialtransition zone is later PAD'S 25-19, CVP 6-10 PCWP 15. K+ 4.2. SBP 97-116/52-76. +BS. Poor R wave progression. Received bumex .5mg at 0900 and 1mg at 1730 with excellant diuresis. PAD 29-21,CVP 8-10,PCWP 22. Noprevious tracing available for comparison. ABD SOFT AND NONTENDER.GU: VOIDS IN ADEQUATE AMTS. PRIOR TO GETTING UP NOTED TO BE TREMELOUS AND STATES, A "LITTLE NERVOUS." Although hemodynamcis unchanged but slightly worsened. SBP 94-110. PADS MID 20S AND IMPROVING OVERNIGHT TO LOW 20S TO HIGH TEENS. GROIN SITE CDI WITH (+) CSM DISTAL TO SITE.RESP: LS SLIGHTLY DECREASED AT LEFT BASE WITH FEW CRACKLES AT RIGHT BASE, OTHERWISE CLEAR. | 24 | [
{
"category": "Radiology",
"chartdate": "2108-09-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 798653,
"text": " 9:08 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pneumonia\n Admitting Diagnosis: DILATED CARDIOMYOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with +3 pedal edema, SOB, EF 10%, and fever of 101\n\n REASON FOR THIS EXAMINATION:\n ? pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: SOB, fever to 101.\n\n CHEST, PA AND LATERAL: Comparison made with prior films of .\n Bilateral pleural effusions are present, greater on the right than on the\n left.\n Bilateral alveolar infiltrates are seen, on the right in the right lower lobe,\n on the left, in a perihilar and left lower lobe configuration.\n\n Appearances are considerably worse than on the prior film of . The\n cardiomegaly and effusions indicate the presence of failure. Infiltrates\n could be due to failure and/or pneumonia.\n\n IMPRESSION: Evidence of failure and bilateral infiltrates.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-09-23 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 798692,
"text": " 12:59 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? obstructive cholangiopathy, ? hepatic congestion\n Admitting Diagnosis: DILATED CARDIOMYOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 yo male with h/o polysubstance abuse here with dilated cardiomyopathy (EF\n 10%) and elevated LFTs.\n REASON FOR THIS EXAMINATION:\n ? obstructive cholangiopathy, ? hepatic congestion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Polysubstance abuse. Dilated cardiomyopathy with ES of 10% and\n elevated LFTs. Question obstructive cholangiopathy. Question hepatic\n congestion.\n\n LIVER ULTRASOUND: There is a pleural effusion. The liver shows no focal\n abnormalities, however there is generalized increased echogenicity of the\n hepatic parenchyma in the right and left lobes, with an area of sparing in the\n right lobe posteriorly. The hepatic veins are distended, but show appropriate\n direction of flow. The portal veins demonstrate appropriate direction of\n flow. There is no intra- or extrahepatic biliary ductal dilatation. There is\n eccentric thickening of the gallbladder wall with a stripe of edema noted.\n\n IMPRESSION: 1) Findings compatible with passive congestion of the liver.\n 2) Fatty liver-- other more serious forms of liver disease such as cirrhosis\n cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 799288,
"text": " 9:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for proper Swan placement\n Admitting Diagnosis: DILATED CARDIOMYOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with s/p right heart cath and found to have elevated wedge and\n currently diuresing\n REASON FOR THIS EXAMINATION:\n Please assess for proper Swan placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW CHEST:\n\n INDICATION: Swan-Ganz placement.\n\n COMPARISON: .\n\n FINDINGS: Left subclavian central venous line contains a Swan-Ganz catheter\n with tip in the right pulmonary artery. The heart remains enlarged. Pulmonary\n vasculature is less prominent than on the previous exam. There is a small left\n pleural effusion. There is no right pleural effusion. There is no\n pneumothorax. Left lower lobe consolidation/collapse is slightly improved in\n the interval.\n\n IMPRESSION: Swan-Ganz in good position. Interval slight decrease in prominence\n of pulmonary vasculature.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 799073,
"text": " 1:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for Swan placement and r/o pneumothorax\n Admitting Diagnosis: DILATED CARDIOMYOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with s/p right heart cath.\n\n REASON FOR THIS EXAMINATION:\n Please assess for Swan placement and r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n , CHEST, AP PORTABLE SINGLE VIEW\n\n INDICATION: Status post right heart catheterization, assess Swan-Ganz\n catheter placement, evaluate for possible complication.\n\n FINDINGS: Marked cardiac enlargement is present. Configuration with\n prominence of left atrial appendage segment into the right-sided double\n contour suggestive of significant left atrial enlargement. The thoracic aorta\n is unremarkable. Central pulmonary edema has regressed in comparison with the\n next previous film of . Some central increased patches remain,\n however, mostly on the left side. Also remaining are blunted lateral pleural\n sinuses. No new parenchymal abnormalities have developed. It is noted that\n the previous pulmonary arterial Swan-Ganz catheter was approached from below\n and has been substituted by a catheter approached from the left subclavian\n approach. The tip of the catheter is located in the central portion of the\n right PA. There is no pneumothorax or any other placement-related\n complication.\n\n IMPRESSION: Cardiac enlargement compatible with dilatory bilateral\n cardiomyopathy. Comparison with the next previous study shows some regression\n of central pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-09-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 799012,
"text": " 4:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess line placement\n Admitting Diagnosis: DILATED CARDIOMYOPATHY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old man with s/p right heart cath.\n REASON FOR THIS EXAMINATION:\n assess line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n CLINICAL INDICATION: Line placement.\n\n Comparison is made to previous study of . A pulmonary artery catheter\n has been placed and terminates in the distal right pulmonary artery near the\n junction of the interlobar artery. The heart remains enlarged and there is\n vascular engorgement. The bilateral perihilar basilar alveolar pattern is\n again demonstrated, slightly improved in the basilar regions. A right pleural\n effusion is slightly improved and a left pleural effusion is unchanged.\n\n IMPRESSION:\n\n 1) Pulmonary artery catheter in satisfactory position.\n 2) Slight improvement in alveolar pattern likely due to improving pulmonary\n edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-10-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 799519,
"text": " 4:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PLACEMENT OF CENTRAL LINE\n Admitting Diagnosis: DILATED CARDIOMYOPATHY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Placement of central line.\n\n COMMENTS: Portable AP view of the chest is reviewed and compared to previous\n study of .\n\n The tip of the left subclavian IV catheter is identified in the superior vena\n cava. No pneumothorax is identified.\n\n Again noted is patchy opacity in the left upper lobe indicating pneumonia.\n There is slight decrease in small left pleural effusion. Again noted is\n slight cardiomegaly with prominent left atrium.\n\n IMPRESSION:\n\n 1) Tip of left subclavian IV catheter is in the superior vena cava. No\n pneumothorax.\n 2) Continued left upper lobe opacity indicating pneumonia or asymmetric\n pulmonary edema.\n 3) Slight cardiomegaly with left atrial swan ganz.\n\n"
},
{
"category": "Echo",
"chartdate": "2108-09-21 00:00:00.000",
"description": "Report",
"row_id": 73852,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Shortness of breath.\nHeight: (in) 71\nWeight (lb): 157\nBSA (m2): 1.90 m2\nBP (mm Hg): 113/82\nHR (bpm): 125\nStatus: Inpatient\nDate/Time: at 16:45\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. There is severe global left\nventricular hypokinesis. Overall left ventricular systolic function is\nseverely depressed.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. The right\nventricular cavity is moderately dilated. There is severe global right\nventricular free wall hypokinesis.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. Moderate to\nsevere (3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. The estimated\npulmonary artery systolic pressure is normal.\n\nPERICARDIUM: There is a trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A left pleural effusion is present.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nmoderately dilated. There is severe global left ventricular hypokinesis.\nOverall left ventricular systolic function is severely depressed. The right\nventricular cavity is moderately dilated. There is severe global right\nventricular free wall hypokinesis. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are structurally normal. Moderate to severe (3+)\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is a trivial/physiologic pericardial effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-10-02 00:00:00.000",
"description": "Report",
"row_id": 1369996,
"text": "CCU NURSING PROGRESS NOTE 2300-0700: CM\nS-\"CAN I HAVE MY PILLS FOR SLEEP?\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:APPEARING IN BETTER SPIRITS FROM LAST CONTACT WITH PATIENT. APPRECIATED BEING OUT OF ROOM TODAY AND AMBULATING AROUND. ADMITTED TO FEELING \"BORED\" AND FEELING CONFINED TO ROOM, PT STATING \"CAN'T WAIT TO GO TO REGULAR ROOM.\" MOTHER VISITING WITH PT WELL INTO MN AND LEAVING AFTER PT FALLING ASLEEP. GIVEN AMBIEN FOR SLEEP AND ON PRIOR SHIFT SERAX FOR ANXIETY. TOLERATING WELL.\nCV: HR 100S TO 119S. ST WITH RARE PVCS. K 4.3 AT MN. MILRINONE CONTINUES AT 0.5MCGS/KG/MIN WITH ATTEMPTED PLANS TO WEAN TODAY. PADS 18-LOW 20S. PCWP 20. CO/CI IMPROVING(4.0/2.16/1200S) AT MN. NUMBERS PRIOR DRAWN BEFORE ACE ON BOARD. DENIES CP OR SOB.\nRESP: LSCTA WITH O2SAT ON RA > 95%. NO OTHER ISSUES\nGU/GI: VOIDING IN URINAL W/O DIFFICULTY. CONTINUES BUMEX WITH EXCELLENT RESPONSE. AT MN 10LS(-) AND FOR LOS 11LS(-). GOOD APPETITE.\nID: AFEBRILE. NO ISSUES.\nA/P: ETOH CM\nANTICIPATE WEAN OF MILRINONE TODAY\nANTICIPATE REMOVAL OF SWAN\nPT TO GO TO HEART FAILURE SUPPORT GROUP TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-30 00:00:00.000",
"description": "Report",
"row_id": 1369992,
"text": "CCU Nursing Progress Note\nS-\"I thought you were starting to take the IV medication off why did you go up on it\".\"I don't like it when everyone comes in the room and just stares at me.\"\nO-Neuro alert and oriented x3, having a hard time today with realization he is going to be in the hospital for his birthday .\nAllowed pt to have shower with supervision and go to a real bathroom for BM's. Went outside with mother and friends for ~ hour with some effect. Mostly appears sad/teary/withdrawn/angry. Received serax 20mg po x1 with good effect, took a nap.\nCV-VSS milrinone at .625mcg/kg/min and captopril at 75mg TID. Hemdynamics PAD 18-26 with CO/CI/SVR at 5.0/2.51/1152 at 10am although at 1700 before captopril dose 4.0/2.01/1440, Ho aware. Started digoxin .125mg QD. Weight 72.2 kg\nResp-LS clear O2 sats 95-99% No cough\nID afebrile\nGU- Voiding well, received bumex .5mg IV with good response.\nGI- Appetite good had 3 pt states not loose on colace.\nActivity- Ambulating well with minimal supervision. VSS no c/o SOB\nTeaching-reviewed POC, alittle about his disease process and his medications again.\nA/P-Cardiomyopathy on milrinone gtt and captopril po\nPossibly change captopril to QID or change to long acting ace .\nGoal to have pt 1 liter negative today\nConsider started a antidepressant for his situational depression.\nNutrition consult for pt and mother regarding 2gm sodium diet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-10-01 00:00:00.000",
"description": "Report",
"row_id": 1369993,
"text": "ccu nsg progress note.\no:social=mother present till approx 2300. md's plan to discuss w pt-antidepressent. pt difficult to engage in conversation. serax 20mg w effect. ambien 10mg @ hs-slept soudly for approx 4hrs.\n pulm=breath sounds=clear. wo overt sob/dyspnea. sats upper 90's throughout shift.\n cv=hemody stable throughout night. milrinone remains @ 0.65mcg/kg/min. #'s before captopril dose-3.8/1.91/1474 mvs-65 after captopril 75mg dose-6.1/3.07/787 mvs-76. maps mid 70's. pads 23-24. cvp 7-8.\n gu=neg approx 600ml @ 2300-bumex 0.5mg iv given @ approx 2200. neg approx 400ml @ 0600.\n labs=am sent. wnl.\n\na:improved #'s after captopril dose. slept.\n\np:discuss w pt-antidepressent. contin prn serax/ambien. start lisinopril 20mg qd in am-follow #'s to assess effect. ?further diuresis verse after load reduction. ?attempt to wean milrinone. teaching-meds, lifestyle chgs, coping w illness.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-10-01 00:00:00.000",
"description": "Report",
"row_id": 1369994,
"text": "CCU Nusring Progress Note\nS-\"What do you mean I might need a heart transplant\"\nO-Neuro alert and oriented, quiet, depressed, not talking much today.\nSpoke to pt about starting a medication to help improve his state of mind and help get through/deal with all this. Was in complete agreement. Will start Zoloft this evening. Called who has yet to see pt regarding substance abuse(ETOH/cigs) and will not be able to see pt until Wednesday. Called social worker, who was not able to see pt/mother today although will see pt on Tuesday. Case Manager will try and see pt/mother this afternoon and look into possible AA meetings within hospital.\nCV-VSS Milrinone at .658mcg/kg/min and started linsinopril 20mg po at 0800, 2 hrs after dose CO/CI/SVR 5.1/2.56/910. Decreased milrinone at .5mcg/kg/min at 1200 and 2 hrs after CO/CI decreased 4.2/2.11/1219. PAD remained the same 18-20 with CVP 6-9.\nResp-LS clear on RA O2 sats 98-99%\nID afebrile\nGU-voiding well to start bumex .5mg po BID this afternoon.\nGI- appetite very good LBM . Spoke to nutrition to start teaching about 2gm sodium diet, will start in am Tues.\nAcitivty-OOB ambulating to shower, tolerated very well. Good activity tolerance no SOB or fatigue.\nSocial-mother in most of day, received a phone call from father.\nA/P-Cardiomyopathy on milrinone wean, with lisinopril/bumex/ dig po.\nContinue to follow hemodynamics closely with any change in meds and check CO/CI/SVR. Keep PAD <20. ? d/c PA catheter.\nEncourage pt to talk about how he feels, ask questions, review meds each time he receives them. Make sure SS and case manager see pt every day. Make sure sees pt first thing on Wednesday.\nEncourage ambulation\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-10-01 00:00:00.000",
"description": "Report",
"row_id": 1369995,
"text": "CCU NPN 3-11PM\nCV: HR 115-130 ST, BP 90-105/60, cont on .5ug/kg/min of milrinone. CO/CI 3.7/1.86, down from earlier today. PA 40/20, PCWP 20, CVP 6-8. Lisinopril , #'s obtained just before evening dose given. Denies SOB, any discomfort. LS clear. Sating 98% on RA. Sitting up in bed. Getting Bumex .5mg po, -500cc for today, -10L LOS. Appetite good.\n\nPsych/coping: verbalized that he is depressed about being here, attached to everything with limited mobility, he feels that once he is out of here his mood will be better. Refusing Zoloft, stating he was on it before and it made him feel terrible, like he was on speed but very tired. Also stated what was the use, by the time it started working he would be out of here anyway. States that he is not going to drink anymore, does not want to end up back in the hospital. Does not feel he needs assistance to keep him from drinking. Voiced interest in attending CHF support group here once he leaves the hospital, \"I'll probably be the youngist one there!\" This eve has been drawing, watching movie, talked with his mother about bringing in his classical guitar.\n\nA/P: CO/CI down a bit, did the same thing last eve, Attending aware, want #'s rechecked at MN. Cont Milrinone at 0.5ug. Cont education, support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-26 00:00:00.000",
"description": "Report",
"row_id": 1369983,
"text": "22 YR OLD STUDENT C HX ETOH,DRUG ABUSE,SMOKING C 2 WKS SOB,EDEMA . FOUND TO HAVE CARDIOMYOPATHY PROBABLY DUE TO ETOH.NOT DIURESING WELL ,SWAN PLACED IN CATH LAB ,NATRECOR STARTED AND DIURESED 1L P BUMEX . PT TOLD HE WILL HAVE TO CHANGE LIFESTYLE TO STOP PROGRESSION OF DISEASE AND QUALIFY FOR TRANSPLANT . HE IS COOPERATIVE BUT HAS FLAT AFFECT. PERCOCETTE FOR BACK PAIN .HE HAS BEEN IN HOSPITAL SINCE FRIDAY SIWA SCALE HAS BEEN DC, ATIVAN AS WELL . PT DID FALL IN HIS HOSPITAL ROOM ,WITNESSED BY AUNT . BEING FOLLOWED BY SOCIAL SERVICE FOR INSURANCE ISSUES. MOTHER LIVES IN .FATHER UNAVAILABLE ,RELATIVES IN , LIVES C SIGNIFICANT OTHER . HAVE PROBLEMS IN RELATIONSHIP .HIV NEG AS OF 6 MOS AGO.\n\nST NO ECT . W 25 .NO BLEEDING FROM CATH SITE R GROIN . PULSES BY DOP .NATRECOR .01 .\n\nBS COARSE THROUHOUT ,HAS DRY COUGH ,SOUNDS HAORSE\n\nTAKING PO ,BS PRESENT\n\nHUO 50 CC VIA FOLEY\n\nMONITOR RESPONSE TO NATRECOR\nMONITOR CHANGES IN MS\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-27 00:00:00.000",
"description": "Report",
"row_id": 1369984,
"text": "CCU progress note 11p-7a\nFailed Natrecor trial - started on Milrinone overnite.\n\nNEURO: A+Ox3. MAE. slept well overnite, given sleeping meds. no voiced c/o.\n\nID: afebrile. no abx.\n\nRESP: LS dim bases. Noted occasional audible wheezes while sleeping, slight SOB noted. O2 3L n/c. no c/o of resp distress when awake. Sats 97%.\n\nCARDIAC: ST 110-120s. SBP 90-100s. failed Natrecor trial CI 1.8 down to 1.5 overnite, PA sats decreased to 55%- natrecor d/c'd - started on Milrinone gtt w/ bolus - currently at 0.5mcg/k/min. PADs were mid 30s now high 20s (28). am cardiac calcs to be drawn - see careview. R groin PA line intact. weak/dopplerable pulses. no c/o CP or discomfort.\n\nGI/GU: foley patent. ~30cc/hr, dark amber urine. abd soft. +BS. no diuresis given overnite.\n\n\nPLAN: monitor cardiac calcs on Milrinone. monitor resp status + u/os. Encourage change in lifestyle and encourage compliance with new medication regimines. Pt will need heart transplant from this new onset cardiomyopathy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-27 00:00:00.000",
"description": "Report",
"row_id": 1369985,
"text": "CCU Nursing Progress Note\nS-\"I just want to know what the plan is today.\" \"I feel alitlle better today\"\nO-Neuro alert and oriented x3, pleasant and cooperative. Anxious this am with plans to change site of PA. Received percocett 1 tab x3 today for various pains; right groin, foley catheter and new LSC PA site with relief.\nCV-HR 120-130's ST early am but gradually decreased to 106-110 by afternoon. SBP 94-110. Hemodynamics PAD 33 with CVP 16, PWP 28 without 'V' waves on milrinone at .5mcg/kg. Initial CO/CI/SVR 3.6/1.81/1400 received lisinopril this am and captopril 12.5mg at 12noon. Repeat # CO/CI/SVR 5.3/2.6/850. PAD decreased to 24 with CVP 7 by 1900 after aggressive diuresis. Right groin PA catheter d/c'd and resited LSC without difficulty.\nResp-LS BBR with occ wheezes this am, RA O2 sat 92% this am and by after noon O2 sat improved to 95-96%. Occ NPC noticeably decreased today.\nID afebrile\nGU- foley draining well, occ c/o pain at foley site from pulling. Received bumex .5mg at 0900 and 1mg at 1730 with excellant diuresis. ? change foley to condom cath.\nGI-appetite good, LBM \n mother in and very supportive, social service scheduled at meeting with her on . Case manager helping pt/mother understand\ninsurance issues. Friends visiting. Pt in better spirits this afternoon.\nA/P-Cardiomyopathy with severe MR now with improved CI/SVR on milrinone and captopril\nFollow CO/CI/SVR q4hrs while adjusting meds. Goal to increase captopril enough to wean milronone.\nAggressive diuresis with bumex goal -2liters PAD <20\nConsult regarding substance abuse/ETOH/smoking\n? change foley to condom cath.\nFOllow elctrolytes\nRestrict po intake 1.5liters.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-28 00:00:00.000",
"description": "Report",
"row_id": 1369986,
"text": "CCU NURSING PROGRESS NOTE 1900-0700: CM, MR\nS-\"CAN I HAVE ANOTHER SLEEPING PILL?\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS'S\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:A/O/X/3. PLEASANT BUT APPROPRIATELY NERVOUS AT TIMES. ASKING APPROPRIATE QUESTIONS. C/O OF INCISIONAL PAIN AT PA SITE AND GENERAL DISCOMFORT, IE GROIN, BACK, AND NECK PAIN. PERC GIVEN AT HS IN ADDITION TO 10MG OF AMBIEN AND RESTING COMFORTABLY DURING NIGHT.\nCV:HR 100S TO 120S. ST WITH OCCASIONAL PAC'S. K 3.8 POST BUMEX ON PRIOR SHIFT. REPLETED WITH 40MEQ AROUND MN. BPS 80S TO 100S. PADS MID 20S AND IMPROVING OVERNIGHT TO LOW 20S TO HIGH TEENS. CVP 6-9. CO/CI'S AT 8PM 3.3/1.66/1818 W/ SVO2 57. CAPTOPRIL DOSE INCREASED TO 25MG AND CO'S 1HR POST 4.8/2.41/833 W/ SVO2 66. AM CO'S PENDING. MILRINONE REMAINS UNCHANGED AT 0.5MCGS/KG/MIN. GROIN SITE CDI WITH (+) CSM DISTAL TO SITE.\nRESP: LS SLIGHTLY DECREASED AT LEFT BASE WITH FEW CRACKLES AT RIGHT BASE, OTHERWISE CLEAR. O2SATS 93-96% ON RA.\nGU/GI: FOLEY DRAINING CYU. HUO > 100CC/HR OVERNIGHT. BUN/CREAT WNLS. NO FURTHER DIURESIS OVERNIGHT. FLUID GOAL OF 2L(-) MET AT MN, AT THUS FAR (-) 4LS FOR LOS. GOOD APPETITE. TAKING PO'S WELL. FLUID RESTRICTION IN PLACE. 1.5L/DAY.\nHEME: HCT STABLE AT 41 AS OF AM WITH AM PENDING.\nID: TM 99.6 AND TC 98.6. WBC WNLS.\nA/P: 22 YO WITH NEWLY DIAGNOSED CM AND MR WITH INITIAL WEDGE OF 35. NATRECOR ADDED WITH ATTEMPT TO IMPROVE PADS AND CI BUT WITH NO IMPROVEMENT AND MILRINONE ADDED WITH NO BENEFIT TO CI. CAPTOPRIL AND BUMEX ADDED WITH SIGNFICANT IMPROVEMT IN PADS AND CI'S\nCONTINUE TO TITRATE CAPTOPRIL\nDIURESE ACCORDING TO PAD'S\nCONTINUE EMOTIONAL SUPPORT\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-28 00:00:00.000",
"description": "Report",
"row_id": 1369987,
"text": "ADDEDUM TO CCU NURSING PROGRESS NOTE 1900-0700:\nMS: AWAKEN OOB TO USE BATHROOM. PRIOR TO GETTING UP NOTED TO BE TREMELOUS AND STATES, A \"LITTLE NERVOUS.\" GAIT ALSO APPEARING UNSTEADY AND SHOULD BE ONE ASSIST AT ALL TIMES. STATING, \"ATIVAN NOT WORKING\" IN PAST. GIVEN SERAX AND AWAITING AFFECT.\n\nRESP:PT WITH DRY HOARSE COUGH, GIVEN ROBITUSSIN AND CEPACOL LOZ WITH GOOD EFFECT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-28 00:00:00.000",
"description": "Report",
"row_id": 1369988,
"text": "CCU NSG NOTE: ALT IN CV/CARDIOMYOPATHY\nS: \"I feel better than before I came in\"\nO: For complete VS see CCU flow sheet.\nID: T-max 99 po.\nCV: Pt continues on milrinone at .5mic/kilo/min. Captopril is at 25mg and numbers after second dose were 4.1/2.06 with SVR 1210, down a bit from earlier labs. HR has been 100-120 ST with no ectopy. He was K+ replaced and repeat K+ was 4.3. BP has ranged 100-1 teens/40s. PAP 30-40/22-26 and RA . PA cath has very poor tracing with lots of fling. Neck site clean. He received bumex 1mg IV at 10a with good response. Pedal edema is decreasing.\nRESP: Pt sating 93-99% on RA. Lungs sound clear. Pt has no c/o of sob.\nRENAL: Pt had foley out at 2pm. He is voiding in urinal without problem. is over 5.5 liters neg LOS and 2100 neg for the day.\nGI: Pt eating and drinking without problem. is staying within fluid restriction. He had BM.\nMS: Pt A & O times 3. However he does not seem to have clear grasp on what is going on. He was becomes anxious about events and at times does not interpret what is said at it is intended. He was concerned about Dr going on vacation. Dr clarified the situation with the pt and his mother.\nA: Slow improvement of CV status.\nP: Continue low dose milrinone. Increase captopril as tolerated. Keep careful I & O. Pt will be seen by social work and NS for assistance with adiction control. ENsure pt understands what is being said by asking for his understanding.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-29 00:00:00.000",
"description": "Report",
"row_id": 1369989,
"text": "NSG NOTE\n\nCV: HR 104-123 ST. NO VEA NOTED. MAP'S 63-81. PAD'S 25-19, CVP 6-10 PCWP 15. CON'T ON MILRINONE 0.5MCG/KG. CO/CI/SVR PRIOR TO INCREASE IN CAPTOPRIL 4.2/2.11/1143. CAPTOPRIL INCREASED TO 37.5MG CO/CI/SVR 4.9/2.46/865. CON'T TO HAVE 3+ PITTING EDEMA. IN LOWER EXT. DENIES CP\n\nRESP: RA SATS 97-98%. DENIES SOB. RR REG. APPEARS COMFORTABLE. FINE CRACKLES NOTED IN BILAT BASES.\n\nGI: TOL PO'S WELL. NEEDS REINFORCMENT REGARDING FLUID RESTRICTIONS AND LOW NA FOOD CHOICES.. + BS LAST BM . ABD SOFT AND NONTENDER.\n\nGU: VOIDS IN ADEQUATE AMTS. LOS NEG BY 6361,MN NEG BY 2637\n\nNEURO; A&O. WILL FOLLOW COMMANDS. ASKS QUESTIONS CONCERNING MEDS,BUT THEY ARE FREQ THE SAME QUESTIONS OVER AGAIN. PERIODS OF RESTLESSNES NOTED. SERAX GIVEN WITH GOOD EFFECT.\n\nSKIN: INTACT\n\nLABS: MG 1.6 MAG REPLACED.\n\nID: WBC 6.7 NO ACTIVE ISSUES\n\nSOCIAL: MOTHER IN ON EVES. SEEMS SUPPORTIVE. TEACHING INITIATED TO FAMILY REGARDING NUTRITION/ CURRENT MEDS AND PLAN.\n\nA:SLIGHT IMPROVMENT IN CARDIAC STATUS\n\nP; CON'T HEMEODYNAMICS/CONSIDER INCREASE IN CAPTOPRIL.\n SS TO MEET WITH FAMILY REARDING COUNSELING\n ONGOING TEACHING REGARDING MEDS/NUTRITION\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-29 00:00:00.000",
"description": "Report",
"row_id": 1369990,
"text": "CCU Nursing Progress Note\nS-\"I understand I will have to weigh myself every day\"\n\"I just need to know what medications I am going to take when I go home\"\nO-Neuro-alert and oriented x3, pleasant and cooperative. No c/o pain or SOB.\nCV-VSS no change in HR 106-122 ST no VEA. SBP stable after captopril 37.5mg at received additional 12.5mg at 1600. Although hemodynamcis unchanged but slightly worsened. CO/CI/SVR @ 8am 3.8/1.91/1284 and at 1500 3.6/1.81/1378 SVO2 sats 62-63%. PAD 27-29 with poor waveform PWP 22 with small V wave.\nResp-LS clear O2 sats 97-99%, Occ NPC this am.\nID afebrile\nGU- voiding well moderate amt. Received Bumex at 1700. Goal -2liters\nGI-Appetite good, BM in toliet.\nActivity-OOB room alittle bit, mostly in bed. Walked in hallway with supervision and went outside in wheelchair for short time.\nTeaching- Spent some time with pt and mother talking about CHF. They admitted to not knowing what questions to ask because they just did not understand everything. Gave pt another CHF packet for him to read again. Mother asking most of the questions. Asked pt if he understood POC so far and understands that he is being put on a pill that will hopefully help his heart. Understands he can not go back to smoking.\nAsking good questions about low salt diet. Gave pt information on ace inhibitors and bumex because he asked for it.\nA/P-Cardiomyopathy with low CO/CI on milrinone\nFollow hemodynamics q6hrs, possibly wean milrinone as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-30 00:00:00.000",
"description": "Report",
"row_id": 1369991,
"text": "NGS NOTE\n\nS\" HOW MANY MORE DAYS DO YOU THINK I WILL BE IN HERE?\"\n\nO: CV: ST WITH HR 112-123. OCCASSIONAL MULTIFOCAL PVC NOTED. K+ 4.2. PAD 29-21,CVP 8-10,PCWP 22. CO/CI/SVR 3.2/1.61/1375. RECEIVED CAPTOPRIL 50MG. CO/CI/SVR AFTER CAPTOPRIL LITTLE TO NO IMPROVEMENT. 3.1/1.56/. DR NOTIFIED. I ALSO SPOKE WITH DR AND UPDATED HER ON PT'S CONDITION AND HEMODYNAMICS. ORDERS GIVEN TO INCREASE MILRINONE TO .65MCG/KG. # AFTER MILRINONE INCREASE 4.5/2.26/1156. SBP 97-116/52-76. NO SIGN CHG IN BP AFTER CAPTOPRIL DOSE.\n\nRESP: CON'T TO RA SATS 95-99%. DENIES SOB. APPEARS COMFORTABLE. CL BS. CRACKLES FINE IN BASES THAT CL WITH COUGH.\n\nGI: TOL PO'S NO STOOL THIS SHIFT.\n\nGU: CON'T ADEQUATE U/O LOS NEG BY 9 LITERS. MN NEG BY 2.5 LITERS.\n\nSKIN: INTACT\n\nID: T MAX 98.6 NO CURRENT ISSUES\n\nNEURO: A&O. FOLLOWS COMMANDS. REQUESTING SERAX. 20MG GIVEN WITH GOOD EFFECT. PT OFF FLOOR ACCOMPANIED BY NURSING. SEEMED TO ENJOY BEING OUTSIDE. HE IS ASKING MORE QUESTIONS RELATED TO HIS CONDITION AND OVERALL STATUS. HE IS AWARE OF HIS NEED TO CHANGE LIFESTYLE. HIS MAIN CONCERNS CENTER AROUND TRANSFERING OUT OF ICU AND TO A FLOOR WHERE HE BECOMES MORE INDEPENDENT.\n\nSOCIAL: MOTHER IN ALL EVE.\n\nA: WORSENING CARDIAC STATUS. REQUIERING INCREASE IN MILRINONE\n\nP;HEMODYNAMICS\n FURTHER INCREASES IN CAPTOPRIL\n PER NSG JUDGEMENT\n ONGOING TEACHING\n"
},
{
"category": "ECG",
"chartdate": "2108-09-27 00:00:00.000",
"description": "Report",
"row_id": 169907,
"text": "Sinus tachycardia\nPremature ventricular contraction\nLong QTc interval\nPossible left atrial abnormality\nRight axis deviation\nConsider biventricular hypertrophy\nLate precordial QRS transition\nQS configuration in leads V1-V2 - could be due to left ventricular hypertrophy\nbut consider prior ischemia\nClinical correlation is suggested\nSince previous tracing of : sinus tachycardia rate faster and precordial\ntransition zone is later\n\n"
},
{
"category": "ECG",
"chartdate": "2108-09-24 00:00:00.000",
"description": "Report",
"row_id": 169908,
"text": "Sinus tachycardia. Left atrial enlargement. Poor R wave progression. Cannot\nrule out old anteroseptal myocardial infarction. Compared to the previous\ntracing of ST segment elevations in the anterior leads with loss of\nR waves persist. However, there are new T wave inversions in the lateral leads\nsuggestive of lateral myocardial ischemia. Inferior ST-T wave changes persist.\n\n"
},
{
"category": "ECG",
"chartdate": "2108-09-21 00:00:00.000",
"description": "Report",
"row_id": 169909,
"text": "Sinus tachycardia. Probable left atrial abnormality. One to two millimeter\nST segment elevation in leads VI-V5. Q waves in leads VI-V3. One millimeter\nST segment depression in leads II, III and aVF. These findings are highly\nsuggestive of anterior myocardial infarction, possibly acute or subacute. There\nis rightward axis deviation. Consider right ventricular hypertrophy. No\nprevious tracing available for comparison.\n\n"
}
] |
86,210 | 148,404 | 64F admitted for a SAH and L MCA aneurysm. She was admitted to the TSICU and underwent a cerebral angiogram for coiling on of a left MCA aneurysm. Post-angio she was transferred to the Neuro-ICU where her exam remained stable through . | IMPRESSION: underwent cerebral angiography and coil embolization of a 7 x 4 mm left middle cerebral artery aneurysm, which was uneventful. Moderate cardiomegaly with tortuous aorta . Left internal carotid artery arteriogram status post coiling of the aneurysm shows no filling of the aneurysm except at its base which is very minimal. Right innominate artery arteriogram shows rather tortuous innominate artery with an aneurysm or dilatation at the origin of the subclavian artery. (Over) 8:48 AM /CERB UNI Clip # Reason: Aneurysm Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 195 FINAL REPORT (Cont) FINDINGS: Right common carotid artery arteriogram showing normal filling of the right external carotid artery and its branches. The right common carotid artery arteriogram fills well with no evidence of stenosis. In addition, the aneurysm appeared to be fully obliterated. Following this, the right common femoral artery area was prepped and draped in a sterile fashion. CT ANGIOGRAM OF THE HEAD: The distal Basilar artery is diminutive, with a fetal PCA pattern and prominent posterior communicating arteries on both sides . Right common femoral artery arteriogram was done. CTA Head: Possible minimal-mild narrowing of left MCA branches- accurate assessment limited due to artifacts from coils. IMPRESSION: underwent cerebral angiography which revealed no evidence of vasospasm. FINDINGS: NON-CONTRAST HEAD CT: There is diffuse subarachnoid hemorrhage predominantly layering over the left cerebral hemisphere, within the Sylvian fissure. FINDINGS: Grayscale and Doppler son of the bilateral common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins were performed. Left common carotid artery arteriogram shows normal filling of the left common carotid artery. Residual contrast from patient's recent CT is seen within the bladder, which partially obscures the coccyx. Left MCA aneurysm, with no significant change in the degree of subarachnoid hemorrhage. Both PCAs are seen to be hypoplastic consistent with fetal PCAs bilaterally. The right common femoral artery arteriogram shows normal filling of the right common femoral artery with no evidence of stenosis. Mild overhydration with moderate cardiomegaly and tortuosity of the thoracic aorta. Decreased conspicuity of the cerebral sulci on the elft side- from priro SAH/edema. Otherwise, the major intracranial arteries are patent without focal flow-limiting stenosis or occlusion. Left common carotid arteriogram shows no significant stenosis of the left common carotid artery, the left external carotid artery and its branches filled well. TECHNIQUE: Bilateral lower extremity ultrasound. IMPRESSION: No evidence of deep venous thrombosis in the bilateral lower extremities. FINDINGS: Single AP view of the pelvis was obtained. The dural venous sinuses are patent. CTP: No perfusion deficit in the imaged portions. DVT PFI REPORT PFI: No evidence of deep venous thrombosis in the bilateral lower extremities. The previously seen middle cerebral artery aneurysm is completely obliterated. The right vertebral artery is seen to arise without any stenosis from the right subclavian and is of a similar caliber as the left vertebral artery. Left atrial abnormality. Left atrial abnormality. Mild iliac enthesopathy is noted. Anyeurysm No contraindications for IV contrast WET READ: ENYa SUN 7:19 PM NECT: Unchanged small amount of SAH layering along the left frontopariteal sulci. Minimal bilateral mastoid effusions are present. PROCEDURE PERFORMED: Right common carotid arteriogram, right innominate artery arteriogram, left common carotid artery arteriogram, left subclavian artery arteriogram left vertebral artery arteriogram, right common femoral artery arteriogram and Angio-Seal closure of right common femoral artery puncture site. The A1 is hypoplastic on the right side. FINDINGS: As compared to the previous radiograph, the patient has received a new right subclavian vein access line. Considerinferior myocardial infarction of indeterminate age. Patent major intracranial arteries without focal flow-limiting stenosis or occlusion without obvious evidence of vasospasm within the limitations of artifacts from the coils in the coiled aneurysm- see details above. There is minimal soft tissue thickening of the right maxillary sinus. The anterior cerebral artery is seen to be hypoplastic on the right side. Diffuse ST-T wave abnormalities ofunclear significance. Left vertebral artery arteriogram shows the left vertebral artery to be fairly diminutive; however, it fills well along with the basilar artery. Consideranterior wall myocardial infarction of indeterminate age. The left internal carotid artery fills well along the cervical, petrous, cavernous, and supraclinoid (Over) 1:38 PM CAROT/CEREB Clip # Reason: eval left mca aneurysm Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 60ML OPTI240; 25ML OPTI320 FINAL REPORT (Cont) portion. | 14 | [
{
"category": "Radiology",
"chartdate": "2146-01-17 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1177960,
"text": " 1:30 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: BED BOUND, ?DVT\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p sah, bed bound in ICU. please perform to r/o DVT\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): OXZa MON 6:10 PM\n PFI: No evidence of deep venous thrombosis in the bilateral lower\n extremities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of subarachnoid hemorrhage. Bedbound.\n\n TECHNIQUE: Bilateral lower extremity ultrasound.\n\n COMPARISON: None available.\n\n FINDINGS: Grayscale and Doppler son of the bilateral common femoral,\n superficial femoral, popliteal, posterior tibial and peroneal veins were\n performed. There is normal compressibility, flow and augmentation.\n\n IMPRESSION: No evidence of deep venous thrombosis in the bilateral lower\n extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-13 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1177326,
"text": " 5:03 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line placement and ?PTX\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with new R SC CVL\n REASON FOR THIS EXAMINATION:\n eval line placement and ?PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n COMPARISON: , 4:32 a.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has received a\n new right subclavian vein access line. The tip of the line projects over the\n inferior cava, the course of the line is unremarkable. There is no evidence\n of complication, notably no pneumothorax.\n\n Otherwise, the radiographic appearance is unchanged. Moderate cardiomegaly\n with tortuous aorta .\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-17 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1177961,
"text": ", J. NSURG SICU-B 1:30 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: BED BOUND, ?DVT\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p sah, bed bound in ICU. please perform to r/o DVT\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of deep venous thrombosis in the bilateral lower\n extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176737,
"text": " 11:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulm status\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SAH admitted to ICU\n REASON FOR THIS EXAMINATION:\n eval pulm status\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pulmonary status.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Mild overhydration with moderate cardiomegaly. No focal parenchymal\n opacity suggesting pneumonia. No pleural effusions. No lung nodules or\n masses.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-10 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 1176781,
"text": " 8:48 AM\n /CERB UNI Clip # \n Reason: Aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 195\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 2ND ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CERVICAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH EMBO THERAPY *\n * F/U TRANS CATH THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with subarachnoid hemorrhage and CTA showing L MCA aneurysm\n REASON FOR THIS EXAMINATION:\n Aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n CLINICIAN: Dr. .\n\n ASSISTANT: , nurse practitioner.\n\n DIAGNOSIS: Subarachnoid hemorrhage with left middle cerebral artery aneurysm.\n\n INDICATION: Diagnostic angiogram with coiling.\n\n ANESTHESIA: General anesthesia.\n\n DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite.\n Anesthesia was induced in the supine position. Following this, access was\n gained to the right common femoral artery using a Seldinger technique and a 6\n French vascular sheath was placed in the right common femoral artery leading\n up into the aortic bifurcation and into the aorta. Following this, the right\n common carotid artery and the left common carotid artery were catheterized and\n AP, lateral filming done. This revealed a 9-mm aneurysm of the middle\n cerebral artery in its largest dimension with a broad neck; therefore we\n decided to manage this endovascularly. The catheter was exchanged out\n and a 6 French Neuron catheter was placed in the left internal carotid artery\n using road mapping technique. Following this, the aneurysm was catheterized.\n It was difficult to gain distal access. Therefore, a DAC, distal access\n catheter and rapid transit catheter as a triaxial system was used to advance\n the Neuron catheter further into the left internal carotid artery. Following\n this, the middle cerebral artery aneurysm was catheterized with a Synchro\n microwire and SL-10 microcatheter. Following this, the aneurysm was\n sequentially coiled, first starting with GDC 360, 4 into 7 mm followed by 4\n into 8 mm UltraSoft coil 3 into 6 UltraSoft coil and finally finishing with\n DeltaPlush microcoils( Micrus). Following this, the aneurysm was completely\n obliterated. Right common femoral artery arteriogram was done. This revealed\n that there was no stenosis. Therefore, a 6 French Angio-Seal was used for\n closure of the right common femoral artery puncture site.\n\n (Over)\n\n 8:48 AM\n /CERB UNI Clip # \n Reason: Aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 195\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n FINDINGS: Right common carotid artery arteriogram showing normal filling of\n the right external carotid artery and its branches. The right internal\n carotid artery fills well along the cervical, petrous, cavernous and\n supraclinoid portion. The anterior cerebral artery is seen to be hypoplastic\n on the right side. There is a large posterior communicating artery, which is\n most likely fetal in origin. The right middle cerebral artery and its\n branches are seen well. There is no evidence of aneurysms.\n\n Left common carotid arteriogram shows no significant stenosis of the left\n common carotid artery, the left external carotid artery and its branches\n filled well. The right internal carotid artery shows a 7 mm x 4 mm aneurysm\n arising from left middle cerebral artery at the takeoff of the first division\n just prior to the bifurcation. This branch goes superiorly and is probably\n the superior division of the left middle cerebral artery.\n\n Left internal carotid artery arteriogram again demonstrates the left middle\n cerebral artery aneurysm with the large posterior communicating artery, most\n likely a fetal posterior communicating artery.\n\n Left internal carotid artery arteriogram status post coiling of the aneurysm\n shows no filling of the aneurysm except at its base which is very minimal.\n\n Right common femoral artery arteriogram shows widely patent right common\n femoral artery.\n\n IMPRESSION:\n\n underwent cerebral angiography and coil embolization of a 7 x\n 4 mm left middle cerebral artery aneurysm, which was uneventful. She was\n maintained on heparin with an ACT about 225 during the entire procedure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-19 00:00:00.000",
"description": "SEL CATH 2ND ORDER",
"row_id": 1178267,
"text": " 1:38 PM\n CAROT/CEREB Clip # \n Reason: eval left mca aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 60ML OPTI240; 25ML OPTI320\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * CAROTID/CERVICAL BILAT VERT/CAROTID A-GRAM *\n * EXT UNILAT A-GRAM MOD SEDATION, FIRST 30 MIN. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with sah\n REASON FOR THIS EXAMINATION:\n eval left mca aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n DIAGNOSIS: Cerebral aneurysm, assess for vasospasm. The patient has been on\n pressors for 5 days and is 8th day post-subarachnoid hemorrhage.\n\n PROCEDURE PERFORMED: Right common carotid arteriogram, right innominate\n artery arteriogram, left common carotid artery arteriogram, left subclavian\n artery arteriogram left vertebral artery arteriogram, right common femoral\n artery arteriogram and Angio-Seal closure of right common femoral artery\n puncture site.\n\n ANESTHESIA: Moderate sedation was given by giving a single dose of 1mg Versed\n and monitoring for a total intra-service time for approximately 30 minutes.\n\n DETAILS OF PROCEDURE: The patient was brought to the angiography suite. IV\n sedation was given. Following this, the right common femoral artery area was\n prepped and draped in a sterile fashion. The access site was infiltrated with\n 1% lidocaine. Following this, a vascular sheath was placed in the right\n common femoral artery using a Seldinger technique. The sheath was 23 cm long\n and distal portion was in the distal aorta. Following this, the\n above-mentioned vessels were catheterized and AP, lateral filming done. This\n revealed no evidence of vasospasm. In addition, the aneurysm appeared to be\n fully obliterated. At this point, we closed the right common femoral artery\n with Angio-Seal 6 French device. The patient tolerated the procedure well and\n was taken back to the ICU, neurologically intact.\n\n FINDINGS: Left subclavian artery arteriogram shows no evidence of stenosis at\n the origin of the left vertebral artery. Left vertebral artery arteriogram\n shows the left vertebral artery to be fairly diminutive; however, it fills\n well along with the basilar artery. Both PCAs are seen to be hypoplastic\n consistent with fetal PCAs bilaterally.\n\n Left common carotid artery arteriogram shows normal filling of the left common\n carotid artery. There is no evidence of stenosis at the bifurcation. The\n external carotid artery and its branches fill well. The left internal carotid\n artery fills well along the cervical, petrous, cavernous, and supraclinoid\n (Over)\n\n 1:38 PM\n CAROT/CEREB Clip # \n Reason: eval left mca aneurysm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 60ML OPTI240; 25ML OPTI320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n portion. The previously seen middle cerebral artery aneurysm is completely\n obliterated. All the middle cerebral artery branches are fully patent. There\n is no evidence of spasm. The A1 is seen to be dominant on the left side and\n there is no evidence of aneurysm in the left anterior communicating segment.\n\n The right PCA is seen to be fetal in origin.\n\n Right innominate artery arteriogram shows rather tortuous innominate artery\n with an aneurysm or dilatation at the origin of the subclavian artery.\n\n The right vertebral artery is seen to arise without any stenosis from the\n right subclavian and is of a similar caliber as the left vertebral artery.\n\n The right common carotid artery arteriogram fills well with no evidence of\n stenosis. The right internal carotid artery fills well along the cervical,\n petrous, cavernous and supraclinoid portion. The A1 is hypoplastic on the\n right side. The middle cerebral artery is seen well. There is a PCA which is\n fetal in origin.\n\n The right common femoral artery arteriogram shows normal filling of the right\n common femoral artery with no evidence of stenosis.\n\n IMPRESSION: underwent cerebral angiography which revealed no\n evidence of vasospasm. The left middle cerebral artery aneurysm is completely\n obliterated and there is no residual filling.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-09 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 1176716,
"text": " 6:02 PM\n PELVIS (AP ONLY) Clip # \n Reason: seizure\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with r hip pain after\n REASON FOR THIS EXAMINATION:\n seizure\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: AP view of the pelvis.\n\n CLINICAL INFORMATION: 64-year-old female with right hip pain after seizure.\n\n COMPARISON: None.\n\n FINDINGS: Single AP view of the pelvis was obtained. Residual contrast from\n patient's recent CT is seen within the bladder, which partially obscures the\n coccyx. No evidence of acute fracture or dislocation is seen. The pubic\n symphysis and sacroiliac joints are intact. Mild iliac enthesopathy is\n noted. There are also evidence of degenerative change along the visualized\n lower lumbar spine. Numerous rounded calcifications projecting over the\n superior buttocks bilaterally may represent calcified injection granulomas\n versus other soft tissue calcification.\n\n IMPRESSION:\n 1. No evidence of acute fracture or dislocation. If clinical concern for\n right hip fracture persists, suggest dedicated AP and lateral views of the\n right hip.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1177308,
"text": " 4:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls confirm no PTX before we attempt R sided CVL\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with failed attempt of L SC & L IJ placement\n REASON FOR THIS EXAMINATION:\n Pls confirm no PTX before we attempt R sided CVL\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Attempted subclavian line placement on the left, confirmation\n that no pneumothorax is present.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Mild overhydration with moderate cardiomegaly and tortuosity of the\n thoracic aorta.\n\n There is no evidence of pneumothorax, neither on the right nor on the left\n side. Minimal atelectasis at the left lung base. No pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-09 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1176712,
"text": " 4:53 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ? Anyeurysm\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with ? SAH\n REASON FOR THIS EXAMINATION:\n ? Anyeurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa SUN 7:19 PM\n NECT: Unchanged small amount of SAH layering along the left frontopariteal\n sulci. No intraventricular hemorrhagic extension. No hydroecephalus.\n\n CTA Head: Pending of 3D rendering. 5-mm saccular aneurysm at the bifurcation\n of the distal L M1 segment into the superior and inferior M2 segments. L MCA\n branches distal to this aneursym remain patent.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 64-year-old female with subarachnoid hemorrhage,\n question aneurysm.\n\n COMPARISON: Outside CT performed .\n\n TECHNIQUE: Axial images were acquired of the head before and after the\n administration of contrast and reformatted into the coronal and sagittal\n planes. On a separate dedicated workstation, VR and curved planar\n reformations were produced and sent to PACS for evaluation.\n\n FINDINGS:\n\n NON-CONTRAST HEAD CT: There is diffuse subarachnoid hemorrhage predominantly\n layering over the left cerebral hemisphere, within the Sylvian fissure. There\n is no mass effect or midline shift. matter/white matter differentiation\n is preserved. The ventricles and sulci are normal in size and configuration.\n The orbits and visualized soft tissues are normal in appearance. Minimal\n bilateral mastoid effusions are present. The visualized paranasal sinuses are\n clear. Periapical lucencies are seen around numerous maxillary molars. There\n is minimal soft tissue thickening of the right maxillary sinus.\n\n CTA HEAD: There is a 5 mm x 10 mm aneurysm originating at the left MCA\n bifurcation, with a 3-mm waist. A \"nipple\" at its apex is suggestive of\n recent rupture and hemorrhage. Elsewhere in the brain there is no aneurysmal\n dilatation of the intracranial arteries. There is no occlusion or\n flow-limiting stenosis. Fenestration is noted of the anterior communicating\n artery but there is no associated aneurysm. The basilar artery is diminutive,\n with much of the posterior circulation originating from prominent posterior\n communicating arteries bilaterally. The dural venous sinuses are patent.\n\n IMPRESSION:\n 1. Left MCA aneurysm, with no significant change in the degree of\n subarachnoid hemorrhage. No other aneurysms are identified.\n (Over)\n\n 4:53 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ? Anyeurysm\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Periapical lucencies around numerous maxillary molars.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-01-13 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1177352,
"text": " 9:03 AM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n Reason: ? vasospasm, abnormal TCDS performed , and change in men\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SAH, s/p L MCA coiling , increasing lethargy and\n confusion, ? vasospasm. please perform CTA/CTP\n REASON FOR THIS EXAMINATION:\n ? vasospasm, abnormal TCDS performed , and change in mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:34 AM\n NOn-contrast CT Head: No acute new hemorrhage. Decreased conspicuity of the\n cerebral sulci on the elft side- from priro SAH/edema.\n\n CTP: No perfusion deficit in the imaged portions.\n\n CTA Head: Possible minimal-mild narrowing of left MCA branches- accurate\n assessment limited due to artifacts from coils.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left MCA aneurysm, status post coiling, SAH, question vasospasm;\n increasing lethargy and confusion.\n\n TECHNIQUE: Non-contrast CT head, CT cerebral perfusion study, and CT\n angiogram of the head with IV contrast; perfusion maps and 2D and 3D\n reformations of the CT angiogram.\n\n COMPARISON: CTA of the head done on .\n\n FINDINGS:\n\n NON-CONTRAST CT HEAD: There is no acute intracranial hemorrhage, mass effect,\n or shift of normally midline structures. There is decreased conspicuity of\n the cerebral sulci on the left side, related to the prior subarachnoid\n hemorrhage along with a possible degree of cerebral edema. Periventricular\n white matter hypodense areas are noted, likely related to small vessel\n ischemic changes. No new acute intracranial hemorrhage or mass effect is\n noted. Artifacts from the coiled aneurysm are noted in the left middle\n cranial fossa.\n No osseous lytic or sclerotic lesions are noted.\n\n CT CEREBRAL PERFUSION STUDY: There is no focus of perfusion deficit in the\n imaged portions of the brain.\n\n CT ANGIOGRAM OF THE HEAD: The distal Basilar artery is diminutive, with a\n fetal PCA pattern and prominent posterior communicating arteries on both sides\n . Otherwise, the major intracranial arteries are patent without focal\n flow-limiting stenosis or occlusion. Assessment of the left M1 and M2\n segments is limited due to artifacts. However, there is no significant\n (Over)\n\n 9:03 AM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n Reason: ? vasospasm, abnormal TCDS performed , and change in men\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n narrowing noted where the arteries are well seen.\n\n IMPRESSION:\n 1. Decreased conspicuity of the sulci in the left cerebral hemisphere from\n prior subarachnoid hemorrhage.\n 2. No evidence of perfusion deficit on the images provided.\n 3. Patent major intracranial arteries without focal flow-limiting stenosis or\n occlusion without obvious evidence of vasospasm within the limitations of\n artifacts from the coils in the coiled aneurysm- see details above.\n\n Other details as above.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-13 00:00:00.000",
"description": "Report",
"row_id": 258148,
"text": "Sinus bradycardia. Compared to the previous tracing of Q waves\nin leads III and aVF are no longer appreciated raising the possibility of lead\nmisplacement and diffuse T wave abnormalities persist.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-11 00:00:00.000",
"description": "Report",
"row_id": 258149,
"text": "Sinus bradycardia with sinus arrhythmia. Q waves in leads III and aVF. Consider\ninferior myocardial infarction of indeterminate age. Q wave in leads V1-V3\nwith late R wave progression with precordial ST-T wave abnormalities. Consider\nanterior wall myocardial infarction of indeterminate age. Since the previous\ntracing of the rate is slower. Axis is more leftward. Voltage is\nincreased. Early precordial R waves are now seen. Since the previous tracing\nthese changes may be to some degree related to axis change but clinical\ncorrelation is highly suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-10 00:00:00.000",
"description": "Report",
"row_id": 258359,
"text": "Sinus rhythm. Left atrial abnormality. T wave inversions in leads V4-V5 and\nT wave flattening in lead V6. Compared to the previous tracing T wave in\nlead V3 is now upright. Otherwise, no diagnostic changes. This may be related\nto different lead positioning.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2146-01-09 00:00:00.000",
"description": "Report",
"row_id": 258360,
"text": "Sinus rhythm. Left atrial abnormality. Diffuse ST-T wave abnormalities of\nunclear significance. Clinical correlation is recommended. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
}
] |
10,953 | 175,567 | Pt was admitted to the hostipal and monitored overnight. On HD #2 she began having temps to 104.0. That night she became hypotensive and somulent and was transferred to the ICU. She was intubated and fluid resusitated. She was taken to the OR emergently for exploration. She was found to have a closed loop obstruction of her SB. 100 cm of SB were resected and she was left open and transferred to the ICU. Post op she had severe sepsis and was started on broad spectrum abx and Xigris. She slowly improved and was weaned from her pressors. She stablized and was taken back to the operating room for a washout and closure. Intraoperatively, a focal area of necrosis of the SB was identified and it was resected. She was closed with Dexon absorbable mesh and a VAC was placed. Plastic surgery was consulted intra-op and followed the her throughout her stay. She was transferred back to the ICU and she slowly improved. She was attempted to be weaned from the vent but was unable. Therefore it was decided to proceed with a perc trach. After the trach was placed she was able to wean from the ventilator and was tolerating trach mask prior to discharge. A post-pyloric feeding tube was placed intra-op and she was started on TF. She had high stool output which was checked multiple times for C diff. All were negative. Her TF were changed and her output decreased. She had a PICC line placed for a 2 wk abx course of Vanco/Levo. She had a MRSA/Ecoli bacteremia likely from her necrotic bowel. She was afebrile for over 1 wk after starting the abx. PT/OT were consulted and worked with her throughout her hospital stay. Speech and Swallow evaluated her and she was able to pass her beside evaluation. She will need a Video swallow when more stable prior to starting to take PO. | NGT to LCWS for sm.->moderate amts. There is mild global leftventricular hypokinesis. PB's for DVT prophylaxis.Resp: LS coarse, diminished at bases; suctioned for sm->moderate amts. Mild (1+) mitralregurgitation is seen. Pneumoboots in place.RESP: Intubated and vented. There is a trivial/physiologic pericardial effusion.IMPRESSION: These findings are most c/w a non-ischemic cardiomyopathy. RV function depressed.AORTA: Normal aortic root diameter.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild globalLV hypokinesis.RIGHT VENTRICLE: Mildly dilated RV cavity. care note - Pt. VAC dsg intact with moderate amts. bowel resection for sm. bowel resection for sm. Vac dsg to abd intact, draining serosang drng. notes.GI: abd obese, open, VAC dsg intact. bilious drainage; dobhoff clamped. with bronchial toliet. Lytes repleted x 1, now wnl. notes.GI: abd obese, open, BS absent. Lasix x 1 w/ gd effect. Borderline PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. R corner of mouth with breakdown d/t ett; OTA.Psych/social: pt's hcp and . Anticipate possible extubation today.GI: Abd large and soft. mdis given. TPN conts. Respiratory CarePt weaned to CPAP/PSV of 14cm peep and 10 psv. NG to suction. A 0.018 Glidewire was advanced through an existing right-sided antecubital PICC line. Absent BS, NGT to LCWS for sm. Protonix for GI prophylaxis.GU: foley patent draining approx. Pedal pulses faintly palpable, confirmed by doppler. Pedal pulses faintly palpable, confirmed by doppler. Resp. hct 34.Resp: LS coarse, diminished; suctioned for sm. Lovenox and PB's for DVT prophylaxis.Resp: LS coarse, suctioned for sm->moderate amts. NGT to LCWS for moderate amts. PB's for DVT prophylaxis.Heme: hct 27.8, PT 15.6/PTT50.9/1.5Resp: LS coarse, diminished; suctioned for sm->moderate amts. PEARRLA.CV: RSR->ST w/o ectopy. Albuterol given. T-SICU Nsg Note See flow sheet for details.Neuro - when propofol dose lower, pt alert, restlesss, communicating by gesture and nodding. NGT to LCWS for sm. Abd open w/trasparent dressing inplace. MDI'S given. Flovent MDI given per nsg. Care: Pt. NG clamped after meds given via NG. BS auscultated reveal bilateral clear apecies with diminshed bases. T-SICU NPN 0700-1900See carevue for specifics. Respiratory failureP: Follow hct. bowel resectiontol. POST PILORIC PEDI TUBE VIA RIGHT NARE W/IMPACT W/FIBER 3/4 STRENGTH INFUSING AT GOAL OF 70CC/HR. Ambu/syringe @ hob. ?etiology for decreasing hct. Potassium repleted.GI- TF's at goal via post-pyloric FT. Abd obese/soft. Resp. ABG-> 7.42/45/90/3/30. Tolerated decreased PEEP and now PSV. Rectal bag leaked and replaced x2, currently with rectal tube in place. Has left subclavian CCO swan, see flow record for #'s. AM ABG's 7.43/47/73/32. Has RIJ Multimed port. vanco/zosyn.Skin: back folds with duoderm in place; breakdown noted to back of head, OTA. GENERALIZED PITTING EDEMA. notes.GI: abd open, BS present. RSBI done on 0 peep/5 ips 63. BS-sl. Telfa placed. Resp Care Note, Pt remains on current vent settings. BS clear to coarse & diminished at bases. MDI's given as ordered & flovent started. serous fluid. lap with sm. Sig. MDI'S given.Temp 99. Lovenox as ordered and PB's for DVT prophylaxis. Resp CarePt reamains on vent and stable. Has right subclavian MML w/ cvp = . Lovenox and PB's for DVT prophylaxis.Resp: LS coarse, suctioned for sm. Tolerating active diuresis.P: Cont to diurese, replete lytes as needed. Enoxeparin and Pneumoboots for DVT prophylaxis.Resp - Placed on trach collar this AM. Protonix for GI prophylaxis.GU: foley patent draining adequate amts. Pneumoboots on. NGT to LCWS with sm. vanco/levofloxacin as ordered.Skin: abd/panus fold with duoderm intact; back fold with sm. Mdis given. + BS.GU - Diuresing well. MDI's as documented. Treat as needed for agitiation. Pedi post piloric feeding tube via right nare w/TF infusing at goal (90cc/hr). notes.GI: abd obese, open, BS present. cath dced and fecal incontinence bag placed.vac dsg intact. Inhalers as ordered have been given by RT.GI: abd obese, open, BS hypoactive, Peptamen 3/4 strength at goal via dobhoff. Advance TF's as tolerated. Post piloric pedi tube via right nare w/TF infusing at goal at 90cc/hr. Pt signed discharge plan. Duoderm intact over L lower abd wound. K repleted x 4, other lytes wnl. Mouthing words and nodding head yes/no to questions asked.CV: RSR w/o ectopy. Trach cares initiated. draining sm amt ser/sanf drainage/resp on vent ps5, peep5 sats adequate stable art line dced. restraints now off.cv stable nsr urine out put adequate lasix given at 2am with very sm diuresis. ~ 2L negative at this time.Skin - Duoderm intact to back folds. TF : str. Haldol and ativan for restlessnes/agitation.CV: RSR w/o ecotpy. Lovenox and PB's for DVT prophylaxis. Vasopressin conts. PB'S ON FOR DVT PROPHYLAXIS. MONITORING RESP STATUS W/SVO2/SATS/FICK CALC. PEARRLA.CV: RSR -> ST w/o ectopy. Titrate levophed as tolerated. HYPOACTIVE BS NOTED - SM/LIQUID/LOOSE BM X1. Has RIJ MML. PERIPHERAL PULSES CONFIRMED VIA DOPPLER - BSK CAP REFILL THROUGHOUT EXTREMITIES. PEARRLA.CV: ST w/o ectopy. Has sump via right nare. CONTINUE PER CURRENT PLAN OF CARE - O.R. PROTONIX QD FOR PROPHYLAXIS. Peripheral pulses w/doppler. Mdis given. MDis given. vanco/zosyn as ordered, tmax 99.5Skin: back with duoderm intact; vac as above; R corner of mouth with sm. On xigris infusion. notes/vent settings.GI: abd open, BS hypoactive, NGT to LCWS for sm. R sc TLCL and a-line wnl. NPO W/TPN INFUSING. Sx small clear via ETT. NPO W/TPN INFUSING AS ORDERED. EXTREMITIES WARM/DRY - PERIPHERAL PULSES CONFIRMED VIA DOPPLER - BSK CAP.REFILL THROUGHOUT. q4hr hct/coags.Resp: LS coarse, diminished at bases; suctioned for sm. Receiving diamox q 6 hr w/+ response.ID: Tmax 100.6 now afebrile. Fluid bolus given. REFER TO CAREVIEW FOR DETAILED C.O/C.I. Protonix for GI prophylaxis. PROTONIX FOR GI PROPHYLAXIS. ASSESSMENT AS NOTEDRES: REMAINS ON ARDS PROTOCOL, 14PEEP, BED PERCUSION Q1H, MAINTAINS SO2>95, SVO2>50. PB'S ON FOR DVT PROPHYLAXIS.HEME: HCT STABLE 27<->28, PT 15/INR 1.5/PTT 39 - LABS MONITOR Q4HR FOR XIGRIS PROTOCOL.RESP: LUNGS SOUNDS COARSE THROUGHOUT, SXN FOR SCANT AMTS THICK CLEAR/WHITE SECRETIONS. CONSISTENTLY F/C'S & MAE'S. REFER TO CAREVIEW FOR DETAILED CCO DATA.GI: ABD OPEN/OCCLUSIVE DSG INTACT. VAC dsg intact, draining mod. RECURRING STEROID DOSE DECREASED.ID: TMAX 100.0, CONTINUES ON FLUCONAZOLE, ZOSYN ADDED; LEVOFLOX/VANCO/FLAGY D/C'D.SKIN: ABD OPEN, COVERED W/STERILE TOWEL AND IOBAN TRANSPARENT DSG - INTACT. | 74 | [
{
"category": "Radiology",
"chartdate": "2107-03-16 00:00:00.000",
"description": "CT RECONSTRUCTION",
"row_id": 858403,
"text": " 9:00 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: PRIOR SB0\n Field of view: 50 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with h/o prior sbo p/w abd pain, n/v\n REASON FOR THIS EXAMINATION:\n r/o sbo\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DDBc WED 10:37 AM\n @ large ventral hernias containing both large and small bowel. Dilated and\n decompressed loops of small bowel sre seen. An exact transition point not\n seen.. Extensive artifact\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n CT ABDOMEN & PELVIS.\n\n INDICATION: Patient with small bowel obstruction previously. Now presenting\n with nausea and vomiting.\n\n TECHNIQUE: Axial multi-detector CT acquisitions of the abdomen and pelvis\n were acquired after the administration of oral and intravenous contrast.\n\n COMPARISON: No study available for comparison.\n\n REPORT\n\n CT LUNG BASES. There are nonspecific atelectatic changes identified in the\n lung bases.\n\n CT ABDOMEN & PELVIS.\n\n 2 large ventral hernias are seen. The most superior hernia has an orifice\n measuring 9 cm. There then appears to be a complete anterior abdominal wall\n before a lower pelvic ventral wall defect measuring 12 cm seen. Extensive\n streak artifact is identified with some hyperconcentrated barium and from\n artifact secondary to the patient's body habitus. Multiple discrete loops of\n colon. large bowel, mesentry and mesenteric vessels are seen within the\n patient's pannus. There are some distended as well as some decompressed loops\n of small bowel, suggesting at least a partial functional component to these\n hernias. The exact size of transition is not identified. The distended bowel\n loops measure up to approximately 3 cm, which is just at the upper limit of\n normal in size. The colon is not distended.\n The liver appears normal. Again, parts of the liver are poorly visualized\n due to streak artifact. No gallstones are seen. Pancreas appears normal.\n Normal spleen. Both kidneys show good uptake and excretion of contrast.\n Normal adrenal glands are seen.\n\n CT PELVIS. A ventral wall defect in the pelvis is seen. The uterus appears\n normal. Normal bladder and distal ureters.\n (Over)\n\n 9:00 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: PRIOR SB0\n Field of view: 50 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n CT BONES.\n Some degenerative disease is identified in the lower lumbosacral spine\n evidenced by vacuum formation within the disc. Vacuum formation within the\n SI joints bilaterally is also seen. In addition, some facet joint\n degenerative disease identified in the lumbosacral junction.\n\n CONCLUSION:\n\n 2 large ventral wall defects containing much of the patient's large and small\n bowel, mesentry. Both decompressed and distended small bowel loops are\n identified suggesting at least partial functional component. Exact size of\n this cannot be estimated due to the poor quality of the study secondary to\n technical problems.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2107-03-22 00:00:00.000",
"description": "Report",
"row_id": 103547,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 62\nWeight (lb): 285\nBSA (m2): 2.22 m2\nBP (mm Hg): 106/64\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 10:54\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: Definity\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. Mild global\nLV hypokinesis.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. RV function depressed.\n\nAORTA: Normal aortic root diameter.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Borderline PA systolic\nhypertension.\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 mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. There is mild global left\nventricular hypokinesis. The right ventricular cavity is mildly dilated. Right\nventricular systolic function appears depressed. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. There is borderline pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: These findings are most c/w a non-ischemic cardiomyopathy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-04-04 00:00:00.000",
"description": "GUID WIRES INCL INF",
"row_id": 860724,
"text": " 10:36 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please advance PICC line\n Admitting Diagnosis: ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * REPOSITION CATHETER FLUORO 1 HR W/RADIOLOGIST *\n * -59 DISTINCT PROCEDURAL SERVICE C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with sbr for dead bowel\n REASON FOR THIS EXAMINATION:\n please advance PICC line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Small bowel resection for necrotic bowel. Needs long-term\n intravenous (IV) access.\n\n PHYSICIANS: The procedure was performed by Dr. and Dr. \n Di with Dr. being present and supervising.\n\n PROCEDURE AND FINDINGS: The patient was placed supine on the angiography\n table. Her right arm was prepped and draped in a sterile fashion. A 0.018\n Glidewire was advanced through an existing right-sided antecubital PICC line.\n The tip of the PICC was in the subclavian vein. With the help of a guidewire,\n the tip of the PICC was readjusted into the superior vena cava under\n fluoroscopic guidance. The catheter was flushed. A final chest x-ray was\n obtained. The film demonstrates the tip to be in the superior vena cava just\n above the atrium. The line is ready for use. A StatLock was applied, and the\n line was heplocked.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Successful repositioning of right antecubital PICC line with its\n tip in the superior vena cava, ready for use.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-19 00:00:00.000",
"description": "Report",
"row_id": 313120,
"text": "Sinus tachycardia\nShort PR interval\nAnterior ST elevation - repeat if myocardial injury is suspected\nGeneralized low QRS voltages\n\n"
},
{
"category": "ECG",
"chartdate": "2107-03-18 00:00:00.000",
"description": "Report",
"row_id": 313121,
"text": "Technically difficult study\nSinus tachycardia\nShort PR interval\nNondiagnostic inferior Q wave - consider inferior infarct - age undetermined\nLow voltage\nSuggest repeat tracing\nClinical correlation is suggested\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-25 00:00:00.000",
"description": "Report",
"row_id": 1406279,
"text": "T/SICU Nursing Progress Note\nS:\nO: Neuro: On propofol and receiving intermittent doses of fentanyl for c/o abdominal pain. Opens eyes to voice, nods appropriately to questions. Moves all extremities. Able to lift arms off bed but not legs.\nCVS: stable heart rate and rhythm. Peripheral pulses palpable. Obtaining BP per R lower arm non invasive cuff. BP 90-110 systolic. CVP 12-15.\nRESP: remains on imv 12X450 50% 14 peep with sats 94-97%. Suctioned for thick white secretions. REceiving albuterol per RT.\nRENAL: Mg 1.9, repleted. Urine output 40-80/hr. BUN and cr acceptable.\nGI: remains npo without audible bowel sounds. REceiving TPN+lipids for nutrition. NG to suction. Dobhoff clamped. On protonix for prophylaxis\nID: off antibiotics, wbc down to 27.8, t max 100.0. Cultures from yesterday still pending\nHEME: hct down to 26, previous 32. INR 1.4. On pneumoboots and lovenox.\nEndo: on insulin gtt. Continues to receive solumedrol.\nSKIN: Large ulceration on R corner of mouth and across r side of face. Underneath fat folds on back area is broken. Abdomen remains open with VAC dressing in place with great function. Remains on Baricare bed rotating side to side\nLINES: has new triple lumen Lsc placed .\nSOCIAL: s/o in on evenings to visit and health care proxy and friend called over night and was updated.\nA: improving hemodynamics. Hct drop, continued elevated wbc, continued totatl body fluid overload\nP: ??need for transfusion\nKeep following cultures\nConsider gently diuresis\nContinue excellent skin and wound care\nContinue to support family with information and emotionally.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-25 00:00:00.000",
"description": "Report",
"row_id": 1406280,
"text": "Resp Care\n\nPt's peep decreased to 12 from 14. Pt had been doing well spo2 in the 94% range. After suctioning spo2 dropped to 92%. Eventually returned to 95% without increasing peep. Bs diminished small amts on white sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-25 00:00:00.000",
"description": "Report",
"row_id": 1406281,
"text": "T/Sicu NSg Note\n0700>>\n\nEVENTS: Vac dsg changed by team today\n Lasix today w/effect\n Trophic tube feeds started\n PEEP decreased to 12cm(14)\n\nNeuro- no changes..see previous note. Remains on propofol with light sedation-opens eyes and moves extremities. Cont to receive prn fentanyl for pain w/effect. Cooperative.\n\nCVS- vital signs have remained stable with NSR, no ectopy and MAP's >60. CVP 18-22. Warm extremities with palpable pulses.\n\nRESP- SIMV w/PSV continues. Only chnage has been a slight decrease in PEEP to 12cm. With no arterial line for abg's, sats are being followed closely as well as pt's WOB. Spontaneous tidal volumes are >550-600cc. Total RR remains in teens. Breath sounds are coarse to clear & diminished at bases. Cough is weak & congested; secretions are small amounts of thick white sputum. Pt will desaturate to 92 following suctioning, but recovers to 94-96 range with time.\n\nRenal- effective response to lasix; pt currently negative ~ 350cc.\n..K+ repleted.\n\nID- temp max of 101 orally. No new findings on pnd cultures.\n flagyl started for ? c.diff( 1sr spec negative; no further stool at this time.)\n\nHeme- hct to 25(26.5)\n\nGI- VAC DSG changed this am; wound base is moist/pink. Drainage has changed from s/s to brickish in color. (~ 300cc). FIB in place w/no additional stool. Protonix continues.\nTPN continues. Trophic tube feeds started via post-pyloric feeding tube.\n\nENDO- continues on insulin drip with increase in rate for glucose levels >140...currently @ 5u/hr with value of 95.\n\nSkin- no new changes; see previous note and careview assessment.\n..lovenox, compression boots, multipodus boots in use. Bari-air bed in use with side to side rotation ongoing.\n\n friends & HCP visited today.\n\nAssess- ongoing slow progress.\n tolerating diuresis\n temp spike again to 101\n tolerating decrease in peep so far\n hct drop of ? etiology\n\nPLAN- follow hct & signs of blood loss\n monitor gastric drainage for reflux of tube feeds\n monitor blood sugars\n monitor temp for ongoing spikes\n follow sats for values <92\n cont w/ current POC\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-22 00:00:00.000",
"description": "Report",
"row_id": 1406270,
"text": "Pt remains on current vent settings, see carevue for details. No vent changes made this shift. Plan to go to OR tommorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-23 00:00:00.000",
"description": "Report",
"row_id": 1406271,
"text": "Respiratory Care:\nPatient remains on ventilatory support (A/C) with no parameter changes made throughout the night. No abg results at this time.\n\nNo RSBI measurement due to the level of PEEP and FIO2 requirements of the patient.\n\nPlan for patient to go to OR this am for abdominal closure and ? of trach placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-23 00:00:00.000",
"description": "Report",
"row_id": 1406272,
"text": "ASSESSMENT AS NOTED\n\nRES: REMAINS ONARDS PROTOCOL, 70%, 14 PEEP, WITH MARGINAL SO2 90-93\nHAS VISCOUS/THICK SPUTUM BOTH NASALY AND IN ETT AND ORALY. LS COARSE\nAIR BED PERCUSIONS Q1H\n\nCV: PA LINE INTACT , WEDGE 20-16, PRESSURES 40S, IN NSR NO ECTOPY.\nGEN. EDEMA, WEAK PULSES. A/LINE WAS NOT INSERTED (H/O WAS UNABLE)\n\nNEURO: AWAKE WHEN OFF SEDATION AND GROSSLY INTACT, FOLOWS COMMANDS. COMMUNICATES WITH GESTURES\n\nGI: HAD MOD BM LAST NIGHT-O.B. POSITIVE. HAS FAINT BOWEL SOUNDS AT TIMES, NG TUBE DRAINED 50CC, JP TOTAL-750\n\nSKIN: ABRASIONS ON THE BACK FOLDS, ABD DRESSING INTACT, ON AIR BED ROTATION\n\nENDO: RI AT 4.5U/H\n\nPLAN:TO OR 0930 WASHUOT, 2U PC ARE READY ON HOLD\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-23 00:00:00.000",
"description": "Report",
"row_id": 1406273,
"text": "T-SICU NPN 0700-1900\n\nEVENTS: To OR today for washout with sm. bowel resection for sm. piece of necrotic bowel. OR course stable.\n\nNeuro: Sedated on propofol gtt, fentanyl prn with adequate pain relief per pt report. Pupils equal and reactive, MAE's, follows commands.\nCV: HR 70-80's SR, no ectopy noted. BP 90-100/50's, CVP 7-8, wedge 11=19, PAP's 40's/20's, see careview for swan specific values. Skin warm, dry. Pedal pulses faintly palpable, confirmed by doppler. MD's unable to place a-line in OR; re-attempted by Dr. in ICU post-op, unable to obtain access at this time. PB's for DVT prophylaxis, lovenox started this afternoon. hct 34.\n\nResp: LS coarse, diminished; suctioned for sm. amts. thick white, occ. yellow sputum; large amt. clear oral secretions; FIO2 weaned to 60%, tolerating well, O2sats 95%, see carevue for specifics/resp. notes.\n\nGI: abd obese, open, VAC dsg intact. Absent BS, NGT to LCWS for sm. amts. bilious drainage; dobhoff clamped. Large amt. liquid green stool this am; 1st spec sent for c-diff; fecal incontinence bag placed. TPN as ordered. Protonix for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in adequate amts. Calcium, Kcl and magnesium repleted.\n\nEndo: BS 90-100 with insulin gtt currently at 5units/hr.\n\nID: tmax 101.4; BC x2 sent from TLCL and swan upon return from OR. No further cultures MD. WBC 21.7. Conts. zosyn/fluconazole.\n\nSKin: open blisters to back folds with scant drainage; adaptic with dsd applied. Buttocks intact, fecal inc. bag applied as above. R corner of mouth with breakdown d/t ett; OTA.\n\nPsych/social: pt's hcp and . other both in today; both spoke with Dr. , affect/questions appropriate, emotional support provided.\n\nA: s/p washout with sm. bowel resection for sm. section of necrotic bowel\n\nP: Monitor VS, I/O, labs/cultures, hemodynamics. Maintain sedation/comfort. Cont. slow vent wean as tolerated. Ongoing comfort/support to pt and family/friends.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-24 00:00:00.000",
"description": "Report",
"row_id": 1406274,
"text": "ASSESSMENT AS NOTED\n\nRES: DOWN TO 50%-TOL WELL WITH SATS IN 95-96. COARSE LS WITH THICK YELOWISH SECRETIONS. WEAK COUGH. BED ROTATING AND PERCUISIONS Q1H\n\nCV: PA LINE WAS REFLOATED AT 0530 AND NOW AT 55CM, WEDGE 14-16, CVP 12\n PA PRESSURES AND CO ARE CONSISTANT OVERNIGHT,SBP IN 90-100S WHEN SEDATED. NO ECTOPY, NSR\n\nNEURO: NODS WHEN OFF SEDATION, MAE ARMS>LEGS, SEDATED ON PROPOFOL AND FENTANY L GIVEN FOR PAIN CONTROL\n\nGI: NGT DRAINED 400CC, VAC - 550+, NO BS , NO STOOL, ABD VAC DRESSING INTACT\n\nID: WBC>31, STARTED ON VANCO LAST NIGHT X 2 DOSES(LAST WILL BE AT 10AM TODAY), LOW GRADE TEMP WITH FAN ON ALL NIGHT. NO TYLENOL WAS GIVEN\n\nENDO/LABS: ON RI GTT 5U/H, BS 90-110, K AND MAG WERE REPLETED\n\nSKIN: LESS OOZING THE BACK FOLDS: WASHED AND COVERED WITH CLOTH\nAS WELL AS ABDOMINAL AND BREAST FOLDS\n\nPLAN: TO PLACE A.LINE\n PLAN FOR TRACH\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-24 00:00:00.000",
"description": "Report",
"row_id": 1406275,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with the FIO2 decreased to 50%. Arterial line to be attempted today, in order to facilitate realistic weaning goals. No morning abg results at this time.\n\nNo RSBI performed due to the level of PEEP currently required.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-24 00:00:00.000",
"description": "Report",
"row_id": 1406276,
"text": "Respiratory Care\nPt weaned to CPAP/PSV of 14cm peep and 10 psv. Appears to be talerating well. MDI given as ordered. Breath sounds diminished.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-24 00:00:00.000",
"description": "Report",
"row_id": 1406277,
"text": "T-SICU NPN 0700-1900\n\nEvents: L sc PA catheter dc'd today; introducer changed over wire for quad lumen central line; R IJ TLCL dc'd, both tips sent for culture.\n\nROS:\nNeuro: Lightly sedated on propofol gtt, fentanyl 50mcg prn for c/o abd pain with adequate relief per pt report. Opens eyes spontaneously and to verbal stimuli; MAE's, follows commands consistently.\n\nCV: HR 80's SR, no ectopy noted. BP 99-110's/30-40's, CVP 10-14. Line changes today as noted above. Skin warm, dry. Pedal pulses faintly palpable, confirmed by doppler. Conts. lovenox, dose increased to 40mg q12hrs. PB's for DVT prophylaxis.\n\nResp: LS coarse, diminished at bases; suctioned for sm->moderate amts. thick white/yellow secretions, mod. amt. oral secretions. Pt placed on CPAP this afternoon, vent settings; CPAP 14 PEEP, 10PS, FIO2 weaned to 50%; Vt 600's, RR 20. O2 sats currently 91-94%. Continue to monitor closely. See carevue for data/resp. notes.\n\nGI: abd obese, open, BS absent. NGT to LCWS for sm.->moderate amts. bilious drainage. Dobhoff clamped. TPN conts. as ordered. Fecal inc. bag intact, scant green stool in initial portion of bag; 1st stool for c-diff sent yesterday. VAC dsg intact with moderate amts. serosang. drainage. Protonix for GI prophylaxis.\n\nGU: foley patent draining approx. 25-65cc/hr clear yellow urine.\n\nEndo: BS 144->120's, insulin gtt titrated, see carevue.\n\nID: tmax 101.2, currently 100.7; wbc 31; abx dc'd today, BC last sent 1500 .\n\nSkin: buttocks intact; back folds with pink, open blisters, scant serosang. drainage, telfa to sites. Open abd with VAC intact as above. R corner of mouth with breakdown d/t ett, open to air.\n\nPsych/social: pt's HCP in to visit this afternoon, affect/questions appropriate, emotional support provided.\n\nA: s/p sm. bowel resection for necrotic bowel, +sepsis\n weaned off pressors\n\nP: Monitor VS, I/O, labs/cultures, hemodynamics, pain->med. prn. Maintain sedation/comfort. Cont. slow vent wean as tolerated, aggressive pulmonary hygiene. Continue ongoing comfort/support to pt and family/friends.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-25 00:00:00.000",
"description": "Report",
"row_id": 1406278,
"text": "Resp. care note - Pt. remaines intubated and vented, no vent changes made at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-27 00:00:00.000",
"description": "Report",
"row_id": 1406287,
"text": "T-SICU NPN\nS/O:\n\n\nNEURO:Sedated on propofol drip, fent boluses for pain control. Opens eyes, MAE's to command, and nods/gestures appropriately.\n\nCV: HR 70-85 SR, no ectopy. Lytes repleted x 1, now wnl. SBP:90-130's, w/ MAP:60-70. CVP:13-17. Pneumoboots in place.\n\nRESP: Intubated and vented. Weaned to PSV 5/5PEEP X 40%. RR:20-26, Tv:400-560, sats:94-95% Sxn'd for mod amts of thick ,pale yellow secretions. Anticipate possible extubation today.\n\nGI: Abd large and soft. Vac dsg to abd intact, draining serosang drng. NPO w/ TPN. Promote w/ fiber at 20cc/hr via post-pyloric tube. NGT to lcws for small amts of bilious output.\n\nGU: Foley patent for 100-400cc/hr clear yellow urine. Lasix x 1 w/ gd effect. BUN/CR stable.\n\nHEME/ID: Hct stable at 28. WBC 19(20). Tmax: 101.1->99.6. No stool output for c.diff spec.\n\nENDO: Blood glucose:106-124 on 4u/hr reg. insulin gtt.\n\nSKIN: 2 Lacs to back skin folds w/ small amt of serosang drng. Thin duoderm placed. Please follow. Bariair bed not turning appopriately, and will need attention by KCI reps who have already been notified.\n\nSOCIAL: Pt's S.O. into visit last eve.\n\nA: Tolerating PSV wean.\n\nP: Cont. to monitor tolerance to PSV wean. Replete lytes as needed. Titrate insulin drip as needed. Wean sedation in anticipation of extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-27 00:00:00.000",
"description": "Report",
"row_id": 1406288,
"text": "Resp Care\npt remains on vent and stable. mdis given. pt suctioned for large amt of yellow thick secretions. Increased settings due to poor blood gas results. Notable increase of secretions. Plan to wean as tolerated and cont. with bronchial toliet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-27 00:00:00.000",
"description": "Report",
"row_id": 1406289,
"text": "T-SICU Nsg Note\n See flow sheet for details.\nNeuro - when propofol dose lower, pt alert, restlesss, communicating by gesture and nodding. Asking to sleep. Occ smiles.\nResp - copious yellow sputum today. Frequent suctioning and also copious oral secretions. PSV increased to 12cm with most recent ABG improved.\nGU - continues to diurese on own, no lasix given this shift. Lytes repleted.\nGI - TF changed to 3/4 strength Promote with fiber. Rate 30cc/hr plan to advance to goal of 90cc/hr. Rectal bag with , removed this afternoon. Small amt loose green stool. Stool sent for C. diff.\nID - flagyl discontinued today.\nEndo - insulin drip 4-5.5units/hr today. Glucose levels 100-120 today.\nSkin - abrasion on R corner of mouth healing. Abrasion on back of neck healing. DUoderm on back abrasions intact. Vac dressing changed today. Abd wound pink, granulating, clean.\nA: More sputum today. Increased PSV with improved ventilation. Wounds healing. Pt asking to sleep.\nP: continue to repelete lytes. Monitor blood glucose levels and titrate insulin drip. Informational support to pt and family and friends.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-28 00:00:00.000",
"description": "Report",
"row_id": 1406290,
"text": "Resp: pt on psv 12/8/50%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral clear apecies with diminshed bases. Suctioned for small amounts of thick yellow secretions. MDI's administered Q4 hrs Alb with no adverse reactions. ETT @ 24 lip, cuff pressure 20. AM ABG's 7.43/47/73/32. RSBI=142. Will continue to wean appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-26 00:00:00.000",
"description": "Report",
"row_id": 1406282,
"text": "T/SICU Nursing Note\nS:\nO: Neuro: continues on propofol and intermittent doses of fentanyl for pain. Lightly sedated. Opens eyes, nods,mouths words. Attempts to write but it is illegible. Moves all extremities.\nCVS: stable. HR 70's no ectopy. CVP14-20, peripheral pulses present\nRESP: no vent changes. Remains on imv 12 X 450 50% 12 peep. Sats 94-97. Suctioned for thick white secretions. Continues on albuterol and solumedrol\nRENAL: weight today 171.5 kg, baseline weight 150 kg. Received lasix 10 mg X 1. Urine output adequate. Electrolytes repleted.\nGI: receiving trophic feedings of fs promote with fiber @10/hr. Absent bowel sounds. Small amount of liquid green stool in fecal incontinence bag. On protonix\nENDO: on insulin gtt, titrating to keep bs<120.\nID: wbc down to 20. On flagyl. T max 101\nHeme: received 1 u prbcs for hct of 25. Repeat hct 27. On lovenox and pneumoboots.\nSKIN: large abdominal vac dressing to open abdomen, draining colored drainage. Broken area at r corner of mouth. Also has broken area on back underneath two fat folds. This began to bleed after being gently cleansed. Telfa placed. Remains on Baricare bed.\nLINES: L sc triple lumen in place\nSOCIAL: health care proxy called for update\nA: stable s/p ischemic and necrotic bowel. ??etiology for decreasing hct. Respiratory failure\nP: Follow hct. ??decrease peep to 10. ??place art line for abg monitoring. Continue meticulous skin care. Support family and pt with information and emotional support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-26 00:00:00.000",
"description": "Report",
"row_id": 1406283,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Current settings IMV/PS 450*12 50% with 12 peep and 10ps. Breathsounds are decreased at bases. Albuterol given. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. Wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-26 00:00:00.000",
"description": "Report",
"row_id": 1406284,
"text": "Resp Care\n\nPt remained intubated and on SIMV/PSV ventilation. Peep was weaned fo 8 form 12 with no drops in Spo2 which remained in the high 90's. Bs diminished\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-26 00:00:00.000",
"description": "Report",
"row_id": 1406285,
"text": "T_SICU nsg note\n Pt had visitors much of day today. While visitors here, propofol off or at low levels so pt could interact. PT tried to use letter board, picture board and writing, none of these methods worked - pt too frustrated. Pt communicates by nodding to questions and gesturing. Pt sedated on propofol as she is very restless off propofol. Medicated with fentanyl prn for pain. Follows commands, purposeful.\n Art line placed in R radial artery. Diastolic BP much higher via artline than NBP on forearm, and MAP also higher.\n Tolerated decreased PEEP and now PSV.\n DIuresesd well from lasix dose about 06.\n TF increased to 20cc/hr via post-plyoric feeding tube. NG clamped after meds given via NG. Small amt green liquid stool in rectal bag.\n Hct stable at 27.\n Insulin drip 3-4units/hr all day.\nA: diuresing, weaning from vent, interactive.\nP: replete lytes, monitor blood glucose levels and titrate insulin drip.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-27 00:00:00.000",
"description": "Report",
"row_id": 1406286,
"text": "Resp Care Note, Pt weaned down to 5/5 with good VT'S and RR. Suctioned for mod amts thick pl yellow secretions. MDI'S given. Sedated with propofol. RSBI done on 0 peep/5 ips 63. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-29 00:00:00.000",
"description": "Report",
"row_id": 1406298,
"text": "T-SICU NPN 0700-1900\n\nNeuro: Lightly sedated on propofol gtt with prn fentanyl for pain with (+) relief per pt report. Follows commands consistently, MAE's, re-oriented prn to place, hospital course, etc. Propofol gtt off 1700-1900, ativan 4mg given total per Dr. ; pt became tachycardic, tachypneic, HTN, propofol restarted MD with effect.\n\nCV: HR 80-90's SR, BP 110-140's/60's, CVP 12-14. Skin warm, diaphoretic this am. Pedal pulses weakly palpable. A-line changed over wire, L sc TLCL dc'd, new R sc TLCL placed d/t +BC. Lovenox and PB's for DVT prophylaxis.\n\nResp: LS coarse, suctioned for sm->moderate amts. thick white/yellow secretions. Placed on CPAP this am, PEEP 8->6, PS 12, FIo2 50%, Vt 600. ABG-> 7.42/45/90/3/30. See carevue for labs/resp. notes.\n\nGI: abd open, BS present. NGT to LCWS for sm. amt. bilious/brown drainage. TF changed to VHP peptamen at 90cc/hr via dobhoff. Rectal bag leaked and replaced x2, currently with rectal tube in place. Large amts. liquid/loose brown stool. VAC dsg changed by MD today, draining mod. amts. serous fluid. Protonix for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in mod. amts. Diamox started, >3L neg. thus far today. Kcl repleted.\n\nEndo: BS 90-130's, insulin titrated accordingly.\n\nID: tmax 102; tylenol x1 given; BC+, conts. vanco/zosyn.\n\nSkin: back folds with duoderm in place; breakdown noted to back of head, OTA. VAC as above.\n\nPsych/social: hcp and . other in to visit today; update provided; affect/questions appropriate.\n\nA: s/p necrotic bowel requiring exp. lap, sm. bowel resection\ntol. slow vent wean, diuresis\n\nP: Monitor VS, I/O, labs/cultures. Aggressive pulmonary hygiene, re-orient prn. ?trach this week. Continue ongoing comfort/support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-29 00:00:00.000",
"description": "Report",
"row_id": 1406294,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned mod amts thick yellow secretions. MDI'S given.Temp 99. Sedated with propofol. RSBI done on 0 peep/ 5 ips 86. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-02 00:00:00.000",
"description": "Report",
"row_id": 1406309,
"text": "NSG NOTE:\nPT ALERT INTERACTIVE MOUTHING WORDS APPROPRIATE BUT OVER NIGHT STARTED TO PICK AT FEEDING TUBE AND KEPT DISCONNECTING TRACH. soft wrist restraints applied at 12mid and removed during am care at 6am. pt given ativan times one for apparent anxiety.\n\ncv stble\n\nlow grade temp on levoflox and vancomycin\n\nurine brisk\n\nvac dsg intact, draining sm amt of murky ser/sang drainage.\n\non vent 5peep 5 ps. resp rate 20's.sats 98% abg adequate. suctioned for thick white mucoid sputum strong cough.\ntube feeds at goal, no insulin requirments, sm amt of liq brown stool thru mushroom cath.\n\nduoderm on back intact abrasion on lip not. draining, no other skin issues noted.\n\nmag and cal to be repleted now.\n\np. place back on trach mask.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-02 00:00:00.000",
"description": "Report",
"row_id": 1406310,
"text": "Respiratory Care:\nPt placed on trach collar via cool mist at 40% FiO2 at approx 8am this morning; tolerated well throughout shift. MDI's given as ordered & flovent started. Suctioned throughout day for white secretions. Trach care given; site intact. Plan to ventilate pt throughout night & place on trach collar in a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-02 00:00:00.000",
"description": "Report",
"row_id": 1406311,
"text": "T/Sicu Nsg Note\n0700>>1900\n\nEVENTS: trach collar since 0800\n lasix x3 today for ~ 2L goal negative\n alert & interactive with staff/visitors\n\nNEURO- alert, oriented x1. C/O abdominal pain x2 today; fentanyl 50mcg ivp x2 with improvement. MAE'S; follows commands. Mouthing words and gesturing to communicate. Pt repeatedly asking & commenting about her asthma & asthma medications. Occasional bronchospasm and mild wheezing following ambu/suctioning, otherwise lunga are clear, decreased and congested at times. Pt states \"Why does it feel like it's worse{the asthma}\"? Pt was reminded that she is receiving her inhaler treatments on a regular schedule & prn; that her lungs have been relatively clear; that her resp rate & O2 sats are wnl; ALSO, that she has been on trach collar & she may be feeling the WOB.\nPt has remained unrestrained all day w/o picking or pulling at tubes; occ pt will remove trach collar to cough & forget to replace it... necessity of oxygen reinforced to pt.\n\nCVS- vss, nsr w/o ectopy. see careview for specific values.\n\nRESP- trach collar @ 40% with RR teens to 20's. BS clear to coarse & diminished at bases. Strong cough but inconsistent at clearing thick secretions; requires occ suctioing for thick mucus which is slightly blood tinged now. sats remain 94-100% but drop to 88 with trach collar removed for any length of time. Pt is unable to articulate what is bothering her about her asthma/breathing situation, but remains somewhat obsessive about it.\n\nRENAL- adequate u/o via foley. LASIX 10mg ivp x3 today; 1st dose @ 1100 with vigorous response. Goal is ~ 2L negative. Potassium repleted.\n\nGI- TF's at goal via post-pyloric FT. Abd obese/soft. Mushroom catheter in place with scant liquid stool today.\nPrevacid ongoing.\n\nID- t /max 100. continues on vancofor GPC in blood culture; vanco trough level due before 0400 dose\n wbc w/o change\n\nEndo- covered x1 per ssri scale.\n\nHEME- stable HCT\n\nSKIN- breakdown in back folds ongoing with sanginous drainage...aquacel & tegaderm covering applied.\n NEW breakdown site noted under left panus area: 2 sized stage 2 pressure areas; no drainge- Duoderm applied.\n.. Compression boots & lovenox ongoing.\n\nSocial- S.O., friend , and HCP- visiting toay; pt very interactive with visitors. Pt able to enjoy a TV movie and music on her radio today. Smiling a lot.\n\nASSESS- tolerating trach collar since 0800\n pt with persistent mild anxiety - clonidine patch in place; prn haldol & ativan.\n\nPLAN- continue with current POC\n attempt trach collar for 12 hours today(to )\n continue with reorientation & reassurance measures.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-03 00:00:00.000",
"description": "Report",
"row_id": 1406312,
"text": "Respiratory Care:\nPatient returned to ventilatory support at 20:00 (CPAP/PSV) to rest for the night. Will continue trach collar trials in the am. No abg results at this time.\n\nRSBI = 53.8 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-05 00:00:00.000",
"description": "Report",
"row_id": 1406319,
"text": "ASSESSMENT AS NOTED\n\nRES:ON TRACH COLLAR COOL MIST,MAINTAINS SO2>96, +STRONG COUGH PRODUCTIVE FOR THICK WHITE, LS COARSE, TRACH IS INTACT, PATENT\nSUCTIONED Q1H FOR SMALL AMNTS.\n\nCV: STABLE, CUFF WAS SWITCHED TO SHOULDER FROM FORARM , NSR, NO ECTOPY\n\nNEURO: MAE , FOLLOWS, MOUTH TALKS, GETS OXYCODON FOR PAIN\n\nGI: AT THE GOAL-TOLEREATES WELL, OOZING SM AMNTS OF LIQUID STOOL,RECTAL BAG STARTED LEAKING LAST NIGHT AND WAS REPLACED BY MUSHROOM CATH.\n\nSKIN: AS PER CAREVUE\n\nGU SEE CAREVUE\n\nENDO: RISS IN USE\n\nPLAN: TRANSFER TO REHAB\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-05 00:00:00.000",
"description": "Report",
"row_id": 1406320,
"text": "Resp. Care:\n Pt. continues on 70% cool aerosol trach. collar. Flovent MDI given per nsg. approx. 0400. BS-sl. diminished, but no wheezes-without albuterol this shift. Sx'ng for thick white secretions, and Pt. also raises on own. Plans for transfer to re-hab facility soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-20 00:00:00.000",
"description": "Report",
"row_id": 1406260,
"text": "ROS:\n\nNeuro: On propofol until 0400, off d/t sustained hypotension and preventing weaning off of levophed. Alert, MAE's x's 4. Follows commands. Nod's head yes/no to questions asked. c/o sore throat. Fentanyl 25 mcg given w/relief. PEARRLA.\n\nCV: RSR->ST w/o ectopy. Vasopressin and Levo weaned off, maintaining MAP >60. Left radial ABP line non functioning and unable to be rewired by Dr. , HO. Resited to right brachial, tubing changed, when attempting to draw blood new aline becomes non functioning, Dr. aware. Peripheral pulses w/doppler only. Has RIJ Multimed port. Has left subclavian CCO swan, see flow record for #'s. P boots on prophylacticly.\n\nResp: Remains orally intubated and on vent, AC 30x450, peep 14, FIO2 80%. Sats 97->99%. Lung sound clear and diminished. Sx clear/white via ETT. Weak to strong cough. No resp distress noted, = rise and fall of chest. SVO2 50->66. Esophageal balloon in place.\n\nGI: sump via right nare to LCS draining bile. Abd obese. No bowel sounds auscultated. Abd open w/trasparent dressing inplace. 4 JP's intact and connected to LCWS draining reddish brown.\n\nGU: Foley patent draining yellow to green (propofol) urine in QS.\n\nEndo: FSG covered w/insulin gtt.\n\nID: Remains on xigris and ATB as noted yesterday. Temp down to 98.8 core temp.\n\nLabs: IC and K repleted this shift.\n\nSocial: Friend in during the evening to visit. SO, phoned during the for update.\n\nPlan: ? Change swan out today d/t fluid back up in protective sheath. A line placement. Continue to monitor, tx, and support.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-20 00:00:00.000",
"description": "Report",
"row_id": 1406261,
"text": "T-SICU NPN 0700-1900\nSee carevue for specifics. Review of systems:\n\nNeuro: Lightly sedated on propofol, opens eyes to verbal stimuli; follow commands, MAE's. Able to nod head yes/no to simple questions, attempting to write with pad and pencil. Fentanyl 25mcg x1 for c/o abd pain with (+) effect per pt.\n\nCV: HR 90-105 ST, no ectopy. CO , CI2.7-4.5. No a-line placement per team due xigris infusion/bleeding risk; SBP 78-90/ on L arm via doppler, now able to obtain NIBP pressure 90's/40's (84 via doppler). Hemodynamics essentially unchanged over day, see carevue for specifics. Skin warm, dry. Pedal pulses via doppler. PB's for DVT prophylaxis.\nHeme: hct 27.8, PT 15.6/PTT50.9/1.5\n\nResp: LS coarse, diminished; suctioned for sm->moderate amts. thick clear/white sputum; sm. amts. oral/nasal drainage. RR decreased to 28, taking few breaths over vent; unable to obtain ABG's. Following pt clinically per team. O2sats 94-96%.\n\nGI: abd open, BS absent. NGT to LCWS for moderate amts. bilious drainage. JPx4 to wall suction for sm. amts. serosang.->tan/brown drainage. TPN initiated this evening. Protonix for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine with occ. sediment in adequate amts. Potassium repleted. IVF KVO'd.\n\nEndo: BS 70-100, no insulin gtt at this time.\n\nID: tmax 100.3; conts. fluconazole, flagyl, levofloxacin, vanco dose increased to 1500mg.\n\nSkin: buttocks intact; back with old open blister draining scant serosang. fluid; new blister remains intact. On barair bed.\n\nPsych/social: pt's mother called from ; update provided. Sig. other and HCP both in to visit today; encouraged by pt's interactions; questions answered, emotional support provided.\n\nA: s/p exp. lap with sm. bowel resection for necrotic bowel; septic, weaned from pressors, requiring vent support\n\nP: Monitor VS/hemodynamics, coags/hct q4hrs. Xigris per protocol, aggressive pulmonary hygiene. ?return to OR for ?attempted closure ? Wednesday. Maintain sedation/comfort. Ongoing open communication with pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-20 00:00:00.000",
"description": "Report",
"row_id": 1406262,
"text": "Patient on PEV protocol pressures measured today.She does not have an arterial line VBG drawn,result acceptable.RR decreased to 28,peep 14,FI02 80%.BS diminished;patient alert,coop,writting note to clinicians will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-29 00:00:00.000",
"description": "Report",
"row_id": 1406295,
"text": "ROS:\n\nNEURO: ON PROPOFOL AT 40 MEQ/KG/MIN. ALERT FOLLOWS COMMANDS. COMMUNICATES VIA MOUTHING WORDS. NEURO INTACT. CONFUSED TO DATE/TIME. MAE X'S 4. C/O ABD PAIN, PHENTANYL GIVEN IV W/RELIEF OF PAIN.\n\nCV: RSR W/O ECTOPY. VSS. PERIPHERAL PULSES WEAK TO PALPATION. HAS RIGHT RADIAL ABP LINE AND LEFT SUBCLAVIAN MULTI MED LINE W/CVP = 8->12. GENERALIZED PITTING EDEMA. P BOOTS AND ENOXOPARIN SQ BOTH FOR DVT PROPHYLAXIS.\n\nRESP: REMAINS ORALLY INTUBATED AND ON VENT CPAP+PS , 50 %. LUNG SOUNDS COARSE SX DARK YELLOW. LARGE AMT OF CLEAR PO SECREATIONS. SATS 94->97%. C/O DIFFICULTY BREATHING WHEN HOB FLATTEND FOR REPOSITIONING. SOB GOES AWAY WHEN HOB^.\n\nGI: SUMP VIA RIGHT NARE TO LCWS DRAINING BILE. POST PILORIC PEDI TUBE VIA RIGHT NARE W/IMPACT W/FIBER 3/4 STRENGTH INFUSING AT GOAL OF 70CC/HR. ABD OPEN, VAC DRESSING INTACT DRAINING SEROUS FLUID. PROTONIX PROPHYLACTILY.\n\nGU: FOLEY PATENT DRAINING CLEAR YELLOW URINE IN QS. RECEIVING LASIX IV X'S 5 DOSES. 5TH DOSE WILL BE GIVEN AT 0600 TODAY. GOOD RESPONSE FROM LASIX THUS FAR.\n\nLABS: IC 1.09, REPLETED W/2 GM CA+ GLUCONATE, MAG 1.9, REPLETED W/2GM MGSO4. OTHER LABS STABLE.\n\nID: TMAX 99.6 PO. BLOOD CULTURES FROM A LINE BOTH BOTTLES GROWING GM + COCCI IN PAIRS AND CHAINS. ALSO BOTH GROWING GM - RODS. STARTED ON VANCO AND PEPERACILLIN.\n\nSOCIAL: PHONE CALL MADE TO LAST EVENING PER PATIENT'S REQUEST. PHONE HELD TO EAR TO ALOW TO TALK TO RUSTY.\n\nPLAN: CONTINUE TO SUPPORT, MONITOR, AND TX. PULMONARY TOILETING. COMFORT. VAC DRESSING CHANGE TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-03 00:00:00.000",
"description": "Report",
"row_id": 1406313,
"text": "nsg note:\npt alert and oriented but during night started to pull at line and had hands restrained until am care at 6am. restraints now off.\ncv stable nsr urine out put adequate lasix given at 2am with very sm diuresis.\n tol tube feeds at goal. no insulin required. pt stooling around mushroom cath. cath dced and fecal incontinence bag placed.\nvac dsg intact. draining sm amt ser/sanf drainage/\nresp on vent ps5, peep5 sats adequate stable art line dced. sputum thin white\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-03 00:00:00.000",
"description": "Report",
"row_id": 1406314,
"text": "RESPIRATORY CARE\n\n Pt to Trach collar at 0800 in NARD. MDI's as documented. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-04 00:00:00.000",
"description": "Report",
"row_id": 1406315,
"text": "Respiratory Care:\nPatient tolerated trach collar for the entire night, with albuterol mdi given Q 4 and Flovent administered at 0400.\n\nNo morning abg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-04 00:00:00.000",
"description": "Report",
"row_id": 1406316,
"text": "nsg note:\n pt alert and appeared oriented, obeys commnds mouthing words appeared appropriate, but pulled out feeding tube at 2am.\nrestraints then applied.\ncv stable\nt max 100.6\nurine out put very brisk pt received 2 doses of diamox.\nk repleted.\nstooling liq browns tool rectal bag intact.\nresp: pt remained on trach mask over night no resp distresas of any kind. suctioned for sm amts of sticky white to blood tinged sputum. sats >96%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-04 00:00:00.000",
"description": "Report",
"row_id": 1406317,
"text": "T-SICU NPN 0700-1900\n\nEvents: To IR today for dobhoff placement (confirmed by x-ray and advancement of PICC (subclavian, advanced to SVC). R sc TLCL dc'd, tip sent for cx. and in to screen pt for rehab.\n\nNeuro: Alert, nodding head/mouthing words appropriately; able to mouth \", hospital, \" to appropriate questions. MAE's, follows commands consistently. Fentanyl 50mcg x1 for discomfort while on table in IR, ativan prn for anxiety per pt request (pt states she takes klonopin at home twice a day).\n\nCV: HR 80-100's SR, BP 100-120's/40-60's. Skin warm, dry. Pedal pulses palpable. R double lumen PICC line via R median vein, advanced in IR, per radiologist, tip in SVC, , TLCL R sc pulled, tip sent for cx. Lovenox and PB's for DVT prophylaxis.\n\nResp: LS coarse, suctioned for sm. amts. thick white/yellow, rarely blood tinged sputum. Off vent x24hrs, remains on cool trach mask 70%. Enc. C+DB. Inhalers as ordered have been given by RT.\n\nGI: abd obese, open, BS hypoactive, Peptamen 3/4 strength at goal via dobhoff. Rectal bag intact with sm. amt. brown liquid stool. VAC intact with decreasing amts. serous drainage. Protonix for GI prophylaxis.\n\nGU: foley patent draining adequate amts. clear yellow urine.\n\nEndo: BS 81->150, covered per ss.\n\nID: tmax 100.6, wbc 9.5 this am. Conts. vanco/levofloxacin as ordered.\n\nSkin: abd/panus fold with duoderm intact; back fold with sm. amt. serosang.draininage, aquacel covered with gauze in place. R corner of mouth with old breakdown, slowly improving.\n\nPsych/social: hcp in to visit in afternoon, , . other called this eve, affect/questions appropriate, update provided.\n\nA: s/p exp. lap with sm. bowel resection for necrotic bowel requiring trach, off vent x24hrs, awaiting rehab placement\n\nP: Monitor VS, I/O, labs/cultures. Assess pain/anxiety->med. prn. Aggressive pulmonary hygiene, enc. increased activity as tolerated. Page 2 initiated, team aware of need for page 1 and d/c summary prior to discharge. Continue ongoing comfort/support to pt/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-04 00:00:00.000",
"description": "Report",
"row_id": 1406318,
"text": "Respiratory Care\n Pt presents with a #8 Portex trach on humidified TM all day, tol well.MDI's given every 4 hours . BS slight coarse.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-05 00:00:00.000",
"description": "Report",
"row_id": 1406321,
"text": "Nsg Note - Transfer to Rehab\n Bed available at Rehab in . Case worker, notified Health Care Proxy and SO, that pt was being transferred today. arrived to visit pt and rode in ambulance to with pt this afternoon.\n Pt having liquid stool, leaking around mushroom cath. Cath removed prior to transfer and adult diaper placed. Pt signed discharge plan. Pt a bit anxious about transfer and requested ativan. 1mg ativan given per feeding tube with calming effect. PICC flushed easily and blood able to be drawn from it. Vac dressing intact. Back abrasions re-dressed with Aquacel, scant amt serosanguinous drainage from back. Duoderm intact over L lower abd wound.\n Pt smiling as left. Said thanks to nurses.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-01 00:00:00.000",
"description": "Report",
"row_id": 1406305,
"text": "ROS:\n\nNeuro: Alert, MAE's x's 4 to command. Mouths words nods head yes/no to questions asked. PEARRLA. Fentanyl for pain. Haldol and ativan for restlessnes/agitation.\n\nCV: RSR w/o ecotpy. VSS. Generalized edema. Peripheral pulses palpable w/ease. Has right abp line. Has right subclavian MML w/CVP = 11->13. P boots and enoxaprin sq for prophylactic dvt control.\n\nResp: Remains trached and on vent cpap+ps 5/5, 40 %. No resp distress noted, = rise and fall of chest. Sx thick clear to light yellow from trach. Trach site WNL. Sats 97% or >.\n\nGI: Abd remains open w/VAC dressing intact draining serosang fluid. Active bowel sounds auscultated. Pedi post piloric feeding tube via right nare w/TF infusing at goal (90cc/hr). Liq brown stool via mushroom cath.\n\nGU: Foley patent draining clear yellow urine in QS. Goal to keep negative fluid . Lasix 10 mg given at 0400 w/+ response.\n\nEndo: Insulin gtt dc's and changed to SQ RSSI.\n\nLytes: IC 1.08, repleted w/2GM Ca+ Gluconate.\n\nID: Remains on Levofloxacin and vanco. Tmax 100.1\n\nSocial: (HCP) in at begging of shift and then called ~ 0230 for update.\n\nPlan: Wean vent. Mobilize. Monitor and support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-01 00:00:00.000",
"description": "Report",
"row_id": 1406306,
"text": "Pt has had relatively comfortable night, weaned PSV 8 to 5 this morn. ABG showing mildly evevated Pco2 and low-normal pH, Po2 is somewhat low given pt age and supplimental O2 althogh adequate.Pt is on vent , mode and 40% O2. Sx multiple times for thick white secretions\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-01 00:00:00.000",
"description": "Report",
"row_id": 1406307,
"text": "Respiratory Care:\nPt placed on cool mist at 40% via trach collar this a.m.; tolerated well for 8 hours & placed back on PSV settings of . Plan to rest pt on these settings overnight & wean to trach collar again tomorrow a.m. Please see Carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-04-01 00:00:00.000",
"description": "Report",
"row_id": 1406308,
"text": "TSICU Nursing Progress Note\nNeuro - Pt alert and interactive today. Mouthing words, answering questions appropriately. Able to make needs known. Moves extremities x4 spontaneously and to command.\n\nCV - SR without ectopy. SBP well controlled. Peripheral pulses palp. Generalized edema. Enoxeparin and Pneumoboots for DVT prophylaxis.\n\nResp - Placed on trach collar this AM. Tolerated x8 hours. Became fatigued, tachypnic. Placed back on 5 PS, 5 Peep. Suctioned for small amounts thick secretions. Trach site clean, intact.\n\nGI - Tolerating 90cc/hour str peptimen. Liquid brown stool drianing via mushroom catheter. Abdominal VAC dressing intact.\n\nGU - Diuresing well with clear yellow urine via foley.\n\nEndo - No sliding scale coverage needed this shift.\n\nDischarge planning - Rehab referrals made. Will be screened early next week. Will be discharged to rehab with open abdomen.\n\nA - Tolerated trach collar trial x8 hours. Not requiring exogenous insulin.\n\nP - Attempt trach collar again in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-28 00:00:00.000",
"description": "Report",
"row_id": 1406291,
"text": "T-SICU NPN\nS/O:\n\nNEURO: Pt sedated on propofol drip, fent boluses for pain. Pt opens eyes, nods appropriately, and follows commands.\n\nCV: HR 70-80's SR, no ectopy. K repleted x 4, other lytes wnl. SBP:90-140's. CVP:13-17. Pneumoboots in place.\n\nRESP: Remains intubated and vented: PSV 12/8 peep/50%. RR:19-26., Tv:400-580. O2sats:95-97%. ABG marginal. Sxn'd for small to mod amts of yelow secretions.RSBI:142. ? plan to trach pt. this week.\n\nGI: Abd soft and large. VAC dsg intact w/ minimal drng. TF : str. Promote w/ fiber advanced to 50cc/hr towards goal rate of 90cc/hr. Low residuals, and minimal NG output via sump. Loose green stool x 2 ->fecal inc. pouch replaced.\n\nGU:BUN/CR stable. Brisk diuresis to 10mg lasix x 2. K repleted.\n\nHEME/ID: Hct stable at 27. WBC down. Tmax: 101.1.\n\nENDO: Insulin drip off for blood glucose<80 coinciding w/ d/c of TPN. Insulin drip back on at 2u/hr w/ B.S.:101.\n\nSKIN: New duoderm placed to abrasion in skin fold of lower back. Abrasion to R lip improving. DSD placed to small wound in L groin.\n\nA:Stable overnight. Tolerating active diuresis.\n\nP: Cont to diurese, replete lytes as needed. Anticipate trach this week. Advance TF's as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-28 00:00:00.000",
"description": "Report",
"row_id": 1406292,
"text": "Resp Care\nPt reamains on vent and stable. Increased settings according to blood gases. Suction moderate amt of thick yellow secretions. Mdis given. Plan to wean as tolerated and trach sometome this week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-28 00:00:00.000",
"description": "Report",
"row_id": 1406293,
"text": "T-SICU NPN 0700-1900\n\nNeuro: Lightly sedated on propofol gtt with prn fentanyl 50-75mcg with adequate pain control per pt report. Follows commands appropriately, MAE's, able to nod/gesture/mouth words to communicate needs.\n\nCV: HR 70-80's SR, BP 90-100's/40-50's, CVP 14-17. Skin warm, dry. Pedal pulses palpable. Lovenox as ordered and PB's for DVT prophylaxis. hct 27.4\n\nResp: LS coarse, diminished at bases; suctioned for sm->moderate amts. thick white/yellow sputum, mod. amt. oral secretions. Conts. on CPAP 12PS/50%, PEEP increased to 10 with improvement in ABG. See carevue for labs/resp. notes.\n\nGI: abd obese, open, BS present. NGT to LCWS with sm. amts. brown/bilious drainage; 3/4strength promote with fiber at 70cc/hr (goal 90cc/hr) via dobhoff, tol. well until 1800; c/o nausea, TF on MD, anzimet with effect. Fecal inc. bag with large amt. liquid stool backed up in pouch; emptied for total 500cc liquid brown stool at 1800. Protonix for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in adequate amts. Ca gluconate and kcl repleted.\n\nEndo: insulin gtt at 1unit/hr all shift; BS 80-100's.\n\nID: tmax 101.7; wbc 16.7; BC x2, sputum and urine sent for culture. Tylenol x2 given.\n\nSKin: back folds with duoderm intact; fecal inc. bag intact; sm. L groin/belly site with aquaphor dsg intact, no drainage. R side of mouth with breakdown slowly improving.\n\nPsych/social: hcp and . other both in to visit today; affect/questions appropriate.\n\nA/p: s/p sm. bowel resection x2 for necrotic bowel, slow vent wean\nMonitor VS, I/O, labs/cultures, aggressive pulmonary hygiene, advance TF as tol. Await trach placement in OR this week. Continue ongoing comfort/support to pt/friends.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-31 00:00:00.000",
"description": "Report",
"row_id": 1406302,
"text": "ROS:\n\nNeuro: Alert w/stim. MAE x's 4 to command. C/o of occasional back pain, fentanyl given w/relief. Propofol gtt at 40 mcg/kg/min. PEARRLA. Mouthing words and nodding head yes/no to questions asked.\n\nCV: RSR w/o ectopy. VSS, see flow record for details. Has right subclavian MML w/ cvp = . Has right radial abp line. Generalized pitting edema. P boots and enoxaprin sq for dvt prophylaxis.\n\nResp: Trach site puffy, old dry blood. Trach cares initiated. On vent CPAP+PS , FIO2 decreased to 50%. Sx yellow blood tinged spit via trach. Sats remain 97-99%. No resp distress noted, = rise and fall of chest.\n\nGI:Found w/ sump out at beginning of shift. Post piloric pedi tube via right nare w/TF infusing at goal at 90cc/hr. Abd open w/VAC dressing draining at times nector like consistancy pink colored fluid.\n\nGU: Foley patent draining clear yellow urine in QS. Lasix 10 mg w/+ response.\n\nEndo: Insulin gtt titrated to keep FSG < 120.\n\nLytes: K, IC, and Mag all repleted this shift x's 1.\n\nHeme: Hct trending up\n\nSocial: and here at beginning of this shift. Patient called this AM and listend to her on the phone.\n\nPlan: Diuresis. Pulmonary toileting. Mobilization\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-31 00:00:00.000",
"description": "Report",
"row_id": 1406303,
"text": "Respiratory Care:\nPt continues to be mechanically ventilated via tracheostomy. Trach site cleaned this a.m.; site looks good with minimal oozing noted; clean drain sponge placed. Ventilatory settings weaned to 40% FiO2 & Peep decreased to 5 & PS decreased to 10. Pt had good ABG results on these settings. Sm amts of secretions suctioned throughout day. Plan to continue ventilatory support & wean further when tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-31 00:00:00.000",
"description": "Report",
"row_id": 1406304,
"text": "TSICU Nursing Progress Note\nNeuro - Alert, interactive. Mouthing words, asking questions repeatedly. Propofol gtt off. Occ agitation treated with ativan and haldol PRN.\n\nCV - SR without ectopy. SBP 100 - 120 mmHg. Enoxeparin dose increased, anti-Xa antibody ordered for 10PM. Pneumoboots on. Peripheral pulses strong. Generalized edema.\n\nResp - Weaned to 40% FiO2, PS 10, Peep 5. Blood gases acceptable. Suctioned for small amounts tan secretions. Trach site somewhat swollen. Strong cough.\n\nGI - Tolerating TF at goal. Mushroom catheter in place and draining brown liquid stool. Catheter flushed PRN to mainain patency. + BS.\n\nGU - Diuresing well. ~ 2L negative at this time.\n\nSkin - Duoderm intact to back folds. VAC dressing changed this AM by surgical team. Wound clean, abdomen open with mesh visable. Serous drainage from dressing.\n\nEndo - Insulin gtt at 1 unit per hour all day.\n\nA - Tolerating vent wean. Tolerating TF with less stool. BS stable on 1 unit/hr insulin gtt.\n\nP - continue to wean vent as tolerated. Replete electrolytes as needed. Treat as needed for agitiation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-18 00:00:00.000",
"description": "Report",
"row_id": 1406253,
"text": "\nPT MAINTAINED ON A/C VENTILATION AT 100%, WITH VT OF 450, RR 35, AN INCREMENT HIGHER THAN ARDS NET PROTOCOL. VITALS UNSTABLE WITH SYSTOLICS OF 75 AND MAPS OF 59. PT HAS HAD POST-OP COURSE WITH HYPOTENSION AND POOR OXYGENATION. B.S. BILAT WITH CRACKLES TO ALL. ESOPHAGEAL BALLOON PLACED WITH NEG. TRANSPULMONARIES, BUT UNABLE TO PEEP UP THE LUNG DUE TO HEMODYNAMIC INSTABILITY. PROTOCOL COPY LEFT INSIDE VENT AND TACKED TO WALL. LAST ABG SHOWED AN ACIDOSIS WITH ACCEPTABLE OXYGENATION. PT ENLISTED INTO BALLON STUDY AND FELL INTO CONTROL GROUP. DIRECTIONS FOR SETTING MANIPULATION SHOULD BE TO INCREASE PEEP IF HEMODYNAMICS PERMIT, WITH FIO2 TO FOLLOW. BE AWARE THAT TODAYS RECRUITMENT MANEUVERS HAD TO BE STOPPED FOR ACUTE DECOMPENSATION. PLAN IS TO CONT. ON CURRENT SETTINGS WITH THE ARDS NET PROTOCOL TO FOLLOW GIVEN THE CLINICAL AVAILABILITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-18 00:00:00.000",
"description": "Report",
"row_id": 1406254,
"text": "Social Work\nSW spoke with pt's domestic partner, , and her health care proxy, (). They are coping fairly well but concerned about pt's mother, , who lives alone in . They have been in touch with her regularly today and will continue to contact her this evening. They weren't sure if they wanted SW to call her tonight but may want this tomorrow. Pt's condition is very poor and family seem somewhat confused about the details. SW suggested a family meeting tomorrow to assess where pt is at and answer questions of family. SW will alert the weekend SW of the situation and request that she check in with the family. Page SW if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-18 00:00:00.000",
"description": "Report",
"row_id": 1406255,
"text": "NPN/admission note T-SICU 0700-1900\n\nAllergies: sulfa, asa->anaphylaxis, trazadone\n\nPMH: Asthma, MI, GERD, morbid obesity, umb. hernia repair, ventral hernia repair, SBO.\nmeds at home: theodur, claritin, nexium, prozac, klonopin, albuterol\n\n56yo female s/p multiple ventral hernia repairs, last for SBO (previously received care at ). Admitted with diffuse, severe abd pain after dinner , mild nausea, vomiting started am, pain slowly worsening. eve into ., temp. spike 104.3, no uo after IVF bolus x2. NGT placed, 900cc stool out in first hour. Decreased MS noted. Transferred from CC6 to T-SICU approx. 0630. RN report, pt arrived with agonal breathing, unable to obtain O2 sat with labile SBP 140->90's. Intubated, requiring fluid resuscitation, pressors. A-line and PA catheter placed, to OR approx. 0830am. Returned to ICU approx. 1345 s/p exp. lap with sm. bowel resection for necrotic bowel.\n\nHCP , Cell , home 6\npartner x6yrs \nmother \n\nROS:\nsee carevue for specifics.\n\nNeuro: Paralytic not reversed from OR; lightly sedated on propofol. Approx. 1700, pt more awake; able to nod head yes/no to simple questions. MAE's, follows commands (able to stick out tongue, open eyes, squeeze with R hand). Pupils equal and reactive. Pt indicated discomfort d/t ett and back. Fentanyl 25mcg IV with some improvement.\n\nCV: HR 100-110ST, CVP 13-20's, BP 60-70/40's, goal MAP >50; requiring high dose levophed and vasopressin with fluid resuscitation throughout day; PA 40's/20's with wedge 16-26. CO , CI 3.1- 2.7. Xigris intiated today. Skin warm, dry. PB's for DVT prophylaxis.\nhct 35\n\nResp: LS coarse, crackles noted, diminished at bases; mod. amt. nasal/oral secretions; pt began balloon study today; see carevue for multiple vent.changes/labs.\n\nGI: abd obese, open, ioband intact, absent BS, NGT to LCWS for mod. amt. brown output. JP x4 to LCWS for sm. amt. serosang. drainage. Prontonix for GI prophylaxis.\n\nGU: foley patent draining adequate clear yellow urine. Lytes repleted.\n\nEndo: BS 120's; may restart insulin gtt.\n\nID: tmax 100; conts. vanco/flagyl/fluconazole/levofloxacin\n\nSkin: abd remains open post-op; ioband intact; groins pink\n\nPsych/social: pt's friend and partner in to visit; teary, appropriate this am. Emotional support provided, SW following. Dr. spoke with above and pt's mother today; ? family meeting in near future to address plans going foward/clarify questions, etc.\n\nA: s/p exp. lap and bowel resection for necrotic bowel requiring large amts. fluids/pressors\n\nP: Monitor VS, I/O, labs, hemodynamics, maintain MAP >50. Continue abx/meds as ordered. Continue ongoing comfort/support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-19 00:00:00.000",
"description": "Report",
"row_id": 1406256,
"text": "ROS:\n\nNeuro: On propofol at 40 mcg/kg/min. Turned off to determin if cause of hypotension. This demonstrated to be NO cause for the hypotension. Propofol resumed and titrated ^ to 40 mcg. When off and on 20 mcg nods head to questions asked, mouths words, and follows commands, MAE x's 4. @ 40 mcq is sedated and does not arrouse. PEARRLA.\n\nCV: ST w/o ectopy. SBP 50->102 w/MAPs 42->74 MAP goal >50. On Levophed at .427 mcg/kg/min (maxed out). Vasopressin at .04 units/min titrated up to .06 units/min w/o change in BP, returned then to .04 units/min. Has left radial ABP line. Manual cuff BP checked several times this shift and = ABP pressure. Has RIJ MML. Has Left SC CCO swan. At beginning of shift noted several cc of bloody drainage in sheath surrounding external portion of swan, reported that this had occured earlier when swan was repostioned. Pressor agents infusing via side port of swan. At approx 0130 SBP dropped from 90 to 50. Fluid bolus given. Then noted ^ fluid accumulation in sheath of swan. Pressor agents changed to RIJ and immediate rebound of SBP to 90. Peripheral pulses w/doppler. P boots on prophylacticly. See flow record for hemodynamic data. Swan repositioned (pulled back 2 cm by HO) earlier in shift d/t dampend wave forms appearing to be wedged.\n\nResp: Remains orally intubated and on vent. AC 32x450 (pulling 550), Peep ^ to 16, 100%. Lung sound coarse w/wheezes, MDI's per RT. Sx small clear via ETT. Sats 96->100%. SVO2 54->75. No resp distress noted, = rise and fall of chest. Esophageal balloon in place, on epVent study. Goal peep = 20's.\n\nGI: Abd open w/occlusive dressing. JP's x's 4 draining bownish red fluid. No bowel sounds auscultated. Has sump via right nare. draining bile fluid. On protonix prophylacticly.\n\nGU: Foley patent draining clear yellow urine in QS. Bladder presure 12.\n\nID: Tmax 102.6, currently climbing. Tylenol 650 mg PR w/o decreasing temp. On xigris infusion. Scheduled ATB include mdtronidazole, levofloxacin, fluconazole, and vanco. Blood cult obtained yesterday.\n\nEndo: Insulin gtt on and titrated to keep glucose < 120.\n\nHem: Hct down to 27, transfused w/2 units of PRBC. INR ^ 2.7, transfused w/4 units FFP, INR down then to 1.6.\n\nLabs: K 3.4, repleted w/40 KCL. Mag 1.8, repleted w/2 GM Mgso4, IC 1.08, repleted w/2 gm Ca+ gluconate.\n\nSocial: S.O. in several times tonoc to visit and check on condition. Friend and Healthcare Proxy, here at 2200 to check on status.\n\nPlan: Continue to monitor, support, and tx. Mobilize more when stable. Change swan d/t leaking into sheath.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-19 00:00:00.000",
"description": "Report",
"row_id": 1406257,
"text": "RESP CARE:Pt remains intubated on vent. Current settings of AC 450/32/100%/16 PEEP. Lungs coarse with exp wheezes bilat. ALB MDI given with increase in aeration noted. Continues on Day 2 EP study, 9Control Group)\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-19 00:00:00.000",
"description": "Report",
"row_id": 1406258,
"text": "Patient remains on mechanical ventilation,no change made today.Abdomen remains open with occlusive dressing,ABG normal on rate of 30 will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-19 00:00:00.000",
"description": "Report",
"row_id": 1406259,
"text": "T-SICU NPN 0700-1900\nreview of systems:\n\nNeuro: Sedated on propofol 40mcg/kg/min, lightened to 20mcg/kg/min and able to follow commands, MAE's, nod head yes/no to simple questions. Pupils 3mm, equal and reactive. Nods head yes at times to pain, sm. amount, fentanyl 25mcg given x2 with (+) effect (did not drop BP).\n\nCV: HR 90-108ST, no ectopy. BP 80-100/50's, MAP 60-70 (goal >60), CVP 15-17, CO , CI 3.0-4.5, PAP's 40-50's/20's EDVI 116-164, SVO2 60's. Unable to wedge swan in am, adjusted in am by Dr. to 56cm, wedge 16-17. Skin warm, diaphoretic at times. Pedal pulses + by doppler. Levophed being tirated down, currently 0.14mcg/kg/min. Vasopressin conts. Xigris per protocol. Heme; hct 34, INR 1.6, cont. q4hr hct/coags.\n\nResp: LS coarse, diminished at bases; suctioned for sm. amts. thick clear secretions. Sm. amt. blood suctioned from mouth (? biting tongue), sm. amts. clear/yellowish nasal drainage. FIO2 weaned to 90%, RR 32->30, PEEP remains at 16. ABG's improved, see carevue for resp. notes, labs. Esophageal balloon intact, study protocol continues.\n\nGI: abd obese, open, BS absent. NGT to LCWS for mod. amts. bilious drainage. Transparent ioband dsg remains intact. JP x4 to wall sxn for sm. amts. brownish/serosang. fluid. Protonix for GI prophylaxis.\n\nGU: foley patent draining yellow, cloudy urine with occ. sediment in adequate amts. Creat improving. Calcium gluconate repleted.\n\nEndo: BS 60-105, insulin gtt off since 0800.\n\nID: temp. down to 99.4; conts. flagyl/vanco/levofloxacin/fluconazole.\n\nSKin: buttocks intact; 2 sm. blisters to lower back pink, no drainage, OTA. Abd open as above.\n\nPsych/social: partner and friend (HCP) both in to visit today; 1 additional friend also into visit; no other visitors and . Affect/questions appropriate, emotional support provided.\n\nA: s/p exp. lap with sm. bowel resection for necrotic bowel, septic requiring pressors, vent. support\n\nP: Monitor VS, I/O, hemodynamics. Titrate levophed as tolerated. Maintain sedation/comfort. Continue ongoing comfort,support,communication with family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-30 00:00:00.000",
"description": "Report",
"row_id": 1406299,
"text": "ROS:\n\nNeuro: Alert nods head yes/no to questions asked. Mouthing words to communicate. PEARRLA. MAEs x's 4 to command. On propofol at 30 mcq/kg/min. Denies pain when asked.\n\nCV: RSR w/o ectopy. VSS. Has right subclavian MML w/CVP 8->12. Has right radial ABP line. Peripheral pulses palpable w/ease. Generalized pitting edema. Enoxaprin sq and p boot for dvt prophylaxis.\n\nResp: Remains orally intubated and on vent. CPAP+PS , 50 %. Lung sounds clear sx small lite yellow. No resp destress noted, = rise and fall of chest. Sats 95% or >.\n\nGI: Right nare w/ sumpt to LCWS draining mucousy clear to bile colored fluid. Right nare also w/pedi tube w/TF infusing at goal at 90cc/hr. Abd open w/VAC dressing intact draining serosang fluid. Rectal tube draining brown liq stool. Protonix prophylacticly.\n\nGU: Foley patient draining clear yellow urine in QS. Receiving diamox q 6 hr w/+ response.\n\nID: Tmax 100.6 now afebrile. on vanco, piperacillin,\n\nEndo: Insulin gtt titrated to keep FSG <120\n\nLytes: K3.7, repleted w/20 kcl, mag 2, repleted w/2 gm mgso4, IC 1.08, repleted w/2 gm ca+ gluconate.\n\nHeme: Hct 26\n\nSocial: Call from (HCP) update given.\n\nPlan: Pulmonary toileting. Monitor. ? plan for trach. ? blood adminsitration for Hct trending down.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-30 00:00:00.000",
"description": "Report",
"row_id": 1406300,
"text": "Pt remains on PSV and 50% O2. There is no plan to wean pt at this time and a trach is being considered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-21 00:00:00.000",
"description": "Report",
"row_id": 1406263,
"text": "ROS:\n\nNeuro: On propofol gtt at 15 mcg/kg/min. Arouses to verbal stim on 15 mcg, nods head yes/no to questions, and follows simple commands. PEARRLA.\n\nCV: RSR -> ST w/o ectopy. NBP checked to be correct via doppler. Peripheral pulse still only dopplerable. Has Left subclavian CCO swan, see carevue flow record for hemodynamics, SVR low. Unable to use sideport of introduce due to fluid backing up into outer protective sheath of swan. Has RIJ Multi Med Line, dressing changed this shift. P boots on for DVT prophylaxis.\n\nResp: remains orally intubated and on vent, AC 30x450, Peep ^ 16, FIO2 ^ 90%. SVO2 55->63. Esophageal balloon , Epvent study. Lung sounds coarse and diminished thoughout. Sx white via ETT. No resp distress noted this shift, = rise and fall of chest. Following mixed venous blood gasses, SVO2, and SAO2. Unable to obtain Aline placement due to Xigris infusion and associated risk for bleeding.\n\nGI: sump via right nare to LCWS draining light brown bilish mucousy drainage. Abd remains open w/Ioban dressing intact. 4 JP's to wall sx draining light brown fluid. Protonix prophylacticly.\n\nGU: Foley patent draining clear yellow to green (propofol) urine in QS.\n\nEndo: Insulin gtt resumed and titrated to keep FSG < 120.\n\nHeme: Hct down to 26, transfused w/1 unit PRBCs.\n\nLytes: Stable except for K of 3.5, repleted w/40KCL.\n\nSocial: SO, phoned for update around 3 AM.\n\nID: Tmax 100.2. On Xigris, metronidazole, levofloxacin, fluconazole and vanco. Bld cultures pending. Abd wound (sinus tract/pre OR) cultures growing pseudomonis.\n\nPlan: Continue Xigris (total hrs of 96) will finish at 1630. OR ? wednesday or Thursday to close abd. Continue to monitor, tx, and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-21 00:00:00.000",
"description": "Report",
"row_id": 1406264,
"text": "RESP CARE: pt remains intubated/on vent per carevue. FI02 and PEEP increased to ^SV02. PT REMAINS IN CONTROL GROUP IN EPVENT STUDY. Lungs coarse bilat. MDI alb given with good affect. Sxd small amts thick sputum. Pt has no A-line at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-21 00:00:00.000",
"description": "Report",
"row_id": 1406265,
"text": "Resp Care\nPt remains on vent and stable. Suctioned moderate white thick secretions. MDis given. Peep was decreased. Plan to wean as necessary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-21 00:00:00.000",
"description": "Report",
"row_id": 1406266,
"text": "T/SICU NPN 0700-1900:\n\nREVIEW OF SYSTEMS:\n\nNEURO: MINIMALLY SEDATED ON PROPOFOL - EASILY AROUSABLE, OPENS EYES SPONTANEOUSLY AS WELL AS TO VOICE/TACTILE STIMULI: PERRLA 3<->4MM/BSK. COUGH/GAG INTACT. CONSISTENTLY F/C'S & MAE'S. NODDING HEAD APPROPRIATELY TO SIMPLE QUESTIONS. SOFT RESTRAINTS ON BOTH ARMS D/T PT PURPOSEFULLY REACHING TOWARD ETT. FENTANYL 50MCG X2 FOR PAIN W/(+)EFFECT - RESTING COMFORTABLY.\n\nCV: HR SR 80'S, NO ECTOPY NOTED ON TELEMETRY. CVP 17-21. SBP VIA CUFF 100-110'S/STABLE: MAPS CONSISTENTLY >60. REFER TO CAREVIEW FOR DETAILED C.O/C.I. DATA. EXTREMITIES WARM/DRY - PERIPHERAL PULSES CONFIRMED VIA DOPPLER - BSK CAP.REFILL THROUGHOUT. PB'S ON FOR DVT PROPHYLAXIS.\n\nHEME: HCT STABLE 27<->28, PT 15/INR 1.5/PTT 39 - LABS MONITOR Q4HR FOR XIGRIS PROTOCOL.\n\nRESP: LUNGS SOUNDS COARSE THROUGHOUT, SXN FOR SCANT AMTS THICK CLEAR/WHITE SECRETIONS. VENT SETTINGS DECREASED X1 - TOLERATED: NOW ON A/C 450X28/14(16)PEEP/80%(90)FIO2 - SATS 93-97%, OVERBREATHES SETTING BY SEVERAL BREATHS AT TIMES. CCO SWAN CHANGED TODAY BY T/SICU TEAM R/T FLUID BACKING UP IN SHEATH OF PREVIOUS LINE. SVO2 AFTER RECALIBRATION 49<->52: TEAM AWARE/MONITORING. PCWP 18:REFER TO CAREVIEW FOR ADDITIONAL DATA. NO A-LINE AT THIS TIME AS PREVIOUS DOCUMENTED.\n\nGI: ABD OPEN/DISTENDED, BS ABSENT. NGT TOP LWCS DRAINING BILIOUS GREEN/BROWN EFFLUENT. NPO W/TPN INFUSING. PROTONIX FOR GI PROPHYLAXIS. JP'S X4 TO WALL SXN - SERO/SANG DRAINAGE AS NOTED.\n\nGU: FOLEY CATHETER PATENT DRAINING ADEQUATE HOURLY VOLUMES: PT NEG FLUID BAL OF (-500)CC SPONTANEOUSLY - TEAM TO ORDER LASIX DOSE THIS EVENING. NO LYTES REPLETED THIS SHIFT. BLADDER PRESSURE 11 - PER DR., QD BLADDER PRESSURES NO LONGER NECESSARY.\n\nENDO: INSULIN GTT TITRATED TO GLUCOSE LEVELS <120: REQUIRED 5-7UNITS/HR TO MAINTAIN PARAMETERS. RECURRING STEROID DOSE DECREASED.\n\nID: TMAX 100.0, CONTINUES ON FLUCONAZOLE, ZOSYN ADDED; LEVOFLOX/VANCO/FLAGY D/C'D.\n\nSKIN: ABD OPEN, COVERED W/STERILE TOWEL AND IOBAN TRANSPARENT DSG - INTACT. FOLDS OF SKIN ON BACK W/(+)BREAKDOWN - CLEANSED W/NS - DSD: MONITORING. CONTINUES ON AIR MATTRESS W/ROTATION AS ORDERED: TOLERATING.\n\nSOCIAL: (S.O.) AND (HCP) IN TO VISIT TODAY - MET W/ DR TO SIGN CONSENT FORMS FOR POTENTIAL O.R. WEDNESDAY FOR ABD WASH-OUT/(?)POSSIBLE CLOSURE. DR. ALSO ADDRESSED FEEDING TUBE PLACEMENT AND TRACH OPTIONS. ALL QUESTIONS BY MD AND THIS RN - S.O. ALSO AWARE OF PLANS. SUPPORT GIVEN.\n\nA/P: STABLE NOT REQUIRING PRESSORS OR FLUID BOLUS TO MAINTAIN CURRENT HEMODYNAMIC PICTURE, TOLERATED MINIMAL VENT CHANGE: CONTINUE PER CURRENT PPLAN OF CARE - XIGRIS PROTOCOL AS ORDERED - XIGRIS INFUSION COMPLETE AS OF TUESDAY @1630->REPEAT OR PLANNED FOR WEDNESDAY FOR ABD WASHOUT AND (?)ABD CLOSURE; PULMONARY HYGEINE, PAIN MGT, GLUCOSE MONITORING, MONITOR PENDING CX'S. FULL SUPPORT/COMFORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-22 00:00:00.000",
"description": "Report",
"row_id": 1406267,
"text": "ASSESSMENT AS NOTED\n\nRES: REMAINS ON ARDS PROTOCOL, 14PEEP, BED PERCUSION Q1H, MAINTAINS SO2>95, SVO2>50. HAS SM AMNT YELLOW THICK SPUTUM, WEAK COUGH. LSCLEAR/COARSE\n\nCV:GOT LASIX 10 LAST NIGHT, DESPITE THAT PA READINGS DID NOT CHANGED, WEDGE 20-18, CVP-19. SBP BY CUFF 110-95, GENERALIZED EDEMA, + PULSES.\n\nGI: HAD SMALL SOFT BM ONCE, MINIMAL DRAINAGE IN NGT, JP'S 300 TOTAL. HAD FAINT BOWEL SOUNDS\n\nLAB: RI GTT AT 4/H, BS 100 RANGE, K WAS REPLETED ,HCT, PT, PTT UNCHANGED\n\nID: 99-98, WBC 13, FAN ON AND OFF\n\nSKIN: BLISTR LIKE BACK FOLDS, ABD OPEN INTACT WITH SCANT OOSING AT THE BOTTOM OF THE DRESSING\n\nPLAN: MORE DIURESIS, LAST DAY OF XIGRIS THERAPY\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-22 00:00:00.000",
"description": "Report",
"row_id": 1406268,
"text": "Respiratory Care:\nPatient currently in control group of protocol with no parameter changes made throughout the night. No morning abg results at this time and no RSBI determined due to the level of PEEP currently required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-22 00:00:00.000",
"description": "Report",
"row_id": 1406269,
"text": "T/SICU NPN 0700-15:30:\n\nREVIEW OF SYSTEMS:\n\nNEURO: PT MINIMALLY SEDATED ON PROPOFOL - EASILY AROUSABLE FOR EXAMS: ABLE TO EFFECTIVELY COMMUNICATE NEEDS VIA MOUTHING WORDS/NODDING HEAD. CONSISTENTLY MAE'S TO COMMAND. MEDICATED W/50MCG FENTANYL X1 FOR C/O OF ABD PAIN W/EFFECT - RESTING COMFORTABLY, SLEPT IN SHORT NAPS.\n\nCV: HR SR 70<->80'S, CVP 16<->20, SBP VIA CUFF 100-110'S/STABLE: PAP (SYSTOLIC) 40'S W/MAPS CONSISTENTLY 30'S. REFER FOR CAREVIEW FOR DETAILED CCO DATA. PERIPHERAL PULSES CONFIRMED VIA DOPPLER - BSK CAP REFILL THROUGHOUT EXTREMITIES. PB'S ON FOR DVT PROPHYLAXIS. NO ECTOPY NOTED ON TELEMETRY.\n\nHEME: PT/PTT/HCT MONITORED Q4HR PER XIGRIS PROTOCOL - STABLE. XIGRIS INFUSION COMPLETED @1630 TODAY.\n\nRESP: LUNG SOUNDS CLEAR IN UPPER FIELDS, BASES DIMINISHED. SXN FOR SM AMTS THICK CLEAR/WHITE SECRETIONS. CONTINUES ON VENT A/C @ 450X28/14PEEP/FIO2 DECREASED TO 70%(80) - TOLERATING. T/SICU TEAM INQUIRING IF PAIN WAS CONTRIBUTING TO SVO2 VALUES - ASKED TO MONITOR SVO2 CLOSELY W/NEXT PAIN MED DOSAGE->NO CORELATION AS NOTED BY THIS RN WHEN LAST FENTANYL DOSE GIVEN => VALUES AND PT CLEARLY ABLE TO INDICATE WHEN BASELINE PAIN PRESENT. SATS DIPPED SLIGHTLY WHEN FIO2 DECREASED. SLOWLY RECOVERING - 94-96% AT THIS TIME. REFER TO CAREVIEW FOR DETAILED CCO DATA.\n\nGI: ABD OPEN/OCCLUSIVE DSG INTACT. NPO W/TPN INFUSING AS ORDERED. PROTONIX QD FOR PROPHYLAXIS. HYPOACTIVE BS NOTED - SM/LIQUID/LOOSE BM X1. B/L JP DRAINS PATENT - L SIDED DRAINS W/LG OUTPUT THIS SHIFT (500 CC) - TEAM AWARE. DRAINAGE SERO/SANG.\n\nGU: FOLEY CATHETER PATENT - U/O CLEAR/YELLOW/CONCENTRATED - HOURLY AVG >40CC. PER T/SICU TEAM - AVOIDING FURTHER DIURESIS AT THIS TIME: RECEIVED 10MG LASIX LAST W/FAIR RESPONSE, THEN U/O SLOWED TO APPOXIMATELY HALF OF THE HOURLY VOLUMES OUT AS CHARTED PRIOR TO MEDICATION - MONITORING.\n\nENDO: REG.INSULIN GTT CONTINUES TITRATING GLUCOSE LEVELS <120: REQUIRE 3-5UNITS/HR THIS SHIFT. CONTINUES ON 25MG HYDROCORTISONE Q8HRS.\n\nID: TMAX 100.6 - NO NEW CX DATA - CONTINUES ON ZOSYN/FLUCONAZOLE.\n\nSKIN: NO NEW ISSUES NOTED - SKIN BREAKDOWN INSET IN SKIN FOLFS OF BACK UNCHANGED: PINK, SCANT SEROUS DRAINAGE OUT: CLEANSED W/NS/DSD.\n\nSOCIAL: HCP MET W/T/SICU HO () TO SIGN ANESTHESIA CONSENT FORMS FOR REPEAT O.R. TOMORROW. ALL QUESTIONS ANSWERED/SUPPORT GIVEN BY TEAM & THIS RN. QUESTIONS/CONCERNS APPROPRIATE. S.O.() ALSO IN FOR VISIT THIS MORNING. PERSONS AWARE THAT SURGERY IS LIKELY SCHEDULED FOR (ADD-ON CASE) FOR ABD WASH-OUT &(?)CLOSURE.\n\nA/P: HEMODYNAMICALLY STABLE NOT RQUIRING PRESSORS OF FLUID BOLUS TO MAINTAIN ADEQUATE BP. TOLERATING SLOW VENT WEAN. XIGRIS INFUSION TO COMPLETE COURSE @16:30 - TEAM PLANS TO PLACE ONCE PT OFF INFUSION >2HRS. MONITORING RESP STATUS W/SVO2/SATS/FICK CALC. CONTINUE PER CURRENT PLAN OF CARE - O.R. FOR ABD WASH-OUT. FULL SUPPORT/COMFORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-30 00:00:00.000",
"description": "Report",
"row_id": 1406301,
"text": "T-SICU NPN 0700-1900\nSee carevue for specifics.\nROS:\nNeuro: Lightly sedated on propofol gtt, fentanyl prn with adequate pain relief per pt. MAE's, follows commands, nods head/mouths words to express needs.\n\nCV: HR 80-90SR, BP 90-120's/50's, CVP 11-13. Skin warm, dry. Pedal pulses palpable. R sc TLCL and a-line wnl. Lovenox and PB's for DVT prophylaxis. hct 27 this afternoon.\n\nResp: LS coarse, suctioned for sm->moderate amts. thick yellow secretions, moderate amt. clear/pale yellow oral secretions. Bedside percutaneous trach done this eve, tol. well without complication. See carevue for labs/resp. notes/vent settings.\n\nGI: abd open, BS hypoactive, NGT to LCWS for sm. amt. bilious drainage. TF at goal 90cc/hr via dobhoff. Rectal tube in place, conts. with mod. amt. liquid brown stool. Protonix for GI prophylaxis. VAC dsg intact, draining mod. amt. serous fluid.\n\nGU: foley patent, + diuresis for clear yellow urine, lytes repleted. Lasix as ordered.\n\nEndo: BS 80-100 on 2units regular insulin per ss.\n\nID: conts. vanco/zosyn as ordered, tmax 99.5\n\nSkin: back with duoderm intact; vac as above; R corner of mouth with sm. amt. yellow drainage, slowly healing. Back of head fold OTA.\n\nPsych/social: pt's mother called from this am, update provided. hcp and . other and 1 additional friend in today; able to see pt pre and post trach; also spoke with Dr. , update provided, questions answered.\n\nA: s/p sm. bowel resection for necrotic bowel with slow vent wean\n s/p trach this eve\n\nP: Monitor VS, I/O, aggressive pulmonary hygeine, wean vent as tol. Maintain comfort; ongoing comfort/support to pt and family/friends.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-29 00:00:00.000",
"description": "Report",
"row_id": 1406296,
"text": "UPDATE: 5TH DOSE OF LASIX HELD PER DR , HO. PATIENT -1300 CC FOR THE DAY ALREADY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-03-29 00:00:00.000",
"description": "Report",
"row_id": 1406297,
"text": "Resp Care\nPt remains on vent. Mdis given. Suctioned large amt of thick yellow secretions. Weaned on settings waiting on blood gases. Plan to wean as tolerated and trach later this week.\n"
}
] |
29,138 | 150,194 | A 69-year-old gentleman with a history of diffuse large B-cell lymphoma with CNS involvement undergoing XRT, PCP (), DVT s/p IVC filter placement, was admitted for hypoxia, shortness of breath, fever, fatigue found to have pneumonia, leukemic transformation of his lymphoma, and septic shock. . Mr. was admitted for with presumptive diagnosis of pneumonia. He was was started on broad spectrum antibiotics (vancomycin, cefipime, and steroids/primaquine/clindamycin for presumed PCP) but clinically worsened. All cultures were negative so ID and Pulmonary were consulted. A broncho-alveolar lavage was performed and was negative for PCP by DFA and grew only OP flora. PCP therapy was withdrawn. The patient continued to decline with increasing oxygen requirement and the morning of he was noted to be tachypneic to 30-40 breaths/min on 100% non-rebreather oxygen. He was transferred to the medical ICU where he was emergently intubated when he began to desaturate on 100% oxygen and went into an SVT with HR 180. He was started back on empiric PCP therapy given his rising LDH, however Mr. continued to decline. He went into septic shock with hypotension refractory to fluid resuscitation and required central venous line placement and vasopressive medications to maintain MAP>65. Discussions were held with the family and the Dr. of oncology because the patient was found to have blast forms on his peripheral smear, consistent with leukemic transformation of his lymphoma. Due to his overall very poor prognosis the family decided to extubate Mr. and change the focus of his care toward comfort measures. He died the next morning. | On the current film, there is a new IJ central venous catheter with its tip low in SVC. Supra sellar area is suboptimally visualized in this study, however, patient is known to have a contrast enhancing suprasellar mass lesion, suggestive of a lymphoma CONCLUSION: No acute intracranial process. CT OF ABDOMEN WITH IV CONTRAST: There has been interval placement of an IVC filter. Consider inferior wall myocardial infarction.Early precordial Q waves. The ventricles and sulci are mildly prominent suggesting age or radiotheraoy related involutional changes. However, looking back to chest radiographs of and , the tip did appear to be further into the SVC, probably at the cavoatrial junction. INDICATION: Hypoxic respiratory failure, intubated, evaluate for ETT placement. There appears to be a P wave just after theQRS complex suggesting the supraventricular tachycardia mechanism isA-V nodal re-entry. Central venous catheter terminates at the cavoatrial junction. REASON FOR THIS EXAMINATION: assess for OG placement FINAL REPORT REASON FOR EXAMINATION: Hypoxia. 1+ pitting pedal edema, R LE chronically edematous since DVT. The right lung now demonstrates pleural effusion with relaxation atelectasis and volume loss at the lung base. pt on neutrapenic precautions. Consider anteroseptal myocardial infarction.ST-T wave abnormalities. na checked and =153 so repeat bolus of 1 liter d5w given. FINDINGS: In comparison with the study of , there is increased opacification in the left apex as seen on the recent CT scan, where it was thought to most likely represent volume loss related to prior radiation treatment. pt admitted on 11.5 for hypoxia,sob,fatigue and temp=101.6 3 days pta. REASON FOR THIS EXAMINATION: r/o PCP, contraindications for IV contrast FINAL REPORT HISTORY: Diffuse B-cell lymphoma, prior PCP, . COMPARISON: FINDINGS: Relatively unchanged appearance of the periventricular low attentuation area adjacent to the frontal of the left lateral ventricle, and could be due to microvascular ischemic changes vs CNS lymphoma infiltration. Neo bumped up briefly to 2.5mcg from 1.2, BP stabilized and now weaning again. this afternoon hr once again in the 140's and ekg done and rhythmn identified by medical team as narrow complexed tachycardia. once pt was intubated hr converted to nsr. Admitted to MICU for progressive hypoxia and confusion. MEDS/ OTHER DATA AS PER CV.WILL C/W PS AS TOLERATED. no stool output this shift.gu: foley cath in place with lg volumes of hourly uo despite pt receiving lg volumes of ivf. ST-T wave abnormalities aremore marked. sbp dropped to 70-80's .pt was given additional 2 liters of rl and neo gtt was initiated. ABG EARLIER WASSTABLE C/W A MILD METABOLIC ACIDOSIS AND STABLE OXYGENATION ON PS .50. Volume loss and further opacification in the posterior segment of left upper lobe, likely representing sequelae of prior radiation treatment. Intubated in MICU for continued resp distress; experieced fever, tachycardia, hypotension.h/o R LE DVT, Neuro: Moderately sedated on Versed @4mg/hr and Fentanyl @100mcg/kg/hr. Stable appearance of the periventricular low attentuation area adjacent to the frontal of the left lateral ventricle and could be due to microvascular ischemic changes vs CNS lymphoma infiltration. The NG tube tip was inserted in the mean time interval with the tip terminating the stomach. CT SCAN TODAY W/ OUT ANYINCIDENTS. Port-a-Cath now in right atrium, however, this appearance seems to change between radiographs and may be due to patient positioning. follow resp status closely.cv: on admission pt tachy to hr of 180 ?svt vs rapid afib. Remains on Vasopressin @ 1.2mg/hr and Neosynepherine, currently at 1.7mcg/kg. addneum to the above note: pt again deveolped tacycardia rate 140-150's/ unclear by ekg what arrhythmia was occuring. Regular supraventricular tachycardia. The trace unchanged appearance of multiple bilateral opacities and known old left apical consolidation or left more than right pleural effusion . NPN 1900-0700DNR NKDA Neutropenic precautionsPt is a 69yo M with h/o diffuse large B-cell lymphoma w/ CNS involvement who has chemo and XRT. 1 liter of ns and electively intubated at 0730 after receiving etomidate and succinycholine. There has been interval intubation and nasogastric tube placement. Portable AP chest radiograph compared to , and chest CT from . ekg was faxed over to cardiologist who felt this rhytmn was a rentry tachycardia. MEDS/ OTHER DATA AS PER CV.WILL C/W AC MODE AS TOLERATED. RESPIRATORY CARE: PT ARRIVED FROM 7 TODAYIN RESPIRATORY DISTRESS SO PT WAS INTUBATED ANDPLACED ON THE AC MODE AS PER CV W/ FIO2 TAPEREDTO .50 AS PER ABG. Intubated, admitted to MICU from floor for hypoxia and mental status changes. In comparison with the next previous study obtained two hours earlier during the same date, the right subclavian approach central venous line is unaltered and so is the density occupying the left apical area and the lower lateral pleural density described previously. There (Over) 1:21 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: staging for lymphoma, for lymphnodes Admitting Diagnosis: LYMPHOMA;HYPOXIA Field of view: 36 FINAL REPORT (Cont) is no free fluid and no pelvic or inguinal lymphadenopathy. | 20 | [
{
"category": "Radiology",
"chartdate": "2168-12-05 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 985450,
"text": " 6:41 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o PCP, \n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with diffuse B-cell lymphoma, h/o PCP in past, DVTs s/p IVC\n filter, presenting with SOB, fatigue.\n REASON FOR THIS EXAMINATION:\n r/o PCP, \n contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diffuse B-cell lymphoma, prior PCP, .\n\n COMPARISON: .\n\n TECHNIQUE: Multiple contiguous 5-mm and 1.25-mm thick axial CT images of the\n chest were obtained from thoracic inlet to upper abdomen without intravenous\n contrast. Subsequently, coronal reformations were performed.\n\n FINDINGS: Interval improvement in the multiple foci of ground-glass opacities\n that were seen in prior study. However, there is new airspace opacity/\n consolidation in the left base peripherally. In the left upper lobe posterior\n segment, dense opacification with bronchiectasis is present, with associated\n anterior bowing of major fissure (likely as a result of volume loss). These\n findings probably represent progressive radiation fibrosis. Calcified nodules\n in the right lower lung are unchanged, so are bibasilar pleural\n calcifications. Small left pleural effusion is associated with mild relaxation\n atelectasis.\n\n Multiple enlarged mediastinal lymph nodes are present, increased in size from\n prior study, the largest measuring 3.1 x 1.5 cm in the prevascular region.\n Right paratracheal node measures 1.1cm, and subcarinal node 3.0 x 1.4 cm.\n Dense LAD calcification is unchanged. Central venous catheter terminates at\n the cavoatrial junction. There is no axillary lymphadenopathy.\n\n Limited non-contrast evaluation of the visualized spleen, and adrenal glands\n are grossly unremarkable. The previously described hepatic lesions are not\n conspicuous in this non-contrast study. The osseous structures are unchanged.\n\n IMPRESSION:\n\n 1. New left basal consolidation which could represent pneumonia. However,\n considering increasing mediastinal lymphadenopathy, this could represent\n pulmonary lymphoma. A followup PET scan can be used to differentiate lymphoma\n from infection.\n\n 2. Volume loss and further opacification in the posterior segment of left\n upper lobe, likely representing sequelae of prior radiation treatment.\n\n 3. New small left pleural effusion\n\n (Over)\n\n 6:41 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o PCP, \n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The results were discussed with Dr. medical resident at 1:40\n p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 986002,
"text": " 9:06 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for OG placement\n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with lymphoma and hypoxia, intubated.\n REASON FOR THIS EXAMINATION:\n assess for OG placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph compared to previous study from the same date\n obtained at 06:15 a.m.\n\n The NG tube tip was inserted in the mean time interval with the tip\n terminating the stomach. The right internal jugular line tip is at the\n cavoatrial junction. The ET tube tip is about 6.2 cm above the carina.\n\n There is overall improvement of pulmonary edema with unchanged appearance of\n left retrocardiac atelectasis and left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 985826,
"text": " 8:10 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ET placement\n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with hypoxic respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n eval for ET placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Hypoxic respiratory failure, intubated, evaluate for ETT\n placement.\n\n FINDINGS: AP single view obtained with patient in semi-upright position\n demonstrates an ETT in place seen to terminate in the trachea some 5 cm above\n the level of the carina. No pneumothorax identified. In comparison with the\n next previous study obtained two hours earlier during the same date, the right\n subclavian approach central venous line is unaltered and so is the density\n occupying the left apical area and the lower lateral pleural density described\n previously.\n\n IMPRESSION: Successful placement of ETT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 985970,
"text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA, pleural effusion\n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with B cell lymphoma intubated\n REASON FOR THIS EXAMINATION:\n PNA, pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with B cell lymphoma and\n pneumonia.\n\n Portable AP chest radiograph compared to . The technique of\n the current radiograph is suboptimal. The trace unchanged appearance of\n multiple bilateral opacities and known old left apical consolidation or left\n more than right pleural effusion _____. The ET tube tip is 5 cm above the\n carina. The right internal jugular line tip is at the cavoatrial junction.\n\n Repeat the chest radiograph _____ technique is recommended for further\n evaluation of the findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-09 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 986052,
"text": " 1:21 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: staging for lymphoma, for lymphnodes\n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with lymphoma, on vent for respiratory failure\n REASON FOR THIS EXAMINATION:\n staging for lymphoma, for lymphnodes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old male with lymphoma, on vent for respiratory failure.\n\n COMPARISON: CT chest from four days ago, CT torso .\n\n TECHNIQUE: MDCT acquired axial images from the thoracic inlet to the pubic\n symphysis were displayed with IV contrast. Coronally and sagittally\n reformatted images were displayed with 5 mm slice thickness.\n\n CT OF THE CHEST WITH IV CONTRAST: In the four days since the previous CT\n chest, there has been collapse/consolidation of the apicoposterior segment of\n the left upper lobe. The superior segment of the left lower lobe is now\n opacified, and the remainder of the left lower lobe is also\n collapsed/consolidated. There is increased left pleural effusion to account\n for atelectasis and volume loss of the left lung, however there is also likely\n consolidation concerning for an infectious process in the left lung. The\n right lung now demonstrates pleural effusion with relaxation atelectasis and\n volume loss at the lung base. There is also a ground-glass opacity in the\n right upper lobe that is concerning for an infectious process.\n\n Extensive mediastinal lymphadenopathy is not significantly changed, the\n largest node measures 2.7 x 1.6 cm in the prevascular region (3:20), which is\n not a significant change. No supraclavicular or axillary lymphadenopathy is\n identified. The heart, pericardium, and great vessels are unremarkable.\n There has been interval intubation and nasogastric tube placement.\n\n CT OF ABDOMEN WITH IV CONTRAST: There has been interval placement of an IVC\n filter. The liver demonstrates slight increase in size of hypoattenuating\n lesions in segment VII (2.3 x 2.5 cm, 3:40) and segment VIII (1.2 x 1.5 cm,\n 3:44). A previously identified hypoattenuating lesion in segment is not\n well visualized in this scan due to a difference in timing of contrast\n administration. There has been interval atrophy and fatty replacement of the\n pancreas, with a slight diffuse increase in fatty appearance of the mesentery.\n There is splenomegaly with the spleen measuring 18.2 cm in the superoinferior\n dimension on the coronal plane. There is clot in the inferior vena cava\n inferior to the filter, extending far inferiorly into the iliac veins. There\n are paraaortic lymph nodes.\n\n CT OF PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, bladder, prostate,\n and seminal vesicles are normal. There is a Foley catheter in place. There\n (Over)\n\n 1:21 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: staging for lymphoma, for lymphnodes\n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is no free fluid and no pelvic or inguinal lymphadenopathy.\n\n Osseous structures are unremarkable in appearance.\n\n IMPRESSION:\n 1. Interval increase in pleural effusions, now bilateral. Left lower lobe\n and partial right lower lobe collapse/consolidation likely an infectious\n component in the bilateral lower lobes and right upper lobe.\n 2. No significant interval change in extensive mediastinal lymphadenopathy.\n 3. Slight increase in size in hypoattenuating liver lesions in segments VII\n and VIII which may represent lymphomatous involvement.\n 4. Fatty replacement atrophy of the pancreas with surrounding fatty mesentery\n likely indicative of interval episode of pancreatitis.\n 5. Splenomegaly which has increased since 4-1/2 months ago.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 985812,
"text": " 6:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: query worsening pneumonia vs pulmonary edema\n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n query worsening pneumonia vs pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n Reason for examination: Worsening hypoxia.\n\n Portable AP chest radiograph compared to , and chest\n CT from .\n\n Heart size is enlarged but unchanged. There is no significant change in left\n basal consolidation and pleural effusion. No left upper lobe opacity has\n slightly increased since yesterday which might represent progression of\n infectious process. Overall the amount of left pleural effusion has\n significantly increased since . These findings might\n represent rapid progression of infection. Pulmonary involvement by lymphoma\n cannot be totally excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 985529,
"text": " 9:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVAL ACUTE BLEED, INCREASED MASS EFFECT, HERNIATION\n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man undergoing whole brain XRT for CNS involvement of diffuse\n B-cell lymphoma, h/o PCP with acute altered mental status\n REASON FOR THIS EXAMINATION:\n r/o acute bleed, increased mass effect, herniation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 69 yp male with whole brain radiotherapy for CNS involvement of\n diffuse B cell lymphoma, h/o PCP, acute altered mental status change.\n for bleed, mass effect, herniation\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: \n\n FINDINGS: Relatively unchanged appearance of the periventricular low\n attentuation area adjacent to the frontal of the left lateral ventricle,\n and could be due to microvascular ischemic changes vs CNS lymphoma\n infiltration.\n There is no evidence of hemorrhage, edema, masses, mass effect, or large\n infarction. The ventricles and sulci are mildly prominent suggesting age or\n radiotheraoy related involutional changes. No fractures are identified.\n\n Supra sellar area is suboptimally visualized in this study, however, patient\n is known to have a contrast enhancing suprasellar mass lesion, suggestive of\n a lymphoma\n\n CONCLUSION: No acute intracranial process.\n Stable appearance of the periventricular low attentuation area adjacent to the\n frontal of the left lateral ventricle and could be due to microvascular\n ischemic changes vs CNS lymphoma infiltration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 985705,
"text": " 11:01 AM\n CHEST (PA & LAT) Clip # \n Reason: assess \n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with DBCLymphoma on whole brain XRT, h/o PCP here with hypoxia,\n multilobar PNA on vanc/cefepime. ? aspiration\n REASON FOR THIS EXAMINATION:\n assess \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lymphoma with new hypoxia suggesting aspiration pneumonia.\n\n FINDINGS: In comparison with the study of , there is increased\n opacification in the left apex as seen on the recent CT scan, where it was\n thought to most likely represent volume loss related to prior radiation\n treatment. Increasing opacification is seen at the left base consistent with\n pleural effusion and basal consolidation consistent with pneumonia. Of\n course, recurrence of pulmonary lymphoma itself cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 985925,
"text": " 3:38 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval line position and r/o pneumothorax\n Admitting Diagnosis: LYMPHOMA;HYPOXIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with hypoxic respiratory failure now s/p RIJ central line\n placement\n REASON FOR THIS EXAMINATION:\n eval line position and r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69-year-old male with respiratory failure, now with right IJ central\n venous catheter placement.\n\n COMPARISON: Two portable chest radiographs performed earlier on the same day\n at 6:33 and 8:20 a.m., as well as chest radiograph of .\n\n PORTABLE CHEST RADIOGRAPH: Again seen is a right Port-A-Cath. Whereas its\n tip was seen in the SVC on the two radiographs earlier today, the tip now\n seems to be within the right atrium. However, looking back to chest\n radiographs of and , the tip did appear to be further into the\n SVC, probably at the cavoatrial junction. On the current film, there is a new\n IJ central venous catheter with its tip low in SVC. No pneumothorax, widening\n of the mediastinum or definite pleural effusion is seen on the right; the left\n costophrenic angle is excluded from the current radiograph. The ET tube is in\n unchanged and standard position. The remainder of the examination is\n unchanged from seven-and-a-half hours ago. Incidentally noted is a region of\n irregular density in the proximal humerus likely represents healed bone\n infarct, of no clinical significance.\n\n Impression: New right IJ in SVC. Port-a-Cath now in right atrium, however,\n this appearance seems to change between radiographs and may be due to patient\n positioning. Findings were discussed with the medical resident at the time of\n dictation.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-10 00:00:00.000",
"description": "Report",
"row_id": 1640082,
"text": "NPN 1900-0700\nComfort Measures\n\nPt is a 69yo male w/ h/o diffuse Bcell lymphoma with CNS involvement. s/ , xrt. Intubated, admitted to MICU from floor for hypoxia and mental status changes. Chest CT, elevated LDH and peripheral blood smear reveal lymphoma in circulating blood and throughout lung fields with left lobe collapsed, R lobe ~ infiltrated.\n\nEvent: Family met with Drs. and , the oncological NP and this RN at 19:30. Dr informed Mrs and her 2 daughters, and , of pt's unfortunate disease progression which will result in his death imminently. The family requested that pressors be d/c'd, extubation, comfort measures which was done at ~8pm.\n\nPt is unarousable. Morphine gtt for respiratory comfort @ 17cc/hr. Current VSS are HR 114, BP 59/35, O2 63%, RR 11. Pt appears comfortable.\n\nFamily visited with pt prior to removing pressors as they expressed anxiety re: witnessing pt's death. Mrs has called twice for update. The family has expressed great appreciation for our care of pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-09 00:00:00.000",
"description": "Report",
"row_id": 1640081,
"text": "MICu/SICU NPN ICU Day #2\nEvents: pt had CT torso for staging of NHL, pt's family met with Dr. to discuss pt's condition and POC\n\nS/O:\n\nNeuro: pt is well sedated with fentanyl/midazolam, no independent movement of extremities, pupils pinpoint\n\nPulm: pt remains intubated on PSV 10+8/0.4, SpO2 93-98%, SRR 15-20\n\nCV: HR 66-127 SR/ST, the acceleerated rate was associated with moving pt in bed and was selft limited, BP 88-123/41-78 on Neo and Vasopressin\n\nInteg: C/W/D/I\n\nGI/GU: abd softly distended, BS present, TF initiated this PM, Foley patent for clear yellow urine in adequate amts\n\nAccess: #20 angio left wrist day #1, new right IJ TLCL, right SC POC, right radial art line day #2\n\nA:\n\naltered breathing r/t acute on chronic inflammatory process\nhigh risk for infection r/t invasive lines, indwelling catheter, ETT\n\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue resp support and wean as tolerated, contiue hemodynamic support as needed and wean as tolerted, plan to meet with family when results of CT scan reported to discuss POC\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 1640074,
"text": "admission note: briefly this is a 69 yo male with nkda. pmh significant for lg b cell lymphoma with cns involvement and mets to brainundergoing xrt,pcp ,dvt s/p ivc filter. pt admitted on 11.5 for hypoxia,sob,fatigue and temp=101.6 3 days pta. overnoc pt became somnulent, tachy and with higher o2 requirements. pt transfered to at o700 for further management. upon arrival to micu pt tachycaridc hr of 180 rapid afib vs svt, tachypneic to 30's and o2 sats of 91% on 100% nrb and sbp 94.. pt medicated with 5 mg ivp lopressor. 1 liter of ns and electively intubated at 0730 after receiving etomidate and succinycholine. cxr confirmed ett placement. wife was called and notified of his transfer to \n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 1640075,
"text": "review of systems:\n\nneuro: upon arrival to micu pt extremely lethargic and noncommunicative. opening eyes to his nane being called. once pt was intubated he was sedated on fentanyl gtt at 50 mcg/hr and versed gtt at 2mg/hr. pt effectively sedated and will titrate sedative gtts as needed.\n\nresp: pt arrived tachypneic and with an o2 sat of 91% on 100% nrb. reslirations labored. anesthesia called and pt was intubated orally with 7.5 ett after being medicated for succinycholine and etomidate. ett placement confirmed by cxr.ett secured at 21 cm r corner of the lip. abg on 100% fio2 on vent=7.42/37/271. vent settings now at 50%/550/ac14 with 5 peep and o2 sats > 97%. lungs clear to upper lobes and diminished at the bases. rr in the 20's. no sputum obtained from ett. follow resp status closely.\n\ncv: on admission pt tachy to hr of 180 ?svt vs rapid afib. pt given 5 mg ivp lopressor and also bolused with liter of ns. once pt was intubated hr converted to nsr. sbp dropped to 70-80's .pt was given additional 2 liters of rl and neo gtt was initiated. na checked and =153 so repeat bolus of 1 liter d5w given. pt has received a total of 4 liters ivf since he arrived. levophed gtt now added and will titrate as needed to keep map> 65 and sbp > 90. will wean neo gtt to off and increase levophed gtt as needed. this afternoon hr once again in the 140's and ekg done and rhythmn identified by medical team as narrow complexed tachycardia. will follow hemodynamics and titrate pressors as needed. check lytes as ordered and replete as needed.\n\ngi: abd distended,soft and nontender on palpation with pos bowel sounds on auscultation. still awaiting decision as to wether pt should have and ogt placed for enteral fdgs or will pt need tpn. all po meds being held at this time. no stool output this shift.\n\ngu: foley cath in place with lg volumes of hourly uo despite pt receiving lg volumes of ivf. urine lytes sent off. ? etiology of this up might be related to brain involvement but pt presently too unstble to be transported for ct of the head. follow fluid balance closely.\n\nid: max temp=100.1 and wbc=1.2. pt on neutrapenic precautions. pt presently receiving vancomycin,cefepime,fluconazole and bactrim for antibiotic/fungal coverage. will follow fever curve and id team continues to follow pt.\n\n\nsocial: pt is a full code. will continue with present medical management. family in to visit and updated y nursing and medical staff.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 1640076,
"text": "RESPIRATORY CARE: PT ARRIVED FROM 7 TODAY\nIN RESPIRATORY DISTRESS SO PT WAS INTUBATED AND\nPLACED ON THE AC MODE AS PER CV W/ FIO2 TAPERED\nTO .50 AS PER ABG. MEDS/ OTHER DATA AS PER CV.\nWILL C/W AC MODE AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 1640077,
"text": "addneum to the above note: pt again deveolped tacycardia rate 140-150's/ unclear by ekg what arrhythmia was occuring. neo gtt was increased to 2.3 mcg/kg.min and neo weaned to off without any drop in his hr. ekg was faxed over to cardiologist who felt this rhytmn was a rentry tachycardia. carotid massage by dr. without improvement.? if pt will require cardioversion. dr. spoke with pt's wife and 2 daughters and updated them on the present concerns/issues. all agreed that we will continue with aggressive tx at present time but he is a dnr. will continue to keep family updated frequently.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-09 00:00:00.000",
"description": "Report",
"row_id": 1640078,
"text": "NPN 1900-0700\nDNR NKDA Neutropenic precautions\n\nPt is a 69yo M with h/o diffuse large B-cell lymphoma w/ CNS involvement who has chemo and XRT. Disease is progressing. Admitted to BMT for hypoxia/SOB/fever/fatigue during clinic visit, sx which had been present for 3d PTA. Admitted to MICU for progressive hypoxia and confusion. Intubated in MICU for continued resp distress; experieced fever, tachycardia, hypotension.\n\nh/o R LE DVT, \n\nNeuro: Moderately sedated on Versed @4mg/hr and Fentanyl @100mcg/kg/hr. Present but impaired gag, +cough. PERRL sluggishly. Tmax 99.1.\n\nCV: Please see carevue for detailed objectives. Remains on Vasopressin @ 1.2mg/hr and Neosynepherine, currently at 1.7mcg/kg. NSR-ST to high 120's w/ PAC's. Pt's HR and BP's stabilized for several hrs overnight but he experienced hypotension and tachycardia again at 0430 during CVL dressing change. Neo bumped up briefly to 2.5mcg from 1.2, BP stabilized and now weaning again. HR spontaneously returned to 60'-70's w/SVPB's observed. Weakly palpable pp's b/l. Skin continues to be clammy. 1+ pitting pedal edema, R LE chronically edematous since DVT. AM labs include Na+=139, Hct 24.4, INR , lactic acid up to 4.4 from 3.3. ABG 7.35/40/123/-.\n\nResp: Improved comfort on CPAP+PS 50/10/5, RR in teens and 20's. LS coarse to clear upper, diminished w/ scatter crackles in LL's. Satting @ 97% consistently. Scant secretions\n\nGI/Endo/GU: soft distended abd w/ hypoactive BS, very small BM x1. NPO, no ngt was placed yesterday low platelet count; team to revisit. AM glu up to 218 w/ pt on Solumedrol, team aware. Patent foley draining clear yellow urine WNL at 60-100cc/hr\n\nID: Pt is on Vanco 1gm , Cefepime q8 and sulfameth/trimeth q6h\n\nSkin: CDI w/ some ecchymosis on ue's b/l.\n\nLines: Patent PIV on L forearm, R IJ TLC, all ports patent, dressing changed today. R radial art line patent. pt has R portacath, accessed and using for pressors.\n\nSocial: wife is HCP and agreed w/ plan to treat aggressively but DNR ordered. Daughters and . lovely family. Contact info on white board.\n\nPlan: monitor and support hemodynamics, fever curve\n monitor lung sounds\n monitor u/o\n IV abx, steroid\n probable RISS\n emotional support for pt and family\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-09 00:00:00.000",
"description": "Report",
"row_id": 1640079,
"text": "Resp Care\n\nPt had become dyspneic at start of shift and was having hypotention as well as tachycardia. Spo2 remained in the mid 90's. Pt was not well sych'd with AC mode and had very long exp phase. Bs were very diminished and there was a mix of fine rales and short,faint, fine wheezes. Pt did not respond to bronchodilator. Pt cannot be rx wth dieretics do to antidieretic hormonal abnormality. He was changed to PSV mode and peep wa increased from 5 to 10 after pt gvn IV neo for hypotention. This combination worked well t/o the night although BP was labile and reactive to changes in neo level, ABG shows only slight met acidosis and very good oxygenation at these settings. no RSBI completed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-09 00:00:00.000",
"description": "Report",
"row_id": 1640080,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED W/ A 7.5 ORAL ETT\nIN PLACE AND CURRENTLY ON PS .50. ABG EARLIER WAS\nSTABLE C/W A MILD METABOLIC ACIDOSIS AND STABLE OXYGEN\nATION ON PS .50. MEDS/ OTHER DATA AS PER CV.\nWILL C/W PS AS TOLERATED. CT SCAN TODAY W/ OUT ANY\nINCIDENTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-10 00:00:00.000",
"description": "Report",
"row_id": 1640083,
"text": " nsg note: 7:00-10:07am\npt appearing very comfortable on morphine gtt at 18mg/hr at 7am and remained comfortable. pt pulseless, aline flat, breathless by 10am. pt did have a few agonal breaths and then was pronounced by 10:07am. md notified pt's wife who did not wish for an autopsy. social worker to speak with wife to assist with funeral arrangements. post mortem care provided.\n"
},
{
"category": "ECG",
"chartdate": "2168-12-08 00:00:00.000",
"description": "Report",
"row_id": 202419,
"text": "Regular supraventricular tachycardia. Low limb lead voltage. Q waves\nin leads III and aVF. Consider inferior wall myocardial infarction.\nEarly precordial Q waves. Consider anteroseptal myocardial infarction.\nST-T wave abnormalities. There appears to be a P wave just after the\nQRS complex suggesting the supraventricular tachycardia mechanism is\nA-V nodal re-entry. Since the previous tracing of the supraventricular\ntachycardia is new. The voltage has decreased. ST-T wave abnormalities are\nmore marked. Clinical correlation is suggested.\n\n"
}
] |
28,281 | 123,827 | 73 yo female with PMH significant for ILD on home O2, diastolic CHF, cor pulmonale, s/p liver on immunosuppression, post- myeloproliferative disorder s/p CHOP and rituximab who was initially admitted to hospital after a mechanical fall for pain control who was transferred to the MICU for hypercarbic/hypoxic respiratory failure in the setting of emesis | Hypotension (not Shock) Assessment: A-line placed, pt HR in rapid A-fib 120-140s BP was stable but then began to drop. Hypotension (not Shock) Assessment: A-line placed, pt HR in rapid A-fib 120-140s BP was stable but then began to drop. Hypotension (not Shock) Assessment: A-line placed, pt HR in rapid A-fib 120-140s BP was stable but then began to drop. Hypotension (not Shock) Assessment: A-line placed, pt HR in rapid A-fib 120-140s BP was stable but then began to drop. Hemodynamics: AF has recurred and we have restarted amiodarone. Respiratory failure, acute (not ARDS/) Assessment: Pt vented on CPAP 10/5 with better ABGs , pC02-60. Antibiotics changed to vanco/zosyn- flagyl d/c Respiratory failure, acute (not ARDS/) Assessment: LS-clear w/ diminished bases. Hypotension (not Shock) Assessment: A-line placed, pt HR in rapid A-fib 120-140s BP was stable but then began to drop. While in Micu pt became unresponsive ABG was drawn and PCO2 in the 100s pt was then intubated. While in Micu pt became unresponsive ABG was drawn and PCO2 in the 100s pt was then intubated. Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: SBP rechecked in R leg94). SBP rechecked in R leg94). While in Micu pt became unresponsive ABG was drawn and PCO2 in the 100s pt was then intubated. While in Micu pt became unresponsive ABG was drawn and PCO2 in the 100s pt was then intubated. adm to MICU after desaturating, ? adm to MICU after desaturating, ? adm to MICU after desaturating, ? Antibiotics changed to vanco/zosyn- flagyl d/cd. # FEN: NPO for now - vit D . - Continue outpt metoprolol . Action: Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330 Response: Remains in NSR with stable QTc .45-.46 Plan: Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: Action: Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330 Response: Remains in NSR with stable QTc .45-.46 Plan: Amiodarone infusion to be stopped at 0630. Action: Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330 Response: Remains in NSR with stable QTc .45-.46 Plan: Amiodarone infusion to be stopped at 0630. # Hypothyroidism: TSH normal this admission. # Hypothyroidism: TSH normal this admission. # FEN: NPO for now given tenuous respiratory status . # FEN: NPO for now given tenuous respiratory status . Started on amio drip and bolus, Neo thru PICC for hypotension. # fever: new low grade temp this am. # fever: new low grade temp this am. CXR and sputum suggest she aspirated. Hypotension (not Shock) Assessment: A-line placed, pt HR in rapid A-fib 120-140s BP was stable but then began to drop. While in Micu pt became unresponsive ABG was drawn and PCO2 in the 100s pt was then intubated. # Hypothyroidism: TSH normal this admission. # fever: new low grade temp this am. Respiratory failure, acute (not ARDS/) Assessment: LS rales though out. Antibiotics changed to vanco/zosyn- flagyl d/cd. While in Micu pt became unresponsive ABG was drawn and PCO2 in the 100s pt was then intubated. Acute decompensation seems to have occurred in the setting of SVT w/ RVR. Pt noted to have cx's and CXR showed pulm edema. Response: Difficult weaning Neo with labile BP Plan: .H/O atrial fibrillation (Afib) Assessment: HR 80s-90 NSR with occasional-frequent PAC QTc .45. # Hypothyroidism: TSH normal this admission. # Hypothyroidism: TSH normal this admission. # Hypothyroidism: TSH normal this admission. # FEN: NPO for now given tenuous respiratory status . Started on amio drip and bolus, Neo thru PICC for hypotension. Respiratory failure, acute (not ARDS/) Assessment: LS rales though out. Acute decompensation seems to have occurred in the setting of SVT w/ RVR. Acute decompensation seems to have occurred in the setting of SVT w/ RVR. Hemodynamics: AF has recurred and we have restarted amiodarone. .H/O atrial fibrillation (Afib) Assessment: Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: # FEN: NPO for now given tenuous respiratory status . # FEN: NPO for now given tenuous respiratory status . # FEN: NPO for now given tenuous respiratory status . # FEN: NPO for now given tenuous respiratory status . # Hypothyroidism: TSH normal this admission. # Hypothyroidism: TSH normal this admission. # Hypothyroidism: TSH normal this admission. # Hypothyroidism: TSH normal this admission. The right PICC is again seen to terminate in the region of superior vena cava. Hemodynamics: AF has recurred and we have restarted amiodarone. See hypotension above. Will reassess after fluid resuscitation this PM. Normal axis and intervals.Q waves are present in leads II, III and aVF consistent with inferiormyocardial infarction, age undetermined. Pneumobilia, which is unchanged from prior chest CT from , is again noted. There is slight ST segmentelevation in leads II and V4-V6 consistent with acute inferolateralmyocardial infarction or possibly related to wall motion abnormalityfrom prior myocardial infarction. Cannot rule out prior inferior myocardial infarction.Compared to the previous tracing of the findings are similar. There is diffuse osteopenia. There is superior endplate depression of the L2 vertebral body that demonstrates slight interval worsening since . There is extreme kyphosis and compression fractures of the thoracic spine that are unchanged from prior examination from and . | 173 | [
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 358262,
"text": "Chief Complaint: rapid Afib, 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 - 1 liter fluid challenege, off Neo, still in Afib with RVR at times\n - struggling with issues aorund code status as noted by Dr in\n prior entries\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 08:07 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Bactrim prophy\n Tacro\n Vit D\n Ca\n Synthroid\n PPI\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 09:18 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: 35.8\nC (96.5\n HR: 138 (80 - 144) bpm\n BP: 104/53(65) {81/47(56) - 109/79(84)} mmHg\n RR: 30 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 592 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,670 mL\n 352 mL\n Blood products:\n Total out:\n 460 mL\n 229 mL\n Urine:\n 460 mL\n 229 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 363 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 98%\n ABG: ///32/\n Ve: 11.3 L/min\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 8.5 g/dL\n 286 K/uL\n 107 mg/dL\n 2.3 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 92 mEq/L\n 134 mEq/L\n 24.0 %\n 10.2 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n Plt\n 393\n 429\n 380\n 286\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 358279,
"text": "Chief Complaint: rapid Afib, 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 - 1 liter fluid challenege, off Neo, still in Afib with RVR at times\n - struggling with issues around code status as noted by Dr in\n prior entries\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 08:07 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Bactrim prophy\n Tacro\n Vit D\n Ca\n Synthroid\n PPI\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 09:18 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: 35.8\nC (96.5\n HR: 138 (80 - 144) bpm\n BP: 104/53(65) {81/47(56) - 109/79(84)} mmHg\n RR: 30 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 592 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,670 mL\n 352 mL\n Blood products:\n Total out:\n 460 mL\n 229 mL\n Urine:\n 460 mL\n 229 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 363 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 98%\n ABG: ///32/\n Ve: 11.3 L/min\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 8.5 g/dL\n 286 K/uL\n 107 mg/dL\n 2.3 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 92 mEq/L\n 134 mEq/L\n 24.0 %\n 10.2 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n Plt\n 393\n 429\n 380\n 286\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Resp Distress: likely due to underlying ILD with superimposed\n atrial fibrillation and some mild vol overload. . Respiratory status\n remains tenuous and will likely need intermittent periods of BiPAP.\n 2. Hemodynamics: AF has recurred and we have restarted\n amiodarone. Continue pressor to maintain perfusion pressureWill\n continue Vanco/Zosyn and hold cipro awaiting cultures.\n 3. ARF: Critical to check all med levels esp. tacrolimus for s/p\n liver transplant and Vanco.\n 4. Continue discussions with family, primary care physician and\n consultants for overall plan of care. Unable to advance diet.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 45 min\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 358538,
"text": "Chief Complaint: 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 24 Hour Events:\n Was on face mask for hours yesterday but desaturated required BIUPAP\n again overnight./\n 7.24/75/75 on venti mask this AM\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:33 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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: Dyspnea\n Flowsheet Data as of 10:25 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: 35.9\nC (96.6\n HR: 86 (73 - 123) bpm\n BP: 123/58(71) {86/34(38) - 123/84(89)} mmHg\n RR: 27 (18 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 1,139 mL\n 644 mL\n PO:\n 640 mL\n 340 mL\n TF:\n IVF:\n 499 mL\n 304 mL\n Blood products:\n Total out:\n 579 mL\n 223 mL\n Urine:\n 579 mL\n 223 mL\n NG:\n Stool:\n Drains:\n Balance:\n 560 mL\n 421 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 375 (375 - 375) mL\n RR (Set): 0\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 70%\n PIP: 18 cmH2O\n SpO2: 95%\n ABG: 7.24/75/75/29/1\n Ve: 6.5 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Gen obese female, sitting up in bed, mild resp distress, fatigies\n appearing\n HEENT: o/p dry\n CV: irreg orreg\n Chest: diffuse inspiratory rales\n Abd obese soft Nt + BS\n Ext 2+ edema\n Neuro A and oriented conversant\n Labs / Radiology\n 8.3 g/dL\n 266 K/uL\n 64 mg/dL\n 2.4 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.0 %\n 8.3 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n 09:58 PM\n 05:30 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n 8.3\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n 24.0\n Plt\n 393\n 429\n 380\n 286\n 266\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n 2.4\n TCO2\n 39\n 38\n 34\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n 64\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Vanco 22.6\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: family meeting planned for 3 PM with Dr and MICU\n team\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356394,
"text": "Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356397,
"text": "Pt was adm to s/p fall at home. on the floor, pt\n developed resp distress with desat to 88% on 2 liters NC. Pt noted to\n have cx's and CXR showed pulm edema. Pt given lasix po and IV with some\n effect. Pt noted to be slight lethargic. Pt sent to MICU for further\n care.\n DNR, CPR not indicated.\n Hypotension (not Shock)\n Assessment:\n A-line placed, pt HR in rapid A-fib 120-140\ns BP was stable but then\n began to drop. Into SBP 70-80.\n Action:\n Fluid boluses given and Amiodarone load and drip started.\n Response:\n Amiodarone did not make much difference with HR, family called to ? if\n they wanted a line placed and pressors started and they declined, we\n are no longer escalating care.\n Plan:\n Cont amiodarone and fluid boluses, not escalating care otherwise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.3\n Action:\n Pt given Tylenol and urine and blood cultures done\n Response:\n Plan:\n Cont to monitor\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356469,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:35 PM\n ARTERIAL LINE - START 08:00 PM\n EKG - At 11:30 PM\n ARTERIAL LINE - STOP 11:32 PM\n ARTERIAL LINE - START 12:10 AM\n BLOOD CULTURED - At 01:30 AM\n URINE CULTURE - At 01:30 AM\n EKG - At 02:04 AM\n FEVER - 102.3\nF - 12:00 AM\n intubated as ABG came back with PCO2 in 100s\n -A-line placed\n -went into SVT to 130s, atrial fib vs MAT. did not break with PO\n toprol, 5mg lopressor IV, IVF. Started amiodarone w/ load.\n -spiked to 102.3, sent blood cx, urine cx, cxr. started vanco/zosyn for\n ? asp PNA.\n -repeat abg w/PCO2 in 50s, decreased MV.\n -pts family , do not want to escalate care.\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:03 PM\n Metoprolol - 11:40 PM\n Midazolam (Versed) - 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100.1\n HR: 117 (76 - 134) bpm\n BP: 81/53(62) {72/46(55) - 134/73(94)} mmHg\n RR: 16 (16 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 631 mL\n 2,929 mL\n PO:\n TF:\n IVF:\n 631 mL\n 2,929 mL\n Blood products:\n Total out:\n 925 mL\n 115 mL\n Urine:\n 925 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n -294 mL\n 2,814 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n Compliance: 19.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/55/151/42/13\n Ve: 6.5 L/min\n PaO2 / FiO2: 302\n Physical Examination\n General Appearance: NAD, more alert than yesterday, intubated\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, Bowel sounds present, Distended, Obese, nontender to\n palp\n Extremities: Right: 1+, Left: 1+ dp pulses, warm, 1+ edema\n Neurologic: Responds to voice and commands, on minimal sedation,\n intubated.\n Labs / Radiology\n 203 K/uL\n 9.2 g/dL\n 164 mg/dL\n 1.0 mg/dL\n 42 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 89 mEq/L\n 136 mEq/L\n 25.5 %\n 7.3 K/uL\n [image002.jpg]\n 02:43 PM\n 04:27 PM\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n WBC\n 8.2\n 7.5\n 7.3\n Hct\n 35.1\n 28.0\n 25.5\n Plt\n 243\n 203\n 203\n Cr\n 1.0\n 1.0\n TropT\n <0.01\n <0.01\n 0.01\n TCO2\n 55\n 46\n 46\n 40\n Glucose\n 141\n 164\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.5 mg/dL, Mg++:1.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensate.\n - continue vanco, zosyn for aspiration pneumonia vs HAP\n - wean to PS as tolerated today, rest on AC\n -monitor fluid status to avoid gross pulmonary edema (lasix 40 IV is\n suspect flash)\n -nebs prn\n - consider adding on steroids if underlying disease appears to have\n worsened\n .\n # emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved but continue NPO for now\n .\n # SVT: Overnight patient went from sinus tachycardia to SVT, ? atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c amiodarone\n -monitor on telemetry\n -restart home toprol 37.5mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch.\n - cont lidocaine patch, tylenol\n - fentanyl for pain now, but may need to wean if ready to extubate\n -PT\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale.\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus, level pending this AM\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - Continue outpt metoprolol and monitor\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV\n .\n # FEN: NPO for now, vitamin D, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:08 AM\n Arterial Line - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Social Work",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 356636,
"text": "Social work received POE for patient family coping. Reviewed chart, no\n mention of specific issues needing to be addressed by SW. Attempted to\n see patient who was in room asleep. No family was present. Please page\n SW if family members arrive and would like to speak with SW. Weekday SW\n will try to see patient again on Monday as does not seem of urgent\n nature.\n , LCSW\n #\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 356343,
"text": "Chief Complaint: Reason for transfer: Hypercarbic respiratory failure\n PCP: , . \n Pulmonologist: , \n Heme/Onc: \n Cardiologist: \n HPI:\n Ms. is a 73 yo female with PMH significant for ILD on .5L\n home O2, diastolic CHF, cor pulmonale, s/p liver transplant on\n immunosuppression, post-transplant myeloproliferative disorder s/p CHOP\n and rituximab who was initially admitted to hospital after a mechanical\n fall for pain control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis.\n Patient was initially admitted to the medicine service on for a\n mechanical fall. She stated that prior to her fall she was in her USOH\n without any change in her baseline respiratory status or other new\n symptoms. She stepped on her scale and then lost her balance and\n landed on her low back. She was then brought to ED. There was no\n head trauma or LOC by report. Here, spine films revealed no acute\n fracture. She was being treated with PT and pain control. She was not\n receiving any opiates due to underlying lung disease. She did received\n tylenol, ibuprofen, and lidoderm patch.\n .\n Yesterday evening, the patient triggered after an episode of nausea and\n vomiting as well as a drop in her O2 saturation. Changed to face mask\n with improvement in O2. She remained hemodynamically stable. No CXR or\n ABG was performed. Changed to 40% ventimask and satting in mid-90s. At\n 10:30 this am, looks ashen, cyanotic, and lethargic on 4 L of 50%\n venti. O2 in high 70s at that time. Sleepy but arousable. Increased O2\n to 15L on 50% ventimask. Given nebs. On exam, tight air movement and\n cracklie but not significantly different from baseline. Initial gas\n 7.29/97/113 on 15L 50% ventimask. Last ABG in system 7.43/47/73 in\n 3/. Mental status improved with increase in oxygenation. She was\n given solumedrol 100 mg IV Q8H. Reevaluated in 1 hr, still lethargic\n but arousable. Repeat ABG 7.28/108/79 on 15L 50% ventimask. CXR\n performed on floor, showed some diffuse fluffiness. She received 40 mg\n IV lasix. She continues to have intermittent nausea and vomiting with\n 2-3 episodes of emesis since yesterday evening.\n .\n On arrival to the ICU, she denies any chest pain, SOB, abdominal pain,\n nausea, fevers, chills. She does not think that she has been in the\n hospital for several days. Appears confused. Lethargic but easily\n arousable.\n Patient admitted from: \n History obtained from Medical records, MD\n Patient unable to provide history: Encephalopathy\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Home medications:\n IPRATROPIUM BROMIDE 0.2 mg/mL inh four times a day\n LEVOTHYROXINE 75 mcg by mouth once a day\n METOPROLOL TARTRATE 75 mg by mouth TID\n OMEPRAZOLE 20 mg by mouth daily\n TACROLIMUS 3mg by mouth twice a day\n DOCUSATE SODIUM 100 mg by mouth once a day\n INSULIN NPH HUMAN RECOMB [HUMULIN N] 44U units before breakfast, 12U at\n 4:30pm.\n INSULIN REGULAR HUMAN [HUMULIN R] - sliding scale four times a day\n Lasix 40 mg daily\n Bactrim TIW\n Tums prn\n .\n Medications on transfer:\n Levothyroxine Sodium 75mcg PO\n Acetaminophen 325-650 mg PO Q6H:PRN\n Lidocaine 5% Patch 1 PTCH TD DAILY\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H\n Metoprolol Tartrate 75 mg PO TID\n Calcium Carbonate 1250 mg PO TID\n MethylPREDNISolone Sodium Succ 100 mg IV Q8H\n Docusate Sodium 100 mg PO DAILY\n Omeprazole 20 mg PO DAILY\n Furosemide 40 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR\n Insulin sliding scale\n Tacrolimus 3 mg PO Q12H\n Dose to be admin. at 6am and 6pm Order date: @ 1603\n Ipratropium Bromide MDI 2 PUFF IH QID\n TraMADOL (Ultram) 50 mg PO Q4H:PRN\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Vitamin D 50,000 UNIT PO QTUES\n Past medical history:\n Family history:\n Social History:\n # Interstitial pulmonary fibrosis\n - home oxygen dependent 2-2.5L NC (etiology unknown, no biopsy)\n - recently titrated off prednisone as unresponsive\n # cor pulmonale\n # S/p Liver transplant for cryptogenic cirrhosis\n # Post-transplant lymphoproliferative disorder s/p CHOP and rituximab\n # Type 2 DM (without peripheral neuropathy)\n # HTN\n # Hypothyroidism\n # Diastolic dysfunction with LVEF of 65%\n # Cholecystectomy.\n # Appendectomy.\n # h/o of atrial fibrillation\n There is no family history of premature coronary artery disease or\n sudden death. Afib in sister\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, previously lived at home but recently discharged to\n rehab. Denies tobacco use.\n Review of systems:\n Constitutional: No(t) Fever\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Psychiatric / Sleep: Delirious, Daytime somnolence\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:18 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 92 (92 - 97) bpm\n BP: 127/59(77) {127/59(77) - 127/73(86)} mmHg\n RR: 20 (20 - 24) insp/min\n SpO2: 97%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -300 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///48/\n Physical Examination\n General Appearance: Overweight / Obese, moon facies, tachypneic,\n accessory muscle use\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: buffalo hump\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, worst at bases, Diminished: throughout)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n midline reducible hernia\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): person and place. , Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 243 K/uL\n 12.2 g/dL\n 141 mg/dL\n 1.0 mg/dL\n 28 mg/dL\n 48 mEq/L\n 86 mEq/L\n 5.3 mEq/L\n 137 mEq/L\n 35.1 %\n 8.2 K/uL\n [image002.jpg]\n \n 2:33 A12/17/ 02:43 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.2\n Hct\n 35.1\n Plt\n 243\n Cr\n 1.0\n Glucose\n 141\n Other labs: PT / PTT / INR:12.2/23.8/1.0, CK / CKMB / Troponin-T:25//,\n ALT / AST:, Alk Phos / T Bili:85/0.3, Amylase / Lipase:55/27,\n Albumin:3.7 g/dL, LDH:264 IU/L, Ca++:10.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.6 mg/dL\n Imaging: CXR :\n Chronic interstitial lung disease with superimposed vague opacity\n may represent aspiration or mild pulmonary edema.\n .\n L-spine XR :\n Slight interval increase in superior endplate wedging of the L2\n vertebral body, and chronic L1 compression fracture. No other acute\n fracture or dislocation.\n .\n Spirometry :\n FEV1: 0.87(42%), FVC:0.97(33%), FEV1/FVC: 90(128%)\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: given current ABG, suspect\n she has had increased CO2 retention over last month. Also given that\n she is not currently obtunded argues in favor of this. Acute worsening\n in oxygenation likely due to aspiration or flash pulmonary edema in the\n setting of emesis. Other possible etiologies including pna or PE seem\n less likely. She has been on DVT ppx. Not good NIPPV candidate\n currently given emesis. Given severity of underlying lung disease,\n intubation unlikely to be reversible.\n - discuss goals of care with family\n - serial ABGs\n - cont supplemental O2\n - add on BNP\n - lasix 40 IV for pulmonary edema\n - hold off on abx without clear infection\n - nebs\n - hold off on steroids as has been steroid unresponsive in past and no\n evidence of obstructive exacerbation at this time\n .\n # emesis: unclear cause. Patient cannot provide adequate history at\n this time. Abdominal exam benign at this time. Does have midline hernia\n but reducible.\n - abdominal film to check fo obstruction\n - add on LFTs, PEs\n - check tacro level to assess for toxicity\n - check cardiac enzymes and ECG\n - NPO for now\n .\n # s/p fall: no evidence of fracture. Pain reasonably controlled at\n rest. Likely mechanical so no need for further syncope work up at this\n time.\n - cont lidocaine patch, ibuprofen and tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: reasonable BG control on floor\n - cont NPH per outpt doses. Half dose while NPO\n - cont insulin sliding scale\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - check tacro level\n - continue Tacrolimus at regular dose for now\n .\n # HTN: normotensive currently.\n - Continue outpt metoprolol\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV\n .\n # FEN: NPO for now\n - vit D\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: FULL CODE. Will need to readdress with HCP\n .\n # Contact: \n .\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:09 PM\n 18 Gauge - 02:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356439,
"text": "Pt was adm to s/p fall at home. on the floor, pt\n developed resp distress with desat to 88% on 2 liters NC. Pt noted to\n have cx's and CXR showed pulm edema. Pt given lasix po and IV with some\n effect. Pt noted to be slight lethargic. Pt sent to MICU for\n hypercarbic/hypoxic resp failure in the setting of emisis. CXR shows\n chronic interstitial lung disease with superimposed vague opacity may\n represent aspiration or mild pulmonary edema.\n ABG from before pt intubated 7.22/127/192, pt very hard intubation\n nurse reported it took 1.5hr. pt with chronic interstitial lung disease\n pt has been trached in the past. Pt with diastolic CHF, s/p liver\n transplant on immunosuppression,\n Events: pt in rapid A-fib 120-140\ns around 2330, fluid bolus given and\n 5mg of lopressor IV given without any affect on pt HR, Amiodarone\n started, loading dose given and then gtt continued after, also no\n change in pt HR ranged from 110-130. SBP dropping into 70\ns-80. Map\n 50-60\ns. At this time ? if we needed central line and wanted to start\n pressors, pt husband was called and he decided not to advance care. Pt\n cont to get fluid boluses to try to keep BP up. A-line placed x2, new\n peripheral IV placed by resident via ultrasound.\n PMH: interstitial pulmonary fibrosis home dependent on O2 pt refractory\n to steroids, s/p liver transplant , post transplant\n lymphoproliferative disorder, type 2 DM, HTN, hypothyroidism, diastolic\n dysfunction with LVEF 65%, Cholecystectomy, appendectomy, h/o A-fib.\n DNR, CPR not indicated.\n Hypotension (not Shock)\n Assessment:\n A-line placed, pt HR in rapid A-fib 120-140\ns BP was stable but then\n began to drop. Into SBP 70-80.\n Action:\n Fluid boluses given and Amiodarone load and drip started.\n Response:\n Amiodarone did not make much difference with HR, family called to ? if\n they wanted a line placed and pressors started and they declined, we\n are no longer escalating care.\n Plan:\n Cont amiodarone and fluid boluses, not escalating care otherwise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 100%/400/5/18 lungs clear/rhonchi, small ETT\n secretions thick yellow/clear, copius amounts of subglottal secretions,\n clear.\n Action:\n Dropped FiO2 to 50% ABG 7.44/66/198. After HR increased to 120-140\n did another ABG\n Response:\n ABG 7.53/53/111, residents did not want bicarb, did turn rate down to\n 16, latest ABG 7.46/55/151\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.3\n Action:\n Pt given Tylenol and urine and blood cultures done\n Response:\n Temp decreased with Tylenol 100.1, WBC WNL\n Plan:\n Cont to monitor\n"
},
{
"category": "Nutrition",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 356622,
"text": "Patient has been NPO and/or on unsupplemented clear liquid diet for 2\n days.\n Comments:\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis, ? of\n asp PNA.\n Remains intubated, per family no escalation of care.\n If unable to extubate in 24-48hrs, would benefit from nutrition support\n if within the plan of care/goals.\n Will f/u with progress and plan for nutrition support if indicated.\n Pls pge w/ questions/issues #\n 11:39\n"
},
{
"category": "General",
"chartdate": "2125-12-14 00:00:00.000",
"description": "ICU Event Note",
"row_id": 356626,
"text": "Clinician: Attending\n Critical Care\n Temp curve trended down and she is more stable hemodynamically. Sputum\n has only grown oral flora so we are narrowing abx to metronidizol\n alone. Her resp status may be as good as we can get her - she has a\n RSBI of 105, CXR shows some clearing of her RUL infiltrate, oxygenation\n adequate. She is awake and her back pain has improved. One negative is\n that creat is up from 1.0 to 1.4 and she is still 3L pos but we will\n decrease vent support and try to wean aggressively. V difficult\n intubation so would have a cook catheter in place and anesthesia\n available for extubation.\n Total time spent: 40 minutes\n Patient is critically ill.\n"
},
{
"category": "Rehab Services",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 356627,
"text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: Pt was transferred to ICU after episode\n of emesis and likely aspiration now intubated in MICU on low level of\n versed.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n T\n\n Supine/\n Sidelying to Sit:\n Mod A x 2\n\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n Min A x 2\n\n\n\n x\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 88\n 119/65\n 23\n 99% CPAP\n Activity\n Sit\n 109\n 120/64\n 40\n 95-100% CPAP\n Recovery\n Supine\n 86\n 112/69\n 28\n 100% CPAP\n Total distance walked:\n Minutes:\n Gait:\n Balance: Pt required Mod A x 2 to transition to . Once at pt was\n able to maintain for approx 10 mins c S-CG. Pt was able to stand for 2\n reps with min A x 2 and tolerated for approx 30secs each rep.\n Education / Communication: Pt status discussed with RN, Pt educated on\n role of PT and goals for interventions, and demonstrated agreement with\n plan.\n Other: Pulm: Pt on CPAP Psup 15 PEEP 5 FiO2 40\n TV at resp .230-.310: TV sitting at .260-.410: TV\n standing .310-.510\n Cognition: Pt able to follow all commands, and make needs known by\n gesturing, head nodding and\n attempting to mouth words\n Assessment: 73 yo f admitted sp fall with back pain with hospital\n course significant for emesis with likely aspiration requiring ICU\n admission and intubation. Pt at this time is able to participate with\n PT and tolerated activity without adverse respiratory effects. Pt did\n have increase in RR with activity, however this resolved with rest, and\n TVs also significantly improved. Feel pt would benefit from increase\n mobility while in the ICU and intubated given pulmonary status, feel\n she would be appropriate for OOB to chair as tolerated. PT will cont to\n follow pt and make d/c recs as medical status and plan develops.\n Anticipated Discharge: Rehab\n Plan: cont to mobilize pt, f/u for ther ex, and transfer training.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356629,
"text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 12:30 PM\n - switched from PS 15/5 to , ABG with Co2 64, switched back to 15/5\n and Co2 remains 60. Need to clarify limit of permissive hypercapnia\n will tolerate during weaning.\n -Poor response to 40 IV lasix, given additional 80 IV lasix x1\n -started on tylenol 1 gm q6h, lopressor 50 TID, d/ced amio\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:38 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Fentanyl - 04:15 PM\n Furosemide (Lasix) - 12:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 81 (72 - 120) bpm\n BP: 112/58(76) {83/45(58) - 140/79(106)} mmHg\n RR: 24 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,845 mL\n 227 mL\n PO:\n TF:\n IVF:\n 3,695 mL\n 167 mL\n Blood products:\n Total out:\n 790 mL\n 580 mL\n Urine:\n 790 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,055 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 375 (300 - 388) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 106\n PIP: 20 cmH2O\n Plateau: 24 cmH2O\n Compliance: 21.1 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/61/337/40/14\n Ve: 9 L/min\n PaO2 / FiO2: 842\n Physical Examination\n General Appearance: NAD, more alert than yesterday, intubated\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, Bowel sounds present, Distended, Obese, nontender to\n palp\n Extremities: Right: 1+, Left: 1+ dp pulses, warm, 1+ edema\n Neurologic: Responds to voice and commands, on minimal sedation,\n intubated.\n Peripheral 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 190 K/uL\n 9.4 g/dL\n 136 mg/dL\n 1.4 mg/dL\n 40 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 91 mEq/L\n 138 mEq/L\n 26.7 %\n 5.8 K/uL\n [image002.jpg]\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n WBC\n 7.5\n 7.3\n 5.8\n Hct\n 28.0\n 25.5\n 26.7\n Plt\n \n Cr\n 1.0\n 1.0\n 1.4\n TropT\n <0.01\n 0.01\n TCO2\n 46\n 46\n 40\n 39\n 42\n 43\n Glucose\n 164\n 190\n 136\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensate.\n - continue vanco, zosyn for aspiration pneumonia vs HAP\n - wean to PS as tolerated today, rest on AC\n -monitor fluid status to avoid gross pulmonary edema (lasix 40 IV is\n suspect flash)\n -nebs prn\n - consider adding on steroids if underlying disease appears to have\n worsened\n .\n # SVT: Overnight patient went from sinus tachycardia to SVT, ? atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c amiodarone\n -monitor on telemetry\n -restart home toprol 37.5mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch.\n - cont lidocaine patch, tylenol\n - fentanyl for pain now, but may need to wean if ready to extubate\n -PT\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale.\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved but continue NPO for now\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus, level pending this AM\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - Continue outpt metoprolol and monitor\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV\n .\n # FEN: NPO for now, vitamin D, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356631,
"text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 12:30 PM\n - switched from PS 15/5 to , ABG with Co2 64, switched back to 15/5\n and Co2 remains 60. Need to clarify limit of permissive hypercapnia\n will tolerate during weaning.\n -Poor response to 40 IV lasix, given additional 80 IV lasix x1\n -started on tylenol 1 gm q6h, lopressor 50 TID, d/ced amio\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:38 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Fentanyl - 04:15 PM\n Furosemide (Lasix) - 12:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 81 (72 - 120) bpm\n BP: 112/58(76) {83/45(58) - 140/79(106)} mmHg\n RR: 24 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,845 mL\n 227 mL\n PO:\n TF:\n IVF:\n 3,695 mL\n 167 mL\n Blood products:\n Total out:\n 790 mL\n 580 mL\n Urine:\n 790 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,055 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 375 (300 - 388) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 106\n PIP: 20 cmH2O\n Plateau: 24 cmH2O\n Compliance: 21.1 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/61/337/40/14\n Ve: 9 L/min\n PaO2 / FiO2: 842\n Physical Examination\n General Appearance: NAD, more alert than yesterday, intubated\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, Bowel sounds present, Distended, Obese, nontender to\n palp\n Extremities: Right: 1+, Left: 1+ dp pulses, warm, 1+ edema\n Neurologic: Responds to voice and commands, on minimal sedation,\n intubated.\n Peripheral 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 190 K/uL\n 9.4 g/dL\n 136 mg/dL\n 1.4 mg/dL\n 40 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 91 mEq/L\n 138 mEq/L\n 26.7 %\n 5.8 K/uL\n [image002.jpg]\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n WBC\n 7.5\n 7.3\n 5.8\n Hct\n 28.0\n 25.5\n 26.7\n Plt\n \n Cr\n 1.0\n 1.0\n 1.4\n TropT\n <0.01\n 0.01\n TCO2\n 46\n 46\n 40\n 39\n 42\n 43\n Glucose\n 164\n 190\n 136\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensate.\n - switch abx to flagyl to cover for aspiration PNA\n - wean to PS as tolerated today\n -monitor fluid status to avoid gross pulmonary edema, IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Overnight patient went from sinus tachycardia to SVT, ? atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c\nd amiodarone\n -monitor on telemetry\n -advanced toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch. Pain well controlled minus lidocaine\n patch\n - d/c lidocaine patch & Tylenol (do not want to mask fever if PNA does\n not respond to Flagyl)\n - fentanyl for pain now, but may need to wean if ready to extubate\n -PT\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - will plan for PICC eval and possible placement\n .\n # FEN: will switch to tube feeds, vitamin D, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 356634,
"text": "Subjective\n Pt intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 152 cm\n 90.4 kg\n 38.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 45.4 kg\n 199\n 56.6\n 72.5 ()\n 125\n Diagnosis: S/P fall\n PMH : IPF (on home O2), cor pulmonale, S/P OLT d/t cryptogenic\n cirrhosis, post-tx lymphoproliferative disorder, type 2 DM, HTN,\n hypothyroidism, diastolic dysfxn, S/P ccy, aapy, A. fib\n Food allergies and intolerances: N/A\n Pertinent medications: RISS+ NPH, Vit D, heparin, tacrolimus, flagyl,\n lansoprazole, others noted.\n Labs:\n Value\n Date\n Glucose\n 136 mg/dL\n 03:12 AM\n Glucose Finger Stick\n 178\n 10:00 AM\n BUN\n 31 mg/dL\n 03:12 AM\n Creatinine\n 1.4 mg/dL\n 03:12 AM\n Sodium\n 138 mEq/L\n 03:12 AM\n Potassium\n 3.5 mEq/L\n 03:12 AM\n Chloride\n 91 mEq/L\n 03:12 AM\n TCO2\n 40 mEq/L\n 03:12 AM\n PO2 (arterial)\n 337 mm Hg\n 04:20 AM\n PCO2 (arterial)\n 61 mm Hg\n 04:20 AM\n pH (arterial)\n 7.44 units\n 04:20 AM\n pH (urine)\n 6.5 units\n 01:25 AM\n CO2 (Calc) arterial\n 43 mEq/L\n 04:20 AM\n Albumin\n 3.0 g/dL\n 01:25 AM\n Calcium non-ionized\n 9.1 mg/dL\n 03:12 AM\n Phosphorus\n 5.2 mg/dL\n 03:12 AM\n Magnesium\n 1.8 mg/dL\n 03:12 AM\n ALT\n 7 IU/L\n 01:25 AM\n Alkaline Phosphate\n 66 IU/L\n 01:25 AM\n AST\n 11 IU/L\n 01:25 AM\n Amylase\n 55 IU/L\n 02:43 PM\n Total Bilirubin\n 0.5 mg/dL\n 01:25 AM\n WBC\n 5.8 K/uL\n 03:12 AM\n Hgb\n 9.4 g/dL\n 03:12 AM\n Hematocrit\n 26.7 %\n 03:12 AM\n Current diet order / nutrition support: NPO, TF c/s\n GI: Abd soft/+BS, dist/obese/NT\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, needs TF\n Estimated Nutritional Needs\n Calories: 1132-1415 kcals/day (20-25 cal/kg)\n Protein: 62-79g/ day (1.1-1.4 g/kg)\n Fluid: per team\n Estimation of current intake: Inadequate\n 73 yo female who was initially admitted to hospital after a mechanical\n fall for pain control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis.\n Pt intubated and consulted for TF recs. Pt w/ OGT\n If unable to extubate in 24-48hrs start TF.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n 1. Start w/ 10cc/hr of FS Nutren Pulmonary and adv to goal of\n 35cc/hr to provide 1260kcals and 57g prot/day\n 2. Check residual q 4-6hrs, hold TF if >150cc\n 3. c/w lyte and BG mngt\n 4. Monitor hydration status.\n Will f/u w/ progress and will make TF recs prn\n Pls pge w/ questions/issues #\n 14:40\n"
},
{
"category": "General",
"chartdate": "2125-12-13 00:00:00.000",
"description": "ICU Event Note",
"row_id": 356385,
"text": "Clinician: Attending\n Pt has had perisistently high HR in 130s to 140s over last 3-4 hours.\n EKG c/w MAT. Amio load initiaited. Subsequently had drop in MAPs to\n 50s despite 1L NS; fever spike to 102.3. ICU resident (Dr. \n spoke with pt's husband and daughter by telephone who do not want to\n escalate care any further. Will not start pressors or place central\n line based on their wishes. Will continue IVF and amio for time being.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356431,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:35 PM\n ARTERIAL LINE - START 08:00 PM\n EKG - At 11:30 PM\n ARTERIAL LINE - STOP 11:32 PM\n ARTERIAL LINE - START 12:10 AM\n BLOOD CULTURED - At 01:30 AM\n URINE CULTURE - At 01:30 AM\n EKG - At 02:04 AM\n FEVER - 102.3\nF - 12:00 AM\n intubated as ABG came back with PCO2 in 100s\n -A-line placed\n -went into SVT to 130s, atrial fib vs MAT. did not break with PO\n toprol, 5mg lopressor IV, 1L NS. Started amiodarone load.\n -spiked to 102.3, sent blood cx, urine cx, cxr. started vanco/zosyn.\n -repeat abg w/PCO2 in 50s, decreased MV.\n -pts family , do not want to escalate care.\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:03 PM\n Metoprolol - 11:40 PM\n Midazolam (Versed) - 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100.1\n HR: 117 (76 - 134) bpm\n BP: 81/53(62) {72/46(55) - 134/73(94)} mmHg\n RR: 16 (16 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 631 mL\n 2,929 mL\n PO:\n TF:\n IVF:\n 631 mL\n 2,929 mL\n Blood products:\n Total out:\n 925 mL\n 115 mL\n Urine:\n 925 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n -294 mL\n 2,814 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n Compliance: 19.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/55/151/42/13\n Ve: 6.5 L/min\n PaO2 / FiO2: 302\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 203 K/uL\n 9.2 g/dL\n 164 mg/dL\n 1.0 mg/dL\n 42 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 89 mEq/L\n 136 mEq/L\n 25.5 %\n 7.3 K/uL\n [image002.jpg]\n 02:43 PM\n 04:27 PM\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n WBC\n 8.2\n 7.5\n 7.3\n Hct\n 35.1\n 28.0\n 25.5\n Plt\n 243\n 203\n 203\n Cr\n 1.0\n 1.0\n TropT\n <0.01\n <0.01\n 0.01\n TCO2\n 55\n 46\n 46\n 40\n Glucose\n 141\n 164\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.5 mg/dL, Mg++:1.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:08 AM\n Arterial Line - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356432,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:35 PM\n ARTERIAL LINE - START 08:00 PM\n EKG - At 11:30 PM\n ARTERIAL LINE - STOP 11:32 PM\n ARTERIAL LINE - START 12:10 AM\n BLOOD CULTURED - At 01:30 AM\n URINE CULTURE - At 01:30 AM\n EKG - At 02:04 AM\n FEVER - 102.3\nF - 12:00 AM\n intubated as ABG came back with PCO2 in 100s\n -A-line placed\n -went into SVT to 130s, atrial fib vs MAT. did not break with PO\n toprol, 5mg lopressor IV, 1L NS. Started amiodarone load.\n -spiked to 102.3, sent blood cx, urine cx, cxr. started vanco/zosyn.\n -repeat abg w/PCO2 in 50s, decreased MV.\n -pts family , do not want to escalate care.\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:03 PM\n Metoprolol - 11:40 PM\n Midazolam (Versed) - 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100.1\n HR: 117 (76 - 134) bpm\n BP: 81/53(62) {72/46(55) - 134/73(94)} mmHg\n RR: 16 (16 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 631 mL\n 2,929 mL\n PO:\n TF:\n IVF:\n 631 mL\n 2,929 mL\n Blood products:\n Total out:\n 925 mL\n 115 mL\n Urine:\n 925 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n -294 mL\n 2,814 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n Compliance: 19.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/55/151/42/13\n Ve: 6.5 L/min\n PaO2 / FiO2: 302\n Physical Examination\n General Appearance: Overweight / Obese, moon facies, tachypneic,\n accessory muscle use\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: buffalo hump\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, worst at bases, Diminished: throughout)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n midline reducible hernia\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): person and place. , Movement: Not\n assessed, Tone: Not assessed\n Peripheral 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 203 K/uL\n 9.2 g/dL\n 164 mg/dL\n 1.0 mg/dL\n 42 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 89 mEq/L\n 136 mEq/L\n 25.5 %\n 7.3 K/uL\n [image002.jpg]\n 02:43 PM\n 04:27 PM\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n WBC\n 8.2\n 7.5\n 7.3\n Hct\n 35.1\n 28.0\n 25.5\n Plt\n 243\n 203\n 203\n Cr\n 1.0\n 1.0\n TropT\n <0.01\n <0.01\n 0.01\n TCO2\n 55\n 46\n 46\n 40\n Glucose\n 141\n 164\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.5 mg/dL, Mg++:1.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: given current ABG, suspect\n she has had increased CO2 retention over last month. Also given that\n she is not currently obtunded argues in favor of this. Acute worsening\n in oxygenation likely due to aspiration or flash pulmonary edema in the\n setting of emesis. Other possible etiologies including pna or PE seem\n less likely. She has been on DVT ppx. Not good NIPPV candidate\n currently given emesis. Given severity of underlying lung disease,\n intubation unlikely to be reversible.\n - discuss goals of care with family\n - serial ABGs\n - cont supplemental O2\n - add on BNP\n - lasix 40 IV for pulmonary edema\n - hold off on abx without clear infection\n - nebs\n - hold off on steroids as has been steroid unresponsive in past and no\n evidence of obstructive exacerbation at this time\n .\n # emesis: unclear cause. Patient cannot provide adequate history at\n this time. Abdominal exam benign at this time. Does have midline hernia\n but reducible.\n - abdominal film to check fo obstruction\n - add on LFTs, PEs\n - check tacro level to assess for toxicity\n - check cardiac enzymes and ECG\n - NPO for now\n .\n # s/p fall: no evidence of fracture. Pain reasonably controlled at\n rest. Likely mechanical so no need for further syncope work up at this\n time.\n - cont lidocaine patch, ibuprofen and tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: reasonable BG control on floor\n - cont NPH per outpt doses. Half dose while NPO\n - cont insulin sliding scale\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - check tacro level\n - continue Tacrolimus at regular dose for now\n .\n # HTN: normotensive currently.\n - Continue outpt metoprolol\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV\n .\n # FEN: NPO for now\n - vit D\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: FULL CODE. Will need to readdress with HCP\n .\n # Contact: \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:08 AM\n Arterial Line - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356424,
"text": "Pt was adm to s/p fall at home. on the floor, pt\n developed resp distress with desat to 88% on 2 liters NC. Pt noted to\n have cx's and CXR showed pulm edema. Pt given lasix po and IV with some\n effect. Pt noted to be slight lethargic. Pt sent to MICU for\n hypercarbic/hypoxic resp failure in the setting of emisis. CXR shows\n chronic interstitial lung disease with superimposed vague opacity may\n represent aspiration or mild pulmonary edema.\n ABG from before pt intubated 7.22/127/192, pt very hard intubation\n nurse reported it took 1.5hr. pt with chronic interstitial lung disease\n pt has been trached in the past. Pt with diastolic CHF, s/p liver\n transplant on immunosuppression,\n Events: pt in rapid A-fib 120-140\ns around 2330, fluid bolus given and\n 5mg of lopressor IV given without any affect on pt HR, Amiodarone\n started, loading dose given and then gtt continued after, also no\n change in pt HR ranged from 110-130. SBP dropping into 70\ns-80. Map\n 50-60\ns. At this time ? if we needed central line and wanted to start\n pressors, pt husband was called and he decided not to advance care. Pt\n cont to get fluid boluses to try to keep BP up. A-line placed x2, new\n peripheral IV placed by resident via ultrasound.\n PMH: interstitial pulmonary fibrosis home dependent on O2 pt refractory\n to steroids, s/p liver transplant , post transplant\n lymphoproliferative disorder, type 2 DM, HTN, hypothyroidism, diastolic\n dysfunction with LVEF 65%, Cholecystectomy, appendectomy, h/o A-fib.\n DNR, CPR not indicated.\n Hypotension (not Shock)\n Assessment:\n A-line placed, pt HR in rapid A-fib 120-140\ns BP was stable but then\n began to drop. Into SBP 70-80.\n Action:\n Fluid boluses given and Amiodarone load and drip started.\n Response:\n Amiodarone did not make much difference with HR, family called to ? if\n they wanted a line placed and pressors started and they declined, we\n are no longer escalating care.\n Plan:\n Cont amiodarone and fluid boluses, not escalating care otherwise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 100%/400/5/18 lungs clear/rhonchi, small ETT\n secretions thick yellow/clear, copius amounts of subglottal secretions,\n clear.\n Action:\n Dropped FiO2 to 50% ABG 7.44/66/198. After HR increased to 120-140\n did another ABG\n Response:\n ABG 7.53/53/111, residents did not want bicarb, did turn rate down to\n 16, latest ABG\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.3\n Action:\n Pt given Tylenol and urine and blood cultures done\n Response:\n Plan:\n Cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356425,
"text": "Pt was adm to s/p fall at home. on the floor, pt\n developed resp distress with desat to 88% on 2 liters NC. Pt noted to\n have cx's and CXR showed pulm edema. Pt given lasix po and IV with some\n effect. Pt noted to be slight lethargic. Pt sent to MICU for\n hypercarbic/hypoxic resp failure in the setting of emisis. CXR shows\n chronic interstitial lung disease with superimposed vague opacity may\n represent aspiration or mild pulmonary edema.\n ABG from before pt intubated 7.22/127/192, pt very hard intubation\n nurse reported it took 1.5hr. pt with chronic interstitial lung disease\n pt has been trached in the past. Pt with diastolic CHF, s/p liver\n transplant on immunosuppression,\n Events: pt in rapid A-fib 120-140\ns around 2330, fluid bolus given and\n 5mg of lopressor IV given without any affect on pt HR, Amiodarone\n started, loading dose given and then gtt continued after, also no\n change in pt HR ranged from 110-130. SBP dropping into 70\ns-80. Map\n 50-60\ns. At this time ? if we needed central line and wanted to start\n pressors, pt husband was called and he decided not to advance care. Pt\n cont to get fluid boluses to try to keep BP up. A-line placed x2, new\n peripheral IV placed by resident via ultrasound.\n PMH: interstitial pulmonary fibrosis home dependent on O2 pt refractory\n to steroids, s/p liver transplant , post transplant\n lymphoproliferative disorder, type 2 DM, HTN, hypothyroidism, diastolic\n dysfunction with LVEF 65%, Cholecystectomy, appendectomy, h/o A-fib.\n DNR, CPR not indicated.\n Hypotension (not Shock)\n Assessment:\n A-line placed, pt HR in rapid A-fib 120-140\ns BP was stable but then\n began to drop. Into SBP 70-80.\n Action:\n Fluid boluses given and Amiodarone load and drip started.\n Response:\n Amiodarone did not make much difference with HR, family called to ? if\n they wanted a line placed and pressors started and they declined, we\n are no longer escalating care.\n Plan:\n Cont amiodarone and fluid boluses, not escalating care otherwise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 100%/400/5/18 lungs clear/rhonchi, small ETT\n secretions thick yellow/clear, copius amounts of subglottal secretions,\n clear.\n Action:\n Dropped FiO2 to 50% ABG 7.44/66/198. After HR increased to 120-140\n did another ABG\n Response:\n ABG 7.53/53/111, residents did not want bicarb, did turn rate down to\n 16, latest ABG 7.46/55/151\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.3\n Action:\n Pt given Tylenol and urine and blood cultures done\n Response:\n Temp decreased with Tylenol 100.9\n Plan:\n Cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356426,
"text": "Pt was adm to s/p fall at home. on the floor, pt\n developed resp distress with desat to 88% on 2 liters NC. Pt noted to\n have cx's and CXR showed pulm edema. Pt given lasix po and IV with some\n effect. Pt noted to be slight lethargic. Pt sent to MICU for\n hypercarbic/hypoxic resp failure in the setting of emisis. CXR shows\n chronic interstitial lung disease with superimposed vague opacity may\n represent aspiration or mild pulmonary edema.\n ABG from before pt intubated 7.22/127/192, pt very hard intubation\n nurse reported it took 1.5hr. pt with chronic interstitial lung disease\n pt has been trached in the past. Pt with diastolic CHF, s/p liver\n transplant on immunosuppression,\n Events: pt in rapid A-fib 120-140\ns around 2330, fluid bolus given and\n 5mg of lopressor IV given without any affect on pt HR, Amiodarone\n started, loading dose given and then gtt continued after, also no\n change in pt HR ranged from 110-130. SBP dropping into 70\ns-80. Map\n 50-60\ns. At this time ? if we needed central line and wanted to start\n pressors, pt husband was called and he decided not to advance care. Pt\n cont to get fluid boluses to try to keep BP up. A-line placed x2, new\n peripheral IV placed by resident via ultrasound.\n PMH: interstitial pulmonary fibrosis home dependent on O2 pt refractory\n to steroids, s/p liver transplant , post transplant\n lymphoproliferative disorder, type 2 DM, HTN, hypothyroidism, diastolic\n dysfunction with LVEF 65%, Cholecystectomy, appendectomy, h/o A-fib.\n DNR, CPR not indicated.\n Hypotension (not Shock)\n Assessment:\n A-line placed, pt HR in rapid A-fib 120-140\ns BP was stable but then\n began to drop. Into SBP 70-80.\n Action:\n Fluid boluses given and Amiodarone load and drip started.\n Response:\n Amiodarone did not make much difference with HR, family called to ? if\n they wanted a line placed and pressors started and they declined, we\n are no longer escalating care.\n Plan:\n Cont amiodarone and fluid boluses, not escalating care otherwise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on CMV 100%/400/5/18 lungs clear/rhonchi, small ETT\n secretions thick yellow/clear, copius amounts of subglottal secretions,\n clear.\n Action:\n Dropped FiO2 to 50% ABG 7.44/66/198. After HR increased to 120-140\n did another ABG\n Response:\n ABG 7.53/53/111, residents did not want bicarb, did turn rate down to\n 16, latest ABG 7.46/55/151\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.3\n Action:\n Pt given Tylenol and urine and blood cultures done\n Response:\n Temp decreased with Tylenol 100.1, WBC WNL\n Plan:\n Cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356548,
"text": "73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356550,
"text": "73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356551,
"text": "73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile, pt last pan cultured results pending.\n Action:\n Pt on scheduled Tylenol Q 6 hr.\n Response:\n Cont to be afebrile\n Plan:\n Cont to monitor for fever. Follow up on pending cultures.\n Hypotension (not Shock)\n Assessment:\n Pt given 80mg of lasix\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt newly changed to CPAP 50% 15/5, O2 sat 95-100%\n clear/diminished lung sounds, thick tan in line secretions, copious\n amounts of oral secretions.\n Action:\n ABG 7.44/55/132, then changed settings to CPAP 40% 12/5, O2 sat 95-100%\n Response:\n ABG 7.41/64/127/42 will increase pressure support back to 15 because of\n CO2 rise.\n Plan:\n Cont on CPAP 40% 15/5.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356589,
"text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 12:30 PM\n - switched from PS 15/5 to , ABG with Co2 64, switched back to 15/5\n and Co2 remains 60. Need to clarify limit of permissive hypercapnia\n will tolerate during weaning.\n -Poor response to 40 IV lasix, given additional 80 IV lasix x1\n -started on tylenol 1 gm q6h, lopressor 50 TID, d/ced amio\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:38 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Fentanyl - 04:15 PM\n Furosemide (Lasix) - 12:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 81 (72 - 120) bpm\n BP: 112/58(76) {83/45(58) - 140/79(106)} mmHg\n RR: 24 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,845 mL\n 227 mL\n PO:\n TF:\n IVF:\n 3,695 mL\n 167 mL\n Blood products:\n Total out:\n 790 mL\n 580 mL\n Urine:\n 790 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,055 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 375 (300 - 388) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 106\n PIP: 20 cmH2O\n Plateau: 24 cmH2O\n Compliance: 21.1 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/61/337/40/14\n Ve: 9 L/min\n PaO2 / FiO2: 842\n Physical Examination\n General Appearance: NAD, more alert than yesterday, intubated\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, Bowel sounds present, Distended, Obese, nontender to\n palp\n Extremities: Right: 1+, Left: 1+ dp pulses, warm, 1+ edema\n Neurologic: Responds to voice and commands, on minimal sedation,\n intubated.\n Peripheral 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 190 K/uL\n 9.4 g/dL\n 136 mg/dL\n 1.4 mg/dL\n 40 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 91 mEq/L\n 138 mEq/L\n 26.7 %\n 5.8 K/uL\n [image002.jpg]\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n WBC\n 7.5\n 7.3\n 5.8\n Hct\n 28.0\n 25.5\n 26.7\n Plt\n \n Cr\n 1.0\n 1.0\n 1.4\n TropT\n <0.01\n 0.01\n TCO2\n 46\n 46\n 40\n 39\n 42\n 43\n Glucose\n 164\n 190\n 136\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356590,
"text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 12:30 PM\n - switched from PS 15/5 to , ABG with Co2 64, switched back to 15/5\n and Co2 remains 60. Need to clarify limit of permissive hypercapnia\n will tolerate during weaning.\n -Poor response to 40 IV lasix, given additional 80 IV lasix x1\n -started on tylenol 1 gm q6h, lopressor 50 TID, d/ced amio\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:38 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Fentanyl - 04:15 PM\n Furosemide (Lasix) - 12:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 81 (72 - 120) bpm\n BP: 112/58(76) {83/45(58) - 140/79(106)} mmHg\n RR: 24 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,845 mL\n 227 mL\n PO:\n TF:\n IVF:\n 3,695 mL\n 167 mL\n Blood products:\n Total out:\n 790 mL\n 580 mL\n Urine:\n 790 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,055 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 375 (300 - 388) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 106\n PIP: 20 cmH2O\n Plateau: 24 cmH2O\n Compliance: 21.1 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/61/337/40/14\n Ve: 9 L/min\n PaO2 / FiO2: 842\n Physical Examination\n General Appearance: NAD, more alert than yesterday, intubated\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, Bowel sounds present, Distended, Obese, nontender to\n palp\n Extremities: Right: 1+, Left: 1+ dp pulses, warm, 1+ edema\n Neurologic: Responds to voice and commands, on minimal sedation,\n intubated.\n Peripheral 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 190 K/uL\n 9.4 g/dL\n 136 mg/dL\n 1.4 mg/dL\n 40 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 91 mEq/L\n 138 mEq/L\n 26.7 %\n 5.8 K/uL\n [image002.jpg]\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n WBC\n 7.5\n 7.3\n 5.8\n Hct\n 28.0\n 25.5\n 26.7\n Plt\n \n Cr\n 1.0\n 1.0\n 1.4\n TropT\n <0.01\n 0.01\n TCO2\n 46\n 46\n 40\n 39\n 42\n 43\n Glucose\n 164\n 190\n 136\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensate.\n - continue vanco, zosyn for aspiration pneumonia vs HAP\n - wean to PS as tolerated today, rest on AC\n -monitor fluid status to avoid gross pulmonary edema (lasix 40 IV is\n suspect flash)\n -nebs prn\n - consider adding on steroids if underlying disease appears to have\n worsened\n .\n # emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved but continue NPO for now\n .\n # SVT: Overnight patient went from sinus tachycardia to SVT, ? atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c amiodarone\n -monitor on telemetry\n -restart home toprol 37.5mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch.\n - cont lidocaine patch, tylenol\n - fentanyl for pain now, but may need to wean if ready to extubate\n -PT\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale.\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus, level pending this AM\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - Continue outpt metoprolol and monitor\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV\n .\n # FEN: NPO for now, vitamin D, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356772,
"text": "Synopsis per prior nursing note:\n 73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events: Placed on 5/o on vent but unable to tolerate- placed back on\n . PICC attempted at bedside but unsuccessful. Antibiotics changed\n to vanco/zosyn- flagyl d/c\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS-clear w/ diminished bases. O2 sats >95%. WBC 6.4(5.8). Tmax 99.1 PO.\n Alert, mouthing words and making gestures. Currently not on sedation.\n Suctioning mouth on own.\n Action:\n Suctioned as needed. Monitored temp curve. Q2-3 hr position changes.\n Emotional support provided.\n Response:\n O2 sats remained >95%. Denied SOB.\n Plan:\n Monitor resp status. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356549,
"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 Procedure location: ICU\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356587,
"text": "Chief Complaint:\n 24 Hour Events:\n SPUTUM CULTURE - At 09:00 AM\n URINE CULTURE - At 12:30 PM\n - switched from PS 15/5 to , ABG with Co2 64, switched back to 15/5\n and Co2 remains 60. Need to clarify limit of permissive hypercapnia\n will tolerate during weaning.\n -Poor response to 40 IV lasix, given additional 80 IV lasix x1\n -started on tylenol 1 gm q6h, lopressor 50 TID, d/ced amio\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 06:38 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Fentanyl - 04:15 PM\n Furosemide (Lasix) - 12:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 36.5\nC (97.7\n HR: 81 (72 - 120) bpm\n BP: 112/58(76) {83/45(58) - 140/79(106)} mmHg\n RR: 24 (16 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,845 mL\n 227 mL\n PO:\n TF:\n IVF:\n 3,695 mL\n 167 mL\n Blood products:\n Total out:\n 790 mL\n 580 mL\n Urine:\n 790 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,055 mL\n -353 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 375 (300 - 388) mL\n PS : 15 cmH2O\n RR (Set): 16\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 106\n PIP: 20 cmH2O\n Plateau: 24 cmH2O\n Compliance: 21.1 cmH2O/mL\n SpO2: 100%\n ABG: 7.44/61/337/40/14\n Ve: 9 L/min\n PaO2 / FiO2: 842\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 190 K/uL\n 9.4 g/dL\n 136 mg/dL\n 1.4 mg/dL\n 40 mEq/L\n 3.5 mEq/L\n 31 mg/dL\n 91 mEq/L\n 138 mEq/L\n 26.7 %\n 5.8 K/uL\n [image002.jpg]\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n WBC\n 7.5\n 7.3\n 5.8\n Hct\n 28.0\n 25.5\n 26.7\n Plt\n \n Cr\n 1.0\n 1.0\n 1.4\n TropT\n <0.01\n 0.01\n TCO2\n 46\n 46\n 40\n 39\n 42\n 43\n Glucose\n 164\n 190\n 136\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.1 mg/dL, Mg++:1.8 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356757,
"text": "Chief Complaint:\n 24 Hour Events:\n - no overnight issues, pt noted to be alert\n - attdg met with family yesterday who would want current treatment, but\n do not want patient resuscitated\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Vancomycin - 08:08 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:09 AM\n Heparin Sodium (Prophylaxis) - 09:42 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 06:17 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: 37.1\nC (98.8\n HR: 87 (74 - 103) bpm\n BP: 129/69(90) {91/47(62) - 148/86(110)} mmHg\n RR: 16 (15 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 946 mL\n 165 mL\n PO:\n TF:\n IVF:\n 656 mL\n 165 mL\n Blood products:\n Total out:\n 2,170 mL\n 140 mL\n Urine:\n 2,170 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,224 mL\n 25 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 313 (301 - 361) mL\n PS : 10 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.43/61/101/39/12\n Ve: 9.2 L/min\n PaO2 / FiO2: 253\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 242 K/uL\n 9.9 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 39 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 94 mEq/L\n 139 mEq/L\n 28.1 %\n 6.4 K/uL\n [image002.jpg]\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n WBC\n 7.5\n 7.3\n 5.8\n 6.4\n Hct\n 28.0\n 25.5\n 26.7\n 28.1\n Plt\n 42\n Cr\n 1.0\n 1.0\n 1.4\n 1.1\n TropT\n 0.01\n TCO2\n 46\n 40\n 39\n 42\n 43\n 42\n Glucose\n 164\n 190\n 136\n 109\n Other labs: PT / PTT / INR:13.0/25.3/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensates.\n - switch back to Vancomycin/Zosyn for 5 more days to cover for PNA\n - wean as tolerated today, eval for extubation\n -monitor fluid status to avoid gross pulmonary edema, IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c\nd amiodarone \n -monitor on telemetry\n -advanced toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch. Pain well controlled minus lidocaine\n patch. Now pt with no c/o pain\n will d/c fetanyl and lidocaine.\n Tylenol PRN\n - PT following\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval and possible placement today\n .\n # FEN: will start tube feeds if not intubated today, replete\n electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356833,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\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 Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356546,
"text": "73 yr old who was initially adm. To hosp after a fall for pain\n control. While on the floor\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356583,
"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 Procedure location: ICU\n Reason: Elective\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments: Pt remains intubated on mechanical ventilation. Wean FiO2\n this shift. Plan: To continue to wean as tolerated.\n"
},
{
"category": "General",
"chartdate": "2125-12-14 00:00:00.000",
"description": "ICU Event Note",
"row_id": 356671,
"text": "Clinician: Attending\n Critical Care\n Temp curve trended down and she is more stable hemodynamically. Sputum\n has only grown oral flora so we are narrowing abx to metronidizol\n alone. Her resp status may be as good as we can get her - she has a\n RSBI of 105, CXR shows some clearing of her RUL infiltrate, oxygenation\n adequate. She is awake and her back pain has improved. One negative is\n that creat is up from 1.0 to 1.4 and she is still 3L pos but we will\n decrease vent support and try to wean aggressively. V difficult\n intubation so would have a cook catheter in place and anesthesia\n available for extubation.\n Total time spent: 40 minutes\n Patient is critically ill.\n ------ Protected Section ------\n Critical Care\n Meeting with patient and her husband to discuss goals of care. Plan\n now is to try to wean progressively with goal of extubation. I informed\n them that because of the difficulty of intubating her we are concerned\n about a possible need to reintubate and Ms would clewarly like\n to be reintubated if necessary\n she would also consider a trache even\n if it means chronic ventilation\n Time spent 40 min\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 19:11 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356970,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 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: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: 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 weaned and extubated to cool mist and NC tol well. See\n respiratory page of meta vision for more information.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356541,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 99.7\n Action:\n Started on standing Tylenol 1gm q6h.\n Response:\n Temp trending downward.\n Plan:\n Continue to monitor temp curve, Tylenol ATC.\n Hypotension (not Shock)\n Assessment:\n SBP 80-130, HR 120s to 130 AFIB\n Action:\n Pt spontaneously converted to NSR this AM at 0900, amio gtt d/c\nd post\n rounds, received Lasix this afternoon with mild response.\n Response:\n Pt remains in NSR 80-90s NSR, BP much improved with better HR.\n Plan:\n Monitor rate and rhythm, remains on PO lopressor for rate control.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on AC 50%/400*16/+5, RR in teens with sats >95%, lungs clear to\n diminished, suctioned for scant amount secretions via ETT.\n Action:\n Switched to CPAP+PS 20/5 this afternoon.\n Response:\n Pt tolerating well, RR teens to 20s with good sats, lung sounds\n slightly improved post suctioning.\n Plan:\n Continue to wean vent support, recently decreased to 15/5, will need\n ABG this evening.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356581,
"text": "73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile, pt last pan cultured results pending.\n Action:\n Pt on scheduled Tylenol Q 6 hr.\n Response:\n Cont to be afebrile\n Plan:\n Cont to monitor for fever. Follow up on pending cultures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt newly changed to CPAP 50% 15/5, O2 sat 95-100%\n clear/diminished lung sounds, thick tan in line secretions, copious\n amounts of oral secretions. AM RISBI 106.\n Action:\n ABG 7.44/55/132, then changed settings to CPAP 40% 12/5, O2 sat 95-100%\n Response:\n ABG 7.41/64/127/42 will increase pressure support back to 15 because of\n CO2 rise.\n Plan:\n Cont on CPAP 40% 15/5.\n Pt given 80mg of lasix with little output, initially pt put out 180 and\n then over the next few hour put out another 300ml.\n Skin: dime sized skin tear on right upper arm of pt, dressing changed\n and antibiotic cream applied to area. Rest of pt skin is intact.\n Access: IV in right arm infiltrated, IV nurse came up and got another\n 20 gauge in L arm. Pt now with x2 gauge IV\ns in Left arm ? if one of\n those is infiltrating. In rounds talk to team about access, pt is very\n hard stick and IV\ns keep infiltrating.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356664,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt vented on CPAP 10/5 with better ABG\ns , pC02-60. Bilateral lungs\n clear with occasional rhonchi heard in upper airways. SaO2 >97%.\n Suctioned q2 hrs for moderate amts of tan thick sputum. Copious oral\n secretions. Pt is alert, appears oriented. Nods head to simple\n questions, mouths words.\n Action:\n IPS decreased from 15-10 with better ABG\ns. Suctioned every 2 hrs.\n Response:\n Tolerating decrease in IPS with plans to extubate on Sunday if pt is\n ready to be extubated. Discussion with family regarding long term plans\n for reintubation vs. trach. Per daughter and pt\ns husband, Ms. \n never discussed advanced directives with anyone.\n Plan:\n Con\nt pulm toilet. Plan to lower IPS on Sat. Discuss with patient what\n she would prefer be to be done.\n Hypotension (not Shock)\n Assessment:\n Pt not hypotensive today. Art line dampened and ~ 15 points lower that\n manual bp. Receiving lopressor.\n Action:\n Pt receiving lopressor. Hypotension is no longer an issue today\n Response:\n MAP >65 all shift.\n Plan:\n Con\nt to monitor BP. Con\nt lopressor.\n Ms. was seen by PT today. She stood at side of bed with assist\n of 1. Very strong and conditioned. Please attempt to get her oob in\n chair tomorrow. Her spirits are good and she is optimistic that she\n will be extubated. This was interpreted by this RN lips and pt\n acknowledging.\n Pt\ns husband, sister and pt\ns daughter in to see Ms. . They have\n been updated by this RN and by attending.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356729,
"text": "Chief Complaint:\n 24 Hour Events:\n - no overnight issues, pt noted to be alert\n - attdg met with family yesterday who would want full resuscitative\n measures for pt\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Vancomycin - 08:08 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:09 AM\n Heparin Sodium (Prophylaxis) - 09:42 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 06:17 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: 37.1\nC (98.8\n HR: 87 (74 - 103) bpm\n BP: 129/69(90) {91/47(62) - 148/86(110)} mmHg\n RR: 16 (15 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 946 mL\n 165 mL\n PO:\n TF:\n IVF:\n 656 mL\n 165 mL\n Blood products:\n Total out:\n 2,170 mL\n 140 mL\n Urine:\n 2,170 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,224 mL\n 25 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 313 (301 - 361) mL\n PS : 10 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.43/61/101/39/12\n Ve: 9.2 L/min\n PaO2 / FiO2: 253\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 242 K/uL\n 9.9 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 39 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 94 mEq/L\n 139 mEq/L\n 28.1 %\n 6.4 K/uL\n [image002.jpg]\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n WBC\n 7.5\n 7.3\n 5.8\n 6.4\n Hct\n 28.0\n 25.5\n 26.7\n 28.1\n Plt\n 42\n Cr\n 1.0\n 1.0\n 1.4\n 1.1\n TropT\n 0.01\n TCO2\n 46\n 40\n 39\n 42\n 43\n 42\n Glucose\n 164\n 190\n 136\n 109\n Other labs: PT / PTT / INR:13.0/25.3/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensate.\n - switch abx to flagyl to cover for aspiration PNA\n - wean to PS as tolerated today\n -monitor fluid status to avoid gross pulmonary edema, IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Overnight patient went from sinus tachycardia to SVT, ? atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c\nd amiodarone\n -monitor on telemetry\n -advanced toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch. Pain well controlled minus lidocaine\n patch\n - d/c lidocaine patch & Tylenol (do not want to mask fever if PNA does\n not respond to Flagyl)\n - fentanyl for pain now, but may need to wean if ready to extubate\n -PT\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - will plan for PICC eval and possible placement\n .\n # FEN: will switch to tube feeds, vitamin D, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356823,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\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 Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356914,
"text": "Chief Complaint:\n 24 Hour Events:\n -PICC attempted, will need to go to IR to have it placed on Monday\n -tried on PS 5/5 but only lasted a few minutes and put back on \n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 08:42 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 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 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 86 (80 - 124) bpm\n BP: 113/68(84) {100/56(74) - 146/116(125)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 703 mL\n 166 mL\n PO:\n TF:\n IVF:\n 643 mL\n 166 mL\n Blood products:\n Total out:\n 550 mL\n 240 mL\n Urine:\n 550 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 153 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 319 (219 - 524) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 8.6 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 242 K/uL\n 9.9 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 39 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 94 mEq/L\n 139 mEq/L\n 28.1 %\n 6.4 K/uL\n [image002.jpg]\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n WBC\n 7.5\n 7.3\n 5.8\n 6.4\n Hct\n 28.0\n 25.5\n 26.7\n 28.1\n Plt\n 42\n Cr\n 1.0\n 1.0\n 1.4\n 1.1\n TropT\n 0.01\n TCO2\n 46\n 40\n 39\n 42\n 43\n 42\n Glucose\n 164\n 190\n 136\n 109\n Other labs: PT / PTT / INR:13.0/25.3/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Will continue to wean as tolerated, keeping in mind her\n small reserve. Has been doing very well on minimal PS, will attempt to\n decrease to 5/0 today. If she does well, might need to consider trach\n placement. Having thick secretions which may be barrier to extubation.\n - continue Vancomycin/Zosyn (last day )\n - wean as tolerated today, eval for extubation\n - IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Has resolved since.\n -d/c\nd amiodarone \n -monitor on telemetry\n - toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Pain well controlled minus\n lidocaine patch. Now pt with no c/o pain. Tylenol PRN\n - PT following\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval and possible placement in AM\n .\n # FEN: TF, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 356354,
"text": "Chief Complaint: Reason for transfer: Hypercarbic respiratory failure\n PCP: , . \n Pulmonologist: , \n Heme/Onc: \n Cardiologist: \n HPI:\n Ms. is a 73 yo female with PMH significant for ILD on .5L\n home O2, diastolic CHF, cor pulmonale, s/p liver transplant on\n immunosuppression, post-transplant myeloproliferative disorder s/p CHOP\n and rituximab who was initially admitted to hospital after a mechanical\n fall for pain control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis.\n Patient was initially admitted to the medicine service on for a\n mechanical fall. She stated that prior to her fall she was in her USOH\n without any change in her baseline respiratory status or other new\n symptoms. She stepped on her scale and then lost her balance and\n landed on her low back. She was then brought to ED. There was no\n head trauma or LOC by report. Here, spine films revealed no acute\n fracture. She was being treated with PT and pain control. She was not\n receiving any opiates due to underlying lung disease. She did received\n tylenol, ibuprofen, and lidoderm patch.\n .\n Yesterday evening, the patient triggered after an episode of nausea and\n vomiting as well as a drop in her O2 saturation. Changed to face mask\n with improvement in O2. She remained hemodynamically stable. No CXR or\n ABG was performed. Changed to 40% ventimask and satting in mid-90s. At\n 10:30 this am, looks ashen, cyanotic, and lethargic on 4 L of 50%\n venti. O2 in high 70s at that time. Sleepy but arousable. Increased O2\n to 15L on 50% ventimask. Given nebs. On exam, tight air movement and\n cracklie but not significantly different from baseline. Initial gas\n 7.29/97/113 on 15L 50% ventimask. Last ABG in system 7.43/47/73 in\n 3/. Mental status improved with increase in oxygenation. She was\n given solumedrol 100 mg IV Q8H. Reevaluated in 1 hr, still lethargic\n but arousable. Repeat ABG 7.28/108/79 on 15L 50% ventimask. CXR\n performed on floor, showed some diffuse fluffiness. She received 40 mg\n IV lasix. She continues to have intermittent nausea and vomiting with\n 2-3 episodes of emesis since yesterday evening.\n .\n On arrival to the ICU, she denies any chest pain, SOB, abdominal pain,\n nausea, fevers, chills. She does not think that she has been in the\n hospital for several days. Appears confused. Lethargic but easily\n arousable.\n Patient admitted from: \n History obtained from Medical records, MD\n Patient unable to provide history: Encephalopathy\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Home medications:\n IPRATROPIUM BROMIDE 0.2 mg/mL inh four times a day\n LEVOTHYROXINE 75 mcg by mouth once a day\n METOPROLOL TARTRATE 75 mg by mouth TID\n OMEPRAZOLE 20 mg by mouth daily\n TACROLIMUS 3mg by mouth twice a day\n DOCUSATE SODIUM 100 mg by mouth once a day\n INSULIN NPH HUMAN RECOMB [HUMULIN N] 44U units before breakfast, 12U at\n 4:30pm.\n INSULIN REGULAR HUMAN [HUMULIN R] - sliding scale four times a day\n Lasix 40 mg daily\n Bactrim TIW\n Tums prn\n .\n Medications on transfer:\n Levothyroxine Sodium 75mcg PO\n Acetaminophen 325-650 mg PO Q6H:PRN\n Lidocaine 5% Patch 1 PTCH TD DAILY\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H\n Metoprolol Tartrate 75 mg PO TID\n Calcium Carbonate 1250 mg PO TID\n MethylPREDNISolone Sodium Succ 100 mg IV Q8H\n Docusate Sodium 100 mg PO DAILY\n Omeprazole 20 mg PO DAILY\n Furosemide 40 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR\n Insulin sliding scale\n Tacrolimus 3 mg PO Q12H\n Dose to be admin. at 6am and 6pm Order date: @ 1603\n Ipratropium Bromide MDI 2 PUFF IH QID\n TraMADOL (Ultram) 50 mg PO Q4H:PRN\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Vitamin D 50,000 UNIT PO QTUES\n Past medical history:\n Family history:\n Social History:\n # Interstitial pulmonary fibrosis\n - home oxygen dependent 2-2.5L NC (etiology unknown, no biopsy)\n - recently titrated off prednisone as unresponsive\n # cor pulmonale\n # S/p Liver transplant for cryptogenic cirrhosis\n # Post-transplant lymphoproliferative disorder s/p CHOP and rituximab\n # Type 2 DM (without peripheral neuropathy)\n # HTN\n # Hypothyroidism\n # Diastolic dysfunction with LVEF of 65%\n # Cholecystectomy.\n # Appendectomy.\n # h/o of atrial fibrillation\n There is no family history of premature coronary artery disease or\n sudden death. Afib in sister\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, previously lived at home but recently discharged to\n rehab. Denies tobacco use.\n Review of systems:\n Constitutional: No(t) Fever\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Psychiatric / Sleep: Delirious, Daytime somnolence\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:18 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 92 (92 - 97) bpm\n BP: 127/59(77) {127/59(77) - 127/73(86)} mmHg\n RR: 20 (20 - 24) insp/min\n SpO2: 97%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -300 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///48/\n Physical Examination\n General Appearance: Overweight / Obese, moon facies, tachypneic,\n accessory muscle use\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: buffalo hump\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, worst at bases, Diminished: throughout)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n midline reducible hernia\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): person and place. , Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 243 K/uL\n 12.2 g/dL\n 141 mg/dL\n 1.0 mg/dL\n 28 mg/dL\n 48 mEq/L\n 86 mEq/L\n 5.3 mEq/L\n 137 mEq/L\n 35.1 %\n 8.2 K/uL\n [image002.jpg]\n \n 2:33 A12/17/ 02:43 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.2\n Hct\n 35.1\n Plt\n 243\n Cr\n 1.0\n Glucose\n 141\n Other labs: PT / PTT / INR:12.2/23.8/1.0, CK / CKMB / Troponin-T:25//,\n ALT / AST:, Alk Phos / T Bili:85/0.3, Amylase / Lipase:55/27,\n Albumin:3.7 g/dL, LDH:264 IU/L, Ca++:10.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.6 mg/dL\n Imaging: CXR :\n Chronic interstitial lung disease with superimposed vague opacity\n may represent aspiration or mild pulmonary edema.\n .\n L-spine XR :\n Slight interval increase in superior endplate wedging of the L2\n vertebral body, and chronic L1 compression fracture. No other acute\n fracture or dislocation.\n .\n Spirometry :\n FEV1: 0.87(42%), FVC:0.97(33%), FEV1/FVC: 90(128%)\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: given current ABG, suspect\n she has had increased CO2 retention over last month. Also given that\n she is not currently obtunded argues in favor of this. Acute worsening\n in oxygenation likely due to aspiration or flash pulmonary edema in the\n setting of emesis. Other possible etiologies including pna or PE seem\n less likely. She has been on DVT ppx. Not good NIPPV candidate\n currently given emesis. Given severity of underlying lung disease,\n intubation unlikely to be reversible.\n - discuss goals of care with family\n - serial ABGs\n - cont supplemental O2\n - add on BNP\n - lasix 40 IV for pulmonary edema\n - hold off on abx without clear infection\n - nebs\n - hold off on steroids as has been steroid unresponsive in past and no\n evidence of obstructive exacerbation at this time\n .\n # emesis: unclear cause. Patient cannot provide adequate history at\n this time. Abdominal exam benign at this time. Does have midline hernia\n but reducible.\n - abdominal film to check fo obstruction\n - add on LFTs, PEs\n - check tacro level to assess for toxicity\n - check cardiac enzymes and ECG\n - NPO for now\n .\n # s/p fall: no evidence of fracture. Pain reasonably controlled at\n rest. Likely mechanical so no need for further syncope work up at this\n time.\n - cont lidocaine patch, ibuprofen and tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: reasonable BG control on floor\n - cont NPH per outpt doses. Half dose while NPO\n - cont insulin sliding scale\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - check tacro level\n - continue Tacrolimus at regular dose for now\n .\n # HTN: normotensive currently.\n - Continue outpt metoprolol\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV\n .\n # FEN: NPO for now\n - vit D\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: FULL CODE. Will need to readdress with HCP\n .\n # Contact: \n .\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:09 PM\n 18 Gauge - 02:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Critical Care\n Present for key portions of history and exam. Agree with Dr. \n assessment and plan as above. Ms. has progressive interstitial\n lung dis w/o clear diagnosis. She has undergone a trial of steroids as\n an outpatient with progression on therapy. Adm now for pain control\n after a fall\n breathing\nbaseline\n but vomited last night and then\n progressive incr in FIO2 requirement and incr PCO2. It is unlikely\n that she has significant reversible dis. Her CXR suggests some incr\n markings c/w aspiration/ infection/ edema but underlying fxn is so poor\n I doubt she will survive mechanical ventilation. Nevertheless, her\n husband believes she would wish to have a period of support. I have\n told him her condition is extremely critical and she would not survive\n cardiac resus but we have intubated now and will treat possibly\n reversible processes such as bacterial infection.\n Time spent 75 min\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 17:41 ------\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356853,
"text": "Synopsis per prior nursing note:\n 73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events12/20: placed on SBT( 5/o) on vent but unable to tolerate-\n placed back on . PICC attempted at bedside but unsuccessful to be\n done in IR on Monday. Antibiotics changed to vanco/zosyn- flagyl d/c\n ~1830 patient\ns HR increased to high 120\ns to 130\ns. Given 5mg IV\n Lopressor and HR decreased to 80\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS-clear w/ diminished bases. O2 sats >95%. Alert, mouthing words and\n making gestures. Pt also able to write needs on board when not\n understood. Currently not on sedation and denies pain when asked.\n Independent w/ oral Suctioning .\n Action:\n Suctioned as needed. Monitored temp curve. Q2-3 hr position changes.\n Emotional support provided.\n Response:\n O2 sats remained >95%. Denied SOB.\n Plan:\n Monitor resp status. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356857,
"text": "Chief Complaint:\n 24 Hour Events:\n -PICC attempted, will need to go to IR to have it placed on Monday\n -tried on PS 5/5 but only lasted a few minutes and put back on \n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 08:42 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 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 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 86 (80 - 124) bpm\n BP: 113/68(84) {100/56(74) - 146/116(125)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 703 mL\n 166 mL\n PO:\n TF:\n IVF:\n 643 mL\n 166 mL\n Blood products:\n Total out:\n 550 mL\n 240 mL\n Urine:\n 550 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 153 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 319 (219 - 524) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 8.6 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 242 K/uL\n 9.9 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 39 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 94 mEq/L\n 139 mEq/L\n 28.1 %\n 6.4 K/uL\n [image002.jpg]\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n WBC\n 7.5\n 7.3\n 5.8\n 6.4\n Hct\n 28.0\n 25.5\n 26.7\n 28.1\n Plt\n 42\n Cr\n 1.0\n 1.0\n 1.4\n 1.1\n TropT\n 0.01\n TCO2\n 46\n 40\n 39\n 42\n 43\n 42\n Glucose\n 164\n 190\n 136\n 109\n Other labs: PT / PTT / INR:13.0/25.3/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356858,
"text": "Chief Complaint:\n 24 Hour Events:\n -PICC attempted, will need to go to IR to have it placed on Monday\n -tried on PS 5/5 but only lasted a few minutes and put back on \n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 08:42 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 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 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 86 (80 - 124) bpm\n BP: 113/68(84) {100/56(74) - 146/116(125)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 703 mL\n 166 mL\n PO:\n TF:\n IVF:\n 643 mL\n 166 mL\n Blood products:\n Total out:\n 550 mL\n 240 mL\n Urine:\n 550 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 153 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 319 (219 - 524) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 8.6 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 242 K/uL\n 9.9 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 39 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 94 mEq/L\n 139 mEq/L\n 28.1 %\n 6.4 K/uL\n [image002.jpg]\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n WBC\n 7.5\n 7.3\n 5.8\n 6.4\n Hct\n 28.0\n 25.5\n 26.7\n 28.1\n Plt\n 42\n Cr\n 1.0\n 1.0\n 1.4\n 1.1\n TropT\n 0.01\n TCO2\n 46\n 40\n 39\n 42\n 43\n 42\n Glucose\n 164\n 190\n 136\n 109\n Other labs: PT / PTT / INR:13.0/25.3/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensates.\n - switch back to Vancomycin/Zosyn for 5 more days to cover for PNA\n - wean as tolerated today, eval for extubation\n -monitor fluid status to avoid gross pulmonary edema, IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c\nd amiodarone \n -monitor on telemetry\n -advanced toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch. Pain well controlled minus lidocaine\n patch. Now pt with no c/o pain\n will d/c fetanyl and lidocaine.\n Tylenol PRN\n - PT following\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval and possible placement today\n .\n # FEN: will start tube feeds if not intubated today, replete\n electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356802,
"text": "Synopsis per prior nursing note:\n 73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events: Placed on 5/o on vent but unable to tolerate- placed back on\n . PICC attempted at bedside but unsuccessful to be done in IR on\n Monday. Antibiotics changed to vanco/zosyn- flagyl d/c\nd. ~1830\n patient\ns HR increased to high 120\ns to 130\ns. Given 5mg IV Lopressor\n and HR decreased to 80\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS-clear w/ diminished bases. O2 sats >95%. WBC 6.4(5.8). Tmax 99.1 PO.\n Alert, mouthing words and making gestures. Currently not on sedation.\n Suctioning mouth on own.\n Action:\n Suctioned as needed. Monitored temp curve. Q2-3 hr position changes.\n Emotional support provided.\n Response:\n O2 sats remained >95%. Denied SOB.\n Plan:\n Monitor resp status. Wean vent as tolerated. Continue antibiotics.\n Suction as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358330,
"text": "Pt admitted to after a fall, lumbar spine films show\n chronic L1 compression. adm to MICU after desaturating, ? asp\n event. Intubated, on antibiotics. Also with SVT vs AR with RVR,\n started on Amiodarone and lopressor. extubated, sent to\n . noted to be lethargic with ^^RR, falling satas. Also in\n AF with RVR. Sent to CCU (MICU service). Placed on CPAP.\n Dysphagia\n Assessment:\n Failed swallowing study this admission, however, able to take pills\n with water without coughing or throat clearing.\n Action:\n HOB ^^ with pills, pills given one at a time.\n Response:\n No coughing/throat clearing.\n Plan:\n Continue with HOB^^ with pills.\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358332,
"text": "Pt admitted to after a fall, lumbar spine films show\n chronic L1 compression. adm to MICU after desaturating, ? asp\n event. Intubated, on antibiotics. Also with SVT vs AR with RVR,\n started on Amiodarone and lopressor. extubated, sent to\n . noted to be lethargic with ^^RR, falling satas. Also in\n AF with RVR. Sent to CCU (MICU service). Placed on CPAP.\n Dysphagia\n Assessment:\n Failed swallowing study this admission, however, able to take pills\n with water without coughing or throat clearing.\n Action:\n HOB ^^ with pills, pills given one at a time. Remains NPO otherwise\n d/t need for CPAP and ? of intubation. Received full dose of am NPH\n after discussing with team, as pt\ns BS\ns were high all day yesterday\n despite being NPO and full dose NPH.\n Response:\n No coughing/throat clearing.\n Plan:\n Continue with HOB^^ with pills, pills one at a time. Remains NPO\n otherwise d/t use of CPAP.\n Impaired Skin Integrity\n Assessment:\n Yeast infection around perineal and buttocks: rash remains red with\n skin peeling.\n Action:\n Cleansing with wound cleaner followed by Nystatin and lidocaine\n ointments. Started Miconazole Nitrate vaginal suppositories for 3\n days. Repositioned at least q 2hours\n Response:\n Vaginal discharge has improving. Rash appears less inflamed.\n Plan:\n Continue treatment as prescribed. Frequent turning and cleansing to\n keep area dry.\n .H/O atrial fibrillation (Afib)\n Assessment:\n In AF rate of 140\ns this am.\n Action:\n Able to take Amiodarone and lopressor this am.\n Response:\n Converted to NSR @ 0930. Maintaining SBP >92 (pressure measured 82 X1\n when pt turned on right side with NBP cuff on L arm. SBP rechecked in\n R leg\n94).\n Plan:\n Continue to administer Amiodarone and lopressor as ordered. Monitor\n lytes. Follow HR/rhythm/BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 70% cool neb with sats >92%. Lungs with bibasilar crackles, pt has\n paradoxical resp pattern. RR in high 30\ns this am.\n Action:\n Sats monitored continuously. No fall in sat below 92%. Receiving\n atrovent nebs.\n Response:\n Pt states breathing is better than yesterday. RR noted to be lower\n after converting to NSR (low 30\ns to high 20\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358333,
"text": "Pt admitted to after a fall, lumbar spine films show\n chronic L1 compression. adm to MICU after desaturating, ? asp\n event. Intubated, on antibiotics. Also with SVT vs AR with RVR,\n started on Amiodarone and lopressor. extubated, sent to\n . noted to be lethargic with ^^RR, falling satas. Also in\n AF with RVR. Sent to CCU (MICU service). Placed on CPAP.\n Dysphagia\n Assessment:\n Failed swallowing study this admission, however, able to take pills\n with water without coughing or throat clearing.\n Action:\n HOB ^^ with pills, pills given one at a time. Remains NPO otherwise\n d/t need for CPAP and ? of intubation. Received full dose of am NPH\n after discussing with team, as pt\ns BS\ns were high all day yesterday\n despite being NPO and full dose NPH.\n Response:\n No coughing/throat clearing.\n Plan:\n Continue with HOB^^ with pills, pills one at a time. Remains NPO\n otherwise d/t use of CPAP.\n Impaired Skin Integrity\n Assessment:\n Yeast infection around perineal and buttocks: rash remains red with\n skin peeling.\n Action:\n Cleansing with wound cleaner followed by Nystatin and lidocaine\n ointments. Started Miconazole Nitrate vaginal suppositories for 3\n days. Repositioned at least q 2hours\n Response:\n Vaginal discharge has improved as per report. Rash appears less\n inflamed.\n Plan:\n Continue treatment as prescribed. Frequent turning and cleansing to\n keep area dry.\n .H/O atrial fibrillation (Afib)\n Assessment:\n In AF rate of 140\ns this am.\n Action:\n Able to take Amiodarone and lopressor this am.\n Response:\n Converted to NSR @ 0930. Maintaining SBP >92 (pressure measured 82 X1\n when pt turned on right side with NBP cuff on L arm. SBP rechecked in\n R leg\n94).\n Plan:\n Continue to administer Amiodarone and lopressor as ordered. Monitor\n lytes. Follow HR/rhythm/BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 70% cool neb with sats >92%. Lungs with bibasilar crackles, pt has\n paradoxical resp pattern. RR in high 30\ns this am.\n Action:\n Sats monitored continuously. No fall in sat below 92%. Receiving\n atrovent nebs.\n Response:\n Pt states breathing is better than yesterday. RR noted to be lower\n after converting to NSR (low 30\ns to high 20\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 357110,
"text": "73 yo female admitted on for pain mgmt after fall.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events: : placed on SBT( 5/o) on vent but unable to tolerate-\n placed back on . PICC attempted at bedside but unsuccessful to be\n done in IR on Monday. Antibiotics changed to vanco/zosyn- flagyl d/c\n ~1830 patient\ns HR increased to high 120\ns to 130\ns. Given 5mg IV\n Lopressor and HR decreased to 80\n : Pt extubated at 2pm and tolerated well, on 3L N/C(O2\n dependent at home) Sat\ns have remained > 95% on 3L. Pt desat\n overnight, ? if sleep apnea. No intervention needed. Aline out. Will\n need PICC placed in IR today.\n ? c/o today and restart diet. NPH held secondary to NPO and\n fingersticks < 150. Pt had had frequent loose stools, please hold\n colace in am. Voice hoarse and c/o sore throat, ice chips tolerated\n and eased sore throat.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 73 female w/ chronic lung disease. Extubated yesterday, tolerated\n well w/o signs of resp distress. Maintains sat\ns of >95% on 3L via\n N/C. Lungs diminishes bases, w/ occas wheezes. Denies SOB. Weak\n non-productive cough noted\n Action:\n Pt encouraged and reminded to cough and deep breath. Continue w/\n supportive O2\n Response:\n Resp status stable\n Plan:\n ? c/o later today\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 357982,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 57.8 None\n Ideal tidal volume: 231.2 / 346.8 / 462.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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: /\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: Tolerated well, Excessive mask\n leak, Mask induced abrasions, Mask discomfort; Comments: sore spot on\n bridge of nose after wearing mask for 5 hours\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments: intermittent hypopneas, may be central in nature ??\n Plan\n Next 24-48 hours: Increase ventilatory support at night; Comments:\n Place pt on NIV as needed at night for present time\n Reason for continuing current ventilatory support: night time\n apneas,hypopneas and desaturations. Sometimes needs MMV mode as she has\n hypopneas on NIV which could be central\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 on NIV for ~ 5 hours continuously last night. Spo2 95% or\n greater. Pt C/O sore spot on bridge of her nose. Of NIV ~ 0500.\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356645,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 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: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n 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: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 357074,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:41 PM\n ARTERIAL LINE - STOP 10:11 PM\n - self diuresing\n -for IR PICC today\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:57 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 06:54 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: 36.2\nC (97.1\n HR: 81 (74 - 96) bpm\n BP: 106/48(57) {88/44(57) - 124/59(74)} mmHg\n RR: 19 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 600 mL\n 229 mL\n PO:\n 60 mL\n 60 mL\n TF:\n IVF:\n 540 mL\n 169 mL\n Blood products:\n Total out:\n 1,687 mL\n 230 mL\n Urine:\n 1,687 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,087 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 286 (286 - 332) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 94%\n ABG: 7.46/50/111/38/10\n Ve: 7.8 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: NAD, more alert than yesterday, intubated\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, Bowel sounds present, Distended, Obese, nontender to\n palp\n Extremities: Right: 1+, Left: 1+ dp pulses, warm, 1+ edema\n Neurologic: Responds to voice and commands, on minimal sedation,\n intubated.\n Peripheral 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 219 K/uL\n 9.3 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 93 mEq/L\n 137 mEq/L\n 26.7 %\n 5.6 K/uL\n [image002.jpg]\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n 06:26 AM\n 06:42 AM\n 11:50 AM\n 05:55 AM\n WBC\n 5.8\n 6.4\n 4.9\n 5.6\n Hct\n 26.7\n 28.1\n 26.3\n 26.7\n Plt\n 190\n 242\n 198\n 219\n Cr\n 1.4\n 1.1\n 1.0\n 0.9\n TCO2\n 39\n 42\n 43\n 42\n 40\n 37\n Glucose\n 136\n 109\n 100\n 126\n Other labs: PT / PTT / INR:12.7/24.7/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Will continue to wean as tolerated, keeping in mind her\n small reserve. Has been doing very well on minimal PS, will attempt to\n decrease to 5/0 today. If she does well, might need to consider trach\n placement. Having thick secretions which may be barrier to extubation.\n - continue Vancomycin/Zosyn (last day )\n - wean as tolerated today, eval for extubation\n - IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Has resolved since.\n -d/c\nd amiodarone \n -monitor on telemetry\n - toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Pain well controlled minus\n lidocaine patch. Now pt with no c/o pain. Tylenol PRN\n - PT following\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval and possible placement in AM\n .\n # FEN: TF, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357075,
"text": "73 yo female admitted on for pain mgmt after fall.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events: : placed on SBT( 5/o) on vent but unable to tolerate-\n placed back on . PICC attempted at bedside but unsuccessful to be\n done in IR on Monday. Antibiotics changed to vanco/zosyn- flagyl d/c\n ~1830 patient\ns HR increased to high 120\ns to 130\ns. Given 5mg IV\n Lopressor and HR decreased to 80\n : Pt extubated at 2pm and tolerated well, on 3L N/C(O2\n dependent at home) Sat\ns have remained > 95% on 3L. Pt desat\n overnight, ? if sleep apnea. No intervention needed. Aline out. Will\n need PICC placed in IR today.\n ? c/o today and restart diet. NPH held secondary to NPO and\n fingersticks < 150. Pt had had frequent loose stools, please hold\n colace in am. Voice hoarse and c/o sore throat, ice chips tolerated\n and eased sore throat.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 73 female w/ chronic lung disease. Extubated yesterday, tolerated\n well w/o signs of resp distress. Maintains sat\ns of >95% on 3L via\n N/C. Lungs diminishes bases, w/ occas wheezes. Denies SOB. Weak\n non-productive cough noted\n Action:\n Pt encouraged and reminded to cough and deep breath. Continue w/\n supportive O2\n Response:\n Resp status stable\n Plan:\n ? c/o later today\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Resident / Attending Notes",
"row_id": 356779,
"text": "Chief Complaint:\n 24 Hour Events:\n - no overnight issues, pt noted to be alert\n - attdg met with family yesterday who would want current treatment, but\n do not want patient resuscitated\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Vancomycin - 08:08 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:09 AM\n Heparin Sodium (Prophylaxis) - 09:42 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 06:17 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: 37.1\nC (98.8\n HR: 87 (74 - 103) bpm\n BP: 129/69(90) {91/47(62) - 148/86(110)} mmHg\n RR: 16 (15 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 946 mL\n 165 mL\n PO:\n TF:\n IVF:\n 656 mL\n 165 mL\n Blood products:\n Total out:\n 2,170 mL\n 140 mL\n Urine:\n 2,170 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,224 mL\n 25 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 313 (301 - 361) mL\n PS : 10 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.43/61/101/39/12\n Ve: 9.2 L/min\n PaO2 / FiO2: 253\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 242 K/uL\n 9.9 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 39 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 94 mEq/L\n 139 mEq/L\n 28.1 %\n 6.4 K/uL\n [image002.jpg]\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n WBC\n 7.5\n 7.3\n 5.8\n 6.4\n Hct\n 28.0\n 25.5\n 26.7\n 28.1\n Plt\n 42\n Cr\n 1.0\n 1.0\n 1.4\n 1.1\n TropT\n 0.01\n TCO2\n 46\n 40\n 39\n 42\n 43\n 42\n Glucose\n 164\n 190\n 136\n 109\n Other labs: PT / PTT / INR:13.0/25.3/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensates.\n - switch back to Vancomycin/Zosyn for 5 more days to cover for PNA\n - wean as tolerated today, eval for extubation\n -monitor fluid status to avoid gross pulmonary edema, IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c\nd amiodarone \n -monitor on telemetry\n -advanced toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch. Pain well controlled minus lidocaine\n patch. Now pt with no c/o pain\n will d/c fetanyl and lidocaine.\n Tylenol PRN\n - PT following\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval and possible placement today\n .\n # FEN: will start tube feeds if not intubated today, replete\n electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n ------ Protected Section ------\n CRITICAL CARE STAFF ADDENDUM\n I saw and examined Ms. with the ICU team, whose note reflects\n my input. I would add/emphasize that she continues to be alert and\n interactive. Family meeting by Dr. yesterday. This morning, she\n notes that her pain is well controlled.\n She looked well on so we pursued an SBT. She tolerated in for\n only about 15 minutes and then required incrased support. She has also\n just converted back into MAT.\n Assessment and Plan\n 73 y/o woman with ILD, liver xplant, PTLD now with respiratory failure\n felt most likely due to aspiration.\n Resp failure\n did not tolerate SBT today but overall seems to be\n improving somewhat.\n - although bacterial infection less likely, not excluding. Will\n continue vanco/zosyn to complete eight day course\n MAT\n - try beta blockade\n ILD\n No acute intervention\n Liver transplant and hx of PTLD\n On tacro\n On bactrim ppx\n Other issues as per ICU team note today\n She is critically ill: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 16:37 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356781,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 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: 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: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: 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: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Attempted SBT, failed after 15min pt c/o sob\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357003,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n On 40 % cpap5/5 this am, TF off after MN for possible extubation\n today, BS+ all lobes, clear, sat > 90, pt comfortable on cpap, pt alert\n & able to lift head off pillow, + air leak\n Action:\n Placed on cpap 5/0 this am & 40 mg iv lasix given, abg sent on 5/0,\n extubated with airway cart present @ 1400(pt was a difficult\n intubation), placed on 3 l np & 40 % OFM, HOB up >45\n Response:\n Tolerated extubation well, VS/sat stable, now on only 3 l np\n Plan:\n Encourage IS & coughing, continue to monitor resp status\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-16 00:00:00.000",
"description": "Resident / Attending Notes",
"row_id": 357004,
"text": "Chief Complaint:\n 24 Hour Events:\n -PICC attempted, will need to go to IR to have it placed on Monday\n -tried on PS 5/5 but only lasted a few minutes and put back on \n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 08:42 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:43 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 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.3\nC (99.1\n HR: 86 (80 - 124) bpm\n BP: 113/68(84) {100/56(74) - 146/116(125)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 703 mL\n 166 mL\n PO:\n TF:\n IVF:\n 643 mL\n 166 mL\n Blood products:\n Total out:\n 550 mL\n 240 mL\n Urine:\n 550 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 153 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 319 (219 - 524) mL\n PS : 10 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 100\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 8.6 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 242 K/uL\n 9.9 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 39 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 94 mEq/L\n 139 mEq/L\n 28.1 %\n 6.4 K/uL\n [image002.jpg]\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n WBC\n 7.5\n 7.3\n 5.8\n 6.4\n Hct\n 28.0\n 25.5\n 26.7\n 28.1\n Plt\n 42\n Cr\n 1.0\n 1.0\n 1.4\n 1.1\n TropT\n 0.01\n TCO2\n 46\n 40\n 39\n 42\n 43\n 42\n Glucose\n 164\n 190\n 136\n 109\n Other labs: PT / PTT / INR:13.0/25.3/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Will continue to wean as tolerated, keeping in mind her\n small reserve. Has been doing very well on minimal PS, will attempt to\n decrease to 5/0 today. If she does well, might need to consider trach\n placement. Having thick secretions which may be barrier to extubation.\n - continue Vancomycin/Zosyn (last day )\n - wean as tolerated today, eval for extubation\n - IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Has resolved since.\n -d/c\nd amiodarone \n -monitor on telemetry\n - toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Pain well controlled minus\n lidocaine patch. Now pt with no c/o pain. Tylenol PRN\n - PT following\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval and possible placement in AM\n .\n # FEN: TF, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n ------ Protected Section ------\n CRITICAL CARE STAFF ADDENDUM\n 12n\n I saw and examined Ms. with the ICU team, whose note reflects\n my input. I would add/emphasize that she continues to be alert and\n interactive. Pain continues to be well controlled. Did not pass SBT\n yesterday. PICC unable to be placed.\n Labs and exam as reviewed above.\n Assessment and Plan\n 73 y/o woman with steroid-resistant ILD on ~2L home O2, liver\n transplant, and quiescent PTLD now with respiratory failure felt most\n likely due to aspiration.\n Respiratory failure\n Given little reserve and cultures after ABX, complete 8d course of ABX\n for possible HAP\n Did not tolerate SBT yesterday\n Repeat SBT today. Complete full two hours.\n Given difficult intubation, consult anesthesia if extubation attempted.\n MAT\n - improved with beta blockade\n ILD\n No acute intervention\n Liver transplant and hx of PTLD\n On tacro\n On bactrim ppx\n PTLD\n Quiescent after therapy\n Other issues as per ICU team note today\n She is critically ill: 40 min\n CRITICAL CARE STAFF ADDENDUM\n 3p\n Tolerated full two hour SBT. Felt well and ABG reassuring. Had a cuff\n leak. After discussing risks and benefits with her, consulted\n anesthesia. After discussion and preparation for difficult\n reintubation (including airway cart, glidescope, etc.), we pursued\n extubation. Tolerating well so far. Discussed with her husband by\n phone\n 40 min\n CRITICAL CARE STAFF ADDENDUM\n 5p\n Continues to do well off the vent.\n ------ Protected Section Addendum Entered By: , MD\n on: 07:29 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 357072,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:41 PM\n ARTERIAL LINE - STOP 10:11 PM\n - self diuresing\n -for IR PICC today\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:57 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 06:54 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: 36.2\nC (97.1\n HR: 81 (74 - 96) bpm\n BP: 106/48(57) {88/44(57) - 124/59(74)} mmHg\n RR: 19 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 600 mL\n 229 mL\n PO:\n 60 mL\n 60 mL\n TF:\n IVF:\n 540 mL\n 169 mL\n Blood products:\n Total out:\n 1,687 mL\n 230 mL\n Urine:\n 1,687 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,087 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 286 (286 - 332) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 94%\n ABG: 7.46/50/111/38/10\n Ve: 7.8 L/min\n PaO2 / FiO2: 277\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 219 K/uL\n 9.3 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 93 mEq/L\n 137 mEq/L\n 26.7 %\n 5.6 K/uL\n [image002.jpg]\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n 06:26 AM\n 06:42 AM\n 11:50 AM\n 05:55 AM\n WBC\n 5.8\n 6.4\n 4.9\n 5.6\n Hct\n 26.7\n 28.1\n 26.3\n 26.7\n Plt\n 190\n 242\n 198\n 219\n Cr\n 1.4\n 1.1\n 1.0\n 0.9\n TCO2\n 39\n 42\n 43\n 42\n 40\n 37\n Glucose\n 136\n 109\n 100\n 126\n Other labs: PT / PTT / INR:12.7/24.7/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Will continue to wean as tolerated, keeping in mind her\n small reserve. Has been doing very well on minimal PS, will attempt to\n decrease to 5/0 today. If she does well, might need to consider trach\n placement. Having thick secretions which may be barrier to extubation.\n - continue Vancomycin/Zosyn (last day )\n - wean as tolerated today, eval for extubation\n - IV Lasix prn\n -nebs prn\n -will d/w pt and family plans options and status of resp support\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Has resolved since.\n -d/c\nd amiodarone \n -monitor on telemetry\n - toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Pain well controlled minus\n lidocaine patch. Now pt with no c/o pain. Tylenol PRN\n - PT following\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale. Will\n adjust accordingly when tube feeds start\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval and possible placement in AM\n .\n # FEN: TF, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357831,
"text": " Admitted s/p mechanical fall @ home. L spine xrays revealed\n chronic L1 compression fx, but no other acute fx or dislocation. \n Desat 85% on 2L NP->increased o2 to 4L with sat's mid 90's. Then nausea\n with vomitting & desat requiring non rebreather->?? asp.\n pneumonia--started vanco & zosyn. Transferred to MICU where she had\n hypercarbic/hypoxic resp. failure requiring intubation. SVT vs Afib\n with RVR->amio gtt->po lopressor. Extubated successfully\n PICC line placed & transferred back to F7. became sl\n lethargic with RR 25-38 & O2 sat 88% 3L NP. Increased O2 6L with sats\n 90-93%. HR from SR->Afib with RVR 130-150's. Metoprolol 5mg VP x2 with\n no response. BP 92/60. Transferred to CCU as MICU border for amio gtt &\n ?? mask ventilation vs intubation. ABG 7.35/73/54/42.\n .H/O atrial fibrillation (Afib)\n Assessment:\n On adm. To ICU HR 130-150\ns Afib. SBP 70-80\n Action:\n 250 NS bolus x2 with no effect. Neo gtt started & titrated to\n 0.75mcg/kg. Amio bolus given followed by amio gtt @ 1mg/min.\n Response:\n HR 110-130 on amio gtt. SBP 90-100\ns on neo.\n Plan:\n Titrate neo to keep map>65. Decrease amio to 0.5mg/min @ 0945.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sat 88-92% on admission to icu. ABG 7.35/73/54/42 on 6L. RR 28-40.\n BS with scattered crackles throughout.\n Action:\n Placed on BIPAP 100%/ PSV8/peep 5.\n Response:\n O2 sat 99%. RR 28-32. ABG 7.35/67/386/39.\n Plan:\n Wean FIO2 to maintain sats in low 90\ns. Presently o2 sat 95% on 50%.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357833,
"text": " Admitted s/p mechanical fall @ home. L spine xrays revealed\n chronic L1 compression fx, but no other acute fx or dislocation. \n Desat 85% on 2L NP->increased o2 to 4L with sat's mid 90's. Then nausea\n with vomitting & desat requiring non rebreather->?? asp.\n pneumonia--started vanco & zosyn. Transferred to MICU where she had\n hypercarbic/hypoxic resp. failure requiring intubation. SVT vs Afib\n with RVR->amio gtt->po lopressor. Extubated successfully\n PICC line placed & transferred back to F7. became sl\n lethargic with RR 25-38 & O2 sat 88% 3L NP. Increased O2 6L with sats\n 90-93%. HR from SR->Afib with RVR 130-150's. Metoprolol 5mg VP x2 with\n no response. BP 92/60. Transferred to CCU as MICU border for amio gtt &\n ?? mask ventilation vs intubation. ABG 7.35/73/54/42.\n .H/O atrial fibrillation (Afib)\n Assessment:\n On adm. To ICU HR 130-150\ns Afib. SBP 70-80\n Action:\n 250 NS bolus x2 with no effect. Neo gtt started & titrated to\n 0.75mcg/kg. Amio bolus given followed by amio gtt @ 1mg/min.\n Response:\n HR 110-130 on amio gtt. SBP 90-100\ns on neo.\n Plan:\n Titrate neo to keep map>65. Decrease amio to 0.5mg/min @ 0945.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sat 88-92% on admission to icu. ABG 7.35/73/54/42 on 6L. RR 28-40.\n BS with scattered crackles throughout.\n Action:\n Placed on BIPAP 100%/ PSV8/peep 5.\n Response:\n O2 sat 99%. RR 28-32. ABG 7.35/67/386/39.\n Plan:\n Wean FIO2 to maintain sats in low 90\ns. Presently o2 sat 95% on 50%.\n ------ Protected Section ------\n 0630->pt requesting to come off mask ventilation. O2 sat 95% & RR 28.\n Dr. notified & ok\nd pt request. Placed on 6L NP, & O2 sat 78-84%\n with RR 30\ns. Placed back on mask ventilation.\n ------ Protected Section Addendum Entered By: , RN\n on: 07:01 ------\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358218,
"text": "Dysphagia\n Assessment:\n Pt intermittently coughing after ice chips. Able to take pills one at\n time without coughing. Had been rated DOSS 1 but improved to 7 on\n .\n Action:\n Keeping HOB elevated to 45-90 degrees.\n Response:\n Continues to cough intermittently\n Plan:\n Follow aspiration precautions and instruct family also.\n Alteration in Nutrition\n Assessment:\n Remains NPO. Pt has been mostly NPO during this admission based on\n nutrition consults and documentation\n Action:\n In setting of requiring freq CPAP, it is preferred to keep NPO to\n prevent aspiration\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Yeast infection and rash remains bright red with skin starting peel.\n Action:\n Cleansing with wound cleaner followed by Nystatin and lidocaine\n ointments. Started Miconazole Nitrate vaginal suppositories.\n Response:\n Vaginal discharge has improved dramatically with only small amount\n noted. Rash appears less inflamed.\n Plan:\n Continue treatment as prescribed. Frequent turning and cleansing to\n keep area dry.\n Hypotension (not Shock)\n Assessment:\n SBP 90-100 Lopressor remains on hold. Amiodarone at 200mg po.\n Action:\n Neo at .6mcg/kg/min was weaned slowly off over the night.\n Response:\n SBP stable with MAPS >60.\n Plan:\n Goal to keep MAPs\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357825,
"text": " Admitted s/p mechanical fall @ home. L spine xrays revealed\n chronic L1 compression fx, but no other acute fx or dislocation. \n Desat 85% on 2L NP->increased o2 to 4L with sat's mid 90's. Then nausea\n with vomitting & desat requiring non rebreather->?? asp.\n pneumonia--started vanco & zosyn. Transferred to MICU where she had\n hypercarbic/hypoxic resp. failure requiring intubation. SVT vs Afib\n with RVR->amio gtt->po lopressor. Extubated successfully\n PICC line placed & transferred back to F7. became sl\n lethargic with RR 25-38 & O2 sat 88% 3L NP. Increased O2 6L with sats\n 90-93%. HR from SR->Afib with RVR 130-150's. Metoprolol 5mg VP x2 with\n no response. BP 92/60. Transferred to CCU as MICU border for amio gtt &\n ?? mask ventilation vs intubation. ABG 7.35/73/54/42.\n .H/O atrial fibrillation (Afib)\n Assessment:\n On adm. To ICU HR 130-150\ns Afib. SBP 70-80\n Action:\n 250 NS bolus x2 with no effect. Neo gtt started & titrated to\n 0.75mcg/kg. Amio bolus given followed by amio gtt @ 1mg/min.\n Response:\n HR 110-130 on amio gtt. SBP 90-100\ns on neo.\n Plan:\n Titrate neo to keep map>65. Decrease amio to 0.5mg/min @ 0945.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 357910,
"text": "Demographics\n Ideal body weight: 57.8 None\n Ideal tidal volume: 231.2 / 346.8 / 462.4 mL/kg\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Non-invasive ventilation assessment: Mask discomfort; Comments: Pt on\n Trach mask throughout the majority of the shift; placed on NIV for 1\n hour today, did not tol mask well.\n Plan\n Next 24-48 hours: Continue with NIV as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357967,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing. Pt remains NPO except for ice\n chips/meds since readmit to ICU .\n Action:\n HOB elevated 45-90 degrees.\n Response:\n No\n Plan:\n Aspiration Precautions and instruct family and friends.\n Crush meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Plan:\n Reassess diet, re consult nutrition regarding recent diarrhea and\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks. Areas are painful to clean and\n treat .Area is also excoriated from recent diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed.\n Frequent turning and cleansing area.\n Response:\n No change in skin, remains red and painful.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Intern to order Nystatin ointment with lidocaine.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9, Ciprofloxacin one dose then d/c\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0530\n Plan:\n Continue to monitor for increase lethargy off CPAP.\n Intern to check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357968,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing. Pt remains NPO except for ice\n chips/meds since readmit to ICU .\n Action:\n HOB elevated 45-90 degrees.\n Response:\n No\n Plan:\n Aspiration Precautions and instruct family and friends.\n Crush meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Plan:\n Re consult nutrition regarding recent diarrhea and poor caloric intake\n for many days.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks. Areas are painful to clean and\n treat .Area is also excoriated from recent diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed.\n Frequent turning and cleansing area.\n Response:\n No change in skin, remains red and painful.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Intern to order Nystatin ointment with lidocaine.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9, Ciprofloxacin one dose then d/c\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0530\n Plan:\n Continue to monitor for increase lethargy off CPAP.\n Intern to check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357969,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing.\n Pt remains NPO except for ice chips/meds since readmit to ICU .\n Action:\n HOB elevated 45-90 degrees.\n Response:\n No\n Plan:\n Aspiration Precautions, instruct family and friends.\n Crush meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Plan:\n Re consult nutrition regarding recent diarrhea and poor caloric intake\n for many days.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks.\n Areas are painful to clean and treat .Area is also excoriated from\n recent diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed.\n Frequent turning and cleansing area.\n Response:\n No change in skin remains red and painful.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Intern to order Nystatin ointment with lidocaine.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9,\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0530\n Plan:\n Continue to monitor for increase lethargy off CPAP.\n Intern to check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357971,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing.\n Pt NPO except for ice chips/meds since readmitted to ICU .\n Action:\n HOB elevated 45-90 degrees. Cutting or crushing medications as\n allowed.\n Response:\n Plan:\n Aspiration Precautions, instruct family and friends.\n Crush meds in applesauce, or cut up medications.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Plan:\n Re consult nutrition especially since recent diarrhea and poor caloric\n intake for many days.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks.\n Areas are painful to clean and treat .Area is also excoriated from\n recent diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed.\n Frequent turning and cleansing area each time.\n Response:\n No change in skin remains red and painful.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Intern to order Nystatin ointment with lidocaine.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9,\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0530\n Plan:\n Continue to monitor for increase lethargy off CPAP.\n Intern to check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357972,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing.\n Pt NPO except for ice chips/meds since readmitted to ICU .\n Action:\n HOB elevated 45-90 degrees. Cutting or crushing medications as\n allowed.\n Response:\n Plan:\n Aspiration Precautions, instruct family and friends.\n Crush meds in applesauce, or cut up medications.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Plan:\n Re consult nutrition especially since recent diarrhea and poor caloric\n intake for many days.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks.\n Areas are painful to clean and treat .Area is also excoriated from\n recent diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed.\n Frequent turning and cleansing area each time.\n Response:\n No change in skin remains red and painful.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Intern to order Nystatin ointment with lidocaine.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9,\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0430 removed d/t\n pressure on bridge of nose and also skin was red/purple. No skin\n breakdown.\n Plan:\n Pt is 3.5liters positive since admit Continue to monitor for\n increase lethargy off CPAP. Maintain O2 sats >92%\n Intern to check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357973,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing.\n Pt NPO except for ice chips/meds since readmitted to ICU .\n Action:\n HOB elevated 45-90 degrees. Cutting or crushing medications as\n allowed.\n Response:\n Plan:\n Aspiration Precautions, instruct family and friends.\n Crush meds in applesauce, or cut up medications.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Plan:\n Re consult nutrition especially since recent diarrhea and poor caloric\n intake for many days.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks.\n Areas are painful to clean and treat .Area is also excoriated from\n recent diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed.\n Frequent turning and cleansing area each time.\n Response:\n No change in skin remains red and painful.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Intern to order Nystatin ointment with lidocaine.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9,\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0430 removed d/t\n pressure on bridge of nose and also skin was red/purple. No skin\n breakdown.\n Plan:\n Pt is 6 liters positive since admit . Last lasix Continue\n to monitor for increase lethargy off CPAP. Maintain O2 sats >92%\n Intern to check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357974,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing.\n Pt NPO except for ice chips/meds since readmitted to ICU .\n Action:\n HOB elevated 45-90 degrees. Cutting or crushing medications as\n allowed.\n Response:\n Plan:\n Aspiration Precautions, instruct family and friends.\n Crush meds in applesauce, or cut up medications.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Plan:\n Re consult nutrition especially since recent diarrhea and poor caloric\n intake for many days.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks.\n Areas are painful to clean and treat .Area is also excoriated from\n recent diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed.\n Frequent turning and cleansing area each time.\n Response:\n No change in skin remains red and painful.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Intern to order Nystatin ointment with lidocaine.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9,\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0430 removed d/t\n pressure on bridge of nose and also skin was red/purple. No skin\n breakdown.\n Plan:\n Pt is 6 liters positive since admit . Last lasix Continue\n to monitor for increase lethargy off CPAP. Maintain O2 sats >92%\n Intern to check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358089,
"text": "Impaired Skin Integrity\n Assessment:\n Severe yeast infection\n Action:\n Meds applied as ordered,,vaginal supp added to regimen\n Response:\n Slight improvement\n Plan:\n Frequent skin care ,continue meds\n Hypotension (not Shock)\n Assessment:\n Neo .89 mic per kg.bp\n Action:\n Liter ns given\n Response:\n BP 90 TO 100 SYSTOLIC\n Plan:\n Wean neo as tol\n .H/O atrial fibrillation (Afib)\n Assessment:\n Continues in afib\n Action:\n Started on po amiodarone,gtt dc 1130\n Response:\n Remains in afib hr 100 to 130\n Plan:\n Monitor response to amiodarone DRIP BEING OFF ,may need po dose\n increased\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Abg 7.25/74/141/34\n Action:\n Alternating between aerosol mask at 60% and cpap mask as tol\n Response:\n Maintaining sat ,tolerating cpap\n Plan:\n PT NEED TO BE INTUBATED,DIFFICULT AIRWAY\n Alteration in Nutrition\n Assessment:\n Pt npo due to need of cpap and possible intubation\n Action:\n Discussed issue c micu team\n Response:\n Delay decision for intubation and feeding tube till tomorrow\n Plan:\n As above\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357960,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing. Pt remains NPO except for ice\n chips/meds since readmit to ICU .\n Action:\n HOB elevated 45-90 degrees.\n Response:\n No\n Plan:\n Aspiration Precautions and instruct family and friends.\n Crush meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Nutrition consult\n \n Action:\n Response:\n Plan:\n Reassess diet, re consult nutrition regarding recent diarrhea and\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with green/yellow vaginal drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks. Areas are painful to clean.\n Area is also excoriated from recent diarrhea.\n Action:\n Using skin cleanser spray and applying aloe vesta antifungal\n ointment.\n Response:\n Plan:\n Hold all stool medications for now. Order double guard ointment to\n Hypotension (not Shock)\n Assessment:\n SBP 88-92 with Neo gtt unchanged at .80mcg/kg/min.\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. WWeight\n documented on was 72.5 kg and admit weight 90kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned BIPAP at HS 50%\n 10/5\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357961,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing. Pt remains NPO except for ice\n chips/meds since readmit to ICU .\n Action:\n HOB elevated 45-90 degrees.\n Response:\n No\n Plan:\n Aspiration Precautions and instruct family and friends.\n Crush meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Nutrition consult\n \n Action:\n Response:\n Plan:\n Reassess diet, re consult nutrition regarding recent diarrhea and\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with green/yellow vaginal drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks. Areas are painful to clean.\n Area is also excoriated from recent diarrhea.\n Action:\n Using skin cleanser spray and applying aloe vesta antifungal\n ointment.\n Response:\n Plan:\n Hold all stool medications for now. Order double guard ointment to\n Hypotension (not Shock)\n Assessment:\n SBP 88-92 with Neo gtt unchanged at .80mcg/kg/min.\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50%\n PEEP 5, resp 24-40 vT 300-400.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358081,
"text": "Impaired Skin Integrity\n Assessment:\n Severe yeast infection\n Action:\n Meds applied as ordered,,vaginal supp added to regimen\n Response:\n Slight improvement\n Plan:\n Frequent skin care ,continue meds\n Hypotension (not Shock)\n Assessment:\n Neo .89 mic per kg.bp\n Action:\n Liter ns given\n Response:\n BP 90 TO 100 SYSTOLIC\n Plan:\n Wean neo as tol\n .H/O atrial fibrillation (Afib)\n Assessment:\n Continues in afib\n Action:\n Started on po amiodarone,gtt dc 1130\n Response:\n Remains in afib hr 100 to 120\n Plan:\n Monitor response to amiodarone DRIP BEING OFF\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Abg 7.25/74/141/34\n Action:\n Alternating between aerosol mask at 60% and cpap mask\n Response:\n Maintaining sat ,tolerating cpap\n Plan:\n PT NEED TO BE INTUBATED,DIFFICULT AIRWAY\n Alteration in Nutrition\n Assessment:\n Pt npo due to need of cpap and possible intubation\n Action:\n Discussed issue c micu team\n Response:\n Delay decision for intubation and feeding tube till tomorrow\n Plan:\n As above\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357817,
"text": " Admitted s/p mechanical fall @ home. L spine xrays revealed\n chronic L1 compression fx, but no other acute fx or dislocation. \n Desat 85% on 2L NP->increased o2 to 4L with sat's mid 90's. Then nausea\n with vomitting & desat requiring non rebreather->?? asp.\n pneumonia--started vanco & zosyn. Transferred to MICU where she had\n hypercarbic/hypoxic resp. failure requiring intubation. SVT vs Afib\n with RVR->amio gtt->po lopressor. Extubated successfully\n PICC line placed & transferred back to F7. became sl\n lethargic with RR 25-38 & O2 sat 88% 3L NP. Increased O2 6L with sats\n 90-93%. HR from SR->Afib with RVR 130-150's. Metoprolol 5mg VP x2 with\n no response. BP 92/60. Transferred to CCU as MICU border for amio gtt &\n ?? mask ventilation vs intubation. ABG 7.35/73/54/42.\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358077,
"text": "Impaired Skin Integrity\n Assessment:\n Severe yeast infection\n Action:\n Meds applied as ordered,,vaginal supp added to regimen\n Response:\n Slight improvement\n Plan:\n Frequent skin care ,continue meds\n Hypotension (not Shock)\n Assessment:\n Neo .89 mic per kg.bp\n Action:\n Liter ns given\n Response:\n Bp reaining above 100 systolic\n Plan:\n Wean neo as tol\n .H/O atrial fibrillation (Afib)\n Assessment:\n Continues in afib\n Action:\n Started on po amiodarone,gtt dc 1130\n Response:\n Remains in afib hr 100 to 120\n Plan:\n Monitor response to amiodarone\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Abg 7.25/74/\n Action:\n Alternating between aerosol mask at 60% and cpap mask\n Response:\n Maintaining sat ,tolerating cpap\n Plan:\n Alteration in Nutrition\n Assessment:\n Pt npo due to need of cpap and possible intubation\n Action:\n Discussed issue c micu team\n Response:\n Delay decision for intubation and feeding tube till tomorrow\n Plan:\n As above\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357958,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing. Pt is also NPO except for ice\n chips/meds.\n Action:\n HOB elevated 45-90 degrees.\n Response:\n No\n Plan:\n Aspiration Precautions and instruct family and friends.\n Crush meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Nutrition consult\n , Weight documented on was 72.5 kg.\n Action:\n Response:\n Plan:\n Reassess diet, re consult nutrition\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with green/yellow vagina drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks. Areas are painful to clean.\n Charts also records days of diareaha\n Action:\n Using skin cleanser spray and applying aloe vesta antifungal\n ointment.\n Response:\n Plan:\n Hold all stool medications for now.\n Hypotension (not Shock)\n Assessment:\n SBP\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358130,
"text": "Impaired Skin Integrity\n Assessment:\n Severe yeast infection\n Action:\n Meds applied as ordered,,vaginal supp added to regimen\n Response:\n Slight improvement\n Plan:\n Frequent skin care ,continue meds\n Hypotension (not Shock)\n Assessment:\n Neo .89 mic per kg.bp\n Action:\n Liter ns given\n Response:\n BP 90 TO 100 SYSTOLIC\n Plan:\n Wean neo as tol\n .H/O atrial fibrillation (Afib)\n Assessment:\n Continues in afib\n Action:\n Started on po amiodarone,gtt dc 1130\n Response:\n Remains in afib hr 100 to 130\n Plan:\n Monitor response to amiodarone DRIP BEING OFF ,may need po dose\n increased\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Abg 7.25/74/141/34\n Action:\n Alternating between aerosol mask at 60% and cpap mask as tol\n Response:\n Maintaining sat ,tolerating cpap for 1 to 2 hr periods\n Plan:\n PT NEED TO BE INTUBATED,DIFFICULT AIRWAY\n Alteration in Nutrition\n Assessment:\n Pt npo due to need of cpap and possible intubation\n Action:\n Discussed issue c micu team\n Response:\n Delay decision for intubation and feeding tube till tomorrow\n Plan:\n As above\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 357151,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:41 PM\n ARTERIAL LINE - STOP 10:11 PM\n - auto diuresing\n -for IR PICC today\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:57 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 06:54 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: 36.2\nC (97.1\n HR: 81 (74 - 96) bpm\n BP: 106/48(57) {88/44(57) - 124/59(74)} mmHg\n RR: 19 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 600 mL\n 229 mL\n PO:\n 60 mL\n 60 mL\n TF:\n IVF:\n 540 mL\n 169 mL\n Blood products:\n Total out:\n 1,687 mL\n 230 mL\n Urine:\n 1,687 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,087 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 286 (286 - 332) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 94%\n ABG: 7.46/50/111/38/10\n Ve: 7.8 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: NAD, breathing spontaneously on NC O2\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, ND/NT, +BS\n Extremities: WWP, +1 LE edema\n Neurologic: AOX3\n Labs / Radiology\n 219 K/uL\n 9.3 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 93 mEq/L\n 137 mEq/L\n 26.7 %\n 5.6 K/uL\n [image002.jpg]\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n 06:26 AM\n 06:42 AM\n 11:50 AM\n 05:55 AM\n WBC\n 5.8\n 6.4\n 4.9\n 5.6\n Hct\n 26.7\n 28.1\n 26.3\n 26.7\n Plt\n 190\n 242\n 198\n 219\n Cr\n 1.4\n 1.1\n 1.0\n 0.9\n TCO2\n 39\n 42\n 43\n 42\n 40\n 37\n Glucose\n 136\n 109\n 100\n 126\n Other labs: PT / PTT / INR:12.7/24.7/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Will continue to wean as tolerated, keeping in mind her\n small reserve. Has been doing very well on minimal PS, will attempt to\n decrease to 5/0 today. If she does well, might need to consider trach\n placement. Having thick secretions which may be barrier to extubation.\n -continue Vancomycin/Zosyn (last day )\n -extubated saturating mid 90s on 4L NC\n -IV Lasix prn\n -nebs prn\n -Will wean O2 down to 2-3L to keep pt in low90s to ensure baseline CO2\n is maintained\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Has resolved since.\n -d/c\nd amiodarone \n -monitor on telemetry\n - toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n - issue resolved\n .\n # s/p fall: no evidence of fracture. C/o back pain now that she is off\n sedation.\n - Lidocaine patch for relief\n - PT following\n .\n # DM: Good FSBG control. On sips, will have speech/swallow eval prior\n to advancing diet for risk of aspiration.\n -will advance diet once recs are in\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - treat PNA\n - alb/atrovent nebs\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval/placement today with IR\n .\n # FEN: sips will advance with speech/swallow recs, replete electrolytes\n prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: C/O to floor\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\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: 73 y/o woman with complicated past history\n (steroid-resistant ILD NOS on 2L home O2, orthotopic liver transplant,\n PTLD s/p CHOP\n> remission) fell and was admitted, treated for pain,\n aspirated with hypoxic / hypercarbic respiratory failure and sent to\n MICU. Difficult intubation. Extubated yesterday ~2p without incident,\n ongoing autodiuresis.\n Exam notable for Tm 98.9 BP 106/48 HR 79 RR 19 with sat 94 on 4L NC\n (baseline 2-2.5L/min). Obese woman, NAD. Coarse BS B, RRR s1s2.\n Non-tender. +BS. Tr edema. Labs notable for WBC 5K, HCT 27, K+ 3.8,\n Cr 0.9, tacro pending. CXR with small volumes, interstitial changes,\n clearer.\n Agree with plan to continue abx x 10-14 days via PICC for aspiration\n pneumonia / pneumonitis. Will obtain PT eval (especially after recent\n fall), mobilize OOB, continue CPT and wean O2 as able for sats >90%\n given chronic hypercarbia. Will use lidoderm to back for pain. Continue\n tacro for immunosupression and f/u level. Will have pulmonary follow\n patient on the floor; no clear role for steroids at this point.\n Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:44 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358057,
"text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n NON-INVASIVE VENTILATION - STOP 08:08 AM\n EKG - At 09:00 AM\n NON-INVASIVE VENTILATION - START 02:00 PM\n NON-INVASIVE VENTILATION - STOP 04:00 PM\n NON-INVASIVE VENTILATION - START 11:30 PM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n EKG - At 06:00 AM\n Yesterday, after discussion with the family and patient, decision was\n made to intubate if situation worsens. The patient requires pressor\n support with phenylephrine. Overnight, she went back into A fib with\n RVR up to the 140\ns. She was continued on the amiodarone drip. This\n AM, an ABG was done which was stable showing hypercarbia. She is\n continued on intermittent BiPap vs. mask ventilation. She continues to\n be NPO given tenuous respiratory status.\n Allergies:\n Codeine Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin - 12:18 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Amiodarone - 0.5 mg/min to stop today\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:18 AM\n Other medications:\n Nystatin cream, Insulin SS, pantoprazole 40 QD, ipratropium nebs,\n albuterol nebs, metoprolol 50mg TID (held for BP), bactrim PPx, calcium\n and Vit D\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 111 (76 - 136) bpm\n BP: 100/50(59) {63/15(43) - 126/97(102)} mmHg\n RR: 33 (21 - 37) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 6,119 mL\n 458 mL\n PO:\n 720 mL\n TF:\n IVF:\n 1,991 mL\n 458 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,694 mL\n 323 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 378 (300 - 391) mL\n PS : 10 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: 7.30/74/145/36/7\n Ve: 9.6 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg. tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 380 K/uL\n 8.8 g/dL\n 379\n 1.8 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 84 mEq/L\n 125 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n TCO2\n 39\n 38\n Glucose\n 132\n 110\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.8 mmol/L, LDH:183 IU/L, Ca++:9.4 mg/dL,\n Mg++:1.6 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Most likely worsening natural course of her ILD with worsening\n pulmonary edema secondary to a fib with RVR. Patient tenuous at\n baseline. Treating for VAP in addition to underlying lung disease, on\n vanco/zosyn day #\n - NIPPV, alternate CPAP with face mask\n - serial ABGs. Seems to be stable, If worsening respiratory acidosis,\n will intubate\n - treat SVT as below\n - continue nebulizer treatments\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. The patient was loaded\n with amiodarone drip, started on amiodarone 200mg QD today. Had\n similar episode on last MICU admission which did not tolerate beta\n blockers and required amio gtt. The patient does not tolerate\n betablockers given hypotensive, thus will attempt to rate control with\n amiodarone only.\n - will continue to monitor on telemetry\n - can attempt bolus IV lopressor if BP will tolerate\n - cont po beta blocker as BP will tolerate\n .\n # hypotension: likely due to RVR, and diastolic heart failure. In the\n setting of low grade fever, must also consider sepsis especially given\n immunosupression . Currently on broad spectrum abx of vanc/zosyn\n - will culture if spikes, follow blood cultures\n - treat SVT as above\n - Will give 1L of NS today, will repeat as tolerated\n - Will continue phenylephrine drip as needed, attempt to wean\n .\n # fever: new low grade temp this am. See hypotension above. On broad\n spectrum Abs. Follow culture\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: Even though patient is NPO BG have been very elevated. Will\n continue to monitor QID and adjust sliding scale accordingly. Will use\n half dose of outpatient insulin while NPO\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - continue Tacrolimus at regular dose for now\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now given tenuous respiratory status\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: Intubation okay. CPR not indicated.\n .\n # Contact: , daughter \n .\n # Dispo: ICU\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate) OK to intubate\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358058,
"text": "Impaired Skin Integrity\n Assessment:\n Severe yeast infection\n Action:\n Meds applied as ordered,,vaginal supp added\n Response:\n Slight improvement\n Plan:\n Frequent skin care ,continue meds\n Hypotension (not Shock)\n Assessment:\n Neo .89 mic per kg.bp\n Action:\n Liter ns given\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Continues in afib\n Action:\n Started on po amiodarone,gtt dc 1130\n Response:\n Remains in afib hr 100 to 120\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Abg 7.25/74/\n Action:\n Alternating between aerosol mask at 60% and cpap mask\n Response:\n Maintaining sat ,tolerating cpap\n Plan:\n Alteration in Nutrition\n Assessment:\n Pt npo due to need of cpap and possible intubation\n Action:\n Discussed issue c micu team\n Response:\n Delay decision for intubation and feeding tube till tomorrow\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 358059,
"text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n NON-INVASIVE VENTILATION - STOP 08:08 AM\n EKG - At 09:00 AM\n NON-INVASIVE VENTILATION - START 02:00 PM\n NON-INVASIVE VENTILATION - STOP 04:00 PM\n NON-INVASIVE VENTILATION - START 11:30 PM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n EKG - At 06:00 AM\n Yesterday, after discussion with the family and patient, decision was\n made to intubate if situation worsens. The patient requires pressor\n support with phenylephrine. Overnight, she went back into A fib with\n RVR up to the 140\ns. She was continued on the amiodarone drip. This\n AM, an ABG was done which was stable showing hypercarbia. She is\n continued on intermittent BiPap vs. mask ventilation. She continues to\n be NPO given tenuous respiratory status.\n Allergies:\n Codeine Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin - 12:18 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Amiodarone - 0.5 mg/min to stop today\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:18 AM\n Other medications:\n Nystatin cream, Insulin SS, pantoprazole 40 QD, ipratropium nebs,\n albuterol nebs, metoprolol 50mg TID (held for BP), bactrim PPx, calcium\n and Vit D\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 111 (76 - 136) bpm\n BP: 100/50(59) {63/15(43) - 126/97(102)} mmHg\n RR: 33 (21 - 37) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 6,119 mL\n 458 mL\n PO:\n 720 mL\n TF:\n IVF:\n 1,991 mL\n 458 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,694 mL\n 323 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 378 (300 - 391) mL\n PS : 10 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: 7.30/74/145/36/7\n Ve: 9.6 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg. tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 380 K/uL\n 8.8 g/dL\n 379\n 1.8 mg/dL\n 33 mEq/L\n 3.9 mEq/L\n 23 mg/dL\n 84 mEq/L\n 125 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n TCO2\n 39\n 38\n Glucose\n 132\n 110\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.8 mmol/L, LDH:183 IU/L, Ca++:9.4 mg/dL,\n Mg++:1.6 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Most likely worsening natural course of her ILD with worsening\n pulmonary edema secondary to a fib with RVR. Patient tenuous at\n baseline. Treating for VAP in addition to underlying lung disease, on\n vanco/zosyn day #\n - NIPPV, alternate CPAP with face mask\n - serial ABGs. Seems to be stable, If worsening respiratory acidosis,\n will intubate\n - treat SVT as below\n - continue nebulizer treatments\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. The patient was loaded\n with amiodarone drip, started on amiodarone 200mg QD today. Had\n similar episode on last MICU admission which did not tolerate beta\n blockers and required amio gtt. The patient does not tolerate\n betablockers given hypotensive, thus will attempt to rate control with\n amiodarone only.\n - will continue to monitor on telemetry\n - can attempt bolus IV lopressor if BP will tolerate\n - cont po beta blocker as BP will tolerate\n .\n # hypotension: likely due to RVR, and diastolic heart failure. In the\n setting of low grade fever, must also consider sepsis especially given\n immunosupression . Currently on broad spectrum abx of vanc/zosyn\n - will culture if spikes, follow blood cultures\n - treat SVT as above\n - Will give 1L of NS today, will repeat as tolerated\n - Will continue phenylephrine drip as needed, attempt to wean\n .\n # fever: new low grade temp this am. See hypotension above. On broad\n spectrum Abs. Follow culture\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: Even though patient is NPO BG have been very elevated. Will\n continue to monitor QID and adjust sliding scale accordingly. Will use\n half dose of outpatient insulin while NPO\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - continue Tacrolimus at regular dose for now\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now given tenuous respiratory status\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: Intubation okay. CPR not indicated.\n .\n # Contact: , daughter \n .\n # Dispo: ICU\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: Heparin SC TID\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate) OK to intubate\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: 73 yo woman w/ h/o fibrotic ILD of unknown\n etiology recently off steroids, s/p liver transplant s/p PTLD on\n immunosuppression, h/o AF, DM, recent admit w/mechanical fall f/b\n aspiration in ICU for hypercarbic resp failure w/short term intubation\n c/b AF, hypotension, transiently on amio. Extubated , to medical\n floor on awaiting rehab. Triggered for increased work of\n breathing, but felt at baseline. Midnight tachy to 150\ns w/AF vs MAT,\n hypotension to 70\ns, new O2 requirement w/ ABG on 6L 7.35/73/54.\n Treated with biPAP for respiratory distress. Reassessed code status\n and wished to be in ICU and have full care. Started on amio drip and\n bolus, Neo thru PICC for hypotension. Repeat 7.35/67/386 on BiPAP. No\n obvious significant infection despite low grade fever, added cipro to\n cover. Converted to NSR after coming off BiPAP 12/27. Returned to AF\n w/RVR at 110\ns last night\n appears dyspneic, but does not report\n dyspnea. Restarted amio drip and oral amio. Rediscussion of code\n status and pt wishes to be reintubated if need be.\n Awake and alert this AM\n mild respiratory distress. Exam notable for\n Tm 100 BP 90/70 HR 76 (NSR) to 136 (AF) RR 20 with sat 97 on 2L.\n 7.25/74/141 Appears cushingoid, crackles at bases, obese abdomen, lower\n extremity 1+ edema . Labs notable for WBC 16.9K, HCT 25, Na 125 (from\n 135), Gluc 379, K+ 4, Cr 1.4. LFTs wnl. CXR with low lung volumes no\n obvious infiltrates.\n Agree with plan that respiratory and hemodynamic compromise likely due\n to underlying ILD with superimposed atrial fibrillation. AF has\n recurred and we have restarted amiodarone. Continue pressor to\n maintain perfusion pressure. Respiratory status remains tenuous and\n will likely need intermittent periods of BiPAP. Will continue\n Vanco/Zosyn and hold cipro awaiting cultures. Continue tacrolimus for\n s/p liver transplant. No new therapy for lung disease. Continue\n discussions with family, primary care physician and consultants for\n overall plan of care. Unable to advance diet. Remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 45 min\n ------ Protected Section Addendum Entered By: , MD\n on: 12:18 ------\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356369,
"text": "Pt was adm to s/p fall at home. on the floor, pt\n developed resp distress with desat to 88% on 2 liters NC. Pt noted to\n have cx's and CXR showed pulm edema. Pt given lasix po and IV with some\n effect. Pt noted to be slight lethargic. Pt sent to MICU for further\n care.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt found on arrival to MICu to have a CO2 of 100, but was awake and\n alert (OX2-3). LS with cx\ns up 2/3 bil. Lasix had been given on the\n floor prior to arrival. At 5pm, pt noted to be completely unresponsive\n and CO2 noted to be 127.\n Action:\n Family meeting done and decision to intubate was done. Pt intubated at\n 17:30. OGT also placed. CXR done and ETT and OGGT in correct place. Pt\n has been deep sx\nd for sml amounts of clear-white secretions. Pt noted\n to have copious amounts of oral clear secretions, and in need of oral\n sx q15-30min.\n Response:\n No change to LS at this time.\n Plan:\n ? need for ABG and wean vent settings as tol by pt. ? need for more\n lasix tonight.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 356370,
"text": "Chief Complaint: Reason for transfer: Hypercarbic respiratory failure\n PCP: , . \n Pulmonologist: , \n Heme/Onc: \n Cardiologist: \n HPI:\n Ms. is a 73 yo female with PMH significant for ILD on .5L\n home O2, diastolic CHF, cor pulmonale, s/p liver transplant on\n immunosuppression, post-transplant myeloproliferative disorder s/p CHOP\n and rituximab who was initially admitted to hospital after a mechanical\n fall for pain control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis.\n Patient was initially admitted to the medicine service on for a\n mechanical fall. She stated that prior to her fall she was in her USOH\n without any change in her baseline respiratory status or other new\n symptoms. She stepped on her scale and then lost her balance and\n landed on her low back. She was then brought to ED. There was no\n head trauma or LOC by report. Here, spine films revealed no acute\n fracture. She was being treated with PT and pain control. She was not\n receiving any opiates due to underlying lung disease. She did received\n tylenol, ibuprofen, and lidoderm patch.\n .\n Yesterday evening, the patient triggered after an episode of nausea and\n vomiting as well as a drop in her O2 saturation. Changed to face mask\n with improvement in O2. She remained hemodynamically stable. No CXR or\n ABG was performed. Changed to 40% ventimask and satting in mid-90s. At\n 10:30 this am, looks ashen, cyanotic, and lethargic on 4 L of 50%\n venti. O2 in high 70s at that time. Sleepy but arousable. Increased O2\n to 15L on 50% ventimask. Given nebs. On exam, tight air movement and\n cracklie but not significantly different from baseline. Initial gas\n 7.29/97/113 on 15L 50% ventimask. Last ABG in system 7.43/47/73 in\n 3/. Mental status improved with increase in oxygenation. She was\n given solumedrol 100 mg IV Q8H. Reevaluated in 1 hr, still lethargic\n but arousable. Repeat ABG 7.28/108/79 on 15L 50% ventimask. CXR\n performed on floor, showed some diffuse fluffiness. She received 40 mg\n IV lasix. She continues to have intermittent nausea and vomiting with\n 2-3 episodes of emesis since yesterday evening.\n .\n On arrival to the ICU, she denies any chest pain, SOB, abdominal pain,\n nausea, fevers, chills. She does not think that she has been in the\n hospital for several days. Appears confused. Lethargic but easily\n arousable.\n Patient admitted from: \n History obtained from Medical records, MD\n Patient unable to provide history: Encephalopathy\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Home medications:\n IPRATROPIUM BROMIDE 0.2 mg/mL inh four times a day\n LEVOTHYROXINE 75 mcg by mouth once a day\n METOPROLOL TARTRATE 75 mg by mouth TID\n OMEPRAZOLE 20 mg by mouth daily\n TACROLIMUS 3mg by mouth twice a day\n DOCUSATE SODIUM 100 mg by mouth once a day\n INSULIN NPH HUMAN RECOMB [HUMULIN N] 44U units before breakfast, 12U at\n 4:30pm.\n INSULIN REGULAR HUMAN [HUMULIN R] - sliding scale four times a day\n Lasix 40 mg daily\n Bactrim TIW\n Tums prn\n .\n Medications on transfer:\n Levothyroxine Sodium 75mcg PO\n Acetaminophen 325-650 mg PO Q6H:PRN\n Lidocaine 5% Patch 1 PTCH TD DAILY\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H\n Metoprolol Tartrate 75 mg PO TID\n Calcium Carbonate 1250 mg PO TID\n MethylPREDNISolone Sodium Succ 100 mg IV Q8H\n Docusate Sodium 100 mg PO DAILY\n Omeprazole 20 mg PO DAILY\n Furosemide 40 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR\n Insulin sliding scale\n Tacrolimus 3 mg PO Q12H\n Dose to be admin. at 6am and 6pm Order date: @ 1603\n Ipratropium Bromide MDI 2 PUFF IH QID\n TraMADOL (Ultram) 50 mg PO Q4H:PRN\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Vitamin D 50,000 UNIT PO QTUES\n Past medical history:\n Family history:\n Social History:\n # Interstitial pulmonary fibrosis\n - home oxygen dependent 2-2.5L NC (etiology unknown, no biopsy)\n - recently titrated off prednisone as unresponsive\n # cor pulmonale\n # S/p Liver transplant for cryptogenic cirrhosis\n # Post-transplant lymphoproliferative disorder s/p CHOP and rituximab\n # Type 2 DM (without peripheral neuropathy)\n # HTN\n # Hypothyroidism\n # Diastolic dysfunction with LVEF of 65%\n # Cholecystectomy.\n # Appendectomy.\n # h/o of atrial fibrillation\n There is no family history of premature coronary artery disease or\n sudden death. Afib in sister\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, previously lived at home but recently discharged to\n rehab. Denies tobacco use.\n Review of systems:\n Constitutional: No(t) Fever\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Psychiatric / Sleep: Delirious, Daytime somnolence\n Pain: No pain / appears comfortable\n Flowsheet Data as of 04:18 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 92 (92 - 97) bpm\n BP: 127/59(77) {127/59(77) - 127/73(86)} mmHg\n RR: 20 (20 - 24) insp/min\n SpO2: 97%\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -300 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 97%\n ABG: ///48/\n Physical Examination\n General Appearance: Overweight / Obese, moon facies, tachypneic,\n accessory muscle use\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: buffalo hump\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, worst at bases, Diminished: throughout)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese,\n midline reducible hernia\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to:\n Verbal stimuli, Oriented (to): person and place. , Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 243 K/uL\n 12.2 g/dL\n 141 mg/dL\n 1.0 mg/dL\n 28 mg/dL\n 48 mEq/L\n 86 mEq/L\n 5.3 mEq/L\n 137 mEq/L\n 35.1 %\n 8.2 K/uL\n [image002.jpg]\n \n 2:33 A12/17/ 02:43 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.2\n Hct\n 35.1\n Plt\n 243\n Cr\n 1.0\n Glucose\n 141\n Other labs: PT / PTT / INR:12.2/23.8/1.0, CK / CKMB / Troponin-T:25//,\n ALT / AST:, Alk Phos / T Bili:85/0.3, Amylase / Lipase:55/27,\n Albumin:3.7 g/dL, LDH:264 IU/L, Ca++:10.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:5.6 mg/dL\n Imaging: CXR :\n Chronic interstitial lung disease with superimposed vague opacity\n may represent aspiration or mild pulmonary edema.\n .\n L-spine XR :\n Slight interval increase in superior endplate wedging of the L2\n vertebral body, and chronic L1 compression fracture. No other acute\n fracture or dislocation.\n .\n Spirometry :\n FEV1: 0.87(42%), FVC:0.97(33%), FEV1/FVC: 90(128%)\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: given current ABG, suspect\n she has had increased CO2 retention over last month. Also given that\n she is not currently obtunded argues in favor of this. Acute worsening\n in oxygenation likely due to aspiration or flash pulmonary edema in the\n setting of emesis. Other possible etiologies including pna or PE seem\n less likely. She has been on DVT ppx. Not good NIPPV candidate\n currently given emesis. Given severity of underlying lung disease,\n intubation unlikely to be reversible.\n - discuss goals of care with family\n - serial ABGs\n - cont supplemental O2\n - add on BNP\n - lasix 40 IV for pulmonary edema\n - hold off on abx without clear infection\n - nebs\n - hold off on steroids as has been steroid unresponsive in past and no\n evidence of obstructive exacerbation at this time\n .\n # emesis: unclear cause. Patient cannot provide adequate history at\n this time. Abdominal exam benign at this time. Does have midline hernia\n but reducible.\n - abdominal film to check fo obstruction\n - add on LFTs, PEs\n - check tacro level to assess for toxicity\n - check cardiac enzymes and ECG\n - NPO for now\n .\n # s/p fall: no evidence of fracture. Pain reasonably controlled at\n rest. Likely mechanical so no need for further syncope work up at this\n time.\n - cont lidocaine patch, ibuprofen and tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: reasonable BG control on floor\n - cont NPH per outpt doses. Half dose while NPO\n - cont insulin sliding scale\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - check tacro level\n - continue Tacrolimus at regular dose for now\n .\n # HTN: normotensive currently.\n - Continue outpt metoprolol\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV\n .\n # FEN: NPO for now\n - vit D\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: FULL CODE. Will need to readdress with HCP\n .\n # Contact: \n .\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 02:09 PM\n 18 Gauge - 02:30 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Critical Care\n Present for key portions of history and exam. Agree with Dr. \n assessment and plan as above. Ms. has progressive interstitial\n lung dis w/o clear diagnosis. She has undergone a trial of steroids as\n an outpatient with progression on therapy. Adm now for pain control\n after a fall\n breathing\nbaseline\n but vomited last night and then\n progressive incr in FIO2 requirement and incr PCO2. It is unlikely\n that she has significant reversible dis. Her CXR suggests some incr\n markings c/w aspiration/ infection/ edema but underlying fxn is so poor\n I doubt she will survive mechanical ventilation. Nevertheless, her\n husband believes she would wish to have a period of support. I have\n told him her condition is extremely critical and she would not survive\n cardiac resus but we have intubated now and will treat possibly\n reversible processes such as bacterial infection.\n Time spent 75 min\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 17:41 ------\n Critical Care\n Extensive family meeting to discuss goals of care with daughter,\n husband and others. They are aware of her grim prognosis and limited\n potential for recovery. They are discussing what her wishes would be.\n Time spent\n 25 min\n ------ Protected Section Addendum Entered By: , MD\n on: 19:55 ------\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357816,
"text": ".H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Rehab Services",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 357142,
"text": "Subjective:\n \"I'm just tired\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: Pt extubated .\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n T\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 83\n 123/65\n 94% 3L\n Activity\n Sit\n 93\n 108/76\n 87-93% 3L\n Recovery\n Supine\n 79\n 124/63\n 95% 3l\n Total distance walked:\n Minutes:\n Gait:\n Balance: Pt has good static and dynamic balance sitting at EOB. Pt\n required min A to stand and maintain for approx 30 secs, and was able\n to perform standing marching.\n Education / Communication: Pt status discussed with RN. Pt educated on\n role of PT and goals of treatments\n Other: Pulm. Coarse BS t/o. Strong , pt productive at times.\n Encouraged her to use tissues or yankaur suction to clear secretions\n Assessment: 73 yo f s/p fall with hospital course c/b respiratory\n distress requiring ICU admission and intubation, now extubated. Pt is\n functioning below baseline, limited by reconditioning related to\n hospitalization and bedrest. Pt may require rehab upon d/c in order to\n optimize safety and function\n Anticipated Discharge: Rehab\n Plan: f/u progress activity, trial RW for ambulation, pulm hygiene\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356410,
"text": "Pt was adm to s/p fall at home. on the floor, pt\n developed resp distress with desat to 88% on 2 liters NC. Pt noted to\n have cx's and CXR showed pulm edema. Pt given lasix po and IV with some\n effect. Pt noted to be slight lethargic. Pt sent to MICU for further\n care.\n Events: pt in rapid A-fib 120-140\ns around 2330, fluid bolus given and\n 5mg of lopressor IV given without any affect on pt HR, Amiodarone\n started, loading dose given and then gtt continued after, also no\n change in pt HR ranged from 110-130. SBP dropping into 70\ns-80. Map\n 50-60\ns. At this time ? if we needed central line and wanted to start\n pressors, pt husband was called and he decided not to advance care. Pt\n cont to get fluid boluses to try to keep BP up.\n DNR, CPR not indicated.\n Hypotension (not Shock)\n Assessment:\n A-line placed, pt HR in rapid A-fib 120-140\ns BP was stable but then\n began to drop. Into SBP 70-80.\n Action:\n Fluid boluses given and Amiodarone load and drip started.\n Response:\n Amiodarone did not make much difference with HR, family called to ? if\n they wanted a line placed and pressors started and they declined, we\n are no longer escalating care.\n Plan:\n Cont amiodarone and fluid boluses, not escalating care otherwise.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.3\n Action:\n Pt given Tylenol and urine and blood cultures done\n Response:\n Plan:\n Cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357953,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, taking small pills with\n water without coughing. Pt is also NPO except for ice chips/meds.\n Action:\n HOB elevated 45-90 degrees.\n Response:\n No c\n Plan:\n Aspiration Precautions and instruct family and friends.\n Crush meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admit on .\n Action:\n Response:\n Plan:\n Reassess diet, re consult nutrition\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with green/yellow vagina drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks. Areas are painful to clean.\n Charts also records days of diareaha\n Action:\n Using skin cleanser spray and applying aloe vesta antifungal\n ointment.\n Response:\n Plan:\n Hold all stool medications for now.\n Hypotension (not Shock)\n Assessment:\n SBP\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC, no PAF.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330\n Response:\n Remains in NSR with stable QTc .45-.46\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 358191,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 57.8 None\n Ideal tidal volume: 231.2 / 346.8 / 462.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: not intubated\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent non-invasive ventilation\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment: Mask discomfort; Comments:\n moderate leak\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356411,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent 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: Not triggering\n Dysynchrony assessment:\n Comments:\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 Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357949,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Coughing intermittently with ice chips, taking small pills with water\n without coughing.\n Action:\n HOB elevated 45-90 degrees.\n Response:\n Plan:\n Aspiration Precautions and instruct family and friends.\n Continue NPO except for chips until repeat bedside swallow study. Crush\n meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO for past\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with green/yellow vagina drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks. Areas are painful to clean.\n Charts also records days of diareaha\n Action:\n Using skin cleanser spray and applying aloe vesta antifungal\n ointment.\n Response:\n Plan:\n Hold all stool medications for now.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 357112,
"text": "73 yo female admitted on for pain mgmt after fall.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events: transferred to the MICU for hypercarbic/hypoxic\n respiratory failure in the setting of emesis. Intubated.\n 12/18 HR increased to 130\ns to 140\ns w/ subsequent BP\n drop. Amiodarone gtt started w/ no change in HR. Self converted into\n NSR. Did have episodes later in ICU coarse of HR increasing to 120\ns to\n 140\ns- IV Lopressor given w/ good effect.\n : placed on SBT( 5/o) on vent but unable to tolerate- placed\n back on . PICC attempted at bedside but unsuccessful to be done in\n IR on Monday. Antibiotics changed to vanco/zosyn- flagyl d/c\n : Pt extubated at 2pm and tolerated well, on 3L\n N/C(O2 dependent at home) Sat\ns have remained > 95% on 3L. Pt desat\n d overnight, ? if sleep apnea. No intervention needed. Aline out.\n ? c/o today and restart diet. NPH held secondary to NPO and\n fingersticks < 150. Pt had had frequent loose stools, please hold\n colace in am. Voice hoarse and c/o sore throat, ice chips tolerated\n and eased sore throat.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 73 female w/ chronic lung disease. Extubated , denies resp\n difficulty. Maintains sat\ns of >93% on 3L via N/C. LS- clear w/\n diminished bases. Weak, occasionally productive cough.\n Action:\n Continued on o2 via NC. Encouraged CDB. Encouraged to expectorate\n sputum. Position changed q2hrs.\n Response:\n O2 sats remained >93% on 3L NC. Occasionally decreased to 90% when\n sleeping.\n Plan:\n Monitor resp status. Wean o2 as tolerated. Encourage CDB.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 357113,
"text": "73 yo female admitted on for pain mgmt after fall.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events: transferred to the MICU for hypercarbic/hypoxic\n respiratory failure in the setting of emesis. Intubated.\n 12/18 HR increased to 130\ns to 140\ns w/ subsequent BP\n drop. Amiodarone gtt started w/ no change in HR. Self converted into\n NSR. Did have episodes later in ICU coarse of HR increasing to 120\ns to\n 140\ns- IV Lopressor given w/ good effect.\n : placed on SBT( 5/o) on vent but unable to tolerate- placed\n back on . PICC attempted at bedside but unsuccessful to be done in\n IR on Monday. Antibiotics changed to vanco/zosyn- flagyl d/c\n : Pt extubated at 2pm and tolerated well, on 3L\n N/C(O2 dependent at home) Sat\ns have remained > 95% on 3L. Pt desat\n d overnight, ? if sleep apnea. No intervention needed. Aline out.\n ? c/o today and restart diet. NPH held secondary to NPO and\n fingersticks < 150. Pt had had frequent loose stools, please hold\n colace in am. Voice hoarse and c/o sore throat, ice chips tolerated\n and eased sore throat.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 73 female w/ chronic lung disease. Extubated , denies resp\n difficulty. Maintains sat\ns of >93% on 3L via N/C. LS- clear w/\n diminished bases. Weak, occasionally productive cough.\n Action:\n Continued on o2 via NC. Encouraged CDB. Encouraged to expectorate\n sputum. Position changed q2hrs.\n Response:\n O2 sats remained >93% on 3L NC. Occasionally decreased to 90% when\n sleeping.\n Plan:\n Monitor resp status. Wean o2 as tolerated. Encourage CDB.\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 357133,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:41 PM\n ARTERIAL LINE - STOP 10:11 PM\n - auto diuresing\n -for IR PICC today\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:57 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 06:54 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: 36.2\nC (97.1\n HR: 81 (74 - 96) bpm\n BP: 106/48(57) {88/44(57) - 124/59(74)} mmHg\n RR: 19 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 600 mL\n 229 mL\n PO:\n 60 mL\n 60 mL\n TF:\n IVF:\n 540 mL\n 169 mL\n Blood products:\n Total out:\n 1,687 mL\n 230 mL\n Urine:\n 1,687 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,087 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 286 (286 - 332) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 94%\n ABG: 7.46/50/111/38/10\n Ve: 7.8 L/min\n PaO2 / FiO2: 277\n Physical Examination\n General Appearance: NAD, breathing spontaneously on NC O2\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, ND/NT, +BS\n Extremities: WWP, +1 LE edema\n Neurologic: AOX3\n Labs / Radiology\n 219 K/uL\n 9.3 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 93 mEq/L\n 137 mEq/L\n 26.7 %\n 5.6 K/uL\n [image002.jpg]\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n 06:26 AM\n 06:42 AM\n 11:50 AM\n 05:55 AM\n WBC\n 5.8\n 6.4\n 4.9\n 5.6\n Hct\n 26.7\n 28.1\n 26.3\n 26.7\n Plt\n 190\n 242\n 198\n 219\n Cr\n 1.4\n 1.1\n 1.0\n 0.9\n TCO2\n 39\n 42\n 43\n 42\n 40\n 37\n Glucose\n 136\n 109\n 100\n 126\n Other labs: PT / PTT / INR:12.7/24.7/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Will continue to wean as tolerated, keeping in mind her\n small reserve. Has been doing very well on minimal PS, will attempt to\n decrease to 5/0 today. If she does well, might need to consider trach\n placement. Having thick secretions which may be barrier to extubation.\n -continue Vancomycin/Zosyn (last day )\n -extubated saturating mid 90s on 4L NC\n -IV Lasix prn\n -nebs prn\n -Will wean O2 down to 2-3L to keep pt in low90s to ensure baseline CO2\n is maintained\n .\n # SVT: Pt had sinus tachycardia to SVT on , ? of atrial\n fibrillation w/PACs vs MAT. Has resolved since.\n -d/c\nd amiodarone \n -monitor on telemetry\n - toprol to 50mg po tid\n -if reverts to SVT reload with amiodarone\n - issue resolved\n .\n # s/p fall: no evidence of fracture. C/o back pain now that she is off\n sedation.\n - Lidocaine patch for relief\n - PT following\n .\n # DM: Good FSBG control. On sips, will have speech/swallow eval prior\n to advancing diet for risk of aspiration.\n -will advance diet once recs are in\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - treat PNA\n - alb/atrovent nebs\n .\n # Emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved, will start tube feeds today based on nutrition\n recs\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - On toprol 50mg TID\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV - PICC eval/placement today with IR\n .\n # FEN: sips will advance with speech/swallow recs, replete electrolytes\n prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: C/O to floor\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356522,
"text": "Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 99.7\n Action:\n Started on standing Tylenol 1gm q6h.\n Response:\n Temp trending downward.\n Plan:\n Continue to monitor temp curve, Tylenol ATC.\n Hypotension (not Shock)\n Assessment:\n SBP 80-130\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356523,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:35 PM\n ARTERIAL LINE - START 08:00 PM\n EKG - At 11:30 PM\n ARTERIAL LINE - STOP 11:32 PM\n ARTERIAL LINE - START 12:10 AM\n BLOOD CULTURED - At 01:30 AM\n URINE CULTURE - At 01:30 AM\n EKG - At 02:04 AM\n FEVER - 102.3\nF - 12:00 AM\n intubated as ABG came back with PCO2 in 100s\n -A-line placed\n -went into SVT to 130s, atrial fib vs MAT. did not break with PO\n toprol, 5mg lopressor IV, IVF. Started amiodarone w/ load.\n -spiked to 102.3, sent blood cx, urine cx, cxr. started vanco/zosyn for\n ? asp PNA.\n -repeat abg w/PCO2 in 50s, decreased MV.\n -pts family , do not want to escalate care.\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Infusions:\n Amiodarone - 1 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:03 PM\n Metoprolol - 11:40 PM\n Midazolam (Versed) - 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 06:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.3\n Tcurrent: 37.8\nC (100.1\n HR: 117 (76 - 134) bpm\n BP: 81/53(62) {72/46(55) - 134/73(94)} mmHg\n RR: 16 (16 - 30) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 631 mL\n 2,929 mL\n PO:\n TF:\n IVF:\n 631 mL\n 2,929 mL\n Blood products:\n Total out:\n 925 mL\n 115 mL\n Urine:\n 925 mL\n 115 mL\n NG:\n Stool:\n Drains:\n Balance:\n -294 mL\n 2,814 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 450) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 29 cmH2O\n Plateau: 26 cmH2O\n Compliance: 19.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.46/55/151/42/13\n Ve: 6.5 L/min\n PaO2 / FiO2: 302\n Physical Examination\n General Appearance: NAD, more alert than yesterday, intubated\n HEENT: NCAT MMM anicteric\n Cardiovascular: tachycardic, irregular rhythm no m/r/g appreciated\n given distant breath sounds\n Respiratory / Chest: Crackles, diffusely diminished throughout\n Abdominal: Soft, Bowel sounds present, Distended, Obese, nontender to\n palp\n Extremities: Right: 1+, Left: 1+ dp pulses, warm, 1+ edema\n Neurologic: Responds to voice and commands, on minimal sedation,\n intubated.\n Labs / Radiology\n 203 K/uL\n 9.2 g/dL\n 164 mg/dL\n 1.0 mg/dL\n 42 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 89 mEq/L\n 136 mEq/L\n 25.5 %\n 7.3 K/uL\n [image002.jpg]\n 02:43 PM\n 04:27 PM\n 07:14 PM\n 08:17 PM\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n WBC\n 8.2\n 7.5\n 7.3\n Hct\n 35.1\n 28.0\n 25.5\n Plt\n 243\n 203\n 203\n Cr\n 1.0\n 1.0\n TropT\n <0.01\n <0.01\n 0.01\n TCO2\n 55\n 46\n 46\n 40\n Glucose\n 141\n 164\n Other labs: PT / PTT / INR:13.5/28.3/1.2, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Lactic Acid:1.3 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:9.5 mg/dL, Mg++:1.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital after a mechanical fall for pain\n control who is now being transferred to the MICU for\n hypercarbic/hypoxic respiratory failure in the setting of emesis\n .\n # Hypercarbic/hypoxic respiratory failure: In the setting of witnessed\n emesis prior to decompensation, it is reasonable to suspect aspiration\n pneumonia. Also, given her elevated PCO2 on ABGs, she has had increased\n CO2 retention for some time, and may have worsening underlying\n pulmonary disease. Post-intubation she did well on AC, and during\n rounds was able to tolerate PS. Will continue to wean as tolerated,\n keeping in mind her small reserve. Also in setting of high fever and\n SVT last night, it may not take much for her to decompensate. While the\n family is ok with intubation, they do not wish to escalate level of\n care so pressors and compressions would not be appropriate should she\n decompensate.\n - continue vanco, zosyn for aspiration pneumonia vs HAP\n - wean to PS as tolerated today, rest on AC\n -monitor fluid status to avoid gross pulmonary edema (lasix 40 IV is\n suspect flash)\n -nebs prn\n - consider adding on steroids if underlying disease appears to have\n worsened\n .\n # emesis: unclear cause. History of one dose of ultram written for on\n the floor however it is unclear if this was the cause of her emesis.\n Has not recurred overnight, not tender to palp on exam, LFTs normal.\n Tac level pending. CE negative.\n - OG in place\n - currently resolved but continue NPO for now\n .\n # SVT: Overnight patient went from sinus tachycardia to SVT, ? atrial\n fibrillation w/PACs vs MAT. Unclear at this point if it could be a\n combination of both, in the setting of pulmonary disease and sepsis.\n Was not resolved with po toprol, IV lopressor and finally was started\n on amiodarone drip. She reverted in the morning back to NSR. It is\n possible she may have reverted on her own, given her significant\n improvement today. At this point, would attempt to restart her home\n beta blocker and take off amiodarone (not an ideal medication given her\n underlying pulmonary disease).\n -d/c amiodarone\n -monitor on telemetry\n -restart home toprol 37.5mg po tid\n -if reverts to SVT reload with amiodarone\n .\n # s/p fall: no evidence of fracture. Complained of back pain during\n rounds this AM, which was present while she was on the wards. Will\n avoid more narcotics- currently she is written for bolus fentanyl,\n Tylenol and has lidocaine patch.\n - cont lidocaine patch, tylenol\n - fentanyl for pain now, but may need to wean if ready to extubate\n -PT\n .\n # DM: Good FSBG control. Currently NPO and on sliding scale.\n .\n # ILD: Pulmonary following, resistant to steroids as outpatient\n treatment. For now, treat for hypercarbic/hypoxic respiratory failure.\n - wean off ventilator if tolerates PS\n - treat PNA\n - alb/atrovent nebs\n -currently no role for steroids\n .\n # PTLD: no known active issues currently.\n - LFTs normal\n - continue tacrolimus, level pending this AM\n .\n # HTN: significantly hypotensive overnight, held beta blocker. Will\n restart today given improvement.\n - Continue outpt metoprolol and monitor\n .\n # Hypothyroidism: Continue Levothyroxine\n .\n # Access: PIV\n .\n # FEN: NPO for now, vitamin D, replete electrolytes prn\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: DNR (DNI ok); no escalation in care per family\n .\n # Contact: , (daughter)\n \n .\n # Dispo: ICU for now\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:08 AM\n Arterial Line - 12:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n ------ Protected Section ------\n Critical Care\n Present for key portions of history and exam. Agree with Dr. \n assessment and plan as outlined. She had a very unstable night with\n fever spike, hypotension, tachycardia but temp now down. CXR and\n sputum suggest she aspirated. No further episodes of emesis since\n transfer. We have converted vent to PSV but at 20 cmH2O she is over\n ventilating. Will decrease pressure and decrease FIO2. She is still\n having back pain so we will up pain meds.\n Time spent 60 min\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 17:41 ------\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356577,
"text": "73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile, pt last pan cultured results pending.\n Action:\n Pt on scheduled Tylenol Q 6 hr.\n Response:\n Cont to be afebrile\n Plan:\n Cont to monitor for fever. Follow up on pending cultures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt newly changed to CPAP 50% 15/5, O2 sat 95-100%\n clear/diminished lung sounds, thick tan in line secretions, copious\n amounts of oral secretions. AM RISBI 106.\n Action:\n ABG 7.44/55/132, then changed settings to CPAP 40% 12/5, O2 sat 95-100%\n Response:\n ABG 7.41/64/127/42 will increase pressure support back to 15 because of\n CO2 rise.\n Plan:\n Cont on CPAP 40% 15/5.\n Pt given 80mg of lasix with little output, initially pt put out 180 and\n then over the next few hour put out another 300ml.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358012,
"text": "Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - STOP 08:08 AM\n EKG - At 09:00 AM\n NON-INVASIVE VENTILATION - START 02:00 PM\n NON-INVASIVE VENTILATION - STOP 04:00 PM\n NON-INVASIVE VENTILATION - START 11:30 PM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n EKG - At 06:00 AM\n Confirmed DNR/OK to intubate\n Still on neo\n went back into SVT HR140s-150s, loaded with amio, started amio drip,\n back into AF again 4:30am\n ABG worse with increased PCo2, intermittently on BiPap vs. mask\n ventilation, diet not advanced\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 12:18 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:18 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 111 (76 - 136) bpm\n BP: 100/50(59) {63/15(43) - 126/97(102)} mmHg\n RR: 33 (21 - 37) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 6,119 mL\n 458 mL\n PO:\n 720 mL\n TF:\n IVF:\n 1,991 mL\n 458 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,694 mL\n 323 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 378 (300 - 391) mL\n PS : 10 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: 7.30/74/145/36/7\n Ve: 9.6 L/min\n PaO2 / FiO2: 290\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 380 K/uL\n 8.8 g/dL\n 110 mg/dL\n 1.6 mg/dL\n 36 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 92 mEq/L\n 135 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n TCO2\n 39\n 38\n Glucose\n 132\n 110\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.8 mmol/L, LDH:183 IU/L, Ca++:9.4 mg/dL,\n Mg++:1.6 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358014,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing.\n Pt NPO except for ice chips/meds since readmitted to ICU .\n Action:\n HOB elevated 45-90 degrees. Cutting or crushing medications as\n allowed.\n Response:\n Plan:\n Aspiration Precautions, instruct family and friends.\n Crush meds in applesauce, or cut up medications.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Plan:\n Re consult nutrition especially since recent diarrhea and poor caloric\n intake for many days.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash starts groin folds, labia, upper inner thighs, anal,\n coccyx, both gluteal folds and buttocks.\n Areas are painful to clean and treat .Area is also excoriated from\n recent diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed.\n Frequent turning and cleansing area each time.\n Response:\n No change in skin remains red and painful.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Intern to order Nystatin ointment with lidocaine.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9,\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC QTc .45. At 0445 PAF rate\n 120 SBP 92-100.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330. Intern\n notified at 0550 and received 150mg Amiodarone IVB. ECG\n Response:\n NSR with stable QTc .45-.46\n Plan:\n Amiodarone infusion to be stopped at 0630. Check with intern before\n stopping.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0430 removed d/t\n pressure on bridge of nose and also skin was red/purple. No skin\n breakdown.\n Plan:\n Pt is 6 liters positive since admit . Last lasix Continue\n to monitor for increase lethargy off CPAP. Maintain O2 sats >92%\n Intern to check ABG in am.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358015,
"text": "Chief Complaint:\n 24 Hour Events:\n NON-INVASIVE VENTILATION - STOP 08:08 AM\n EKG - At 09:00 AM\n NON-INVASIVE VENTILATION - START 02:00 PM\n NON-INVASIVE VENTILATION - STOP 04:00 PM\n NON-INVASIVE VENTILATION - START 11:30 PM\n NON-INVASIVE VENTILATION - STOP 04:30 AM\n EKG - At 06:00 AM\n Confirmed DNR/OK to intubate\n Still on neo\n went back into SVT HR140s-150s, loaded with amio, started amio drip,\n back into AF again 4:30am\n ABG worse with increased PCo2, intermittently on BiPap vs. mask\n ventilation, diet not advanced\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 12:18 AM\n Infusions:\n Phenylephrine - 0.8 mcg/Kg/min\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:18 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 111 (76 - 136) bpm\n BP: 100/50(59) {63/15(43) - 126/97(102)} mmHg\n RR: 33 (21 - 37) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 6,119 mL\n 458 mL\n PO:\n 720 mL\n TF:\n IVF:\n 1,991 mL\n 458 mL\n Blood products:\n Total out:\n 425 mL\n 135 mL\n Urine:\n 425 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,694 mL\n 323 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Set): 300 (300 - 300) mL\n Vt (Spontaneous): 378 (300 - 391) mL\n PS : 10 cmH2O\n RR (Spontaneous): 36\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: 7.30/74/145/36/7\n Ve: 9.6 L/min\n PaO2 / FiO2: 290\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 380 K/uL\n 8.8 g/dL\n 110 mg/dL\n 1.6 mg/dL\n 36 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 92 mEq/L\n 135 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n TCO2\n 39\n 38\n Glucose\n 132\n 110\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.8 mmol/L, LDH:183 IU/L, Ca++:9.4 mg/dL,\n Mg++:1.6 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Patient tenuous at baseline. Acute decompensation seems to have\n occurred in the setting of SVT w/ RVR. No dramatic changes on CXR.\n Difficult to interpret pulmonary exam given baseline rales d/t IPF.\n Must also consider worsening pulmonary infection although already on\n broad spectrum antibiotics. Was intubated so could be set up for ASBL\n bacteria and other resistent organisms.\n - NIPPV\n - serial ABGs. If worsening respiratory acidosis, will intubate\n - cont vanco/zosyn day #\n - broaden antibiotic coverage with cipro\n - treat SVT as below\n - diuresis if BP will tolerate\n - nebs\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. Had similar episode on\n last MICU admission which did not tolerate beta blockers and required\n amio gtt. Again, associated with hypotension and may be contributing to\n respiratory distress. unclear inciting event. ? fever. At risk given\n underlying lung disease\n - amio bolus and gtt\n - d/c amio as able once converts\n - can attempt bolus IV lopressor if BP will tolerate\n - cont po beta blocker as BP will tolerate\n .\n # hypotension: likely due to RVR. In the setting of low grade fever,\n must also consider sepsis. Currently on broad spectrum abx.\n - cont vanco,zosyn as above with addition of cipro\n - pan culture\n - treat SVT as above\n - IVF boluses prn\n .\n # fever: new low grade temp this am. Patient immunosuppressed at\n baseline on tacrolimus. No leukocytosis this am. CXR unchanged. ?\n noninfectious etiologies. No increased sputum productive, abdominal\n pain, diarrhea.\n - panculture: blood, urine, sputum\n - broaden antibiotic coverage as above\n - repeat CBC stat with diff\n - check LFTs\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: reasonable BG control recently.\n - cont NPH per outpt doses. Half dose while NPO\n - cont insulin sliding scale\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - continue Tacrolimus at regular dose for now\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now\n - vit D\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: Intubation okay. CPR not indicated.\n .\n # Contact: , daughter \n .\n # Dispo: ICU\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356721,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 45.4 None\n Ideal tidal volume: 181.6 / 272.4 / 363.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: 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": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358018,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing.\n Pt NPO except for ice chips/meds since readmitted to ICU .\n Action:\n elevated 45-90 degrees. Cutting or crushing medications as\n allowed.\n Response:\n Despite pt continues to cough after water.\n Plan:\n Aspiration Precautions, instruct family and friends.\n Suggest using nectar thickened liquids. Crush meds in applesauce, or\n cut up medications.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Pt asking for juice, food.\n Plan:\n Re consult nutrition especially since recent diarrhea and poor caloric\n intake for many days.\n Reassess NPO order.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash, erythemic that starts groin folds, labia, upper inner\n thighs, anal, coccyx, both gluteal folds and buttocks. Areas are\n painful to clean and treat .Area is also excoriated from recent\n diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed. Intern ordered Nystatin and\n lidocaine ointment, applied at 0600. Frequent turning q1-2hr and\n cleansing area each time.\n Response:\n No change in skin remains red and painful at this time.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Nystatin ointment with lidocaine.\n OOB chair with chair pad.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9, Received Tylenol at 0500.\n Response:\n Difficult weaning Neo with labile BP\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC QTc .45. At 0445 PAF rate\n 120 SBP 92-100.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330.ECG\n obtained and Intern notified at 0550. Pt received 150mg\n Amiodarone IVB.\n Response:\n Converted back to AF but with a slower ventricular response on\n Amiodarone gtt.\n Plan:\n .Continue to monitor HR/rhythm\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0430 removed d/t\n pressure on bridge of nose and also skin was red/purple. No skin\n breakdown.\n Plan:\n Pt is 6 liters positive since admit . Last lasix Continue to\n monitor for increase lethargy off CPAP. Maintain O2 sats >92% Intern to\n check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358020,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Pt is coughing intermittently with ice chips, however taking small\n pills with water without coughing.\n Pt NPO except for ice chips/meds since readmitted to ICU .\n Action:\n elevated 45-90 degrees. Cutting or crushing medications as\n allowed.\n Response:\n Despite pt continues to cough after water.\n Plan:\n Aspiration Precautions, instruct family and friends.\n Suggest using nectar thickened liquids. Crush meds in applesauce, or\n cut up medications.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO on and off since admitted on . Last nutrition\n consult \n Blood sugars/FS 110-209\n Action:\n Receiving insulin at\n dose while NPO\n Response:\n Pt asking for juice, food.\n Plan:\n Re consult nutrition especially since recent diarrhea and poor caloric\n intake for many days.\n Reassess NPO order.\n Impaired Skin Integrity\n Assessment:\n Severe yeast infection with large amount of green/yellow vaginal\n drainage,\n Bright red rash, erythemic that starts groin folds, labia, upper inner\n thighs, anal, coccyx, both gluteal folds and buttocks. Areas are\n painful to clean and treat .Area is also excoriated from recent\n diarrhea.\n Action:\n Using skin cleanser spray VS foam cleaner and applying aloe vesta\n antifungal ointment as needed. Intern ordered Nystatin and\n lidocaine ointment, applied at 0600. Frequent turning q1-2hr and\n cleansing area each time.\n Response:\n No change in skin remains red and painful at this time.\n Plan:\n Hold all stool medications for now. Order double guard ointment,\n Nystatin ointment with lidocaine.\n OOB chair with chair pad.\n Hypotension (not Shock)\n Assessment:\n SBP 88-100 Temperature 99.9-100po with elevated WBC 18.\n Action:\n Neo at .89mcg/kg/min, with very slow wean. Antibiotics: Zosyn day # 9,\n Vancomycin day #9, Received Tylenol at 0500. Temp down 0600 97.\n Response:\n Slow wean Neo with labile BP\n Plan:\n Continue to wean Neo and maintain SBP >100\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 80\ns-90 NSR with occasional-frequent PAC QTc .45. At 0445 PAF rate\n 120 SBP 92-100.\n Action:\n Amiodarone at 1mg/min after 6hrs decreased to .5mg/min at 2330.ECG\n obtained and Intern notified at 0550. Pt received 150mg\n Amiodarone IVB.\n Response:\n Converted back to AF but with a slower ventricular response on\n Amiodarone gtt.\n Plan:\n .Continue to monitor HR/rhythm. Continue Amiodarone infusion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 at 100% cool neb with O2 sats 99-100%. Respiratory rate 28-42\n intermittently shallow and labored with minimal activity. LS rales\n Admit weight 90kg. Today weight 94kg.\n Action:\n O2 weaned to 50% and maintained sats 96-97%. Planned CPAP at HS 50% PS\n 10/PEEP 5, resp 24-40 vT 300-400. Having periods of apnea <20 seconds.\n Response:\n Pt tolerating CPAP fairly well during the night 2330-0430 removed d/t\n pressure on bridge of nose and also skin was red/purple. No skin\n breakdown.\n Plan:\n Pt is 6 liters positive since admit . Last lasix Continue to\n monitor for increase lethargy off CPAP. Maintain O2 sats >92% Intern to\n check ABG in am.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 357111,
"text": "73 yo female admitted on for pain mgmt after fall.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events: transferred to the MICU for hypercarbic/hypoxic\n respiratory failure in the setting of emesis. Intubated.\n : placed on SBT( 5/o) on vent but unable to tolerate- placed\n back on . PICC attempted at bedside but unsuccessful to be done in\n IR on Monday. Antibiotics changed to vanco/zosyn- flagyl d/c\nd. ~1830\n patient\ns HR increased to high 120\ns to 130\ns. Given 5mg IV Lopressor\n and HR decreased to 80\n : Pt extubated at 2pm and tolerated well, on 3L\n N/C(O2 dependent at home) Sat\ns have remained > 95% on 3L. Pt desat\n d overnight, ? if sleep apnea. No intervention needed. Aline out.\n Will need PICC placed in IR today.\n ? c/o today and restart diet. NPH held secondary to NPO and\n fingersticks < 150. Pt had had frequent loose stools, please hold\n colace in am. Voice hoarse and c/o sore throat, ice chips tolerated\n and eased sore throat.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 73 female w/ chronic lung disease. Extubated yesterday, tolerated\n well w/o signs of resp distress. Maintains sat\ns of >95% on 3L via\n N/C. Lungs diminishes bases, w/ occas wheezes. Denies SOB. Weak\n non-productive cough noted\n Action:\n Pt encouraged and reminded to cough and deep breath. Continue w/\n supportive O2\n Response:\n Resp status stable\n Plan:\n ? c/o later today\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 356507,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 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: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 356719,
"text": "73 yr old who was initially admitted to hosp after a fall for pain\n control. While on the floor pt developed resp distress with desat to\n 88% on 2 liters NC. Pt noted to have cx's and CXR showed pulm edema. Pt\n given lasix po and IV with some effect. Pt noted to be slight\n lethargic. Pt sent to MICU for further care. While in Micu pt became\n unresponsive ABG was drawn and PCO2 in the 100\ns pt was then intubated.\n Pt was a very hard intubation. Early in AM of pt went into SVT\n to 130\ns and BP began to drop SBP 70-80\ns. fluid boluses given and\n Amiodarone was started pt HR converted back to SR yesterday and since\n then BP has been stable. During the time pt BP was dropping pt family\n was contact about ? line placement and pressors, family did not want\n to escalate care.\n Code status: DNR no escalation in care per family.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on CPAP 10/5, clear lung sounds, small amount of in-line tan\n secretions, copious amounts of clear secretions in mouth. Pt very\n alert, mouthing questions: she wants to know when the tube will come\n out.\n Action:\n None\n Response:\n Plan:\n ? turning down to 5/5 see how pt tolerates.\n Pt seen by PT/OT yesterday and stood at side of bed with 1 person\n assisting.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 356720,
"text": "Chief Complaint:\n 24 Hour Events:\n - no overnight issues, pt noted to be alert\n - attdg met with family yesterday who would want full resuscitative\n measures for pt\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:38 AM\n Vancomycin - 08:08 AM\n Metronidazole - 04:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:09 AM\n Heparin Sodium (Prophylaxis) - 09:42 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 06:17 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: 37.1\nC (98.8\n HR: 87 (74 - 103) bpm\n BP: 129/69(90) {91/47(62) - 148/86(110)} mmHg\n RR: 16 (15 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 946 mL\n 165 mL\n PO:\n TF:\n IVF:\n 656 mL\n 165 mL\n Blood products:\n Total out:\n 2,170 mL\n 140 mL\n Urine:\n 2,170 mL\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,224 mL\n 25 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 313 (301 - 361) mL\n PS : 10 cmH2O\n RR (Spontaneous): 33\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 96\n PIP: 16 cmH2O\n SpO2: 100%\n ABG: 7.43/61/101/39/12\n Ve: 9.2 L/min\n PaO2 / FiO2: 253\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 242 K/uL\n 9.9 g/dL\n 109 mg/dL\n 1.1 mg/dL\n 39 mEq/L\n 4.0 mEq/L\n 27 mg/dL\n 94 mEq/L\n 139 mEq/L\n 28.1 %\n 6.4 K/uL\n [image002.jpg]\n 01:25 AM\n 01:34 AM\n 05:16 AM\n 05:27 AM\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n WBC\n 7.5\n 7.3\n 5.8\n 6.4\n Hct\n 28.0\n 25.5\n 26.7\n 28.1\n Plt\n 42\n Cr\n 1.0\n 1.0\n 1.4\n 1.1\n TropT\n 0.01\n TCO2\n 46\n 40\n 39\n 42\n 43\n 42\n Glucose\n 164\n 190\n 136\n 109\n Other labs: PT / PTT / INR:13.0/25.3/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 12:10 AM\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358474,
"text": ".H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 358609,
"text": "Chief Complaint: 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 24 Hour Events:\n Was on face mask for hours yesterday but desaturated required BIPAP\n again overnight.\n Worsening resp distress.\n 7.24/75/75 on venti mask this AM\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:33 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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: Dyspnea\n Flowsheet Data as of 10:25 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: 35.9\nC (96.6\n HR: 86 (73 - 123) bpm\n BP: 123/58(71) {86/34(38) - 123/84(89)} mmHg\n RR: 27 (18 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 1,139 mL\n 644 mL\n PO:\n 640 mL\n 340 mL\n TF:\n IVF:\n 499 mL\n 304 mL\n Blood products:\n Total out:\n 579 mL\n 223 mL\n Urine:\n 579 mL\n 223 mL\n NG:\n Stool:\n Drains:\n Balance:\n 560 mL\n 421 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 375 (375 - 375) mL\n RR (Set): 0\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 70%\n PIP: 18 cmH2O\n SpO2: 95%\n ABG: 7.24/75/75/29/1\n Ve: 6.5 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Gen obese female, lying in bed, resp distress, somnelent\n HEENT: o/p dry\n CV: irreg irreg\n Chest: diffuse inspiratory rales\n Abd obese soft Nt + BS\n Ext 2+ edema\n Neuro : somnolent but arousable\n Labs / Radiology\n 8.3 g/dL\n 266 K/uL\n 64 mg/dL\n 2.4 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.0 %\n 8.3 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n 09:58 PM\n 05:30 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n 8.3\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n 24.0\n Plt\n 393\n 429\n 380\n 286\n 266\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n 2.4\n TCO2\n 39\n 38\n 34\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n 64\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Vanco 22.6\n CXR with significant acute pulm edema on top of underlying ILD\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Respiratory Failure: Significantly worse this AM likely due to\n volume overload and progressive CO2 retention. Will try NIPPV again\n this AM but heading toward reintubation. Will call family and try to\n move up family meeting\n 2. ARF: ATN in setting of hypotension and repeated episodes of AF\n with RVR. Art this point we are forced to give Lasix to try to help her\n resp status\n 3. Afib\n on Amio\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: family meeting ASAP\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 358610,
"text": "Comments:\n Noted change in pt\ns code to CMO.\n Signing off.\n Pge w/ questions/issues #\n 15:54\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 358463,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 57.8 None\n Ideal tidal volume: 231.2 / 346.8 / 462.4 mL/kg\n Airway\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Ventilation Assessment\n Non-invasive ventilation assessment: Tolerated well\n Bedside Procedures:\n Comments: ABG results after returning patient to NIV revealed a\n partially compensated respiratory academia with mild hypoxemia.\n Patient was more alert and was switched to aerosol mask. Back on mask\n ventilation for 3 hours and then back to aerosol mask.\n"
},
{
"category": "General",
"chartdate": "2125-12-25 00:00:00.000",
"description": "ICU Event Note",
"row_id": 358585,
"text": "Clinician: Resident\n Earlier this morning, Ms. S was noted to be somnolent and obtunded. CO2\n was found to be 112 and thus based on prior discussions with Ms.\n , we called anesthesia to intubate her. Just prior to\n intubation, she awoke and said that she did not want to be intubated if\n the likelihood was that she would not be able to be extubated. She\n asked for a family meeting to be called.\n Based, on this, we had a discussion with Ms. S, her daughter ,\n her 2 sisters and husband regarding goals of care. Ms. was\n quite confused during most of the conversation and was not able to make\n a final decision regarding intubation. Her daughter is her HCP and\n believes that intubation would not be consistent with her prior stated\n wishes.\n We will thus make Ms. measures only at this point. Her\n family is aware that she will likely die within the next day.\n Total time spent: 60 minutes\n Patient is critically ill.\n"
},
{
"category": "General",
"chartdate": "2125-12-25 00:00:00.000",
"description": "ICU Event Note",
"row_id": 358670,
"text": "Clinician: Resident\n Earlier this morning, Ms. S was noted to be somnolent and obtunded. CO2\n was found to be 112 and thus based on prior discussions with Ms.\n , we called anesthesia to intubate her. Just prior to\n intubation, she awoke and said that she did not want to be intubated if\n the likelihood was that she would not be able to be extubated. She\n asked for a family meeting to be called.\n Based, on this, we had a discussion with Ms. S, her daughter ,\n her 2 sisters and husband regarding goals of care. Ms. was\n quite confused during most of the conversation and was not able to make\n a final decision regarding intubation. Her daughter is her HCP and\n believes that intubation would not be consistent with her prior stated\n wishes.\n We will thus make Ms. measures only at this point. Her\n family is aware that she will likely die within the next day.\n Total time spent: 60 minutes\n Patient is critically ill.\n ------ Protected Section ------\n Addendum\n I led the family meeting that Dr described above and agree with\n her description of the conversation and the conclusions.\n Critically ill\n 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 18:50 ------\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 357070,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 02:41 PM\n ARTERIAL LINE - STOP 10:11 PM\n - self diuresing\n -for IR PICC today\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 12:57 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 06:54 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: 36.2\nC (97.1\n HR: 81 (74 - 96) bpm\n BP: 106/48(57) {88/44(57) - 124/59(74)} mmHg\n RR: 19 (15 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 600 mL\n 229 mL\n PO:\n 60 mL\n 60 mL\n TF:\n IVF:\n 540 mL\n 169 mL\n Blood products:\n Total out:\n 1,687 mL\n 230 mL\n Urine:\n 1,687 mL\n 230 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,087 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 286 (286 - 332) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 94%\n ABG: 7.46/50/111/38/10\n Ve: 7.8 L/min\n PaO2 / FiO2: 277\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 219 K/uL\n 9.3 g/dL\n 126 mg/dL\n 0.9 mg/dL\n 38 mEq/L\n 3.8 mEq/L\n 19 mg/dL\n 93 mEq/L\n 137 mEq/L\n 26.7 %\n 5.6 K/uL\n [image002.jpg]\n 07:40 PM\n 01:45 AM\n 03:12 AM\n 04:20 AM\n 03:40 PM\n 04:10 AM\n 06:26 AM\n 06:42 AM\n 11:50 AM\n 05:55 AM\n WBC\n 5.8\n 6.4\n 4.9\n 5.6\n Hct\n 26.7\n 28.1\n 26.3\n 26.7\n Plt\n 190\n 242\n 198\n 219\n Cr\n 1.4\n 1.1\n 1.0\n 0.9\n TCO2\n 39\n 42\n 43\n 42\n 40\n 37\n Glucose\n 136\n 109\n 100\n 126\n Other labs: PT / PTT / INR:12.7/24.7/1.1, CK / CKMB /\n Troponin-T:83//0.01, ALT / AST:, Alk Phos / T Bili:66/0.5, Amylase\n / Lipase:55/27, Differential-Neuts:81.4 %, Lymph:14.5 %, Mono:2.8 %,\n Eos:1.1 %, Lactic Acid:0.8 mmol/L, Albumin:3.0 g/dL, LDH:216 IU/L,\n Ca++:8.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n FEVER (HYPERTHERMIA, PYREXIA, NOT FEVER OF UNKNOWN ORIGIN)\n HYPOTENSION (NOT SHOCK)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n NAUSEA / VOMITING\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:15 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358483,
"text": ".H/O atrial fibrillation (Afib)\n Assessment:\n Hx Afib/RVR on amio and lopressor po. Went back into Afib at ~ 2200\n rate 100-130. HO aware. BP 90\ns-100\ns/ 50.\n Action:\n Gave po lopressor 50mg early at 2200.\n Response:\n Remains in Afib\n rate mainly 100-120 with occas. bursts to 130. gave\n 6am lopressor.\n Plan:\n Monitor HR\n amio at 0800. monitor BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Hx pulm. Fibrosis exacerbated with acute pulm. Process possibly\n aspiration. s/p extubation . requiring interminnant CPAP for low\n sats and labored/dyspnea.\n - sats dipping to 88-90% in eve on cool neb O2.\n ABG\n 7.24/75/75. HO aware. RR 30\ns. pt. c/o tiring.\n Crackles\n up bilat.\n u/o 15-25cc/hr. creatinine elevated from admission.\n Action:\n placed on CPAP 2100- 2300 and again ~ 0100-0330.\n Response:\n Sats improve on CPAP to mid 90\ns, pt. appearing more comf. /sleeping\n then wakes up and tries to take mask off. Also wakes slightly confused\n which she has done previous times. Oriented to self only but becomes\n oriented to place/date easily and able to retain. She asks how long\n she has been in the hospital.\n Placed on 70% cool neb while off CPAP. Sats 90-94%. Dropping to\n 85-90% when mask off. Breathing appears comf. And pt. denies SOB or\n increase work of breathing.\n Plan:\n Contin. To treat with intermittent CPAP as needed. Monitor ABG\ns as\n needed.\n Monitor u/o and follow lytes.\n Alteration in Nutrition\n Assessment:\n Taking pills well with water. No coughing or gagging. NPO d/t mask\n ventilation.\n FS 82-102\n Action:\n No NPH or regular insulin given. Also gave apple juice in eve.\n Response:\n FS remains low 88 at 0600.\n Plan:\n Check with team about holding AM NPH or adjusting dose. Follow FS\n closely.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358229,
"text": "Dysphagia\n Assessment:\n Pt intermittently coughing after ice chips. Able to take pills one at\n time without coughing. Had been rated DOSS 1 but improved to 7 on\n .\n Action:\n Keeping HOB elevated to 45-90 degrees.\n Response:\n Continues to cough intermittently\n Plan:\n Follow aspiration precautions and instruct family also.\n Alteration in Nutrition\n Assessment:\n Remains NPO. Pt has been mostly NPO during this admission based on\n nutrition consults and documentation\n Action:\n In setting of requiring freq CPAP, it is preferred to keep NPO to\n prevent aspiration\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Yeast infection and rash remains bright red with skin starting peel.\n Action:\n Cleansing with wound cleaner followed by Nystatin and lidocaine\n ointments. Started Miconazole Nitrate vaginal suppositories for 3\n days.\n Response:\n Vaginal discharge has improved dramatically with only small amount\n noted. Rash appears less inflamed.\n Plan:\n Continue treatment as prescribed. Frequent turning and cleansing to\n keep area dry.\n Hypotension (not Shock)\n Assessment:\n .\n Action:\n Neo at .6mcg/kg/min was weaned slowly off over the night.\n Response:\n SBP stable with MAPS >60.\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 120-140\ns RAF Brief episodes of NSR rate 90\n Action:\n Received NS 500cc x1 Lopressor remains on hold. Amiodarone at 200mg po\n s/p Amiodarone infusion .\n Response:\n HR remains 130-150 without change in rate.\n Plan:\n Continue to monitor and keep team aware of rate.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rales though out. Requiring CPAP for most of the day.\n Action:\n Removed at 2130 due to family present and again at 0500 due to pressure\n on bridge of nose.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358663,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with 70% neb with shallow resps and sats >95%, then resp pattern\n becoming more paradoxical in motion. Pt\ns mentation changed from alert\n and oriented X3 to , easily arousable, but oriented only X2.\n Action:\n Team in to assess patient, ABG done and pt placed back on mask\n ventilation. Patient\ns family called to come in. Pt then became\n somnolent, difficult to arouse. Anesthesia to pt\ns bedside, setting up\n to intubate. Pt opened her eyes and said,\nwhat are you doing? \n you know I\nm not supposed to be intubated\nll never get off of the\n machine.\n Pt stayed on bi-pap, attending physician notified and came\n in to talk with patient and her family. While patient and family\n were discussing options, pt again became somnolent. Pt\ns daughter\n (HCP) expressed her feelings that her mother, if she were\n thinking clearly, would say that she would not want to be reintubated\n and live on a ventilator. Patient\ns status was changed to comfort\n focused care. Pt given IV ativan and morphine. Respirations became\n more labored and patient diaphoretic. Morphine drip added. Pt\n husband, daughter, 2 sisters and grandson at her bedside. Catholic\n priest in to anoint.\n Response:\n Pt currently non-responsive with sats in the 60\n Plan:\n Continue to keep patient comfortable. Support family, provide\n information as needed.\n ------ Protected Section ------\n Patient with deteriorating O2 sat. Then became bradycardic. Family at\n bedside. Patient pronounced by Dr. \n. Pt\ns engagement ring\n (clear stone) and wedding band given to patient\ns daughter .\n Family expressed patient\ns desire that there be no autopsy or organ\n donation.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:35 ------\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358230,
"text": "Chief Complaint:\n 24 Hour Events:\n - Received 1L NS following rounds\n - HR increased from 110's to 140s over the course of the day\n - Spent time on and off CPAP\n - Pt remained on phenylephrine\n - Patient and subsequent separate Family Meeting with Dr. \n (Patients outpatient pulmonologist).\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 141 (80 - 141) bpm\n BP: 92/69(74) {81/43(56) - 109/75(78)} mmHg\n RR: 37 (19 - 39) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 229 mL\n PO:\n TF:\n IVF:\n 2,670 mL\n 229 mL\n Blood products:\n Total out:\n 460 mL\n 149 mL\n Urine:\n 460 mL\n 149 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 96%\n ABG: 7.25/74/141/31/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 282\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 380 K/uL\n 8.8 g/dL\n 115 mg/dL\n 2.2 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 93 mEq/L\n 132 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358231,
"text": "Chief Complaint:\n 24 Hour Events:\n - Received 1L NS following rounds\n - HR increased from 110's to 140s over the course of the day\n - Spent time on and off CPAP\n - Pt remained on phenylephrine\n - Patient and subsequent separate Family Meeting with Dr. \n (Patients outpatient pulmonologist).\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 141 (80 - 141) bpm\n BP: 92/69(74) {81/43(56) - 109/75(78)} mmHg\n RR: 37 (19 - 39) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 229 mL\n PO:\n TF:\n IVF:\n 2,670 mL\n 229 mL\n Blood products:\n Total out:\n 460 mL\n 149 mL\n Urine:\n 460 mL\n 149 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 96%\n ABG: 7.25/74/141/31/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 282\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg. tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 380 K/uL\n 8.8 g/dL\n 115 mg/dL\n 2.2 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 93 mEq/L\n 132 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358232,
"text": "Chief Complaint:\n 24 Hour Events:\n - Received 1L NS following rounds\n - HR increased from 110's to 140s over the course of the day\n - Spent time on and off CPAP\n - Pt remained on phenylephrine\n - Patient and subsequent separate Family Meeting with Dr. \n (Patients outpatient pulmonologist).\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 141 (80 - 141) bpm\n BP: 92/69(74) {81/43(56) - 109/75(78)} mmHg\n RR: 37 (19 - 39) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 229 mL\n PO:\n TF:\n IVF:\n 2,670 mL\n 229 mL\n Blood products:\n Total out:\n 460 mL\n 149 mL\n Urine:\n 460 mL\n 149 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 96%\n ABG: 7.25/74/141/31/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 282\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg. tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 380 K/uL\n 8.8 g/dL\n 115 mg/dL\n 2.2 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 93 mEq/L\n 132 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Most likely worsening natural course of her ILD with worsening\n pulmonary edema secondary to a fib with RVR. Patient tenuous at\n baseline. Treating for VAP in addition to underlying lung disease, on\n vanco/zosyn day #\n - NIPPV, alternate CPAP with face mask\n - serial ABGs. Seems to be stable, If worsening respiratory acidosis,\n will intubate\n - treat SVT as below\n - continue nebulizer treatments\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. The patient was loaded\n with amiodarone drip, started on amiodarone 200mg QD today. Had\n similar episode on last MICU admission which did not tolerate beta\n blockers and required amio gtt. The patient does not tolerate\n betablockers given hypotensive, thus will attempt to rate control with\n amiodarone only.\n - will continue to monitor on telemetry\n - can attempt bolus IV lopressor if BP will tolerate\n - cont po beta blocker as BP will tolerate\n .\n # hypotension: likely due to RVR, and diastolic heart failure. In the\n setting of low grade fever, must also consider sepsis especially given\n immunosupression . Currently on broad spectrum abx of vanc/zosyn\n - will culture if spikes, follow blood cultures\n - treat SVT as above\n - Will give 1L of NS today, will repeat as tolerated\n - Will continue phenylephrine drip as needed, attempt to wean\n .\n # fever: new low grade temp this am. See hypotension above. On broad\n spectrum Abs. Follow culture\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: Even though patient is NPO BG have been very elevated. Will\n continue to monitor QID and adjust sliding scale accordingly. Will use\n half dose of outpatient insulin while NPO\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - continue Tacrolimus at regular dose for now\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now given tenuous respiratory status\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-17 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 357183,
"text": "73 yo female admitted on for pain mgmt after fall.\n PMH: chronic interstitial lung disease on home O2, diastolic CHF, s/p\n liver transplant on immunosuppression. DM2 insulin dependent, HTN,\n hypothyroidism, h/o A-fib, s/p chole and appy.\n Events: transferred to the MICU for hypercarbic/hypoxic\n respiratory failure in the setting of emesis. Intubated.\n 12/18 HR increased to 130\ns to 140\ns w/ subsequent BP\n drop. Amiodarone gtt started w/ no change in HR. Self converted into\n NSR. Did have episodes later in ICU coarse of HR increasing to 120\ns to\n 140\ns- IV Lopressor given w/ good effect.\n : placed on SBT( 5/o) on vent but unable to tolerate- placed\n back on . PICC attempted at bedside but unsuccessful to be done in\n IR on Monday. Antibiotics changed to vanco/zosyn- flagyl d/c\n : Pt extubated at 2pm and tolerated well, on 3L\n N/C(O2 dependent at home) Sat\ns have remained > 95% on 3L. Pt desat\n d overnight, ? if sleep apnea. No intervention needed. Aline out.\n : NPH held secondary to NPO status and fingersticks < 150. Voice\n hoarse and c/o sore throat, ice chips tolerated and eased sore throat.\n Failed speech/swallow- rec\ns include crushed meds in applesauce if\n needed and ice chips. Will follow up tomorrow.\n Urine output ~15-35cc/hr.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 73 female w/ chronic lung disease. Extubated , denies resp\n difficulty. Maintains sat\ns of 90-93% on 4L via N/C. LS- clear w/\n diminished bases. Weak, occasionally productive cough.\n Action:\n Continued on o2 via NC. Encouraged CDB. Encouraged to expectorate\n sputum. Position changed q2hrs.\n Response:\n O2 sats remained 90-93% on 4L NC. Occasionally decreased to high 80\n when sleeping.\n Plan:\n Monitor resp status. Wean o2 as tolerated. Encourage CDB. OOB to chair.\n PT following.\n Pain control (acute pain, chronic pain)\n Assessment:\n Occasionally complains of back pain. Originally admitted s/p fall. Pain\n mostly w/ activity, rated ~.\n Action:\n Repositioned and back rubbed.\n Response:\n Patient stated relief w/ repositioning.\n Plan:\n Assess/treat pain. Reposition frequently.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n S/P FALL\n Code status:\n DNR (do not resuscitate)\n Height:\n 60 Inch\n Admission weight:\n 90.4 kg\n Daily weight:\n Allergies/Reactions:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Precautions: Contact\n PMH: Diabetes - Insulin\n CV-PMH: CHF, Hypertension\n Additional history: interstitial pulm fibrosis, s/p liver transplant\n ', DM2, HTN, hypothyroidism, diastolic dysfunction with EF of 65%,\n s/p chole and appy, afib hx and after liver transplant, and s/p CHOP\n and rituximab.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:128\n D:65\n Temperature:\n 97.9\n Arterial BP:\n S:127\n D:68\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Face tent\n O2 saturation:\n 95% %\n O2 flow:\n 15 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 500 mL\n 24h total out:\n 495 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 05:55 AM\n Potassium:\n 3.8 mEq/L\n 05:55 AM\n Chloride:\n 93 mEq/L\n 05:55 AM\n CO2:\n 38 mEq/L\n 05:55 AM\n BUN:\n 19 mg/dL\n 05:55 AM\n Creatinine:\n 0.9 mg/dL\n 05:55 AM\n Glucose:\n 126 mg/dL\n 05:55 AM\n Hematocrit:\n 26.7 %\n 05:55 AM\n Finger Stick Glucose:\n 154\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": "2125-12-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 358366,
"text": "Chief Complaint: rapid Afib, 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 - 1 liter fluid challenege, off Neo, still in Afib with RVR at times\n - struggling with issues around code status as noted by Dr in\n prior entries\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 08:07 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Bactrim prophy\n Tacro\n Vit D\n Ca\n Synthroid\n PPI\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 09:18 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: 35.8\nC (96.5\n HR: 138 (80 - 144) bpm\n BP: 104/53(65) {81/47(56) - 109/79(84)} mmHg\n RR: 30 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 592 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,670 mL\n 352 mL\n Blood products:\n Total out:\n 460 mL\n 229 mL\n Urine:\n 460 mL\n 229 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 363 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 98%\n ABG: ///32/\n Ve: 11.3 L/min\n Physical Examination\n Gen obese female, sitting up in bed, mild resp distress, fatigies\n appearing\n HEENT: o/p dry\n CV: irreg orreg\n Chest: diffuse inspiratory rales\n Abd obese soft Nt + BS\n Ext 2+ edema\n Neuro A and oriented conversant\n Labs / Radiology\n 8.5 g/dL\n 286 K/uL\n 107 mg/dL\n 2.3 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 92 mEq/L\n 134 mEq/L\n 24.0 %\n 10.2 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n Plt\n 393\n 429\n 380\n 286\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Resp Distress: likely due to underlying ILD with superimposed\n atrial fibrillation and some mild vol overload. . Respiratory status\n remains tenuous and she is essentially dependent on BiPAP with periods\n she is able to come off.\n 2. Hemodynamics: AF has recurred and we have restarted\n amiodarone. Continue pressor to maintain MAP 65. Will continue\n Vanco/Zosyn and hold cipro awaiting cultures.\n 3. ARF: Critical to check all med levels esp. tacrolimus for s/p\n liver transplant and Vanco.\n 4. Continue discussions with family, primary care physician and\n consultants for overall plan of care. Unable to advance diet.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ICU Care\n Nutrition: NPO while on bipap\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358373,
"text": "Pt admitted to after a fall, lumbar spine films show\n chronic L1 compression. adm to MICU after desaturating, ? asp\n event. Intubated, on antibiotics. Also with SVT vs AR with RVR,\n started on Amiodarone and lopressor. extubated, sent to\n . noted to be lethargic with ^^RR, falling satas. Also in\n AF with RVR. Sent to CCU (MICU service). Placed on CPAP.\n Dysphagia\n Assessment:\n Failed swallowing study this admission, however, able to take pills\n with water without coughing or throat clearing.\n Action:\n HOB ^^ with pills, pills given one at a time. Remains NPO otherwise\n d/t need for CPAP and ? of intubation. Received full dose of am NPH\n after discussing with team, as pt\ns BS\ns were high all day yesterday\n despite being NPO and full dose NPH.\n Response:\n No coughing/throat clearing. 1700 BS 80, MICU team notified, to give pt\n milk and decrease insulin to\n dose while NPO\n Plan:\n Continue with HOB^^ with pills, pills one at a time. Remains NPO\n otherwise d/t use of CPAP.\n dose NPH for now.\n Impaired Skin Integrity\n Assessment:\n Yeast infection around perineal and buttocks: rash remains red with\n skin peeling.\n Action:\n Cleansing with wound cleaner followed by Nystatin and lidocaine\n ointments. Started Miconazole Nitrate vaginal suppositories for 3\n days. Repositioned at least q 2hours\n Response:\n Vaginal discharge has improved as per report. Rash appears less\n inflamed.\n Plan:\n Continue treatment as prescribed. Frequent turning and cleansing to\n keep area dry.\n .H/O atrial fibrillation (Afib)\n Assessment:\n In AF rate of 140\ns this am.\n Action:\n Able to take Amiodarone and lopressor this am.\n Response:\n Converted to NSR @ 0930. Maintaining SBP >92 (pressure measured 82 X1\n when pt turned on right side with NBP cuff on L arm. SBP rechecked in\n R leg\n94).\n Plan:\n Continue to administer Amiodarone and lopressor as ordered. Monitor\n lytes. Follow HR/rhythm/BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 70% cool neb with sats >92%. Lungs with crackles ^, pt has\n paradoxical resp pattern. RR in high 30\ns this am.\n Action:\n Sats monitored continuously. No fall in sat below 92%. Receiving\n atrovent nebs.\n Response:\n Pt states breathing is better than yesterday. RR noted to be lower\n after converting to NSR (low 30\ns to high 20\n Plan:\n Continue to monitor closely, cpap as needed. Dr. to come in today\n to further clarify DNR status\nplease page MICU team when Dr. \n arrives.\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 357797,
"text": "Demographics\n Day of intubation: 0\n Day of mechanical ventilation: 0\n Ideal body weight: 57.8 None\n Ideal tidal volume: 231.2 / 346.8 / 462.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason: NIV, Not intubated\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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: /\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: Tolerated well; Comments: Pt takes\n very small Vt and breaths at rapid rate. Hx ILD may cause small Vt. ABG\n show improved po2 and Pco2 on NIV with PSV 8 and CPAP 5\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: continue current respiratory support next 12 hour if\n needed , then re-evaluate.\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 Triggered for Dyspnea on floor, Hx ILD, short term Dx is CHF\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 357786,
"text": "Chief Complaint: respiratory distress\n PCP: , . \n Pulmonologist: , \n Heme/Onc: \n Cardiologist: \n HPI:\n For complete details, please refer to initial medicine admission note\n and MICU call out note . In brief, Ms. is a 73 yo\n female with PMH significant for ILD on .5L home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital on after a mechanical fall for\n pain control. On patient had an aspiration event and hypoxia. The\n following day, she had evidence of aspiration on CXR and hypercarbic\n respiratory failure. At that time, goals of care were discussed with\n her HCP, her husband, as well as her daughter and they felt they would\n want intubation. She was made DNR as it was felt that CPR would not be\n indicated. She was transferred to the MICU.\n .\n In the MICU, she was intubated on for worsening hypercarbia. That\n evening she spiked a fever, went into AF vs MAT with HRs into the 160s,\n and hypotension to the 80s. She did not tolerate beta blockers at that\n time and was started on an amiodarone gtt. She was also started on\n empiric vancomycin and zosyn for possible aspiration pna. She received\n aggressive volume resuscitation and converted to NSR the following\n morning. Her amiodarone was discontinued given concern for worsening\n lung and liver disease. Her beta blocker was uptitrated. Antibiotics\n were briefly discontinued on and restarted on . She was\n eventually diuresed and was able to be extubated on . She was\n called out to the medical floor on .\n .\n While on the medical floor, she was continued on vancomycin and zosyn\n for presumed aspiration pna. She had no microbiology data to help guide\n therapy. She was continued on diuretics but has run I/O even per\n documentation. While on floor, SBPOs 100s, HRs 80s, RR 20s, O2 90s on\n 3LNC.\n .\n On the evening of transfer, trigger called for increased work of\n breathing. Upon floor evaluation, patient denied any subjective SOB. O2\n requirement the same at 90s n 3LNC and no significant change in RR.\n However, at ~ MN, patient went into irregular SVT (AF vs MAT) to 150s,\n T100.3, with SBPs into 90s, RR increased to 30s, and O2 sats low 90s\n on 4-6L. She received lopressor 5 mg IV x 2 without significant change\n in her HR and decrease in SBP to 80s. CXR repeated without significant\n change compared to this am. ABG showed 7.35/73/54.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Home medications:\n IPRATROPIUM BROMIDE 0.2 mg/mL inh four times a day\n LEVOTHYROXINE 75 mcg by mouth once a day\n METOPROLOL TARTRATE 75 mg by mouth TID\n OMEPRAZOLE 20 mg by mouth daily\n TACROLIMUS 3mg by mouth twice a day\n DOCUSATE SODIUM 100 mg by mouth once a day\n INSULIN NPH HUMAN RECOMB [HUMULIN N] 44U units before breakfast, 12U at\n 4:30pm.\n INSULIN REGULAR HUMAN [HUMULIN R] - sliding scale four times a day\n Lasix 40 mg daily\n Bactrim TIW\n Tums prn\n .\n Medications on transfer:\n Insulin Sliding Scale\n NPH 44 units qam, 12 units qpm\n Ipratropium Bromide Neb 1 NEB IH QID\n Acetaminophen (Liquid) 1000 mg PO Q6H:PRN pain/fever\n Levothyroxine Sodium 75 mcg PO DAILY\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n Lidocaine 5% Patch 1 PTCH TD 12HR ON/OFF\n Metoprolol Tartrate 50 mg PO TID\n Pantoprazole 40 mg PO Q24H\n Calcium Carbonate 1250 mg PO TID\n Piperacillin-Tazobactam Na 4.5 g IV Q8H\n Docusate Sodium (Liquid) 100 mg PO BID\n Furosemide 40 mg PO DAILY\n Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR\n Tacrolimus 3 mg PO Q12H\n Vancomycin 1000 mg IV Q 24H\n Heparin 5000 UNIT SC TID\n Vitamin D 50,000 UNIT PO QTUES\n Past medical history:\n Family history:\n Social History:\n # Interstitial pulmonary fibrosis\n - home oxygen dependent 2-2.5L NC (etiology unknown, no biopsy)\n - recently titrated off prednisone as unresponsive\n # cor pulmonale\n # S/p Liver transplant for cryptogenic cirrhosis\n # Post-transplant lymphoproliferative disorder s/p CHOP and rituximab\n # Type 2 DM (without peripheral neuropathy)\n # HTN\n # Hypothyroidism\n # Diastolic dysfunction with LVEF of 65%\n # Cholecystectomy.\n # Appendectomy.\n # h/o of atrial fibrillation\n There is no family history of premature coronary artery disease or\n sudden death. Afib in sister\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, previously lived at home but recently discharged to\n rehab. Denies tobacco use.\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Flowsheet Data as of 02:56 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: 150 (147 - 150) bpm\n BP: 64/43(48) {64/43(48) - 83/50(58)} mmHg\n RR: 38 (38 - 40) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 66 Inch\n Total In:\n 501 mL\n PO:\n TF:\n IVF:\n 501 mL\n Blood products:\n Total out:\n 0 mL\n 80 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 421 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: see OMR for recent labs\n Imaging: CXR :\n low lung volumes. No obvious pulmonary edema or infiltrate compared to\n am.\n Spirometry :\n FEV1: 0.87(42%), FVC:0.97(33%), FEV1/FVC: 90(128%)\n .\n ECHO :\n The left atrium is moderately dilated. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%). There is no ventricular septal defect. The right ventricular\n free wall is hypertrophied. The right ventricular cavity is mildly\n dilated with mild global free wall hypokinesis. The ascending aorta is\n mildly dilated. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is no mitral valve\n prolapse. Trivial mitral regurgitation is seen. The left ventricular\n inflow pattern suggests impaired relaxation. The tricuspid valve\n leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , no change.\n ECG: ECG : MAT vs sinus tach w/ frequent PACs. Nl axis and\n intervals. Early RW progression. Nondiagnostic QWs inferiorly. NSSTTW\n changes. Compared to prior, no sig change.\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Patient tenuous at baseline. Acute decompensation seems to have\n occurred in the setting of SVT w/ RVR. No dramatic changes on CXR.\n Difficult to interpret pulmonary exam given baseline rales d/t IPF.\n Must also consider worsening pulmonary infection although already on\n broad spectrum antibiotics. Was intubated so could be set up for ASBL\n bacteria and other resistent organisms.\n - NIPPV\n - serial ABGs. If worsening respiratory acidosis, will intubate\n - cont vanco/zosyn day #\n - broaden antibiotic coverage with cipro\n - treat SVT as below\n - diuresis if BP will tolerate\n - nebs\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. Had similar episode on\n last MICU admission which did not tolerate beta blockers and required\n amio gtt. Again, associated with hypotension and may be contributing to\n respiratory distress. unclear inciting event. ? fever. At risk given\n underlying lung disease\n - amio bolus and gtt\n - d/c amio as able once converts\n - can attempt bolus IV lopressor if BP will tolerate\n - cont po beta blocker as BP will tolerate\n .\n # hypotension: likely due to RVR. In the setting of low grade fever,\n must also consider sepsis. Currently on broad spectrum abx.\n - cont vanco,zosyn as above with addition of cipro\n - pan culture\n - treat SVT as above\n - IVF boluses prn\n .\n # fever: new low grade temp this am. Patient immunosuppressed at\n baseline on tacrolimus. No leukocytosis this am. CXR unchanged. ?\n noninfectious etiologies. No increased sputum productive, abdominal\n pain, diarrhea.\n - panculture: blood, urine, sputum\n - broaden antibiotic coverage as above\n - repeat CBC stat with diff\n - check LFTs\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: reasonable BG control recently.\n - cont NPH per outpt doses. Half dose while NPO\n - cont insulin sliding scale\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - continue Tacrolimus at regular dose for now\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now\n - vit D\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: Intubation okay. CPR not indicated.\n .\n # Contact: , daughter \n .\n # Dispo: ICU\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Physician Attending / Resident Admission Note - MI",
"row_id": 357790,
"text": "Chief Complaint: respiratory distress\n PCP: , . \n Pulmonologist: , \n Heme/Onc: \n Cardiologist: \n HPI:\n For complete details, please refer to initial medicine admission note\n and MICU call out note . In brief, Ms. is a 73 yo\n female with PMH significant for ILD on .5L home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab who\n was initially admitted to hospital on after a mechanical fall for\n pain control. On patient had an aspiration event and hypoxia. The\n following day, she had evidence of aspiration on CXR and hypercarbic\n respiratory failure. At that time, goals of care were discussed with\n her HCP, her husband, as well as her daughter and they felt they would\n want intubation. She was made DNR as it was felt that CPR would not be\n indicated. She was transferred to the MICU.\n .\n In the MICU, she was intubated on for worsening hypercarbia. That\n evening she spiked a fever, went into AF vs MAT with HRs into the 160s,\n and hypotension to the 80s. She did not tolerate beta blockers at that\n time and was started on an amiodarone gtt. She was also started on\n empiric vancomycin and zosyn for possible aspiration pna. She received\n aggressive volume resuscitation and converted to NSR the following\n morning. Her amiodarone was discontinued given concern for worsening\n lung and liver disease. Her beta blocker was uptitrated. Antibiotics\n were briefly discontinued on and restarted on . She was\n eventually diuresed and was able to be extubated on . She was\n called out to the medical floor on .\n .\n While on the medical floor, she was continued on vancomycin and zosyn\n for presumed aspiration pna. She had no microbiology data to help guide\n therapy. She was continued on diuretics but has run I/O even per\n documentation. While on floor, SBPOs 100s, HRs 80s, RR 20s, O2 90s on\n 3LNC.\n .\n On the evening of transfer, trigger called for increased work of\n breathing. Upon floor evaluation, patient denied any subjective SOB. O2\n requirement the same at 90s n 3LNC and no significant change in RR.\n However, at ~ MN, patient went into irregular SVT (AF vs MAT) to 150s,\n T100.3, with SBPs into 90s, RR increased to 30s, and O2 sats low 90s\n on 4-6L. She received lopressor 5 mg IV x 2 without significant change\n in her HR and decrease in SBP to 80s. CXR repeated without significant\n change compared to this am. ABG showed 7.35/73/54.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Home medications:\n IPRATROPIUM BROMIDE 0.2 mg/mL inh four times a day\n LEVOTHYROXINE 75 mcg by mouth once a day\n METOPROLOL TARTRATE 75 mg by mouth TID\n OMEPRAZOLE 20 mg by mouth daily\n TACROLIMUS 3mg by mouth twice a day\n DOCUSATE SODIUM 100 mg by mouth once a day\n INSULIN NPH HUMAN RECOMB [HUMULIN N] 44U units before breakfast, 12U at\n 4:30pm.\n INSULIN REGULAR HUMAN [HUMULIN R] - sliding scale four times a day\n Lasix 40 mg daily\n Bactrim TIW\n Tums prn\n .\n Medications on transfer:\n Insulin Sliding Scale\n NPH 44 units qam, 12 units qpm\n Ipratropium Bromide Neb 1 NEB IH QID\n Acetaminophen (Liquid) 1000 mg PO Q6H:PRN pain/fever\n Levothyroxine Sodium 75 mcg PO DAILY\n Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN\n Lidocaine 5% Patch 1 PTCH TD 12HR ON/OFF\n Metoprolol Tartrate 50 mg PO TID\n Pantoprazole 40 mg PO Q24H\n Calcium Carbonate 1250 mg PO TID\n Piperacillin-Tazobactam Na 4.5 g IV Q8H\n Docusate Sodium (Liquid) 100 mg PO BID\n Furosemide 40 mg PO DAILY\n Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR\n Tacrolimus 3 mg PO Q12H\n Vancomycin 1000 mg IV Q 24H\n Heparin 5000 UNIT SC TID\n Vitamin D 50,000 UNIT PO QTUES\n Past medical history:\n Family history:\n Social History:\n # Interstitial pulmonary fibrosis\n - home oxygen dependent 2-2.5L NC (etiology unknown, no biopsy)\n - recently titrated off prednisone as unresponsive\n # cor pulmonale\n # S/p Liver transplant for cryptogenic cirrhosis\n # Post-transplant lymphoproliferative disorder s/p CHOP and rituximab\n # Type 2 DM (without peripheral neuropathy)\n # HTN\n # Hypothyroidism\n # Diastolic dysfunction with LVEF of 65%\n # Cholecystectomy.\n # Appendectomy.\n # h/o of atrial fibrillation\n There is no family history of premature coronary artery disease or\n sudden death. Afib in sister\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, previously lived at home but recently discharged to\n rehab. Denies tobacco use.\n Review of systems:\n Constitutional: Fatigue, Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema,\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Flowsheet Data as of 02:56 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: 150 (147 - 150) bpm\n BP: 64/43(48) {64/43(48) - 83/50(58)} mmHg\n RR: 38 (38 - 40) insp/min\n SpO2: 92%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 66 Inch\n Total In:\n 501 mL\n PO:\n TF:\n IVF:\n 501 mL\n Blood products:\n Total out:\n 0 mL\n 80 mL\n Urine:\n 80 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 421 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg.\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: see OMR for recent labs\n Imaging: CXR :\n low lung volumes. No obvious pulmonary edema or infiltrate compared to\n am.\n Spirometry :\n FEV1: 0.87(42%), FVC:0.97(33%), FEV1/FVC: 90(128%)\n .\n ECHO :\n The left atrium is moderately dilated. Left ventricular wall thickness,\n cavity size and regional/global systolic function are normal (LVEF\n >55%). There is no ventricular septal defect. The right ventricular\n free wall is hypertrophied. The right ventricular cavity is mildly\n dilated with mild global free wall hypokinesis. The ascending aorta is\n mildly dilated. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is no mitral valve\n prolapse. Trivial mitral regurgitation is seen. The left ventricular\n inflow pattern suggests impaired relaxation. The tricuspid valve\n leaflets are mildly thickened. There is moderate pulmonary artery\n systolic hypertension. There is no pericardial effusion.\n Compared with the prior study (images reviewed) of , no change.\n ECG: ECG : MAT vs sinus tach w/ frequent PACs. Nl axis and\n intervals. Early RW progression. Nondiagnostic QWs inferiorly. NSSTTW\n changes. Compared to prior, no sig change.\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Patient tenuous at baseline. Acute decompensation seems to have\n occurred in the setting of SVT w/ RVR. No dramatic changes on CXR.\n Difficult to interpret pulmonary exam given baseline rales d/t IPF.\n Must also consider worsening pulmonary infection although already on\n broad spectrum antibiotics. Was intubated so could be set up for ASBL\n bacteria and other resistent organisms.\n - NIPPV\n - serial ABGs. If worsening respiratory acidosis, will intubate\n - cont vanco/zosyn day #\n - broaden antibiotic coverage with cipro\n - treat SVT as below\n - diuresis if BP will tolerate\n - nebs\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. Had similar episode on\n last MICU admission which did not tolerate beta blockers and required\n amio gtt. Again, associated with hypotension and may be contributing to\n respiratory distress. unclear inciting event. ? fever. At risk given\n underlying lung disease\n - amio bolus and gtt\n - d/c amio as able once converts\n - can attempt bolus IV lopressor if BP will tolerate\n - cont po beta blocker as BP will tolerate\n .\n # hypotension: likely due to RVR. In the setting of low grade fever,\n must also consider sepsis. Currently on broad spectrum abx.\n - cont vanco,zosyn as above with addition of cipro\n - pan culture\n - treat SVT as above\n - IVF boluses prn\n .\n # fever: new low grade temp this am. Patient immunosuppressed at\n baseline on tacrolimus. No leukocytosis this am. CXR unchanged. ?\n noninfectious etiologies. No increased sputum productive, abdominal\n pain, diarrhea.\n - panculture: blood, urine, sputum\n - broaden antibiotic coverage as above\n - repeat CBC stat with diff\n - check LFTs\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: reasonable BG control recently.\n - cont NPH per outpt doses. Half dose while NPO\n - cont insulin sliding scale\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - continue Tacrolimus at regular dose for now\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now\n - vit D\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n .\n # Code status: Intubation okay. CPR not indicated.\n .\n # Contact: , daughter \n .\n # Dispo: ICU\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n Attending: history reviewed. Patient was seen and examined with Dr.\n . Mrs is followed by Drs and in the pulmonary\n clinic. DM, HTN, hypothyroidism, ILD without diffuse\n fibrosis/honeycombing, s/p liver transplant, s/p myeloprolif disorder\n s/p CHOP and Rituximab now with acute respiratory failure,\n pressor-dependent hypotension, and SVT.\n Admitted with resp failure, intubated in MICU , treated\n with Abx (no steroids), transferred to floor on . Triggered today\n for low grade fever 100.3, tachycardia to 150s, hypoxia on pO2 53 on 6\n liters O2. BP dropped following lopressor, transferred to MICU, put on\n BiPAP and amiodarone 150 mg IV given.\n Currently, MAP>60 on neo, HR 120 MAT vs. Afib, tolerating BiPAP 10/5,\n 100% O2. 7.35/67/385. Unclear what precipitated tachycardia today-\n fever/infection vs volume changes unlikely vs. PE possible but on\n prophylaxis. On Vanco/Zosyn, agree with broadening coverage with cipro.\n Hypotension likely due to SVT and beta blocker, doubt sepsis. Follow up\n cultures.\n Other issues as per Dr. \ns note. Code status: okay for intubation,\n no CPR. Husband is HCP.\n is critically ill and will remain in ICU. 35 minutes critical\n care time spent.\n ------ Protected Section Addendum Entered By: , MD\n on: 03:45 ------\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357890,
"text": " Admitted s/p mechanical fall @ home. L spine xrays revealed\n chronic L1 compression fx, but no other acute fx or dislocation. \n Desat 85% on 2L NP->increased o2 to 4L with sat's mid 90's. Then nausea\n with vomitting & desat requiring non rebreather->?? asp.\n pneumonia--started vanco & zosyn. Transferred to MICU where she had\n hypercarbic/hypoxic resp. failure requiring intubation. SVT vs Afib\n with RVR->amio gtt->po lopressor. Extubated successfully\n PICC line placed & transferred back to F7. became sl\n lethargic with RR 25-38 & O2 sat 88% 3L NP. Increased O2 6L with sats\n 90-93%. HR from SR->Afib with RVR 130-150's. Metoprolol 5mg VP x2 with\n no response. BP 92/60. Transferred to CCU as MICU border for amio gtt &\n ?? mask ventilation vs intubation. ABG 7.35/73/54/42.\n .H/O atrial fibrillation (Afib)\n Assessment:\n CONVERTED TO SR AT 830 AM .AMIODARONE DRIP DC ,CONTINUES ON NEO TO\n SUPPORT BP,FAILED ATTEMPT TO WEAN NEO DRIP.HUO 15 CC HR .\n Action:\n NEO TITRATED TO TO KEEP BP SYSTOLIC ABOVE 90 .PRESENTLY AT .75 MIC/KG\n ,SECOND BLOOD CX SENT\n Response:\n REMAINS IN SR C PACS ,PRESSER DEPENDENT\n Plan:\n CONTINUE TO MONITOR, WEAN NEO IF TOL ,CHECK LABS 4PM\n Respiratory failure, acute (not ARDS/)\n Assessment:\n OFF BIPAP 8AM TO 2 PM ,ABG 7.30/74/145/7 ATTEMPTED TO PLACE PT BACK ON\n BIPAP BUT TOO UNCOMFORTABLE.PT IS CONSIDERING INTUBATION IF NECESSARY\n ,FAMILY WIILL ACCEPT HER DECISION\n Action:\n MAINTAINING SAT ABOVE 92 ON COOL AEROSOL 50%, ,POSITIONING FOR\n COMFORT ,NPO EXCEPT FOR MEDS\n Response:\n PCO2 RISING,PT REFUSING CPAP\n Plan:\n CONTINUE TO MONITOR,,SUPPORTIVE CARE\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357945,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Coughing intermittently with ice chips, taking small pills with water\n without coughing.\n Action:\n HOB elevated 45-90 degrees.\n Response:\n Plan:\n Aspiration Precautions and instruct family and friends.\n Continue NPO except for chips until repeat bedside swallow study. Crush\n meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO for past\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-22 00:00:00.000",
"description": "ICU Attending Critical Care Note",
"row_id": 357872,
"text": "Clinician: Attending\n MICU ATTENDING Critical Care 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 Dr.\n \n note from earlier today, including the assessment and plan. I\n would emphasize and add the following points: 73 yo woman w/ h/o\n fibrotic ILD of unknown etiology recently off steroids, s/p liver\n transplant s/p PTLD on immunosuppression, h/o AF, DM, recent admit\n w/mechanical fall f/b aspiration in ICU for hypercarbic resp\n failure w/short term intubation c/b AF, hypotension, transiently on\n amio. Extubated , to medical floor on awaiting rehab.\n Triggered for increased work of breathing, but felt at baseline.\n Midnight tachy to 150\ns w/AF vs MAT, hypotension to 70\ns, new O2\n requirement w/ ABG on 6L 7.35/73/54. Treated with biPAP for\n respiratory distress. Reassessed code status and wished to be in ICU\n and have full care. Started on amio drip and bolus, Neo thru PICC for\n hypotension. Repeat 7.35/67/386 on BiPAP. No obvious significant\n infection despite low grade fever, added cipro to cover. Converted to\n NSR this am after coming off BiPAP.\n Awake and alert this AM. Exam notable for Tm 98.3 BP 103/45 HR 76 RR\n 12 with sat 97 on 2L. Appears cushingoid, crackles at bases, obese\n abdomen, lower extremity 1+ edema . Labs notable for WBC 18.4K, HCT 27,\n K+ 4, Cr 1.4. LFTs wnl. CXR with low lung volumes no obvious\n infiltrates.\n Agree with plan that respiratory and hemodynamic compromise likely due\n to atrial fibrillation. Now converted back to NSR after amio and will\n stop amio this am and try to increase beta blocker as pressor comes\n off. Will continue Vanco/Zosyn and hold cipro awaiting cultures.\n Watch WBC and ensure not rising. Continue tacrolimus for s/p liver\n transplant. Wean O2 as tolerated. No new therapy for lung disease.\n Continue discussions with family, primary care physician and\n consultants for overall plan of care. Begin to advance diet. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357943,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rated 1-severe. Coughing intermittently with ice chips, taking\n small pills with water without coughing.\n Action:\n HOB elevated 45-90 degrees.\n Response:\n Plan:\n Aspiration Precautions and instruct family and friends.\n Continue NPO except for chips until repeat bedside swallow study. Crush\n meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO for past\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357946,
"text": "Dysphagia\n Assessment:\n bedside swallow study revealed DOSS (Dysphagia Outcome Severity\n Scale) rating 1-severe, repeat exam and follow up video swallowing\n evaluation on rating improved to 7, WFL.\n Coughing intermittently with ice chips, taking small pills with water\n without coughing.\n Action:\n HOB elevated 45-90 degrees.\n Response:\n Plan:\n Aspiration Precautions and instruct family and friends.\n Continue NPO except for chips until repeat bedside swallow study. Crush\n meds in applesauce.\n Alteration in Nutrition\n Assessment:\n Pt has been NPO for past\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Hold all stool medications for now.\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357867,
"text": " Admitted s/p mechanical fall @ home. L spine xrays revealed\n chronic L1 compression fx, but no other acute fx or dislocation. \n Desat 85% on 2L NP->increased o2 to 4L with sat's mid 90's. Then nausea\n with vomitting & desat requiring non rebreather->?? asp.\n pneumonia--started vanco & zosyn. Transferred to MICU where she had\n hypercarbic/hypoxic resp. failure requiring intubation. SVT vs Afib\n with RVR->amio gtt->po lopressor. Extubated successfully\n PICC line placed & transferred back to F7. became sl\n lethargic with RR 25-38 & O2 sat 88% 3L NP. Increased O2 6L with sats\n 90-93%. HR from SR->Afib with RVR 130-150's. Metoprolol 5mg VP x2 with\n no response. BP 92/60. Transferred to CCU as MICU border for amio gtt &\n ?? mask ventilation vs intubation. ABG 7.35/73/54/42.\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357937,
"text": " Admitted s/p mechanical fall @ home. L spine xrays revealed\n chronic L1 compression fx, but no other acute fx or dislocation. \n Desat 85% on 2L NP->increased o2 to 4L with sat's mid 90's. Then nausea\n with vomitting & desat requiring non rebreather->?? asp.\n pneumonia--started vanco & zosyn. Transferred to MICU where she had\n hypercarbic/hypoxic resp. failure requiring intubation. SVT vs Afib\n with RVR->amio gtt->po lopressor. Extubated successfully\n PICC line placed & transferred back to F7. became sl\n lethargic with RR 25-38 & O2 sat 88% 3L NP. Increased O2 6L with sats\n 90-93%. HR from SR->Afib with RVR 130-150's. Metoprolol 5mg VP x2 with\n no response. BP 92/60. Transferred to CCU as MICU border for amio gtt &\n ?? mask ventilation vs intubation. ABG 7.35/73/54/42.\n .H/O atrial fibrillation (Afib)\n Assessment:\n CONVERTED TO SR AT 830 AM .AMIODARONE DRIP DC ,UNTIL 1720 WHEN SHE\n AGAIN WENT INTO AFIB 139,BP 80S.STABLIZED BY RESTARTING AMIODARONE C\n 150 MG BOLLUS AND INCREASING NEO TO .89 MIC .PT DENIES CP ,SOB .\n Action:\n NEO TITRATED TO TO KEEP BP SYSTOLIC ABOVE 90 .PRESENTLY AT .89 MIC/KG\n ,SECOND BLOOD CX,CBC,LYTES SENT\n Response:\n REMAINS IN SR C PACS ,PRESSER DEPENDENT\n Plan:\n CONTINUE TO MONITOR, WEAN NEO IF TOL\n Respiratory failure, acute (not ARDS/)\n Assessment:\n OFF BIPAP 8AM TO 2 PM ,ABG 7.30/74/145/7 ATTEMPTED TO PLACE PT BACK ON\n BIPAP BUT TOO UNCOMFORTABLE.PT AGREES TO INTUBATION IF NECESSARY,BUT\n OTHERWISE IS DNR\n Action:\n MAINTAINING SAT ABOVE 92 ON COOL AEROSOL 50%, ,POSITIONING FOR\n COMFORT ,NPO EXCEPT FOR MEDS\n Response:\n PCO2 RISING,PT REFUSING CPAP\n Plan:\n CONTINUE TO MONITOR,,SUPPORTIVE CARE ,TRY BIPAP AGAIN LATER\n"
},
{
"category": "Respiratory ",
"chartdate": "2125-12-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 358102,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 57.8 None\n Ideal tidal volume: 231.2 / 346.8 / 462.4 mL/kg\n Airway\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Ventilation Assessment\n Non-invasive ventilation assessment: Tolerated well; Comments: Pt wore\n NIV for 3 hours today & placed on again at 4:45pm.\n Plan\n Next 24-48 hours: Continue with NIV when indicated.\n"
},
{
"category": "Case Management ",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Discharge Planning Note",
"row_id": 358542,
"text": "TITLE: Discharge Planning\n Update\n Rehab following for post-acute care prior to MICU admission.\n Previously clinically accepted for the . Now clinically accepted\n for MACU. RNs will continue to follow patient.\n NCM available for further assistance anytime at .\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358638,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with 70% neb with shallow resps and sats >95%, then resp pattern\n becoming more paradoxical in motion. Pt\ns mentation changed from alert\n and oriented X3 to , easily arousable, but oriented only X2.\n Action:\n Team in to assess patient, ABG done and pt placed back on mask\n ventilation. Patient\ns family called to come in. Pt then became\n somnolent, difficult to arouse. Anesthesia to pt\ns bedside, setting up\n to intubate. Pt opened her eyes and said,\nwhat are you doing? \n you know I\nm not supposed to be intubated\nll never get off of the\n machine.\n Pt stayed on bi-pap, attending physician notified and came\n in to talk with patient and her family. While patient and family\n were discussing options, pt again became somnolent. Pt\ns daughter\n (HCP) expressed her feelings that her mother, if she were\n thinking clearly, would say that she would not want to be reintubated\n and live on a ventilator. Patient\ns status was changed to comfort\n focused care. Pt given IV ativan and morphine. Respirations became\n more labored and patient diaphoretic. Morphine drip added. Pt\n husband, daughter, 2 sisters and grandson at her bedside. Catholic\n priest in to anoint.\n Response:\n Pt currently non-responsive with sats in the 60\n Plan:\n Continue to keep patient comfortable. Support family, provide\n information as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358318,
"text": "Dysphagia\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n .H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 357866,
"text": ".H/O atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358240,
"text": "Dysphagia\n Assessment:\n Pt intermittently coughing after ice chips. Able to take pills one at\n time without coughing. Had been rated DOSS 1 but improved to 7 on\n .\n Action:\n Keeping HOB elevated to 45-90 degrees.\n Response:\n Continues to cough intermittently\n Plan:\n Follow aspiration precautions and instruct family also.\n Alteration in Nutrition\n Assessment:\n Remains NPO. Pt has been mostly NPO during this admission based on\n nutrition consults and documentation\n Action:\n In setting of requiring freq CPAP, the plan is to keep NPO to prevent\n aspiration\n Response:\n Pt not hungry but asking for ice chips.\n Plan:\n Nutrition consults to reassess malnutrition.\n Impaired Skin Integrity\n Assessment:\n Yeast infection and rash remains bright red with skin starting peel.\n Action:\n Cleansing with wound cleaner followed by Nystatin and lidocaine\n ointments. Started Miconazole Nitrate vaginal suppositories for 3\n days.\n Response:\n Vaginal discharge has improved dramatically with only small amount\n noted. Rash appears less inflamed.\n Plan:\n Continue treatment as prescribed. Frequent turning and cleansing to\n keep area dry.\n Hypotension (not Shock)\n Assessment:\n SBP 90-100.\n Action:\n Neo at .6mcg/kg/min was weaned slowly off over the night.\n Response:\n SBP stable with MAPS >60.\n Plan:\n Continue to maintain MAP>60 and SBP >90 with Neo on standby.\n .H/O atrial fibrillation (Afib)\n Assessment:\n HR 120-140\ns RAF Brief episodes of NSR rate 90\n Action:\n Received NS 500cc x1 Lopressor remains on hold. Amiodarone at 200mg po\n s/p Amiodarone infusion .\n Response:\n HR remains 130-150 without change in rate.\n Plan:\n Continue to monitor and keep team aware of rate.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS rales though out. O2 70% with sats 92-96% on cool neb. RR 30-40\n and requiring CPAP for most of the day RR 20\ns when comfortable. Pt\n feeling that she is going to die and all family came in at 2100.\n Action:\n Removed at 2130 due to family present and again at 0500 due to pressure\n on bridge of nose. Attending and intern/resident had family\n meeting to reassess DNI or comfort measures.\n Response:\n Pt does maintain her sats but becomes sommulent after 2-3 hrs. Pt\n talking about when she is going to die.\n Plan:\n Continue to keep pt comfortable and keep pt and family aware of the POC\n as discussed in multi disciplinary rounds.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Family Meeting Note",
"row_id": 358157,
"text": "TITLE: Attending- family meeting\n I met with Mrs and her daughter at 7PM to discuss the severity\n of her illness and poor response to corticosteroid therapy and poor\n prognosis. We made a plan to discuss further tomorrow. Pt\ns daughter\n then requested another meeting at 10PM. I met with her and her\n boyfriend, with Dr . Pt has been extremely anxious and has been\n increasingly talking about being in the process of dying today,\n according to pt\ns daughter and her nurse . Pt\ns daughter\n expressed that the family (including her father, pt\ns husband) feels\n intubation would not be in her interest, that they understand that her\n therapeutic options are extremely limited. They are worried that pt is\n so scared of dying that she can\nt agree to avoid intubation. We made a\n plan to meet together with pt tomorrow to discuss the lung disease,\n reassure that a decision to DNI will not be abandonment, that she will\n continue to be very closely cared for and we can help her\n symptomatically even if her resp failure worsens. In the meantime she\n remains full code.\n Critically ill.\n 30 minutes.\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 358269,
"text": "Chief Complaint: rapid Afib, 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 - 1 liter fluid challenege, off Neo, still in Afib with RVR at times\n - struggling with issues around code status as noted by Dr in\n prior entries\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 08:07 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n Bactrim prophy\n Tacro\n Vit D\n Ca\n Synthroid\n PPI\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 09:18 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: 35.8\nC (96.5\n HR: 138 (80 - 144) bpm\n BP: 104/53(65) {81/47(56) - 109/79(84)} mmHg\n RR: 30 (19 - 39) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 592 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,670 mL\n 352 mL\n Blood products:\n Total out:\n 460 mL\n 229 mL\n Urine:\n 460 mL\n 229 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 363 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 98%\n ABG: ///32/\n Ve: 11.3 L/min\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Neuro\n Labs / Radiology\n 8.5 g/dL\n 286 K/uL\n 107 mg/dL\n 2.3 mg/dL\n 32 mEq/L\n 4.0 mEq/L\n 26 mg/dL\n 92 mEq/L\n 134 mEq/L\n 24.0 %\n 10.2 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n Plt\n 393\n 429\n 380\n 286\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Resp Distress: likely due to underlying ILD with superimposed\n atrial fibrillation and some mild vol overload. . Respiratory status\n remains tenuous and will likely need intermittent periods of BiPAP.\n 2. Hemodynamics: AF has recurred and we have restarted\n amiodarone. Continue pressor to maintain perfusion pressureWill\n continue Vanco/Zosyn and hold cipro awaiting cultures.\n 3. ARF: Critical to check all med levels esp. tacrolimus for s/p\n liver transplant and Vanco.\n 4. Continue discussions with family, primary care physician and\n consultants for overall plan of care. Unable to advance diet.\n Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 45 min\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: sc hep\n Stress ulcer: PPI\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358280,
"text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n - Received 1L NS following rounds\n - HR increased from 110's to 140s over the course of the day\n - Spent time on and off CPAP\n - Pt remained on phenylephrine\n - Patient and subsequent separate Family Meeting with Dr. \n (Patients outpatient pulmonologist).\n The patient reports that she feels the same as yesterday. She has no\n complaints other than her shortness of breath currently.\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 141 (80 - 141) bpm\n BP: 92/69(74) {81/43(56) - 109/75(78)} mmHg\n RR: 37 (19 - 39) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 229 mL\n PO:\n TF:\n IVF:\n 2,670 mL\n 229 mL\n Blood products:\n Total out:\n 460 mL\n 149 mL\n Urine:\n 460 mL\n 149 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 96%\n ABG: 7.25/74/141/31/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 282\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg. tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 380 K/uL\n 8.8 g/dL\n 115 mg/dL\n 2.2 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 93 mEq/L\n 132 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Most likely worsening natural course of her ILD with worsening\n pulmonary edema secondary to a fib with RVR, improved with rate\n control. Patient tenuous at baseline. Treating for VAP in addition to\n underlying lung disease, on vanco/zosyn day #\n - NIPPV, alternate CPAP with face mask\n - serial ABGs. Seems to be stable, If worsening respiratory acidosis,\n will intubate\n - treat SVT as below\n - continue nebulizer treatments\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. The patient was loaded\n with amiodarone drip, started on amiodarone 200mg QD today. Had\n similar episode on last MICU admission which did not tolerate beta\n blockers and required amio gtt. The patient does not tolerate\n betablockers given hypotensive, thus will attempt to rate control with\n amiodarone only.\n - will continue to monitor on telemetry\n - can attempt bolus IV lopressor if BP will tolerate\n - cont po beta blocker as BP will tolerate\n .\n # hypotension: likely due to RVR, and diastolic heart failure. In the\n setting of low grade fever, must also consider sepsis especially given\n immunosupression . Currently on broad spectrum abx of vanc/zosyn\n - will culture if spikes, follow blood cultures\n - treat SVT as above\n - Will give 1L of NS today, will repeat as tolerated\n - Will continue phenylephrine drip as needed, attempt to wean\n .\n # fever: new low grade temp this am. See hypotension above. On broad\n spectrum Abs. Follow culture\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: Even though patient is NPO BG have been very elevated. Will\n continue to monitor QID and adjust sliding scale accordingly. Will use\n half dose of outpatient insulin while NPO\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - continue Tacrolimus at regular dose for now\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now given tenuous respiratory status\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358285,
"text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n - Received 1L NS following rounds\n - HR increased from 110's to 140s over the course of the day\n - Spent time on and off CPAP\n - Pt remained on phenylephrine\n - Patient and subsequent separate Family Meeting with Dr. \n (Patients outpatient pulmonologist).\n The patient reports that she feels the same as yesterday. She has no\n complaints other than her shortness of breath currently.\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 141 (80 - 141) bpm\n BP: 92/69(74) {81/43(56) - 109/75(78)} mmHg\n RR: 37 (19 - 39) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 229 mL\n PO:\n TF:\n IVF:\n 2,670 mL\n 229 mL\n Blood products:\n Total out:\n 460 mL\n 149 mL\n Urine:\n 460 mL\n 149 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 96%\n ABG: 7.25/74/141/31/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 282\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg. tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 380 K/uL\n 8.8 g/dL\n 115 mg/dL\n 2.2 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 93 mEq/L\n 132 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Most likely worsening natural course of her ILD with worsening\n pulmonary edema secondary to a fib with RVR, improved with rate\n control. Patient tenuous at baseline. Treating for VAP in addition to\n underlying lung disease, on vanco/zosyn day #. Will renally dose\n zosyn at 2.25mg starting today.\n - NIPPV, alternate CPAP with face , need to increase time on\n CPAP\n - will monitor respiratory status closely, if any change will consider\n intubation, overall plan to be discussed with patient and family today\n with her primary pulmonologist Dr. \n - treat SVT as below\n - continue nebulizer treatments\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. The patient was loaded\n with amiodarone drip, started on amiodarone 200mg QD yesterday. Will\n continue to rate control with lopressor as tolerated by BP.\n Spontaneously converts into NSR\n - will continue to monitor on telemetry\n .\n # hypotension: resolved, likely was due to RVR, and diastolic heart\n failure\n - responded to rate control and IV fluids, will repeat today\n as needed.\n - Will restart pressors as needed\n .\n #. ARF: likely prerenal secondary to hypotension. Will reassess after\n fluid resuscitation this PM. If continues to deteriorate will get\n further workup. Given the patient has concominant anemia, will use\n PRBCs for resuscitation. Will continue to renally dose medications.\n Will check vanc and tacrolimus level.\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: Even though patient is NPO BG have been very elevated. Will\n continue to monitor QID and adjust sliding scale accordingly. Will use\n half dose of outpatient insulin while NPO\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids.\n - continue supplemental O2\n - no steroids for now\n - alb/atrovent nebs\n .\n # PTLD: no known active issues currently.\n - check LFTs as above\n - continue Tacrolimus at regular dose for now\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now given tenuous respiratory status\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: heparin sc tid\n Stress ulcer:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358287,
"text": "Chief Complaint: respiratory distress\n 24 Hour Events:\n - Received 1L NS following rounds\n - HR increased from 110's to 140s over the course of the day\n - Spent time on and off CPAP\n - Pt remained on phenylephrine\n - Patient and subsequent separate Family Meeting with Dr. \n (Patients outpatient pulmonologist).\n The patient reports that she feels the same as yesterday. She has no\n complaints other than her shortness of breath currently.\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Ciprofloxacin - 03:00 AM\n Vancomycin - 09:00 PM\n Piperacillin - 12:30 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 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 07:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37.2\nC (99\n HR: 141 (80 - 141) bpm\n BP: 92/69(74) {81/43(56) - 109/75(78)} mmHg\n RR: 37 (19 - 39) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 2,670 mL\n 229 mL\n PO:\n TF:\n IVF:\n 2,670 mL\n 229 mL\n Blood products:\n Total out:\n 460 mL\n 149 mL\n Urine:\n 460 mL\n 149 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,210 mL\n 80 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 306 (249 - 473) mL\n PS : 12 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 20 cmH2O\n SpO2: 96%\n ABG: 7.25/74/141/31/2\n Ve: 11.3 L/min\n PaO2 / FiO2: 282\n Physical Examination\n General Appearance: Well nourished, moon facies, buffalo hump\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: cannot assess JVP d/t habitus\n Cardiovascular: (S1: Normal), (S2: Normal), irreg irreg. tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffusely, greatest at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, time, Movement: Purposeful,\n Tone: Normal\n Labs / Radiology\n 380 K/uL\n 8.8 g/dL\n 115 mg/dL\n 2.2 mg/dL\n 31 mEq/L\n 3.6 mEq/L\n 25 mg/dL\n 93 mEq/L\n 132 mEq/L\n 25.3 %\n 16.9 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n WBC\n 18.4\n 18.4\n 16.9\n Hct\n 26.9\n 27.0\n 25.3\n Plt\n 393\n 429\n 380\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n TCO2\n 39\n 38\n 34\n Glucose\n 132\n 110\n 379\n 115\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.1 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Most likely worsening natural course of her ILD with worsening\n pulmonary edema secondary to a fib with RVR, improved with rate\n control. Patient tenuous at baseline. Treating for VAP in addition to\n underlying lung disease, on vanco/zosyn day #. Will renally dose\n zosyn at 2.25mg starting today.\n - NIPPV, alternate CPAP with face , need to increase time on\n CPAP\n - will monitor respiratory status closely, if any change will consider\n intubation, overall plan to be discussed with patient and family today\n with her primary pulmonologist Dr. \n - treat SVT as below\n - continue nebulizer treatments\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. The patient was loaded\n with amiodarone drip, started on amiodarone 200mg QD yesterday. Will\n continue to rate control with lopressor as tolerated by BP.\n Spontaneously converts into NSR\n - will continue to monitor on telemetry\n .\n # hypotension: resolved, likely was due to RVR, and diastolic heart\n failure\n - responded to rate control and IV fluids, will repeat today\n as needed.\n - Will restart pressors as needed\n .\n #. ARF: likely prerenal secondary to hypotension. Will reassess after\n fluid resuscitation this PM. If continues to deteriorate will get\n further workup. Given the patient has concominant anemia, will use\n PRBCs for resuscitation. Will continue to renally dose medications.\n Will check vanc and tacrolimus level.\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: Even though patient is NPO BG have been very elevated. Will\n continue to monitor QID and adjust sliding scale accordingly. Will use\n half dose of outpatient insulin while NPO\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids. See\n above for plan.\n .\n # PTLD: no known active issues currently. Will check tacrolimus trough\n today given ARF. Will dose following level.\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now given tenuous respiratory status\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT: heparin sc tid\n Stress ulcer:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2125-12-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 358386,
"text": "Pt admitted to after a fall, lumbar spine films show\n chronic L1 compression. adm to MICU after desaturating, ? asp\n event. Intubated, on antibiotics. Also with SVT vs AR with RVR,\n started on Amiodarone and lopressor. extubated, sent to\n . noted to be lethargic with ^^RR, falling satas. Also in\n AF with RVR. Sent to CCU (MICU service). Placed on CPAP.\n Dysphagia\n Assessment:\n Failed swallowing study this admission, however, able to take pills\n with water without coughing or throat clearing.\n Action:\n HOB ^^ with pills, pills given one at a time. Remains NPO otherwise\n d/t need for CPAP and ? of intubation. Received full dose of am NPH\n after discussing with team, as pt\ns BS\ns were high all day yesterday\n despite being NPO and full dose NPH.\n Response:\n No coughing/throat clearing. 1700 BS 80, MICU team notified, to give pt\n milk and decrease insulin to\n dose while NPO\n Plan:\n Continue with HOB^^ with pills, pills one at a time. Remains NPO\n otherwise d/t use of CPAP.\n dose NPH for now.\n Impaired Skin Integrity\n Assessment:\n Yeast infection around perineal and buttocks: rash remains red with\n skin peeling.\n Action:\n Cleansing with wound cleaner followed by Nystatin and lidocaine\n ointments. Started Miconazole Nitrate vaginal suppositories for 3\n days. Repositioned at least q 2hours\n Response:\n Vaginal discharge has improved as per report. Rash appears less\n inflamed.\n Plan:\n Continue treatment as prescribed. Frequent turning and cleansing to\n keep area dry.\n .H/O atrial fibrillation (Afib)\n Assessment:\n In AF rate of 140\ns this am.\n Action:\n Able to take Amiodarone and lopressor this am.\n Response:\n Converted to NSR @ 0930. Maintaining SBP >92 (pressure measured 82 X1\n when pt turned on right side with NBP cuff on L arm. SBP rechecked in\n R leg\n94).\n Plan:\n Continue to administer Amiodarone and lopressor as ordered. Monitor\n lytes. Follow HR/rhythm/BP\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 70% cool neb with sats >92%. Lungs with crackles ^, pt has\n paradoxical resp pattern. RR in high 30\ns this am.\n Action:\n Sats monitored continuously. No fall in sat below 92%. Receiving\n atrovent nebs.\n Response:\n Pt states breathing is better than yesterday. RR noted to be lower\n after converting to NSR (low 30\ns to high 20\n Plan:\n Continue to monitor closely, cpap as needed. Dr. to come in today\n to further clarify DNR status\nplease page MICU team when Dr. \n arrives.\n ------ Protected Section ------\n Dr in to see patient. Would like to have family meeting tomorrow,\n and is available between 1 and 3:30 pm. Would like pt\ns husband and\n daughter present.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:17 ------\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358487,
"text": "Chief Complaint:\n 24 Hour Events:\n - Pt had desaturation down to low 90's while on face mask during the\n day. ABG showed relative hypoxia. Restarted on CPAP and O2 sat came\n up to 96%. During the episode the patient was in a fib with a rate in\n the 110's.\n - Pt weaned off phenylephrine\n - Patient and subsequent separate Family Meeting with Dr. \n (Patients outpatient pulmonologist) at 1500 today (need to let Dr. \n know)\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 118 (73 - 144) bpm\n BP: 93/46(59) {86/34(26) - 117/84(89)} mmHg\n RR: 30 (18 - 37) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 1,139 mL\n 267 mL\n PO:\n 640 mL\n 100 mL\n TF:\n IVF:\n 499 mL\n 167 mL\n Blood products:\n Total out:\n 579 mL\n 163 mL\n Urine:\n 579 mL\n 163 mL\n NG:\n Stool:\n Drains:\n Balance:\n 560 mL\n 104 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 375 (375 - 375) mL\n RR (Set): 0\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 70%\n PIP: 18 cmH2O\n SpO2: 95%\n ABG: 7.24/75/75/29/1\n Ve: 6.5 L/min\n PaO2 / FiO2: 150\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 266 K/uL\n 8.3 g/dL\n 64 mg/dL\n 2.4 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.0 %\n 8.3 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n 09:58 PM\n 05:30 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n 8.3\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n 24.0\n Plt\n 393\n 429\n 380\n 286\n 266\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n 2.4\n TCO2\n 39\n 38\n 34\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n 64\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 358488,
"text": "Chief Complaint:\n 24 Hour Events:\n - Pt had desaturation down to low 90's while on face during the\n day. ABG showed relative hypoxia. Restarted on CPAP and O2 sat came\n up to 96%. During the episode the patient was in a fib with a rate in\n the 110's.\n - Pt weaned off phenylephrine\n - Patient and subsequent separate Family Meeting with Dr. \n (Patients outpatient pulmonologist) at 1500 today (need to let Dr. \n know)\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin - 12:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 118 (73 - 144) bpm\n BP: 93/46(59) {86/34(26) - 117/84(89)} mmHg\n RR: 30 (18 - 37) insp/min\n SpO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 94.1 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 1,139 mL\n 267 mL\n PO:\n 640 mL\n 100 mL\n TF:\n IVF:\n 499 mL\n 167 mL\n Blood products:\n Total out:\n 579 mL\n 163 mL\n Urine:\n 579 mL\n 163 mL\n NG:\n Stool:\n Drains:\n Balance:\n 560 mL\n 104 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 375 (375 - 375) mL\n RR (Set): 0\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 70%\n PIP: 18 cmH2O\n SpO2: 95%\n ABG: 7.24/75/75/29/1\n Ve: 6.5 L/min\n PaO2 / FiO2: 150\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 266 K/uL\n 8.3 g/dL\n 64 mg/dL\n 2.4 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.0 %\n 8.3 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n 09:58 PM\n 05:30 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n 8.3\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n 24.0\n Plt\n 393\n 429\n 380\n 286\n 266\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n 2.4\n TCO2\n 39\n 38\n 34\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n 64\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Assessment and Plan\n 73 yo female with PMH significant for ILD on home O2, diastolic CHF,\n cor pulmonale, s/p liver transplant on immunosuppression,\n post-transplant myeloproliferative disorder s/p CHOP and rituximab\n transferred to ICU for respiratory distress.\n .\n # respiratory distress: hypercarbic and hypoxic respiratory failure.\n Most likely worsening natural course of her ILD with worsening\n pulmonary edema secondary to a fib with RVR, improved with rate\n control. Patient tenuous at baseline. Treating for VAP in addition to\n underlying lung disease, on vanco/zosyn day #. Will renally dose\n zosyn at 2.25mg starting today.\n - NIPPV, alternate CPAP with face , need to increase time on\n CPAP\n - will monitor respiratory status closely, if any change will consider\n intubation, overall plan to be discussed with patient and family today\n with her primary pulmonologist Dr. \n - treat SVT as below\n - continue nebulizer treatments\n - No indication for steroids. Has not been responsive to steroids in\n the past\n .\n # SVT: appears to be AF vs MAT on tele and ECG. The patient was loaded\n with amiodarone drip, started on amiodarone 200mg QD yesterday. Will\n continue to rate control with lopressor as tolerated by BP.\n Spontaneously converts into NSR\n - will continue to monitor on telemetry\n .\n # hypotension: resolved, likely was due to RVR, and diastolic heart\n failure\n - responded to rate control and IV fluids, will repeat today\n as needed.\n - Will restart pressors as needed\n .\n #. ARF: likely prerenal secondary to hypotension. Will reassess after\n fluid resuscitation this PM. If continues to deteriorate will get\n further workup. Given the patient has concominant anemia, will use\n PRBCs for resuscitation. Will continue to renally dose medications.\n Will check vanc and tacrolimus level.\n .\n # s/p fall: no evidence of fracture. Pain controlled currently.\n - cont lidocaine patch, tylenol\n - avoid narcotics given tenuous respiratory status\n - PT\n .\n # DM: Even though patient is NPO BG have been very elevated. Will\n continue to monitor QID and adjust sliding scale accordingly. Will use\n half dose of outpatient insulin while NPO\n .\n # ILD: unclear etiology. Followed by Pulm. Refractory to steroids. See\n above for plan.\n .\n # PTLD: no known active issues currently. Will check tacrolimus trough\n today given ARF. Will dose following level.\n .\n # Hypothyroidism: TSH normal this admission. Continue Levothyroxine\n .\n # Access: PICC, PIV\n .\n # FEN: NPO for now given tenuous respiratory status\n .\n # Prophylaxis: Heparin SC 5000 tid, PPI\n - Bactrim M/W/F\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 358539,
"text": "Chief Complaint: 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 24 Hour Events:\n Was on face mask for hours yesterday but desaturated required BIPAP\n again overnight.\n Worsening resp distress.\n 7.24/75/75 on venti mask this AM\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:33 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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: Dyspnea\n Flowsheet Data as of 10:25 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: 35.9\nC (96.6\n HR: 86 (73 - 123) bpm\n BP: 123/58(71) {86/34(38) - 123/84(89)} mmHg\n RR: 27 (18 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 1,139 mL\n 644 mL\n PO:\n 640 mL\n 340 mL\n TF:\n IVF:\n 499 mL\n 304 mL\n Blood products:\n Total out:\n 579 mL\n 223 mL\n Urine:\n 579 mL\n 223 mL\n NG:\n Stool:\n Drains:\n Balance:\n 560 mL\n 421 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 375 (375 - 375) mL\n RR (Set): 0\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 70%\n PIP: 18 cmH2O\n SpO2: 95%\n ABG: 7.24/75/75/29/1\n Ve: 6.5 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Gen obese female, lying in bed, resp distress, somnelent\n HEENT: o/p dry\n CV: irreg irreg\n Chest: diffuse inspiratory rales\n Abd obese soft Nt + BS\n Ext 2+ edema\n Neuro : somnolent but arousable\n Labs / Radiology\n 8.3 g/dL\n 266 K/uL\n 64 mg/dL\n 2.4 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.0 %\n 8.3 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n 09:58 PM\n 05:30 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n 8.3\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n 24.0\n Plt\n 393\n 429\n 380\n 286\n 266\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n 2.4\n TCO2\n 39\n 38\n 34\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n 64\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Vanco 22.6\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n 1. Respiratory Failure: Significantly worse this AM likely due to\n volume overload and progressive CO2 retention. Will try NIPPV again\n this AM but heading toward reintubation. Will call family and try to\n move up family meeting\n 2. ARF: ATN in setting of hypotension and repeated episodes of AF\n with RVR. Art this point we are forced to give Lasix to try to help her\n resp status\n 3. Afib\n on Amio\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: family meeting planned for 3 PM with Dr and MICU\n team\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2125-12-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 358537,
"text": "Chief Complaint: 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 24 Hour Events:\n Was on face mask for hours yesterday but desaturated required BIUPAP\n again overnight./\n 7.24/75/75 on venti mask this AM\n Allergies:\n Codeine\n Unknown;\n Oxycodone/Acetaminophen (Oral) (Oxycodone Hcl/Acetaminophen\n Unknown;\n Morphine Sulfate\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:00 PM\n Piperacillin - 12:00 AM\n Piperacillin/Tazobactam (Zosyn) - 08:33 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:00 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: Dyspnea\n Flowsheet Data as of 10:25 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: 35.9\nC (96.6\n HR: 86 (73 - 123) bpm\n BP: 123/58(71) {86/34(38) - 123/84(89)} mmHg\n RR: 27 (18 - 36) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 92.6 kg (admission): 90.5 kg\n Height: 66 Inch\n Total In:\n 1,139 mL\n 644 mL\n PO:\n 640 mL\n 340 mL\n TF:\n IVF:\n 499 mL\n 304 mL\n Blood products:\n Total out:\n 579 mL\n 223 mL\n Urine:\n 579 mL\n 223 mL\n NG:\n Stool:\n Drains:\n Balance:\n 560 mL\n 421 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 375 (375 - 375) mL\n RR (Set): 0\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 70%\n PIP: 18 cmH2O\n SpO2: 95%\n ABG: 7.24/75/75/29/1\n Ve: 6.5 L/min\n PaO2 / FiO2: 150\n Physical Examination\n Labs / Radiology\n 8.3 g/dL\n 266 K/uL\n 64 mg/dL\n 2.4 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 28 mg/dL\n 92 mEq/L\n 133 mEq/L\n 24.0 %\n 8.3 K/uL\n [image002.jpg]\n 02:50 AM\n 03:20 AM\n 12:24 PM\n 03:48 PM\n 04:50 AM\n 07:21 AM\n 12:34 AM\n 06:01 AM\n 09:58 PM\n 05:30 AM\n WBC\n 18.4\n 18.4\n 16.9\n 10.2\n 8.3\n Hct\n 26.9\n 27.0\n 25.3\n 24.0\n 24.0\n Plt\n 393\n 429\n 380\n 286\n 266\n Cr\n 1.4\n 1.6\n 1.8\n 2.2\n 2.3\n 2.4\n TCO2\n 39\n 38\n 34\n 34\n Glucose\n 132\n 110\n 379\n 115\n 107\n 64\n Other labs: PT / PTT / INR:14.1/29.3/1.2, ALT / AST:, Alk Phos / T\n Bili:96/0.4, Differential-Neuts:85.4 %, Lymph:11.4 %, Mono:2.2 %,\n Eos:0.8 %, Lactic Acid:0.9 mmol/L, LDH:183 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.5 mg/dL, PO4:5.2 mg/dL\n Vanco 22.6\n Assessment and Plan\n DYSPHAGIA\n ALTERATION IN NUTRITION\n IMPAIRED SKIN INTEGRITY\n HYPOTENSION (NOT SHOCK)\n .H/O ATRIAL FIBRILLATION (AFIB)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 01:50 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: family meeting planned for 3 PM with Dr and MICU\n team\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-17 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1052686,
"text": " 2:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: non heparinized PICC placement please\n Admitting Diagnosis: S/P FALL\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with need for PICC access, IV team unable to place PICC\n REASON FOR THIS EXAMINATION:\n non heparinized PICC placement please\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for phlebotomy and antibiotics. The procedure was\n explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Drs. and (the attending radiologist) who was\n present for 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 The wire would not pass into the axilla, venogram showed stenosis of the\n basilic, with an acute angulation before passage into the central veins. The\n right brachial vein was then punctured under direct ultrasound guidance. Hard\n copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel- away sheath was then placed over a\n guidewire and a 5Fr PICC line measuring 37 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.\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 Fr Vaxcel\n double lumen PASV, PICC line placement via the right brachial venous\n approach. Final internal length is 37 cm, with the tip positioned in SVC. The\n line is ready to use.\n\n Of note the right basilic vein is narrowed and angulated prior to reaching the\n central veins, and is not amenable to central line placement.\n\n (Over)\n\n 2:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: non heparinized PICC placement please\n Admitting Diagnosis: S/P FALL\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053335,
"text": " 12:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, fluid, interval change.\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73F with ILD, s/p liver transplant, here with fall complicated by resp arrest\n and MICu stay. On floor, now with RVR, worsening hypoxia, slight fever.\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, fluid, interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH FROM AT 0053 HOURS\n\n HISTORY: Status post liver transplant and with interstitial lung disease.\n Respiratory arrest and in the ICU previously. Now with worsening hypoxia and\n slight fever. Evaluate for infiltrate and fluid.\n\n COMMENT: AP view of chest provided. Comparison is made to at 0924.\n\n The lungs are hypoinflated. Linear opacities are seen bilaterally compatible\n with patient's history of interstitial lung disease. There is prominence of\n the central pulmonary vasculature, which may be due to pulmonary arterial\n hypertension.\n\n The right PICC is again seen to terminate in the region of superior vena cava.\n Pneumobilia and surgical clips in the upper abdomen. Calcification in aortic\n arch.\n\n IMPRESSION: No significant change. No radiographic evidence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1052134,
"text": " 3:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate? fluid?\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with worsening resp failure, now in ICU\n REASON FOR THIS EXAMINATION:\n infiltrate? fluid?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Worsening respiratory failure.\n\n FINDINGS: In comparison with study of , the tip of the endotracheal tube\n lies about 1.5 cm above the carina. The tube is directly facing the right\n side of the trachea and could probably be better centered.\n\n Lower lung volumes than on the previous study. Continued enlargement of the\n cardiac silhouette with interstitial changes consistent with chronic pulmonary\n disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053575,
"text": " 9:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate? changes?\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with worsening resp status\n REASON FOR THIS EXAMINATION:\n infiltrate? changes?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, :\n\n COMPARISON: .\n\n INDICATION: Worsening respiratory status.\n\n FINDINGS: Lung volumes remain low, and there is unchanged appearance of\n chronic interstitial lung disease. Additional patchy left retrocardiac\n opacity and peripheral left-sided predominantly pleural opacity are also\n unchanged with no acute findings since the recent examination. Peripheral\n left-sided predominantly pleural opacity and patchy left retrocardiac\n parenchymal opacity are also without change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051739,
"text": " 10:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for acute processes to explain hypoxia\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with interstitial lung disease on chronic 02 with shortness\n of breath and hypoxia, s/p vomitting last night\n REASON FOR THIS EXAMINATION:\n evaluate for acute processes to explain hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Interstitial lung disease and shortness of breath following\n vomiting.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: Low lung volumes and peripheral increased reticular\n and linear markings are compatible with known chronic interstitial lung\n disease. Superimposed increased opacity particularly within the right upper\n and left lower lung fields may represent superimposed edema or aspiration.\n The cardiomediastinal silhouette is unchanged. Pneumobilia is stable.\n\n IMPRESSION: Chronic interstitial lung disease with superimposed vague opacity\n may represent aspiration or mild pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-12 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1051830,
"text": " 4:25 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: eval for obstruction\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with iterstitial lung disease, s/p liver transplant for\n criptogenic cirrhosis on immunosuppression now w/ unexplained emesis\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc WED 5:31 PM\n Nonobstructive bowel gas pattern. No free air is seen.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old female with interstitial lung disease status post liver\n transplantation for cryptogenic cirrhosis, on immunosuppression, now with\n unexplained emesis concerning for small-bowel obstruction.\n\n COMPARISON: CT torso, most recently performed on .\n\n ABDOMINAL RADIOGRAPHS, SUPINE AND LEFT LATERAL DECUBITUS VIEWS: Surgical\n clips are noted in the right abdomen consistent with the provided history of\n liver transplantation. The bowel gas pattern is nonobstructive, with stool\n and gas noted in the right colon and the rectosigmoid colon. No free air is\n noted. Note is made of diffuse mild demineralization of the visualized\n osseous structures.\n\n IMPRESSION: Non-obstructive bowel gas pattern. No free air is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-12 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 1051831,
"text": ", MED MICU 4:25 PM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: eval for obstruction\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with iterstitial lung disease, s/p liver transplant for\n criptogenic cirrhosis on immunosuppression now w/ unexplained emesis\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n PFI REPORT\n Nonobstructive bowel gas pattern. No free air is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053201,
"text": " 8:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with acute on chronic shortness of breath\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old woman with acute-on-chronic shortness of breath for\n evaluation of infiltrate.\n\n COMPARISON: .\n\n PORTABLE AP UPRIGHT CHEST AT 9:20 A.M.: A new right PICC terminates in the\n mid SVC. The cardiomediastinal silhouette is unchanged. Streaky interstitial\n lung markings are unchanged since . There is no focal consolidation or\n effusion.\n\n IMPRESSION:\n\n 1. No radiographic evidence of pneumonia.\n\n 2. New right PICC terminates in the mid SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1052559,
"text": ", MED MICU 2:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with pulm fibrosis, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n Better aeration of lungs. Otherwise unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1052558,
"text": " 2:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with pulm fibrosis, intubated\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb MON 11:54 AM\n Better aeration of lungs. Otherwise unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with pulmonary fibrosis, post liver transplant,\n with post-transplant lymphoma.\n\n COMPARISON: Prior chest radiograph on .\n\n PORTABLE AP CHEST RADIOGRAPH: ET tube and NG tubes were removed. Unchanged\n appearance of low lung volumes, mildly enlarged cardiac silhouette, as well as\n known interstitial lung disease. There is better aeration in both lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051852,
"text": " 6:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: intubated\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with respiratory distress s/p intubation\n REASON FOR THIS EXAMINATION:\n intubated\n ______________________________________________________________________________\n WET READ: DMFj WED 9:02 PM\n ETT could be withdrawn 1.5 cm for optimal positioning. New NG tube terminates\n in stomach. Finding d/w Dr. at 9 pm by Dr. \n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: :06 a.m.\n\n FINDINGS: As compared to the previous radiograph, a nasogastric tube has\n inserted and is in correct position with the tip projecting over the distal\n parts of the stomach. A newly inserted endotracheal tube projects 2 cm above\n the carina with its tip. Otherwise, the radiographic appearance is unchanged.\n Mildly enlarged cardiac silhouette, low lung volumes, bilateral subpleural and\n peripheral opacities suggesting chronic fibrosing lung disorder. No newly\n occurred focal parenchymal opacities.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Report",
"row_id": 106977,
"text": "Atrial fibrillation with rapid ventricular response. There is baseline\nartifact. Prior noted ST segment elevations in lead II are still\npresent, again consistent with acute myocardial injury.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-12-22 00:00:00.000",
"description": "Report",
"row_id": 106978,
"text": "Baseline artifact. Probable sinus rhythm. Normal axis and intervals.\nQ waves are present in leads II, III and aVF consistent with inferior\nmyocardial infarction, age undetermined. There is slight ST segment\nelevation in leads II and V4-V6 consistent with acute inferolateral\nmyocardial infarction or possibly related to wall motion abnormality\nfrom prior myocardial infarction. Compared to the previous tracing\nthe Q waves in the inferior leads are old but the slight ST segment\nelevations in leads II and V4-V6 are new consistent with myocardial\ninfarction.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2125-12-21 00:00:00.000",
"description": "Report",
"row_id": 106979,
"text": "Sinus tachycardia. Cannot rule out prior inferior myocardial infarction.\nCompared to the previous tracing of the findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-12-13 00:00:00.000",
"description": "Report",
"row_id": 106980,
"text": "Atrial fibrillation with a rapid ventricular response. There are\nnon-diagnostic Q waves in the inferior leads. Compared to the previous tracing\nthere is no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2125-12-12 00:00:00.000",
"description": "Report",
"row_id": 106981,
"text": "Atrial fibrillation with a rapid ventricular response. There are\nnon-diagnostic Q waves in the inferior leads. Compared to the previous tracing\natrial fibrillation is new and Q waves are less in the inferior leads.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-12-12 00:00:00.000",
"description": "Report",
"row_id": 107035,
"text": "Artifact is present. Sinus rhythm. Atrial ectopy. There are Q waves in\nthe inferior leads consistent with probable prior inferior myocardial\ninfarction. Compared to the previous tracing the rate is slower.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2125-12-10 00:00:00.000",
"description": "Report",
"row_id": 107036,
"text": "Sinus tachycardia and occasional atrial ectopy. Compared to the previous\ntracing of the rate has slowed. Sinus rhythm has appeared.\nOtherwise, no diagnostic interim change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1051254,
"text": " 10:59 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate, mediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 73-year-old female with shortness of breath. Please\n evaluate for possible infiltrate and evaluate mediastinum.\n\n EXAMINATION: PA and lateral chest radiographs.\n\n COMPARISONS: Comparison to CT of the chest from and chest\n radiographs from and .\n\n FINDINGS: There is increased interstitial markings throughout all lung\n fields, most pronounced at the lung periphery that are unchanged and\n compatible with patient's known chronic interstitial lung disease. There is\n no acute superimposed evidence of congestive heart failure or pneumonia. The\n cardiac and mediastinal contours are stable in appearance. There is no\n evidence of pleural effusions or pneumothorax. Post-surgical clips within the\n upper abdomen are noted. Pneumobilia, which is unchanged from prior chest CT\n from , is again noted. There is extreme kyphosis and compression\n fractures of the thoracic spine that are unchanged from prior examination from\n and . Diffuse osteopenia is present.\n\n IMPRESSION: Chronic interstitial lung disease with no evidence of\n superimposed pneumonia or congestive heart failure. Stable pneumobilia.\n Stable thoracic spine compression fractures with severe kyphosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053770,
"text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: changes from previous film?\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with worsening resp status, h/o ILD\n REASON FOR THIS EXAMINATION:\n changes from previous film?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Worsening respiratory status.\n\n Examination is quite technically limited due to a large amount of image noise\n and underpenetrated technique. There is an apparent new area of lung\n opacification in the right upper and mid lung regions, which could potentially\n represent an acute aspiration event. However, considering the technical\n limitations of this exam, a repeat radiograph is suggested to confirm and\n better characterize this finding.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-18 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1052869,
"text": " 2:06 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: Please eval for visualized aspiration\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with hypoxic episodes when swallowing here with aspiration\n pna.\n REASON FOR THIS EXAMINATION:\n Please eval for visualized aspiration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dysphagia.\n\n FINDINGS: Oral and pharyngeal swallowing videofluoroscopy was performed in\n conjunction with the speech pathology service. The oral phase of swallowing\n was notable for a mild delay in oral transit time. The pharyngeal phase of\n swallowing was grossly normal. Overall, only a single flash episode of\n penetration was seen with one self-administered cup of thin liquids, and\n otherwise there was no aspiration or penetration.\n\n IMPRESSION:\n 1. Flushed penetration of thin liquids and otherwise grossly normal\n swallowing study. For further details can be found in the online medical\n record to the speech pathology note from .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-10 00:00:00.000",
"description": "L-SPINE (AP & LAT)",
"row_id": 1051278,
"text": " 12:51 PM\n L-SPINE (AP & LAT) Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with fall onto buttocks now complaining of LBP---pt on\n prednisone for intersitial fibrosis\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 73-year-old female, status post fall on to buttocks,\n now complaining of lower back pain. Please evaluate for possible fracture,\n patient on prednisone.\n\n EXAMINATION: Two views of the lumbar spine.\n\n COMPARISONS: Comparison to radiographs of the lumber spine from .\n\n FINDINGS: There are five non-rib-bearing vertebral bodies. The lumbar\n lordosis is preserved. There is a chronic compression fracture of the L1\n vertebral body dating back to study from . There is superior endplate\n depression of the L2 vertebral body that demonstrates slight interval\n worsening since . Post- surgical clips are noted within the abdomen.\n There is an unremarkable bowel gas pattern. There is no evidence of\n subluxation or degenerative changes. There is diffuse osteopenia. No focal\n lytic or sclerotic lesions are identified.\n\n IMPRESSION: Slight interval increase in superior endplate wedging of the L2\n vertebral body, and chronic L1 compression fracture. No other acute fracture\n or dislocation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-12-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1052455,
"text": " 10:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with interstitial lung disease, s/p liver transplant now\n intubated for respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Status post liver transplant, interstitial lung disease.\n\n REFERENCE EXAM: .\n\n FINDINGS: The endotracheal tube tip is again seen to be 2 cm above the\n carina. The lung volumes continue to be low. There continues to be slightly\n enlarged cardiac silhouette with diffuse interstitial changes consistent with\n the known chronic pulmonary disease. NG tube is unchanged in position.\n\n IMPRESSION: No significant change.\n\n\n"
}
] |
10,774 | 130,230 | The patient was admitted to the MICU for monitoring and serial Hcts. His BP reamined in the 90-110 systolic range. A Hct drop from 39 to 32 was noted, which then stabilized. GI saw the patient, no plan for emergent scope. Cardiology saw the pt and recommended an echocardiogram. Cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. Diuretics and anti-hypertensives were held. . | Afib: - continue sotalol, mexilitine and dig - s/p reversal of INR given GIB. EGD revealed esophagitis, Barrett's esophagus, and duodenitis. Psych: - continue meds . Psych: - continue meds . Psych: - continue meds . c/oof chest pain Action: Given morphin 2mg x3 IV. Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. Hyperlipidemia: - continue statin . Hyperlipidemia: - continue statin . Hyperlipidemia: - continue statin . Hypothyroidism: - continue levothyroxine . Hypothyroidism: - continue levothyroxine . Hypothyroidism: - continue levothyroxine . 72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. 72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. 72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. 72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. Chief Complaint: Gi bleed HPI: 72 y.o. Chief Complaint: Gi bleed HPI: 72 y.o. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI showed erosions in stomach and duodenum c/w NSAID gastropathy (only takes ASA), had a normal in . GI bleed: Hx GI bleeding in the past, recent EGD by GI showed erosiions in stomach and duodenum c/w NSAID gastropathy, had a normal in . Psych: - continue meds . Psych: - continue meds . Psych: - continue meds . Psych: - continue meds . Psych: - continue meds . Hyperlipidemia: - continue statin . Hyperlipidemia: - continue statin . Hyperlipidemia: - continue statin . Hyperlipidemia: - continue statin . Hyperlipidemia: - continue statin . Hypothyroidism: - continue levothyroxine . Hypothyroidism: - continue levothyroxine . Hypothyroidism: - continue levothyroxine . Hypothyroidism: - continue levothyroxine . Hypothyroidism: - continue levothyroxine . Moderate tosevere aortic stenosis. Ck;s and troponin neg. Ck;s and troponin neg. EGD revealed esophagitis, Barrett's esophagus, and duodenitis. Ck and troponin drawn d/t diaphoresis. Ck and troponin drawn d/t diaphoresis. At o530 pt requested the mso4 2mg ivp. At o530 pt requested the mso4 2mg ivp. c/oof chest pain Action: Given morphin 2mg x2 IV. med abd with mso4. med abd with mso4. FEN: NPO, replete lytes PRN, IVFs . FEN: NPO, replete lytes PRN, IVFs . FEN: NPO, replete lytes PRN, IVFs . FEN: NPO, replete lytes PRN, IVFs . FEN: NPO, replete lytes PRN, IVFs . Moderate mitral regurgitation.Compared with the report of the prior study (images unavailable for review) of, the degrees of aortic stenosis, ventricular dilatation and leftventricular dysfunction are similar. Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. Simethicone PRN given. Simethicone PRN given. Sinus rhythm with demand ventricular pacingVentricular premature complexesSince previous tracing of the same date, QRS width shorter, assess LV pacing - Hct stabilized ~ 34 - 2 large bore IVs in place - IV PPI: switch to PO - GI recs: no plan to scope emergently, recent scope done and Hct stable - Held diuretics: concern is restarting could exacerbate possible ischemic colitis - D/W pts cardiologist, plan is to d/c coumadin given risk/benefit . - Hct stabilized ~ 34 - 2 large bore IVs in place - IV PPI: switch to PO - GI recs: no plan to scope emergently, recent scope done and Hct stable - Held diuretics: concern is restarting could exacerbate possible ischemic colitis - D/W pts cardiologist, plan is to d/c coumadin given risk/benefit . | 40 | [
{
"category": "Nursing",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345129,
"text": "Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness)\n Assessment:\n c/o abd pai\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-12 00:00:00.000",
"description": "ICU Attending Addendum",
"row_id": 345108,
"text": "CRITICAL CARE STAFF ADDENDUM\n 10:20a\n I saw and examined Mr. with the ICU team, whose note from today\n reflects my input. I would add/emphasize that he is a 72-year-old man\n with a complicated PMH [CAD/CABG, thoracic aneurysm s/p repair, VFib\n arrest, AICD, EF 20%, biV pacer, PAF on warfarin, CKD (baseline\n 1.6-2.0), dementia, divericulosis, GERD, etc.] who presents now with\n melena and chest pain. See Dr. \ns and Dr. \ns notes for\n details.\n Overnight: admitted to ICU.\n This morning, he says his chest discomfort feels better but that his\n abdominal discomfort is a bit worse.\n On exam he is comfortable. 75, 100/61, 13, 95%.\n Meds are as per (reviewed).\n Labs, and imaging reviewed on rounds and especially notable for:\n Hct 39.8\n 32.8\n 32.5\n 34.5\n INR 2.4\n 2.2\n Cr 1.9\n Troponin 0.02\n Dig 0.4\n Assessment and Plan\n 72 y/o man with complicated PMH now with a small-volume GI bleed, chest\n pain, and abdominal discomfort.\n GI bleed\n Clinically stable. On PPI. GI is following.\n Chest discomfort\n He has had similar issues before, and cardiac enzymes are reassuring.\n Cardiology following\n TTE to evaluate AS\n Resume cardiac meds today except for diuretics.\n Abdominal discomfort\n I am concerned that he may have ischemic colitis (as distinct from\n mesenteric arterial ischemia); he is certainly at risk for it. Will\n discuss with GI today. For now, hold diuretics and give\n ceftriaxone/flagyl until this is sorted out.\n Chronic kidney disease\n At baseline. Follow.\n Heart failure, systolic, chronic\n Mgmt as above\n Other issues as detailed in ICU team note today\n Critical care time: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 345316,
"text": "72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\n diverticulosis. H/O GIB with most recent admission on . Now\n admiited with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\n tender , audible bowel sounds. C/O nausea.\n Action:\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\n tolerating well.\n Response:\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\n abdominal pain. Cardiac enzymes being negative.\n Plan:\n Cont to assess the pain. F/U with GI .\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\n then.\n Action:\n Follow HCT curve (stable)\n Response:\n No active bleeding noted.\n Plan:\n Follow HCT.\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345317,
"text": "72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\n diverticulosis. H/O GIB with most recent admission on . Now\n admiited with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\n tender , audible bowel sounds. C/O nausea.\n Action:\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\n tolerating well.\n Response:\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\n abdominal pain. Cardiac enzymes being negative.\n Plan:\n Cont to assess the pain. F/U with GI .\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\n then.\n Action:\n Follow HCT curve (stable)\n Response:\n No active bleeding noted.\n Plan:\n Follow HCT.\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345191,
"text": "Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain ,chest pain \n Action:\n Received morphine 2 mg iv x3,started on flagyl,ceftraixone for concern\n of ischemic colitis,pt had TTE done to r/o AS,all cardiac meds(except\n diuretics)restarted\n Response:\n Abd pain better after morphine,as per the pt his chest pain is resolved\n ,3 sets of cardiac enzymes were neg.\n Plan:\n Cont to assess the pain.GI is following the pt,prn morphine\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm,no stooling then\n Action:\n Checked hct iv protonix increased to \n Response:\n No active bleeding,hct stable 34.5\n Plan:\n Cont to check hct q6-8hrly,next @1900 hrs\n .pt complaints of sweating,no chest pain,vs stable,ekg done,fs 83,md\n notified\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345085,
"text": "Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stools since MN accompanied by mid-sternal CP with\n radiation to left arm. Took all BP meds this AM. Also c/o\n lightheadedness and SOB.\n .\n In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black\n stool. Patient received morphine for CP with mild improvement in pain.\n EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x\n 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L\n IVFs. Seen by Cards in ED, recommennd echo in AM,\n .\n On arrival to the MICU, pt states his discomfort has imporved,d own\n from to , described as dull ache in chest, non-radiating,\n constant since 11 PM last night, as well as discomfort in the lower\n abdomen (identical to past abd pain in setting of past GIB x 2). +\n nausea.\n Abdominal pain, chest pain\n Assessment:\n Pt c/o of low ABD pain,no tenderness, ABD soft/dist, BS +, no stool.\n c/oof chest pain \n Action:\n Given morphin 2mg x3 IV. Cardia enzymes sent x2, flat\n Response:\n Minimal repsosne of ABD pain to Morphin. Md aware.\n Plan:\n Cont follow ABD pain. Given Morphin as needed EChO in am.last sent of\n cardiac enzymes at 1100\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No stool , no c/o N/V\n Action:\n HCT done q6hr\n Response:\n Last HCT 32. morning HCT 34\n Plan:\n Cont follow HCT q6hr\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345087,
"text": "Chief Complaint:\n 24 Hour Events:\n - Hct stabilized at 32\n - Lactate 0.7\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\n - BP stable overnight\n - Pain improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:23 PM\n Morphine Sulfate - 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 75 (75 - 80) bpm\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\n RR: 19 (9 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 60 mL\n 100 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 34.5 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345089,
"text": "Chief Complaint:\n 24 Hour Events:\n - Hct stabilized at 32\n - Lactate 0.7\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\n - BP stable overnight\n - Pain improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:23 PM\n Morphine Sulfate - 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 75 (75 - 80) bpm\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\n RR: 19 (9 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 60 mL\n 100 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: No edema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, MAE\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 34.5 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345091,
"text": "Chief Complaint:\n 24 Hour Events:\n - Hct stabilized at 32\n - Lactate 0.7\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\n - BP stable overnight\n - Pain improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:23 PM\n Morphine Sulfate - 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 75 (75 - 80) bpm\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\n RR: 19 (9 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 60 mL\n 100 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: No edema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, MAE\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 34.5 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed: Hx GI bleeding in the past, recent EGD by GI showed\n erosions in stomach and duodenum c/w NSAID gastropathy (only takes\n ASA), had a normal in .\n - monitor HCTs q4hrs initially and then less frequently if stable\n - 2 large bore IVs in place\n - IVFs PRN\n - Transfuse for HCT < 30 given ? of active ischemia\n - IV PPI\n - F/u GI recs: no plan to scope emergently, await resolution of chest\n pain\n .\n 2. Chest pain:\n - telemetry\n - cards recs: repeat Echo\n - F/U CE's\n - F/U cards recs: plan for TTE tomorrow\n - continue statin,\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone overnight and restart in AM if patient\n is stable\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin (held sotalol last night)\n - s/p reversal of INR given GIB. Will hold off on further\n anticoagulation for now except for ASA in AM\n .\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n CODE: presumed full\n .\n Communication: Pt, wife )\n .\n DISPO: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-11 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 345025,
"text": "Chief Complaint: Black stools, chest pain, abdominal pain\n HPI:\n Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stools since MN accompanied by mid-sternal CP with\n radiation to left arm. Took all BP meds this AM. Also c/o\n lightheadedness and SOB.\n .\n In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black\n stool. Patient received morphine for CP with mild improvement in pain.\n EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x\n 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L\n IVFs. Seen by Cards in ED, recommennd echo in AM,\n .\n On arrival to the MICU, pt states his discomfort has imporved,d own\n from to , described as dull ache in chest, non-radiating,\n constant since 11 PM last night, as well as discomfort in the lower\n abdomen (identical to past abd pain in setting of past GIB x 2). +\n nausea.\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 Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n --GI bleed of unknown etiology . EGD revealed esophagitis,\n Barrett's esophagus, and duodenitis. No ulcers.\n --CAD status post CABG with simultaneous aortic aneurysm repair\n in , history of stenting of the left circumflex artery \n --s/p VT/VF arrest, s/p ICD placement in \n --Ischemic cardiomyopathy with an EF of 20%, s/p BiV pacer \n --Chest wall cellulitis over pacer site vs. ICD pacer\n pocket infection\n --PAF on coumadin\n --CKD with baseline Cr. 1.6-2.0\n --Hyperlipidemia\n --Asthma\n --Anxiety\n --Alzheimer's dementia\n --Hypothyroidism\n --Diverticulosis\n --GERD\n --S/P Cholecystectomy\n Meds at home:\n Sotalol 80mg \n Lipitor 20mg daily\n Donepezil 5mg daily\n Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS\n Celexa 60mg daily\n Protonix 40mg daily\n ASA 81mg daily\n Clonazepam 0.5mg TID PRN\n Lisinopril 5mg daily\n Digoxin 125mcg, tab daily\n K-Dur daily\n Spironolactone 25mg daily\n Levothyroxin3e 112mcg daily\n Trazodone 25mg qHS\n Mexiletine 150mg TID\n Albuterol MDI 2puf q6hPRN\n Fluticasone 110mcg 2puff \n Toprol SL 50mg daily\n Lasix 40mg TID\n Coumadin\n NC\n Occupation: retired\n Drugs: none\n Tobacco: none\n Alcohol: former, none x 20 yrs\n Other: Patient originally from and moved to the United States\n in . Worked as an off-set printer. Father of five children.\n Retired 6 years ago, and since his recent heart problems, says\n he rarely leaves the house. No history of smoking, past or present.\n Patient was a heavy drinker until 20 years ago, when he stopped\n completely after attending AA. No history of illicit drug use\n Review of systems:\n Cardiovascular: Chest pain\n Respiratory: SOB\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Pain: Mild\n Pain location: chest abd\n Flowsheet Data as of 07:35 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 78) bpm\n BP: 100/73(64) {100/73(64) - 100/73(80)} mmHg\n RR: 11 (11 - 17) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\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: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: Right: Absent\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 149\n 2.0\n 31\n 30\n 100\n 3.9\n 140\n 39.8\n 9.9\n [image002.jpg]\n Other labs: PT / PTT / INR:24.7/29.8/2.4, CK / CKMB / Troponin-T:97/MB\n not done/ trop 0.01, Differential-Neuts:77, Lymph:11, Mono:8, Ca++:9.5,\n Mg++:2.2, PO4:2.7\n Imaging: CXR: NAD\n ECG: V-paced\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n GI bleed: Hx GI bleeding in the past, recent EGD by GI showed erosiions\n in stomach and duodenum c/w NSAID gastropathy, had a normal in\n .\n - monitor HCTs q4hrs initially and then less frequently if stable\n - 2 large bore IVs in place\n - IVFs PRN\n - Transfuse for HCT < 30 given ? of active ischemia\n - IV PPI\n - F/u GI recs: no plan to scope emergently, await resolution of chest\n pain\n .\n Chest pain:\n - telemetry\n - cards recs: repeat Echo\n - F/U CE's\n - F/U cards recs\n - continue ASA, statin, bblocker, ACE-I\n .\n Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone overnight and restart in AM if patient\n is stable\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n Afib:\n - continue sotalol, mexilitine and dig\n - s/p reversal of INR given GIB. Will hold off on further\n anticoagulation for now except for ASA\n .\n Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n Hyperlipidemia:\n - continue statin\n .\n Hypothyroidism:\n - continue levothyroxine\n .\n Asthma:\n - continue home meds\n .\n Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n CONTACT:\n .\n CODE: presumed full\n .\n Communication: Pt, wife )\n .\n DISPO: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345174,
"text": "Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain ,chest pain \n Action:\n Received morphine 2 mg iv x2,started on flagyl,ceftraixone for concern\n of ischemic colitis,pt had TTE done to r/o AS,all cardiac meds(except\n diuretics)restarted\n Response:\n Abd pain better after morphine,as per the pt his chest pain is resolved\n ,3 sets of cardiac enzymes were neg.\n Plan:\n Cont to assess the pain.GI is following the pt,prn morphine\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm,no stooling then\n Action:\n Checked hct iv protonix increased to \n Response:\n No active bleeding,hct stable 34.5\n Plan:\n Cont to check hct q6-8hrly,next @1900 hrs\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 345307,
"text": "72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\n diverticulosis. H/O GIB with most recent admission on . Now\n admiited with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\n tender , audible bowel sounds. C/O nausea.\n Action:\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\n tolerating well.\n Response:\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\n abdominal pain. Cardiac enzymes being negative.\n Plan:\n Cont to assess the pain. F/U with GI .\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\n then.\n Action:\n Follow HCT curve (stable)\n Response:\n No active bleeding noted.\n Plan:\n Follow HCT.\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345016,
"text": "awoke this am with +CP and dark stools. (pt had similar episode 1 month\n ago with EGD done). Received SL NTG and IV morphine. INR 2.4->5 mg Vit\n K given and 1st of 2 u FFP ^. Received total of 1.5 L NS, Zofran for N\n and IV protonix. NG lavage negative.\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345017,
"text": "awoke this am with +CP and dark stools. (pt had similar episode 1 month\n ago with EGD done). Received SL NTG and IV morphine. INR 2.4->5 mg Vit\n K given and 1st of 2 u FFP ^. Received total of 1.5 L NS, Zofran for N\n and IV protonix. NG lavage negative.\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345018,
"text": "awoke this am with +CP and dark stools. (pt had similar episode 1 month\n ago with EGD done). Received SL NTG and IV morphine. INR 2.4->5 mg Vit\n K given and 1st of 2 u FFP ^. Received total of 1.5 L NS, Zofran for N\n and IV protonix. NG lavage negative.\n Please see FHPA and assessment for other details. Awaiting orders from\n MICU team. HD stable.\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 345296,
"text": "72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\n diverticulosis. H/O GIB with most recent admission on . Now\n admiited with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\n tender , audible bowel sounds. C/O nausea.\n Action:\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\n tolerating well.\n Response:\n Abdominal pain tolerable. Cardiac enzymes being negative.\n Plan:\n Cont to assess the pain. F/U with GI .\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\n then.\n Action:\n Follow HCT curve (stable)\n Response:\n No active bleeding noted.\n Plan:\n Follow HCT.\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Physician Fellow/Attending Progress Note - MICU",
"row_id": 345305,
"text": "Chief Complaint: Gi bleed\n HPI:\n 72 y.o. man with CAD, AFib, h/o GI bleed of unclear etiology p/w melena\n and abdominal pain.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n Overnight, one episode of chest pain with diaphoresis. ECG was\n unchanged and cardiac enzymes were checked and normal.\n He continues to c/o lower abdominal pain with nausea though he was able\n to tolerate broth for breakfast. His chest pain has resolved.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Synthroid\n Mexilitine\n Seroquel\n Fluticasone INH\n Celexa\n Digoxin\n ASA\n Sotalol\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: Chest pain\n Respiratory: No(t) Cough, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 79) bpm\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Total In:\n 360 mL\n 610 mL\n PO:\n 300 mL\n 600 mL\n TF:\n IVF:\n 60 mL\n 10 mL\n Blood products:\n Total out:\n 1,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Edema Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 121 K/uL\n 68 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 103 mEq/L\n 142 mEq/L\n 34.7 %\n 7.8 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n 06:38 AM\n WBC\n 7.0\n 7.4\n 7.8\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n 34.7\n Plt\n 134\n 120\n 121\n Cr\n 2.0\n 1.9\n 1.5\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n 68\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\n ischemic colitis.\n 1) Colitis: Continued abdominal pain with perhaps some subjective\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\n gram negative coverage.\n Antiemetics. Advance diet slowly.\n 2) Afib: Holding coumadin per cardiology.\n 3) CAD: Continue current regimen.\n 4) CKD: Cr is stable\n 5) Asthma: Restart home Advair.\n ICU Care\n Nutrition:\n Comments: Advance diet as tolerated.\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n ------ Protected Section ------\n CRITICAL CARE STAFF ADDENDUM\n 3p\n I saw and examined Mr. with the ICU team today; Dr. \ns note\n reflects my input. I would add/emphasize that he is a 72-year-old man\n with a complicated PMH [CAD/CABG, thoracic aneurysm s/p repair, VFib\n arrest, AICD, EF 20%, biV pacer, PAF on warfarin, CKD (baseline\n 1.6-2.0), dementia, divericulosis, GERD, etc.] now admitted with\n melena, abdominal pain, and chest pain. His chest pain has resolved\n and his GI bleeding has not recurred. Some abdominal discomfort\n persists, though he was able to tolerate clears at breakfast.\n Examination as per Dr. \ns note and the ICU team note today. In\n particular, his abdomen is soft and he does not have clinically\n decompensated heart failure.\n Assessment and Plan\n 72 y/o man with complicated PMH now with a small-volume GI bleed, chest\n pain, and abdominal discomfort.\n GI bleed\n Clinically stable. On PPI. GI is following and does not plan\n endoscopy.\n Chest discomfort\n Has resolved. Echo showed stable abnormalities compared with prior.\n Probable ischemic colitis\n I am concerned that he may have non-occlusive ischemic colitis (as\n distinct from mesenteric arterial ischemia); he is certainly at risk\n for it. Awaiting GI\ns thoughts on this. For today, will hold\n diuretics and continue abx (high risk for translocation, and AICD\n increased the risk of seeding).\n Chronic kidney disease\n At baseline. Follow.\n Heart failure, systolic, chronic\n Mgmt as above\n Other issues as detailed in Dr. \ns note and ICU team note today\n To floor.\n ------ Protected Section Addendum Entered By: , MD\n on: 03:21 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Physician Fellow/Attending Progress Note - MICU",
"row_id": 345283,
"text": "Chief Complaint: Gi bleed\n HPI:\n 72 y.o. man with CAD, AFib, h/o GI bleed of unclear etiology p/w melena\n and abdominal pain.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n Overnight, one episode of chest pain with diaphoresis. ECG was\n unchanged and cardiac enzymes were checked and normal.\n He continues to c/o lower abdominal pain with nausea though he was able\n to tolerate broth for breakfast. His chest pain has resolved.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Synthroid\n Mexilitine\n Seroquel\n Fluticasone INH\n Celexa\n Digoxin\n ASA\n Sotalol\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: Chest pain\n Respiratory: No(t) Cough, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 79) bpm\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Total In:\n 360 mL\n 610 mL\n PO:\n 300 mL\n 600 mL\n TF:\n IVF:\n 60 mL\n 10 mL\n Blood products:\n Total out:\n 1,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Edema Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 121 K/uL\n 68 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 103 mEq/L\n 142 mEq/L\n 34.7 %\n 7.8 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n 06:38 AM\n WBC\n 7.0\n 7.4\n 7.8\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n 34.7\n Plt\n 134\n 120\n 121\n Cr\n 2.0\n 1.9\n 1.5\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n 68\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\n ischemic colitis.\n 1) Colitis: Continued abdominal pain with perhaps some subjective\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\n gram negative coverage.\n Antiemetics. Advance diet slowly.\n 2) Afib: Holding coumadin per cardiology.\n 3) CAD: Continue current regimen.\n 4) CKD: Cr is stable\n 5) Asthma: Restart home Advair.\n ICU Care\n Nutrition:\n Comments: Advance diet as tolerated.\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345287,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n - Hct stable @ 34\n - D/W pt\ns cardiologist and pt risk of bleeding on coumadin\n and risk of stroke from AF, decided to discontinue coumadin; also\n discussed possibility of ischemic colitis as etiology of pt\ns sxs.\n - GI: will not rescope now, PPI and misoprostil\n - Pt had episode of diaphoresis, ongoing chest pain, CE\n negative\n - TTE: EF 20-25%, mod to severe AS, moderate MR; compared with\n prior,.\n - TTE: Increased dilation of the aortic sinus and increased MR\n since prior study.\n -\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 75 (75 - 79) bpm\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Total In:\n 360 mL\n 400 mL\n PO:\n 300 mL\n 400 mL\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 100 mL\n Respiratory support\n SpO2: 95%\n ABG: ////\n Physical Examination\n Gen: NAD, comfortable\n HEENT: PERRL\n Neck: No JVD\n Lungs: CTAB, no crackles\n Heart: s1s2 RRR, +SEM\n Abd:+BS, obese, soft, nontender to palpation of the lower quadrants, no\n rebound or guarding\n Ext: No edema, warm/well-perfused\n Neuro: Nonfocal\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 35.4 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n CXR: None today\n Micro: None\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\n takes ASA), had a normal in . Also consider ischemic colitis,\n particularly given risk factors (low CO, diuretics). A CTA of the\n abdomen in when he had a similar episode revealed no acute\n abnormality but did show narrowing at the proximal aspect of the celiac\n axis but normal SMA/. Pt has had no further BMs since admission but\n has been NPO.\n - Hct stabilized ~ 34\n - 2 large bore IVs in place\n - IV PPI: switch to PO PPI\n - GI recs: no plan to scope emergently, recent scope done and Hct\n stable\n - Will ask GI about possible ischemic colitis given clinical picture\n - Continue CTX/flagyl while pt still having pain and ischemic colitis\n is in differential, given risk of gut bacteria translocation\n - Advance to clears\n - No imaging at this time given overall reassuring and improving\n clinical picture\n - Held diuretics: concern is restarting could exacerbate possible\n ischemic colitis, continue to hold for now given pt still having sxs\n and does not seem fluid overloaded currently\n - D/W pt\ns cardiologist, plan is to d/c coumadin given risk/benefit\n .\n 2. Chest pain: Pain has been ongoing intermittently, similar to past\n pain. Unlikely to be active cardiac ischemia given time course, pain\n not typical for aortic dissection.\n - telemetry\n - repeat Echo yesterday\n no significant change from prior\n - CE: negative thus far\n - continue statin\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n - poor candidate for aortic valve replacement\n .\n 3. Systolic heart failure: Currently satting well on 2L, has not\n received diuretics x 2 days. Echo yesterday similar to prior, with EF\n 20-25%, mod to severe AS, moderate MR; compared with prior,. Increased\n dilation of the aortic sinus and increased MR since prior study.\n - Hold lasix and spironolactone\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin and sotolol\n - s/p reversal of INR given GIB, plan per his cardiologist is to d/c\n coumadin\n .\n 5. Chronic renal insufficiency: BL creat 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n ICU Care\n Nutrition:\n Comments: Clears\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: Call out to the medical floor\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345243,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n - Hct stable @ 34\n - D/W pt\ns cardiologist and pt risk of bleeding on coumadin\n and risk of stroke from AF, decided to discontinue coumadin; also\n discussed possibility of ischemic colitis as etiology of pt\ns sxs\n - GI: will not rescope now, PPI and misoprostil\n - Pt had episode of diaphoresis, ongoing chest pain, CE\n negative\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 75 (75 - 79) bpm\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Total In:\n 360 mL\n 400 mL\n PO:\n 300 mL\n 400 mL\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 100 mL\n Respiratory support\n SpO2: 95%\n ABG: ////\n Physical Examination\n Gen:\n HEENT:\n Lungs:\n Heart:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 35.4 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n CXR:\n Micro:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345244,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n - Hct stable @ 34\n - D/W pt\ns cardiologist and pt risk of bleeding on coumadin\n and risk of stroke from AF, decided to discontinue coumadin; also\n discussed possibility of ischemic colitis as etiology of pt\ns sxs\n - GI: will not rescope now, PPI and misoprostil\n - Pt had episode of diaphoresis, ongoing chest pain, CE\n negative\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 75 (75 - 79) bpm\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Total In:\n 360 mL\n 400 mL\n PO:\n 300 mL\n 400 mL\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 100 mL\n Respiratory support\n SpO2: 95%\n ABG: ////\n Physical Examination\n Gen:\n HEENT:\n Lungs:\n Heart:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 35.4 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n CXR:\n Micro:\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\n takes ASA), had a normal in . Also consider ischemic colitis,\n particularly given risk factors (decreased CO, diuretics). Pt has had\n no further BMs since admission.\n - Hct stabilized ~ 34\n - 2 large bore IVs in place\n - IV PPI: switch to PO\n - GI recs: no plan to scope emergently, recent scope done and Hct\n stable\n - Held diuretics: concern is restarting could exacerbate possible\n ischemic colitis\n - D/W pt\ns cardiologist, plan is to d/c coumadin given risk/benefit\n .\n 2. Chest pain: Pain has been ongoing intermittently, similar to past\n pain. Unlikely to be active cardiac ischemia given time course, pain\n not typical for aortic dissection.\n - telemetry\n - repeat Echo yesterday\n - CE: negative thus far\n - continue statin\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin and sotolol\n - s/p reversal of INR given GIB, plan per his cardiologist is to d/c\n coumadin\n .\n 5. Chronic renal insufficiency: BL creat 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345245,
"text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n - Hct stable @ 34\n - D/W pt\ns cardiologist and pt risk of bleeding on coumadin\n and risk of stroke from AF, decided to discontinue coumadin; also\n discussed possibility of ischemic colitis as etiology of pt\ns sxs.\n - GI: will not rescope now, PPI and misoprostil\n - Pt had episode of diaphoresis, ongoing chest pain, CE\n negative\n - TTE: EF 20-25%, mod to severe AS, moderate MR; compared with\n prior,.\n - TTE: Increased dilation of the aortic sinus and increased MR\n since prior study.\n -\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:28 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 06:59 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.6\nC (96.1\n HR: 75 (75 - 79) bpm\n BP: 105/61(71) {88/28(46) - 114/78(80)} mmHg\n RR: 12 (10 - 26) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Total In:\n 360 mL\n 400 mL\n PO:\n 300 mL\n 400 mL\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 1,550 mL\n 300 mL\n Urine:\n 1,550 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 100 mL\n Respiratory support\n SpO2: 95%\n ABG: ////\n Physical Examination\n Gen:\n HEENT:\n Lungs:\n Heart:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 35.4 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n CXR:\n Micro:\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\n takes ASA), had a normal in . Also consider ischemic colitis,\n particularly given risk factors (decreased CO, diuretics). Pt has had\n no further BMs since admission.\n - Hct stabilized ~ 34\n - 2 large bore IVs in place\n - IV PPI: switch to PO\n - GI recs: no plan to scope emergently, recent scope done and Hct\n stable\n - Held diuretics: concern is restarting could exacerbate possible\n ischemic colitis\n - D/W pt\ns cardiologist, plan is to d/c coumadin given risk/benefit\n .\n 2. Chest pain: Pain has been ongoing intermittently, similar to past\n pain. Unlikely to be active cardiac ischemia given time course, pain\n not typical for aortic dissection.\n - telemetry\n - repeat Echo yesterday\n - CE: negative thus far\n - continue statin\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L, has not\n received diuretics x 2 days. Echo yesterday similar to prior, with EF\n 20-25%, mod to severe AS, moderate MR; compared with prior,. Increased\n dilation of the aortic sinus and increased MR since prior study.\n - Hold lasix and spironolactone\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin and sotolol\n - s/p reversal of INR given GIB, plan per his cardiologist is to d/c\n coumadin\n .\n 5. Chronic renal insufficiency: BL creat 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 345263,
"text": "Chief Complaint: Gi bleed\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n No events overnight\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Synthroid\n Mexilitine\n Seroquel\n Fluticasone INH\n Celexa\n Digoxin\n ASA\n Sotalol\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: Chest pain\n Respiratory: No(t) Cough, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 79) bpm\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Total In:\n 360 mL\n 610 mL\n PO:\n 300 mL\n 600 mL\n TF:\n IVF:\n 60 mL\n 10 mL\n Blood products:\n Total out:\n 1,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 121 K/uL\n 68 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 103 mEq/L\n 142 mEq/L\n 34.7 %\n 7.8 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n 06:38 AM\n WBC\n 7.0\n 7.4\n 7.8\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n 34.7\n Plt\n 134\n 120\n 121\n Cr\n 2.0\n 1.9\n 1.5\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n 68\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\n possible ischemic colitis.\n 1) Colitis: Continued abdominal pain with perhaps some subjective\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\n gram negative coverage.\n Antiemetics. Advance diet slowly.\n 2) Afib: Holding coumadin per cardiology.\n 3) CAD: Continue current regimen.\n 4) CKD: Cr is stable\n 5) Asthma: Restart home Advair.\n ICU Care\n Nutrition:\n Comments: Advance diet as tolerated.\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 345295,
"text": "72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\n diverticulosis. H/O GIB with most recent admission on . Now\n admiited with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\n tender , audible bowel sounds. C/O nausea.\n Action:\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\n given. Zofran 4 mg X1 IVPB given.\n Response:\n Abdominal pain tolerable. Cardiac enzymes being negative.\n Plan:\n Cont to assess the pain. F/U with GI .\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\n then.\n Action:\n Follow HCT curve (stable)\n Response:\n No active bleeding noted.\n Plan:\n Follow HCT.\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 345344,
"text": "72 yo M with PMH of CAD s/p CABG and PCI to L circx, AS, VT/VF arrest\n with pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and\n diverticulosis. H/O GIB with most recent admission on . Now\n admiited with black stool,chest pain and abd pain.\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain , denied chest pain. No BM since Tuesday. Abdomen\n tender , audible bowel sounds. C/O nausea.\n Action:\n Contd on flagyl, ceftraixone for ischemic colitis. Simethicone PRN\n given. Zofran 4 mg X1 IVPB given. Advanced to clear liquid diet,\n tolerating well.\n Response:\n Abdominal pain tolerable. Morphine sulfate 2 mg X1 IVPB given for\n abdominal pain. Cardiac enzymes being negative.\n Plan:\n Cont to assess the pain. F/U with GI .\n H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm, No BM since\n then.\n Action:\n Follow HCT curve (stable)\n Response:\n No active bleeding noted.\n Plan:\n Follow HCT.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n CHEST PAIN;TELEMETRY;GI BLEED\n Code status:\n Full code\n Height:\n Admission weight:\n 104.9 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Asthma, GI Bleed\n CV-PMH: Angina, Arrhythmias, CAD, Pacemaker\n Additional history: ckd; barrett's esphogus; diverticulosis; asthma;\n hyperlipidemia; of note, pt's ef is 15%; s/p choly; hypothyroidism;\n gerd; anxiety; alzheimers dementia\n Surgery / Procedure and date: s/p cabg with aaa repair in ; s/p icd\n placement in ; s/p choly\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:95\n D:54\n Temperature:\n 97.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,160 mL\n 24h total out:\n 1,600 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 06:38 AM\n Potassium:\n 4.1 mEq/L\n 06:38 AM\n Chloride:\n 103 mEq/L\n 06:38 AM\n CO2:\n 27 mEq/L\n 06:38 AM\n BUN:\n 26 mg/dL\n 06:38 AM\n Creatinine:\n 1.5 mg/dL\n 06:38 AM\n Glucose:\n 68 mg/dL\n 06:38 AM\n Hematocrit:\n 34.7 %\n 06:38 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: micu7\n Transferred to: cc727\n Date & time of Transfer: 2130\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 345059,
"text": "Chief Complaint: Black stools, chest pain, abdominal pain\n HPI:\n Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stools since MN accompanied by mid-sternal CP with\n radiation to left arm. Took all BP meds this AM. Also c/o\n lightheadedness and SOB.\n .\nIn the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. per resident had guaiac pos bla\nck stool. Patient received morphine for CP with mild improvement in pain. EKG wa\ns v-paced with no obvious ST/TW changes. NG lavage was negative x 2. He received\n 2U FFP and 5 mg PO vitamin K for INR reversal and 1L IVFs. Seen by Cards in ED\n, recommend echo in AM. Of note, last , the patient had a similar presentat\nion and EGD, c-scope, and capsule endoscopy demonstrated gastritis, Barrett's, a\nnd grade 1 hemorrhoids, without any active bleeding.\n .\n On arrival to the MICU, pt states his discomfort has improved, down\n from to , described as dull ache in chest, non-radiating,\n constant since 11 PM last night, as well as discomfort in the lower\n abdomen (identical to past abd pain in setting of past GIB x 2). +\n nausea.\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 Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n --GI bleed of unknown etiology . EGD revealed esophagitis,\n Barrett's esophagus, and duodenitis. No ulcers.\n --CAD status post CABG with simultaneous thoracic aortic aneurysm\n repair\n in , history of stenting of the left circumflex artery \n --s/p VT/VF arrest, s/p ICD placement in \n --Ischemic cardiomyopathy with an EF of 20%, s/p BiV pacer \n --Chest wall cellulitis over pacer site vs. ICD pacer\n pocket infection\n --PAF on coumadin\n --CKD with baseline Cr. 1.6-2.0\n --Hyperlipidemia\n --Asthma\n --Anxiety\n --Alzheimer's dementia\n --Hypothyroidism\n --Diverticulosis\n --GERD\n --S/P Cholecystectomy\n Meds at home:\n Sotalol 80mg \n Lipitor 20mg daily\n Donepezil 5mg daily\n Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS\n Celexa 60mg daily\n Protonix 40mg daily\n ASA 81mg daily\n Clonazepam 0.5mg TID PRN\n Lisinopril 5mg daily\n Digoxin 125mcg, tab daily\n K-Dur daily\n Spironolactone 25mg daily\n Levothyroxin3e 112mcg daily\n Trazodone 25mg qHS\n Mexiletine 150mg TID\n Albuterol MDI 2puf q6hPRN\n Fluticasone 110mcg 2puff \n Toprol SL 50mg daily\n Lasix 40mg TID\n Coumadin\n NC\n Occupation: retired\n Drugs: none\n Tobacco: none\n Alcohol: former, none x 20 yrs\n Other: Patient originally from and moved to the United States\n in . Worked as an off-set printer. Father of five children.\n Retired 6 years ago, and since his recent heart problems, says\n he rarely leaves the house. No history of smoking, past or present.\n Patient was a heavy drinker until 20 years ago, when he stopped\n completely after attending AA. No history of illicit drug use\n Review of systems:\n Cardiovascular: Chest pain\n Respiratory: SOB\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Pain: Mild\n Pain location: chest abd\n Flowsheet Data as of 07:35 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 78) bpm\n BP: 100/73(64) {100/73(64) - 100/73(80)} mmHg\n RR: 11 (11 - 17) insp/min\n SpO2: 97%\n Heart rhythm: AV Paced\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: Nasal cannula\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: No edema\n Rectal: Trace guaiac positive black stool\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 149\n 2.0\n 31\n 30\n 100\n 3.9\n 140\n 39.8\n 9.9\n [image002.jpg]\n Other labs: PT / PTT / INR:24.7/29.8/2.4, CK / CKMB / Troponin-T:97/MB\n not done/ trop 0.01, Differential-Neuts:77, Lymph:11, Mono:8, Ca++:9.5,\n Mg++:2.2, PO4:2.7\n Imaging: CXR: NAD\n ECG: V-paced, similar to prior\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed: Hx GI bleeding in the past, recent EGD by GI showed\n erosions in stomach and duodenum c/w NSAID gastropathy (only takes\n ASA), had a normal in .\n - monitor HCTs q4hrs initially and then less frequently if stable\n - 2 large bore IVs in place\n - IVFs PRN\n - Transfuse for HCT < 30 given ? of active ischemia\n - IV PPI\n - F/u GI recs: no plan to scope emergently, await resolution of chest\n pain\n .\n 2. Chest pain:\n - telemetry\n - cards recs: repeat Echo\n - F/U CE's\n - F/U cards recs: plan for TTE tomorrow\n - continue statin,\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone overnight and restart in AM if patient\n is stable\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin (held sotalol tonight)\n - s/p reversal of INR given GIB. Will hold off on further\n anticoagulation for now except for ASA in AM\n .\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n CODE: presumed full\n .\n Communication: Pt, wife )\n .\n DISPO: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345213,
"text": "Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345216,
"text": "Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o some abd pain . c/o of feeling sweaty and anxious. At 0530\n pt c/o abd .\n Action:\n Pt refused mso4, at beginning of shift stated pain was not that bad. Pt\n afebrile and was started back on seroquel and trazadone. At o530 pt\n requested the mso4 2mg ivp. Ck and troponin drawn d/t diaphoresis.\n Response:\n Pt less sweaty and was able to fall asleep for the night. pt stated\n that he was able to get some quality sleepl pt stated that the mso4\n gives him relief. Ck;s and troponin neg.\n Plan:\n Continue to monitor level of pain and med as needed.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct stable, vss, c/o abd pain but has not passed any stool at this\n time.\n Action:\n Following hct\ns. med abd with mso4.\n Response:\n Pt obtains relief from the morphine\n Plan:\n Cont to follow hct\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345217,
"text": "Abdominal pain (including abdominal tenderness)\n Assessment:\n Pt c/o some abd pain . c/o of feeling sweaty and anxious. At 0530\n pt c/o abd .\n Action:\n Pt refused mso4, at beginning of shift stated pain was not that bad. Pt\n afebrile and was started back on seroquel and trazadone. At o530 pt\n requested the mso4 2mg ivp. Ck and troponin drawn d/t diaphoresis.\n Response:\n Pt less sweaty and was able to fall asleep for the night. pt stated\n that he was able to get some quality sleepl pt stated that the mso4\n gives him relief. Ck;s and troponin neg.\n Plan:\n Continue to monitor level of pain and med as needed.\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hct stable, vss, c/o abd pain but has not passed any stool at this\n time.\n Action:\n Following hct\ns. med abd with mso4.\n Response:\n Pt obtains relief from the morphine\n Plan:\n Cont to follow hct\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345044,
"text": "Abdominal pain (including abdominal tenderness)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345046,
"text": "Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stools since MN accompanied by mid-sternal CP with\n radiation to left arm. Took all BP meds this AM. Also c/o\n lightheadedness and SOB.\n .\n In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black\n stool. Patient received morphine for CP with mild improvement in pain.\n EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x\n 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L\n IVFs. Seen by Cards in ED, recommennd echo in AM,\n .\n On arrival to the MICU, pt states his discomfort has imporved,d own\n from to , described as dull ache in chest, non-radiating,\n constant since 11 PM last night, as well as discomfort in the lower\n abdomen (identical to past abd pain in setting of past GIB x 2). +\n nausea.\n Abdominal pain, chest pain\n Assessment:\n Pt c/o of low ABD pain,no tenderness, ABD soft/dist, BS +, no stool.\n c/oof chest pain \n Action:\n Given morphin 2mg x2 IV. Cardia enzymes sent x2, flat\n Response:\n Minimal repsosne of ABD pain to Morphin. Md aware.\n Plan:\n Cont follow ABD pain. Given Morphin as needed EChO in am.last sent of\n cardiac enzymes at 1100\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No stool , no c/o N/V\n Action:\n HCT done q6hr\n Response:\n Last HCT 32\n Plan:\n Cont follow HCT q6hr\n"
},
{
"category": "Nursing",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 345131,
"text": "Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF\n arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr\n 1.6-2), and diverticulosis. H/O GIB w most recent admission on .\n Now with black stool,chest pain and abd pain.\n Events:\n Abdominal pain (including abdominal tenderness),including chest pain\n Assessment:\n c/o abd pain ,chest pain \n Action:\n Received morphine 2 mg iv x2,started on flagyl,ceftraixone for concern\n of ischemic colitis,pt had TTE done to r/o AS,all cardiac meds(except\n diuretics)restarted\n Response:\n Abd pain better after morphine,as per the pt his chest pain is\n stable(),3 sets of cardiac enzymes were neg.\n Plan:\n Cont to assess the pain.GI is following the pt,\n .H/O gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n h/o malenic stool,as per the pt last bm on 1 pm,no stooling then\n Action:\n Checked hct\n Response:\n No active bleeding\n Plan:\n Cont to check hct q6-8hrly,\n"
},
{
"category": "General",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Generic Note",
"row_id": 345041,
"text": "TITLE: Addendum to Dr. \ns note\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n 72M with CAD, CHF, CRI, a-fib, VF, EF 20%, diverticulosis, UGI bleed\n due to gastritis\n admitted with melena, chest pain, dyspnea. In ER\n guaiac positive, negative NG lavage. Given FFP and vitamin K for INR\n 2.4. Hct 40.\n Exam notable for Tm HR 76 BP 96/61 RR 21 with 97 sat on 2L\n Comfortable, no distress, lungs clear, heart regular, abdomen benign,\n trace guaiac pos\n Labs notable for WBC 10 K, HCT 33, HCO3 30 ,Cr 2.0, lactate 0.7 cardiac\n enzymes negative\n EKG: v-paced\n Imaging: chest x-ray reviewed\n PPM, cardiomegaly\n Problems:\n GIB\n Chest pain\n a-fib\n CRI\n Agree with plan to follow Hct, maintain adequate IV access, PPI, GI\n involved, more FFP and vitamin K if Hct falls, complete rule out\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 35 min\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345119,
"text": "Chief Complaint:\n 24 Hour Events:\n - Hct stabilized at 32\n - Lactate 0.7\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\n - BP stable overnight\n - Pain improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:23 PM\n Morphine Sulfate - 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 75 (75 - 80) bpm\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\n RR: 19 (9 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 60 mL\n 100 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: No edema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, MAE\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 34.5 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\n takes ASA), had a normal in . Also consider ischemic colitis,\n although abd is benign, with trace guaiac positive stool.\n - monitor HCTs q4hrs initially and then less frequently if stable\n - 2 large bore IVs in place\n - IVFs PRN\n - Transfuse for HCT < 30 given ? of active ischemia\n - IV PPI\n - F/u GI recs: no plan to scope emergently, await resolution of chest\n pain\n - Hold diuretics\n .\n 2. Chest pain:\n - telemetry\n - cards recs: repeat Echo\n - F/U CE's\n - F/U cards recs: plan for TTE tomorrow\n - continue statin,\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin (held sotalol last night)\n - s/p reversal of INR given GIB. Will hold off on further\n anticoagulation for now except for ASA in AM\n .\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n .\n DISPO: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 345120,
"text": "Chief Complaint:\n 24 Hour Events:\n - Hct stabilized at 32\n - Lactate 0.7\n - Two sets CE flat, third troponin 0.02 (has been this in the past)\n - BP stable overnight\n - Pain improved\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:23 PM\n Morphine Sulfate - 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 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (96.9\n HR: 75 (75 - 80) bpm\n BP: 97/60(69) {84/45(58) - 108/73(80)} mmHg\n RR: 19 (9 - 26) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 60 mL\n 100 mL\n PO:\n 50 mL\n 100 mL\n TF:\n IVF:\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 450 mL\n Urine:\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 60 mL\n -350 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),\n (Murmur: Systolic), displaced PMI laterally\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: mild TTP bilateral LQ,\n no rebound or guarding\n Extremities: No edema\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x 3, MAE\n Labs / Radiology\n 120 K/uL\n 11.5 g/dL\n 79 mg/dL\n 1.9 mg/dL\n 34 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 34.5 %\n 7.4 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n WBC\n 7.0\n 7.4\n Hct\n 32.8\n 32.5\n 34.5\n Plt\n 134\n 120\n Cr\n 2.0\n 1.9\n TropT\n 0.01\n 0.02\n Glucose\n 92\n 79\n Other labs: PT / PTT / INR:22.5/29.5/2.2, CK / CKMB /\n Troponin-T:90/3/0.02, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.4 mg/dL, Mg++:2.1\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 72 yo M with MMP including CAD, CHF, CRI here with GIB and chest pain.\n .\n 1. GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI\n showed erosions in stomach and duodenum c/w NSAID gastropathy (only\n takes ASA), had a normal in . Also consider ischemic colitis,\n although abd is benign, with trace guaiac positive stool.\n - monitor HCTs q4hrs initially and then less frequently if stable\n - 2 large bore IVs in place\n - IVFs PRN\n - Transfuse for HCT < 30 given ? of active ischemia\n - IV PPI\n - F/u GI recs: no plan to scope emergently, await resolution of chest\n pain\n - Hold diuretics\n .\n 2. Chest pain:\n - telemetry\n - cards recs: repeat Echo\n - F/U CE's\n - F/U cards recs: plan for TTE tomorrow\n - continue statin,\n - restart b-blocker, ACE-I tomorrow if stable\n - restart ASA if Hct stable in AM\n .\n 3. Systolic heart failure: Currently satting well on 2L\n - Hold lasix and spironolactone\n - Continue digoxin for afterload reduction\n - monitor I/O's, daily weights\n .\n 4. Afib:\n - continue mexilitine and digoxin (held sotalol last night)\n - s/p reversal of INR given GIB. Will hold off on further\n anticoagulation for now except for ASA in AM\n .\n 5. Chronic renal insufficiency: BL cr 1.6-2. Currently at baseline.\n - avoid nephrotoxins if possible\n - keep MAP >60.\n .\n 6. Hyperlipidemia:\n - continue statin\n .\n 7. Hypothyroidism:\n - continue levothyroxine\n .\n 8. Asthma:\n - continue home meds\n .\n 9. Psych:\n - continue meds\n .\n FEN: NPO, replete lytes PRN, IVFs\n .\n PPX: IV PPI , no anticoagulation, boots\n .\n ACCESS: 2 18g IVs in place\n .\n Communication: Pt, wife )\n .\n DISPO: ICU for now\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments: Family updated\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2140-10-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 345282,
"text": "Chief Complaint: Gi bleed\n HPI:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 10:09 AM\n No events overnight\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 03:51 PM\n Metronidazole - 08:29 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:51 PM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Synthroid\n Mexilitine\n Seroquel\n Fluticasone INH\n Celexa\n Digoxin\n ASA\n Sotalol\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: Chest pain\n Respiratory: No(t) Cough, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea\n Endocrine: History of thyroid disease\n Flowsheet Data as of 10:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 75 (75 - 79) bpm\n BP: 92/54(64) {92/28(46) - 114/78(80)} mmHg\n RR: 13 (10 - 26) insp/min\n SpO2: 94%\n Heart rhythm: AV Paced\n Total In:\n 360 mL\n 610 mL\n PO:\n 300 mL\n 600 mL\n TF:\n IVF:\n 60 mL\n 10 mL\n Blood products:\n Total out:\n 1,550 mL\n 400 mL\n Urine:\n 1,550 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,190 mL\n 210 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis\n Skin: Not assessed, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 121 K/uL\n 68 mg/dL\n 1.5 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 26 mg/dL\n 103 mEq/L\n 142 mEq/L\n 34.7 %\n 7.8 K/uL\n [image002.jpg]\n 07:15 PM\n 10:50 PM\n 03:22 AM\n 10:54 AM\n 06:47 PM\n 10:26 PM\n 06:38 AM\n WBC\n 7.0\n 7.4\n 7.8\n Hct\n 32.8\n 32.5\n 34.5\n 34.5\n 35.4\n 34.7\n Plt\n 134\n 120\n 121\n Cr\n 2.0\n 1.9\n 1.5\n TropT\n 0.01\n 0.02\n 0.01\n Glucose\n 92\n 79\n 68\n Other labs: PT / PTT / INR:19.0/30.3/1.8, CK / CKMB /\n Troponin-T:102/4/0.01, ALT / AST:24/38, Alk Phos / T Bili:86/0.3,\n Amylase / Lipase:72/35, Differential-Neuts:70.3 %, Lymph:17.5 %,\n Mono:7.3 %, Eos:4.8 %, Lactic Acid:0.7 mmol/L, Ca++:8.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n 72 y.o. man with GI bleed and lower abdominal pain, concern for\n possible ischemic colitis.\n 1) Colitis: Continued abdominal pain with perhaps some subjective\n improvement. Consistent with ischemic colitis. Plan to hold diuretics\n to avoid hypoperfusion of bowels. Continue empiric antibiotics for\n gram negative coverage.\n Antiemetics. Advance diet slowly.\n 2) Afib: Holding coumadin per cardiology.\n 3) CAD: Continue current regimen.\n 4) CKD: Cr is stable\n 5) Asthma: Restart home Advair.\n ICU Care\n Nutrition:\n Comments: Advance diet as tolerated.\n Glycemic Control:\n Lines:\n 18 Gauge - 06:08 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Echo",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Report",
"row_id": 68785,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease.\nHeight: (in) 70\nWeight (lb): 222\nBSA (m2): 2.18 m2\nBP (mm Hg): 113/56\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 11:36\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV cavity. Severe\nregional LV systolic dysfunction. No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - akinetic; basal inferolateral - akinetic; mid\ninferolateral - akinetic; basal anterolateral - akinetic;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Moderately dilated aortic sinus. Focal calcifications in aortic root.\nNormal ascending aorta diameter. No 2D or Doppler evidence of distal arch\ncoarctation.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets.\nModerate-severe AS (area 0.8-1.0cm2). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Moderate (2+) MR. Uninterpretable LV inflow pattern due\nto MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic 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 dilated. Left ventricular wall thicknesses are normal. The\nleft ventricular cavity is severely dilated. There is severe regional left\nventricular systolic dysfunction with akinesis of all inferior and\ninferolateral segments and of the basal lateral segments. The other segments\nare severely hypokinetic. There is no ventricular septal defect. The right\nventricular cavity is mildly dilated with mild global free wall hypokinesis.\nThe aortic root is moderately dilated at the sinus level. The aortic valve\nleaflets are severely thickened/deformed. There is moderate to severe aortic\nvalve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\nModerate (2+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Severe focal and global LV systolic dysfunction. Moderate to\nsevere aortic stenosis. Moderate mitral regurgitation.\n\nCompared with the report of the prior study (images unavailable for review) of\n, the degrees of aortic stenosis, ventricular dilatation and left\nventricular dysfunction are similar. The aortic sinus is more dilated and the\ndegree of mitral regurgitation has increased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-10-12 00:00:00.000",
"description": "Report",
"row_id": 149422,
"text": "Atrial sensed and ventricular paced rhythm\nAtrial mechanism may be ectopic atrial rhythm or possibly paced\nVentricular premature complex\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2140-10-11 00:00:00.000",
"description": "Report",
"row_id": 149423,
"text": "Sinus rhythm with demand ventricular pacing\nVentricular premature complexes\nSince previous tracing of the same date, QRS width shorter, assess LV pacing\n\n"
},
{
"category": "ECG",
"chartdate": "2140-10-11 00:00:00.000",
"description": "Report",
"row_id": 149424,
"text": "Sinus rhythm with ventricular demand pacing\nVentricular premature complex\nSince previous tracing of , QRS width wider, consider check pacer\n\n"
}
] |
22,438 | 118,722 | Addressed by problem: . # ID: The patient arrived on the floor afebrile with stable hemodynamics. She was continued on vancomycin for treatment of her recent MRSA bacteremia and port-a-cath infection with L5-S1 disciitis and right sacroiliitis. There was no evidence of cellulitis at the former port-a-cath site in the right upper chest wall. The surgical site appeared well-healed and no drainage was noted. Ultrasound was performed at this site and revealed a small simple fluid collection (0.8x0.8x1.8cm) that was likely due to post-operative changes. Surgery evaluated the former port-a-cath site and recommended no need for drainage. MR of the right hip, lumbar, and thoracic spine were performed and revealed resolving discitis, sacroiliitis, and no evidence of osteomyelitis or epidural abscess. The patient requested HIV test and was antibody negative. C. Diff stool toxin was negative x 1. On hospital day #2, surveillance blood cultures drawn in the ED grew high-grade vancomycin-resistant enterococcus. The patient remained afebrile with stable vitals. The source of this bacteremia was unknown but thought to be most likely related to the indwelling PICC line. ID team was consulted and the patient was switched to IV daptomycin. Her right antcubital PICC line was removed on . Subsequent daily blood cultures have shown no growth. A new PICC line was placed in the right upper extremity by Interventional on for antibiotics and blood draws as there was no other venous access available despite multiple attempts by both IV nursing and the MICU team (failed left subclavian line placement, no complications). Regarding the etiology of her VRE bacteremia: line infection, cardiac, and GI sources were considered. Although believed to be the most likely source, there was no evidence of line infection as the culture from the PICC tip was negative. There was also no evidence of endocarditis or valvular vegetations on both TTE and TEE. Abdominal sources were considered but believed unlikely given no complaints, normal exam and LFTs, and therefore an abdominal CT scan was not performed. ID desired to transition the patient to oral antibiotics, however the patient was taking effexor and had to be weaned off this medication given the theoretical risk for serotonin syndrome. Pharmacy and psychiatry were consulted regarding effexor weaning which was successfully performed over 5 days without noted withdrawal symptoms and then discontinued completely on . Daptomycin was discontinued on and the patient was started on linezolid PO 600mg to complete at least a 2 week course. She remained afebrile with stable vital signs and serial neurological exams revealed no evidence of serotonin syndrome. She will need weekly CBC, BUN, Creatinine, and LFTs to monitor for side effects while on linezolid. She will f/u with Dr. from Infectious Disease. - CBC, BUN, Creatinine, LFTs qweekly --> fax results to Dr. @ . # Loss of consciousness: On , the patient was found by staff lying on the floor of her room responding only to painful stimuli with no spontaneous movement of extremities. The event was unwitnessed. She was placed in a hard cervical collar. CT head was negative; CT c-spine revealed no fracture but there was a question of C1-C2 rotational instability. She was transferred to the MICU for close observation. Neurology who suggested unlikely to be CVA. Neurosurgery requested c-spine flexion and extension films which showed no signs of instability, however given the C1-C2 rotational instability noted in her c-spine she was continued with a hard collar. She was ruled-out for MI with serial cardiac enzymes. EEG suggested encephalopathy medications vs. toxic/metabolic vs. infection. As her symptoms resolved, she displayed evidence of a post-ictal state. Her mental status gradually improved and her neurological exam resolved back to baseline. Given her h/o seizure disorder, this event appeared to be most likely a seizure, however her dilantin level was therapeutic. Given her positive blood cx, there was concern for septic emboli, however given the transient nature of her symptoms it was believed less likely. One possible etiology in light of the cervical CT findings was atlantoaxial subluxation. The patient stabilized in the MICU and was transferred back to the floor for continued care on . Daily dilantin levels were followed and were therapeutic. Per neurology, she was transitioned to keppra 1000mg po bid and weaned off dilantin. She had no further LOC episodes while on the floor and her neurological examination remained non-focal. She is scheduled to follow-up in with Dr. in Clinic. . # C1/C2 rotational instability: (see above LOC for description of event) Neurosurgery evaluated the patient s/p unwitness fall. C-spine flexion/extension films were stable but rotation of C1 on C2 was noted on c-spine CT. It was recommended that the patient wear a hard cervical collar (Aspen) for 4 weeks given concern about rotational instability in her cervical spine. Despite frequent reminders about the severity of this potential problem, the patient continued to occasionally remove and refuse to wear the cervical collar. She was counseled extensively regarding the risks including paralyzation and death. She should call to schedule a f/u appointment with Dr. from Neurosurgery in 3 weeks for evaluation. . # Dysphagia: The patient reported difficulty swallowing large pieces of meat for at least one year. She stated that frequently she would have to vomit to remove the obstruction. Denies difficulty swallowing liquids or odynophagia. Also states she was told by her PCP that she had an esophageal stricture that needed to be dilated. Her last EGD was approximately following partial gastrectomy for peptic ulcers. GI and was consulted for evaluation, and believed the problem to likely be oropharyngeal in nature. She was noted to have a small cervical esophageal web on video swallow study; barium swallow was limited due to cervical collar but revealed no evidence of obstruction or stricture. Speech and swallow evaluation was performed and negative for signs of aspiration, however it she did struggle swallowing mixed consistency liquids (e.g. cereal with milk, soup with peas) and therefore her diet was changed to eliminate these components. GI suggested outpatient evaluation including EGD. She will follow-up with Dr. from GI after discharge. . # HTN: Her BP was well-controlled throughout admission, however chagnes were made to her regimen to optimize long-term management. She was changed from metoprolol to atenolol 100mg po qd. Lisinopril was started and increased 2.5mg qod to reach goal dose of 10mg qd. She was begun to be weaned off clonidine by decreasing 0.1mg qod. She tolerated these medication changes without difficulty and showed no signs of rebound hypertension during clonipine taper. She should be monitored as an outpatient by her PCP and her medications titrated for goal BP<130/80. - follow BP's as outpatient and titrate regimen . # CAD: The patient is s/p CABG . Cardiac cath with patent grafts. ETT c myoview normal. Stable c no active ischemia. She was r/o for MI with serial cardiac enzymes. EKG's were unchanged from prior studies. She was continued on beta blocker, lipitor, and imdur. Plavix (patient has aspirin allergy) was briefly discontinued s/p fall and transfer to MICU but reinstituted shortly after returning to the floor. Of note, on TEE the patient had mobile atheroma present in the aortic arch. . # CHF: Carries this diagnosis but EF 60-70% and requires no diuretics at home. She had both TTE and TEE while inpatient which were within normal limits. She remained euvolemic throughout admission. I&Os and daily weights were monitored. She had no SOB or signs of volume overload during admission and required no lasix. . # Hypothyroidism: Currently euthyroid with TSH 0.73 at admission. She was continued on her home dose of levothyroxine. . # Chronic Anemia: Etiology is likely due to chronic disease. B12 and folate levels were within normal levels. She was guaiac negative x 1 and positive x 1. The patient reports occasional BRBPR that she attributes to hemorrhoids. Reports colonoscopy approximately 5 years ago at (Dr. which was negative. Her hematocrit remained stable throughout admission. - consider outpatient colonoscopy referral, patient has appointment for clinic . # GERD: No active issues, she was continued on proton pump inhibitor. . # Chronic LBP: Possibly related to disciitis, although per report and prior notes obtained from Medical Center this appears to be a chronic problem. She has had prior back surgery while a teenager. She was continued on her outpatient regimen while in house and required no breakthrough pain medications. . # Psych: Patient wih history of depression and anxiety. Initially she was continued on effexor, xanax, and serax. As it was desired that she start linezolid, she was weaned off of effexor with no obvious adverse side effects noted. Psychiatry was consulted regarding management of depression off effexor and benzodiazepines. She was not restarted on a new anti-depressant as she was not currently showing signs of major depression and did not desire continued treatment. Regarding her benzodiazepines, zanax and serax were discontinued and she was started on klonapin 0.5mg po tid and slowly weaned to klonapin 0.5mg po qd prn prior to discharge. She was closely monitored and displayed no active signs of benzo withdrawal . # Tremors: The patient complained of occasional chronic tremors involving her arms and legs that occur with activity. She was evaluated by neurology. No resting or intention tremors were noted and she had a normal neurological exam. It was though that this may be related to deconditioning and chronic illness, however other possibilities include medication side effects from her polypharmacy. She will be followed by Neurlogy as an outpatient. . # Osteoporosis: The patient was continued with vitamin D and calcium supplements. Consideration should be given for starting alendronate after the cervical collar is removed. Outpatient bone density scan may also be helpful in management. . # Cough: Patient complained of a dry cough on day of discharge. Afebrile, no leukocytosis. CXR without PNA. . # FEN: diabetic/cardiac diet (no mixed consistency liquids, give pills in applesauce); electrolytes were monitored daily and repleted as needed . # PPX: pneumoboots (pt refuses sc heparin), PPI . # Dispo: return to Rehabilitation Facility | Focal calcifications in aortic root.Normal ascending aorta diameter. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass orvegetation on mitral valve.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal main PA. NoDoppler evidence for PDAPERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The absence of a vegetation by 2D echocardiography does notexclude endocarditis if clinically suggested.Conclusions:The left atrium is mildly dilated. Normal LV inflowpattern for age.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single-lumen PICC line placement via the right brachial vein with the tip positioned in SVC. No mass orvegetation on tricuspid valve.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. FINDINGS: From T1-T2 to T12-L1, mild disc degenerative changes are seen without significant bulging, herniation or spinal stenosis. Following gadolinium, no abnormal intraspinal enhancement seen. T1 sagittal and axial images were obtained following the administration of gadolinium. PATIENT/TEST INFORMATION:Indication: Endocarditis, rule out vegetation.Height: (in) 59Weight (lb): 190BSA (m2): 1.81 m2BP (mm Hg): 160/85HR (bpm): 60Status: InpatientDate/Time: at 11:35Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal LV cavity size. PATIENT/TEST INFORMATION:Indication: Evaluate for endocarditis.Height: (in) 60Weight (lb): 175BSA (m2): 1.77 m2BP (mm Hg): 151/74HR (bpm): 63Status: InpatientDate/Time: at 17:47Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Nomasses or vegetations are seen on the aortic valve. Normal tricuspid valve supporting structures.Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. From L1-L2 to L4-L5, mild disc degenerative changes are noted without spinal stenosis. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. Mild mitral annular calcification. T1 sagittal images were obtained following gadolinium. PT CLEARED BY NEURO SURGERY, COLLAR REMOVED R/T PT DENIES NECK PAIN AND C-SPIN XRAY NEGATIVE. Non-specific ST-T wave changes. LS= CLEAR/DIM. Anterior ST segment depression and T wave inversionsuggestive of ischemia. Mildly thickened aortic valveleaflets. THORACIC SPINE: TECHNIQUE: T1, T2 and inversion-recovery sagittal images were obtained before gadolinium. IMPRESSION: Mild degenerative changes. EKG CHANGES NOTED S/P FALL, T WAVE CHANGES. CONTINUE ICU SUPPORTIVE CARE. IMPRESSION: Slight improvement of right sacroiliitis at the inferior/posterior aspects of the joint, with unchanged appearance at the anterior/superior aspect of the joint. Small amount of presacral fluid remains unchanged. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Complex (mobile) atheroma in the aortic arch.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). PORTACATH SITE W/ GUAZE INTACT, NO DRAINAGE NOTED AT THIS TIME. Mild degenerative changes. IV VANCO Q24HRS CONTINUES. Possible left atrial abnormality. Mild thickeningof mitral valve chordae. The subtle signal changes and enhancement seen at the L5-S1 disc are less than , and unchanged compared to . Compared to the previoustracing of the anterior ST-T wave changes are much less.TRACING #2 0.1 mg of IV glycopyrrolate was given as an antisialogogueprior to TEE probe insertion. CARDIOLOGY TEAM CONSULTED, TEE ORDERED, CKMB AND TROPONIN PENDING. Theestimated pulmonary artery systolic pressure is normal. LUMBAR SPINE: TECHNIQUE: T1, T2 and inversion-recovery sagittal and T1 and T2 axial images were obtained before gadolinium. The left ventricular cavity size is normal. There is no pericardial effusion.Compared with the findings of the prior study (images reviewed) of , no major change is evident. Nursing Progress Note:Pt. There is no aortic valvestenosis. No LV mass/thrombus. Left ventricular wall thickness, cavitysize, and systolic function are normal (LVEF 70%). Clinicalcorrelation is suggested. Note is again made of mild edema along the deep fibers of the right iliacus muscle, similar to the prior examinations. Anterolateral ST-T waveabnormalities are non-specific but cannot exclude ischemia. UPON ARRIVAL TO MICU, PT SLIGHTLY DIFFICULT TO AROUSE AND DISORIENTED. NBP= 101-167/55-72. Since the previous tracing of nosignificant change. CERVICAL COLLAR APPLIED AND STAT C-SPINE COMPLETED. PMH OF SEIZURE DISORDER, PT TAKES DILANTIN. Overall left ventricularsystolic function is normal (LVEF>55%).3. A single-lumen PICC line was then placed through the sheath over the wire and its tip positioned in SVC under fluoroscopic guidance. This is need until cultures clear and permanent PICC can be put back in. FINDINGS: Changes of abnormally elevated signal on STIR imaging as well as post-gadolinium imaging remains present at the right sacroiliac joint, involving both the sacral and the iliac sides of the joint. ABD SOFT/ DISTENDED. REASON FOR THIS EXAMINATION: r/o osteomeylitis FINAL REPORT INDICATION: Sacroiliitis, cellulitis. ASSESS NEURO STATUS CLOSELY. There are mobile, complex (mobile) atheroma in the aortic arch.4. These findings indicate stable appearances of previously described improving disc space infection. siezure, transferred to MICU for further evaluation.Neuro: Pt. PT ARRIVED TO MICU W/ C-COLLAR ON, ACCOMPANIED BY MEDICAL FLOOR MD. Needs new CVL or midline(temporary - any site OK) for antibiotic therapy. Sinus rhythm. No masses or thrombi areseen in the left ventricle. Pt.taken for C-spine flexion and extension x-ray, results pending.CV: HR 50s-60s. Rightventricular chamber size and free wall motion are normal. The patient was sedated for the TEE.Medications and dosages are listed above (see Test Information section). Sinus bradycardia. Sinus bradycardia. The absence of a vegetation by 2Dechocardiography does not exclude endocarditis if clinically suggested. No TEE relatedcomplications. No previous tracing available forcomparison.TRACING #1 has R PICC which is patent and WNL. No masses orvegetations on aortic valve. Following gadolinium, enhancement is seen near the posterior margin of the disc. Calcified tips of papillary muscles. PT FOUND ON FLOOR W/ NECK HYPEREXTENDED. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2188-08-21 00:00:00.000",
"description": "Report",
"row_id": 1555890,
"text": "0700-1900 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET AND ADMISSION DATABASE FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. PT TRANSFER FROM CC7 TO MICU AT APPROX 1600, S/P FALL. PT FOUND ON FLOOR W/ NECK HYPEREXTENDED. CERVICAL COLLAR APPLIED AND STAT C-SPINE COMPLETED. PT ARRIVED TO MICU W/ C-COLLAR ON, ACCOMPANIED BY MEDICAL FLOOR MD. FALL, PT ALERT AND ORIENTED X3 AND AMBULATING INDEP. S/P FALL, SLURRED SPEECH TO NO SPEECH W/ CHANGE IN MS, DIFFICULTY AROUSING. SEEN BY NEURO TEAM AND NEURO SURGERY TEAM UPON ARRIVAL TO MICU. PT CLEARED BY NEURO SURGERY, COLLAR REMOVED R/T PT DENIES NECK PAIN AND C-SPIN XRAY NEGATIVE. UPON ARRIVAL TO MICU, PT SLIGHTLY DIFFICULT TO AROUSE AND DISORIENTED. APPROX 1HR LATER, PT AWAKE AND ALERT/ORIENTED X3. FOLLOWING COMMANDS, NO SLURRED SPEECH, MAE, PERLA. HOWEVER PT HAS NO MEMORY OF EVENT ON CCY. PMH OF SEIZURE DISORDER, PT TAKES DILANTIN. EKG CHANGES NOTED S/P FALL, T WAVE CHANGES. CARDIOLOGY TEAM CONSULTED, TEE ORDERED, CKMB AND TROPONIN PENDING. SB TO NSR @ 59-64. NBP= 101-167/55-72. AFEBRILE. 02 SAT 98%. RR=14-18. LS= CLEAR/DIM. ABD SOFT/ DISTENDED. PRESENT BS. SOFT BROWN STOOL X2, FOLEY CATH DRAINING CLEAR YELLOW URINE 50-100CC/HR. PORTACATH SITE W/ GUAZE INTACT, NO DRAINAGE NOTED AT THIS TIME. FULL CODE. CONTACT PRECAUTIONS FOR MRSA BACTREMIA, 4 BOTTLES POSITVIE FOR GPC. IV VANCO Q24HRS CONTINUES. FS QID, FS= 77-246. NPO STATUS MAINTAINED AT THIS TIME.\n\nPLAN- POSSIBLE NECK FLEXION/EXTENSION SERIES NEEDED TONIGHT OR IN AM PER NEURO SURGERY TEAM RECOMM. TEE TO BE DONE IN NEAR FUTURE AFTER NECK SERIES. ASSESS NEURO STATUS CLOSELY. CONTINUE IV ABX. FOLLOW CARDIAC ENZYMES, NEXT DUE AT 2200. CONTINUE ICU SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-08-22 00:00:00.000",
"description": "Report",
"row_id": 1555891,
"text": "Nursing Progress Note:\n\nPt. is a 62yo woman who was being trated for a port-o-cath line infection on CC7 and was found on floor unresponsive with her neck hyperextended, evaluated by neurology, head CT done (no evidence of bleed or CVA),? siezure, transferred to MICU for further evaluation.\n\nNeuro: Pt. is alert, OX3, very pleasant and cooperative, MAE, with no c/o numbness, tingling or lateralizing signs. She c/o pain to her back which is chronic and for which she takes Morphine SR and Percocet. She also takes Fioricet for headaches. Her pain was well contolled with medication and she slept well. She did not have any generalized seizure activity but did have a twitch to her hand and head which she noticed but was not observed. Pt.taken for C-spine flexion and extension x-ray, results pending.\n\nCV: HR 50s-60s. NBP 100s-120s/50s-60s. Pt. has R PICC which is patent and WNL. Enzymes cycled s/p fall and are WNL, TEE planned for today to r/o vegetation.\n\nResp: RR teens, 02 sats >96% on 2L NC, lungs sounds clear to all lobes.\n\nGI: Pt. is NPO for possible TEE, taking PO meds with sips. BSX4, golden, liquid stool, mushroom catheter placed, C-diff culture sent.\n\nGU: UO initially WNL but became <30cc/hour, team notified and NS@125cc/hour for 1L initiated (fluids being given slowly due to hx of CHF). UO now hovering around 30cc/hour. Urine tox sent.\n\nID: Pt. being treated for MRSA bacteremia, blood cultures sent. Pt. is growing 4/4 bottles GPC pairs/chains. HIV test ordered with AM labs but consent is needed so this will need to be resent.\n\nSkin: Intact except for healing incision in R chest (site of old port-o-cath).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2188-08-28 00:00:00.000",
"description": "Report",
"row_id": 61236,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for endocarditis.\nHeight: (in) 60\nWeight (lb): 175\nBSA (m2): 1.77 m2\nBP (mm Hg): 151/74\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 17:47\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (mobile) atheroma in the aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The patient was sedated for the TEE.\nMedications and dosages are listed above (see Test Information section). The\nposterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related\ncomplications. 0.1 mg of IV glycopyrrolate was given as an antisialogogue\nprior to TEE probe insertion. The patient appears to be in sinus rhythm.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\n1. The left atrium is dilated.\n2. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF>55%).\n3. There are mobile, complex (mobile) atheroma in the aortic arch.\n4. The aortic valve leaflets (3) are mildly thickened.\n5. No echocardiographic evidence of endocarditis is seen.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2188-08-26 00:00:00.000",
"description": "Report",
"row_id": 61237,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis, rule out vegetation.\nHeight: (in) 59\nWeight (lb): 190\nBSA (m2): 1.81 m2\nBP (mm Hg): 160/85\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 11:35\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: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient. No LV mass/thrombus. 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: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No masses or vegetations on aortic valve. No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\nof mitral valve chordae. Calcified tips of papillary muscles. Normal LV inflow\npattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Normal tricuspid valve supporting structures.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\nDoppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The absence of a vegetation by 2D echocardiography does not\nexclude endocarditis if clinically suggested.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF 70%). No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. There are three\naortic valve leaflets. The aortic valve leaflets are mildly thickened. No\nmasses or vegetations are seen on the aortic valve. There is no aortic valve\nstenosis. The mitral valve leaflets are mildly thickened. There is no mitral\nvalve prolapse. No mass or vegetation is seen on the mitral valve. The\nestimated pulmonary artery systolic pressure is normal. No vegetation/mass is\nseen on the pulmonic valve. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , no major change is evident. The absence of a vegetation by 2D\nechocardiography does not exclude endocarditis if clinically suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2188-08-24 00:00:00.000",
"description": "Report",
"row_id": 116097,
"text": "Sinus rhythm. Possible left atrial abnormality. Anterolateral ST-T wave\nabnormalities are non-specific but cannot exclude ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2188-08-23 00:00:00.000",
"description": "Report",
"row_id": 116098,
"text": "Sinus rhythm\nAnteroseptal T wave changes may be due to ischemia\nSince previous tracing of , increased rate\n\n"
},
{
"category": "ECG",
"chartdate": "2188-08-22 00:00:00.000",
"description": "Report",
"row_id": 116099,
"text": "Sinus bradycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing of the anterior ST-T wave changes are much less.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2188-08-21 00:00:00.000",
"description": "Report",
"row_id": 116100,
"text": "Sinus bradycardia. Anterior ST segment depression and T wave inversion\nsuggestive of ischemia. Late transition. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-08-26 00:00:00.000",
"description": "FLUOR GUID PLCT/REPLCT/REMOVE",
"row_id": 924906,
"text": " 7:44 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Patient with very difficult access, in collar for cervical i\n Admitting Diagnosis: CELLULITIS\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 62 year old woman with recent osteomyelitis and bactermeia, now with line\n sepsis - PICC pulled on Sunday.\n REASON FOR THIS EXAMINATION:\n Patient with very difficult access, in collar for cervical instability, now\n with VRE bacteremia secondary to PICC line which was pulled on /6 after a\n lower-extremity was placed. Needs new CVL or midline(temporary - any site OK)\n for antibiotic therapy. This is need until cultures clear and permanent PICC\n can be put back in. Please page if problem.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: 62-year-old woman with osteomyelitis, needs IV access.\n\n Details of the procedure were explained to the patient.\n\n RADIOLOGIST: Dr. was performing the procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia the right brachial\n vein was localized with ultrasound and punctured under direct ultrasound\n guidance using a micropuncture set. Hard copies of the ultrasound images were\n obtained before and immediately after obtaining intravenous access. A peel-\n away sheath was then placed. A single-lumen PICC line was then placed through\n the sheath over the wire and its tip positioned in SVC under fluoroscopic\n guidance. Position of the catheter was confirmed by chest x-ray in one view.\n\n A guidewire and a peel-away sheath were then removed. The catheter was\n secured to the skin.\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 right brachial vein with the tip positioned in\n SVC. Total length of the catheter 34 cm.\n\n\n\n\n\n\n\n\n (Over)\n\n 7:44 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Patient with very difficult access, in collar for cervical i\n Admitting Diagnosis: CELLULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-08-21 00:00:00.000",
"description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS",
"row_id": 924320,
"text": " 7:21 AM\n MRI PELVIS W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: LOWER EXTREMITY AND BILATERAL HIPS PAIN AND LOSS OF MOTION\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with multiple medical problems recent MRSA bacteremia,\n sacroiliitis, presents with cellulitis, new GPC bacteremia, low back pain.\n REASON FOR THIS EXAMINATION:\n r/o osteomeylitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sacroiliitis, cellulitis. Evaluate interval change.\n\n TECHNIQUE: Multiplanar MR imaging of the pelvis was performed with images\n obtained both before and after the administration of IV contrast, with imaging\n on a 1.5 Tesla magnet. Comparison was made to examinations dated and\n .\n\n FINDINGS: Changes of abnormally elevated signal on STIR imaging as well as\n post-gadolinium imaging remains present at the right sacroiliac joint,\n involving both the sacral and the iliac sides of the joint. While the\n inferior/posterior aspect of involvement appears slightly improved on post-\n contrast imaging, the anterior/superior aspects are not significantly changed.\n There are no loculated/drainable fluid collections seen.\n\n Note is again made of mild edema along the deep fibers of the right iliacus\n muscle, similar to the prior examinations. Note is also made of atrophy\n involving both gluteus maximus muscles, and edema seen within the subcutaneous\n soft tissues. Small amount of presacral fluid remains unchanged. There is no\n hip joint effusion.\n\n IMPRESSION: Slight improvement of right sacroiliitis at the\n inferior/posterior aspects of the joint, with unchanged appearance at the\n anterior/superior aspect of the joint. No drainable fluid collection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-08-22 00:00:00.000",
"description": "MR L-SPINE W & W/O CONTRAST",
"row_id": 924558,
"text": " 5:40 PM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: vertebral osteomyelitis\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL ADDENDUM\n Comparison was made with the prior studies of and . The subtle\n signal changes and enhancement seen at the L5-S1 disc are less than ,\n and unchanged compared to . These findings indicate stable appearances\n of previously described improving disc space infection. No new findings are\n seen.\n\n\n 5:40 PM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: vertebral osteomyelitis\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with MRSA bacteremia and sacroilitis, concern for seeding.\n REASON FOR THIS EXAMINATION:\n vertebral osteomyelitis\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI OF THE THORACIC AND LUMBAR SPINE.\n\n CLINICAL INFORMATION: Patient with MRSA bacteremia and concerning for\n vertebral osteomyelitis.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1, T2 and inversion-recovery sagittal images were obtained before\n gadolinium. T1 sagittal images were obtained following gadolinium.\n\n FINDINGS: From T1-T2 to T12-L1, mild disc degenerative changes are seen\n without significant bulging, herniation or spinal stenosis. The vertebral\n bodies and discs demonstrate no evidence of abnormal signal indicative of\n discitis or osteomyelitis. Following gadolinium, no abnormal intraspinal\n enhancement seen.\n\n IMPRESSION: Mild degenerative changes. No evidence of discitis or\n osteomyelitis in the thoracic region. No evidence of spinal cord compression\n or abnormal intrinsic signal within the spinal cord.\n\n LUMBAR SPINE:\n\n TECHNIQUE: T1, T2 and inversion-recovery sagittal and T1 and T2 axial images\n were obtained before gadolinium. T1 sagittal and axial images were obtained\n following the administration of gadolinium.\n\n FINDINGS: The L5-S1 disc demonstrate increased signal on T2 and inversion-\n recovery images with subtle decreased signal along the endplates on T1-\n weighted images. Following gadolinium, enhancement is seen near the posterior\n margin of the disc. There is no epidural phlegmon identified. No evidence of\n paraspinal mass seen.\n\n At L4-L5 level, there has been previous spinal fusion noted posteriorly.\n\n From L1-L2 to L4-L5, mild disc degenerative changes are noted without spinal\n stenosis.\n\n IMPRESSION: Signal changes within the L5-S1 disc with subtle enhancement are\n suspicious for early changes of discitis. No epidural mass or epidural\n phlegmon seen or paraspinal abscess identified. Mild degenerative changes.\n Findings suggestive of previous fusion at L4-L5 level.\n (Over)\n\n 5:40 PM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: vertebral osteomyelitis\n Admitting Diagnosis: CELLULITIS\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n"
}
] |
99,472 | 161,362 | 82 yo female with PMH of HTN, HL, presenting to OSH with respiratory distress, intubated, hypotensive on pressors, found to have NSTEMI with TropI>100. Cath showing significant 2VD, and complicated by hypotension intraprocedurally. Transferred to for eval for urgent CABG. . # NSTEMI: Pt initially presenting to OSH with respiratory distress complicated by refractory hypotension requiring dopamine for pressor support likely NSTEMI. Her enzymes were followed showing troponin >100 and cath significant for 2VD and requiring placement of balloon pump. Bedside echo on admission showed EF of 35-40% with moderate regional left ventricular systolic dysfunction with basal and mid anterioseptal, anterior, anteriolateral, and apical hypokenesis. Patient was continued on medical management with heparin ggt, asa 325, atorva 80. Dopamine and levophed were weaned off over the course of 3 days. IABP remained in at one to one. Echo showed a preserved EF 55%. Patient was taken for CABG.... . # Respiratory failure: Patient remained intubated. Oxygen was weaned down to 40% over the next 24 hours after arrival. Initial cause of respiratory distress likely secondary to NSTEMI with resultant CHF. As she began to spike fevers and CXR showed probable pneumonia, she was experically treated for pneumonia with vancomycin and zosyn. . # Hypotension: On arrival to , patient was maxed out on dopamine 20mcg/kg/hr. Initial PA catheter readings indicated a mixed picture of cardiogenic and distributive shock. Patient's calculated SVR then began to decrease, and echo showed globally normal LVEF without major wall motion abnormalities. It was determined that she was in distributive/septic shock. She was weaned off dopamine, and transitioned to levophed. After 2 days on levophed, her MAPs remained > 60 and she was weaned off. . #. Carotid Artery: During replacement of PA catheter, cordis sheath was placed in the carotid artery. CT aorta showed no evidence of hematoma. Patient was evaluated by vascular surgery and cardiac surgery. On the patient was brought to the operating room for sternotomy and removal of cordis sheath as well as coronary bypass grafting by cardiac and vascular surgery. Please see the operative report for details. Following the operation she was transferred to the cardiac surgery ICU paralyzed and sedated in critical condition on multiple pressors and inotropes with an open chest. Over the next several days she remained with an open chest on multiple pressors, she eventually developed acute renal failure and was begun on CVVHD. Her condition continued to deteriorate and on POD 5 she was made comfort measures only. She expired on POD 5 with family present | FINDINGS: As compared to the previous radiograph, the tip of the Swan-Ganz catheter is still located distally in the right pulmonary artery. FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post CABG, dropping saturation. A new right internal jugular approach sheath is identified, seen to terminate in the upper right-sided mediastinum corresponding to the area of the right jugular/subclavian venous junction. New Swan-Ganz catheter from the left IJ approach extends to the right pulmonary artery. Previously described Swan-Ganz catheter, approached from below, has been withdrawn. Left IJ at confluence of svc and left brachiocephalic v. There is bilateral atelectasis and pulmonary edema. Increased right lower lung atelectasis and unchanged left lower lung atelectasis. UNDER FLUORO Admitting Diagnosis: CORONARY ARTERY DISEASE FINAL REPORT HISTORY: Jugular catheter placement under fluoroscopy. FINDINGS: Since the prior study, endotracheal tube has advanced distally with its tip now at the carina. 7:46 PM CHEST (PORTABLE AP) Clip # Reason: Eval for acute process and balloon pump location. Aberrant placement of the right-sided central venous introducer sheath, which traverses both the external jugular and internal jugular veins, with its tip within the right brachiocephalic artery at the origin of the right subclavian artery. via carotid. COMPARISON: Chest radiograph from FINDINGS: Targeted son is performed in the right supraclavicular tissues, at the site of catheter exit from the skin. At the right lung base, however, a subtle remnant pulmonary opacity is still visible. COMPARISON: Portable chest x-ray from . CHEST: The tip of the Swan-Ganz catheter lies in the right pulmonary artery. carotid WET READ: SPfc 5:21 PM nonvisualization of the intraluminal course, if any, of the right neck catheter. Right Swan-Ganz sheath seen traversing the external jugular and internal jugular with the tip within the right brachiocephalic at the location where the right subclavian originates. Right Swan-Ganz sheath seen traversing the external jugular and internal jugular with the tip within the right brachiocephalic at the location where the right subclavian originates. (Over) 10:28 AM CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # Reason: please eval neck down to carina to look at aortic arch archi Admitting Diagnosis: CORONARY ARTERY DISEASE FINAL REPORT (Cont) IMPRESSION: 1. Mild (1+)aortic regurgitation is seen. Mild (1+)aortic regurgitation is seen. Mild (1+) aorticregurgitation is seen. Mild(1+) mitral regurgitation is seen. Mild aortic regurgitation. Mild mitral annularcalcification. There is mild regional leftventricular systolic dysfunction with anterior hypokinesis. Moderate pulmonaryhypertension. Thereis mild aortic valve stenosis (valve area 1.2-1.9cm2). The right ventricular cavity is mildly dilated with normal free wallcontractility. There is mild pulmonary artery systolichypertension. There are simple atheroma in the descendingthoracic aorta. There is an anterior space which most likelyrepresents a prominent fat pad.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.Cannot exclude hemodynamically-significant aortic stenosis. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. ]TRICUSPID VALVE: Mild to moderate [+] TR.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. There is an anterior space which mostlikely represents a fat pad, though a loculated anterior pericardial effusioncannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor parasternal views.Conclusions:The left atrium is normal in size. Mild mitralregurgitation. Trivial mitral regurgitation is seen. Mild to moderate [+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Mild-moderate tricuspidregurgitation. Moderate mitralannular calcification. Mild regional LVsystolic dysfunction. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal ascending aortadiameter.AORTIC VALVE: Moderately thickened aortic valve leaflets. The gallbladder is moderately distended. Mild [1+]TR. Mild [1+] TR. ]TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Shortness of breath.Height: (in) 63Weight (lb): 189BSA (m2): 1.89 m2BP (mm Hg): 118/74HR (bpm): 74Status: InpatientDate/Time: at 20:43Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion. Mildmitral regurgitation. Unchanged appearance of the lung parenchyma and the cardiac silhouette. There is ananterior space which most likely represents a prominent fat pad.IMPRESSION: Suboptimal image quality.Mild aortic regurgitation. Mild PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. Preservedglobal biventricular systolic function. Normal RV systolic function.AORTA: Normal aortic diameter at the sinus level. There is moderate pulmonary artery systolic hypertension.There is no pericardial effusion. There is no pericardial effusion.IMPRESSION: Normal global and regional biventricular systolic function.Calcific aortic valve disease with mild stenosis/mild regurgbitation. Mild pulmonary hypertension.Compared with the prior study (images reviewed) of , anteriorhypokinesis is no longer appreciated (prior study technically-suboptimal). If there is any pleural effusion it is minimal. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Distended and edematous gallbladder without gallstones. Trace aorticregurgitation is seen. Regional left ventricular wall motion isnormal. The mitral valve leaflets are mildly thickened.No mitral regurgitation is seen. Mild AS (area1.2-1.9cm2). No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. The aortic valve leaflets are mildly thickened (?#). | 30 | [
{
"category": "Radiology",
"chartdate": "2193-12-23 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1172807,
"text": " 9:37 AM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: Location of balloon tip\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with IABP, ? position of balloon tip\n REASON FOR THIS EXAMINATION:\n Location of balloon tip\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Intra-aortic balloon pump, check position of tip.\n\n What appears to be the tip of the tube lies in the lower abdominal aorta at\n the level of the interspace of L2 and L3.\n\n The bowel gas appears normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173708,
"text": " 1:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, evaluation for pleural effusion.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lungs have improved in\n transparency, likely reflecting improved ventilation. At the right lung base,\n however, a subtle remnant pulmonary opacity is still visible.\n\n No newly occurred parenchymal opacities, no edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-24 00:00:00.000",
"description": "O CHEST (SINGLE VIEW) IN O.R.",
"row_id": 1173004,
"text": " 2:44 PM\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: RT JUGULAR LINE PL. UNDER FLUORO\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Jugular catheter placement under fluoroscopy.\n\n FINDINGS: Single image fails to show a definite jugular catheter. Further\n information can be gathered from the operative report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1173005,
"text": " 2:47 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 82 Y.O. WOMAN WITH SWAN PLACED IN ARTERY, PLEASE ECALUATE FOR PNEUMO\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with Swan placed in artery, please evaluate for pneumo\n REASON FOR THIS EXAMINATION:\n Thanks\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: 82-year-old female patient with Swan-Ganz catheter placed in\n artery, evaluate for pneumothorax.\n\n AP single view of the chest has been obtained with patient in sitting\n semi-upright position. Comparison is made with the next preceding similar\n study dated . Previously described Swan-Ganz catheter,\n approached from below, has been withdrawn. A new right internal jugular\n approach sheath is identified, seen to terminate in the upper right-sided\n mediastinum corresponding to the area of the right jugular/subclavian venous\n junction. No pneumothorax has developed, and in comparison with the previous\n chest, no significantly increased width of the superior mediastinum is noted.\n Previously identified intra-aortic balloon pump device remains in unchanged\n position. Central pulmonary edema slightly improved. No new pulmonary\n infiltrates are seen, and the lateral pleural sinuses remain free. Heart size\n as before moderately enlarged and typical dense mitral ring calcification is\n observed.\n\n IMPRESSION: No evidence of pneumothorax or significant superior mediastinal\n hematoma following unintended arterial stick.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-24 00:00:00.000",
"description": "CAROTID LMTD/ DPP",
"row_id": 1173023,
"text": " 4:24 PM\n CAROTID LMTD/ DPP Clip # \n Reason: Please evaluate for placement of the cannula, ? carotid\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cannulization of brachiocephalic, ? via carotid.\n REASON FOR THIS EXAMINATION:\n Please evaluate for placement of the cannula, ? carotid\n ______________________________________________________________________________\n WET READ: SPfc 5:21 PM\n nonvisualization of the intraluminal course, if any, of the right neck\n catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Placement of a catheter into the arterial system with question\n of carotid versus brachiocephalic position.\n\n COMPARISON: Chest radiograph from \n\n FINDINGS: Targeted son is performed in the right supraclavicular\n tissues, at the site of catheter exit from the skin. At this level, note is\n made of a structure with posterior acoustic shadowing in the subcutaneous soft\n tissues, presumably related to the superficial component of the catheter. Due\n to limited acoustic windows, the intraluminal course of the catheter, if any,\n is not visualized on the current study. Note is made of a trace amount of\n atherosclerotic disease in the carotid artery.\n\n IMPRESSION: Nonvisualization of the intraluminal portion of the catheter, if\n any. If further confirmation is required, would recommend direct contrast\n injection under fluoroscopy.\n\n Results discussed via telephone with Dr. by Dr. at\n 17:15 on \n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1172738,
"text": " 7:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for acute process and balloon pump location.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cardiogenic shock, intubated and w/ ballon pump. Eval\n for acute process and balloon pump location.\n REASON FOR THIS EXAMINATION:\n Eval for acute process and balloon pump location.\n ______________________________________________________________________________\n WET READ: NATg 8:54 PM\n Right groin S-G catheter is in right PA. Aortic balloon pump tip is 5cm from\n arch. ETT 3cm from carina. Left IJ at confluence of svc and left\n brachiocephalic v. There is bilateral atelectasis and pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cardiogenic shock, intubated with balloon pump.\n\n CHEST:\n\n The tip of the Swan-Ganz catheter lies in the right pulmonary artery. The\n aortic balloon tip lies 5 cm from the aortic arch which shows some unwinding.\n The endotracheal tube lies 3 cm from the carinal angle. The tip of the left\n IJ line lies at the junction of the left brachiocephalic and SVC.\n\n Bilateral interstitial edema is present.\n\n The tip of the nasogastric tube and the side hole lie within the stomach.\n\n IMPRESSION:\n Support tubes and lines as described. Pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173076,
"text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tubes, lines, interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with nstemi, intubated sedated for resp failure\n REASON FOR THIS EXAMINATION:\n tubes, lines, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post NSTEMI, intubated for respiratory failure.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The right large-bore sheath ends over the right superior\n mediastinum; there is no evidence of bleeding adjacent to the catheter tip.\n The ET tube ends 4.5 cm above the carina. The intra-aortic balloon pump tip\n is midway between the upper margin of the left main bronchus and apex of the\n aortic arch. The NG tube ends within the stomach. Mild pulmonary edema has\n minimally improved. Right lower lung atelectasis is increased and left\n basilar atelectasis is unchanged. There is no pneumothorax. Dense\n calcification of the mitral annulus is unchanged.\n\n IMPRESSION:\n 1. Right large bore sheath ending over the right superior mediastinum. No\n evidence of adjacent bleeding.\n 2. Increased right lower lung atelectasis and unchanged left lower lung\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173246,
"text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with NSTEMI, resp failure\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with non-ST elevation MI.\n\n Portable AP chest radiograph was compared to prior study obtained on , .\n\n The NG tube tip is now at the gastroesophageal junction with the sidehole in\n the mid esophagus and should be repositioned. The ET tube tip is obscured by\n the NG tube tip and most likely is in an appropriate position. The right\n internal jugular line is appropriate. Cardiomediastinal silhouette is stable.\n Intra-aortic balloon pump is approximately 4.5 cm below the superior margin of\n the aortic arch. The left retrocardiac opacity is unchanged.\n\n Widespread parenchymal opacities are redemonstrated, unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-25 00:00:00.000",
"description": "CT NECK W/O CONTRAST (EG: PAROTIDS)",
"row_id": 1173106,
"text": ", 10:28 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: please eval neck down to carina to look at aortic arch archi\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with multivessel CAD, swan incidentally floated in carotid.\n Aortic balloon in place.\n REASON FOR THIS EXAMINATION:\n please eval neck down to carina to look at aortic arch architecture\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PFI REPORT\n 1. Right Swan-Ganz sheath seen traversing the external jugular and internal\n jugular with the tip within the right brachiocephalic at the location where\n the right subclavian originates. There is no evidence of organizing hematoma\n in this location.\n 2. Constellation of findings suggestive of congestive heart failure.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1172893,
"text": " 9:27 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Tip of Swan\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with shock, Swan-Ganz catheter\n REASON FOR THIS EXAMINATION:\n Tip of Swan\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Swan-Ganz catheter.\n\n COMPARISON: , 8:29 a.m.\n\n FINDINGS: As compared to the previous radiograph, the tip of the Swan-Ganz\n catheter is still located distally in the right pulmonary artery. The tip\n should be pulled back by approximately 6 cm. The other monitoring and support\n devices are unchanged. The pre-existing right parenchymal opacities have\n decreased in extent. Unchanged size of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173393,
"text": " 10:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: s/p CABG w/dropping PO2 r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/dropping PO2 r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG with dropping pO2.\n\n FINDINGS: In comparison with the study of , there is little overall\n change in the appearance of the heart and lungs. Monitoring and support\n devices remain in place. Some continued widening of the upper mediastinum is\n again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2194-01-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1174078,
"text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/elevated INR and decreased SpO2 r/o collapse\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/elevated INR and decreased SpO2 r/o collapse\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, elevated INR, decreased oxygen saturation.\n\n COMPARISON: multiple prior radiographs.\n\n FINDINGS: Since the prior study, endotracheal tube has advanced distally with\n its tip now at the carina. Numerous other monitoring and support devices are\n stable including a left internal jugular Swan-Ganz catheter and orogastric\n tube and three chest tubes. Diffuse bilateral pulmonary markings are still\n present in both lungs consistent with elevated pulmonary venous pressure.\n\n IMPRESSION: Endotracheal tube at the carina which is advanced since prior\n study. Tube should be pulled back by 4 cm for optimal positioning. This\n finding was communicated with on CC7 at 10 a.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1173376,
"text": " 6:46 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: CARDIAC SURGERY. Pleural effusion, pulmonary edema, tamponad\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with CABG\n REASON FOR THIS EXAMINATION:\n CARDIAC SURGERY. Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n ______________________________________________________________________________\n WET READ: 8:23 PM\n NGT in stomach. ETT 1.6 cm above carina, pls retract at least 2 cm. New\n Swan-Ganz in prox RPA, mediastinal and drains. Low lung vols w/o PTX.\n Bibasilar opacities L>R, likely atelectasis, cannot r/o infx. Prominent\n mediastinum - likely projectional, pls correlate clinically for possible\n hematoma formation. Mitral annular Ca.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with study of , the endotracheal tube tip lies\n only 1.6 cm above the carina and should be pulled back about 2 cm. New\n Swan-Ganz catheter from the left IJ approach extends to the right pulmonary\n artery. Nasogastric tube tip is in the upper stomach, though the side hole is\n within the distal esophagus. Left chest tube is in place and there is no\n evidence of pneumothorax. Mild bibasilar atelectasis is seen. Prominence of\n the mediastinum most likely represents post-surgical change, though this\n should be correlated clinically to assess for possible hematoma formation.\n Dense calcification of the mitral annulus persists.\n\n This information was discussed with Dr. by the resident on call.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-25 00:00:00.000",
"description": "CT NECK W/O CONTRAST (EG: PAROTIDS)",
"row_id": 1173105,
"text": " 10:28 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: please eval neck down to carina to look at aortic arch archi\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with multivessel CAD, swan incidentally floated in carotid.\n Aortic balloon in place.\n REASON FOR THIS EXAMINATION:\n please eval neck down to carina to look at aortic arch architecture\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SZm WED 8:32 PM\n 1. Right Swan-Ganz sheath seen traversing the external jugular and internal\n jugular with the tip within the right brachiocephalic at the location where\n the right subclavian originates. There is no evidence of organizing hematoma\n in this location.\n 2. Constellation of findings suggestive of congestive heart failure.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old female with multivessel CAD and Swan incidentally\n forced into the carotid.\n\n COMPARISON: Portable chest x-ray from .\n\n TECHNIQUE: CT of the neck done without contrast due to the patient's renal\n insufficiency.\n\n FINDINGS: A Cordis-type central venous access introducer sheath traverses the\n right external jugular and right internal jugular veins, following an\n oblique-inferior course with its tip at the take-off of the right subclavian\n from the brachiocephalic artery. There is an approximately 9-mm fascial\n interval between the right IJ venous exit and the brachiocephalic arterial\n entry site. There is no evidence of organizing hematoma in the region, at\n either the skin entry or the site where the sheath traverses the internal\n jugular vein. Extravasation cannot be assessed in the absence of intravenous\n contrast.\n\n An endotracheal tube has its tip 2.8 cm from the carina. The tip of the\n oro-enteric tube is not included in the imaging volume.\n\n There are bilateral pleural effusions, right greater than left and pleural\n seen in the oblique fissures bilaterally. There is thickening of the\n interlobular septae and ground-glass opacities consistent with pulmonary\n edema. Evaluation of cervical lymph chain demonstrates no lymphadenopathy by\n imaging criteria. There are several nodules seen within the thyroid gland,\n the largest measuring 1.3 cm in the lower pole of its left lobe. There are\n multilevel degenerative changes of the spine seen with near-complete loss of\n disc space height between C2 and C3 as well as loss of disc space height\n between C4 and C5. There is no evidence of fracture.\n (Over)\n\n 10:28 AM\n CT NECK W/O CONTRAST (EG: PAROTIDS) Clip # \n Reason: please eval neck down to carina to look at aortic arch archi\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Aberrant placement of the right-sided central venous introducer sheath,\n which traverses both the external jugular and internal jugular veins, with its\n tip within the right brachiocephalic artery at the origin of the right\n subclavian artery.\n 2. No evidence of signficant organizing hematoma in this location.\n 2. Findings of CHF, with mild pulmonary edema.\n\n COMMENT: These findings concerning the aberrant arterial placement of this\n catheter were discussed with Dr. (Cardiology service) by Dr. ,\n at 1200H, and again by Dr. , at 1230H, , who conveyed information\n regarding the traversal of the right internal jugular vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173646,
"text": " 7:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for collapse/ effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p cabg with dropping sats\n REASON FOR THIS EXAMINATION:\n eval for collapse/ effusion\n ______________________________________________________________________________\n WET READ: JMGw SAT 7:29 PM\n increased bilateral pulmonary markings concerning for new pulmonary edema.\n small left effusion. stable appearance to support lines.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, dropping saturation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is an increase in\n bilateral radiodensity of the lungs, predominantly caused by bilateral\n pulmonary markings that are concerning for newly occurred pulmonary edema.\n Unchanged small retrocardiac atelectasis. Unchanged monitoring and support\n devices. No focal parenchymal opacities suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1172797,
"text": " 7:51 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: 82 year old woman with NSTEMI and cardiogenic shock. Intubat\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with NSTEMI and cardiogenic shock. Intubated. Eval for\n change.\n REASON FOR THIS EXAMINATION:\n 82 year old woman with NSTEMI and cardiogenic shock. Intubated. Eval for\n change.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Heart attack, cardiogenic shock.\n\n CHEST: There has been some change in distribution of fluid with some clearing\n of the left side but increased opacifications on the right suggesting\n unchanged degree of pulmonary edema.\n\n IMPRESSION: Failure persists.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173466,
"text": " 12:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with open chest s/p CABG/carotid repair\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 01:26 P.M., \n\n HISTORY: Open chest following CABG and carotid repair. Evaluate for pleural\n effusions.\n\n IMPRESSION: AP chest compared to through 20:\n\n Hazy opacification projecting over the right lower lung is probably residual\n edema. If there is any pleural effusion it is minimal. The upper mediastinum\n has been stably widened postoperatively. Left lung is clear. No\n pneumothorax. ET tube and Swan-Ganz catheter and intra-aortic balloon pump\n are in standard placements. Nasogastric tube would need to be advanced 5 cm\n to move all the side ports into the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1172895,
"text": " 10:22 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Location\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with PA catheter, pulled back 6-7 cm\n REASON FOR THIS EXAMINATION:\n Location\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PA catheter, pulled back 6-7 mm.\n\n COMPARISON: , 9:48 p.m.\n\n FINDINGS: As compared to the previous radiograph, the pulmonary artery\n catheter has been pulled back by approximately 6 cm. The tip now projects\n over the outflow tract of the right ventricle. The other monitoring and\n support devices are unchanged. Unchanged appearance of the lung parenchyma\n and the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-12-30 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1173783,
"text": " 8:37 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: assess for stone\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n assess for stone\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, assess for stone.\n\n COMPARISON: None.\n\n TECHNIQUE: Right upper quadrant ultrasound.\n\n FINDINGS: The examination is markedly limited by patient body habitus and\n inability to position as well as bandage material. There is no gross evidence\n of intra- or extra-hepatic biliary dilation. The common hepatic duct measures\n 4 mm. The portal vein is patent with flow in the appropriate direction. The\n gallbladder is moderately distended. There is gallbladder wall edema. No\n gallstones are identified and there is no evidence of pericholecystic fluid.\n Kidneys are echogenic. Right kidney measures 10.4 cm. Left kidney was\n difficult to visualize due to positioning. The spleen was also not adequately\n visualized due to positioning and bowel gas.\n\n IMPRESSION:\n 1. Markedly limited study. Distended and edematous gallbladder without\n gallstones. Gallbladder wall edema may result from a number of factors\n including congestive heart failure, hypoalbuminemia, but acalculous\n cholecystitis cannot be excluded by the ultrasound findings. If clinical\n suspicion warrants, then HIDA is recommended for further assessment. A page\n was sent to at 11:17 a.m. on to discuss these\n findings and results were discussed at 12:08 PM.\n 2. Echogenic appearance of the right kidney suggestive of medical renal\n disease. Left kidney poorly visualized.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2193-12-30 00:00:00.000",
"description": "Report",
"row_id": 92218,
"text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery. Left ventricular function. ?pericardial effusion. Pressor dependent.\nHeight: (in) 65\nWeight (lb): 180\nBSA (m2): 1.89 m2\nBP (mm Hg): 124/71\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 18:12\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Good RAA ejection velocity (>20cm/s). Dynamic\ninteratrial septum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No glycopyrrolate was\nadministered. The rhythm appears to be atrial fibrillation. MD caring for the\npatient was notified of the echocardiographic results by e-mail.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. Right atrial appendage ejection velocity is good (>20 cm/s). 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 simple atheroma in the descending\nthoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Preserved biventricular global systolic function. Mild mitral\nregurgitation. Mild aortic regurgitation. Mild-moderate tricuspid\nregurgitation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2193-12-29 00:00:00.000",
"description": "Report",
"row_id": 92219,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. ?tamponade.\nHeight: (in) 65\nWeight (lb): 180\nBSA (m2): 1.89 m2\nBP (mm Hg): 100/60\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 13:43\nTest: Portable TTE (Focused views)\nDoppler: Limited 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 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.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Abnormal septal\nmotion/position.\n\nAORTIC VALVE: Aortic valve not well seen. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. [Due to acoustic\nshadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mild to moderate [+] TR.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Emergency\nstudy performed by the cardiology fellow on call. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nLeft ventricular 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. Right ventricular chamber size and free\nwall motion are normal. There is abnormal septal motion/position. Mild (1+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nNo mitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] There is an\nanterior space which most likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality.Mild aortic regurgitation. Preserved\nglobal biventricular systolic function. No significant pericardial effusion\nidentified.\nCompared with the prior study (images reviewed) of \n\n\n"
},
{
"category": "Echo",
"chartdate": "2193-12-24 00:00:00.000",
"description": "Report",
"row_id": 92220,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease.\nHeight: (in) 64\nWeight (lb): 192\nBSA (m2): 1.92 m2\nBP (mm Hg): 108/53\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 10:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n Fagenholz, fellow did study\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Mild AS (area\n1.2-1.9cm2). Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Calcified tips of papillary muscles. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic 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. Regional left ventricular wall motion is\nnormal. Overall left ventricular systolic function is normal (LVEF>55%). There\nis no ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets are moderately thickened. There\nis mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\nCalcific aortic valve disease with mild stenosis/mild regurgbitation. Mild\nmitral regurgitation. Mild pulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , anterior\nhypokinesis is no longer appreciated (prior study technically-suboptimal).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2193-12-22 00:00:00.000",
"description": "Report",
"row_id": 92221,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Coronary artery disease. Left ventricular function. Murmur. Myocardial infarction. Preoperative assessment. Shortness of breath.\nHeight: (in) 63\nWeight (lb): 189\nBSA (m2): 1.89 m2\nBP (mm Hg): 118/74\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 20:43\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Cannot exclude AS. Trace\nAR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Mild functional MS due to MAC. Trivial MR. [Due to\nacoustic shadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+]\nTR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\n\nConclusions:\nThe left atrium is normal in size. The left atrium is elongated. No atrial\nseptal defect is seen by 2D or color Doppler. Left ventricular wall\nthicknesses and cavity size are normal. There is mild regional left\nventricular systolic dysfunction with anterior hypokinesis. The remaining\nsegments appear to contract normally, though images are suboptimal (LVEF =\n40%). The right ventricular cavity is mildly dilated with normal free wall\ncontractility. The aortic valve leaflets are mildly thickened (?#). The study\nis inadequate to exclude significant aortic valve stenosis. Trace aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nThere is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral\nannular calcification. Trivial 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. There is an anterior space which most likely\nrepresents a prominent fat pad.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.\nCannot exclude hemodynamically-significant aortic stenosis. Moderate pulmonary\nhypertension.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-29 00:00:00.000",
"description": "Report",
"row_id": 256498,
"text": "Atrial fibrillation with a controlled ventricular response. Low limb lead\nvoltage. Since the previous tracing of the rhythm is now probably\natrial fibrillation.\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-27 00:00:00.000",
"description": "Report",
"row_id": 256499,
"text": "Sinus rhythm with prolonged P-R interval. Non-specific ST-T wave changes.\nCompared to tracing #1 the rhythm is clearly sinus with the long P-R interval.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-26 00:00:00.000",
"description": "Report",
"row_id": 256720,
"text": "Sinus rhythm with A-V conduction delay. Left atrial abnormality. Modest\nST-T wave abnormalities with borderline prolonged QTc interval are\nnon-specific but cannot exclude drug/electrolyte/metabolic effect or possible\nischemia. Clinical correlation is suggested. Since the previous tracing\nof the rate is slower and ST-T wave abnormalities have decreased.\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-25 00:00:00.000",
"description": "Report",
"row_id": 256721,
"text": "Sinus rhythm. Borderline P-R interval prolongation. ST-T wave abnormalities.\nSince the previous tracing of there is probably no significant change.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-24 00:00:00.000",
"description": "Report",
"row_id": 256722,
"text": "Sinus rhythm. P-R interval prolongation. ST segment depression. Since the\nprevious tracing of ST segment depression may be more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-23 00:00:00.000",
"description": "Report",
"row_id": 256723,
"text": "Sinus rhythm. Prolonged P-R interval. Anterolateral ST-T wave changes may be\nsecondary to myocardial ischemia. No previous tracing available for comparison.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2193-12-26 00:00:00.000",
"description": "Report",
"row_id": 256719,
"text": "Undetermined rhythm may be sinus but with slightly long P-R interval,\nectopic atrial rhythm or an accelerated junctional rhythm. P waves are seen in\nsome of the limb leads which makes it more likely that this is sinus rhythm.\nNon-specific inferolateral ST-T wave changes. Compared to the previous tracing\nof the rhythm is less clearly sinus with the long P-R on the current\ntracing. The ST-T wave changes are similar.\nTRACING #1\n\n"
}
] |
56,872 | 187,216 | The patient was admitted to the hospital and underwent a flexible bronchoscopy which showed small/ moderate granulation tissue/ridge in proximal trachea anterior wall with severe cervical malacia proximal to the trach tube with complete dynamic collapse. She underwent exchange trach cannulation and was capped with no significant result in the immediate period. She was saturating well and had no major issues and was without stridor. . On telemetry on at around 6pm, she was noted to become bradycardic for about 45 seconds down to the 30s. MD was immediately aware and entered the room to notice her cyanotic and minimally responsive. At this time, her pulses were weak and she was notably hypoxic and without spontaneous respirations. She was minimally arousable to sternal rub. A code blue was initiated. Her trach was immediately uncapped and her airway was suctioned vigorously with good response. Her ABG was notable for mild respiratory acidosis consistent with respiratory failure. She responded well to positive pressure ventilation and was brought to the MICU for further intensive monitoring. She regained mental status. . MICU course: This is an 81 y/o woman with PMH notable for Parkinson's disease and C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia admitted to MICU after PEA arrest on the floor. . # Respiratory distress: Patient was noted to be apneic on the floor prior to PEA arrest. Likely related to mucous plugging but patient reportedly had dinner so could be related to aspiration. Per notes from Rehab was eating a soft diet there with thin liquids. Do not feel that there is evidence of new pneumonia at this time (no WBC elevation, no fever); will continue to monitor for signs/symptoms of infection. CXR with LLL opacity consistant with resolving mucous plugging - npo for now, consider soft diet after stable on trach mask - weaned off ventilation, now on TM at 40% - continue to monitor closely and suction prn - IP team to see today to decide dispo ?????? d/w IP team pt to go to floor - continue albuterol/atrovent nebs with mucomyst nebs - further trach interventions (i.e., rigid bronch) per IP team -CXR tomorrow to eval change in LLL opacity ?????? persistent LLL opacity, c/w atelectasis, PA and lateral may be better to assess -blood gas this AM to better assess pulmonary status in presence of increased CO2 . # s/p PEA arrest: Likely related to hypoxia secondary to the above. Telemetry monitoring during time of event appears to have artifact (versus VT but out of sync on 2 leads so this is unlikely) followed by bradycardia. Artifact could represent chest compressions and no other telemetry strips printed from time of event. Cardiac enzymes sent peri-code negative and ekg is unchanged from prior. - repeat EKG without any new changes - cardiac enzymes neg x2 hrs apart, no need for 3rd set. - monitor respiratory status closely as above . # Osteoporosis: Continue calcium and vitamin D. . # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and entacapone (the last two ordered non-formulary) . # FEN: npo for now while on positive pressure ventilation, soft diet with thick nectar liquids when back on trach collar/cap, replete lytes prn . # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care . ______________________________________________________________ After her MICU course, the patient was stable and received a T-Tube on which she tolerated well. There were some proximal narrowing points found on her bronchoscopy, so the patient was left uncapped with a PM valve intermittently. She tolerated this well. She then subsequently was admitted to the SICU on for increased secretions and was discharged to the floor on after aggressive suctioning. Throughout the rest of her stay, she continued uncapped with intermittent PM valve utilization for speaking, and was noted to have some minor breath stacking when her PM was placed for long periods. Therefore, it was deemed that she was not a strong candidate for capping completely. She is, however, a good candidate for intermittent usage of PM for vocalization. She underwent diagnostic/therapeutic bronchoscopy on and mucus was cleared from her airways. She tolerated the procedure well and was brought to the floor, again uncapped, because of upper airway edema. Therefore, we are sending her out on steriods for a few more days. She is able to suction herself and maintain her airway with the t-tube uncapped. | Possible to floor today .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: CXR: rotated, sig kyphosis, partial LLL collapse, ECG--atrial ectopy and freq PACs, sinus rhythm, no acute ischemic changes ISSUES: * s/p PEA arrest presumably from mucus plugging * TBM * Parkinsons ds Agree with plan to transition to trach mask with close monitoring. Awake and alert, following commands, sig kyphosis, trach site clean, lungs CTA with decreased b/b BS, RR, peg site without erythema, abd benign, baseline tremor and cogwheeling Labs notable for WBC 9.5 (11)K, 30 HCT , 3.9K+ , 0.6Cr . # DISP: pending overnight monitoring, tolerating trach mask .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Gastrointestinal / Abdomen: G-tube Nutrition: Speech and Swallow eval, G-tube feeds Renal: Foley, foley placed for incontinence; will diuresis for CHF Hematology: stable Endocrine: RISS Infectious Disease: Sputum cultures today, Levo for RLL infiltrate. # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care . # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care . # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care . Possible to floor today .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Awake and alert, following commands and speaking appropriately, kyphoitc, trach site clean, lungs CTA with decreased b/b BS, RR, abd benign, baseline tremor and cogwheeling Labs notable for WBC 6.0, cr 0.5, serum CO2 34 (29). # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: ------ Protected Section ------ MICU ATTENDING ADDENDUM I saw and examined the patient, and was physically present with the ICU team for the key portions of the services provided. IMPRESSION: New dense opacity in the right lower lobe status post bronchoscopy and tracheal T-tube change. Admitted for stridor/desats w/ when cap placed on trach. LLL opacity on previous CXR REASON FOR THIS EXAMINATION: interval change LLL FINAL REPORT STUDY: AP chest, . underwent trach change for malpositioned tube. Voltage criteriafor left ventricular hypertrophy. Sinus rhythm with occasional ventricular ectopy and occasional atrial ectopy.Non-specific inferior ST-T wave changes. BLS x1-2mins w/ trach suction. .H/O airway obstruction, Central / Upper Assessment: Action: Mucomyst nebs given Q 6. Lucency projecting over the mid thoracic spine, compatible with patient's known hiatal hernia appears similar to previous studies. 7:36 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: eval for progressing ? t/c echo Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway edema; ?RLL infiltrate started on levo; Pt able to cough up secretion, self suction. # DISP: pending overnight monitoring, tolerating trach mask .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 08:35 PM 20 Gauge - 02:46 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: Plan to go to Rehab this AM. FINAL REPORT PORTABLE CHEST CLINICAL INFORMATION: Pneumothorax. Response: Tolerating trach mask. Flex bronch performed (no rigid bronch concern of hyperextension) showed mod granulation tissue in prox trachea ant wall w/ severe cervical malacia proximal to trach. | 46 | [
{
"category": "Physician ",
"chartdate": "2141-11-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548551,
"text": "SICU\n HPI:\n ADMISSION NOTE:\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\n T-tube secretions.\n Chief complaint:\n tracheal stenosis, inct T-tube secretions\n PMHx:\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\n fusion at , Recurrent pneumonia\n Current medications:\n 24 Hour Events:\n CALLED OUT\n Post operative day:\n HD 5, POD 1 (T-tube)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:27 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.5\n T current: 36.9\nC (98.5\n HR: 68 (68 - 71) bpm\n BP: 145/59(80) {142/59(80) - 145/62(84)} mmHg\n RR: 25 (12 - 25) insp/min\n SPO2: 98%\n Total In:\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 0 mL\n 240 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -240 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : bilateral), (Sternum: Stable )\n Abdominal: Soft, Non-distended, G-tube\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli), Moves all extremities,\n hard of hearing, able to communicate w/ writing.\n Labs / Radiology\n 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n 02:34 PM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Creatinine\n 0.6\n 0.5\n Troponin T\n <0.01\n TCO2\n 35\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 81yo F w/ trach and tracheal stenosis who is s/p\n T-tube placement.\n Neurologic: h/o parkinson on sinemet, entacapone; Modafinil;\n Mirtazapine for depression\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \n will diuresis w/ Lasix 20mg. Plan to get 500-1000mL negative\n Pulmonary: T-tube, on trach collar. maintining saturations. Self\n suction and suction by nursing. Dexamethasone for edema. Cont atrovent\n nebs, mucomyst nebs; ?RLL infiltrate, started on Levo.\n Gastrointestinal / Abdomen: G-tube\n Nutrition: Speech and Swallow eval, G-tube feeds\n Renal: Foley, foley placed for incontinence; will diuresis for CHF\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: Sputum cultures today, Levo for RLL infiltrate.\n Lines / Tubes / Drains: Foley, T-tube\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Thoracic, Interventional Pulm\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 08:12 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548606,
"text": "SICU\n HPI:\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\n T-tube secretions.\n Chief complaint:\n tracheal stenosis\n PMHx:\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\n fusion at , Recurrent pneumonia\n Current medications:\n 24 Hour Events:\n SPUTUM CULTURE - At 05:27 AM\n NASAL SWAB - At 05:29 AM\n CALLED OUT\n Post operative day:\n HD 6, POD 2 (T-tube)\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 03:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.7\nC (98\n HR: 68 (55 - 71) bpm\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\n RR: 22 (12 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 229 mL\n PO:\n Tube feeding:\n 65 mL\n IV Fluid:\n 164 mL\n Blood products:\n Total out:\n 880 mL\n 1,480 mL\n Urine:\n 880 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -1,251 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, hard of hearing, able to communicate w/ writing.\n Labs / Radiology\n 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n 02:34 PM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Creatinine\n 0.6\n 0.5\n Troponin T\n <0.01\n TCO2\n 35\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\n placement.\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\n Modafinil, Mirtazapine\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \n will diuresis. t/c echo\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\n self suction.\n Gastrointestinal / Abdomen: g-tube\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: levoquin for RLL infiltrate by team\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\n Wounds: none\n Imaging: cxr\n Fluids: KVO\n Consults: Thoracic, Interventional Pulm\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 11:08 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548607,
"text": "SICU\n HPI:\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\n T-tube secretions.\n Chief complaint:\n tracheal stenosis\n PMHx:\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\n fusion at , Recurrent pneumonia\n Current medications:\n 24 Hour Events:\n SPUTUM CULTURE - At 05:27 AM\n NASAL SWAB - At 05:29 AM\n CALLED OUT\n Post operative day:\n HD 6, POD 2 (T-tube)\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 03:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.7\nC (98\n HR: 68 (55 - 71) bpm\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\n RR: 22 (12 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 229 mL\n PO:\n Tube feeding:\n 65 mL\n IV Fluid:\n 164 mL\n Blood products:\n Total out:\n 880 mL\n 1,480 mL\n Urine:\n 880 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -1,251 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable ). Some secretions\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, hard of hearing, able to communicate w/ writing.\n Speaking with Passemuir valve.\n Labs / Radiology\n 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n 02:34 PM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Creatinine\n 0.6\n 0.5\n Troponin T\n <0.01\n TCO2\n 35\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\n placement.\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\n Modafinil, Mirtazapine\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \n . Diuresis. t/c echo\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\n self suction.\n Gastrointestinal / Abdomen: g-tube\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: levoquin for RLL infiltrate by team\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\n Wounds: none\n Imaging: cxr\n Fluids: KVO\n Consults: Thoracic, Interventional Pulm\n Billing Diagnosis: Resp Abnormaliity\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 11:08 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 548631,
"text": "81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for\n increased T-tube secretions.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Sats 99% on 50% o2 via trach mask. Able to expectorate secretions and\n suction independently with Yankauer. Tolerating Passey-muir valve. LS\n coarse at times, clears with cough.\n Action:\n Encouraged cough, deep breaths. Sputum sample sent for culture.\n Response:\n Resp status stable.\n Plan:\n continue aggressive pulm hygiene.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n AIRWAY OBSTRUCTION\n Code status:\n Full code\n Height:\n Admission weight:\n 70.7 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\n spinal fusion,s/p trach following that. s/p mechanical fall few months\n ago w/ C2-4 fx s/p spinal fusion/ hardware placement.Trache placed d/t\n unstable cervical spine. Admitted from rehab to floor d/t\n stridor and desats while trying to cap trache. Flex Bronch which\n revealed granulation tissue in the proximal trachea\n (tracheobroncomalacia). Trach changed from boniva to portex. on \n trach capped, pt w/ pea arrest on the floor while eating. OR\n trach tube changed to t tube and bronch.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:112\n D:56\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 37 insp/min\n Heart Rate:\n 64 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 97% %\n O2 flow:\n 12 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 588 mL\n 24h total out:\n 1,795 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:49 AM\n Potassium:\n 3.8 mEq/L\n 04:49 AM\n Chloride:\n 100 mEq/L\n 04:49 AM\n CO2:\n 34 mEq/L\n 04:49 AM\n BUN:\n 14 mg/dL\n 04:49 AM\n Creatinine:\n 0.6 mg/dL\n 04:49 AM\n Glucose:\n 89 mg/dL\n 04:49 AM\n Hematocrit:\n 29.8 %\n 04:49 AM\n Finger Stick Glucose:\n 101\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU A\n Transferred to: 716\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 548614,
"text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 548615,
"text": "81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for\n increased T-tube secretions.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Sats 99% on 50% o2 via trach mask. Able to expectorate secretions and\n suction independently with Yankauer. Tolerating Passey-muir valve. LS\n coarse at times, clears with cough.\n Action:\n Encouraged cough, deep breaths. Sputum sample sent for culture.\n Response:\n Resp status stable.\n Plan:\n continue aggressive pulm hygiene.\n"
},
{
"category": "Nutrition",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 548621,
"text": "Subjective: Pt is very HOH, unable to converse with her.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 163 cm\n 70.7 kg\n 26.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 54.4kg\n 130%\n 58.5kg\n Diagnosis: Airway Obstruction\n PMH : Parkinson's disease, Fall with C2-4 fracture in , s/p\n cervical fusion at , Recurrent pneumonia, h/o PEG feeding\n Food allergies and intolerances:\n Pertinent medications: Abx, others noted\n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 04:49 AM\n Glucose Finger Stick\n 101\n 10:00 AM\n BUN\n 14 mg/dL\n 04:49 AM\n Creatinine\n 0.6 mg/dL\n 04:49 AM\n Sodium\n 142 mEq/L\n 04:49 AM\n Potassium\n 3.8 mEq/L\n 04:49 AM\n Chloride\n 100 mEq/L\n 04:49 AM\n TCO2\n 34 mEq/L\n 04:49 AM\n PO2 (arterial)\n 136 mm Hg\n 02:34 PM\n PCO2 (arterial)\n 51 mm Hg\n 02:34 PM\n pH (arterial)\n 7.43 units\n 02:34 PM\n pH (urine)\n 5.0 units\n 04:44 PM\n CO2 (Calc) arterial\n 35 mEq/L\n 02:34 PM\n Calcium non-ionized\n 9.2 mg/dL\n 04:49 AM\n Phosphorus\n 3.5 mg/dL\n 04:49 AM\n Magnesium\n 1.9 mg/dL\n 04:49 AM\n WBC\n 6.9 K/uL\n 04:49 AM\n Hgb\n 10.2 g/dL\n 04:49 AM\n Hematocrit\n 29.8 %\n 04:49 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 40cc/hr (960kcal, 60g protein)\n Diet: NPO\n GI: soft, +BS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to:\n Estimated Nutritional Needs\n Calories: 1400-1640 (BEE x or / 24-28 cal/kg)\n Protein: 58-70 (1-1.2 g/kg)\n Fluid: per team\n Specifics:\n 81 y.o. F with h/o Parkinson\ns Disease s/p mechanical with\n C2=C4 fracture, s/p spinal fusion/hardware placement with trach placed\n due to ? of unstable C-spine. Pt now adm with stridor and destatting.\n Flex bronch showed moderate granulation tissue in proximal trachea, and\n trach tube was changed for malpositioning (). Trach was capped,\n and pt went into brady/PEA arrest. Pt then had a rigid bronch and was\n changed to a T-tube (). Pt is now in ICU for the management of\n T-tube secretions. Pt has a PEG, but had been weaned off her TF at her\n care facility, and was tolerating a soft diet. But TF are now\n restarted, and pt unable to take po\ns until S/S eval can be done with\n PMV today. If pt is able to take po\ns, TF\ns might not be needed at\n this time. Will follow results of PMV/speech/swallow eval.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Until pt can take po\ns, rec TF goal of Fibersource @ 50cc/hr\n (1440kcal, 64g protein) via PEG.\n 2) S/S eval, advance diet as recommended by SLP.\n 3) Monitor lytes, hydration.\n Please page with ?\ns #\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548002,
"text": "Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n On , the patient underwent flexible bronchoscopy which revealed\n TBM with trach malpositioned. Her trach was changed from Bovona to\n Portex 6 mm cuffed with inner cannula.\n On the evening of , the patient was doing well on the Thoracics\n floor. At about 1817, the patient was noted to have bradycardia on\n telemetry and the patient was noted to be pulseless. She was cyanotic\n and apneic at that time. Her trach cap was uncapped and she was\n suctioned with good result. She had about 1-2 minutes of chest\n compressions and no medications and regained a good femoral pulse. BP\n following this was in the 160s systolic. The patient was immediately\n more alert but not answering questions. ABG during this time was\n 7.29/64/290..\n On arrival to the ICU, the patient is alert and answering questions\n appropriately. She denies any pain. She denies any difficulty with her\n breathing.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Received the pt on 100%CPAP with RR 20-30.LS rhonchi with diminished\n base.Pt apneic frequently.\n Action:\n Put on MMV with 40%.Suctioned for thick yellow secretion.CXR revealed\n atelectasis on LLL.\n Response:\n Saturating well on the current settings.\n Plan:\n Transition to trach collar in the am,Pt uses psm valve,?decannulation\n given recent events.?c/o.\n"
},
{
"category": "General",
"chartdate": "2141-11-11 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 547990,
"text": "TITLE:\n Chart reviewed, pt examined, case discussed in detail with Dr. . I\n agree with her note and in addition would add/emphasize:\n 81F h/o Parkinson\ns dz, recurrent PNA, s/p tracheostomy at ,\n admitted from rehab after dev stridor and desat after placing cap\n on trache. FOB on notable for tracheobroncheofmalacia. \n trache changed. Post-proc on floor, brady to 40s noted on tele, pulse\n lost\n code blue called\n CPR performed, pulse rapidly returned within\n 1-2 minutes, suctioned with good result. Arrest presumed secondary to\n plugging. Transferred to MICU for close observation / care s/p\n arrest. Mental status rapidly improving. Close pulm toilet. Cont\n PSV settings for now, TM trial in morning. Cycle enzymes.\n Pt is critically ill.\n Time spent: 35min\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 547994,
"text": "Chief Complaint: respiratory distress, PEA arrest\n HPI:\n Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n .\n The patient was evaluated by neurosurgery on due to recent spinal\n fusion and ? of rigid bronchoscopy. Based on her recent surgery, rigid\n bronch is not indicated but the patient is apparently physically unable\n to hyperextend her neck. On , the patient underwent flexible\n bronchoscopy which revealed TBM with trach malpositioned. Her trach was\n changed from Bovona to Portex 6 mm cuffed with inner cannula by Dr.\n . She tolerated the procedure well with exception of atrial\n tachyarrhythmia intermittently.\n .\n On the evening of , the patient was doing well on the Thoracics\n floor. She was noted to be talking with her trach cap in place and had\n her dinner. At about 1817, the patient was noted to have bradycardia on\n telemetry monitoring. RN and MD personnel quickly went to the\n bedside and the patient was noted to be pulseless. She was cyanotic and\n apneic at that time. Her trach cap was uncapped and she was suctioned\n with good result. She had about 1-2 minutes of chest compressions and\n no medications and regained a good femoral pulse. BP following this was\n in the 160s systolic. The patient was immediately more alert but not\n answering questions. ABG during this time was 7.29/64/290.\n .\n On arrival to the ICU, the patient is alert and answering questions\n appropriately. She denies any pain. She denies any difficulty with her\n breathing.\n Patient admitted from: \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Meds at rehab:\n acetylcysteine neb \n albuterol neb q6h\n calcium carbonate 650 mg (via peg)\n carbidopa/levodopa 37.5/150 tid (give at 0630, 1100, and 1600)\n carbodopa/levodopa 12.5/50 at 0830\n carbidopa/levodopa 37.5/150 at 1400\n vit d 1000 U daily\n cyanocobalamin 1000 mcg daily\n bisacodyl 10 mg daily prn\n mag hydroxide 30 ml once daily prn\n ambien 5 mg prn\n miconazole powder prn\n mupirocin to anterior neck \n senna 17.2 mg at bedtime\n omeprazole 20 mg \n modafinil 50 mg (0800, 1400)\n mirtazapine 30 mg at bedtime\n atrovent neb q6h\n ferrous sulfate 325 mg at bedtime (g tube)\n entacapone 200 mg at 0630, 11, 1400, 1600 (with sinemet)\n .\n MEDS on transfer:\n acetylcysteine 20% neb \n calcium carbonate 500 (given via PEG)\n vit d 800 U daily\n cyanocobalamin 1000 mcg daily\n ambien 5 mg qhs\n colace 100 mg \n omeprazole 20 mg \n hep sc tid\n sinemet 25/100, 1.5 tab tid\n albuterol inhalers prn\n Past medical history:\n Family history:\n Social History:\n * Parkinson's disease\n * Fall with C2-4 fracture in , s/p cervical fusion at \n * Recurrent pneumonia, s/p trach after difficulty weaning from vent\n after surgery\n Occupation:\n Drugs:\n Tobacco: denies\n Alcohol: denies\n Other: Recently living at Rehab.\n Review of systems:\n Flowsheet Data as of 02:00 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 (98.2\n HR: 64 (63 - 80) bpm\n BP: 124/59(73) {80/43(52) - 137/68(85)} mmHg\n RR: 13 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 250 mL\n 10 mL\n PO:\n TF:\n IVF:\n 250 mL\n 10 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n 10 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: MMV/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 515 (103 - 515) mL\n PS : 15 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 22 cmH2O\n SpO2: 97%\n ABG: ///34/\n Ve: 11 L/min\n Physical Examination\n T: 98.6 BP: 134/61 HR: 78 RR: 20 O2 100% on PS 15/5, FiO2 100%\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: coarse breath sounds bilaterally, no wheezing\n ABD: soft, PEG in place in LUQ, normoactive bowel sounds, nontender to\n palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Labs / Radiology\n 253\n 10.5\n 140\n 0.6\n 14\n 34\n 101\n 3.7\n 141\n 31.1\n 11.1\n [image002.jpg]\n Other labs: PT / PTT / INR://1.2, CK / CKMB / Troponin-T:29 / / < 0.01,\n Lactic Acid:2.8, Ca++:9.4, Mg++:2.1, PO4:4.2\n Fluid analysis / Other labs: ABG: 7.29/64/290\n Imaging: Bronch (): superior glottis + edema, mucosal ridge seen\n in anterior tracheal wall, just below cricoid + malacia at cervical\n trachea, trach tube found Right lateral wall, distal trach/LMS with\n malacia\n .\n CXR: No pneumothorax identified. Retrocardiac opacity may represent\n left lower lobe atelectasis. Right basilar atelectasis also likely.\n ECG: ekg: sinus rhythm at 70, normal axis, t wave flattening in v4-6,\n III, avf, overall similar to prior from \n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection.\n - npo for now\n - positive pressure ventilation this evening with repeat ABG\n - transition back to trach mask, hopefully by tomorrow AM\n - continue to monitor closely and suction prn\n - IP team to see tomorrow to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg in the Am\n - cycle cardiac enzymes\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\n formulary.\n - resume home mirtazapine\n - resume home modafinil on transfer to Rehab\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending overnight monitoring, tolerating trach mask\n ICU Care\n Nutrition:\n Comments: npo for now until off ventilator\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 08:35 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 547999,
"text": "Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n On , the patient underwent flexible bronchoscopy which revealed\n TBM with trach malpositioned. Her trach was changed from Bovona to\n Portex 6 mm cuffed with inner cannula.\n On the evening of , the patient was doing well on the Thoracics\n floor. At about 1817, the patient was noted to have bradycardia on\n telemetry and the patient was noted to be pulseless. She was cyanotic\n and apneic at that time. Her trach cap was uncapped and she was\n suctioned with good result. She had about 1-2 minutes of chest\n compressions and no medications and regained a good femoral pulse. BP\n following this was in the 160s systolic. The patient was immediately\n more alert but not answering questions. ABG during this time was\n 7.29/64/290..\n On arrival to the ICU, the patient is alert and answering questions\n appropriately. She denies any pain. She denies any difficulty with her\n breathing.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548124,
"text": "Events: Off vent to track mask- tolerating weel. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Likely will return as\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\n Rehab- reviewing POC and events, daughter (HCP) and family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt sating 95-100% on trach mask 40%, rec\nd pt with PMV in, tolerating\n well, A&Ox3- able to make needs known.\n Action:\n PMV taken out by respiratory for night, Close monitoring s/s\n aspiration. Sxned x2 for sm-mod. Amounts of white thick sputum. Pt\n able to raise most secretions on own, using yankuer by self.\n Response:\n Tolerating trach mask.\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n PRN. Plan to go to Rehab this AM.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548034,
"text": "Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n On , the patient underwent flexible bronchoscopy which revealed\n TBM with trach malpositioned. Her trach was changed from Bovona to\n Portex 6 mm cuffed with inner cannula.\n On the evening of , the patient was doing well on the Thoracics\n floor. At about 1817, the patient was noted to have bradycardia on\n telemetry and the patient was noted to be pulseless. She was cyanotic\n and apneic at that time. Her trach cap was uncapped and she was\n suctioned with good result. She had about 1-2 minutes of chest\n compressions and no medications and regained a good femoral pulse. BP\n following this was in the 160s systolic. The patient was immediately\n more alert but not answering questions. ABG during this time was\n 7.29/64/290..\n On arrival to the ICU, the patient is alert and answering questions\n appropriately. She denies any pain. She denies any difficulty with her\n breathing.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Received the pt on 100%CPAP with RR 20-30.LS rhonchi with diminished\n base.Pt apneic frequently.\n Action:\n Put on MMV with 40%.Suctioned for thick yellow secretion.CXR revealed\n atelectasis on LLL.\n Response:\n Saturating well on the current settings.\n Plan:\n Transition to trach collar in the am,Pt uses psm valve,?decannulation\n given recent events.?c/o.\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548054,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Entacapone\n Modadinil\n Mirtazapine\n Carbidopa-levodopa\n Albuterol\n Chlorhexidine\n Heparin SQ\n Omeprazole\n Colace\n Bisacodyl\n Tylenol\n MOM\n Cyanocobalamin\n Vit D\n Calcium carbonate\n Albuterol\n Mucomyst\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100% (97-100)\n Heart rhythm: SR (Sinus Rhythm)\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: clear BS, no wheezing\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Peripheral 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n CXR: retrocardiac opacity likely LLL ateletasis\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection.\n - npo for now\n - positive pressure ventilation this evening with repeat ABG\n - transition back to trach mask, hopefully by tomorrow AM\n - continue to monitor closely and suction prn\n - IP team to see tomorrow to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg in the Am\n - cycle cardiac enzymes\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\n formulary.\n - resume home mirtazapine\n - resume home modafinil on transfer to Rehab\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending overnight monitoring, tolerating trach mask\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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": "2141-11-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548055,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Entacapone\n Modadinil\n Mirtazapine\n Carbidopa-levodopa\n Albuterol\n Chlorhexidine\n Heparin SQ\n Omeprazole\n Colace\n Bisacodyl\n Tylenol\n MOM\n Cyanocobalamin\n Vit D\n Calcium carbonate\n Albuterol\n Mucomyst\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100% (97-100)\n Heart rhythm: SR (Sinus Rhythm)\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: clear BS, no wheezing\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Peripheral 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n CXR: retrocardiac opacity likely LLL ateletasis\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaning off positive pressure ventilation am\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n -CXR tomorrow to eval change in LLL opacity\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg this am\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet.\n - resume home mirtazapine\n - NF request for modafinil and entacapone\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\n Possible to floor today\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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": "2141-11-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548060,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Entacapone\n Modadinil\n Mirtazapine\n Carbidopa-levodopa\n Albuterol\n Chlorhexidine\n Heparin SQ\n Omeprazole\n Colace\n Bisacodyl\n Tylenol\n MOM\n Cyanocobalamin\n Vit D\n Calcium carbonate\n Albuterol\n Mucomyst\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100% (97-100)\n Heart rhythm: SR (Sinus Rhythm)\n Iiregular O/N Afib vs frequent PAC. Back in NSR this am\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: clear BS, no wheezing\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Peripheral 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n CXR: retrocardiac opacity likely LLL ateletasis\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaning off positive pressure ventilation am\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n -CXR tomorrow to eval change in LLL opacity\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg this am\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet.\n - resume home mirtazapine\n - NF request for modafinil and entacapone\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\n Possible to floor today\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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: 81 yo F with h/o Parkinson\ns dz, recurrent\n PNA, s/p tracheostomy at , admitted from rehab after\n developing stridor and desaturations after placing cap on trach. FOB\n on notable for tracheobroncheomalacia and malpositioning of\n trache. \n> trache changed. Post-proc on floor became brady to\n 40s with pea arrest\n code blue called\n > CPR performed with pulse\n returned within 1-2 minutes, suctioned with good result. Arrest\n presumed secondary to mucus plugging. Transferred to MICU for close\n observation / care s/p arrest. Remained on PP vent overnight.\n Exam notable for Tm AF 98.8 BP 80/37-137/68 HR 64 (63-80) RR with sat\n 97-100 on 40% PS 5/5. Awake and alert, following commands, sig\n kyphosis, trach site clean, lungs CTA with decreased b/b BS, RR, peg\n site without erythema, abd benign, baseline tremor and cogwheeling\n Labs notable for WBC 9.5 (11)K, 30 HCT , 3.9K+ , 0.6Cr .\n CXR: rotated, sig kyphosis, partial LLL collapse,\n ECG--atrial ectopy and freq PACs, sinus rhythm, no acute ischemic\n changes\n ISSUES:\n * s/p PEA arrest presumably from mucus plugging\n * TBM\n * Parkinson\ns ds\n Agree with plan to transition to trach mask with close monitoring.\n Continue mucomyst, nebs, pulm toilet. Repeat cxr in am to monitor LLL\n though no fever or wbc to suggest asp pna. IP service following. Given\n significant TBM will likely require long term trach. Remains stable\n from hemodynamic standpoint since PEA arrest.Neg CEs. Follow/replete\n lytes given atrial ectopy on monitor. Continue Parkinson's regimen per\n Rehab. Remainder of plan as outlined above.\n Patient is critically ill, Once stable off PP on trach collar will\n transfer to surgical floor.\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:45 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548118,
"text": "Events: Off vent to track mask- tolerating weel. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Likely will return as\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\n Rehab- reviewing POC and events, daughter (HCP) and family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"
},
{
"category": "General",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Generic Note",
"row_id": 548131,
"text": "TITLE: Resp Care Note, Pt remains on t-collar 40%. Instilled with\n mucomyst and given MDI albuterol. Suctioned for thick tan plugs. Inner\n cannula inn cuff inflated at this time.Needs inner cannula out during\n suctioning. H20 filled all equipment present. Will cont to monitor resp\n status.\n"
},
{
"category": "Respiratory ",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548091,
"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 Size:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 6.0mm\n PMV: Yes\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\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:\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": "Physician ",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548187,
"text": "Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaned off ventilation, now on TM at 40%\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n d/w IP team pt to go to floor\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) per IP team\n -CXR tomorrow to eval change in LLL opacity\n persistent LLL opacity,\n c/w atelectasis, PA and lateral may be better to assess\n -blood gas this AM to better assess pulmonary status in presence\n of increased CO2\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - repeat EKG without any new changes\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\n entacapone (the last two ordered non-formulary)\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thick nectar liquids when back on trach collar/cap, replete lytes\n prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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": "2141-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548188,
"text": "Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Producing thin, nonpurulent sputum\n CV: RRR. normal S1, S2\n LUNGS: clear at apices, mild crackles at bases\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, masked\n facies, rhythmic tremor R > L hand with pillrolling\n Peripheral 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaned off ventilation, now on TM at 40%\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n d/w IP team pt to go to floor\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) per IP team\n -CXR tomorrow to eval change in LLL opacity\n persistent LLL opacity,\n c/w atelectasis, PA and lateral may be better to assess\n -blood gas this AM to better assess pulmonary status in presence\n of increased CO2\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - repeat EKG without any new changes\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\n entacapone (the last two ordered non-formulary)\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thick nectar liquids when back on trach collar/cap, replete lytes\n prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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": "2141-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548202,
"text": "Events: Off vent to track mask- tolerating well. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Pt very anxious to go\n back t o Rehab- reviewing POC and events, daughter (HCP) and\n family. IP/surgery following - plan for flexible broncoscopy in AM for\n re-eval for regarding ? T tube placement in house. C/O to floor.\n Returning to Rehab pending results of broncoscopy.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up secretios\n to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 548203,
"text": "Events: Occ suctioning sm amts of thick yellow secretions- pt able to\n bring up secretions to RN able to easily suction out- occ deep\n suctioning. Very anxious to go back t o Rehab- reviewing POC\n and events, daughter (HCP) and family. IP/surgery following - plan for\n flexible broncoscopy in AM for re-eval for regarding ? T tube placement\n in house. C/O to floor. Returning to Rehab pending results of\n broncoscopy.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up\n secretions to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\n Demographics\n Attending MD:\n \n Admit diagnosis:\n AIRWAY OBSTRUCTION\n Code status:\n Full code\n Height:\n Admission weight:\n 71.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\n spinal fusion,s/p trach following that.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:59\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 98% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 420 mL\n 24h total out:\n 740 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 02:57 AM\n Potassium:\n 3.7 mEq/L\n 02:57 AM\n Chloride:\n 106 mEq/L\n 02:57 AM\n CO2:\n 34 mEq/L\n 02:57 AM\n BUN:\n 11 mg/dL\n 02:57 AM\n Creatinine:\n 0.5 mg/dL\n 02:57 AM\n Glucose:\n 83 mg/dL\n 02:57 AM\n Hematocrit:\n 30.6 %\n 02:57 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: red and white shirt, white shoes, head phone to\n increase hearing\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 6\n Transferred to: 7\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 548205,
"text": "Ms. is an 81 y/o woman with PMH notable for Parkinson's disease,\n fall with c2-4 fracture earlier this year admitted on due to\n stridor and desaturations at her rehab facility in setting of placing\n trach cap.\n .\n The patient was evaluated by neurosurgery on due to recent spinal\n fusion and ? of rigid bronchoscopy. Based on her recent surgery, rigid\n bronch is not indicated but the patient is apparently physically unable\n to hyperextend her neck. On , the patient underwent flexible\n bronchoscopy which revealed TBM with trach malpositioned. Her trach was\n changed from Bovona to Portex 6 mm cuffed with inner cannula by Dr.\n . She tolerated the procedure well with exception of atrial\n tachyarrhythmia intermittently.\n .\n On the evening of , the patient was doing well on the Thoracics\n floor. She was noted to be talking with her trach cap in place and had\n her dinner. At about 1817, the patient was noted to have bradycardia on\n telemetry monitoring. RN and MD personnel quickly went to the\n bedside and the patient was noted to be pulseless. She was cyanotic and\n apneic at that time. Her trach cap was uncapped and she was suctioned\n with good result. She had about 1-2 minutes of chest compressions and\n no medications and regained a good femoral pulse. BP following this was\n in the 160s systolic. The patient was immediately more alert but not\n answering questions. ABG during this time was 7.29/64/290.\n Events: Occ suctioning sm amts of thick yellow secretions- pt able to\n bring up secretions to RN able to easily suction out- occ deep\n suctioning. Very anxious to go back t o Rehab- reviewing POC\n and events, daughter (HCP) and family. IP/surgery following - plan for\n flexible broncoscopy in AM for re-eval for regarding ? T tube placement\n in house. C/O to floor. Returning to Rehab pending results of\n broncoscopy.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up\n secretions to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach - inner cannula in, cont PMV\n Demographics\n Attending MD:\n \n Admit diagnosis:\n AIRWAY OBSTRUCTION\n Code status:\n Full code\n Height:\n Admission weight:\n 71.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Parkinson's disease,C2-4 # from recent fall,s/p\n spinal fusion,s/p trach following that.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:59\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 28 insp/min\n Heart Rate:\n 65 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Trach mask\n O2 saturation:\n 98% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 420 mL\n 24h total out:\n 740 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 02:57 AM\n Potassium:\n 3.7 mEq/L\n 02:57 AM\n Chloride:\n 106 mEq/L\n 02:57 AM\n CO2:\n 34 mEq/L\n 02:57 AM\n BUN:\n 11 mg/dL\n 02:57 AM\n Creatinine:\n 0.5 mg/dL\n 02:57 AM\n Glucose:\n 83 mg/dL\n 02:57 AM\n Hematocrit:\n 30.6 %\n 02:57 AM\n Valuables / Signature\n Patient valuables:\n Other valuables: red and white shirt, white shoes, head phone to\n increase hearing\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 6\n Transferred to: 7\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548093,
"text": "Events: Off vent to track mask- tolerating weel. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Likely will return as\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\n Rehab- reviewing POC and events, daughter (HCP) and family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548191,
"text": "Events: Off vent to track mask- tolerating well. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Pt very anxious to go\n back t o Rehab- reviewing POC and events, daughter (HCP) and\n family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up secretios\n to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548192,
"text": "Events: Off vent to track mask- tolerating well. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Pt very anxious to go\n back t o Rehab- reviewing POC and events, daughter (HCP) and\n family. Plan to consult pt MD regarding ? T place\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up secretios\n to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548193,
"text": "Events: Off vent to track mask- tolerating well. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Pt very anxious to go\n back t o Rehab- reviewing POC and events, daughter (HCP) and\n family. IP/surgery following - plan for flexible broncoscopy in AM for\n re-eval for regarding ? T tube placement in house. C/O to floor.\n Returning to Rehab pending results of broncoscopy.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Tolerating being placed on trach mask then PMV, large amount of oral\n secretions-able to manage on own w/ suction, able to cough up secretios\n to mouth, trach- mod amount thick yellow secretions\n Action:\n Close monitoring s/s aspiration\n Response:\n tolerating\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548194,
"text": "Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of LLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Producing thin, nonpurulent sputum\n CV: RRR. normal S1, S2\n LUNGS: clear at apices, mild crackles at bases\n ABD: soft, PEG in place in LUQ small fibrinous exudate from PEG. No\n erythema., normoactive bowel sounds, nontender to palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, masked\n facies, rhythmic tremor R > L hand with pillrolling\n Peripheral 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaned off ventilation, now on TM at 40%\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n d/w IP team pt to go to floor\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) per IP team\n -CXR tomorrow to eval change in LLL opacity\n persistent LLL opacity,\n c/w atelectasis, PA and lateral may be better to assess\n -blood gas this AM to better assess pulmonary status in presence\n of increased CO2\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - repeat EKG without any new changes\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet, mirtazapine, modafinil and\n entacapone (the last two ordered non-formulary)\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thick nectar liquids when back on trach collar/cap, replete lytes\n prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: doing well, tolerating TM, tolerating diet -> to floor with IP\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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: 81 yo F with h/o Parkinson\ns dz, recurrent\n PNA, s/p tracheostomy at , admitted from rehab after\n developing stridor and desaturations after placing cap on trach. FOB\n on notable for tracheobroncheomalacia and malpositioning of\n trache. \n> trache changed. Post-proc on floor became brady to\n 40s with pea arrest\nwith pulse returned within 1-2 minutes, suctioned\n with good result. Arrest presumed secondary to mucus plugging.\n Transferred to MICU for close observation / care s/p arrest.\n Tolerating TM since yesterday. Diet advanced to prior.\n Exam notable for Tm 97.8 BP 138/64 HR 62 RR 23 with sat 98% on\n TM--40%. Awake and alert, following commands and speaking\n appropriately, kyphoitc, trach site clean, lungs CTA with decreased b/b\n BS, RR, abd benign, baseline tremor and cogwheeling\n Labs notable for WBC 6.0, cr 0.5, serum CO2 34 (29).\n CXR: rotated, sig kyphosis, underpenetrated\nstable partial LLL\n collapse\n Active issues include:\n * s/p PEA arrest, presumably from mucus plugging\n * TBM\n * Parkinson\ns ds\n Has tolerated trach mask X 24 hrs. Managing secretions well. Continue\n mucomyst, nebs, pulm toilet, sx\ning. CXR with stable partial LLL\n collapse in setting of significant kyphosis, though clinically without\n fever or leukcoytosis to suggest pna/tracheobronchitis. Secretions are\n clear/nonpurulent. Tolerating prior diet without evidence of\n aspiration. Given significant TBM will likely require long term trach.\n Remains stable from hemodynamic standpoint since PEA arrest with less\n ectopy on monitor. Serum CO2 is elevated today--may be from mild\n contraction as put out sig urine. Is at risk for hypoventilation and\n co2 retention given kyphosis and probable restrictive lung ds. Will\n check abg to assess baseline CO2 but has remained very alert and\n mentating appropriately. Would suggest monitoring of this at rehab.\n Continue Parkinson's regimen. Remainder of plan as outlined above.\n Stable for rehab transfer.\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:18 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 548008,
"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 Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 6.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details. Pt rested on MMV overnight for periods of apnea. RSBI done on\n 0 peep 5 ips 56. Pt awake and alert.Will consider weaning to t- collar\n this AM.\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548154,
"text": "Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of RLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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": "2141-11-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548155,
"text": "Chief Complaint:\n 24 Hour Events:\n URINE CULTURE - At 05:00 PM\n cloudy urine\n - IP recs - wean as tol, repeat CXR ? of RLL PNA, hold off on abx,\n cannot bronch to spinal fusion, can go to IP if looks good\n - weaned off vent - sitting pretty on TM\n - advanced to soft dysphagia/nektar thick liquids\n - disimpacted for hard stool - may need more bowel meds\n - desires to go back to rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:10 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 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\nC (96.8\n HR: 62 (52 - 91) bpm\n BP: 138/64(82) {86/41(55) - 147/76(87)} mmHg\n RR: 23 (16 - 32) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 395 mL\n 60 mL\n PO:\n TF:\n IVF:\n 35 mL\n Blood products:\n Total out:\n 1,170 mL\n 640 mL\n Urine:\n 1,170 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n -776 mL\n -580 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 171 (171 - 171) mL\n PS : 5 cmH2O\n RR (Spontaneous): 42\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SpO2: 98%\n ABG: ///34/\n Ve: 12.5 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 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Cr\n 0.6\n 0.5\n TropT\n <0.01\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7\n %, Eos:5.3 %, Ca++:9.5 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection. CXR with LLL opacity consistant with resolving mucous\n plugging\n - npo for now, consider soft diet after stable on trach mask\n - weaning off positive pressure ventilation am\n - continue to monitor closely and suction prn\n - IP team to see today to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n -CXR tomorrow to eval change in LLL opacity\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg this am\n - cardiac enzymes neg x2 hrs apart, no need for 3^rd set.\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet.\n - resume home mirtazapine\n - NF request for modafinil and entacapone\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending tolerating trach mask, likely to rehab Sunday.\n Possible to floor today\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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": "2141-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548142,
"text": "Events: Off vent to track mask- tolerating weel. Placed on PMV and\n tolerating throughout day- able to eat dinner. Occ suctioning sm amts\n of thick yellow secretions- pt able to bring up secretions to RN\n able to easily suction out- rare deep suctioning. Plan for MICU OBS\n overnight and transfer to Rehab in AM. Likely will return as\n scheduled rigid broncoscopy next week. Pt very anxious to go back t o\n Rehab- reviewing POC and events, daughter (HCP) and family.\n .H/O airway obstruction, Central / Upper\n Assessment:\n Pt sating 95-100% on trach mask 40%, rec\nd pt with PMV in, tolerating\n well, A&Ox3- able to make needs known.\n Action:\n PMV taken out by respiratory for night, Close monitoring s/s\n aspiration. Sxned x2 for sm-mod. Amounts of white thick sputum. Pt\n able to raise most secretions on own, using yankuer by self.\n Response:\n Tolerating trach mask.\n Plan:\n Cont to monitor- DO NOT cap trach mask- inner cannula in, cont PMV\n PRN. Plan to go to Rehab this AM.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548588,
"text": ".H/O airway obstruction, Central / Upper\n Assessment:\n 02 sats 95-100% on 50% fi02 trache collar. LS w/ rhonch throughout.\n Scant tan secretions noted.\n Action:\n Mucomyst nebs given Q 6. IV levaquin started. Sputum sample sent.\n Response:\n 02 sats 95-100% throughout the noc. No c/o sob. Pt able to expectorate\n own scant, tan secretions.\n Plan:\n Continue pulmonary toilet. Q 6 hour mucomyst nebs. Follow up on results\n of sputum sample sent.\n"
},
{
"category": "Nursing",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 548579,
"text": ".H/O airway obstruction, Central / Upper\n Assessment:\n Action:\n Mucomyst nebs given Q 6. IV levaquin started. Sputum sample sent.\n Response:\n 02 sats 95-100% throughout the noc. No c/o sob. Pt able to expectorate\n own scant, tan secretions.\n Plan:\n Continue pulmonary toilet. Q 6 hour mucomyst nebs. Follow up on results\n of sputum sample sent.\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 548580,
"text": "SICU\n HPI:\n 81yo F s/p C2-C4 fx from fall who is s/p C2-4 fusion w/ trach\n placed for concern of unstable C-spine. Admitted for\n stridor/desats w/ when cap placed on trach. Flex bronch performed (no\n rigid bronch concern of hyperextension) showed mod granulation\n tissue in prox trachea ant wall w/ severe cervical malacia proximal to\n trach. underwent trach change for malpositioned tube. That\n night after capping trach, pt went to brady/PEA arrest thought to be\n hypoxia. BLS x1-2mins w/ trach suction. To MICU. had rigid\n bronch and 12mm T-tube placement. Tx to floor. Tx to SICU for incr\n T-tube secretions.\n Chief complaint:\n tracheal stenosis\n PMHx:\n Parkinson's disease, Fall with C2-4 fracture in , s/p cervical\n fusion at , Recurrent pneumonia\n Current medications:\n 24 Hour Events:\n SPUTUM CULTURE - At 05:27 AM\n NASAL SWAB - At 05:29 AM\n CALLED OUT\n Post operative day:\n HD 6, POD 2 (T-tube)\n 24hr events: tx to sicu. diuresis w/ lasix. stable o/n.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Levofloxacin - 03:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.7\nC (98\n HR: 68 (55 - 71) bpm\n BP: 146/67(87) {113/47(65) - 153/83(95)} mmHg\n RR: 22 (12 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 229 mL\n PO:\n Tube feeding:\n 65 mL\n IV Fluid:\n 164 mL\n Blood products:\n Total out:\n 880 mL\n 1,480 mL\n Urine:\n 880 mL\n 1,480 mL\n NG:\n Stool:\n Drains:\n Balance:\n -880 mL\n -1,251 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n SPO2: 98%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities, hard of hearing, able to communicate w/ writing.\n Labs / Radiology\n 243 K/uL\n 10.2 g/dL\n 83 mg/dL\n 0.5 mg/dL\n 34 mEq/L\n 3.7 mEq/L\n 11 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.6 %\n 6.0 K/uL\n [image002.jpg]\n 04:15 AM\n 02:57 AM\n 02:34 PM\n WBC\n 9.5\n 6.0\n Hct\n 30.0\n 30.6\n Plt\n 241\n 243\n Creatinine\n 0.6\n 0.5\n Troponin T\n <0.01\n TCO2\n 35\n Glucose\n 107\n 83\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CK-MB / Troponin\n T:27//<0.01, Differential-Neuts:73.6 %, Lymph:14.1 %, Mono:6.7 %,\n Eos:5.3 %, Ca:9.5 mg/dL, Mg:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n Assessment and Plan: 81yo F with tracheal stenosis, s/p T-tube\n placement.\n Neurologic: h/o parkinson on sinemet, entacapone; home meds of\n Modafinil, Mirtazapine\n Cardiovascular: s/p PEA arrest hypoxia, CE neg. BNP 2457 on \n will diuresis. t/c echo\n Pulmonary: atrovent nebs, mucomyst nebs; dexamethasone for airway\n edema; ?RLL infiltrate started on levo; Pt able to cough up secretion,\n self suction.\n Gastrointestinal / Abdomen: g-tube\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, lasix 20mg IV x1 overnight.\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: levoquin for RLL infiltrate by team\n Lines / Tubes / Drains: Foley, G-tube, T-Tube\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Thoracic, Interventional Pulm\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:26 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 22 Gauge - 11:08 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548022,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 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": "2141-11-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 548023,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 06:50 PM\n -found PEA on floor, brief Chest compression, pulse returned after\n suction of trach\n -transfered to MICU, no further events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 64 (63 - 80) bpm\n BP: 101/47(59) {80/37(49) - 137/68(85)} mmHg\n RR: 18 (10 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 250 mL\n 35 mL\n PO:\n TF:\n IVF:\n 250 mL\n 35 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 250 mL\n -116 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 387 (103 - 515) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///29/\n Ve: 6.7 L/min\n Physical Examination\n Gen: Pleasant elderly female in no distress\n HEENT: Sclerae slightly pale, tongue moist and midline\n NECK: supple, no lad, no thyromegaly\n CV: RRR. normal S1, S2. no murmurs appreciated.\n LUNGS: coarse breath sounds bilaterally, no wheezing\n ABD: soft, PEG in place in LUQ, normoactive bowel sounds, nontender to\n palpation\n EXT: warm throughout, dp pulses 2+ bilaterally\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: alert, answering questions, hard of hearing in right ear, face\n symmetric, tongue midline, pupils small but reactive bilaterally,\n following commands (moving toes, grasping hand), moving all extremities\n without difficulty, rhythmic tremor R > L hand and arm consistent with\n h/o parkinson's\n Peripheral 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 241 K/uL\n 10.2 g/dL\n 107 mg/dL\n 0.6 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 14 mg/dL\n 105 mEq/L\n 140 mEq/L\n 30.0 %\n 9.5 K/uL\n [image002.jpg]\n 04:15 AM\n WBC\n 9.5\n Hct\n 30.0\n Plt\n 241\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 107\n Other labs: PT / PTT / INR:13.8/25.1/1.2, CK / CKMB /\n Troponin-T:27//<0.01, Differential-Neuts:84.6 %, Lymph:9.6 %, Mono:4.4\n %, Eos:1.2 %, Ca++:9.3 mg/dL, Mg++:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n This is an 81 y/o woman with PMH notable for Parkinson's disease and\n C2-4 fracture s/p fusion with tracheostomy due to recurrent pneumonia\n admitted to MICU after PEA arrest on the floor.\n .\n # Respiratory distress: Patient was noted to be apneic on the floor\n prior to PEA arrest. Likely related to mucous plugging but patient\n reportedly had dinner so could be related to aspiration. Per notes from\n Rehab was eating a soft diet there with thin liquids. Do not\n feel that there is evidence of new pneumonia at this time (no WBC\n elevation, no fever); will continue to monitor for signs/symptoms of\n infection.\n - npo for now\n - positive pressure ventilation this evening with repeat ABG\n - transition back to trach mask, hopefully by tomorrow AM\n - continue to monitor closely and suction prn\n - IP team to see tomorrow to decide dispo\n - continue albuterol/atrovent nebs with mucomyst nebs\n - further trach interventions (i.e., rigid bronch) at discretion of IP\n team\n .\n # s/p PEA arrest: Likely related to hypoxia secondary to the above.\n Telemetry monitoring during time of event appears to have artifact\n (versus VT but out of sync on 2 leads so this is unlikely) followed by\n bradycardia. Artifact could represent chest compressions and no other\n telemetry strips printed from time of event. Cardiac enzymes sent\n peri-code negative and ekg is unchanged from prior.\n - ekg in the Am\n - cycle cardiac enzymes\n - monitor respiratory status closely as above\n .\n # Osteoporosis: Continue calcium and vitamin D.\n .\n # Parkinson's disease: Continue sinemet. Do not have entacapone on\n formulary.\n - resume home mirtazapine\n - resume home modafinil on transfer to Rehab\n .\n # FEN: npo for now while on positive pressure ventilation, soft diet\n with thin liquids when back on trach collar/cap, replete lytes prn\n .\n # PPx: hep sc tid, ppi, bowel meds, chlorhexidine mouth care\n .\n # CODE: full code, confirmed with daughter\n .\n # COMM: with patient and daughter , \n .\n # DISP: pending overnight monitoring, tolerating trach mask\n .H/O AIRWAY OBSTRUCTION, CENTRAL / UPPER\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:35 PM\n 20 Gauge - 02:46 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051013,
"text": " 3:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change LLL\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with trach s/p PEA arrest after likely mucous plug. Fully\n recoved. LLL opacity on previous CXR\n REASON FOR THIS EXAMINATION:\n interval change LLL\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 81-year-old woman with tracheostomy, status post PEA arrest. Likely\n mucous plug. Evaluate left lower lobe opacity.\n\n FINDINGS: Comparison is made to previous study from .\n\n There has been decrease in the amount of gas within the known hiatal hernia.\n There remains cardiomegaly stable. There is improvement of the air\n bronchograms within the left base; however, there remains consolidation in\n this location. There are no signs for overt pulmonary edema. There has also\n been improvement of the infiltrate at the right base.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1050857,
"text": " 7:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumothorax\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with\n REASON FOR THIS EXAMINATION:\n pneumothorax\n ______________________________________________________________________________\n WET READ: ARHb FRI 8:43 PM\n No pneumothorax identified. Retrocardiac opacity may represent left lower lobe\n atelectasis. Right basilar atelectasis also likely. D/ @\n 20:40.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Pneumothorax.\n\n FINDINGS:\n\n There is a very large hiatal hernia which occupies the mid section of the\n chest. There is large left lower lobe consolidation with air bronchograms and\n a moderate left pleural effusion. These findings have increased since prior\n study. There is also focal right lower lobe consolidation. Heart is\n enlarged. Aorta is tortuous. Tracheostomy remains in the midline.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051468,
"text": " 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with T-tube and rigid bronch yesterday, increased secretions\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj TUE 12:21 PM\n New right lower lobe opacity may represent aspiration or less likely\n hemorrhage/edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old female status post tracheal T-tube change and rigid\n bronchoscopy on .\n\n PORTABLE AP CHEST: Comparison is made to . The cardiomediastinal\n contours are stable. A new right lower lobe opacity is evident. Dense\n consolidation versus atelectasis at the left lung base is unchanged. The\n upper lungs are well aerated. Lucency projecting over the mid thoracic spine,\n compatible with patient's known hiatal hernia appears similar to previous\n studies.\n\n IMPRESSION: New dense opacity in the right lower lobe status post\n bronchoscopy and tracheal T-tube change. The differential diagnosis includes\n aspiration given recent procedure. Other diagnostic considerations include\n hemorrhage or edema. Close interval followup is recommended.\n\n Findings were discussed with Dr. on the morning of by Dr.\n over the telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051469,
"text": ", TSURG FA7A 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with T-tube and rigid bronch yesterday, increased secretions\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n PFI REPORT\n New right lower lobe opacity may represent aspiration or less likely\n hemorrhage/edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1051625,
"text": " 7:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for progressing ? PNA\n Admitting Diagnosis: AIRWAY OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with purulent secretions\n REASON FOR THIS EXAMINATION:\n eval for progressing ? PNA\n ______________________________________________________________________________\n WET READ: KYg TUE 8:42 PM\n PRELIMINARY REPORT: MULTIFOCAL BILATERAL OPACITIES WORRISOME FOR PNEUMONIA.\n COMPARED TO THE PRIOR EXAM THERE IS SLIGLHTLY IMPROVED AERATION OF THE RIGHT\n LUNG BASE. NO PNEUMOTHORAX. NOTE IS MADE OF CHANGES RELATED TO CERVICAL FUSION\n AND LAMINECTOMY. \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:49 P.M. \n\n HISTORY: Purulent secretions.\n\n IMPRESSION: AP chest compared to and 16:\n\n Severe bibasilar consolidation which developed between and has worsened on the right since , stable on the left since\n though associated moderate left pleural effusion is slightly\n smaller today than on . Moderate-to-severe cardiomegaly is stable.\n Esophagus is distended above a large gastric hiatus hernia. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-13 00:00:00.000",
"description": "Report",
"row_id": 224169,
"text": "Sinus rhythm with occasional ventricular ectopy and occasional atrial ectopy.\nNon-specific inferior ST-T wave changes. Compared to the previous tracing\nof the limb lead voltage has diminished and ventricular ectopy has\nappeared. Otherwise no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-11 00:00:00.000",
"description": "Report",
"row_id": 224170,
"text": "Sinus rhythm. Frequent premature atrial contractions. Voltage criteria\nfor left ventricular hypertrophy. Lateral ST-T wave abnormalities which are\nnon-specific. Compared to the previous tracing of frequent atrial\npremature beats are new. There are voltage criteria for left ventricular\nhypertrophy which are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-11-10 00:00:00.000",
"description": "Report",
"row_id": 224171,
"text": "Sinus rhythm. Poor R wave progression. Non-specific low amplitude\nT waves in the inferior and lateral leads. Compared to the previous tracing\nof T wave flattening is more pronounced and the Q-T interval is\nshorter.\n\n"
}
] |
27,097 | 177,588 | He was admitted to the Trauma service. Neurosurgery/Spine was consulted for his spine injuries which were non operative. He underwent MRI of Thoracic and Lumbar spine and was maintained on log roll precautions pending MRI outcome. He was fitted for TLSO brace and will need to wear this when out of bed. His pain is being controlled with Tylenol around the clock and prn Oxycodone. Follow up in clinic with Dr. in 6 weeks. Orthopedics was also consulted given his for his left clavicle fracture; this was also nonoperative. A sling was recommended; he is to remain non weight bearing on his left arm. Follow up with Dr. in 2 weeks. He did have an elevated blood pressure postoperatively; systolic BP was on high 160's, and was started on Lopressor.His systolic BP has been in 140's range since starting Lopressor. He was evaluated by Physical and Occupational therapy and was recommended for rehab following acute hospital stay. | The aorta is mildly tortuous, with atherosclerotic calcifications. Hypertension resloved after ativan given. A separate well-corticated ossification is seen at the superior aspect of the left acromioclavicular joint, which reflects old trauma. Mild anterior wedging of the T5 and T7 vertebral bodies. Sinus rhythmVentricular premature complexBorderline first degree A-V delayConsider left atrial abnormalityProminent precordial low QRS voltage - consider left ventricular hypertrophyalthough is nondiagnosticNo previous tracing available for comparison Comminuted, mildly displaced fracture of the distal clavicle. afebrile.Resp: on 4L NC, LS clear bilat, diminished in bases. Linear hypodense structures coursing adjacent to the largest lesion, may reflect a minimally dilated intrahepatic duct. mild bilateral neuroforaminal narrowing at these levels. Minimally displaced right transverse process fractures at L3 and L4. Pt continued with hypertension and slightly tachycardic (100's). Mild compression deformity of the T5 and T7 vertebral bodies, may be acute. There are multilevel degenerative changes, with a slight accentuation of the normal cervical lordosis. Nursing Noteevents: C-spine clearedNeuro: Pt. Remote trauma noted cephalad to the acromioclavicular joint. On delayed images, these subsequently demonstrate centripetal enhancement, suggestive of hemangiomas. The adenoma signal changes in compressions of T6-T10 and T12 are suggestive of mild acute compressions. Compression boots and SC Heparin for prophylaxis.RESP-Lung sounds clear with diminished bases R>L. MAE, LUE without full ROM d/t clavicle fx. Slight anterior wedging of T5 and T7 vertebral bodies, without associated hematoma or retropulsion. At L5-S1 level, disc degenerative changes are identified with mild bulging without spinal stenosis. Left distal clavicle fracture. There is also slight irregularity of the inferior endplate of the T6 vertebral body, which likely represents a degenerative/Schmorl's node. There is a mildly displaced fracture of the coracoid process of the scapula with slight inferior displacement of the coracoid. T/SICU NURSING PROGRESS NOTE*PLEASE SEE CAREVUE FOR EXACT DATA*SIGNIFICANT EVENTS: Pt noted for hypertension unrelated to pain. HCT stable Compression boots and SC Heparin.RESP-Lung sounds clear with diminished bases, 4L NC. The lungs are essentially clear except for right lower lobe opacity consistent with atelectasis. OOB as tolerated Dr. . afebrile.Resp: On 2L NC, LS diminished throughout. Left shoulder abrasion and ecchymosis. The humeral head is grossly in place. FINAL REPORT HISTORY: Status post MVA, Rule out bleed or fracture. Degenerative disc disease and mild bulging seen from L1 and S2-L4 L5 level. SBP 160-190-no parameters.Resp: 2L NC, BS diminished bilaterally.GI: +BS, soft abdomen non tender, non distended. Prolonged A-V conduction.Possible left ventricular hypertrophy. LUMBAR SPINE: TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of the (Over) 12:53 AM MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # Reason: assess soft tissue around fx Admitting Diagnosis: BLUNT TRAUMA FINAL REPORT (Cont) lumbar spine were acquired. In the visualized lower thoracic region, mild acute compression of T12 vertebra seen on the superior endplate, as seen on the thoracic spine MRI. Chronic compressions of T3-T5 vertebral bodies. Rule out fracture. Probable left shoulder joint effusion. Otherwise, paranasal sinuses and mastoid air cells are normally aerated. PORTABLE SUPINE AP CHEST, ON A TRAUMA BACKBOARD: Heart size is in the upper limits of normal. CT left shoulder done, MRI TLS done.N: A/O x3. FINDINGS: There is an oblique fracture through the distal diaphysis of the left clavicle with no definite intra-articular extension. There is a focal rounded hypodense lesion within the corona radiata on the left, which may represent a prior lacunar infarct. for brace.CV: HR as noted, BP WNL.Resp: on 3L NC, 1250 on IS. There are minimally displaced fractures of the right transverse process at L3 and L4. There is a comminuted fracture of the distal left clavicle. If TLS clear get OOB. small bulges and facet hypertrophy at L3/4, L4/5, L5/S1. Morphine PCA for pain- using appropriately. THORACIC SPINE: TECHNIQUE: T1, T2, and inversion recovery sagittal, and T2 axial images obtained. There is marrow edema seen in the inferior aspect of T6 with mild compression. The airways are patent to the subsegmental level. Logg roll precautions-awaiting MRI Thoracic and LS. T/SICU NURSING PROGRESS NOTENO SIGNIFICANT EVENTS TIHS SHIFT*REVIEW OF SYSTEMS*NEURO-Pt A&Ox3, able to MAE's with LUE slightly weaker due to injury. MG 1.7-2gr given. Compression boots and SC Heparin for prophylaxis.RESP-Lung sounds diminished, continues on 2L NC. Nursing NoteEvents: Pt. Nursing NoteEvents: Pt. TECHNIQUE: Contiguous axial images of the head were obtained without IV contrast. There is no evidence of There is subtle increased signal is seen in the interspinous region at T5-6.07 T5-6 and T6 and inversion recovery images, which could be secondary to mild trauma to the interspinous ligament. Mild acute compressions of T6, T10 and T12 without spinal stenosis. Initial Chem 10 hemolyzed, labs repeated and WNL.INTEG-Skin tear noted to LUE and right knee, adaptic dressings intact. T/SICU NURSING PROGRESS NOTENO SIGNIFICANT EVENTS THIS SHIFTREVIEW OF SYSTEMS:NEURO-Pt A&Ox3, exam intact. NEOPS in to measure pt. Neuro checks Q1hr. Neuro checks Q1hr. Neuro checks Q1hr. Sinus rhythm with ventricular premature beats. A well-corticated bony fragment lies cephalad to the acromioclavicular joint and may be the result of more remote trauma. Additionally, there is minimal grade 1 retrolisthesis of C3 on C4 and C4 on C5. Subtle linear increased signal within the mid thoracic spinal cord represents an incidental slight prominence of central canal. SBP 140-190.Resp: BS diminished throughout. | 20 | [
{
"category": "Nursing/other",
"chartdate": "2112-05-08 00:00:00.000",
"description": "Report",
"row_id": 1616501,
"text": "Addendum\nHOB may be increased >30 degrees and pt. OOB as tolerated Dr. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-05-09 00:00:00.000",
"description": "Report",
"row_id": 1616502,
"text": "T/SICU NURSING PROGRESS NOTE\n\nNO SIGNIFICANT EVENTS THIS SHIFT\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt A&Ox3, exam intact. MAE's LUE weaker due to injury. Continues on Morphine PCA 0.5mg q6minutes with adequate pain control. Pt given Ambien as sleep aide and slept throughout majority of night.\n\nCV-NSR with occ PVC's rate 60-70's, NIBP with SBP raning 120-150's. PIVx2. HCT stable Compression boots and SC Heparin.\n\nRESP-Lung sounds clear with diminished bases, 4L NC. Using IS at 1500. Strong cough. No distress noted\n\nGI/GU-Abdomen soft with present bowel sounds. House diet. No BM, colace given. H2B\n\nENDO-RISS, no coverage required.\n\nID-Afebrile, no antibiotics ordered.\n\nINTEG-Skin tear and abrasion to LUE, right knee with laceration and adaptic dressing.\n\n nephew called and updated last night.\n\nPLAN-Continue to monitor for pain control, increase activity as ordered, encourage diet, coughing/deep breathing and IS use.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-05-09 00:00:00.000",
"description": "Report",
"row_id": 1616503,
"text": "Nursing Note\nEvents: Pt. OOB to chair, fitted for TLSO brace today.\n\nNeuro: Pain well controlled with PCA. Pt. very anxoius to get OOB this am, able to move quite well with PCA. NEOPS in to measure pt. for brace.\n\nCV: HR as noted, BP WNL.\n\nResp: on 3L NC, 1250 on IS. LS clear bilat diminished in bases.\n\nGI/GU: House diet, aqueqaute UOP.\n\nSocial: No family contact overnight.\n\nPlan: Brace placement on Wed.\nPain control\nEncourage ambulation\nPt. support and encouragement.\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1014772,
"text": " 5:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: trauma chest\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVC vs truck, ejected, +LOC, abdominal pain\n REASON FOR THIS EXAMINATION:\n trauma chest\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of a patient after trauma.\n\n Portable AP supine radiograph which was obtained on was brought\n to our review today on .\n\n The heart size is mildly enlarged but stable. The mediastinal contours are\n unremarkable. The lungs are essentially clear except for right lower lobe\n opacity consistent with atelectasis. Multiple rib fractures are noted in the\n right hemithorax. For more detailed description of the chest pathology please\n refer to torso CT obtained on at 5:49 p.m. and the corresponding\n report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-06 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1014768,
"text": " 5:35 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p MVA\n REASON FOR THIS EXAMINATION:\n r/o fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc FRI 6:54 PM\n No acute fx or malalignment. Multilevel degenerative changes.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old status post MVA. Rule out fracture.\n\n No prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images were obtained from the skull base to T1.\n Coronal and sagittal reformatted images were reviewed in conjunction with the\n axial.\n\n FINDINGS: There is no prevertebral soft tissue abnormality. No acute\n fracture or malalignment is identified. There are multilevel degenerative\n changes, with a slight accentuation of the normal cervical lordosis.\n Degenerative changes are most severe at C3-4 and C4-5, with loss of disc\n height space and slight bony proliferative changes. Additionally, there is\n minimal grade 1 retrolisthesis of C3 on C4 and C4 on C5. The central canal\n appears largely patent. Visualized lung apices reveal no evidence for\n pneumothorax.\n\n IMPRESSION:\n 1. No acute fracture or malalignment.\n 2. Multilevel degenerative changes.\n\n Findings entered into the emergency dashboard at the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-06 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1014770,
"text": " 5:36 PM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: r/o injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p MVA\n REASON FOR THIS EXAMINATION:\n r/o injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc FRI 7:59 PM\n Multiple right sided rib fx with small hemothorax. Right transverse fx\n involving L3 and L4. Coracoid fx on the left with extension to the glenoid.\n Extensive soft tissue swelling and hematoma in the region of the left deltoid.\n Mild compression deformity of the T5 and T7 vertebral bodies, may be acute.\n D/w Dr. from surgery.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old status post MVA, rule out injury.\n\n No prior studies for comparison.\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis with the administration of IV contrast. Delayed images\n through the liver were also obtained. Coronal and sagittal reformatted images\n were viewed in conjunction with the axial.\n\n CT OF THE CHEST WITH IV CONTRAST: Mild atherosclerotic calcifications of the\n coronary arteries and aortic arch are seen. Otherwise, the heart,\n pericardium, and great vessels are unremarkable, without evidence of an acute\n injury. There are no pathologically enlarged mediastinal, hilar, or axillary\n lymphadenopathy.\n\n The lungs are clear without evidence of a focal contusion. There is a small\n amount of fluid within the right posterior pleural space in the region of\n multiple rib fractures, consistent with a small hemothorax. Within this\n hemothorax, there is a sliver of bone from an adjacent rib fracture. The\n airways are patent to the subsegmental level.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Within the right lobe of the liver, there\n is a large heterogeneous 5 cm predominantly hypodense lesion, and a smaller\n one measuring approximately 1.6 cm slightly cephalad. On delayed images,\n these subsequently demonstrate centripetal enhancement, suggestive of\n hemangiomas. Linear hypodense structures coursing adjacent to the largest\n lesion, may reflect a minimally dilated intrahepatic duct. There is no\n evidence of an acute injury in the liver. The kidneys, gallbladder, spleen,\n adrenal glands, and pancreas are unremarkable. Stomach and bowel are within\n normal limits. There is no free air, free fluid, or adenopathy. There are\n atherosclerotic calcifications of the abdominal aorta, with atheromatous\n plaque seen. There is no evidence of an acute aortic injury.\n\n CT OF THE PELVIS WITH IV CONTRAST: Foley catheter courses into the bladder.\n (Over)\n\n 5:36 PM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: r/o injury\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Prostate and rectum are unremarkable. There is no free fluid or adenopathy.\n\n OSSEOUS STRUCTURES: There are multiple minimally displaced right-sided rib\n fractures. Specifically, there is a fracture involving the posterior right\n fifth, sixth, seventh, and eighth ribs; the lateral right ninth, tenth, and\n eleventh ribs; and the posterior right twelfth rib.\n\n There are minimally displaced fractures of the right transverse process at L3\n and L4.\n\n There is a displaced fracture of the left coracoid process, and a bone\n fragment in the joint space, possibly from the glenoid. There is associated\n extensive soft tissue swelling and hematoma in the left upper extremity and\n around the deltoid. Within the soft tissues in the right posterior pelvis,\n subcutaneous stranding may also possibly represent an area of contusion.\n\n Mild anterior wedging of the T5 and T7 vertebral bodies. Although there is no\n associated hematoma or retropulsion of fragments into the central canal, these\n may represent acute compression fractures. There is also slight irregularity\n of the inferior endplate of the T6 vertebral body, which likely represents a\n degenerative/Schmorl's node.\n\n IMPRESSION:\n 1. Multiple right-sided rib fractures, with an associated small right\n hemothorax.\n\n 2. Left coracoid fracture, with possible involvement of the glenoid, and\n associated extensive soft tissue swelling and hematoma.\n\n 3. Minimally displaced right transverse process fractures at L3 and L4.\n\n 4. Slight anterior wedging of T5 and T7 vertebral bodies, without associated\n hematoma or retropulsion. These may represent an acute compression fracture.\n If clinically warranted, an MR may be obtained for confirmation.\n\n 5. Two rounded hypodense lesions within the liver, likely representing\n hemangiomas.\n\n Findings posted to the ED dashboard at the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1014767,
"text": " 5:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed, fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p MVA\n REASON FOR THIS EXAMINATION:\n r/o bleed, fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc FRI 5:55 PM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post MVA, Rule out bleed or fracture.\n\n No prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, edema, mass effect,\n shift of normally midline structures, or acute major vascular territorial\n infarction. Periventricular white matter low attenuation is most consistent\n with chronic small vessel ischemic disease. There is a focal rounded\n hypodense lesion within the corona radiata on the left, which may represent a\n prior lacunar infarct. The ventricles and sulci are normal in caliber and\n configuration. No acute fractures are identified. Atherosclerotic\n calcification of the cavernous portions of the carotid arteries are seen\n bilaterally. There is mild mucosal thickening of the ethmoidal sinuses.\n Otherwise, paranasal sinuses and mastoid air cells are normally aerated.\n\n IMPRESSION: No acute intracranial process.\n\n Findings posted to the ED dashboard at the time of interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-07 00:00:00.000",
"description": "MR THORACIC SPINE W/O CONTRAST",
"row_id": 1014801,
"text": " 12:53 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: assess soft tissue around fx\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVC, T5 & T7 end plate fx\n REASON FOR THIS EXAMINATION:\n assess soft tissue around fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KN SAT 4:07 AM\n MR - superior endplate fx's of T6,10, 12. no extension to posterior\n elements. no retropulsion, epidural hematoma or cord compression.\n\n MR - NO fx. small bulges and facet hypertrophy at L3/4, L4/5, L5/S1.\n mild bilateral neuroforaminal narrowing at these levels.\n\n , MD NIghtvision\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the thoracic and lumbar spine.\n\n CLINICAL INFORMATION: Patient with motor vehicle accident and T5-T7\n fractures, for further evaluation.\n\n THORACIC SPINE:\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal, and T2 axial images\n obtained.\n\n FINDINGS: There are chronic compressions of T3-T4 and T5 vertebral bodies\n identified without any marrow edema. There is marrow edema seen in the\n inferior aspect of T6 with mild compression. Additionally, superior endplate\n of T10 and T2 demonstrate increased signal with mild compression. The adenoma\n signal changes in compressions of T6-T10 and T12 are suggestive of mild acute\n compressions. There is no retropulsion identified or spinal canal stenosis\n seen. There is no evidence of spinal cord compression or intraspinal hematoma\n identified. Subtle linear increased signal within the mid thoracic spinal\n cord represents an incidental slight prominence of central canal. There is no\n evidence of There is subtle increased signal is seen in the interspinous\n region at T5-6.07 T5-6 and T6 and inversion recovery images, which could be\n secondary to mild trauma to the interspinous ligament. However, there is no\n MRI evidence of disruption of the ligament idea identified.\n\n IMPRESSION:\n 1. Mild acute compressions of T6, T10 and T12 without spinal stenosis.\n Chronic compressions of T3-T5 vertebral bodies. No spinal stenosis or spinal\n cord compression. Other changes as described above.\n\n LUMBAR SPINE:\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of the\n (Over)\n\n 12:53 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: assess soft tissue around fx\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lumbar spine were acquired.\n\n FINDINGS: There is no evidence of marrow edema seen or fracture identified in\n the lumbar vertebral bodies or in the visualized upper sacrum. Degenerative\n disc disease and mild bulging seen from L1 and S2-L4 L5 level. At L5-S1\n level, disc degenerative changes are identified with mild bulging without\n spinal stenosis. There is no evidence of high-grade foraminal narrowing seen.\n\n In the visualized lower thoracic region, mild acute compression of T12\n vertebra seen on the superior endplate, as seen on the thoracic spine MRI.\n\n Mild decreased signal within the right side of L4 vertebra on T1- and T2-\n weighted images, is not confirmed on inversion recovery images could be due to\n an atypical hemangioma. This could also be due to heterogenous marrow signal.\n\n IMPRESSION: No evidence of compression fracture or marrow edema in the lumbar\n region. Degenerative changes.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-07 00:00:00.000",
"description": "CT UP EXT W/O C",
"row_id": 1014803,
"text": " 1:28 AM\n CT UP EXT W/O C Clip # \n Reason: assess fx of shoulder\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with coracoid fx, ? glenoid fx\n REASON FOR THIS EXAMINATION:\n assess fx of shoulder\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE LEFT SHOULDER WITHOUT CONTRAST\n\n INDICATION: Evaluate for coracoid fracture or glenoid fracture.\n\n TECHNIQUE: CT scan of the left shoulder was performed without intravenous\n contrast. Images were acquired in the axial plane. Coronal and sagittal\n reformats were created and reviewed. No comparisons.\n\n FINDINGS: Numerous fractures are seen about the shoulder. There is a\n comminuted fracture of the distal left clavicle. There is a mildly displaced\n fracture of the coracoid process of the scapula with slight inferior\n displacement of the coracoid. Numerous fracture fragments are seen in\n association with the glenoid, including comminuted fracture of the posterior\n lip of the glenoid as well as a cortical fracture fragment seen in the\n superior aspect of the glenohumeral joint. No scapular body or humeral\n fracture is seen. The visualized left upper ribs are intact. Multilevel\n degenerative changes of the lower cervical spine are seen. Visualized portion\n of the left lung apex is clear. Hemorrhage and edema is seen tracking into\n the axilla, likely related to the fractures. A focal hematoma is seen within\n the subcutaneous soft tissues of the upper arm and there is contiguous edema\n and standing likely also related to the known fractures. There is a\n suggestion of a left shoulder joint effusion. A separate well-corticated\n ossification is seen at the superior aspect of the left acromioclavicular\n joint, which reflects old trauma.\n\n IMPRESSION:\n\n 1. Fracture of the coracoid process of the scapula with inferior displacement\n of the coracoid.\n\n 2. Comminuted, mildly displaced fracture of the distal clavicle.\n\n 3. Numerous fracture fragments adjacent to the glenoid, likely arising from\n the posterior and superior aspects of the glenoid rim.\n\n 4. No evidence of proximal humeral or scapular body fractures.\n\n 5. Extensive associated soft tissue stranding and focal hematoma in the\n subcutaneous soft tissues of the left upper arm. Probable left shoulder joint\n effusion.\n\n (Over)\n\n 1:28 AM\n CT UP EXT W/O C Clip # \n Reason: assess fx of shoulder\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-05-10 00:00:00.000",
"description": "Report",
"row_id": 1616504,
"text": "T/SICU NURSING PROGRESS NOTE\n\nNO SIGNIFICANT EVENTS TIHS SHIFT\n\n*REVIEW OF SYSTEMS*\n\nNEURO-Pt A&Ox3, able to MAE's with LUE slightly weaker due to injury. Ambien given at 2100, pt slept for 3 hour periods throughout night. Denies pain at rest, c/o pain to right ribs with activity/turning which is relieved by Morphine PCA 0.5mg q6 minutes. Pt OOB to chair throughout day, fitted for TLSO brace yesterday (brace needed x6wks for ambulating).\n\nCV-NSR rate 60-80's with occ. PVC's. SBP ranging 130-160 and stable. New #18G PIV placed to right FA. HCT stable at 30.9. Compression boots and SC Heparin for prophylaxis.\n\nRESP-Lung sounds clear with diminished bases R>L. Continues on 4L NC sat mid to high 90's. Strong productive cough. Using IS at 1000-1250.\n\nGI/GU-Abdomen soft with present bowel sounds. Non tender to palpation. Tolerating regular diet. H2B. Indwelling foley catheter with adequate amounts of clear yellow UOP. Initial Chem 10 hemolyzed, labs repeated and WNL.\n\nINTEG-Skin tear noted to LUE and right knee, adaptic dressings intact. Left shoulder abrasion and ecchymosis. Sling to left arm for comfort.\n\nENDO-BS q12hours, no insulin coverage required.\n\nID-No issues, wbc's 8.6 and stable. No abx.\n\n nephew is spokesperson, called last night and updated on pts progress and poc. He or his wife will be in this afternoon, pt requested they bring his glasses.\n\nPLAN-?transfer to floor, monitor for pain, encourage IS use and coughing/deep breathing, oob to chair, awaiting arrival of tlso brace (pt fitted yesterday)\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-05-08 00:00:00.000",
"description": "Report",
"row_id": 1616499,
"text": "T/SICU NURSING PROGRESS NOTE\n\n*PLEASE SEE CAREVUE FOR EXACT DATA*\n\nSIGNIFICANT EVENTS: Pt noted for hypertension unrelated to pain. Spoke to Dr. (SBP 170's), Hydralizine given 10mg x2 doses with little effect. Pt continued with hypertension and slightly tachycardic (100's). Pt denied pain however reported that he was anxious because he thought he was going to die. He began speaking about his will and last rights. He reported he was unable to get enough oxygen to his lungs and that he \"would just close my eyes and it will be over\". Spoke to Dr and pt given Ativan 0.5mg x1 dose IV for anxiety. Continuing to monitor.\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt A&Ox3, MAE's. LUE slightly weaker due to injury. , strong cough and gag. +sensation throughout extremities. Please note episode listed above. Pt denies pain at rest, however reports pain to right ribs with turning/movement. Morphine PCA 0.5mg q6mintues tolerated well. HOB<30degrees, needs TLSO brace.\n\nCV-NSR rate 60-80's with occ PVC's. SBP ranging 130-170's, Hydralizine 10mg iv given x2 doses w/ little relief. Hypertension resloved after ativan given. PIVx2. Compression boots and SC Heparin for prophylaxis.\n\nRESP-Lung sounds diminished, continues on 2L NC. Attempted to weak off o2 and sats down to 92%. Using IS at 1250.\n\nGI-Abdomen soft with present bowel sounds. House diet as ordered. H2b\n\nGU-Indwelling foley catheter with adequate amounts of clear yellow uop. Lytes wnl.\n\nENDO-RISS without coverage required.\n\nID-No issues\n\nSOCIAL-No family contacts overnight.\n\nPLAN-Follow up with TLSO brace status, encourage diet and is use, monitor hemodynamics, montior for pain/anxiety issues and medicate as needed. ?transfer to floor if cleared by team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-05-08 00:00:00.000",
"description": "Report",
"row_id": 1616500,
"text": "Nursing Note\nEvents: Pt. ordered for TLSO brace. NEOPS unable to come until Tuesday d/t holiday.\n\nNeuro: Pt. remains on PCA, using only during movements. Pain controled well with PCA. MAE's, follows commands. Trauma team wants to keep HOB no higher than 30 degrees.\n Pt. describing dream he had last evening where he thought medical team was giving him his last rights. Pt. stating that the dream was so vivid and he thought the staff was out to get him and he was going to die. Pt. revealed that when he woke up this morning everything was suddenl\\y clear and he knew he was dreaming. Pt. asked for encouragement that he was going to survive and continue an active life.\n\nCV: HR 80-90's NSR with occasional PVC. BP WNL. Pt. afebrile.\n\nResp: on 4L NC, LS clear bilat, diminished in bases. Pt. acheiving 1250 on IS.\n\nGI/GU: on house diet, abd. benign, no stool. Foley in place draining clear yellow urine.\n\nEndo: No insulin given per RISS.\n\nSkin: Abrasions and skin tears as documented.\n\nSocial: Family called today, updated to POC.\n\nPlan:\nTLSO brace on Tues/Wed.\nGet pt. OOB\nPain control/ HOB<30 degrees\nPt. and family support\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-05-07 00:00:00.000",
"description": "Report",
"row_id": 1616497,
"text": "addendum admission Note\nEvents: Patient admitted(see admission note). CT left shoulder done, MRI TLS done.\n\nN: A/O x3. normal strengths LE upper extremities not able to lift and hold but can move on bed. Purposeful. PERRLA 3mm bilaterally and briskly reactive. Neuro checks Q1hr. Morphine PCA for pain- using appropriately. MG 1.7-2gr given. Pt on log roll precautions- J in place until TLS cleared. LR @60.\n\nCVS: NSR-70-80's with occasional- frequent PVC's. A febrile. SBP 140-190.\n\nResp: BS diminished throughout. Pt encouraged to CDB. 2L NC. Multip rib fx's see FHP for full injury list.\n\nGI: NPO except meds. +BS throughout. NO BM this shift.\n\nGU: voiding adequate amounts of clear yellow urine.\n\nEndo: covered per RISS- 148,166\n\nSkin: see carevue for specifics.\n\nPlan: Awaiting results of MRI and CT. ? D/c log roll and or J when results read. Encourage to CDB. If TLS clear get OOB. Pain Management- continue to educate about use of PCA. Neuro checks Q1hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-05-07 00:00:00.000",
"description": "Report",
"row_id": 1616498,
"text": "Nursing Note\nevents: C-spine cleared\n\nNeuro: Pt. very pleasant, A&O x3, appropriate. MAE, LUE without full ROM d/t clavicle fx. , pt. follows commands, on Morphine PCA with good pain control. HOB up to 30 degrees, TLS brace ordered.\n\nCV: HR 60-70's NSR with frequent PVC's. BP WNL. Pt. afebrile.\n\nResp: On 2L NC, LS diminished throughout. IS encouraged, pt. up to 1500.\n\nGI/GU: Pt. on House diet, Abd. benign, no stool. Foley in place draining clear yellow urine.\n\nendo: Insulin given as noted.\n\nSkin: Abrasion and skin tears as documented, adaptics in place.\n\nPlan:\nTLS brace then OOB\nPain control\nencourage IS, CDB\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-05-06 00:00:00.000",
"description": "Report",
"row_id": 1616496,
"text": "admission\n85 y.o male s/p rollover MVC-pt hit from side. restrained driver. Initially didn't remember events at scene. Med flighted to . Now recalls all events- pt was restrained unbelted self and crawled out of car waited on side of road. Injuries Include: Multiple rib fractures right side, right side small hemothorax, Left transverse fracture L3-L4, Left coracoid fracture extending to glenoid. Left distal clavicle fracture. Skin abrasion to left shoulder, skin tear left lower arm, skin tear to right knee, and hematoma to left upper arm.\n\nNo PMH: no medications on admission.\n\nPast surgeries: hernia repair, surgery to left eye WWII after ? shrapnel got into eye from stove explosion.\n\nN: A/o X3. Neuro checks Q1hr. Follows commands pleasant. LUE able to move on bed but not able to lift and hold. All other extremities equal strength. PERRLA 3mm briskly reactive bilaterally. PCA morphine for pain. Logg roll precautions-awaiting MRI Thoracic and LS. Also awaiting CT left shoulder\n\nCVS: HR 70-80's NSR with occasional to frequent PVC's. SBP 160-190-no parameters.\n\nResp: 2L NC, BS diminished bilaterally.\n\nGI: +BS, soft abdomen non tender, non distended. NPO at this time\n\nGU: foley draining patent yellow urine.\n\nSocial: nephew and wife into visit. Nephew is spokesperson.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-06 00:00:00.000",
"description": "L HUMERUS (AP & LAT) LEFT",
"row_id": 1014773,
"text": " 6:05 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT; HUMERUS (AP & LAT) LEFTClip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p MVC vs truck, ejected, +LOC, abdominal pain\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n LEFT SHOULDER THREE VIEWS LEFT HUMERUS TWO VIEWS AT 18:03 HOURS\n\n HISTORY: Motor vehicle collision post-ejection.\n\n COMPARISON: CT of the torso acquired earlier same day.\n\n FINDINGS: There is an oblique fracture through the distal diaphysis of the\n left clavicle with no definite intra-articular extension. A well-corticated\n bony fragment lies cephalad to the acromioclavicular joint and may be the\n result of more remote trauma. The humeral head is grossly in place. Please\n note orthogonal views such as scapular, Y or axillary were not obtained. There\n are multiple bony fragments retracted at the level of the proximal diaphysis\n of the humerus. The elbow joint is grossly appropriately aligned.\n\n IMPRESSION: Oblique fracture of the distal clavicle with no significant\n displacement or distraction. Remote trauma noted cephalad to the\n acromioclavicular joint. No definite dislocation is seen although for\n confirmatory evidence consider orthogonal view. Bony fragments seen in the\n medial aspect of the arm have likely avulsed from the coracoid process or\n possibly the glenoid.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-06 00:00:00.000",
"description": "TRAUMA #3 (PORT CHEST ONLY)",
"row_id": 1014761,
"text": " 4:59 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Trauma.\n\n No prior studies for comparison.\n\n PORTABLE SUPINE AP CHEST, ON A TRAUMA BACKBOARD: Heart size is in the upper\n limits of normal. The aorta is mildly tortuous, with atherosclerotic\n calcifications. Prominence of the right upper mediastinum likely reflects\n vascular shadows. No focal pulmonary consolidation is identified. There is\n no evidence of pneumothorax or pleural effusion. There are multiple mildly\n displaced right rib fractures, specifically the posterior aspect of the 5-8th\n ribs.\n\n IMPRESSION: Multiple mildly displaced right rib fractures. No clear evidence\n of a pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1015118,
"text": " 9:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with rib fractures\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rib fractures, to evaluate for change.\n\n FINDINGS: In comparison with study of , there has been development of\n some atelectatic changes at the left base. Rib fractures again seen but no\n evidence of pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2112-05-06 00:00:00.000",
"description": "Report",
"row_id": 213951,
"text": "Sinus rhythm\nVentricular premature complex\nBorderline first degree A-V delay\nConsider left atrial abnormality\nProminent precordial low QRS voltage - consider left ventricular hypertrophy\nalthough is nondiagnostic\nNo previous tracing available for comparison\n\n"
},
{
"category": "ECG",
"chartdate": "2112-05-06 00:00:00.000",
"description": "Report",
"row_id": 213952,
"text": "Sinus rhythm with ventricular premature beats. Prolonged A-V conduction.\nPossible left ventricular hypertrophy. No previous tracing availa comparison.\n\n"
}
] |
17,592 | 182,639 | He was admitted to the Trauma Service. Orthopedics was consulted because of his femur fracture; he was taken to the operating room for repair of his perineal laceration and ORIF of left femur. Postoperatively there were some pain control issues; he initially required PCA Dilaudid with same fro breakthrough pain. he was eventually changed to oral Dilaudid which has been effective in controlling his pain. Plastic Surgery was consulted because of ear and nasal lacerations; these were sutured in the ED, his nose required packing with Xeroform gauze, this was later removed. It was also noted that he had a right brachial plexus injury; Plastic surgery was consulted for this as well. Physical and Occupational therapy were consulted; there were some balance issues initially, but then he was later cleared for discharge to home. He is being discharged to home and will continue on Lovenox injections until follow up with Orthopedics. He will also need to follow up with Trauma Surgery nd Plastic Surgery in 2 weeks. | IMPRESSION: No definite fracture, although evaluation of the left lower extremity is markedly limited due to overlying external fixation device. No definite mucosal injury is identified and contrast is noted in the more proximal aspects of the urethra. FINDINGS: Trauma back board artifact obscures portions of the chest and pelvis. secreations minimal.Plan: Wean to extubate. No bony trauma to the pelvis, although linear lucencies in the region of the scrotum suggest soft tissue injury. Minimal movement of LE's noted yet left leg in traction splint on admission. IMPRESSION: Evaluation with no obvious shoulder injury identified. Backside not visualized at this time, Perineum w/ laceration to be washed out and repaired in OR. IMPRESSION: Limited nonfluroscopic retrograde urethrogram done portably in the trauma bay. t/fer'd here for futher managment of injuries.Injuries include left. Please note, not mentioned above, there are extensive linear lucencies in the region of the perineum likely related to laceration seen intially on the scout radiograph. This is a smooth concentric extrinsic compression. RIGHT TIB-FIB: There is soft tissue defect overlying the right lateral lower extremity. This obscures portions of the sacrum and pelvis. There is, however, marked narrowing of approximately 1.7 cm in length in the region of the membranous and proximal bulbous urethra. LEFT TIB-FIB: Evaluation is markedly limited due to overlying external fixation device. The Foley catheter was withdrawn. FINDINGS: At described on multiple prior examinations, there is contrast filling the bladder which obscures the sacrum and portions of the pelvis. The regional soft tissues are unremarkable. IMPRESSION: Comminuted mid diaphyseal left femur fracture. Of note, the patient has contrast within the bladder from an outside CT scan, which obscures the base of the bladder and the most proximal urethra. TECHNIQUE: A portable retrograde urethrogram was performed. Within that limitation, the pelvis is intact. Again, the knee joint is grossly aligned, however there is marked low position of the patella. INDICATION: Status post trauma. Please note posterior dislocations may not be evident on AP views. The mediastinum is unremarkable and stable. This would correspond to a type 1 urethral injury. There is no orthogonal projection as the patient is intubated. Within these limited views, there is no obvious fracture. The iliac crests have been excluded from view. No LOC at scene,TLS cleared. These demonstrate intramedullary rod fixation of a comminuted fracture of the mid left femoral diaphysis. No definite fracture is seen. O2 sats 99-100% on 100%.GI- abd firm yet not distended, bowel sounds present, small amt brown aspirate via OGT, Pt started on famotidine.GU- 16 French Coude cath foley placed at bedside w/o difficulty. BP 130-160/85-95, left radial a-line placed just prior to OR. Soft tissue defect overlying the right calf. Evaluation is suboptimal secondary to portable technique. There is slight posterior displacement and anterior angulation of the distal fracture fragment. There is, however concentric extrinsic compression in the region of the membranous and proximal bulbar urethra resulting in marked narrowing. Intubated in our ED for in preparation for OR.BS:clear equal bilat. Nasogastric tube ends in the stomach. There is no obvious mucosal disruption. The cardiac silhouette is within normal limits for size. Bilateral femoral heads are appropriately located. There are linear lucencies in the region overlying the scrotum. HISTORY: Status post intubation. External fixation device is noted over the proximal left femur. Pt w/ palpable pulses in LE's + bilaterally, feet pale and cool yet brisk cap refill. The mediastinum is unremarkable. No gross dislocation is evident. Grossly, the pelvis and sacrum are intact. No effusion or pneumothorax is evident. No effusion or pneumothorax is evident. The descending thoracic aorta is well defined. Resp CarePt. pt fully vented, ETT advanced 3cm as high per postextubation x-ray, repeat x-ray w/ tube in good position, breath sounds clear bilaterally, slightly diminished at right base. No definite disruption is identified. PT as per ortho, GI ADT. Question quadriceps rupture. IMPRESSION: No radiographic evidence of traumatic injury to the chest. The coracoclavicular interval is appropriate. Cardiac function should be assessed to exclude pericardial effusion and cardiac injury. FINDINGS: This is a limited examination as dynamic evaluation under fluoroscopy could not be performed due to patient condition. If clinically feasible, consider orthogonal views such scapular Y or axillary. Please note absolute integrity of the urethra to the bladder is not possible given the presence of contrast material already in the bladder from an outside hospital CT scan. No pneumothorax, pleural effusion, or mediastinal widening. There is contrast within the bladder from the outside facility CT scan. The femoral heads are appropriately located. There is no osseous erosion or joint space narrowing. The patient was not stable enough to be transported to the fluoroscopy suite. There is no gross dislocation. Left ear repaired by plastics in EW as well. Of note, there was a strong gush of contrast material and a postvoid radiograph was obtained. No prior comparisons. No immediate hardware-related complication is seen. No displaced fractures are seen. The penis was repositioned and additional radiograph was obtained to attempt to obtain a different level of obliquity. 4:14 AM FEMUR (AP & LAT) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # Reason: S/P TRAUMA FRACTURE FEMUR Admitting Diagnosis: BLUNT TRAUMA FINAL REPORT LEFT FEMUR, EIGHT VIEWS. femur fx, 8cm perineal lac and partial left ear amputation. Please evaluate for fracture. Pt w/ no PMHx, no meds, Pt does smoke one PPD, drinks occaisionally. Please note that the film was overexposed such that the right knee is grossly difficult to evaluate on lateral view. No fracture is seen. FINDINGS: The endotracheal tube is high at approximately 7 cm from the carina. | 10 | [
{
"category": "Radiology",
"chartdate": "2121-06-09 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 960058,
"text": " 6:13 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: 5\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AND AP PELVIS, , AT 1800 HOURS.\n\n HISTORY: Trauma.\n\n COMPARISON: None.\n\n FINDINGS: Trauma back board artifact obscures portions of the chest and\n pelvis. Lungs are clear. The mediastinum is unremarkable. The descending\n thoracic aorta is well defined. The cardiac silhouette is within normal\n limits for size. No effusion or pneumothorax is evident. No displaced\n fractures are seen. The iliac crests have been excluded from view. There is\n contrast within the bladder from the outside facility CT scan. This obscures\n portions of the sacrum and pelvis. Within that limitation, the pelvis is\n intact. The femoral heads are appropriately located. There are linear\n lucencies in the region overlying the scrotum. External fixation device is\n noted over the proximal left femur.\n\n IMPRESSION: No radiographic evidence of traumatic injury to the chest. No\n bony trauma to the pelvis, although linear lucencies in the region of the\n scrotum suggest soft tissue injury.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-09 00:00:00.000",
"description": "BILAT HIPS (AP,LAT & AP PELVIS)",
"row_id": 960076,
"text": " 7:25 PM\n BILAT HIPS (AP,LAT & AP PELVIS); FEMUR (AP & LAT) BILAT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS, TWO VIEWS RIGHT FEMUR, TWO VIEWS LEFT FEMUR, AT 19:46\n HOURS.\n\n HISTORY: Motor vehicle collision.\n\n COMPARISON: None.\n\n FINDINGS: At described on multiple prior examinations, there is contrast\n filling the bladder which obscures the sacrum and portions of the pelvis.\n There is also high attenuation foci within the region of the perineum, likely\n related to recent retrograde urethrogram. Grossly, the pelvis and sacrum are\n intact. Bilateral femoral heads are appropriately located.\n\n The proximal two thirds of the femur are noted on AP view and the distal two\n thirds are noted on lateral view. Within these limited views, there is no\n obvious fracture. Please note that the film was overexposed such that the\n right knee is grossly difficult to evaluate on lateral view.\n\n There is an external fixation device on the left leg. There is a comminuted\n fracture with a large butterfly fragment medially of the mid diaphysis of the\n left femur. There is slight posterior displacement and anterior angulation of\n the distal fracture fragment. Again, the knee joint is grossly aligned,\n however there is marked low position of the patella. Question quadriceps\n rupture.\n\n IMPRESSION: Comminuted mid diaphyseal left femur fracture. Evaluation is\n suboptimal secondary to portable technique.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-09 00:00:00.000",
"description": "R SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT",
"row_id": 960074,
"text": " 7:24 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE TWO VIEWS OF THE RIGHT SHOULDER, , AT 20:04 HOURS.\n\n HISTORY: Status post motor vehicle collision.\n\n COMPARISON: None.\n\n FINDINGS: AP, internal and external rotation views remained available for\n review. There is no orthogonal projection as the patient is intubated. No\n gross dislocation is evident. No fracture is seen. The AC joint is\n approximately 8 mm wide which is within the wide range of normal. The\n coracoclavicular interval is appropriate. The regional soft tissues are\n unremarkable. The visualized adjacent lung is clear.\n\n IMPRESSION: Evaluation with no obvious shoulder injury identified. Please\n note posterior dislocations may not be evident on AP views. If clinically\n feasible, consider orthogonal views such scapular Y or axillary.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-09 00:00:00.000",
"description": "B TIB/FIB (AP & LAT) BILAT",
"row_id": 960075,
"text": " 7:24 PM\n TIB/FIB (AP & LAT) BILAT; ANKLE (AP, MORTISE & LAT) BILAT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 23-year-old male status post MVC. Please evaluate for fracture.\n\n FINDINGS: Total of eight radiographs comprising multiple views of the\n bilateral tibia and fibula were reviewed. No prior comparisons.\n\n RIGHT TIB-FIB: There is soft tissue defect overlying the right lateral lower\n extremity. There is no fracture or dislocation. There is no osseous erosion\n or joint space narrowing. There is no soft tissue calcification or radiopaque\n foreign object.\n\n LEFT TIB-FIB: Evaluation is markedly limited due to overlying external\n fixation device. No definite fracture is seen. There is no gross\n dislocation. There is no soft tissue calcification or radiopaque foreign\n object.\n\n IMPRESSION: No definite fracture, although evaluation of the left lower\n extremity is markedly limited due to overlying external fixation device. Soft\n tissue defect overlying the right calf.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-10 00:00:00.000",
"description": "L FEMUR (AP & LAT) LEFT",
"row_id": 960114,
"text": " 4:14 AM\n FEMUR (AP & LAT) LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT IN O.R.Clip # \n Reason: S/P TRAUMA FRACTURE FEMUR\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n LEFT FEMUR, EIGHT VIEWS.\n\n INDICATION: Status post trauma.\n\n FINDINGS: Comparison to . A series of eight intraoperative\n radiographs of the left femur were obtained without a radiologist present.\n These demonstrate intramedullary rod fixation of a comminuted fracture of the\n mid left femoral diaphysis. No immediate hardware-related complication is\n seen. Please refer to operative report for full details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960091,
"text": " 9:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with s/p MVC, intubated in ED. check placement\n\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:56 p.m. on \n\n HISTORY: Motor vehicle accident.\n\n IMPRESSION: AP chest compared to at 6:51 p.m.:\n\n ET tube has been advanced to standard placement, tip approximately 4 cm from\n the carina. Lungs are low in volume but clear. No pneumothorax, pleural\n effusion, or mediastinal widening. Nasogastric tube ends in the stomach.\n Heart, though not clearly enlarged, is somewhat larger than expected for a\n young patient, perhaps exaggerated by low lung volumes and supine positioning.\n Cardiac function should be assessed to exclude pericardial effusion and\n cardiac injury.\n\n Dr. was paged to report these findings, at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960067,
"text": " 6:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with s/p MVC, intubated in ED. check placement\n REASON FOR THIS EXAMINATION:\n check ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, , 1851 HOURS.\n\n HISTORY: Status post intubation.\n\n COMPARISON: Earlier same day.\n\n FINDINGS: The endotracheal tube is high at approximately 7 cm from the\n carina. A nasogastric tube is well positioned, coiled within the gastric\n body. The lungs remain clear. The mediastinum is unremarkable and stable.\n No effusion or pneumothorax is evident.\n\n IMPRESSION: Endotracheal tube is high at approximately 7 cm from the carina.\n Advance 3 cm for optimal placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-06-09 00:00:00.000",
"description": "RETRO UROGRAM (74450,51610)",
"row_id": 960068,
"text": " 6:53 PM\n RETRO UROGRAM (,) Clip # \n Reason: eval for Floey placement, urethral injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for Floey placement, urethral injury\n ______________________________________________________________________________\n FINAL REPORT\n RETROGRADE URETHROGRAM, AT 18:52 HOURS.\n\n HISTORY: Perineal trauma.\n\n TECHNIQUE: A portable retrograde urethrogram was performed. The patient was\n not stable enough to be transported to the fluoroscopy suite. A scout\n radiograph was obtained. Of note, the patient has contrast within the bladder\n from an outside CT scan, which obscures the base of the bladder and the most\n proximal urethra. Using sterile technique, a Foley catheter was introduced\n into the distal tip of the penis and approximately 3 cc of water expanded the\n balloon within the fossa navicularis. Approximately 20 cc of Conray contrast\n material was injected and the radiograph was taken with the tube obliqued to\n approximately 45 degrees. The penis was repositioned and additional\n radiograph was obtained to attempt to obtain a different level of obliquity.\n The Foley catheter was withdrawn. Of note, there was a strong gush of\n contrast material and a postvoid radiograph was obtained.\n\n FINDINGS: This is a limited examination as dynamic evaluation under\n fluoroscopy could not be performed due to patient condition. No definite\n mucosal injury is identified and contrast is noted in the more proximal\n aspects of the urethra. There is, however, marked narrowing of approximately\n 1.7 cm in length in the region of the membranous and proximal bulbous urethra.\n This is a smooth concentric extrinsic compression. No definite disruption is\n identified.\n\n Please note, not mentioned above, there are extensive linear lucencies in the\n region of the perineum likely related to laceration seen intially on the\n scout radiograph.\n\n IMPRESSION: Limited nonfluroscopic retrograde urethrogram done portably in\n the trauma bay. There is no obvious mucosal disruption. There is, however\n concentric extrinsic compression in the region of the membranous and proximal\n bulbar urethra resulting in marked narrowing. This would correspond to a type\n 1 urethral injury. Please note absolute integrity of the urethra to the\n bladder is not possible given the presence of contrast material already in the\n bladder from an outside hospital CT scan.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-10 00:00:00.000",
"description": "Report",
"row_id": 1493432,
"text": "TSICU Nsg Admit Note\n Pt is a 24y/o male s/p rollover MVC. Pt unrestrained, tox screen negative, no LOC at the scene and awake and alert x's 3 at the OSH (). Pt medflighted to for further tx. Injuries include left femur fx, 8cm perineal laceration from scrotum to anus, left partial ear amputaion, small nose lac, right lower leg laceration. Pt intubated in EW on arrival and plan for OR. Pt admitted to TSICU till OR ready. Left ear repaired by plastics in EW as well.\n Pt w/ no PMHx, no meds, Pt does smoke one PPD, drinks occaisionally. Pt taken to OR at 11pm on for repair of left femur fx and repair of perineal laceration.\n\nReview of systems:\n\n pt sedated and intubated on propofol at 70mcgs/kg/min, receiving fentanyl 50-100mcgs q 2hrs for pain, when light pt moving upperextremities purposefully yet not following commands, agitated and attempting to sit up in bed. Minimal movement of LE's noted yet left leg in traction splint on admission. Pt placed in J collar from stiff neck collar, TLS cleared by team.\n\n pt in sinus, initially tachy w/ rate > 100, slowed after pain med to 85-95, no ectopy. BP 130-160/85-95, left radial a-line placed just prior to OR. Pt w/ palpable pulses in LE's + bilaterally, feet pale and cool yet brisk cap refill.\n\n pt fully vented, ETT advanced 3cm as high per postextubation x-ray, repeat x-ray w/ tube in good position, breath sounds clear bilaterally, slightly diminished at right base. O2 sats 99-100% on 100%.\n\nGI- abd firm yet not distended, bowel sounds present, small amt brown aspirate via OGT, Pt started on famotidine.\n\nGU- 16 French Coude cath foley placed at bedside w/o difficulty. 500cc's amber urine emptied prior to OR.\n\nID- temp on admission 99.1, pt written for cefazolen, had received vanco, cefazolen and flagyl preadmission.\n\n pt written for sliding scale, BS at midnight 129 yet pt in OR at the time.\n\n pt w/ multiple abrasions on face above right eye, left neck w/ abrasions, right lower leg w/ open gash to be washed out in the OR and sutured, left ear sutured and suture on small lac under nose w/ xeroform gauze as packing. Backside not visualized at this time, Perineum w/ laceration to be washed out and repaired in OR.\n\n pt's parents in to visit, they report that patient had been at his grandmother's funeral earlier in the day and had gone out to do an errand and had reportedly fallen asleep at the wheel.\n\nA/P- neuro stable, pain management as ordered, CV stable follow hcts , resp- wean and extubate post-op w/ post op pulmonary hygeine. PT as per ortho, GI ADT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-06-10 00:00:00.000",
"description": "Report",
"row_id": 1493433,
"text": "Resp Care\nPt. is a 23 yom t/fer via s/p MVC rollover/unrestrained. No LOC at scene,TLS cleared. t/fer'd here for futher managment of injuries.Injuries include left. femur fx, 8cm perineal lac and partial left ear amputation. Intubated in our ED for in preparation for OR.\nBS:clear equal bilat. secreations minimal.\nPlan: Wean to extubate.\n"
}
] |
29,141 | 172,116 | # Respiratory distress/COPD: The patient presented in hypercarbic respiratory failure, with a pCO2 in the 80s. A chest X-ray at the outside hospital was read as possible CHF or pneumonia. He was treated for both diagnoses, and given lasix 40mg IV, 60mg of prednisone, Combivent nebs, and ceftriaxone. . A repeat CXR at was questionable for CHF and there was no focal infiltrate. His report of green sputum was thought to represent a COPD flare. Antibiotic coverage was changed to azithromycin, which he completed a 5 day course. He was also given systemic steroids, which were tapered to 20 mg prednisone prior to discharge. His regimen of inhaled medications were optimized with long-acting beta-agonists, anticholinergics, and steroids. . # CHF - The patient has a h/o CHF w/ a dilated left atrium and EF of 50%. A CXR at the OSH was reported as heart failure. The patient was diuresed with 40mg IV lasix. In the ED here, he received a second dose of 40mg IV Lasix. However, on admission to the MICU his creatinine was noted to have increased to 1.3, and his home lasix and spironolactone were held. After he clinically stabilized on the floor, he received IV lasix 80mg for four days for bibasilar crackles and lower extremity edema. He was continued on beta-blocker and ACE inhibitor, and transitioned back to his home PO Lasix prior to discharge. . # Atrial fibrillation/flutter: The patient has a known history of AF on bisoprolol 2.5mg qday. However, in the setting of his acute respiratory illness, his HR rose to the 130's-140's. He received additional beta blockade with 5mg of Lopressor IV, but with little effect. He responded well to IV diltiazem, and was started on PO Diltiazem 30mg QID. This was titrated up and converted to 240mg of long-acting Diltiazem with good effect. His HR was in the 70-80s at discharge. He will need to follow up with his cardiologist to evaluate the effect of the medication, as there is the possibility that as the CHF resolves less rate control will be needed. At , his INR was 1.6, and he was continued on his home dose of coumadin. However, his INR became supratherapeutic during his hospitalization, presumed due to concomitant antibiotic therapy. He was discharged on 3mg of Coumadin daily. . # Acute Renal Failure: The patient was noted to be in acute renal failure with a creatinine of 1.3 on admission after receiving 2 of IV lasix. Both Lasix and spironolactone were held because prerenal azotemia was suspected. The patient received gentle IV hydration and his creatinine normalized to 0.9. As noted above, he received several of IV lasix after he clinically stabilized on the floor, for bibasilar crackles and lower extremity edema. He was transitioned back to his home lasix and spironolactone prior to discharge. . # CAD: An EKG was performed and did not show active ischemia. Cardiac enzymes were sent and were negative X3. The patient was continued on aspirin, statin, lopressor, and lisinopril. . # Neuropathy. This was not an active issue, and the patient was continued on his home dose of fentanyl patch, gabapentin, and percocet. . # Depression: This was not an active issue. The patient was continued on his home sertraline . # FEN: The patient was placed on a cardiac/heart healthy diet. | IMPRESSION: PA and lateral chest compared to and 9: Vascular congestion and cardiomegaly are borderline unchanged since . Atrial flutterModest nonspecific intraventricular conduction delayConsider prior inferior myocardial infarction although is nondiagnosticModest nonspecific ST-T wave changesSince previous tracing of , sinus rhythm absent Lung volumes remain low, particular on the right where there is relative elevation of the lung base, with disparity more pronounced now than it was in , probably due to progressive diaphragmatic eventration. Bibasal linear opacities are unchanged, most likely representing atelectasis. Atrial flutterModest nonspecific intraventricular conduction delayConsider prior inferior myocardial infarction although is nondiagnosticModest nonspecific ST-T wave changesSince previous tracing of the same date, no significant change FINDINGS: There are low lung volumes. Since previous tracingof the ventricular response has decreased. The overall lung volumes remain low. HISTORY: Respiratory distress. Abd soft, obese, + stool x 1. HR 100-130s aflutter with variable block. Regular narrow complex rhythm. There is persistent elevation of the right hemidiaphragm. IMPRESSION: No acute cardiopulmonary process. Respiratory Care NotePt given Atrovent neb at 12noon. Probable atrial flutterwhich is not counterclockwise in configuration. Portable AP chest radiograph compared to . LS coarse t/o, expectorated yellow/green sputum x1 this shift. Pt has a congested cough. The cardiomediastinal and hilar contours are stable. No sizable pleural effusion is noted. Secretions swallowed. There is right lower lobe atelectasis. Sputum spec sent. Baseline artifact. Linear area of scarring is seen in the right upper lobe. The heart size is moderately enlarged but stable. FINAL REPORT PA AND LATERAL CHEST ON HISTORY: COPD, CHF, look for vascular congestion. REASON FOR THIS EXAMINATION: assess for vascular congestion progression. NBP WNL. Nursing Progress Note 0700-1900Please see carevue and FHP for additional data.Dispo: FULL codeAllergies: NeosporinAccess: 1 pivPt alert, avioding orientation questions, needy at times, carries on coversation appropriately. 12:10 PM CHEST (PA & LAT) PORT Clip # Reason: assess for vascular congestion progression. Called out to floor. There is no pleural effusion. There are no consolidations or effusions. last pm. There is no pneumothorax. There is no evidence of congestive heart failure. Remains on 3L nc, with sats 95%, will desat with exertion, but recovers quickly. Foley secure and patent draining adequate amounts of urine. 3:23 AM CHEST (PORTABLE AP) Clip # Reason: please eval for interval change Admitting Diagnosis: CONGESTIVE HEART FAILURE MEDICAL CONDITION: 74 year old man with COPD, SOB REASON FOR THIS EXAMINATION: please eval for interval change FINAL REPORT REASON FOR EXAMINATION: Shortness of breath. c/o floormonitor resp status/vitals/MAP > 60update with pt and family Rec'd 5mg lopressor x 1 for HR 130s, restarted on home BP medication. 74 y/o male with PMH of COPD (steroid ddependent and on Home O2),CHF,A-Fib on Coumadin,Neuropathy with chronic pain,Ca Lungs diagnosed 5 yrs ago s/P resection of rt lung,Depression... was found unresposive at home,wife called EMS and transferred to tried to intubate,gag was and positive and pt woke up Lasix,nebs,steroids and ceftriaxone was given Pt was transferred to ED and at 2300 pt was transferred in MICU for further management because pt had increased confusion yesterday.On admission to MICU pt is coherent Alert and oriented X 3,follows all commands,moves all extrimities C/O pain all over body percocet given with good relief.Denies any SOB or CP.In A-Fib on coumadin EKG obtained on admission,blood work up done NBP dropped to 80's on admission NS 500 ml bolused with good effect.HR 80-100,NBP 90-110/30-50.Extrimities has pitting edema,Pedal pulses are doppled.For access one PIV on lt hand.Multiple ecchymotic areas all over the body.RR 16-25 breathing efforts are normal,LS are coarse throughout,expectorating thick yellow sputum,c/s sent.O2 sats are maintained 94-96% on NC 2L.Abdomen obese positive bowel sounds,had liquids orally.No bowel movement at this shift.voiding adequate amts of clear urineNo contact from family at this shiftPLAN; ? 1:23 PM CHEST (PORTABLE AP) Clip # Reason: eval for chf/infiltrate MEDICAL CONDITION: 74 year old man with resp distress REASON FOR THIS EXAMINATION: eval for chf/infiltrate FINAL REPORT CHEST PORTABLE AP COMPARISON: . | 9 | [
{
"category": "Radiology",
"chartdate": "2163-12-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 985960,
"text": " 3:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with COPD, SOB\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath.\n\n Portable AP chest radiograph compared to .\n\n The heart size is moderately enlarged but stable. There is no evidence of\n congestive heart failure. Bibasal linear opacities are unchanged, most likely\n representing atelectasis. No sizable pleural effusion is noted. The overall\n lung volumes remain low.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 985901,
"text": " 1:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf/infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n eval for chf/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMPARISON: .\n\n HISTORY: Respiratory distress.\n\n FINDINGS: There are low lung volumes. There is persistent elevation of the\n right hemidiaphragm. There are no consolidations or effusions. There is no\n pneumothorax. Linear area of scarring is seen in the right upper lobe. There\n is right lower lobe atelectasis. The cardiomediastinal and hilar contours are\n stable.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-12-18 00:00:00.000",
"description": "P CHEST (PA & LAT) PORT",
"row_id": 986265,
"text": " 12:10 PM\n CHEST (PA & LAT) PORT Clip # \n Reason: assess for vascular congestion progression.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with copd exacerbation, chf.\n REASON FOR THIS EXAMINATION:\n assess for vascular congestion progression.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: COPD, CHF, look for vascular congestion.\n\n IMPRESSION: PA and lateral chest compared to and 9:\n\n Vascular congestion and cardiomegaly are borderline unchanged since . There is no pleural effusion. Lung volumes remain low, particular on the\n right where there is relative elevation of the lung base, with disparity more\n pronounced now than it was in , probably due to progressive diaphragmatic\n eventration.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-12-16 00:00:00.000",
"description": "Report",
"row_id": 1640109,
"text": "Nursing Progress Note 0700-1900\nPlease see carevue and FHP for additional data.\n\nDispo: FULL code\nAllergies: Neosporin\nAccess: 1 piv\n\nPt alert, avioding orientation questions, needy at times, carries on coversation appropriately. HR 100-130s aflutter with variable block. Rec'd 5mg lopressor x 1 for HR 130s, restarted on home BP medication. NBP WNL. Remains on 3L nc, with sats 95%, will desat with exertion, but recovers quickly. LS coarse t/o, expectorated yellow/green sputum x1 this shift. Sputum spec sent. last pm. Abd soft, obese, + stool x 1. Foley secure and patent draining adequate amounts of urine. Called out to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-12-16 00:00:00.000",
"description": "Report",
"row_id": 1640110,
"text": "Respiratory Care Note\nPt given Atrovent neb at 12noon. Pt has a congested cough. Secretions swallowed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-12-16 00:00:00.000",
"description": "Report",
"row_id": 1640108,
"text": "74 y/o male with PMH of COPD (steroid ddependent and on Home O2),CHF,A-Fib on Coumadin,Neuropathy with chronic pain,Ca Lungs diagnosed 5 yrs ago s/P resection of rt lung,Depression... was found unresposive at home,wife called EMS and transferred to tried to intubate,gag was and positive and pt woke up Lasix,nebs,steroids and ceftriaxone was given Pt was transferred to ED and at 2300 pt was transferred in MICU for further management because pt had increased confusion yesterday.\n\nOn admission to MICU pt is coherent Alert and oriented X 3,follows all commands,moves all extrimities C/O pain all over body percocet given with good relief.Denies any SOB or CP.\n\nIn A-Fib on coumadin EKG obtained on admission,blood work up done NBP dropped to 80's on admission NS 500 ml bolused with good effect.HR 80-100,NBP 90-110/30-50.Extrimities has pitting edema,Pedal pulses are doppled.For access one PIV on lt hand.Multiple ecchymotic areas all over the body.\n\nRR 16-25 breathing efforts are normal,LS are coarse throughout,expectorating thick yellow sputum,c/s sent.O2 sats are maintained 94-96% on NC 2L.\n\nAbdomen obese positive bowel sounds,had liquids orally.No bowel movement at this shift.\n\nvoiding adequate amts of clear urine\n\nNo contact from family at this shift\n\nPLAN; ? c/o floor\nmonitor resp status/vitals/MAP > 60\nupdate with pt and family\n\n\n"
},
{
"category": "ECG",
"chartdate": "2163-12-19 00:00:00.000",
"description": "Report",
"row_id": 287790,
"text": "Baseline artifact. Regular narrow complex rhythm. Probable atrial flutter\nwhich is not counterclockwise in configuration. Since previous tracing\nof the ventricular response has decreased.\n\n"
},
{
"category": "ECG",
"chartdate": "2163-12-17 00:00:00.000",
"description": "Report",
"row_id": 287791,
"text": "Atrial flutter\nModest nonspecific intraventricular conduction delay\nConsider prior inferior myocardial infarction although is nondiagnostic\nModest nonspecific ST-T wave changes\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2163-12-17 00:00:00.000",
"description": "Report",
"row_id": 287792,
"text": "Atrial flutter\nModest nonspecific intraventricular conduction delay\nConsider prior inferior myocardial infarction although is nondiagnostic\nModest nonspecific ST-T wave changes\nSince previous tracing of , sinus rhythm absent\n\n"
}
] |
14,311 | 198,441 | The pt was transferred from the ERCP suite to the ICU for close monitoring. A NGT, Foley, amd R CVL was placed. CT abdomen upon admission read the following: Large amount of free air within the peritoneum and in the porta hepatis region. ? duodenal perforation. No extravasation. Large amount of ascites tracking into the pelvis. Diverticulosis without diverticulitis. Bibasilar atelectasis. Clinically, the pt looked well and denied abdominal pain. Pt was hemodynamincally stable w/ O2 sats of 96% on RA. Abdominal exam was significant only for mild distention, NT, no R/G. See admission labs/PE. The pt was administered IVF, kept NPO, and started on Zosyn. HD1, the pt required 1 L bolus for decreasing urine output with a good response. The pt recieved 2 U PRBC and recieved prn hydralazine for hypertension. NGT was DC'd on HD 3 and the pt was kept NPO. On HD4, the pt was overall much improved. She was started on lopressor despite her hx of mild asthma and tolerated it well. Her HR and blood pressure was better controlled and the pt was ultimately DC'd on lopressor. The pt was started on clears and transferred to the floor. The pt tolerated clears without problems and was advanced to a regular diet on HD 6. Upon DC, the pt was passing flatus and voiding on her own. She was passing flatus and having bowel movements. She was afebrile with stable vital signs. Her PE was unremarkable. Please see DC labs. Her WBC was nl and LFT's were steadily trending down. The pt was DC's w/ VNA for umbilical dressing changes (pre admission) and PT on 7 days of PO levofloxacin. | responsive to one albuterol neb. neuro intact.CV: afebrile, HR cont. pt denies c/o nausea. CT ABODMEN W/O CONTRAST: Bibasilar atelectasis is seen. hct stable. Abd is softly distended with + hypoactive BS. peripheral pulses intact x 4 afebrile sys bp 140-190 with stim. abg on nasal cannula: 7.46/36/99/26/1. Pulm: As stated above. K/mg/ca repleted this am. BT hypoactive. amt.SKIN: intact, small drsg and intact.PAIN: deniesACCESS: multilumen catheter in place, artline dampened, will dc this am.PLAN: cont. NGT to LIWS. CV: Afebrile. Pt in NSR but with ventricular bigeminy/frequent ectopy. PT RECIEVED WITH VS STABLE. slightly hem positive. GU: Foley to gravity. GU: Foley to gravity. abd drsg and . bruised around abd.ACCESS: art line /right subclavian placed. Noted to MD. PERL.CV: HT sys. Coronal and sagittal reformatted images were obtained. GI: Pt strictly NPO. UOP as above. CVP 10-12.RESP: clear bil. assess or resp status. Free fluid is seen tracking into the pelvis. receiving abx as ordered. in vent bigem. Lungs essentially clear, but diminished bases. and postitioning. GU urine drk min. pulmonary toilet with freq. Endo: FS consistantly < 110. no runs Vtach, sys 110-160, cont. ogt to lis with bilious, trace+ drainage. remains npo. FOR VITAL SIGNS. murmur, sinus tach with vent. pt. PT. verified placement by xray. CT PELVIS W/ IV CONTRAST A Foley catheter remains in place. prob. Lungs diminished but clear. An NG tube remains in place. Amber/clear. Non tender to palpation. CXR clear without sx of failure. remain NPO, low suction to ng. wbc slightly elevated today (up to 14 from 12.2).access-> left radial a-line has a very slugglish blood return and tracing is positional. Abd soft distended with absent bowel sounds. sys. denies nausea, no BT. NPN Addendum 0630Pt. Pt in NSR, frequent ventricular ectopy. 3) Diverticulosis without diverticulitis. IMPRESSION 1. amb with standby assist, oriented and calm. IV metoprolol for rate control and bp. remains drk.SKIN: no issues. CT abd without contrast early pm then return for IV and ng contrast early am.GU: urine drk. returns bilious. Coronal and sagittal reformatted images confirm these findings. she is up oob to chair and doing quite well so far.review of systemsrespiratory-> lung sounds are course w/diminished breath sounds bibasilarly. Plan is to c/o pt tommorrow if she remains stable. This was discussed with Dr. . xray did verify.SOCIAL: pt. since mn, the pt has maintained an even fluid balance but is ~1.7 liters tfb positive for her los.id-> tmax 100.6 rectally. There is a biliary stent in place. md did pull back slightly for optimum postitioning. A biliary stent remains in place. Updated by Dr. today. upper, coarse at bases. GI: Pt remains strictly NPO. -bm .gu-> uop >30cc/hr. TECHNIQUE: CT abdomen and pelvis without oral or IV contrast. No c/o pain. Now post op from laparoscopic cholecystectomy and ERCP with increasing jaundice, free air on plain film. Lytes replaced this am--f/u lytes wnl except K+ =3.9--repleted with 20 meq kcl IV. There is a persistent amount of free air and ascites within the abdomen. Contrast is seen within the ascending and transverse colon from a prior contrast enhanced study. Tube patent--flushed by surgery. pulm toilet, transfer to floor today, encourage amb. emotional support and information to pt. BM at 0400 soft to formed brown. sbp ranging 120-160's. Free air is seen throughout the abdomen including within the porta hepatis region. This is most likely due to a duodenal perforation. central line pulled back 2 cm by md . There is a ventral abdominal hernia containing free air and a loop of large bowel. cough non productive.GI: abd distended firm to soft with ngt to low intermittant suction. Mucous membranes dry. Sinus tachycardiaFrequent multiform PVCsRV conduction delayPossible left atrial abnormalityProbable old inferior infarctPossible anterior infarct - age undeterminedNo previous tracing Last ABG sl alkalotic with P02 in 70's. bigem., occasional runs of three mulitfocal pvc, denies cp. Pt often in bigeminy. will refer. EKG DONE AND EXAMINED BY DR . amber urine minimal until fluid bolus x 2. Skin: INtact. Sinus tachycardiaFrequent multiform PVCsRV conduction delayInferior infarct - age undeterminedPossible old anteroseptal myocardial infarctionSince previous tracing of , no significant change A large amount of free fluid tracts into the pelvis. (Over) 2:27 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: PAIN S/P ERCP. Pt remains NPO X 1 more day. No pain with palpation. 2:27 AM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION Reason: PAIN S/P ERCP. This is likely due to a duodenal perforation. Pt showing good technique with IS. pt has been using the incentive spirometer since getting oob.cardiac-> hr 90-110's, vent bigemy/trigemy. UOp excellent 80-200 cc/hr. IN TO SEEPT AND ARRANGED FOR TRANSFER TO MICUA FOR POSS NEED FOR FINDING OF FREE AIR IN ABD. she did well getting oob to the chair w/minimal 2 person assist.gi-> abd is soft, distended w/absent bs. The patient is status-post cholecystectomy. There are numerous diverticula without diverticulitis within the sigmoid colon. PT C/O CHEST PRESS NON RADIATING AT 1745. 2. Pt able to stand/pivot to chair with 1 minimal assist. Pt able to assist with turning. Abdomen remains soft/non tender. Team considering fluids. OOBTC X 2, walking in place and frequent use of IS. earlier. MICU NPN 0700-: Overall pt had an excellent day. Scattered diverticula are seen within the sigmoid without evidence of diverticulitis. Minimal output. Neuro: Alert and oriented. CT ABDOMEN W/ IV CONTRAST There are persistent atelectatic changes at the lung bases. | 12 | [
{
"category": "Radiology",
"chartdate": "2107-10-22 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 844323,
"text": " 2:27 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: PAIN S/P ERCP.?PERF\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\n Field of view: 45 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with possible perforation after ERCP for jaundice after lap\n chole\n REASON FOR THIS EXAMINATION:\n po and iv contrast looking for duodenal perf\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old with perforation post ERCP, assess for extravasation\n of contrast.\n\n TECHNIQUE: CT of the abdomen and pelvis with IV and oral contrast. 150 cc of\n Optiray were used for this examination due to history of debility. Coronal\n and sagittal reformatted images were obtained.\n\n COMPARISON: Comparison is made to noncontrast study performed 3 hrs. earlier.\n\n CT ABDOMEN W/ IV CONTRAST\n\n There are persistent atelectatic changes at the lung bases. There is a hypo-\n density in the left lobe of the liver, which is incompletely visualized, but\n likely represents a hemangioma. The liver is otherwise unremarkable. The\n spleen, pancreas, adrenals, and kidneys are normal in appearance. The patient\n is post-Billroth II with a gastrojejunostomy and jejuno-jejunostomy. An NG\n tube remains in place. No extravasation of oral contrast is seen from loops\n of small bowel. A biliary stent remains in place. The patient is status-post\n cholecystectomy. There is a persistent large amount of free air and ascites\n within the abdomen. There is a ventral abdominal hernia containing free air\n and a loop of large bowel. In addition, there appears to be added loops of\n small bowel adjacent to the hernia with a smaller hernia sac containing small\n bowel. Several small lymph nodes are seen throughout the abdomen.\n\n CT PELVIS W/ IV CONTRAST\n\n A Foley catheter remains in place. Scattered diverticula are seen within the\n sigmoid without evidence of diverticulitis. A large amount of free fluid\n tracts into the pelvis.\n\n Coronal and sagittal reformatted images confirm these findings.\n\n IMPRESSION\n\n 1. No evidence of contrast extravasation.\n\n 2. There is a persistent amount of free air and ascites within the abdomen.\n This is likely due to a duodenal perforation.\n (Over)\n\n 2:27 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: PAIN S/P ERCP.?PERF\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\n Field of view: 45 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The findings were discussed with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-10-21 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 844317,
"text": " 10:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ?perf there was free air on X-ray of chest\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\n Field of view: 45\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with possible perforation afetr ERCP for jaundice after lap\n chole\n REASON FOR THIS EXAMINATION:\n ?perf there was free air on X-ray of chest\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72 year old with histor of Billroth II for peptic ulcer disease.\n Now post op from laparoscopic cholecystectomy and ERCP with increasing\n jaundice, free air on plain film.\n\n TECHNIQUE: CT abdomen and pelvis without oral or IV contrast.\n\n No prior studies for comparison.\n\n CT ABODMEN W/O CONTRAST:\n Bibasilar atelectasis is seen. No pleural effusions. The heart is somewhat\n enlarged. An NG tube is present with its tip coiled within the stomach. The\n patient is post Billroth II with a gastrojejunostomy. Clips are seen in the\n gallbladder fossa from prior cholecystectomy. There is a biliary stent in\n place. Free air is seen throughout the abdomen including within the porta\n hepatis region. The liver, spleen, pancreas, adrenals, and kidneys are\n unremarkable. There is a ventral hernia containing large bowel. Contrast is\n seen within the ascending and transverse colon from a prior contrast enhanced\n study. The descending colon is collapsed. The intraabdominal small bowel is\n unremarkable. Ascites is seen throughout the abdomen tracking into the\n pelvis. There is no pathologic lymphadenopathy within the abdomen.\n\n CT PELVIS W/O IV CONTRAST:\n A Foley catheter is seen within the bladder which is collapsed. Free fluid is\n seen tracking into the pelvis. There are numerous diverticula without\n diverticulitis within the sigmoid colon. There is no lymphadenopathy within\n the pelvis.\n\n The osseous structures demonstrate degenerative changes throughout the lower\n thoracic and lumbar spine.\n\n IMPRESSION:\n 1) Large amount of free air within the peritoneum and in the porta hepatis\n region. This is most likely due to a duodenal perforation. This was discussed\n with Dr. .\n\n 2) Large amount of ascites tracking into the pelvis.\n\n 3) Diverticulosis without diverticulitis.\n\n (Over)\n\n 10:38 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ?perf there was free air on X-ray of chest\n Admitting Diagnosis: NICKED BILE DUCT;CHEST PAIN\n Field of view: 45\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4) Bibasilar atelectasis.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-10-21 00:00:00.000",
"description": "Report",
"row_id": 297373,
"text": "Sinus tachycardia\nFrequent multiform PVCs\nRV conduction delay\nPossible left atrial abnormality\nProbable old inferior infarct\nPossible anterior infarct - age undetermined\nNo previous tracing\n\n"
},
{
"category": "ECG",
"chartdate": "2107-10-21 00:00:00.000",
"description": "Report",
"row_id": 297374,
"text": "Sinus tachycardia\nFrequent multiform PVCs\nRV conduction delay\nInferior infarct - age undetermined\nPossible old anteroseptal myocardial infarction\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-23 00:00:00.000",
"description": "Report",
"row_id": 1449242,
"text": "pmicu 7p-7a\n\n\n pt slept poorly, c/o feeling \"stiff\" from being in bed for more than a week. she was intermittently restless and anxious but responded well to verbal reassurance/family presence. although acutely tachypneic w/turning, she was eventually weaned to 6l via cannula and has been maintaining sats >95%. she is up oob to chair and doing quite well so far.\n\nreview of systems\n\nrespiratory-> lung sounds are course w/diminished breath sounds bibasilarly. rr 20's, intermittently tachypneic w/exertion but appears more comfortable sitting up in the chair. abg on nasal cannula: 7.46/\n36/99/26/1. pt has been using the incentive spirometer since getting oob.\n\ncardiac-> hr 90-110's, vent bigemy/trigemy. sbp ranging 120-160's. as discussed w/the surgical resident this morning, iv lopressor did little to lower the pt's hr and reduce her blood pressure; however, she did respond to a total of 20mg iv hydralazine given in 10mg increments. she was repleted w/ca gluconate and magnesium sulfate this morning.\n\nneuro-> a&o x3 and able to participate in her care. she did well getting oob to the chair w/minimal 2 person assist.\n\ngi-> abd is soft, distended w/absent bs. remains npo. ogt to lis with bilious, trace+ drainage. hct stable. pt denies c/o nausea. -bm .\n\ngu-> uop >30cc/hr. since mn, the pt has maintained an even fluid balance but is ~1.7 liters tfb positive for her los.\n\nid-> tmax 100.6 rectally. receiving abx as ordered. wbc slightly elevated today (up to 14 from 12.2).\n\naccess-> left radial a-line has a very slugglish blood return and tracing is positional. right sc triple lumen central line is patent and intact.\n\nsocial-> pt's dtr stayed in the waiting area and was updated on her condition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-23 00:00:00.000",
"description": "Report",
"row_id": 1449243,
"text": "MICU NPN 0700-:\n\n Overall pt had an excellent day. OOBTC X 2, walking in place and frequent use of IS. Abd remains benign with no s/sx of peritonitis. NGT removed by Green Surgery. Pt remains NPO X 1 more day. Plan is to c/o pt tommorrow if she remains stable.\n\n Neuro: Alert and oriented X 3, pleasant, cooperative and conversant. Pt able to stand/pivot to chair with 1 minimal assist. No c/o pain.\n\n CV: Afebrile. Pt in NSR, frequent ventricular ectopy. Pt often in bigeminy. BP stable and lopressor increased to 10 mg IV q 6 hours. K/mg/ca repleted this am. Mucous membranes dry. CVP 4-8 with UOP dropping to 30-80 cc/hr. Concentrated/dark urine. Team considering fluids.\n\n Pulm: Pt remains on 6 L NP with sats 95-98%. Lungs essentially clear, but diminished bases. Pt showing good technique with IS. No cough.\n\n GI: Pt remains strictly NPO. She swishes/spits ice water frequently for comfort. Abd is softly distended with + hypoactive BS. Non tender to palpation.\n\n GU: Foley to gravity. UOP as above.\n\n Endo: FS consistantly < 110.\n\n Skin: INtact.\n\n Family: At bedside continuously. Updated by Dr. today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-22 00:00:00.000",
"description": "Report",
"row_id": 1449240,
"text": "NPN Addendum 0630\nPt. noted to have 5 beat run Vtach, asymptomatic, no change in VS. Noted to MD. Magnesium, Calcium gluconate and potassium as ordered.\n\nrepeat hct 25.2, reported to md. no orders received.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-22 00:00:00.000",
"description": "Report",
"row_id": 1449241,
"text": "MICU NPN 0700-:\n\n Events: Pt recieved 2 u prbc with hct bump from 25 to 30. Resp status has continued to worsen today with 02 requirements increasing from 4 L NP to 70% high flow neb. CXR clear without sx of failure. Abdomen remains soft/non tender. Lactate 1.0--surgery is following closely, but do not plan on taking her to OR unless she starts showing signs of worsening sepsis.\n\n Neuro: Alert and oriented. Increasing mild agitation with resp distress during the afternoon. Pt able to assist with turning.\n\n CV: Pt developed low grade temp today during blood transfusion to 100.0, but temperature change was less than 2 degrees. No other s/sx of reaction. Pt in NSR but with ventricular bigeminy/frequent ectopy. PT hypertensive to 170's this afternoon--she was given 10 mg IV hydralazine X 3 and pressure now in 130's. Lytes replaced this am--f/u lytes wnl except K+ =3.9--repleted with 20 meq kcl IV.\n\n Pulm: As stated above. Pt currently on 70% high flow neb with sats 98%. Last ABG sl alkalotic with P02 in 70's. Lungs diminished but clear. No wheezes.\n\n GI: Pt strictly NPO. NGT to LIWS. Minimal output. Tube patent--flushed by surgery. Abd soft distended with absent bowel sounds. No pain with palpation.\n\n GU: Foley to gravity. UOp excellent 80-200 cc/hr. Amber/clear. Team considering lasix, but UOP is brisk.\n\n Skin: Pt has open area from cholecystectomy incision--wtd dressing change done by surgery. Plan to change dressing .\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-21 00:00:00.000",
"description": "Report",
"row_id": 1449238,
"text": "PT RECIEVED WITH VS STABLE. SEE AND ADMIT NOTE.\nRESP: PT WAS 100% SAT ON NRB 12 LITERS AND PROGRESSED TO HUMIDIFIED MASK NAT 10 LITERS. IN TO SEEPT AND ARRANGED FOR TRANSFER TO MICUA FOR POSS NEED FOR FINDING OF FREE AIR IN ABD. PT WAS IS AND OUT OF VENT BIGEMENY THE ENTIRE TIME IN FIN MICU. PT C/O CHEST PRESS NON RADIATING AT 1745. EKG DONE AND EXAMINED BY DR . NO CHANGES OR ACUTE PROBLEMS NOTED PER TEAM AND PT WAS THEN TRANSFERED VIA AMBULANCE TO MICU_A. REPORT GIVEN TO NURSE BY THIS NURSE. FOR VITAL SIGNS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-22 00:00:00.000",
"description": "Report",
"row_id": 1449239,
"text": "NPN 1900-0730\nNEURO: MAE, follow commands, easily anxious, able to calm with reassurance. PERL.\n\nCV: HT sys. murmur, sinus tach with vent. bigem., occasional runs of three mulitfocal pvc, denies cp. peripheral pulses intact x 4 afebrile sys bp 140-190 with stim. amber urine minimal until fluid bolus x 2. CVP 10-12.\n\nRESP: clear bil. upper, coarse at bases. Initially on 40% mask and able to wean to nc.sats 90's 2-4 liters, did desat into 80's when flat for CT and began to wheeze. responsive to one albuterol neb. and postitioning. sats return to 90's. cough non productive.\n\nGI: abd distended firm to soft with ngt to low intermittant suction. returns bilious. verified placement by xray. md did pull back slightly for optimum postitioning. denies nausea, no BT. BM at 0400 soft to formed brown. abd drsg and . CT abd without contrast early pm then return for IV and ng contrast early am.\n\nGU: urine drk. min output early in shift until fluid bolus x 2 then 100cc hr. remains drk.\n\nSKIN: no issues. bruised around abd.\n\nACCESS: art line /right subclavian placed. central line pulled back 2 cm by md . xray did verify.\n\nSOCIAL: pt. very anxious but cooperative. family at bedside. dtr to spend night in hospital for assist. pt. does speak english but feels more comfortable with italian with family.\n\nPLAN: Careful monitoring of GI status. remain NPO, low suction to ng. IVF for rehydration, antibiotics. emotional support for pt and family. pulmonary toilet with freq. assess or resp status. Respond to abnormal labs, vs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-24 00:00:00.000",
"description": "Report",
"row_id": 1449244,
"text": "1900-0700 NPN\nNEURO: pt. up in chair most pm. amb with standby assist, oriented and calm. neuro intact.\n\nCV: afebrile, HR cont. in vent bigem. no runs Vtach, sys 110-160, cont. IV metoprolol for rate control and bp. sys. murmur\n\nRESP: on 3 liter nc, sats high90's, cough non productive, uses IS to 1000cc with little prompting.\n\nGU/GI: soft, rounded, passed liquid brown stool mod amt. slightly hem positive. no nausea, tol sips water. BT hypoactive. GU urine drk min. amt.\n\nSKIN: intact, small drsg and intact.\n\nPAIN: denies\n\nACCESS: multilumen catheter in place, artline dampened, will dc this am.\n\nPLAN: cont. pulm toilet, transfer to floor today, encourage amb. prob. progress in diet. emotional support and information to pt. and family. PT. would like social service to see regarding visiting nurse at home on dc for followup and Physical therapy. will refer.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-24 00:00:00.000",
"description": "Report",
"row_id": 1449245,
"text": "See transfer note.\n"
}
] |
83,981 | 147,314 | 45 yo M presented worsening shortness of breath over the past several months and was at preparing for sinus surgery and had a syncopal event,coded briefly. Transferred to . Patient was found to have severe mitral regurgitation with a flailed valve leaflet. In the ER he vasovagaled after blood was drawn and had 9 second asystole. He was intubated and had a swan placed and was found to have a low CI (1.7). Patient had aortic balloon pump placed because of low cardiac output and impaired forward flow. Balloon pump (1:1) to which he responded well; post-IABP CI was 2.6. We felt his mitral regurg was likely chronic given the progression of his EKG changes since (increasing RVH, new RAD), his elevated PA pressures without florid pulmonary edema, and the gradual worsening of his symptoms, which were previously attributed to sinusitis alone. Echo showed myxomatous mitral valve. While he was here we gave him lasix to diurese him. He had a temp max of 100.6 which we thought could be a pneumonitis from intubation causing gastric contents to irritate his lungs and cause a fever. CXR showed no PNA but we treated him for possible aspiration pneumonia because he was at high aspiration risk because he was intubated. We started him on vancomycin and zosyn. He was on a heparin drip because he was on the balloon pump. On pt was taken to the OR and underwent MV repair with #32 ring resection of P2. He arrived from OR fully vented on pressor and inotropes. His first night post-op he had significant rise in his pulmonary artery pressures and was hypotensive. TTE/TEE showed significant RV and LV dysfunction. He remained intubated, sedated and on pressors and inotropes for several days. All gtts were weaned off slowly. He developed post-op afib and was started on amiodarone. After a few days her returned to sinus rhythm. His sedation was weaned off and he eventually extubated on POD #4. On night of POD#3 he had 2min seizure that was treated with propofol and ativan. Neurology was consulted, head CT and MRI unremarkable. No further seizure activity was noted. He initially was confused with generalized weakness, greater left sided weakness noted. Pain meds were adjusted and he was seen by the Psych service for his depression and Wellbutrin was increased. He was thrombocytopenic while IABP was in this had since resolved and he was started on anticoagulation for his a-fib. He was febrile consistently in the first few days post-op and sputum culture was positive for PANTOEA SPECIES. His antibiotics were adjusted and he was treated with a course of meropenem at the recommendations of ID. On POD #5 the patient transferred to the floor. He developed intermittant atrial fibrillation and his lopressor was increased and he was started on amiodarone and coumadin. he did convert to sinus rhythm and will continue on coumadin therapy upon discharge. Chest tubes and pacing wires were removed without incident. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #9 the patient was ambulating independently, the sternal wound was healing with scant serosanguinous drainage from the distal and he was placed on Keflex. He was also note to have folliculitis over his anterior chest. Pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. | Mild [1+] TR.PERICARDIUM: Very small pericardial effusion.GENERAL COMMENTS: Informed consent was obtained. The end-diastolic PR velocity isincreased c/w PA diastolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows.Conclusions:The left atrium is mildly dilated. Abnormal septalmotion/position.AORTIC VALVE: No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Right perihilar opacity most likely represents a combination of atelectasis, with potentially minimal edema. At least moderatepulmonary artery systolic hypertension. Mild to moderate [+] TR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads orelectrodes. Abnormal septal motion/position consistent with RVpressure/volume overload.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). The right ventricle appears mildlyhypokinetic on the current echocardiogram. Moderately dilated LV cavity.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). There is moderate pulmonary artery systolichypertension. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.LEFT VENTRICLE: Normal LV wall thickness. Echocardiographic signs of tamponade may be absent in the presenceof elevated right sided pressures.Conclusions:The left atrium and right atrium are markedly dilated. Normalappearing coronary sinus.POSTBYPASS: Normally functioning MV repair with ring and neochord to anteriorleaflet. Moderate PAsystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There is a small circumferential pericardialeffusion located predominantly along the infero-lateral wall and right atrium(small-moderate along the RA) . No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Overallleft ventricular systolic function is mildly depressed There is abnormalsystolic septal motion/position consistent with right ventricular pressureoverload. The right ventricular cavity ismoderately dilated with mild global free wall hypokinesis. No PS.Physiologic PR.PERICARDIUM: Small pericardial effusion.GENERAL COMMENTS: Informed consent was obtained. The ascending,transverse and descending thoracic aorta are normal in diameter and free ofatherosclerotic plaque with IABP distal to arch about 2-3cm.. right chest tube and mediasinal drains removed. No VSD.RIGHT VENTRICLE: Moderately dilated RV cavity. There is no evidence of tamponade.Echocardiographic signs of tamponade may be absent in the presence of elevatedright sided pressures.IMPRESSION: Moderately dilated left ventricular cavity with hyperdynamic leftventricular function and severe mitral regurgitation secondary to a flailposterior mitral leaflet and thorn mitral valve chordae. Severe (4+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Right ventricular functionappears depressed. Moderate [2+]tricuspid regurgitation is seen. There is abnormalseptal motion/position consistent with right ventricular pressure/volumeoverload. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS. Mildthickening of mitral valve chordae. There ismoderate pulmonary artery systolic hypertension (RA pressure not estimated asthe patient is intubated). ]TRICUSPID VALVE: Normal tricuspid valve leaflets. Well-seated mitral annular ring with normal gradient. Non-specific ST segment flattening in theprecordial leads. Normal intracranial flow voids are present. Left atrial abnormality is no longer apparent.QRS morphology is much more fractionated in lead V1. Left atrialabnormality, incomplete right bundle-branch block, right ventricularhypertrophy, right axis deviation are unchanged. Stability of the retrocardiac opacity that could be atelectasis. Non-specific ST segment flattening persists in the limb leads.Computed Q-T interval is normal. Left atrial abnormality, right axis deviation,right ventricular hypertrophy, and incomplete right bundle-branch block patternare unchanged. There is increasing obscuration of the right hemidiaphragm and less prominent on the left concerning for bilateral effusions. Mild bilateral pleural effusions. FINDINGS: Position of endotracheal tube and right-sided Swan-Ganz is unchanged. T wave inversions are nolonger present in leads V3-V5, replaced with more non-specific repolarizationabnormalities. Left atrial abnormality. Right ventricular hypertrophy withST segment changes suggestive of right ventricular strain. Right axis deviation and rightventricular hypertrophy. Right axis deviation. Right axis deviation. Mild bilateral pleural effusions are unchanged. Right ventricular hypertrophy, rightaxis deviation, non-specific ST segment flattening in the limb leads persist.Precordial electrode placement is clearly different, with concomitant extensionof T wave inversions from lead V2 now into lead V3. Retrocardiac opacities consistent with atelectasis are unchanged. Moderate-to-severe enlargement of the cardiac silhouette is stable, is possible that there is pericardial effusion. RSR' pattern is no longerpresent in lead V2 with deep T wave inversions. Non-specific ST segment abnormalities in the limb leads aremore prominent. However, prioranterior myocardial ischemia cannot be excluded. Mild mucosal thickening in the mastoids, ethmoids, and left maxillary sinus retention cyst. Also, possible posteriormyocardial infarction. Sinus bradycardia. Compared to the previous tracing precordial electrode placementis clearly different. Compared to the previous tracing from the same dateQRS morphology in lead V1 is different. Consider myocardial ischemia.TRACING #2 Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. The patient with moderate to important cardiomegaly and mitral valve repair. Sinus tachycardia. TECHNIQUE: Sagittal T1, axial FLAIR, T2, susceptibility, and diffusion-weighted images were obtained. Incomplete rightbundle-branch block pattern. IMPRESSION: The ET tube has been removed and the lung volumes are thus low. FINDINGS: There is mucosal thickening involving the bilateral mastoid air cells, the ethmoids, and a small retention cyst in the left maxillary sinus. The basal cisterns appear patent, and there is preservation of -white differentiation. An ongoing anteroseptal ischemic processcannot be excluded. An endotracheal tube is seen. Right-sided Swan-Ganz ends in the right pulmonary artery. There is mild vascukar congestion with no overt edema. The ET tube has been removed and the lung volumes are low. Bilateral patchy lung opacifications, likely represent atelectasis and crowding of pulmonary vasculature secondary to low volumes. Prolonged Q-T interval.Compared to the previous tracing of ST-T wave changes, particularly inleads V1-V4, have improved and the rhythm is no longer sinus.TRACING #1 ET tube is in standard position. The normally midline structures are midline. T wave inversions are somewhat deeper in leads V3-V4 extendingnow to lead V5, although precordial electrode placement is clearly different.Non-specific ST segment flattening in lead V6. | 29 | [
{
"category": "Echo",
"chartdate": "2109-08-28 00:00:00.000",
"description": "Report",
"row_id": 65057,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/P MV repair .\nHeight: (in) 71\nWeight (lb): 244\nBSA (m2): 2.30 m2\nBP (mm Hg): 135/62\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 11:57\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal interatrial\nseptum. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV free wall\nhypokinesis. Abnormal septal motion/position consistent with RV\npressure/volume overload.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mitral valve annuloplasty ring. Well-seated mitral annular ring\nwith normal gradient. No MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate\n[2+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. The end-diastolic PR velocity is\nincreased c/w PA diastolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\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. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is mildly dilated. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is preserved (LVEF>50%).\nThere is no ventricular septal defect. The right ventricular cavity is\nmoderately dilated with mild global free wall hypokinesis. There is abnormal\nseptal motion/position consistent with right ventricular pressure/volume\noverload. 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. A mitral valve annuloplasty ring is present. The mitral\nannular ring appears well seated with normal gradient. No mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. The end-diastolic pulmonic regurgitation velocity is increased\nsuggesting pulmonary artery diastolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , no clear\nchange.;\n\n\n"
},
{
"category": "Echo",
"chartdate": "2109-08-24 00:00:00.000",
"description": "Report",
"row_id": 65058,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/p MV repair for ruptured chordae (P2).Hypotension and increased pulmonary pressures on pressors.\nHeight: (in) 71\nWeight (lb): 239\nBSA (m2): 2.28 m2\nBP (mm Hg): 90/40\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 02:53\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: Mild global LV hypokinesis. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: RV not well seen. RV function depressed. Abnormal systolic\nseptal motion/position consistent with RV pressure overload. Abnormal septal\nmotion/position.\n\nAORTIC VALVE: No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve\nannuloplasty ring. Well-seated mitral annular ring with normal gradient. Mild\nthickening of mitral valve chordae. Trivial MR. [Due to acoustic shadowing,\nthe severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality - body habitus. Suboptimal image quality\n- ventilator. Suboptimal image quality - patient unable to cooperate. If\nclinically indicated, a transesophageal echocardiographic examination is\nrecommended. Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nThere is mild global left ventricular hypokinesis (LVEF = 40-45 %). Overall\nleft ventricular systolic function is mildly depressed There is abnormal\nsystolic septal motion/position consistent with right ventricular pressure\noverload. There is abnormal septal motion/position. Right ventricular function\nappears depressed. No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. A mitral valve annuloplasty ring is present. The mitral\nannular ring appears well seated with normal gradient. Trivial mitral\nregurgitation is seen. [Due to acoustic shadowing, the severity of mitral\nregurgitation may be significantly UNDERestimated.] There is a\ntrivial/physiologic pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of ,\nleft ventricular systolic function has declined. Mitral annuloplasty ring is\npresent with only trivial regurgitation. Ring is well-seated with normal\ntransvalvular gradient. Pulmonary artery pressures were not assessed.\nPericardial effusion has resolved. A pacing wire is identified and there is\nmore tricuspid regurgitation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2109-08-23 00:00:00.000",
"description": "Report",
"row_id": 65059,
"text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve disease.\nStatus: Inpatient\nDate/Time: at 09:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Moderately dilated LV cavity.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Torn mitral chordae. Severe (4+) 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: Small pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations.\n\nConclusions:\nPREBYASS: SEVERE MR from P2 flail and leaflet with anteriorly directed MR jet\nwith coanda effect, with LA and LV dilation from LV volume overload from MR\notherwise essentially normal exam.Torn mitral chordae are present. Severe (4+)\nmitral regurgitation is seen.Preserved LV systolic function with LVEF > 55%,\nno segmental wall motion abnormalities. Other valves are normal Balloon pump\nin good position. Intact interatrial septum. As expected with severe MR, no\nclot in the LAA . The left atrium is moderately dilated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is moderately dilated.\nRight ventricular chamber size and free wall motion are normal. The ascending,\ntransverse and descending thoracic aorta are normal in diameter and free of\natherosclerotic plaque with IABP distal to arch about 2-3cm.. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic stenosis or aortic regurgitation. There is a small pericardial\neffusion. Diastolic function appears to be normal with e' >10 cm/sec. Normal\nappearing coronary sinus.\n\nPOSTBYPASS: Normally functioning MV repair with ring and neochord to anterior\nleaflet. No sig MR . , otherwise unchanged\n\n\n"
},
{
"category": "Echo",
"chartdate": "2109-08-22 00:00:00.000",
"description": "Report",
"row_id": 65060,
"text": "PATIENT/TEST INFORMATION:\nIndication: Severe mitral regurgitation, preoperative assessment\nHeight: (in) 71\nWeight (lb): 237\nBSA (m2): 2.27 m2\nBP (mm Hg): 97/48\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 10:57\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: No atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Partial mitral leaflet flail. Mitral leaflets fail to fully\ncoapt. Eccentric MR jet. Severe (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPERICARDIUM: Very small pericardial effusion.\n\nGENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. The patient was monitored by a nurse throughout the\nprocedure. The patient was sedated for the TEE. Medications and dosages are\nlisted above (see Test Information section). No glycopyrrolate was\nadministered. No TEE related complications.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis or aortic regurgitation. There is posterior mitral leaflet\nflail. An eccentric, anteriorly directed jet of severe (4+) mitral\nregurgitation is seen. There is a small circumferential pericardial effusion.\n\nIMPRESSION: Myxomatous mitral valve disease with flail posterior mitral\nleaflet. Severe mitral regurgitation. No evidence of papillary muscle rupture,\nregional LV dysfunction, or endocarditis.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2109-08-21 00:00:00.000",
"description": "Report",
"row_id": 65061,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Mitral valve disease.\nHeight: (in) 71\nWeight (lb): 200\nBSA (m2): 2.11 m2\nBP (mm Hg): 119/66\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 16:30\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. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity.\nHyperdynamic LVEF >75%. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Partial mitral leaflet\nflail. Torn mitral chordae. Severe (4+) 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: Small pericardial effusion. No echocardiographic signs of\ntamponade. Sustained RA diastolic collapse, c/w low filling pressures or early\ntamponade. Echocardiographic signs of tamponade may be absent in the presence\nof elevated right sided pressures.\n\nConclusions:\nThe left atrium and right atrium are markedly dilated. Left ventricular wall\nthicknesses are normal. The left ventricular cavity is moderately dilated.\nLeft ventricular systolic function is hyperdynamic (EF>75%). Right ventricular\nchamber size is normal. with mild global free wall hypokinesis. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic stenosis or aortic regurgitation. The mitral valve leaflets are\nmildly thickened. There is posterior mitral leaflet flail (P2 scallop) with\ntorn mitral chordae. Severe (4+) mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension (RA pressure not estimated as\nthe patient is intubated). There is a small circumferential pericardial\neffusion located predominantly along the infero-lateral wall and right atrium\n(small-moderate along the RA) . There is no evidence of tamponade.\nEchocardiographic signs of tamponade may be absent in the presence of elevated\nright sided pressures.\n\nIMPRESSION: Moderately dilated left ventricular cavity with hyperdynamic left\nventricular function and severe mitral regurgitation secondary to a flail\nposterior mitral leaflet and thorn mitral valve chordae. At least moderate\npulmonary artery systolic hypertension. Small circumferential pericardial\neffusion with no evidence of tamponade.\n\nCompared with the earlier echocardiographic study dated (images\nunavailable for review), the pericardial effusion is more prominent although\nstill not hemodynamically significant. The right ventricle appears mildly\nhypokinetic on the current echocardiogram. Other findings are similar.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1248124,
"text": " 4:38 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check swan placement\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man\n REASON FOR THIS EXAMINATION:\n check swan placement\n ______________________________________________________________________________\n WET READ: MDAg SUN 6:51 PM\n ETT ends 7.7cm above carina and could be advanced for better seating. NGT ends\n in the distal esophagus. Swan ganx ends in proximal right main pulmonary\n artery. right chest tube and mediasinal drains removed. intra-aortic balloon\n pump unchanged in position.\n -MAgarwal d/ by phone 6:50pm .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Swan placement.\n\n FINDINGS: In comparison with the earlier study of this date, the Swan-Ganz\n catheter tip lies well into the right pulmonary artery. Nasogastric tube has\n been pulled back so that the tip is in the region of the esophagogastric\n junction. The right chest tube has been removed and there is no pneumothorax.\n IABP is unchanged in position.\n\n Left hemidiaphragm is again not well seen, suggesting substantial volume loss\n in the left lower lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1247997,
"text": " 10:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulmonary edema\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with MVR, pulm HTN\n REASON FOR THIS EXAMINATION:\n eval for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with mitral valve\n replacement and pulmonary hypertension.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Tubes and lines are in unchanged position. The right chest tube is in place.\n Left retrocardiac opacity is slightly more pronounced than on the prior study.\n Left infrahilar opacity has minimally improved. No pneumothorax is seen. No\n interval development of pulmonary edema is demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1248159,
"text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval line placement\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man\n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: In comparison with the study of , the IABP has been removed.\n The tip of the Swan-Ganz catheter is in the right pulmonary artery.\n Nasogastric tube extends to the body of the stomach with the side hole in the\n region of the esophagogastric junction.\n\n Continued low lung volumes with enlargement of the cardiac silhouette.\n Retrocardiac opacification is consistent with volume loss in the left lower\n lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1247722,
"text": " 9:45 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Confirm position of swan and balloon pump\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with chordae tendinae rupture now with Swan and IABP\n REASON FOR THIS EXAMINATION:\n Confirm position of swan and balloon pump\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Swan-Ganz catheter, aortic balloon pump.\n\n COMPARISON: , 4:08 p.m.\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects approximately 3 cm above\n the carina. The course and the tip of the Swan-Ganz catheter is unremarkable,\n but the catheter should be pulled back by approximately 2 cm, as the tip\n projects over the rather distal parts of the right pulmonary artery. Moderate\n pulmonary edema is unchanged, moderate-to-severe cardiomegaly. No pleural\n effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1248085,
"text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p MV repair w/continued inotropic requirement r/o effusion\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p MV repair w/continued inotropic requirement r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after mitral valve repair\n with continued inotropic requirement.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n As compared to the prior study, there is impression of increased cardiac\n silhouette that might reflect pericardial effusion, correlation with\n echocardiography is required. Swan-Ganz catheter tip is at the level of the\n right ventricle outflow tract. Intra-aortic balloon pump is approximately 3.3\n cm below the roof of the aortic arch. The replaced mitral valve is in place\n as well as the right chest tube. No pulmonary edema or substantial increase\n in pleural effusions or no pneumothorax is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1247829,
"text": " 4:35 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please assess for O/G tube\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with severe mitral regurg with baloon pump, intubated, please\n assess for OG tube\n REASON FOR THIS EXAMINATION:\n please assess for O/G tube\n ______________________________________________________________________________\n WET READ: 6:02 PM\n OG tube could be advanced by 1-2 cm to ensure that the sideport is beyond the\n GE junction. Swan-Ganz catheter has been removed. IABP tip terminates over\n the left 2nd rib anteriorly. Study is otherwise unchanged. T. Pinar\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess NG tube.\n\n Comparison is made with prior study performed five hours earlier.\n\n NG tube tip is in the stomach but the side port is just distal to the EG\n junction. It can be advanced couple of centimeters. Enlargement of the\n cardiac silhouette is stable. There is mild vascular congestion. No\n pulmonary edema and no pleural effusion. ET tube is in standard position.\n Intra-aortic balloon is in unchanged position. It could be withdrawn 1.5 cm\n for more standard position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1247920,
"text": " 11:53 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: cardiac srugery fast t rack. eval for ptx, effusions. c\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with s/p MV Repair\n REASON FOR THIS EXAMINATION:\n cardiac srugery fast t rack. eval for ptx, effusions. is the\n CVICU provider page him if there is concern\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after mitral valve repair.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The ET tube tip is 6 cm above the carina. The Swan-Ganz catheter tip is at\n the level of the right ventricular outflow tract. Mediastinal drains, right\n chest tube and replaced mitral valve are in place, in expected positions.\n There is no pneumothorax or appreciable pleural effusion. The\n cardiomediastinal silhouette is stable. The intra-aortic balloon tip is\n approximately 2.5 cm below the roof of the aorta.\n\n Right perihilar opacity most likely represents a combination of atelectasis,\n with potentially minimal edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1247736,
"text": " 5:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: line & OG placement, ? stable pulmonary congestion\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with pulmonary congestion, IABP, Swan, ETT, OG tube\n REASON FOR THIS EXAMINATION:\n line & OG placement, ? stable pulmonary congestion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Pulmonary congestion, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, monitoring and support\n devices are constant. A Swan-Ganz catheter is located very distally, it\n should be pulled back, as already noted in the previous report.\n\n Marked cardiomegaly with evidence of mild-to-moderate pulmonary edema.\n Retrocardiac atelectasis. No evidence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1247693,
"text": " 4:03 PM\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \n -76 BY SAME PHYSICIAN\n : s/p intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 45M with arrest\n REASON FOR THIS EXAMINATION:\n s/p intubation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n HISTORY: Status post intubation after arrest.\n\n COMPARISONS: None available.\n\n TECHNIQUE: Chest, portable AP supine.\n\n FINDINGS: The patient is intubated. The endotracheal tube terminates at the\n thoracic inlet approximately 7 cm above the carina. Advancing the tube by\n approximately 3 cm could be considered for more optimal positioning. The\n heart is moderate to severely enlarged with a globular configuration.\n Perihilar fullness suggests mild vascular congestion but otherwise the lungs\n appear clear. Although the left costophrenic sulcus is not entirely included,\n there is no definite pleural effusion. There is no pneumothorax.\n\n IMPRESSION:\n\n 1. Striking cardiomegaly; true cardiac enlargement or the possibility of a\n pericardial effusion, or perhaps both, could be considered.\n\n 2. Prominent main pulmonary artery contour.\n\n 3. Findings suggesting mild vascular congestion.\n\n 4. Status post endotracheal intubation, with relatively high lying\n endotracheal tube, which could be advanced by approximately 3 cm for more\n optimal positioning, if clinically indicated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1248788,
"text": " 7:10 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p mvr\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n WET READ: OXZa FRI 8:36 PM\n interval removal of esophageal catheter. lung volumes remain low however there\n is improved aeration at bases and decreased effusions.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST X-RAY \n\n COMPARISON: radiograph as well as earlier radiograph dating\n back to .\n\n FINDINGS: The patient is status post median sternotomy and mitral valve\n replacement procedure. Cardiac silhouette is markedly enlarged but stable in\n size. Improved pulmonary vascular congestion and decrease in size of pleural\n effusions with residual small to moderate right and small left effusions\n remaining. Marked improvement in bibasilar atelectasis.\n\n IMPRESSION: Improving bibasilar atelectasis and effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1247793,
"text": " 12:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OG tube placement\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with cardiogenic shock and baloon pump, OG tube was placed\n please evaluate\n REASON FOR THIS EXAMINATION:\n OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Catheter check, evaluate balloon pump and also OJ tube.\n\n Comparison is made with prior study performed six hours earlier.\n\n NG tube is no longer visualized. ET tube is in standard position. Swan-Ganz\n catheter tip is too distal in the right pulmonary artery, it should be\n withdrawn at least 4 cm for more standard position. Moderate-to-severe\n enlargement of the cardiac silhouette is stable, is possible that there is\n pericardial effusion. There is no evidence of pneumothorax or pleural\n effusion. Retrocardiac opacities consistent with atelectasis are unchanged.\n Intra-aortic balloon pump tip is 3.1 cm above the left main bronchus, can be\n withdrawn 1 cm. When compared to prior study performed a day earlier, the\n intra-aortic balloon pump was more distally located in appropriate position.\n There is mild vascukar congestion with no overt edema.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-29 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1248561,
"text": " 12:24 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: eval for evidence of bleeding in patient w left sided weakne\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man s/p MVR\n REASON FOR THIS EXAMINATION:\n eval for evidence of bleeding in patient w left sided weakness who needs\n coumadin for afib. NEEDS COUMADIN, WHICH IS BEING HELD FOR MR.\n contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE HEAD\n\n CLINICAL INFORMATION: 45-year-old man status post mitral valve replacement.\n Evaluate for evidence of bleeding in patient with left-sided weakness.\n\n COMPARISON: None.\n\n TECHNIQUE: Sagittal T1, axial FLAIR, T2, susceptibility, and\n diffusion-weighted images were obtained.\n\n FINDINGS: There is mucosal thickening involving the bilateral mastoid air\n cells, the ethmoids, and a small retention cyst in the left maxillary sinus.\n There is no focal signal abnormality within the brain parenchyma, no evidence\n of hemorrhage, and no evidence of slow diffusion. The ventricles, sulci,\n subarachnoid spaces are normal in size and configuration. Normal intracranial\n flow voids are present.\n\n IMPRESSION:\n 1. No acute intracranial abnormality. No evidence of hemorrhage.\n 2. Mild mucosal thickening in the mastoids, ethmoids, and left maxillary\n sinus retention cyst.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1248169,
"text": " 8:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ischemic vs.hemorrhagic event\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with s/p MVr\n REASON FOR THIS EXAMINATION:\n ischemic vs.hemorrhagic event\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n INDICATION: Ischemic versus hemorrhagic event.\n\n TECHNIQUE: MDCT continuous axial images were acquired through the brain at a\n slice thickness of 5 mm without administration of IV contrast.\n\n COMPARISON: None.\n\n FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or\n infarction. The ventricles and sulci are normal in size and configuration.\n The basal cisterns appear patent, and there is preservation of -white\n differentiation. The normally midline structures are midline.\n\n There is opacification of many ethmoid air cells. Mucosal thickening is also\n seen in the maxillary sinuses and the sphenoid sinus. The left maxillary\n sinus is notable for a mucus retention cyst. An endotracheal tube is seen.\n Mucosal thickening in the - and oro-pharyngeal area is consistent with\n intubation.\n\n No bony abnormality is seen. The mastoid air cells and middle ear cavities\n are clear. The globes are unremarkable.\n\n IMPRESSION: No evidence of acute hemorrhage, edema. No significant\n abnormalities on head CT.\n\n COMMENT: These findings were communicated by telephone by Dr. \n to Ms. , PA (cardiac surgery) at 10:58 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1248315,
"text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with s/p MVr\n REASON FOR THIS EXAMINATION:\n ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 45-year-old man status post mitral valve replacement,? pneumonia.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST RADIOGRAPH.\n\n FINDINGS: Position of endotracheal tube and right-sided Swan-Ganz is\n unchanged. NG tube projects over the stomach. Sternotomy wires and outline\n of artificial mitral valve noted. Heart is moderately enlarged as before.\n Mild bilateral pleural effusions are unchanged. Bilateral patchy lung\n opacifications, likely represent atelectasis and crowding of pulmonary\n vasculature secondary to low volumes. No focal areas of consolidation to\n suggest pneumonia. No pneumothorax.\n\n IMPRESSION:\n No significant changes compared to the prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1248440,
"text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p MV repair w/continued hypoxia r/o effusion\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p MV repair w/continued hypoxia r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE\n\n INDICATION: 45-year-old man with status post MV repair, continued hypoxia,\n rule out effusion.\n\n Comparison is made to prior examination of . There is cardiomegaly.\n This is unchanged. The ET tube has been removed and the lung volumes are low.\n There is increasing obscuration of the right hemidiaphragm and less prominent\n on the left concerning for bilateral effusions. An NG tube is identified with\n its tip in the stomach. Crowding of the vasculature may also represent low\n lung volumes.\n\n IMPRESSION: The ET tube has been removed and the lung volumes are thus low.\n Obscuration of the hemidiaphragm bilaterally may be due to atelectasis is\n worsening compared to prior examination. There could be some element of\n bilateral pleural effusions as well. A lateral film or ultrasound could\n evaluate the extent of the size of pleural effusions bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1248203,
"text": " 11:48 AM\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \n -76 BY SAME PHYSICIAN\n : *low film check DHT placement\n Admitting Diagnosis: CHORDAE RUPTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old man with s/p MVr\n REASON FOR THIS EXAMINATION:\n *low film check DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: Patient with mitral valve repair, assess Dobhoff placement.\n\n COMPARISON: at 7:59 a.m.\n\n FINDINGS:\n\n The first film shows a Dobhoff tube that is going to mid esophagus and going\n back up where we cannot see the tip of the tube and the second film shows an\n adequate placement of Dobhoff in the stomach. Right-sided Swan-Ganz ends in\n the right pulmonary artery. ET tube ends at 5.3 cm above carina. NG tube is\n in adequate position. The patient with moderate to important cardiomegaly and\n mitral valve repair. Stability of the retrocardiac opacity that could be\n atelectasis. Mild bilateral pleural effusions.\n\n CONCLUSION:\n\n The tubes and lines are in adequate position.\n\n"
},
{
"category": "ECG",
"chartdate": "2109-08-26 00:00:00.000",
"description": "Report",
"row_id": 131183,
"text": "Baseline artifact. Sinus tachycardia. Compared to the previous tracing the\nrate is faster, the rhythm is sinus, and ST-T wave changes are more\nsignificant. Consider myocardial ischemia.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2109-08-21 00:00:00.000",
"description": "Report",
"row_id": 131237,
"text": "Sinus rhythm. Compared to the previous tracing the rate has increased and is\nno longer bradycardic. Q-T interval remains prolonged. Left atrial\nabnormality, incomplete right bundle-branch block, right ventricular\nhypertrophy, right axis deviation are unchanged. RSR' pattern is more apparent\nin lead V2. T wave inversions persist in leads V3-V4 but are slightly less in\nlead V5. An ongoing anterolateral ischemic process cannot be excluded.\nClinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2109-08-21 00:00:00.000",
"description": "Report",
"row_id": 131238,
"text": "Baseline artifact. Sinus bradycardia. Compared to the previous tracing from\nthe same date the rate is much slower and now bradycardic. Computed\nQ-T interval is prolonged. Left atrial abnormality, right axis deviation,\nright ventricular hypertrophy, and incomplete right bundle-branch block pattern\nare unchanged. Non-specific ST segment abnormalities in the limb leads are\nmore prominent. T wave inversions are somewhat deeper in leads V3-V4 extending\nnow to lead V5, although precordial electrode placement is clearly different.\nNon-specific ST segment flattening in lead V6. An ongoing anterolateral\nischemic process cannot be excluded. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2109-08-26 00:00:00.000",
"description": "Report",
"row_id": 131184,
"text": "Accelerated junctional rhythm. Right axis deviation. Prolonged Q-T interval.\nCompared to the previous tracing of ST-T wave changes, particularly in\nleads V1-V4, have improved and the rhythm is no longer sinus.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2109-08-23 00:00:00.000",
"description": "Report",
"row_id": 131185,
"text": "Sinus rhythm. Right axis deviation. Right ventricular hypertrophy with\nST segment changes suggestive of right ventricular strain. However, prior\nanterior myocardial ischemia cannot be excluded. Also, possible posterior\nmyocardial infarction. Compared to the previous tracing of the\nfindings are similar. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2109-08-22 00:00:00.000",
"description": "Report",
"row_id": 131236,
"text": "Sinus rhythm. Compared to the previous tracing precordial electrode placement\nis clearly different. Left atrial abnormality is no longer apparent.\nQRS morphology is much more fractionated in lead V1. RSR' pattern is no longer\npresent in lead V2 with deep T wave inversions. T wave inversions are no\nlonger present in leads V3-V5, replaced with more non-specific repolarization\nabnormalities. Non-specific ST segment flattening persists in the limb leads.\nComputed Q-T interval is normal. An ongoing anteroseptal ischemic process\ncannot be excluded. Clinical correlation is suggested.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2109-08-21 00:00:00.000",
"description": "Report",
"row_id": 131239,
"text": "Localized baseline artifact. Sinus rhythm. Right axis deviation and right\nventricular hypertrophy. Left atrial abnormality. Incomplete right\nbundle-branch block pattern. Non-specific ST segment flattening in the\nprecordial leads. T wave inversions in leads V1-V4 may be ischemic in origin.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2109-08-22 00:00:00.000",
"description": "Report",
"row_id": 131186,
"text": "Sinus rhythm. Compared to the previous tracing from the same date\nQRS morphology in lead V1 is different. Right ventricular hypertrophy, right\naxis deviation, non-specific ST segment flattening in the limb leads persist.\nPrecordial electrode placement is clearly different, with concomitant extension\nof T wave inversions from lead V2 now into lead V3. An ongoing anteroseptal\nischemic process cannot be excluded. Clinical correlation is suggested.\nTRACING #5\n\n"
}
] |
25,030 | 128,473 | 1. E. coli bacteremia. 39 yo W with h/o ESRD, DMI, HTN, CVA, multiple line infections who was admitted to general medicine service with fevers and c/o tenderness at the right subclavian catheter site. Blood cultures grew E. coli in bottles from and then in bottles on . The patient was initially covered broadly with Vancomycin and Zosyn. When culture and sensitivity results returned Vancomycin was discontinued and then Zosyn was changed to Levaquin. Initially right subclavian line was not removed per Nephrology request because the patient has very difficult access. However, after the work up of potential sources of infection was unrevealing, the R subclavian line was removed on and the tip culture grew E coli and Citrobacter. Temporary femoral line placed for HD. Overnight of , patient spike to 105, became tachy to 140's, WBC went up to 37 and cooling blanket started on floor. She received IV lopressor, tylenol on floor, then became hypothermic to 91 w/ sbp 70's and was tranferred to MICU for hypotension. She was given fluids, one dose of Gentamycin was given and Levaquin was changed back to Zosyn. She required Dopa briefly but was quickly weaned off pressors. She remained hemodynamically stable. The patient was transferred back to the general floor on . She defervesced and her leukocytosis quickly resolved. The patient was doing well and being screened for transfer back to . She underwent permanent hemodialysis line placement by IR on . She had a new fever of 102 later that day and was changed from Levaquin back to Zosyn. On she was started on higher dose of Levaquin with good effect. She is to complete a 2 week course of levoquin. 2. DM, Type I. The patient was continued on glargine and ISS for tight glycemic control. 3. Pulmonary nodules on CT chest. Per discussion with radiology these are new and were not seen on CT back in . The appearance was not specific but consistent with infectious etiology. The patient had no pulmonary complaints. Follow up CT to assess for resolution/interval change was recommended. She also has significant adenopathy on past CTs and exam. Workup has been limited thus far secondary to chronic infection. Her low grade fevers may be attributed to this adenopathy as she is clinically without infection. 4. HTN. Continued Lisinopril, metoprolol. Amlodipine was discontinued to maximize cardiac regimen. Blood pressure medications were briefly held while she was hypotensive. 5. Hypercholesterolemia. Lipitor was continued. 6. ESRD secondary to DM s/p failed transplant. HD treatments and renal medications were continues per nephrology 8. Elevated LFTs. Abdominal CT with liver hemangiomas. Bili normal. Patient on lipitor. Hepatitis serologies negative. Monitor. Elevated alk phos and ggt. PTH sent. 9. Left shoulder pain. The patient developed left shoulder pain in left sternoclavicular area. CT was done to evaluate this further and showed no abnormalities. It was thought to be secondary do DJD. 10. Cardiomypathy. EF ~25-30%. The patient had a normal EF in . Given significant decline in EF, the patient should have a follow up echo when she is recovered from acute event. If repeat echo is still with decreased EF, further work up may be indicated. The patient was continued on ASA, beta-blocker, lisinopril, lipitor. | Stable retroperitoneal lymphadenopathy. Bulky left axillary and mediastinal lymphadenopathy, notably in the prevascular, AP window, pretracheal, precarinal, and subcarinal regions is demonstrated, and that was also described on the prior CT report of . The right common femoral vein was found to be patent and compressible by ultrasound. Also seen is the retroperitoneal mass which appears to splay the celiac axis, and is unchanged. IMPRESSION: Aspiration of tiny anterior abdominal wall fluid collection, which appears to be a hematoma. Under fluoroscopic guidance, a 0.035 Amplatz wire was advanced through the indwelling catheter lumen into the inferior vena cava. Mild (1+) mitral regurgitation is seen. Tunneled right subclavian dialysis catheter removal was performed by Dr. , Dr. , and Dr. . The tip of the catheter is present in the inferior vena cava. Able to tolerate hemodialysis today. CT OF THE ABDOMEN WITH IV CONTRAST: There is minor atelectasis at both lung bases. FINDINGS: A fluoroscopic spot image of the abdomen was obtained at the termination of the procedure, demonstrating the catheter tip to be present within the inferior vena cava. also with lymphadenopathy. Successful removal of a tunneled right subclavian dialysis catheter. Vanco and Gentamycin dc'd.A&P: Resolution of hypotension d/t sepsis with fluids and transient dopa. Sinus rhythmProbable inferior infarct, age indeterminate - possibly acuteAnterolateral ST-T wave abnormalities - Cannot exclude in part ischemiaClinical correlation is suggestedSince previous tracing of , ST-T wave abnormalities less prominent andL-R arm lead now in normal position As previously identified on ultrasound (), there is a 21 x 95 mm complex fluid collection in the anterior aspect of the liver, which is probably unchanged. It has peripheral puddling, and is most likely a hemangioma. Infected tunneled right subclavian dialysis catheter. There is focal calcification of thenon-coronary cusp. An appropriate catheter exit site was chosen in the right groin. Procedure done by radiologist:Limited ultrasound over the anterior abdominal wall, just to the right of midline showed a small fluid collection measuring 1.6 x 3 x 0.6 cm. A 0.018 guidewire was advanced through the needle into the IVC under fluoroscopic guidance. FINAL REPORT HISTORY: Sepsis, anterior abdominal wall fluid collection. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 60Weight (lb): 100BSA (m2): 1.39 m2BP (mm Hg): 103/57HR (bpm): 87Status: InpatientDate/Time: at 15:22Test: Portable TEE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA. FINDINGS: CT OF THE CHEST WITHOUT IV CONTRAST: Examination of the osseous structures demonstrate very mild irregularity along the articular surface of both clavicular heads, which appears somewhat symmetric, with appearances typically seen with degenerative joint disease. Diffuse non-specific ST-T wave abnormalities.Clinical correlation is suggested. possible hemodialysis . Normal interatrial septum. Remains on Zosyn Q 12hrs and 1 x dose of gentamycin.Endo: Cortstim test done. Possible old inferior wall myocardial infarction.Anterolateral ST-T wave abnormalities - cannot rule out myocardial ischemia.Clinical correlation is suggested. Her right groin, including the indwelling temporary dialysis catheter, was prepped and draped in the standard sterile fashion. Stable chest radiographic findings with cardiomegaly and prominent mediastinal contour. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. There are simple atheroma in the descending thoracic aorta.There are three aortic valve leaflets. CT OF THE PELVIS WITH IV CONTRAST: There is thickening of the rectal wall, which may represent edema. After the Amplatz wire was removed, the new 14.5-French catheter was advanced through the peel-away sheath into the inferior vena cava. There is moderate global right ventricular freewall hypokinesis. A final fluoroscopic abdominal radiograph was obtained, documenting the catheter tip in the IVC. PT WAS TREATED WITH IVF WIDE OPEN AND STARTED ON DOPA 5MCG WITH NEW IV INSERTED.ON ARRIVAL, 1 LITER IVF HAD INFUSED AND DOPA WAS AT 5MCG- BP ON ARRIVAL- 95/60 AND HR- 70 SR. TECHNIQUE: MDCT-acquired images of the chest were obtained before and after the administration of IV contrast. Moderate global LV hypokinesis.RIGHT VENTRICLE: Normal RV chamber size. Attention was then turned to the patient's tunneled right subclavian dialysis catheter. Limited images of the upper abdomen demonstrate extensive vascular calcifications. TECHNIQUE: Axial CT images of the upper chest were performed, which included thin-collimation slices and coronal and sagittal reformatted images. REASON FOR THIS EXAMINATION: placement of temporary dialysis femoral catheter FINAL REPORT HISTORY: Endstage renal disease requiring hemodialysis. 1% lidocaine was used for local anesthesia. The catheter was flushed, capped, and heplocked. Pressure was applied at the venous entry site until hemostasis was achieved. REASON FOR THIS EXAMINATION: aspiration of anterior abdominal wall fluid collection under US guidance. Clinical correlation is suggested.TRACING #1 There is moderate globalleft ventricular hypokinesis. The patient was sedated forthe TEE. Note is made of marked left axillary lymphadenopathy, associated with adenopathy including lymph nodes predominantly in the prevascular space and the AP window. Since the previous tracing of sinustachycardia is absent. Reversed L-R arm leadSinus rhythmConsider left atrial abnormalityProbable inferior myocardial infarction with ST-T wave configuration suggestsacute processPrecordial/anterior ST-T wave abnormalities - suggests ischemiaClinical correlation is suggestedSince previous tracing of , inferior myocardial infarction suggested,further ST-T wave abnormalities present and L-R arm lead reversed A tiny hypervascular focus measuring 6 mm is seen near the gallbladder fossa on the same slice (series 2 image 30). Note is made of coronary artery and aortic mural calcifications. The venous puncture site in the right groin was then closed with an absorbable 2-0 Vicryl suture, followed by a dry sterile dressing. Compared to the previous tracing of the patient is significantly tachycardic. Subtle low density lesion in the right anterior abdominal/pelvic wall, which is new since the last examination, and may represent an abscess. Pt recieved at total of 2250cc IV fluids to maintain MAP >60 and wean Dopamine to off. | 17 | [
{
"category": "Nursing/other",
"chartdate": "2117-07-22 00:00:00.000",
"description": "Report",
"row_id": 1588800,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P FEVER/HYPOTENSION\n\nS- \" CAN I HAVE SOME MORE TOAST?\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE. HR- 88-90 ST, NO VEA- BP- 118/77-109/56 VIA DYNAMAP.\nNO FURTHER PRESSORS OR FLUID BOLUSES.\n\n PT 96 PO- 97.8 RECTAL.\nREMAINS ON ZOSYN AS ORDERED AND DOSING VANCO/GENT AS NEEDED PER RENAL FX.\nSPECIMENS PENDING\nSENT STOOL FOR R/O CDIFF AS WELL.\n\nGU- ANURIC- AWAITING DIALYSIS TODAY\nAM LABS PENDING.\nS/P K EX FOR K- 5.3 EVES.\n\nGI- TAKING TOAST AND LIQUIDS FOR NUTRITION- APPEARS HUNGRY, ASKING FOR MORE- AFTER 2ND ROUND OF PT HAD LARGE AMT LOOSE LIX STOOL\nG (-)- SENT FOR CULTURE- ALSO ON REGLAN- HOLDING COLACE.\nSS REG INSULIN AND DAILY FIXED GLARGINE DOSE.\n\n PT A AND O X 3- SLEEPING MUCH OF SHIFT\nASKING APPROPRIATE QUESTIONS.\nAPPEARS COMFORTABLE.\nNO FAMILY CALLS THIS SHIFT.\n\nLINES- BILATERAL PERIPHERAL IV'S AND RT FEMORAL QUENTIN- REQUIRES REMINDING ABOUT NOT BENDING RT LEG AND SITTING UP AT 45 DEGREES.\n\nA/ PT WITH FEVER/HYPOTENSION CURRENTLY AFEBRILE AND HEMODYNAMICALLY STABLE.\nPLAN FOR DIALYSIS TODAY\nCONTINUE ANTIBX AS ORDERED.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE\nC/O TO FLOOR IF REMAINS HEMODYNAMICALLY STABLE.\nSS REG INSULIN/AWAIT CULTURES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-07-22 00:00:00.000",
"description": "Report",
"row_id": 1588801,
"text": "Nursing Progress Note\n\nS: \"Am I going home today?\"\n\nO: Please see flow sheet for objective data. >100. Tolerated hemodialysis run well. 3 liters removed. BS slightly ^ today. Recieved full dose off lantis this am with SS coverage. Steriods dc'd after 6am dose. Tolerating diet well after hemo. T 96-97.4 po. WBC down to 9,000. Temp Quinton remains in R fem. Lungs are diminshed at bases. Conts on Zosyn Q 12. Vanco and Gentamycin dc'd.\n\nA&P: Resolution of hypotension d/t sepsis with fluids and transient dopa. Able to tolerate hemodialysis today. to monitor lytes. ? source for long term access.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-07-21 00:00:00.000",
"description": "Report",
"row_id": 1588798,
"text": "CCU NSG ACCEPTANCE NOTE 6:15A\n\nS- LETHARGIC\n\n PT ARRIVED FROM CC7 AFTER DROPPING TEMP TO 90 PO AND BP TO 60/40 AFTER A LATE EVE TEMP SPIKE/RECULTURE. PT WAS TREATED WITH IVF WIDE OPEN AND STARTED ON DOPA 5MCG WITH NEW IV INSERTED.\nON ARRIVAL, 1 LITER IVF HAD INFUSED AND DOPA WAS AT 5MCG- BP ON ARRIVAL- 95/60 AND HR- 70 SR. GIVEN STAT DOSE GENT 50 MG AND AN ADDITIONAL 500CC IVF. PT IS RESPONSIVE TO CONVERSATION BUT IS LETHARGIC, DENIES PAIN.\nSTAT LABS FROM CC7 PENDING, TO INSERT CENTRAL ACCESS AND ? ALINE CURRENTLY.\n\nA/ PT WITH EXTENSIVE MEDICAL HX/RENAL FX/ESRD/VRE/MRSA CURRENTLY ADMITTED TO CCU FOR HYPOTENSION/SEPSIS\n\nPLAN- LINE INSERTION, BAIR HUGGER, 500CC MORE IVF AND ANTIBX AS ORDERED. CONTINUE TO FOLLOW SPECIMENS/MONITOR HEMODYNAMICS AND KEEP MAPS > 60. KEEP PT AND FAMILY AWARE OF PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-07-21 00:00:00.000",
"description": "Report",
"row_id": 1588799,
"text": "Nursing Progress Note\n\nS\" \" I'm so hot.\"\n\nO: Please see flow sheet for objective data. Tele sinus rhythm. Pt recieved at total of 2250cc IV fluids to maintain MAP >60 and wean Dopamine to off. Presently dopamine remains off. TEE done, did not show any evidence of vegatation or endocarditis. EF approx 35%.\n\nResp: Lungs diminshed throughout the bases. O2 sat 93-98%.\n\nNeuro: Pt lethargic throughout the day. Pt did receive versed .5mg & fentanyl 25mcgs for TEE which she tolerated well.Easily arousable to verbal stimulation. Seems to be aware of what's happening.\n\nGU/GI: Pt NPO for most of the day for TEE. Tolerating diet well this pm. Abd is soft with bowel sounds present. Pt does not void. Hemodialysis held off today. K 5.6 repeat pending.\n\nID: Temp 94-96 po. Bear hugger removed early this am when pt c/o being too hot and temp had started to come up. Placed back on blanket after temp remained down. Off at present. WBC 27,000 this am. Dose of vancomycin held today d/t vancomycin level of 21.3. Remains on Zosyn Q 12hrs and 1 x dose of gentamycin.\n\nEndo: Cortstim test done. Started on Decadron 10mg IV Q 8. given half dose of Glargine at 12n d/t NPO. BS in better control with SS.\n\nAccess: Pt has R fem Quinton. Pt has no other site for central access so central line not placed.\n\nA&P: Pt able to wean off dopamine throughout the day. to monitor hemodynamics. to monitor K. ? possible hemodialysis . with POC.\n"
},
{
"category": "Radiology",
"chartdate": "2117-07-26 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 870747,
"text": " 6:51 PM\n CHEST (PA & LAT); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: evaluate for metastatic lesion, evidence of joint infection\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with IDDM, ESRD, with E.coli sepsis, now w/ shoulder pain.\n also with lymphadenopathy. evaluate for evidence of metastatic lestion or joint\n space infection\n REASON FOR THIS EXAMINATION:\n evaluate for metastatic lesion, evidence of joint infection\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Evaluate for metastatic lesion or joint infection.\n\n The cardiac silhouette is enlarged but stable. There is stable widening of\n the mediastinum. The pulmonary vascularity is normal, and the lungs appear\n grossly clear allowing for low lung volumes. No pleural effusions are\n identified. Surgical clips are seen in the left paratracheal region.\n\n IMPRESSION:\n 1. Stable chest radiographic findings with cardiomegaly and prominent\n mediastinal contour. The latter is likely related to lymphadenopathy.\n 2. No evidence of pulmonary nodules or masses.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-07-26 00:00:00.000",
"description": "UNRELATED PROCEDURE/SERVICE DURING POSTOPERATIVE PERIOD",
"row_id": 870659,
"text": " 7:15 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: placement of a new permanent line for dialysis\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ********************************* CPT Codes ********************************\n * TUNNELED W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUOR GUID PLCT/REPLCT/REMOVE C1750 CATH,HEMO/PERTI DIALYSIS LONG *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with ESRD on HD whose R sublclavian tunneled line was\n infected and recently d/c'd needs new permanent dialysis access.\n\n REASON FOR THIS EXAMINATION:\n placement of a new permanent line for dialysis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old female with end-stage renal disease and multiple line\n infections who presents with an indwelling temporary right groin catheter. The\n patient now needs placement of a tunneled dialysis catheter.\n\n PHYSICIANS: The procedure was performed by Dr. , Dr. \n , and Dr. . Dr. , the staff\n radiologist, was present and supervising throughout.\n\n PROCEDURE: After the risks and benefits of the procedure were discussed with\n the patient and informed consent was obtained, the patient was placed supine\n on the angiography table. Her right groin, including the indwelling temporary\n dialysis catheter, was prepped and draped in the standard sterile fashion. The\n skin and subcutaneous tissues in the right groin were anesthetized thoroughly\n with 1% lidocaine. Under fluoroscopic guidance, a 0.035 Amplatz wire was\n advanced through the indwelling catheter lumen into the inferior vena cava.\n Our attention was then turned to creation of the subcutaneous tunnel.\n\n An appropriate catheter exit site was chosen in the right groin. A small skin\n incision was created using a #11 blade scalpel. A subcutaneous tunnel was then\n created using blunt dissection with the assistance of a hemostat device. A new\n 14.5-French tunneled dual lumen hemodialysis catheter was then advanced\n through the subcutaneous tunnel to the venous puncture site in the right\n groin. The existing catheter was then removed and a 15-French peel-away sheath\n was advanced over the Amplatz wire into the right femoral vein. After the\n Amplatz wire was removed, the new 14.5-French catheter was advanced through\n the peel-away sheath into the inferior vena cava. The peel-away sheath was\n removed. The catheter was flushed, capped, and heplocked. It was secured to\n the skin using 2-0 silk sutures. The venous puncture site in the right groin\n was then closed with an absorbable 2-0 Vicryl suture, followed by a dry\n sterile dressing.\n\n FINDINGS: A fluoroscopic spot image of the abdomen was obtained at the\n termination of the procedure, demonstrating the catheter tip to be present\n within the inferior vena cava.\n\n COMPLICATIONS: None.\n (Over)\n\n 7:15 AM\n TUNNEDLED DIALYSIS CATH PLACE Clip # \n Reason: placement of a new permanent line for dialysis\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MEDICATIONS: 1% lidocaine SQ. Totals of 0.5 mg of Versed and 50 mcg of\n fentanyl were administered in intermittent doses with continuous monitoring of\n vital signs by the nursing staff.\n\n IMPRESSION: Successful replacement of a 14.5-French temporary catheter for a\n new 14.5-French, 32-cm long tunneled dual lumen hemodialysis catheter over a\n guidewire via the right common femoral vein. The catheter tip to cuff length\n measures 27 cm. The tip of the catheter is present in the inferior vena cava.\n The catheter is ready for immediate use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-07-27 00:00:00.000",
"description": "CT RECONSTRUCTION",
"row_id": 870861,
"text": " 4:24 PM\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \n Reason: please evaluate for soft tissue infectious process, evidence\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with E coli bacteremia now with pain in left sternoclavicular\n joint area.\n REASON FOR THIS EXAMINATION:\n please evaluate for soft tissue infectious process, evidence of osteomyelitis\n in the left sternoclaricular area.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: E. coli bacteremia with pain in the left sternoclavicular joint\n area. Evaluate for evidence of osteomyelitis or other infectious processes.\n\n TECHNIQUE: Axial CT images of the upper chest were performed, which included\n thin-collimation slices and coronal and sagittal reformatted images.\n Comparison is also made to CT examination of the chest performed . No\n post-contrast images could be obtained due to the limited IV access.\n\n FINDINGS:\n CT OF THE CHEST WITHOUT IV CONTRAST: Examination of the osseous structures\n demonstrate very mild irregularity along the articular surface of both\n clavicular heads, which appears somewhat symmetric, with appearances typically\n seen with degenerative joint disease. There are no associated effusions or\n other fluid collections. Without IV contrast, we cannot assess for\n enhancement.\n\n Metallic clip is seen just anterior to the inferior aspect of the left\n thyroid.\n\n Note is made of marked left axillary lymphadenopathy, associated with\n adenopathy including lymph nodes predominantly in the prevascular space and\n the AP window. Visualized aspects of the heart appear markedly enlarged, with\n marked vascular calcifications including the coronary arteries.\n\n Examination of the lungs demonstrate changes related to tracheobronchomalacia,\n particularly at the level of the carina and left main stem bronchus. In\n addition, there is a stable dominant nodule in the right upper lobe anteriorly\n which measures approximately 1 cm in size and is unchanged since the\n comparison. Multiple other tiny nodular pulmonary opacities are also\n appreciated, also stable.\n\n Examination of coronally and sagittally reformatted images of the\n sternoclavicular joints was also reviewed, not demonstrating frank destructive\n changes or evidence of effusion/abscess at the joints.\n\n IMPRESSION:\n\n 2) Very mild irregularity of both sternoclavicular joints, without significant\n difference in severity between the left and right side, has appearances most\n (Over)\n\n 4:24 PM\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \n Reason: please evaluate for soft tissue infectious process, evidence\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n often seen in the setting of mild degenerative changes. While osteomyelitis\n cannot be excluded, no complication of osteomyelitis such as adjacent abscess\n or fluid collection is evident.\n\n"
},
{
"category": "Echo",
"chartdate": "2117-07-21 00:00:00.000",
"description": "Report",
"row_id": 100302,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 60\nWeight (lb): 100\nBSA (m2): 1.39 m2\nBP (mm Hg): 103/57\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 15:22\nTest: Portable TEE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Normal interatrial septum. No ASD\nby 2D or color Doppler.\n\nLEFT VENTRICLE: Symmetric LVH. Moderate global LV hypokinesis.\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTA: No atheroma in aortic arch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve\nleaflets. No masses or vegetations on aortic valve. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No mass or\nvegetation on mitral valve. No mitral valve abscess. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. No abscess of tricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. No 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 sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. No TEE\nrelated complications. 0.2 mg of IV glycopyrrolate was given as an\nantisialogogue prior to TEE probe insertion. The patient appears to be in\nsinus rhythm. The house officer caring for the patient was notified of the\nresults by text page.\n\nConclusions:\nThe left atrium is dilated. There is symmetric LVH. There is moderate global\nleft ventricular hypokinesis. There is moderate global right ventricular free\nwall hypokinesis. There are simple atheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. There is focal calcification of the\nnon-coronary cusp. No masses or vegetations are seen on the aortic valve.\nTrace aortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. There is a 2-3 mm calcified mobile echodensity attached to the tip\nof the anterior mitral leaflet seen on ventricular side of the valve, which\nlikely represents a torn chordae (present on prior TEE from , see below).\nNo discrete mass or vegetation is seen on the mitral valve. No mitral valve\nabscess is seen. Mild (1+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. There is no abscess of the tricuspid valve. No\nvegetation/mass is seen on the pulmonic valve. There is no pericardial\neffusion.\nCompared with the findings of the prior study (tape reviewed) of ,\nbiventricular systolic dysfunction is now present. The degree of valvular\ndisease is unchanged.\n\nImpression: no echocardiographic evidence of endocarditis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-07-18 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 869724,
"text": " 10:01 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: rule out abscess/evaluate for source of infection\n Admitting Diagnosis: FEVER-LINE SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with ESRD on HD with Gram negative rod bacteremia and mild\n abdominal tenderness\n REASON FOR THIS EXAMINATION:\n rule out abscess/evaluate for source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old woman with end-stage renal disease, bacteremia.\n Evaluate for possible abscess.\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images from the lung\n bases to the pubic symphysis after administration of oral and IV contrast.\n\n COMPARISON: CT scan.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is minor atelectasis at both lung\n bases. A previously identified low density lesion within the right lobe of\n the liver measures 19 x 17 mm. It has peripheral puddling, and is most likely\n a hemangioma. A tiny hypervascular focus measuring 6 mm is seen near the\n gallbladder fossa on the same slice (series 2 image 30). Another\n hypervascular focus, 9 x 8 mm, is seen in the left lobe of the liver (junction\n of 4a and 4b). No other lesions are seen in the liver. There is a gallstone,\n without evidence of cholecystitis. The pancreas is atrophic. Native kidneys\n are shrunken; there are heavy calcifications within the renal arteries,\n superior mesenteric artery, and celiac axis. The spleen is unremarkable. The\n adrenals are unchanged. The stomach is within normal limits. As previously\n identified on ultrasound (), there is a 21 x 95 mm complex fluid\n collection in the anterior aspect of the liver, which is probably unchanged.\n Also seen is the retroperitoneal mass which appears to splay the celiac axis,\n and is unchanged. A small amount of free fluid is seen in the abdomen. Again,\n as noted, there are extensive vascular calcifications throughout the abdominal\n vasculature.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is thickening of the rectal wall,\n which may represent edema. The remainder of the bowel loops are unremarkable.\n Again seen in the right lower quadrant is a heavily calcified rejected\n transplant kidney. No lymphadenopathy is definitively identified in the\n pelvis. However, in the right anterior rectus sheath, there is a 16 x 42 mm\n low density lesion. A small amount of free fluid is seen in the pelvis. As\n previously noted, there are heavy vascular calcifications throughout all\n pelvic vessels.\n\n Osseous structures are remarkable for renal osteodystrophy disease.\n\n IMPRESSION:\n (Over)\n\n 10:01 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST\n Reason: rule out abscess/evaluate for source of infection\n Admitting Diagnosis: FEVER-LINE SEPSIS\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Subtle low density lesion in the right anterior abdominal/pelvic wall,\n which is new since the last examination, and may represent an abscess.\n Ultrasound may be useful for further characterization.\n 2. Thickening/edema of the rectal wall, which may represent proctitis.\n Correlation with physical exam may be useful in excluding this as a source of\n bacteremia.\n 3. Hemangioma in liver. Two hypervascular foci in liver on this single-\n contrast study; ultrasound or MRI may be useful for further characterization,\n if clinically indicated.\n 4. Stable retroperitoneal lymphadenopathy.\n 5. Stable appearance of complex fluid collection in anterior aspect of liver.\n 6. Heavily calcified abdominal vasculature as previously identified, probably\n due to end-stage renal disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-07-16 00:00:00.000",
"description": "CT 100CC NON IONIC CONTRAST",
"row_id": 869547,
"text": " 2:49 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with pleuritic R chest pain, low grade fever.\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl FRI 3:41 PM\n NO evidence of PE.\n multifocal vague, small nonspecific lung opacities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pleuritic right chest pain and low-grade fever, rule out PE.\n\n No CT is available for comparison on PACs.\n\n TECHNIQUE: MDCT-acquired images of the chest were obtained before and after\n the administration of IV contrast.\n\n CT OF THE CHEST WITH IV CONTRAST: There are no filling defects within the\n pulmonary arterial system to suggest PE. The great vessels are unremarkable.\n Note is made of coronary artery and aortic mural calcifications. There are\n extensive calcifications within the abdominal vasculature as well. Lung\n windows demonstrate several patchy nonspecific opacities in the right upper\n lobe (series 3, image 87), right lower lobe (series 3, image 51), and left\n lower lobe (series 3, image 24). No images were available for comparison.\n There is a 3.5 mm nodular density near the left major fissure in the left\n lower lobe (series 3, image 52). An additional tiny pleural-based density is\n also seen in the lingula (series 3, image 68). Bulky left axillary and\n mediastinal lymphadenopathy, notably in the prevascular, AP window,\n pretracheal, precarinal, and subcarinal regions is demonstrated, and that was\n also described on the prior CT report of .\n\n Limited images of the upper abdomen demonstrate extensive vascular\n calcifications.\n\n Bone windows demonstrate no suspicious lytic or sclerotic foci.\n\n IMPRESSION:\n 1) No evidence of PE.\n 2) Multifocal, nonspecific, vague small patchy opacities with a tiny nodular\n density in the left lower lobe. No comparison studies are currently available\n on PACs for comparison.\n 3) Extensive atherosclerotic disease.\n (Over)\n\n 2:49 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-07-20 00:00:00.000",
"description": "GUIDANCE CYST OR RENAL ANY LOC US",
"row_id": 870015,
"text": " 2:22 PM\n US SIMPLE/SING ABSC/CYST DRAIN/INCISION; GUIDANCE CYST OR RENAL ANY LOC USClip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: aspiration of anterior abdominal wall fluid collection under\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with ESRD, E coli bacteremia with aterior abdominal wall\n fluid collection.\n REASON FOR THIS EXAMINATION:\n aspiration of anterior abdominal wall fluid collection under US guidance.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis, anterior abdominal wall fluid collection.\n\n Procedure done by radiologist:Limited ultrasound over the anterior abdominal\n wall, just to the right of midline showed a small fluid collection measuring\n 1.6 x 3 x 0.6 cm. The risks and benefits were explained to the patient and\n informed consent was obtained. A preprocedure timeout was performed regarding\n the patient's name and procedure. The area was prepped and draped in a\n sterile fashion. 1% lidocaine was used for local anesthesia. Using\n ultrasonographic guidance, an 18-gauge spinal needle was inserted into this\n collection and approximately 2 mL of blood-tinged fluid was aspirated. This\n was sent for Gram stain and culture. No more fluid was able to be aspirated.\n\n Dr. , the attending radiologist, was present and supervised the\n entire procedure. There were no immediate post-procedure complications.\n\n IMPRESSION: Aspiration of tiny anterior abdominal wall fluid collection,\n which appears to be a hematoma. This fluid was sent for Gram stain and\n culture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-07-20 00:00:00.000",
"description": "TUNNELED CENTRAL W/O PORT",
"row_id": 870029,
"text": " 3:42 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: placement of temporary dialysis femoral catheter\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ********************************* CPT Codes ********************************\n * NON-TUNNELED TUNNELED CENTRAL W/O PORT *\n * -51 MULTI-PROCEDURE SAME DAY FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old woman with ESRD on HD with E coli bacteremia.\n\n REASON FOR THIS EXAMINATION:\n placement of temporary dialysis femoral catheter\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Endstage renal disease requiring hemodialysis. Infected tunneled\n right subclavian dialysis catheter.\n\n PHYSICIANS: Temporary dialysis catheter placement was performed by Dr. \n and Dr. . Tunneled right subclavian dialysis catheter\n removal was performed by Dr. , Dr. , and Dr. \n . The attending physician, . , was present and supervising.\n\n CONSENT: After the risks and benefits of the procedure were discussed with\n the patient, written informed consent was obtained.\n\n PROCEDURE/FINDINGS: The patient was placed supine on the procedure table. The\n right common femoral vein was found to be patent and compressible by\n ultrasound. The right groin was prepped and draped in a standard sterile\n fashion. 1% lidocaine was administered to the skin and subcutaneous tissues\n over the right femoral vein for local anesthesia. The right common femoral\n vein was accessed by a 21-gauge needle under ultrasound guidance. A 0.018\n guidewire was advanced through the needle into the IVC under fluoroscopic\n guidance. The needle was exchanged for a 4-French micropuncture sheath. The\n guidewire was exchanged for wire, which was advanced into the IVC\n under fluoroscopic guidance. The venous access site was widened by a scalpel.\n It was then sequentially dilated by 12 and 14-French dilators. The last\n dilator was exchanged for a 20 cm, 14.5-French dual lumen dialysis catheter,\n which was advanced into the IVC under fluoroscopic guidance. A final\n fluoroscopic abdominal radiograph was obtained, documenting the catheter tip\n in the IVC. The catheter was flushed and capped with extension tubing. It\n was sutured with two 2-0 nylon sutures. A dry dressing was applied. The\n catheter was hep-locked. The catheter is ready for use.\n\n Attention was then turned to the patient's tunneled right subclavian dialysis\n catheter. The catheter hub sutures and the tunnel exit site sutures were cut.\n The catheter was easily removed from the tunnel. Pressure was applied at the\n venous entry site until hemostasis was achieved. A dressing was applied at\n the tunnel exit site. The catheter tip was cut and sent for culture.\n\n COMPLICATIONS: No immediate complications.\n (Over)\n\n 3:42 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: placement of temporary dialysis femoral catheter\n Admitting Diagnosis: FEVER-LINE SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MEDICATIONS: Versed IV, fentanyl IV, and 1% lidocaine subq were administered\n by a registered nurse who was monitoring the patient throughout the procedure.\n Please refer to the nursing records for dosages.\n\n IMPRESSION:\n 1. Successful placement of a 20 cm, 14.5-French dual lumen temporary dialysis\n catheter via the right common femoral vein, with tip in the IVC, ready for\n use.\n 2. Successful removal of a tunneled right subclavian dialysis catheter.\n Catheter tip was sent for culture.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-07-17 00:00:00.000",
"description": "Report",
"row_id": 276744,
"text": "Reversed L-R arm lead\nSinus rhythm\nConsider left atrial abnormality\nProbable inferior myocardial infarction with ST-T wave configuration suggests\nacute process\nPrecordial/anterior ST-T wave abnormalities - suggests ischemia\nClinical correlation is suggested\nSince previous tracing of , inferior myocardial infarction suggested,\nfurther ST-T wave abnormalities present and L-R arm lead reversed\n\n"
},
{
"category": "ECG",
"chartdate": "2117-07-24 00:00:00.000",
"description": "Report",
"row_id": 276740,
"text": "Sinus rhythm. Rightward axis is non-specific. Consider prior inferior wall\nmyocardial infarction, although is non-diagnostic. Low precordial lead\nQRS voltage is non-specific. Diffuse non-specific ST-T wave abnormalities.\nClinical correlation is suggested. Since the previous tracing of sinus\ntachycardia is absent.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-07-19 00:00:00.000",
"description": "Report",
"row_id": 276741,
"text": "Sinus tachycardia. Compared to tracing #1 the heart rate is slightly slower.\nAnterolateral ST-T wave abnormalities persist. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2117-07-19 00:00:00.000",
"description": "Report",
"row_id": 276742,
"text": "Sinus tachycardia. Possible old inferior wall myocardial infarction.\nAnterolateral ST-T wave abnormalities - cannot rule out myocardial ischemia.\nClinical correlation is suggested. Compared to the previous tracing of \nthe patient is significantly tachycardic. Anterolateral ST-T wve abnormalities\npersist. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2117-07-18 00:00:00.000",
"description": "Report",
"row_id": 276743,
"text": "Sinus rhythm\nProbable inferior infarct, age indeterminate - possibly acute\nAnterolateral ST-T wave abnormalities - Cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , ST-T wave abnormalities less prominent and\nL-R arm lead now in normal position\n\n"
}
] |
23,483 | 158,887 | 59 yo F with h/o severe NICM EF 15-20%, severe MR, CAD s/p MI, mild 2v-d in ', biV/ICD in 7/. Pt now presents with dig toxicity and ICD shocks. . 1. rhythym: The pt was admitted to the Cardiac Intensive care unit, given the history of v-fib arrest with loss of pulse and unresponsiveness in the ambulance to the hospital. The electrophysiology team was called to evaluate the pacemaker/ICD and found that the device was functioning according to its programmed parameters, sensing fast Vfib/Vtach. However, the ICD was unable to detect slow VT, which the pt was experiencing in the setting of digoxin toxicity. The device was reprogrammed to sense lower rates of VT. On , the pt was taken to the EP lab for generator change since the battery was low. This operation proceeded without complications. The unstable rhythm occured in the setting of digoxin toxicity in acute renal failure. Digoxin was stopped, with the plan to not restart given the history of prior episodes of dig toxicity. The pt was noted to have a hematoma around the device, on the day prior to discharge. This was evaluated by the EP team, found to be stable. Should be followed up at rehab. . 2. CHF: Primarily secondary to valvular dz with 4+ MR, CAD s/p MI and CABG (SVG--> LAD), Pt was euvolemic most of the hospital stay. After the EP lab operation, the pt was found to be volume overloaded and diuresed with lasix over the following several days, returned to . Pt did not appear to tolerate ACE or well with creatinine , plan is to continue Imdur/hydral. Pt will be continued on aldactone, Imdur/Hydral, lasix 120 PO Bid. . 3. CAD: No active ischemia during the hospitalization. Pt has chronic CP symtoms, likely not anginal. Pt had LAD dissection 20 y ago, CABG SVG to LAD, last cath shows occ SVG, but otherwise mild 2V disease. Pt will be continued on ASA, statin . 3. Chronic back pain: The pt's PCP, . recommended high doses of pain medicines, given the patient's poor overal prognosis with severe CHF. The plan was to help provide as much comfort for the patient as possible. The patient agreed with this plan. Pt was started on a regimen of fentanyl patch, morphine IR, and valium. . 4. Weakness/deconditioning: Pt will get further conditioning at rehab. . 5. ARF: Resolved. cr bumped to 1.6 from baseline cr. 0.7 secondary to pre-renal state. . 5. Paroxysm a-fib: Pt was in paced rhythm during hospitalization. The a-fib was not an acute issue. Continue amio, was loaded with 200 for 2 weeks, then started 200 daily. Continue coumadin 3 mg HS, being discharged on lovenox bridge. . 6. hypothyroid: on levoxyl . 7. diarrhea: resolved | Pt to on , pacer interogated, pacer in need of battery/generator change, generator change on , please see careview for VS and additional data.CV: Pt AV paced HR 70 DDD mode, NBP 103-130/66-80, pt down to EP during previous shift for generator change, dsd over site, scant amt of bld noted on dsg, betadyne noted, dsg unchanged throghout shift. dorsal/tibial pulses palp.Resp- c/o SOB since procedure on Mon. Admitted for GI distress, N/V, dig tox, and episodes of VF/VT relieved by ICD. ACE and lasix stopped.O: For complete VS see CCU flow sheet.ID: Pt remains afebrile. Heparin/coumadin to be started later this am, check with CCU Team/HO.Resp: Pt LS clear at apices with fine crackles noted bilateral bases. Per CCU Team, pt fluid goal of even, per Dr. , gentle hydration through PO fluids.ID: Pt afebrile.Skin: Pt skin with some brusing/ecchymosis on legs, pt with sm 1cm x1cm pressure sore/ulceration on R buttock cheek, duoderm applied.Social: Pt (whom pt states and states is HCP-no form in chart- asked by Dr. to bring in copy of form), called and spoke with RN x 3 this am. Upon arriving AICD was reprogramed to shock at lower HR.SHe has had no further episodes of VT. Captopril with rising creatine is supposed to be the source of dig toxicity.CV: Pt has been pain free. Nursing Progress Note 7am-7pmS: The pain in my back radiates down my legs and they feel numb.O: Please see carevue for complete objective data.CV-HR=80 AV paced, no ectopy. Medicated with prn Percocet, backrubs and frequent position changes. Am labs sent-> Hct 31, K 4.8, Na 131, PTT 63.7, INR 1.9-> Dr. aware.Resp: Pt LS clear at apices to crackles at bases, pt RR teens to mid 20's with exertion, O2 sats 98-100% on 3 L n.c. Pt SOB with movement/turning, pt RR decreases to teens with rest.GI/GU: Pt abd soft, +BS x 4, no stool this shift, pt NPO after midnoc for planned ICD battery change this am. Pt voiding via bedpan, pt with poor u/o-Dr. aware, see flowsheet. "O: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 80 AVpaced, rare PVC noted. "O- see flowsheet for all objective data.cv- Tele: AV paced rhythm- rate 80- b/p 100-108/63-78- dig level 4.1 this am- Hct 30.6- K 3.6 KCL 40meq given- Mg 1.9 Mg sulfate 1gm given-heparin gtt @ 700u/hr- PTT 63.6- plan is for battery change tomorrow.resp- In O2 2L via NC- lung sounds with bibasilar crackles- RR 18-22- very SOB with exertion- SPO2 97-99%- sats drop to 91% on room air.neuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.gi- abd soft (+) bowel sounds- taking Po fair- c/o nausea this afternoon- tylenol held @ 1600 due to nausea- no BM today- LFT's added to am labs- results pending- NPO after 12am for EP lab.gu- voiding conc amber colored urine- incontinent lg amt of urine while napping- U/O essentially = today- BUN 35 Crea 1.4comfort- c/o severe back pain with movement- morphine sulfate 15mg Po q12hr & tylenol 1000mg Po q8hr working well controlling pain overall- back care given PRN.A- Pre-op for battery change tomorrow- seen by anesthesia this am.P- monitor vs, lung sounds, I&O and labs- ? "O: Please see carevue for complete objective data.CV- S/P generator change, AV paced, HR-70, BP 108-125/56-87. CCU NGS NOTE: ALT IN CV/SP PACER GENERATOR REVISIONS: "That was long"O: For complete VS see CCU flow sheet. "O: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 80, initially vpaced, AVpaced most of the night. RR-16-21, regular, and LS clear with diminished bases.GI/GU- BS present and abd soft. REstrart morphine SR as needed. She has been able to sleep.A: Stable/awaiting replacement of pacer generated.P: Shut off heparin at 4am . THek wrote to start coumadin in am.RESP: She is sating 100% on 4L NP, but drops to high 80s on RA. states she has had PTA.Neuro: Pt. Duoderm from previous shift intact on buttocks from pressure sore, Pt. ICD FIRED " AFTER 1 TO 1.5 MINUTES" AND PT BACK IN PACED AND ALERT/ORIENTED. REPEAT EPISODE IN ER ABOUT 1-1.5 HOUR LATER WITH THE SAME PT "FINE" ONCE RESTORED WITH OWN ICD FIRING.DECIDED TO TRANSFER TO CCU.PT 3:30A- BY REPORT OF PT HAD VT ARREST AGAIN IN AMBULANCE AND WAS SHOCKED/DEFIB WITH 120 J BY PARAMEDICS AND RESTORED TO PACED WITHOUT LOC OR NEED FOR AMBU/CPR.TO CCU VSS. Started Hydralazine, tolerating well. SHe has multiple eccymotic areas.MS/COMFORT: Pt was quite groggy upon returning. Pt with c/o back/leg pain out of 1 to 10 pain scale, percocet given with minimal relief. Pt bladder slightly firm, pt denies pain with palpation, denies difficulty voiding, Dr. aware, obtain U&A when pt voids this eve. "O: Please see careview for VS and additional data.CV: Pt HR 60 AVpaced, NBP 111-136/61-81, bilateral pedal and radial pulses palp. Pt voided x 3 via bedpan. Pt MAE, pt moves bilateral LE minimally, + sensation. PT PUT ON /DEFIB CURRENTLY.INR CURRENTLY 1.5- TO DISCUSS STARTING HEPARIN TO KEEP THERAPEUTIC IN LOW EF STATE, NO COUMADIN IN CASE OF NEED FOR INVASIVE PROCEDURE THIS AM.CPK THIS AM (-) AS WELL. Pt remains on 1L nc.GI/GU- No BM, BS present x 4, abd soft. She has usual discomfort with position changes, but appears comfortable when lying still.A: Successful generator replacement/DTVP: Monitor urine output closely. Pt bilateral pedal pulses palp, pt with bilateral LE edema +. gave scheduled and PRN pain meds and repositioned. O2 stopped after rounds and sats remained 92 and above. Pt LS clear at apices to coarse at bases this am, pt LS clear this afternoon.Neuro: Pt alert and oriented x 3-> pt has some difficulty recalling exact date, but aware of Month, year and Day. Stitches on scalp due to fall, clean and intact.Neuro- hx of depression, taking zoloft and ativan. | 20 | [
{
"category": "Nursing/other",
"chartdate": "2166-09-05 00:00:00.000",
"description": "Report",
"row_id": 1569280,
"text": "CCU NSG PROGRESS NOTE/ACCEPTANCE NOTE 3:30-7A/ VT\n\n\nS- \" MY BACK IS REALLY HURTING..BEFORE I FELL DOWN AT HOME, IT'S BEEN HURTING, MAYBE - I DON'T REMEMBER.. I ONLY GOT HOME A COUPLE OF WEEKS AGO...\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\nSEE NSG FHPA AND CCU TEAM NOTES FOR DETAILS R/T HPI/PMH.\n\nTHIS IS A 60 YR OLD PT WITH EXTENSIVE PMH MOST SIG FOR CM, CRI, CHF/CAD WHO WAS FOUND FALLEN AT HOME BY VNA AND BROUGHT TO ER FOR HEAD LACERATION WHICH WAS STITCHED/STAPLED- SHE WAS SENT TO CT WHICH WAS (-) FOR BLEED BY REPORT. ON ROUTE TO STEP DOWN FLOOR AROUND MN, HAD WITNESSED ARREST- GASPED, LOC AND REQUIRED CPR/AMBU. ICD FIRED \" AFTER 1 TO 1.5 MINUTES\" AND PT BACK IN PACED AND ALERT/ORIENTED. REPEAT EPISODE IN ER ABOUT 1-1.5 HOUR LATER WITH THE SAME PT \"FINE\" ONCE RESTORED WITH OWN ICD FIRING.\nDECIDED TO TRANSFER TO CCU.\n\nPT 3:30A- BY REPORT OF PT HAD VT ARREST AGAIN IN AMBULANCE AND WAS SHOCKED/DEFIB WITH 120 J BY PARAMEDICS AND RESTORED TO PACED WITHOUT LOC OR NEED FOR AMBU/CPR.\nTO CCU VSS.\n\n PT WITH V PACING- 80'S, INFREQ VEA NOTED. ALL LYTES CHECKED ON ARRIVAL -WNL.K- 4.4, MG-1.9,FREE CA- 1.15.\nBP- 106/72- 119/62 VIA DYNAMAP.\n12L EKG OBTAINED- 100% PACED.\nEP FELLOW CALLED AND IS CURRENTLY REVIEWING PT CASE AND TO INTEROGATE PACER/ICD. PT PUT ON /DEFIB CURRENTLY.\nINR CURRENTLY 1.5- TO DISCUSS STARTING HEPARIN TO KEEP THERAPEUTIC IN LOW EF STATE, NO COUMADIN IN CASE OF NEED FOR INVASIVE PROCEDURE THIS AM.\nCPK THIS AM (-) AS WELL.\n\n PT ARRIVED ON 100% NR- WEANED TO 40% FACE TENT- O2 SATS >97%\nCOMFORTABLE- BASE CX LEFT/RT.\nNO ISSUES CURRENTLY\n\nID- AFEBRILE\n\nGU- NO FOLEY CATH CURRENTLY. VOIDED 50CC X 1.\nAM CREATININE 1.6 UP FROM 0.7.\nRECEIVED 500CC NS AT OSH.\n\nGI- NO N/V CURRENTLY- STATES HAS NOT BEEN WELL FOR PAST SEVERAL DAYS.\n(+) DIG TOXIC. (+) BOWEL SOUNDS.\n\nMS-PT ALERT , ORIENTED, DIFFICULT TO FOLLOW HISTORY/STORY AT TIMES.\nSTATES SHE HAS NO SOB, WANTING PAIN MED FOR \"BACK PAIN\" - REPOSITIONED AND ATTEMPTED BACK RUB , ETC.\nRECEIVING 0.5 MSO4- SLEEPING CURRENTLY\n\nSTATES HEALTH CARE PROXY- - PH- \n\nLINES- #22 RT HAND IV ACCESS.\n\nA/ PT ADMITTED TO CCU FOR W/U OF POSSIBLE ICD MALFUNCTION/DELAY AND S/P SEVERAL EPISODES PRESUMED VT\n\nCONTINUE TO MONITOR PT , ON STANDBY.\nAWAIT PACER/ICD INTEROGATION AND PLAN FROM EP FELLOW.\nTO RESTART HEPARIN AND CV MEDS THIS AM.\nFOLLOW RENAL FX ? WET/DRY AND POSSIBLE NEED FOR MORE IVF.\nWEAN TENT TO NP AS ABLE THIS AM.\nCONTINUE TO PROVIDE INFO FOR PT, PLAN OF CARE AS WELL AS COMFORT/MEDS AS NEEDED. CALL TO TO OBTAIN CT REPORT.\nHOLD DIG.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-05 00:00:00.000",
"description": "Report",
"row_id": 1569281,
"text": "CCU NPN 7a-7p\nS: \"My back and legs really hurt...the pain is always kinda there.\"\n\nO: Please see careview admission note and flowsheet for VS and additional data.\n\n\nCV: Pt HR 80 v paced, Dr. from EP up to interrogate pacer this am, see note in chart, plan for pt to have ICD battery change on Monday. NBP 97-117/62-72, MAPs>74. Pt bilateral pedal pulses palp, pt with bilateral LE edema +. No VT this shift. Pt started on heparin gtt at 900 units/hr, PTT subtherapeutic at 41, Heparin gtt increased to 1000 units/hr at 1650, PTT to be drawn this eve. Pt CK (CPK) 29 (was 33), troponin 0.06 (was 0.08). Dr. in to speak with pt regarding code status, per Dr. and order pt is but otherwise full code.\n\nResp: Received pt on face tent 40% with rr teens, O2 sats 100%-> pt weaned to 2L n.c with RR 16-23 (in 20's with pt c/o pain and after movement/turning in bed), O2 sats 99-100%. Pt denies SOB, appears comfortable at rest. Pt LS clear at apices to coarse at bases this am, pt LS clear this afternoon.\n\nNeuro: Pt alert and oriented x 3-> pt has some difficulty recalling exact date, but aware of Month, year and Day. Pt pleasant cooperative with care. Pt asking appropriate questions regarding care. Pt MAE, follows commands, appears to have good strength bilateral , pt moves bilateral slightly with difficulty, pt states d/t pain, pt able to wiggle toes, bend knees slightly,+sensation. Pt with c/o back/leg pain out of 1 to 10 pain scale, percocet given with minimal relief. Pt to L and T spine Xray this afternoon, results pending. Pt dozing intermittently, engaging in conversation at times.\n\nGI/GU: Pt abd soft, + BS x 4, no stool this shift, pt NPO this am-> changed to heart healthy diet with 1500 mL fluid restriction, pt ate some of dinner, pt compliant with fluid restriction, pt denies nausea. Pt voided x 3 via bedpan. Pt bladder slightly firm, pt denies pain with palpation, denies difficulty voiding, Dr. aware, obtain U&A when pt voids this eve. Per CCU Team, pt fluid goal of even, per Dr. , gentle hydration through PO fluids.\n\nID: Pt afebrile.\n\nSkin: Pt skin with some brusing/ecchymosis on legs, pt with sm 1cm x1cm pressure sore/ulceration on R buttock cheek, duoderm applied.\n\nSocial: Pt (whom pt states and states is HCP-no form in chart- asked by Dr. to bring in copy of form), called and spoke with RN x 3 this am. Pt changed prior code status (per HCP , pt had previous documented wishes DNR/DNI) pt verbalized wishes to have CPR/external defibrillation but does not wish to be intubted per Dr. . Pt brother called and spoke with pt this afternoon.\n\nA/P: 59 y/o female pacer/ICD interrogated, pt code status DNI but otherwise full code, pacer to T&L spine Xray this afternoon. As discussed per CCU Team rounds, continue to monitor pt hemodyanmics, rhythm, cont to monitor pt resp status-fluid I & O's, ? obtain U&A this eve, cont to follow. Continue to monitor PTT, lytes. Continue to p\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-05 00:00:00.000",
"description": "Report",
"row_id": 1569282,
"text": "CCU NPN 7a-7p\n(Continued)\nrovide emotional support to pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-06 00:00:00.000",
"description": "Report",
"row_id": 1569283,
"text": "ccu npn 7p-7a\nS:\"I've had this back and leg pain for more than 2 weeks, I think its from being in a hospital bed for so long.\"\nO: Please see carevue for VS and objective data\nCVS: Hemodynamically stable with HR 80, initially vpaced, AVpaced most of the night. Isolated PVC's noted. BP ranges 90's-111/50-70. IV Heparin at 1000 units/hour, PTT 92.2.\nResp: Sats 97-100% on 2L n/c. Lungs clear to diminished bases with fine rales in left base. Pt. denies SOB.\nID: Afebrile\nGI:GU: Taking po's, no N/V. Abdomen soft with active bowel sounds, no stool this shift. Voiding qs clear, yellow urine via bedpan. U/A sent as urine has strong odor. pnd results. Total I/O approx. even for day.\nSkin: Head s/p laceration from fall at home PTA, D/I with 4 staples. No drainage or bleeding noted. Duoderm from previous shift intact on buttocks from pressure sore, Pt. states she has had PTA.\nNeuro: Pt. A/A/0X3, able to state name, place and time and events leading up to hospitalization including her Pmhx. Pleasant and cooperative. Conversing easily with RN, appreciative of care. Continues with moderate to severe back and leg pain, which she states she has had for 2 weeks which she attributes to prolonged bedrest. Awaiting results of xrays taken previous shift. Medicated with prn Percocet, backrubs and frequent position changes. Slept at short intervals after 5mg po Ambien. CCU MDs, Dr. , spoke to , earlier this eve.\nA: Hemodynamically stable, NO NSVT, VT/VFIB\nP: Cont. to monitor hemodynamics, monitor rhythm, maintain IV Heparin, follow up with am labs. Repeat Dig.level. Follow up with U/A, XRAY results. Prn Perocet. Comfort and emotional support to Pt. and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-09 00:00:00.000",
"description": "Report",
"row_id": 1569289,
"text": "CCU NPN 7p-7a\nS: My back really hurts when I move.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 60 AVpaced, NBP 111-136/61-81, bilateral pedal and radial pulses palp. Received pt on Heparin gtt 900 units/hr, Heparin gtt dc'd at 0400 for ICD battery change/generator change this am. Am labs sent-> Hct 31, K 4.8, Na 131, PTT 63.7, INR 1.9-> Dr. aware.\n\nResp: Pt LS clear at apices to crackles at bases, pt RR teens to mid 20's with exertion, O2 sats 98-100% on 3 L n.c. Pt SOB with movement/turning, pt RR decreases to teens with rest.\n\nGI/GU: Pt abd soft, +BS x 4, no stool this shift, pt NPO after midnoc for planned ICD battery change this am. Pt voiding via bedpan, pt with poor u/o-Dr. aware, see flowsheet. Pt +753 cc at midnoc, +.7 cc LOS. AM BUN 32, creat 1.2.\n\nNeuro: Pt alert and oriented x 3, pleasant and cooperative with care, pt conversing appropriately. Pt with c/o back pain, pain increased with movement, pt repositioned and PO morphine sulfate and tylenol given as ordered with some relief. Pt took 5 mg ambien for sleep with good effect.\n\nID: Pt afebrile, WBC 9.4.\n\nSkin: pt with mult areas of brusing/ecchymosis noted, duoderm intact on coccyx, site not visualized. Pt staples on head CDI.\n\nSocial: Pt received several phone calls overnoc.\n\nA/P: 54 y/o female awaiting ICD battery change/generator replacement in EP today, remains hemodynamically stable overnoc. Continue to monitor pt hemodynamics, cont to monitor pt resp status, u/o lytes-cont to update CCU Team. Conntinue to provide emotional support to pt. Awaiting further plan of care from CCU Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-09 00:00:00.000",
"description": "Report",
"row_id": 1569290,
"text": "CCU NGS NOTE: ALT IN CV/SP PACER GENERATOR REVISION\nS: \"That was long\"\nO: For complete VS see CCU flow sheet. This 59y old woman with long hx of cardiomypathy with -v pacer with AICD was admitted to OSH after a fall at home. She was found to be dig toxic and had 2 episodes of VF which were not shocked until they converted to VF. She received digibind and was transfered to . She was shocked by EMTs in route for more VT. Upon arriving AICD was reprogramed to shock at lower HR.\nSHe has had no further episodes of VT. Captopril with rising creatine is supposed to be the source of dig toxicity.\nCV: Pt has been pain free. She went to EP today at 1030 for generator replace. THey put in temporary wire in preparation for change. All present caridac wires were in good operating condition so only generator was changed. HR on pacer was increased from 60 to 70 in DDD mode. She has therapies for VF, fast and slow VT. She received 1gm kefzol at 2pm and will cont that Q8. She received 2.5 of versed and 75 fentanyl. Pacing wire was removed from groin and she returned to CCU at 1630. HR now 70 AV paced with BP in 1-teens to 120/60. Her groin has very slight ooze, all pulses palpable. Dressing on L chest is dry and in tact. Heparin was d/c at 4am and as per EP should not be restarted until am. THek wrote to start coumadin in am.\nRESP: She is sating 100% on 4L NP, but drops to high 80s on RA. Decreased BS at bases.\nGI: Was NPO until she returned and ate fair dinner.\nRENAL: She voided in BP which spilled mod amt prior to leaving. She has not voided since. She tried upon returning but was unable to. Will try again\nSKIN: She has 2 very small skin tears on either side of coccyx. Duoderm replaced today. They seem to be healing. SHe has multiple eccymotic areas.\nMS/COMFORT: Pt was quite groggy upon returning. She had not received usual morphine SR 15mg at noon. She did get tylenol and percocette at 1730. She has usual discomfort with position changes, but appears comfortable when lying still.\nA: Successful generator replacement/DTV\nP: Monitor urine output closely. SHe is ~2 liters pos LOS. She has not received her usual lasix 100mg since admit so monitor resp status closely. REstrart morphine SR as needed. Do not restart anticoagulation until am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-10 00:00:00.000",
"description": "Report",
"row_id": 1569291,
"text": "CCU NPN 7p-7a\nS: \"Is it time for more pain medicine...when will this pain get better?\"\n\nO: 54 y/o female with cardiomyopathy, EF 15-20%, PAF, see admit note for additional hx, pt with -v pacer/AICD who fell at home and was admitted to OSH. While at OSH,head CT neg for bleed, pt found to be dig toxic, rec'd digibind, pt into VT/VF x 2 while at OSH-pt requiring CPR, ICD fired after approx 1.5 mins, VS restored, pt in ambulance to , pt into VT, shocked/defib and rhythm restored. Pt to on , pacer interogated, pacer in need of battery/generator change, generator change on , please see careview for VS and additional data.\n\nCV: Pt AV paced HR 70 DDD mode, NBP 103-130/66-80, pt down to EP during previous shift for generator change, dsd over site, scant amt of bld noted on dsg, betadyne noted, dsg unchanged throghout shift. R groin site CDI, area soft, no hematoma noted. Pt bilateral radial and pedal pulses palp, bilateral feet and hands cool. Am labs to be drawn. Heparin/coumadin to be started later this am, check with CCU Team/HO.\n\nResp: Pt LS clear at apices with fine crackles noted bilateral bases. Pt RR teens to 20's, pt SOB/RR increasing with movement/turning, RR teens at rest, O2 sats 95-100% on 2 L n.c.\n\nNeuro: Pt alert and oriented x 3, pt pleasant and cooperative with care, pt conversing and appropriate questions regarding care. Pt MAE, pt moves bilateral LE minimally, + sensation. Pt with c/o back/leg pain, PO morphine sulfate SR 15 mg and acetaminophen 1000 mg given, pt position change with some relief. Pt with some c/o discomfort when moving L arm-pt reminded not to move left arm.\n\nID: Pt afebrile, pt cont on Keflex 500 mg Q6 H for 7 days.\n\nGI/GU: Pt abd soft, + BS x 4, no stool this shift. Pt voiding via bedpan, approx 230 cc of measured u/o from -0300, pt with lg amt spilled x 1 and sm amt spilled x 1. Pt +730 cc at midnoc, +2689.7 cc LOS. AM BUN and creat to be drawn.\n\nSocial: Pt received one phone call last eve.\n\nA/P: 54 y/o female hemodynamically stable s/p battery/generator change biv pacer/ICD. Continue to monitor pt hemodynamics, rhythm, pacer site and groin site, start PO warfarin/? heparin-check with HO. Continue to monitor pt resp status, fluid status, u/o-pt has not rec'd home lasix dose since admission. Continue to monitor pt temps, lytes. Continue to provide emotional support to pt, awaiting further plan of care from CCU Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-10 00:00:00.000",
"description": "Report",
"row_id": 1569292,
"text": "Nursing Progress Note 7am-7pm\nS: \"Even if they say I have to move today, I don't think I am going to!\"\n\nO: Please see carevue for complete objective data.\n\nCV- S/P generator change, AV paced, HR-70, BP 108-125/56-87. started Heparin drip at 0945, then dc'd hep drip at 1100. Set to start coumadin tonight. dorsal/tibial pulses palp.\n\nResp- c/o SOB since procedure on Mon. Sats-98% and higher on 2L nc, 92% and up on Room air. RR-16-21, regular, and LS clear with diminished bases.\n\nGI/GU- BS present and abd soft. No BM this shift. Gave lasix 100 mg to diurese, but diff to evaluate progress b/c of ocas. incontinence of urine. I&O's not exact due to leaks. ~ -120.0 for the shift\n\nNeuro-continuing pain throughout back and legs. gave scheduled and PRN pain meds and repositioned. Some relief achieved but not much. increasing negative attitude about recovery, (i.e. not wanting rehab, depressed about amount of pain.) Cooperative and A&O x 3.\n\nID-Afebrile, Keflex 500mg QID for 7 days\n\nSkin- 4 staples in scalp. CD&I, not s/s of infection or drainage. R femoral dressing clean and dry, no sign of hemotoma. LUQ dressing soaked with betadine, cov'd with gauze and transparent dressing. Coccyx area red, washed with soap and H2O, frequent turns.\n\n friend visit and brother call.\n\nA/P: 54yo female with cardiomyopathy s/p ICD generator change . Monitor hemodynamics, frequent position changes to prevent skin impairments. Manage Pain with meds and alternative options.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-07 00:00:00.000",
"description": "Report",
"row_id": 1569286,
"text": "CCU Progress Note:\n\nS- \"I feel sick to my stomach!\"\n\nO- see flowsheet for all objective data.\n\ncv- Tele: AV paced rhythm- rate 80- b/p 100-108/63-78- dig level 4.1 this am- Hct 30.6- K 3.6 KCL 40meq given- Mg 1.9 Mg sulfate 1gm given-\nheparin gtt @ 700u/hr- PTT 63.6- plan is for battery change tomorrow.\n\nresp- In O2 2L via NC- lung sounds with bibasilar crackles- RR 18-22- very SOB with exertion- SPO2 97-99%- sats drop to 91% on room air.\n\nneuro- A&O X3- moving all extremities- pleasant & cooperative- follows command.\n\ngi- abd soft (+) bowel sounds- taking Po fair- c/o nausea this afternoon- tylenol held @ 1600 due to nausea- no BM today- LFT's added to am labs- results pending- NPO after 12am for EP lab.\n\ngu- voiding conc amber colored urine- incontinent lg amt of urine while napping- U/O essentially = today- BUN 35 Crea 1.4\n\ncomfort- c/o severe back pain with movement- morphine sulfate 15mg Po q12hr & tylenol 1000mg Po q8hr working well controlling pain overall- back care given PRN.\n\nA- Pre-op for battery change tomorrow- seen by anesthesia this am.\n\nP- monitor vs, lung sounds, I&O and labs- ? heparin gtt INR needs to be < 1.8 in am- offer emotional support to Pt & family- keep them updated on plan of care.\n\naddendum: Pt c/o of CP @ 1800- on pain scale- EKG done- paced rhythm- Ntg Sl X2 given with total relief of pain- vss.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-08 00:00:00.000",
"description": "Report",
"row_id": 1569287,
"text": "CCU NURSING PROGRESS NOTE\nS:\"MY BACK IS SORE\"\nO:PT END STAGE HEART FAILURE, ICD BATTERY REPLACEMENT ON HOLD. PT W/ SEVERE DYSPNEA ON EXERTION. SATS REMAIN >95%. LUNGS W/ BIB CRACKLES. EXTREMITIES COLD AND MOTTLED, NOW COOL AND W/SLT COLOR IMPROVEMENT.\nPT W/ A GREY HUE TO GENERAL COLORING. NAUSEA ON AND OFF THROUGH THE NOC. TOL LIQ AND MEDS. VOIDING ON BED PAN. PT RECEIVED ATIVAN FOR ANXIETY W/ GOOD EFFECT. AMBIEN FOR SLEEP W/ SOME EFFECT.\nA/P:PT PRESENTLY FULL CODE, DISCUSS FINAL CODE STATUS IF PT WILL NOTE BE GOING TO EP LAB. SEE FLOW SHEET FOR ADDITIONAL INFORMATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-08 00:00:00.000",
"description": "Report",
"row_id": 1569288,
"text": "CCU NSG NOTE: ALT IN CV:CARDIOMYOPATHY/SP VF ARREST\nS: \"I'd rather go tomorrow. I'm now hungry for the first time\"\nTHis 59y old woman with hx of cardiomyopathy with EF ~15% with -V pacer and AICD was transfered from OSH .She went after fall at home with dig toxicity and increasing creatinine. She received 4 vials of digibind after VF arrest and slow response from AICD. ONce arriving here AICD reprogramed to shock at lower rate. ACE and lasix stopped.\nO: For complete VS see CCU flow sheet.\nID: Pt remains afebrile. UA neg for infection.\nCV: No episodes of chest discomfort today. She remains AV paced at a rate of 60s. No ectopy seen. EP should increase her hr, but have not yet done it. It was decided to change her generator tomorrow. Dig, lasix and ace continue to be held. Hydralizine was increased to 20mg . AM Ptt was subtheraputic and she was bolused with 1000u and drip increased to 900u/hr. Repeat PTT theraputic at 67.9. Heparin should be stopped at 4am in preparation for pacer generator change tomorrow. Trial was lying flat on usual analgesic-nothing aditional was successful. She had no sob lying flat.\nRESP: Pt has BBR. She had no C/O of dyspnea. She is sating 98-100% on 3.5 L NP.\nGI: THough c/o of baseline mild nausea she ate well at lunch and dinner. No BM.\nRENAL: Creatinine continues to decrease to 1.2 today. Urine output is poor and urine appears very consentrated. She is considered to be uvolemic at this point. She is ~700cc pos for the day. and 1900cc pos LOS.\nSKIN: She has multiple eccomotic areas on her arms and legs. She has two small stage one skin tears to left and right of coccyx. Thin duoderm applied.\nCOMFORT: Pt conts on standing MS SR 15mg and 1000mg tylenol Q 8 and occasional percocette which is giving fair relief. She appears comfortable if not being moved. She has been able to sleep.\nA: Stable/awaiting replacement of pacer generated.\nP: Shut off heparin at 4am . Continue with standing back pain regimine. Monitor for heart failure. Keep careful I & O.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-06 00:00:00.000",
"description": "Report",
"row_id": 1569284,
"text": "Nursing Progress Note 7am-7pm\nS: The pain in my back radiates down my legs and they feel numb.\n\nO: Please see carevue for complete objective data.\n\nCV-HR=80 AV paced, no ectopy. BP-100-110/69-73. Started Hydralazine, tolerating well. PTT-113.9, reduced heparin to 900 units/hour. EP requesting a goal PTT of 60-80 on heparin. PTT redrawn at 1630, results pending. Scheduled for ICD battery change on \n\nRESP- RR=14-22, varies on pain level and activity. Lungs clear with bilateral base crackles. O2 stopped after rounds and sats remained 92 and above. After CT scan sats dropped to high 80's. Gave O2 2L via nc and sats increased to high 90's. Pt remains on 1L nc.\n\nGI/GU- No BM, BS present x 4, abd soft. Voiding dark yellow urine via bedpan. Foley cath is not appropriate d/t pending procedure on Mon. Voided only 95cc for this shift. + 1.1L DC'd 1500cc restrictive diet. Gave 250 NS bolus for potential of being dry. Need UA on next void.\n\nSkin- PIV 22G in left hand, WNL. Impaired skin on coccyx area. Cov'd with duoderm, CD&I. Stitches on scalp due to fall, clean and intact.\n\nNeuro- hx of depression, taking zoloft and ativan. No s/s of confusion. A&O x3. Radiating pain from back down the legs. Legs are tingling and numb and has difficulty moving legs. Had pain consult and new meds prescribed. Heating pad applied to back, and pt expressed relief. CT scan done to locate pain source.\n\nSocial- very pleasant and cooperative. 2 nieces came to visitand made phone calls.\n\nA/P: 59 yo female with end satge cardiomyopathy, EF 15-20%, s/p CABG and MI with LAD dissection. Admitted for GI distress, N/V, dig tox, and episodes of VF/VT relieved by ICD. ICD reprogrammed and set for generator replacement on mon .\n\nMonitor VS and lab values to adjust heparin according to goal PTT 60-80. Attempt to wean off O2, keeping sats above 93%. Assess and manage pain with appropriate therapies.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-09-07 00:00:00.000",
"description": "Report",
"row_id": 1569285,
"text": "ccu npn 7p-7a\nS:\"I'm tired tonight.\"\nO: Please see carevue for VS and objective data\nCVS: Hemodynamically stable with HR 80 AVpaced, rare PVC noted. BP ranges 100-117/50-70, tolerating po Hydralazine. IV Heparin at 800u/hour with repeat PTT 81.7, decreased to 700u/hour at 0000, to have PTT/PT, INR with am labs.\nResp; Sats 95-99% on 2l n/c. Lungs clear, diminished right base, left with fine rales.\nGI:GU: Taking po's, no N/V. Abdomen soft with active bowel sounds, no stool this shift. Voiding qs clear, yellow urine via bedpan. Urine lytes sent as ordered, pnd. Total I/O remains positive.\nID: afebrile\nNeuro: Pt. A/A/0x3, pleasant and cooperative, appreciative of care. Conts with back and leg pain, slightly improved with heating pad prn, Morphine sulfate SR 15mg q12hours and tylenol 1000mg po q 8hours. Given backrub and frequent repositioned. Slept well at intervals.\nA: Hemodynamically stable, no sign. vea noted, awaiting battery change by EP.\nP: Cont to monitor hemodynamics, rhythm, maintain IV Heparin with goal PTT 60-80, follow up with am labs. Plan for battery change with EP. Cont to assess Pt's response to pain management. Comfort and emotional support to Pt. and family.\n"
},
{
"category": "ECG",
"chartdate": "2166-09-10 00:00:00.000",
"description": "Report",
"row_id": 283830,
"text": "A-V paced rhythm. Since the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-09-07 00:00:00.000",
"description": "Report",
"row_id": 283831,
"text": "A-V paced rhythm\nPacemaker rhythm - no further analysis\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2166-09-09 00:00:00.000",
"description": "Report",
"row_id": 283832,
"text": "A-V sequential paced rhythm\nNo change from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2166-09-08 00:00:00.000",
"description": "Report",
"row_id": 283833,
"text": "A-V paced rhythm. Since the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-09-06 00:00:00.000",
"description": "Report",
"row_id": 283834,
"text": "A-V sequential paced rhythm\nCompared to previous tracing, no change\n\n"
},
{
"category": "ECG",
"chartdate": "2166-09-07 00:00:00.000",
"description": "Report",
"row_id": 283835,
"text": "A-V sequential paced rhythm\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2166-09-05 00:00:00.000",
"description": "Report",
"row_id": 283836,
"text": "A-V sequentially paced rhythm, new compared to the previous tracing of .\nOtherwise, no diagnostic interim change.\n\n"
}
] |
17,644 | 108,088 | The patient was admitted for further surgical therapy of his recurrent rectal cancer. In the operating room, the decision was made to proceed with abdominoperineal resection. The patient seemed to tolerate the procedure well without complication. Postoperatively, the patient was recovering nicely on bedrest until the morning of , postoperative day number two. The patient on postoperative day number two had some mental status changes and was initially somewhat lethargic and became agitated and intermittently violent. The patient became disoriented although he was alert. Initial workup including cardiac and metabolic workups proved to be negative. The patient did have some crackles on physical examination throughout his lung fields. After speaking with the family, the patient had a history of some altered mental status changes preceding a previous episode of pneumonia that he had had. Working diagnosis at that time was pneumonia versus hospital psychosis. The patient's mental status did not improve over the course of the following two days with some intermittent agitation. The patient was medicated with Haldol and Ativan. This had some success. On the evening of postoperative day number four, the patient had an acute episode of respiratory distress and required intubation on the floor. Subsequent to this, the patient was transferred to the Intensive Care Unit for closer monitoring and ventilatory management. In the Intensive Care Unit, the patient did well and was extubated postoperative day number six. The patient was empirically covered for a probable aspiration pneumonia with Levaquin, a seven day course. The patient was transferred back to the floor on postoperative day number six. His mental status was normal at that time. Throughout the rest of his hospital course, the patient did quite well. His diet was advanced as tolerated. The patient was discharged on postoperative day number ten tolerating a regular diet and having regular ostomy output, good pain control on p.o. pain medications. | There is probable COPD and a persistent small right pleural effusion with associated atelecatasis in the right lower zone, unchanged since the prior film of the same date if allowances are made for technical differences. Right CV line is in distal SVC. Since the previous tracing of ventricular premature beats are seen.TRACING #1 There is haziness of the pulmonary vasculature centrally. Tip of right subclavian cv line is in distal SVC. The cardiomediastinal silhouette is within normal limits. Slight left heart failure is again noted. TECHNIQUE: Noncontrast head CT. Small bilateral pleural effusions and atelectasis right lung base. 3) Mild mucosal thickening of the right ethmoid air cells. There is continued, residual, right mid lung and right lower lobe interstitial pattern. This is most likely due to an intrathoracic goiter. IMPRESSION: 1) Cardiomegaly with CHF. Interval improvement in appearance of right lung, but with residual interstitial patern in right mid lung and right lower lung. Persistent opacity consistent with atelectasis and possible small pleural effusion is present at the right lung base and there is a probable tiny left pleural effusion. Resp. Indeterminate frontal QRS axis. Indeterminate frontal QRS axis. Probable COPD. Sinus rhythm. Sinus rhythm. Sinus rhythm. Minimal blunting of the left costophrenic angle is present. Since the previous tracing of probably nosignificant change.TRACING #3 Lungs clear and decreased at bases. 11:53 AM CHEST (PA & LAT) Clip # Reason: ? Comparison is made to a spot film from chest fluoroscopy dated . PORTABLE AP CHEST: A single AP semiupright view. Extubated after ABG 7.40/52/80. Baseline artifact. Baseline artifact. Currently, low O2 sats. doing well post-ext. The central venous line is again seen with its tip in the right atrium and is in unchanged position. Right bundle-branch block. Right bundle-branch block. Right bundle-branch block. Some ill defined infiltrate is noted in the right lower lobe. The right hemidiaphragm is not well identified and a small right pleural effusion might be present. There is a minimal amount of mucosal thickening within the right ethmoid air cells. Currently hypoxic. 2) Mild brain atrophy and chronic small vessel ischemic changes. There is a low attenuation in the periventricular white matter consistent with chronic small vessel ischemic changes. Rightbundle-branch block. Right subclavian portacath is in upper right atrium. ot HR is 110-140.Resp: pt was tranfered on 2 liters, pt sao2 decreased to 88 and ABG drawn 7.42/53/59/36. 10:53 AM CT HEAD W/O CONTRAST Clip # Reason: PT FOUND UNRESPONSIVE, CHANGE IN MENTAL STATUS, R/O BLEED FINAL REPORT INDICATION: Mental status changes. There has been interval improvement in the appearance of the right lung. There is slight cardiomegaly with pulmonary vascular engorgement and small bilateral pleural effusions consistent with CHF, likely superimposed on background of COPD. Cont. Heart size is borderline for supine technique. Sinus tachycardia. Pt. Pt. Pt. Pt. Sincethe previous tracing of ventricular premature beats are not seen.TRACING #2 The endotracheal tube, the left and right subclavian lines remain in satisfactory and unchanged positions. Overall appearances are essentially unchanged, when compared with prior study of . offered small amount of cl with no signs of aspiration noted.P: Encourage activity, couging/deep breathing, increase activity as tolerated. The ventricles are mildly prominent as well as mild prominence of the sulci consistent with mild brain atrophy. There is cardiomegaly but no definite chf. pt is able to answer questions appropriatly and able to aid in own care.CV: Pt Bp is stable @ 140-130/70-80. effusion ? effusion ? There is narrowing of the trachea in the mid portion. pt PERLA. Since the previous film of the same date, a left subclavian CV line has been introduced with tip overlying proximal SVC. Background emphysema is appreciated. There is cardiomegaly. There is cardiomegaly. review of systems:Neuro: pt is A & O x3, pt is appropriate and MAE x4. A right subclavian central venous line is seen with tip in the right atrium. Cardiomegaly, but no definite pulmonary edema. expectorating moderate amount clear-white sputum. The heart again shows slight left ventricular enlargement and there is some unfolding of the aorta. ?ASPIR.PNA FINAL REPORT CHEST, SINGLE AP FILM. ETT is cm above carina. These findings are consistent with slight left heart failure, unchanged since the prior study. IMPRESSION: There has been slight clearing of the ill defined infiltrate at both lung bases since the prior study. Low QRS voltages in the limb leads.Since the previous tracing of probably no significant change.TRACING #4 Pt denies pain or other distress. 2) Narrowing of the trachea in its mid portion. Pt assisted oob to chair with transfer accomplished with one assist. IMPRESSION: Right subclavian catheter with tip in the right atrium. Respitory hygiene encouraged with pt. The pulmonary vessels show upper zone redistribution and there is some blurring of vascular detail at the bases suggesting slight left heart failure. No congestive heart failure. ET tube is 2 cm above carina. | 14 | [
{
"category": "Radiology",
"chartdate": "2197-11-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 774674,
"text": " 11:53 AM\n CHEST (PA & LAT) Clip # \n Reason: ? effusion ? infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p for rectal CA. Currently, low O2 sats.\n REASON FOR THIS EXAMINATION:\n ? effusion ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63 year old man status post for rectal cancer. Currently\n hypoxic.\n\n CHEST X-RAY, PA AND LATERAL: Comparison is made to films of . A right\n subclavian central venous line is seen with tip in the right atrium. There\n has been interval improvement in the appearance of the right lung. There is\n continued, residual, right mid lung and right lower lobe interstitial pattern.\n The cardiomediastinal silhouette is within normal limits. Background\n emphysema is appreciated.\n\n IMPRESSION: Right subclavian catheter with tip in the right atrium. No\n pneumothorax. Interval improvement in appearance of right lung, but with\n residual interstitial patern in right mid lung and right lower lung.\n Recommend further followup to confirm clearing. No congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 774123,
"text": " 9:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute process, ?pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/p for rectal CA, with mental status changes.\n REASON FOR THIS EXAMINATION:\n ?acute process, ?pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63 year old man status post for rectal carcinoma with mental\n status change, evaluate for pneumonia.\n\n CHEST PORTABLE: No prior studies are available for comparison. There is\n cardiomegaly. Comparison is made to a spot film from chest fluoroscopy dated\n . There is cardiomegaly. There is narrowing of the trachea in the mid\n portion. There is upper zone vascular redistribution. There is haziness of\n the pulmonary vasculature centrally. The right hemidiaphragm is not well\n identified and a small right pleural effusion might be present. The central\n venous line is again seen with its tip in the right atrium and is in unchanged\n position.\n\n IMPRESSION:\n\n 1) Cardiomegaly with CHF.\n\n 2) Narrowing of the trachea in its mid portion. This is most likely due to an\n intrathoracic goiter. Comparison with prior outside studies is recommended, if\n available. Otherwise a CT examination of the chest could be performed to\n exclude other etiologies of a mediastinal mass.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1260452,
"text": " 8:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP FILM:\n\n HISTORY: Respiratory distress with intubation and line placements.\n\n Since the previous film of the same date, a left subclavian CV line has been\n introduced with tip overlying proximal SVC. Right CV line is in distal SVC.\n ETT is ____ cm above carina. No pneumothorax. There is slight cardiomegaly\n with pulmonary vascular engorgement and small bilateral pleural effusions\n consistent with CHF, likely superimposed on background of COPD.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-11-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1260416,
"text": " 10:53 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: PT FOUND UNRESPONSIVE, CHANGE IN MENTAL STATUS, R/O BLEED\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Mental status changes.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intra axial or extra axial hemorrhage. There is no\n shift of normally midline structures or mass effect. The ventricles are mildly\n prominent as well as mild prominence of the sulci consistent with mild brain\n atrophy. There is a low attenuation in the periventricular white matter\n consistent with chronic small vessel ischemic changes.\n\n On bone windows there are no skull fractures. There is a minimal amount of\n mucosal thickening within the right ethmoid air cells. The orbits are\n unremarkable.\n\n IMPRESSION:\n\n 1) No evidence of intracranial hemorrhage.\n 2) Mild brain atrophy and chronic small vessel ischemic changes.\n 3) Mild mucosal thickening of the right ethmoid air cells.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1260270,
"text": " 12:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: Intubation and line placement in patient with recent surgery for\n rectal and colonic cancer and persistent respiratory distress.\n\n ET tube is 2 cm above carina. Tip of right subclavian cv line is in distal\n SVC. No pneumothorax. Heart size is borderline for supine technique. There\n is probable COPD and a persistent small right pleural effusion with\n associated atelecatasis in the right lower zone, unchanged since the prior\n film of the same date if allowances are made for technical differences. No\n pneumothorax.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2197-11-19 00:00:00.000",
"description": "Report",
"row_id": 176041,
"text": "Sinus rhythm. Right bundle-branch block. Low QRS voltages in the limb leads.\nSince the previous tracing of probably no significant change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2197-11-17 00:00:00.000",
"description": "Report",
"row_id": 176042,
"text": "Baseline artifact. Sinus tachycardia. Indeterminate frontal QRS axis. Right\nbundle-branch block. Since the previous tracing of probably no\nsignificant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2197-11-16 00:00:00.000",
"description": "Report",
"row_id": 176043,
"text": "Sinus rhythm. Indeterminate frontal QRS axis. Right bundle-branch block. Since\nthe previous tracing of ventricular premature beats are not seen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2197-11-15 00:00:00.000",
"description": "Report",
"row_id": 176044,
"text": "Baseline artifact. Sinus rhythm. Frequent multiform ventricular premature\nbeats. Right bundle-branch block. Since the previous tracing of \nventricular premature beats are seen.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1260461,
"text": " 7:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Cough and fever. Check for pneumonia.\n\n PORTABLE AP CHEST: A single AP semiupright view. Comparison is made to\n previous films from . The heart again shows slight left ventricular\n enlargement and there is some unfolding of the aorta. The pulmonary vessels\n show upper zone redistribution and there is some blurring of vascular detail\n at the bases suggesting slight left heart failure. Some ill defined\n infiltrate is noted in the right lower lobe. Minimal blunting of the left\n costophrenic angle is present. These findings are consistent with slight left\n heart failure, unchanged since the prior study. The endotracheal tube, the\n left and right subclavian lines remain in satisfactory and unchanged\n positions.\n\n IMPRESSION: There has been slight clearing of the ill defined infiltrate at\n both lung bases since the prior study. The appearances are otherwise\n unchanged. Slight left heart failure is again noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1260269,
"text": " 12:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB.?ASPIR.PNA\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST, SINGLE AP FILM.\n\n HISTORY: Rectal/colon cancer resection with chemo/radiation therapy and line\n placement with persistent respiratory distress.\n\n Right subclavian portacath is in upper right atrium. No pneumothorax. There\n is cardiomegaly but no definite chf. Persistent opacity consistent with\n atelectasis and possible small pleural effusion is present at the right lung\n base and there is a probable tiny left pleural effusion. Overall appearances\n are essentially unchanged, when compared with prior study of .\n\n IMPRESSION: No significant change since prior studies. Cardiomegaly, but no\n definite pulmonary edema. Small bilateral pleural effusions and atelectasis\n right lung base. Probable COPD.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-11-21 00:00:00.000",
"description": "Report",
"row_id": 1493972,
"text": "review of systems:\n\nNeuro: pt is A & O x3, pt is appropriate and MAE x4. pt PERLA. pt is able to answer questions appropriatly and able to aid in own care.\n\nCV: Pt Bp is stable @ 140-130/70-80. pt is in Atrial fib and on a amio gtt @ .5 mg/min and is being transitioned to PO amio. ot HR is 110-140.\n\nResp: pt was tranfered on 2 liters, pt sao2 decreased to 88 and ABG drawn 7.42/53/59/36. pt o2 was increased to 6 liters. pt sao2 increased to 97%, ABG pending. pt is able to give himeslf nebs PRN\n\nGI/GU: pt has good UO per foly cath, pt urine is yellow with seds. pt has had no BM since transfer, and is reciving tube feeds @ 50 cc/hr\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-11-21 00:00:00.000",
"description": "Report",
"row_id": 1493973,
"text": "D: Please see , MD progress notes/orders for assessment and all pertinent data. Pt. a&o this a.m., team member in on rounds and dc/d NGT. A-line and foley catheter, IVF and amiodorone gtt also discontinued. Pt assisted oob to chair with transfer accomplished with one assist. Pt denies pain or other distress. Pt. converted to SR with occ PAC's from Afib early this morning. 02 decr to 4L nc from 6L with sats ranging 91-94%. Lungs clear and decreased at bases. Respitory hygiene encouraged with pt. expectorating moderate amount clear-white sputum. Pt. with soft abd, +bs and colostomy draining brown liquid stool to gravity in moderate amounts. Stoma is pink. Pt. offered small amount of cl with no signs of aspiration noted.\n\nP: Encourage activity, couging/deep breathing, increase activity as tolerated. Cont. to assess comfort level, vs and 02 sats, notify team of any change. Continue on CL diet and monitor for any signs of aspiration.\n\nR: as above, pt up in chair for most of day with vs/02 sats stable. No signs of aspiration noted, no pain voiced. Pt for transfer to telemetry when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-11-20 00:00:00.000",
"description": "Report",
"row_id": 1493971,
"text": "Resp. Care Note\nPt received intubated and vented on PSV 10 peep 5 35%. Pt weaned to CPAP5 and 35%. Extubated after ABG 7.40/52/80. doing well post-ext. currently on 2L NP with sats 91%. Using MDI's with spacer, excellent technique.\n"
}
] |
31,986 | 178,804 | 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB, wheezing and hypoxia w/ possible LLL opacity on OSH film. ICU course by problem: . #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status thought PNA (either NH/CAP vs. aspiration). Her PNA was supported by possible infiltrate but also by heavy secretions. Secretions improved within 2 days. We suspect PNA may have triggered COPD flare. Minimal evidence of CHF exacerbation on imaging, exam and labs, but does have CHF history. We treated her as follows: - PNA: treated with vanco, ceftaz, flagyl for nosocomial coverage with plans for an 8 day course. She will need 4 more days of this regimen. Note that her vanco trough on am of was 35 so we recommend rechecking vanco trough on and dose 1gm q24 for trough<20. We also treated with azithromycin to cover atypicals. She will need two more doses of this. - COPD: We treated with prednisone 40mg daily and tapered down. Recommend 20mg daily x3d, 10mg daily x3d then stop. We also treated with q1-2h albuterol nebs and q6h ipratropium nebs. This was spaced out to q4h with breakthrough prn nebs. - UCx negative but BCx still pending - low suspicion for MI. CE as above - she was on 4L NC prior to discharge from the hospital. . #. COPD: -- management as above . #. chronic systolic CHF: no evidence of volume overload on exam; BNP 38 (negative) at OSH. Echo here was of poor quality but did not reveal obvious wall motion abnl. We gently diuresed with lasix 10mg IV to keep her even to slightly negative. She tolerated this well. . #. HTN: Initially held her metoprolol but this was restarted. . #. Hypothyroidism -- continue levothyroxine 88 mcg QD . #. Dementia: not currently on medications . #. Depression: was on venlafaxine in past; held on last admission for c/f NMS. Nothing on med list currently. . #. Osteoporosis: currently on calcium supplements -- cont calcium; -- fall precautions . #. FEN: on admission, takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc free water flushes Qshift. we used Replete w/fiber Full strength during her ICU stay. Nutrition recs included in d/c paperwork. . #. PPX: no indication for PPI currently; SHQ (wears boots at rehab); bowel regimen . #. Code: DNR/DNI, confirmed with family by ED staff. . #. Contacts: Spoke with daughter (HCP) for ICU consent and confirm code status. . #. Dispo: to Rehab from the ICU. . #. Access: PICC placed on . It was confirmed on CXR. Please d/c PICC when done with IV abx. | 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. Resting tachycardia (HR>100bpm). Right ventricular function.Height: (in) 63Weight (lb): 150BSA (m2): 1.71 m2BP (mm Hg): 115/70HR (bpm): 103Status: InpatientDate/Time: at 11:29Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA.LEFT VENTRICLE: LV not well seen. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status likely PNA (either NH/CAP vs. aspiration). FINDINGS: The hand of the patient obscures most of the right hemithorax. Depression: was on venlafaxine in past; held on last admission for c/f NMS. The rhythmappears to be atrial fibrillation.Conclusions:The left atrium is dilated. Pt asymptomatic other than more lethargic: responding only to sternal rub when crackles developed. Chest pt given with turns. IMPRESSION: Limited exam. Hypothyroidism -- continue levothyroxine 88 mcg QD . Nebs and Chest PT to help Pt. Osteoporosis: currently on calcium supplements -- cont calcium; t/c starting Vit D -- fall precautions . LS rhonkie with occ wheez. FINDINGS: In comparison with the earlier study of this date, there has been placement of a left subclavian PICC line that extends to the mid portion of the SVC. Left PICC remains in place, there is mild increase in right lower lobe atelectasis. I/O at this time +112cc. Response: Remains afebrile. Baseline artifact makes interpretation difficultSinus tachycardiaSince previous tracing of the same date, baseline artifact present Baseline artifactSinus tachycardiaPoor R wave progressionNonspecific T wave flatteningSince previous tracing of , no significant change Pneumonia, other Assessment: Scattered rhonchi t/o lungs at beginning of shit with sats in mid 90s on 70% cool neb. Leftventricular function is probably normal, a focal wall motion abnormalitycannot be fully excluded. on 70% cool neb mask. Overall normal LVEF (>55%).No resting LVOT gradient.RIGHT VENTRICLE: RV not well seen.AORTIC VALVE: Aortic valve not well seen.MITRAL VALVE: Mitral valve leaflets not well seen.TRICUSPID VALVE: Tricuspid valve not well visualized.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Today was hypoxemic and transferred to - Afeb, 99.8 HR 106, 122.68, RR 22, 92% on 2L NC, WBC 28 with 19% bands, troponin <0.04. # Hypothyroidism - cont. # Hypothyroidism - cont. #PPx: PPI, SQH, bowel regimen . #PPx: PPI, SQH, bowel regimen . #.HTN: -cont. #.HTN: -cont. Cont require ICU care for tenuous resp status with desats and requiring suctioning q1-2hrs. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status likely PNA (either NH/CAP vs. aspiration). Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status likely PNA (either NH/CAP vs. aspiration). Chief Complaint: hypoxia/dyspnea 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. #COPD -cont. #COPD -cont. albuterol nebs q2h -atrovent nebs q6h . albuterol nebs q2h -atrovent nebs q6h . Pt turned freq. #F/E/N -TF via g-tube -goal: -even to negative . TFs through G-tube. Assessment and Plan ASSESSMENT/PLAN: 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB, wheezing and hypoxia w/ possible LLL opacity on OSH film. levothyroxine . levothyroxine . Hypothyroidism -- continue levothyroxine 88 mcg QD . Hypothyroidism -- continue levothyroxine 88 mcg QD . #F/E/N -TF via g-tube -may consider S&S eval, G-tube study to eval. # PNA Unimproved clinically with persistent leukocytosis (perhaps an element of reactive WBC from steroids) and copious purulent secretions -cont. # PNA Unimproved clinically with persistent leukocytosis (perhaps an element of reactive WBC from steroids) and copious purulent secretions -cont. 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. # Hypothyroidism - cont. # Hypothyroidism - cont. # Hypothyroidism - cont. #.HTN: -cont. #.HTN: -cont. #.HTN: -cont. #PPx: PPI, SQH, bowel regimen #. -albuterol nebs at q2h -atrovent nebs q6h #.CHF - CXR reflects mild degree of volume overload. albuterol nebs q2h -atrovent nebs q6h #.CHF - CXR reflects mild degree of volume overload. #COPD -cont. #COPD -cont. #COPD -cont. #PPx: PPI, SQH, bowel regimen . #F/E/N -TF via g-tube -goal: -even to negative . #F/E/N -TF via g-tube -goal: -even to negative . albuterol nebs q2h -atrovent nebs q6h . Rhochi diffusely CV: RRR, s1 & s2 nl, no m/r/g ABD: + BS, nt, nd, soft, G-tube in place with dressing C-D-I. Chief Complaint: hypoxia/dyspnea 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. levothyroxine . levothyroxine . Vancomycin d/c Response: Pt presently tolerating 2l/m nasal cannula with adequate o2 sats. Chief Complaint: hypoxia & dyspnea 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. Chief Complaint: hypoxia & dyspnea 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration PNA and COPD exacerbation. Hypothyroidism -- continue levothyroxine 88 mcg QD . Hypothyroidism -- continue levothyroxine 88 mcg QD . Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC 22-28; resp status likely PNA (either NH/CAP vs. aspiration). | 41 | [
{
"category": "Radiology",
"chartdate": "2152-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022648,
"text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, PNA\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: COPD, pneumonia.\n\n Comparison is made with prior study .\n\n There are low lung volumes. Atelectasis in the left base has improved. Left\n PICC remains in place, there is mild increase in right lower lobe atelectasis.\n There is mild fluid overload.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2152-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022477,
"text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 81 year old woman with ? LLL pneumonia in ICU; please evalua\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with ? LLL pneumonia in ICU; please evaluate for interval\n change in infiltrates and effusions.\n REASON FOR THIS EXAMINATION:\n 81 year old woman with ? LLL pneumonia in ICU; please evaluate for interval\n change in infiltrates and effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible left lower lobe pneumonia.\n\n FINDINGS: In comparison with the study of , there are lower lung volumes.\n Some increased opacification at the left base with silhouetting in the\n hemidiaphragm is most consistent with pleural fluid and atelectatic change,\n though the possibility of supervening pneumonia cannot be definitely excluded.\n Similar changes are seen at the right base medially, though some of this may\n merely be crowding of vessels.\n\n Indistinct prominence of pulmonary vessels suggests some elevated pulmonary\n venous pressure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022210,
"text": " 8:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrate, pulm edema\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, PNA a/w congestion, hypoxia\n REASON FOR THIS EXAMINATION:\n Eval for infiltrate, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 81-year-old woman with COPD and hypoxia.\n\n FINDINGS: Comparison is made to previous study from .\n\n The cardiac silhouette is upper limits of normal but unchanged. There is\n again seen some subsegmental atelectasis at the left base. The rest of the\n lung fields are clear. There are no signs for overt pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022314,
"text": " 5:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD a/w PNA\n REASON FOR THIS EXAMINATION:\n Eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD with possible pneumonia.\n\n FINDINGS: The hand of the patient obscures most of the right hemithorax.\n Otherwise, there is little change in the appearance of the heart and lungs\n from the study of . A repeat examination would be helpful.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1022156,
"text": " 8:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with cough and hypoxia\n REASON FOR THIS EXAMINATION:\n assess pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 81-year-old female with cough and hypoxia. Please assess for\n pneumonia.\n\n FINDINGS: AP upright chest radiograph is reviewed and compared to .\n Evaluation is limited by rotation, despite technologist's attempts to properly\n position the patient. Evaluation is also limited by low lung volumes. There\n is no large consolidation, though retrocardiac area cannot be reliably\n assessed. There is no definite pleural effusion or pneumothorax.\n\n IMPRESSION: Limited exam. No focal consolidation.\n\n"
},
{
"category": "Echo",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Report",
"row_id": 82576,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 63\nWeight (lb): 150\nBSA (m2): 1.71 m2\nBP (mm Hg): 115/70\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 11:29\nTest: Portable TTE (Complete)\nDoppler: Full 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.\n\nLEFT VENTRICLE: LV not well seen. Suboptimal technical quality, a focal LV\nwall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%).\nNo resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - bandages, defibrillator pads or electrodes. Suboptimal image\nquality as the patient was difficult to position. Suboptimal image quality -\npatient unable to cooperate. Resting tachycardia (HR>100bpm). The rhythm\nappears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is dilated. The left ventricle is not well seen. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Overall left ventricular systolic function is normal (LVEF>55%). The\naortic valve is not well seen. The mitral valve leaflets are not well seen.\n\nIMPRESSION: poor technical quality due to patient's body habitus. Left\nventricular function is probably normal, a focal wall motion abnormality\ncannot be fully excluded. The right ventricle is not well seen. Valvular\nfunction could not be evaluated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-06-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1022579,
"text": " 2:48 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: l dl picc 43cm\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with\n REASON FOR THIS EXAMINATION:\n l dl picc 43cm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement.\n\n FINDINGS: In comparison with the earlier study of this date, there has been\n placement of a left subclavian PICC line that extends to the mid portion of\n the SVC. Little change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2152-06-03 00:00:00.000",
"description": "Report",
"row_id": 199242,
"text": "Baseline artifact makes interpretation difficult\nSinus tachycardia\nSince previous tracing of the same date, baseline artifact present\n\n"
},
{
"category": "ECG",
"chartdate": "2152-06-03 00:00:00.000",
"description": "Report",
"row_id": 199243,
"text": "Baseline artifact\nSinus tachycardia\nPoor R wave progression\nNonspecific T wave flattening\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330481,
"text": "81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\n presented to Hospital from with dyspnea.\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\n 1700 via foley. Pt is DNR/DNI, admitted to for further\n management of pneumonia.\n Pneumonia, other\n Assessment:\n Pt continues on 40% cool neb, CXR~ LLL infiltrate. Pt suctioned q 2\n -3 hours for thick yellow secretions, afebrile, WBC 20.8 pt remains\n on Vanco, Ceftazidime, and Flagyl. On prednisone 40 mg per G-tube qd.\n Prednisone 40 mg qd, cpt done\n Action:\n Suctioned q 2 hrs, nebs q 6 hrs, aggressive pulmonary toilet\n Response:\n Sx helps clear airway\n Plan:\n Continue current therapies, monitor for worsening resp status\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt with Alzheimers dementia, parkinsonian gehavior, repetitive\n speech, expressive aphasia\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330464,
"text": "Alteration in Nutrition\n Assessment:\n Family states noted poor po intake over last few weeks, possibly due to\n compromised resp status\n Action:\n TF held for now poor resp status frequent NT suctioning w/ copious\n amts of secretions, coughing\n Response:\n Pt w/o s/s nutritional compromise, dehydration\n Plan:\n Re assess nutrition needs may start TF in 24 hr when pt settles\n Pneumonia, other\n Assessment:\n Pt w/ pneu w/ worsening cxr, copious amt thick yellow secretions, , low\n grade temp\n Action:\n Suctioned q1 hr , nebs q2-4 hrs prn , aggressive pulm toileting, ab tx\n Response:\n Cont to have need for freq suctioning, pulm toileting transient relief\n noted\n Plan:\n Cont current therapies, monitor for worsening resp status pt is\n DNR/DNI\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt w/ alzheimers dementia, parkinsonian behavior, repetitive speech,\n expressive aphasia\n Action:\n Allowed pt to answer question at own , occ be lucid\n Response:\n Able to communicate at times, able to answer appropriately when asked\n oif she was soilded or in pain\n Plan:\n Cont focused patient interaction with pt\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330547,
"text": "81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\n presented to Hospital from with dyspnea.\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\n 1700 via foley. Pt is DNR/DNI, admitted to for further\n management of pneumonia.\n Pneumonia, other\n Assessment:\n Pt. on 70% cool neb mask. Pulling mask off face frequently and desating\n to 85%. LS rhonkie with occ wheez.\n Action:\n Lasix 10 mg IV for I/O goal -500cc. Nebs and Chest PT to help Pt.\n mobilize secretions. NT suctioned few time this shift for thick yellow\n sectretions. IV abx as ordered.\n Response:\n Remains afebrile. I/O at this time +112cc.\n Plan:\n Cont. current care. Will give additional Lasix to meet I/O goal.\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330638,
"text": "81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation. Pt with s/p L cva summer of with\n residual aphasia and dementia including Alzheimers, multi-infarct.\n Pneumonia, other\n Assessment:\n Scattered rhonchi t/o lungs at beginning of shit with sats in mid 90s\n on 70% cool neb.\n Action:\n Pt nt suctioned for moderate amts clear white/clear secretions. Chest\n pt given with turns.\n Response:\n 02 sats remaining stable on 70% cool neb. Pt developed crackles around\n 9:30pm and noted to have a drop in urine to 17cc/hr. pt was given 10mg\n iv lasix with good response. At this time, pt has also been having\n short runs v tach up to 10 beat runs. Pt asymptomatic other than more\n lethargic: responding only to sternal rub when crackles developed.\n Still lethargic but more easily arousable.\n Plan:\n Continue nt suction prn, chest pt with turns, monitor fluid status, f/u\n with am labs and replete lytes prn.\n Alteration in Nutrition\n Assessment:\n Nutren pulmonary increased to goal of 65cc/hr . 100cc free water\n boluses given q6hrs. large loose ob + brown stool.\n Action:\n Tolerating tube feedings well with no residuals.\n Response:\n Continues to tolerate tube feedings.\n Plan:\n Continue tube feedings with free water boluses. Hold colace as pt\n having loose stool.\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330454,
"text": "Chief Complaint: SOB\n 24 Hour Events:\n SPUTUM CULTURE - At 05:11 AM\n --\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 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 07:35 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: 93 (78 - 104) bpm\n BP: 112/44(62) {89/27(42) - 117/56(70)} mmHg\n RR: 24 (16 - 24) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 57 Inch\n Total In:\n 4,835 mL\n PO:\n TF:\n IVF:\n 135 mL\n Blood products:\n Total out:\n 0 mL\n 2,650 mL\n Urine:\n 2,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,185 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG:\n Physical Examination\n Gen:\n Lungs:\n CV:\n ABD:\n EXT\n Labs / Radiology\n [image002.jpg]\n PROBLEM LIST:\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT AND PLAN:\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- will place on vanco/zosyn for NH/HAP broad coverage esp since she\n failed the levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- will order sputum cultures\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- monitor for signs of volume overload; gentle IVF overnight if needed\n .\n #. HTN:\n -- will hold home metoprolol overnight to ensure that BP remains stable\n in light of possible infection.\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: no indication for PPI currently; SHQ (wears boots at rehab);\n bowel regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Generic Note",
"row_id": 330457,
"text": "TITLE:\n Broadened abx regimen overnight to Vanc/Zosyn. This morning\n desaturation requiring inc. FiO2. and suctioning. Requiring frequent\n suctioning yielding tenacious white material. Outside film with\n bibasilar infiltrates. Repeat film at less impressive though\n rotated. Cont require ICU care for tenuous resp status with desats\n and requiring suctioning q1-2hrs.\n Pt is critically ill. 35min spent on care.\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330459,
"text": "Chief Complaint: SOB\n 24 Hour Events:\n Overnight patient was placed on vanco/zosyn for broad coverage in a\n pt. She was placed on O2.\n SPUTUM CULTURE - At 05:11 AM\n Episode of SOB this AM, Desat to 88% on 4L NC. Patient was\n suctioned. Started on FM with 100% FiO2 briefly and then quickly down\n to 40%. Afebrile at the time. She was given a neb treatment without\n much effect. A repeat CXR was obtained. Per nursing patient has\n copious resp secretions that are white.\n Subjective: patient is aphasic and incoherent.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 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 07:35 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: 93 (78 - 104) bpm\n BP: 112/44(62) {89/27(42) - 117/56(70)} mmHg\n RR: 24 (16 - 24) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 57 Inch\n Total In:\n 4,835 mL\n PO:\n TF:\n IVF:\n 135 mL\n Blood products:\n Total out:\n 0 mL\n 2,650 mL\n Urine:\n 2,650 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,185 mL\n Respiratory support\n O2 Delivery Device: FM 40% FiO2\n SpO2: 96%\n ABG:\n Physical Examination\n Gen: aphasic, with residual right sided hemiparesis, repeating sounds\n incoherently.\n Lungs: diffuse rhonchi\n CV: rapid rate, regular rhythm, s1 & s2 nl, no m/r/g\n ABD: + bs, nt, nd, soft\n EXT: some LE edema bilat\n Labs / Radiology\n [image002.jpg]\n Labs pending this morning due to difficult draw.\n PROBLEM LIST:\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT AND PLAN:\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history. Patient has copious\n respiratory secretions.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\n levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- follow up re: sputum cx\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n --suctioning Q1 hr., Chest PT.\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- d/c maintenance fluids\n -- obtain ECHO\n .\n #. HTN:\n -- restart home dose of metoprolol\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- holding TF pending improved respiratory status. Concern re:\n aspiration if patient requires BPAP.\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\n regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330440,
"text": "81 y.o.female with h/o CVA, dementia, COPD presented to \n Hospital from with dyspnea. Tranferred to \n EW, diagnosed with pneumonia, sat 88% on 4 liters n/c, temp 102.4 HR\n 136, lactate 3.1 WBC 22..4 received Vanco, Cefepime,\n Azithromycin. Pt received 3-4 liters NS, urine output 1700 via\n foley. Pt is DNR/DNI, admitted to for further management of\n pneumonia.\n Pneumonia, other\n Assessment:\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. Os sat\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\n cough, pt sleeping on/off. Nonverbal (mumbles words)\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Left hip\n stage 1 skin broken, area cleansed with foam cleanser,\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 330441,
"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 81 yo women resident of Rehab p/w hypoxemia (sat of 90s on 2L\n NC). Has had\n two weeks of worsening SOB, cough with sputum, and 3 days of fever to\n 101. Was started on Levoquin. Today was hypoxemic and transferred to\n - Afeb, 99.8 HR 106, 122.68, RR 22, 92% on 2L NC, WBC 28 with\n 19% bands, troponin <0.04. BNP 38. ABG 7.46/32/91. Got Medrol, Nebs,\n Tylenol, CTX and Flagyl. CXR with ? LLL infiltrate and Right\n infiltrate. Transferred to where she got 3L of saline, and\n Vanco,Cefepine,Azithro.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD\n aspiration PNA\n Dementia\n CVA with expressive aphasia\n G-tube\n legally blind\n pulmonary HTN\n CHF\n Meds at home:\n Synthroid\n Albuterol/atroven\n Prednisone 5mg qd\n lopressor 25 \n unremarkable\n Occupation: Rehab\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: Daughter is \n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: Cough\n Gastrointestinal: No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Integumentary (skin): No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Anemia\n Neurologic: No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated\n Signs or concerns for abuse : No\n Flowsheet Data as of 03:04 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: 95 (95 - 104) bpm\n BP: 89/27(42) {89/27(42) - 117/42(56)} mmHg\n RR: 18 (18 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 4,700 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 2,050 mL\n Urine:\n 2,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,650 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Crackles : bases, Rhonchorous: )\n Abdominal: Soft, Non-tender, G-tube\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 338\n 39.3\n 187\n 0.7\n 15\n 20\n 102\n 4.3\n 138\n 22.4\n [image002.jpg]\n Other labs: Lactic Acid:3.1\n Fluid analysis / Other labs: U/A: 0-2 WBC\n Assessment and Plan\n Aspiration PNA: High WBC, ? of multilobar infilatrates on CXR. Vanco\n and Zosyn for HAP as she is from institution and failed levoflox\n therapy. Check sputum cultures.\n COPD: Continue nebs, lower dose to prednisone 40mg.\n Dementia: Poor MS not far from her baseline, no need to image head\n HTN: Hold antihypertensives as BP is low.\n HOTN: Likely due to sepsis from aspiration PNA.\n TFs through G-tube.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 20 Gauge - 01:08 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 330444,
"text": "Chief Complaint: SOB, decreasing O2 sats\n HPI:\n Ms. is an 81 yo F with h/o aspiration PNA, COPD and\n CVA/aphasia, who presented to the ED from Rehab with SOB,\n wheezing and low O2 sats (92% on 2LNC). Her daughter states that she\n became progressively more SOB with cough and inc sputum and decreasing\n PO intake for the past 2 weeks. 2 days ago she ran a temp to 100.1 F\n and she was given two doses of levaquin at the rehab yesterday (unclear\n if had gotten more) for increased secretions. She was also given lasix\n 40 mg PO x1. She initially presented to the ED this afternoon\n but was transferred to the per the request of her family.\n At , VS were 99.8, 106, 22, 142/68, and 92% 2LNC. WBC was 28.1\n w/ 19% bands, trop < 0.04, BNP 38, bicarb 26; ABG was 7.46/32/91 on ?\n O2. She was given solumedrol, duonebs, Tylenol, ceftriaxone x 1, and\n flagyl x 1. She had one set of cardiac enzymes that were nagtive and\n CXR reportedly had a LLL PNA. VS on arrival to were 99.5, HR\n 134, BP 100/78, RR 22, 92% on 4L NC. She was given 3 L NS as well as\n vancomycin 1 g IV, azithromycin 500 mg IV and cefepime 2 g IV.\n Per daughter: She was placed in long-term care facility ~3.5 yrs ago\n for alzheimer's dementia. About 1-2 years ago she fell out of bed at\n NH and fx'ed her hip. She has not ambulated since then. She had 2\n strokes in summer of that left her with an expressive aphasia. She\n can speak in simple sentences/phrases when well. She will often string\n together non-coherent words and believe she is communicating\n coherently. Daughter states the current babbling of word fragments is\n worse than her baseline.\n Unable to obtain ROS due to MS, aphasia.\n Patient admitted from: Transfer from other hospital, via ED;\n transferred per family's wishes\n History obtained from Family / Medical records\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n HOME MEDICATIONS (per d/c summary and ED notes):\n Synthroid 88 mcg QD\n Albuterol nebs Q4 hours PRN\n Ipratropium neb Q6 hours PRN\n levaquin 250 mg PO qday (day )\n Prednisone 5 mg QD\n Senna, colace, MOM\n \n Metoprolol Tartrate 25 mg \n Calcium carbonate\n hyocysamine 0.25 mg Q4 hours PRN\n MVI, Vit C\n Tylenol 325-650mg PO PRN\n Past medical history:\n Family history:\n Social History:\n COPD\n Dementia\n HTN\n Hypothyroidism\n CVA-- aphasic, right sided weakness; has G tube\n Legally blind (macular degeneration)\n Pulmonary hypertension\n CHF\n Depression\n Left hallux ulceration\n s/p R humerous and pelvic fx\n s/p CCY\n s/p TAH for adenocarcinoma\n Osteoporosis\n Non-contributory\n Occupation: NC\n Drugs: denied\n Tobacco: denied\n Alcohol: denied\n Other: lives at Rehab\n Review of systems: could not obtain aphasia, mental status\n Flowsheet Data as of 03:41 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.8\nC (96.4\n Tcurrent: 35.8\nC (96.4\n HR: 95 (95 - 104) bpm\n BP: 89/27(42) {89/27(42) - 117/42(56)} mmHg\n RR: 18 (18 - 19) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 4,700 mL\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 2,050 mL\n Urine:\n 2,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,650 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, No(t)\n Diaphoretic\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n at bases b/l, Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, No(t)\n Tender: , Obese, G tube\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Skin: Not assessed\n Neurologic: No(t) Follows simple commands, Responds to: Tactile\n stimuli, No(t) Oriented (to): cannot communicate, Movement: Not\n assessed, Tone: Not assessed, rt arm contracture; rt foot fixed\n extension;RU/LE weakness/paralysis; CN II - XII symmetric; aphasic\n Labs / Radiology\n 338\n 187\n 0.7\n 15\n 20\n 102\n 4.3\n 138\n 39.3\n 22.4\n [image002.jpg]\n 95% PMN\ns, 0% bands\n Lactate 3.1\n Trop 0.04, CK 134, MB 5\n UA negative\n Imaging: ADMISSION CXR:\n AP upright chest radiograph is reviewed and compared to .\n Evaluation is limited by rotation, despite technologist's attempts to\n properly position the patient. Evaluation is also limited by low lung\n volumes. There is no large consolidation, though retrocardiac area\n cannot be reliably assessed. There is no definite pleural effusion or\n pneumothorax.\n IMPRESSION: Limited exam. No focal consolidation.\n Microbiology: UCx, BCx pending\n ECG: AMDISSION EKG: noisy background, sinus tach at 130; poor R wave\n progression; no ST seg changes or TWI; LAD.\n Assessment and Plan\n ASSESSMENT/PLAN:\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n .\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- will place on vanco/zosyn for NH/HAP broad coverage esp since she\n failed the levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- will order sputum cultures\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n .\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- monitor for signs of volume overload; gentle IVF overnight if needed\n .\n #. HTN:\n -- will hold home metoprolol overnight to ensure that BP remains stable\n in light of possible infection.\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: no indication for PPI currently; SHQ (wears boots at rehab);\n bowel regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Comments: NPO for now; will clarify tube feed vs. PO feed regimen in am\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT: SQ UF Heparin(bowel regimen)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments: Spoke with daughter on admission\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330438,
"text": "81 y.o. with h/o CVA, dementia, COPD presented to Hospital\n from with dyspnea. CXR~ pneumonia. Pt received 3\n liters of IVF, Tylenol x 1, Vanco, Cefepime, Azithromycin\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330439,
"text": "81 y.o.female with h/o CVA, dementia, COPD presented to \n Hospital from with dyspnea. Tranferred to \n EW, diagnosed with pneumonia, sat 88% on 4 liters n/c, temp 102.4 HR\n 136, lactate 3.1 WBC 22..4 received Vanco, Cefepime,\n Azithromycin. Pt received 3-4 liters NS, urine output 1700 via\n foley. Pt is DNR/DNI, admitted to for further management of\n pneumonia.\n Pneumonia, other\n Assessment:\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. Os sat\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\n cough, pt sleeping on/off. Nonverbal (mumbles words)\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330446,
"text": "81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\n presented to Hospital from with dyspnea.\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\n 1700 via foley. Pt is DNR/DNI, admitted to for further\n management of pneumonia.\n Pneumonia, other\n Assessment:\n Afebrile 96.4 axillary, bp 99/42, HR 100 ST, no vea noted. O2 sat\n 98% on 4 liters n/c. rr~22, lungs with scattered rhonchi, no\n cough, pt sleeping on/off. Nonverbal (mumbles words) pt on Vanco and\n Zosyn, prednisone po, Albuterol/Atovent inhalers q 6 hrs\n Action:\n Pt with coarse breath sounds, nasally suctioned for thick yellow\n secretions\n sent for gram stain, and culture.\n Response:\n Pt sounds better\n Plan:\n Continue with pulmonary toilet. Check sputum cx, continue antibx for\n ?LLL infiltrate from OSH film. Continue steroids, nebs.\n Impaired Skin Integrity\n Assessment:\n Left hip\n stage 1 skin broken, area cleansed with foam cleanser,\n aloe vesta cream applied. Pt turned freq.\n Action:\n Kept off back\n Response:\n Plan:\n Consult skin care for left hip. Keep off back. Follow closely.\n NEURO: Per daughter: She was placed in long-term care facility ~3.5\n yrs ago for alzheimer's dementia. About 1-2 years ago she fell out of\n bed at NH and fx'ed her hip. She has not ambulated since then. She\n had 2 strokes in summer of that left her with an expressive\n aphasia. She can speak in simple sentences/phrases when well. She\n will often string together non-coherent words and believe she is\n communicating coherently. Daughter states the current babbling of word\n fragments is worse than her baseline.\n per resident\ns note. Pt\n currently babbling, r arm contracted, can move though, moves left\n arm. Unable to draw pt\ns blood\n intern will need to perform groin\n stick. Pt is legally blind.\n GI: pt with a G-tube. Was on Probalance 65 cc/hr on at 9 pm, off\n at 6 am.\n GU: great urine output. >2 liters.\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330532,
"text": "Chief Complaint: Pneumonia\n 24 Hour Events: per ID, zosyn changed to ceftaz/flagyl\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 PM\n Metronidazole - 12:00 AM\n Ceftazidime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 12:34 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: pt non-communicative\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: 35.9\nC (96.6\n HR: 84 (57 - 132) bpm\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\n RR: 28 (16 - 37) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 5,549 mL\n 386 mL\n PO:\n TF:\n 33 mL\n IVF:\n 849 mL\n 353 mL\n Blood products:\n Total out:\n 3,950 mL\n 330 mL\n Urine:\n 3,950 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 92%\n Physical Examination\n Gen: aphasic, with residual right sided hemiparesis, perseverative,\n incoherent\n CV: reg tachy, nl S1S2 no m/r/g\n PULM: diffuse rhonchi and wheezing bilat\n ABD: soft NTND + BS G-tube site c/d/i\n EXT: warm, dry 1+LE edema bilat\n Labs / Radiology\n 321 K/uL\n 11.3 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 143 mEq/L\n 34.0 %\n 20.8 K/uL\n [image002.jpg]\n 06:15 PM\n WBC\n 20.8\n Hct\n 34.0\n Plt\n 321\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 130\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n .\n # PNA\n Unimproved clinically with persistent leukocytosis (perhaps an\n element of reactive WBC from steroids) and copious purulent secretions\n -cont. vanco/ceftaz/flagyl (day 2), and start azithro (day 1) for\n atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n -consider bronch if suspect severe plugging or not improved\n .\n #COPD\n -cont. prednisone 40 mg, may taper if improves clinically\n -incr. freq. albuterol nebs q2h\n -atrovent nebs q6h\n .\n #.CHF - CXR reflects mild degree of volume overload\n -gentle diuresis, 10 mg lasix IV now, goal: -500 cc/day\n -TTE today, f/u final read\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n .\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -may consider S&S eval, G-tube study to eval. aspiration risk prior to\n giving anything PO\n -goal: -500 cc/day\n -- has G tube; will obtain c/s for tube feeds in am\n .\n #PPx: PPI, SQH, bowel regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nutrition",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 330520,
"text": "Subjective\n Patient with poor PO intake PTA. Noted per chart, on TFs of Probalance\n at 65ml/hr x 9 hours (provides 702kcal and 46g protein)\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 160 cm\n 75 kg\n 29.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 52.2 kg\n 144%\n 66\n Diagnosis: Pneumonia\n PMH : CVA, dementia, aspiration pneumonia, COPD\n Food allergies and intolerances: none noted\n Pertinent medications: prednisone, 20meqKCl\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 07:27 AM\n BUN\n 16 mg/dL\n 07:27 AM\n Creatinine\n 0.5 mg/dL\n 07:27 AM\n Sodium\n 143 mEq/L\n 07:27 AM\n Potassium\n 3.7 mEq/L\n 07:27 AM\n Chloride\n 111 mEq/L\n 07:27 AM\n TCO2\n 23 mEq/L\n 07:27 AM\n Calcium non-ionized\n 8.8 mg/dL\n 07:27 AM\n Phosphorus\n 2.5 mg/dL\n 07:27 AM\n Magnesium\n 2.2 mg/dL\n 07:27 AM\n Current diet order / nutrition support: Nutren Pulmonary at 40ml/hr x\n 24 hours (currently at 20ml/hr) to provide 1440kcal and 65g protein\n GI: Abdomen soft with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: Low po intake\n Estimated Nutritional Needs\n Calories: 1650- (BEE x or / 25-30 cal/kg)\n Protein: 80-100 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n 81 year old female with history of CVA, dementia, aphasia presenting\n with SOB to OSH now transferred to with pneumonia. Noted patient\n with stage I ulcer on hip. Patient was on night tube feedings at NH.\n Consult received for tube feedings. For now would recommend doing feeds\n to meet 100% of needs. Suggest goal of Replete with Fiber at 65ml/hr x\n 24 hours to provide 1560kcal and 97g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Change tube feeding to Replete with Fiber at 65ml/hr x 24\n hours\n 2. Monitor residuals q4H and hold if >150ml\n 10:03\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 330521,
"text": "Chief Complaint: Pneuomonia\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 admit with aspiration PNA and COPD exacerbation\n 24 Hour Events:\n Persistent close treatment with some improvement in level of\n respiratory distress.\n She has remaining significant pulmonary secretions requiring frequent\n suctioning and also has continued wheezing throughout her exam.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 PM\n Metronidazole - 08:04 AM\n Ceftazidime - 09:07 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 08:04 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 Genitourinary: Foley\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\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: 36.9\nC (98.4\n Tcurrent: 36.6\nC (97.9\n HR: 92 (57 - 114) bpm\n BP: 135/52(74) {83/34(36) - 159/111(110)} mmHg\n RR: 28 (16 - 31) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 5,549 mL\n 919 mL\n PO:\n TF:\n 80 mL\n IVF:\n 849 mL\n 699 mL\n Blood products:\n Total out:\n 3,950 mL\n 390 mL\n Urine:\n 3,950 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 529 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///23/\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\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: Bronchial: , Wheezes : ) She does have significant\n increase in expiratory time and evidence of persistent airflow\n obstruction.\n Abdominal: Soft\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.4 g/dL\n 330 K/uL\n 91 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 111 mEq/L\n 143 mEq/L\n 34.6 %\n 20.6 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n WBC\n 20.8\n 20.6\n Hct\n 34.0\n 34.6\n Plt\n 321\n 330\n Cr\n 0.5\n 0.5\n TropT\n 0.02\n Glucose\n 130\n 91\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/11/0.02, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n CXR\nShe has right mid-lung zone opacity which is her right arm\n overlying. She persists in left lower lobe ill defined opacity.\n Assessment and Plan\n 81 yo female\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION-\n -continue prednisone and will move to taper as possible.\n -Will have to follow exam to determine taper\n -Will continue with current prednisone dosing as she is requiring nebs\n PRN (atrovent) and will need to get a better and more durable response\n to bronchodilators.\n -This may require intermittent IPPV to aid with lung recruitment.\n PNEUMONIA, OTHER-\n -Will move to vanco/CTZ/Flagyl/Azithro for ongoing Rx of Pneumonia\n -She raises clear concern for persistent aspiration events leading to\n inability to clear her pulmonary secretions and pneumonia.\n -Add urine legnionella to testing.\n -Will need Chest PT and continued support\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:44 AM 20 mL/hour\n Glycemic Control:\n Lines: NO CVL\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330624,
"text": "Pneumonia, other\n Assessment:\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\n suctioning\n Action:\n Aggressive pulm toileting , suctioning q 2hr\n Response:\n Pt maint sats 96-99%\n Plan:\n Cont ab tx, cont aggressive pulm toileting\n Alteration in Nutrition\n Assessment:\n Pt was taking po\ns in rehab along w/ nighttime supplement TF ,\n unable to take pos at this time\n Action:\n Pt tolerating cont TF at goal\n Response:\n No s/s malnutrition or weight loss\n Plan:\n Cont TF as ordered ,resume PO intake when indicated\n K of 3.5 repleted w/ 40 K via peg, as well as phos. Pt currently being\n evaluated for PICC for antibiotic course as well as blood draws\n ------ Protected Section ------\n At 1600 pt medicated with 10 mg ivp lasix and will follow fluid balance\n closely.\n ------ Protected Section Addendum Entered By: , RN\n on: 17:07 ------\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330623,
"text": "Chief Complaint: hypoxia/dyspnea\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:33 AM\n following cardiac enzymes\n CK 134 ->-264 -->224\n Trop .04 -->.02 -->.03\n diuresis overnight with lasix 10 x 3.\n Patient lost last PIV this morning. Difficulty to obtain blood for\n labs.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 AM\n Metronidazole - 04:00 PM\n Ceftazidime - 04:56 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 06:10 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 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 104 (76 - 109) bpm\n BP: 108/64(74) {89/32(47) - 158/99(102)} mmHg\n RR: 23 (10 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 2,076 mL\n 355 mL\n PO:\n TF:\n 476 mL\n 286 mL\n IVF:\n 1,240 mL\n 69 mL\n Blood products:\n Total out:\n 2,317 mL\n 785 mL\n Urine:\n 2,317 mL\n 785 mL\n NG:\n Stool:\n Drains:\n Balance:\n -241 mL\n -430 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Gen: Less agitated and interactive this morning. Breathing\n comfortably, in NAd\n Lungs: breathing symmetrically, diffuse rhonchi and moderate secretions\n CV: rapid rate, regular rhythm s1 & s2 nl, no m/r/g\n Abd: +bs, non-tender, nd, soft\n Ext: warm dry trace edema\n Labs / Radiology\n 330 K/uL\n 11.4 g/dL\n 91 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 111 mEq/L\n 143 mEq/L\n 34.6 %\n 20.6 K/uL\n : [image002.jpg]\n :\n 142\n [image004.gif]\n 108\n [image004.gif]\n 16\n [image006.gif]\n 103\n AGap=15\n [image007.gif]\n 3.5\n [image004.gif]\n 23\n [image004.gif]\n 0.6\n [image009.gif]\n Comments:\n K: Hemolysis Falsely Elevates K\n Ca: 8.3 Mg: 2.0 P: 1.8\n Comments:\n Mg: Hemolysis Falsely Elevates Mg\n 86\n 17.4\n [image009.gif]\n 11.5\n [image006.gif]\n 371\n [image010.gif]\n [image006.gif]\n 35.0\n [image009.gif]\n 06:15 PM\n 07:27 AM\n WBC\n 20.8\n 20.6\n Hct\n 34.0\n 34.6\n Plt\n 321\n 330\n Cr\n 0.5\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n Other labs: PT / PTT / INR:12.9/26.0/1.0,\n CK / CKMB / Troponin-T:224/10/0.03,\n ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR \n hazy LL infiltrate bilaterally. Right side\n appears improved from previous.\n ECHO \n CONCLUSION:\n The left atrium is dilated. The left ventricle is not well seen. Due to\n suboptimal technical quality, a focal wall motion abnormality cannot be\n fully excluded. Overall left ventricular systolic function is normal\n (LVEF>55%). The aortic valve is not well seen. The mitral valve\n leaflets are not well seen.\n IMPRESSION: poor technical quality due to patient's body habitus. Left\n ventricular function is probably normal, a focal wall motion\n abnormality cannot be fully excluded. The right ventricle is not well\n seen. Valvular function could not be evaluated.\n Microbiology: urine cx neg\n urine leg neg\n blood cx neg\n sputum cx - contaminated\n Assessment and \n PROBLEM LIST:\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT & PLAN:\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n # PNA\n Unimproved clinically with persistent leukocytosis (perhaps an\n element of reactive WBC from steroids) and copious purulent secretions\n -cont. vanco/ceftaz/flagyl (day 3), and start azithro (day ) for\n atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n -consider bronch if suspect severe plugging or not improved\n .\n #COPD\n -cont. prednisone 40 mg, wrote to decrease to 30mg PO tomorrow AM.\n -incr. freq. albuterol nebs q2h\n -atrovent nebs q6h\n .\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\n study but showed good overall LV fn so less likely to be playing a role\n in pt\ns dyspnea.\n -gentle diuresis, 10 mg lasix IV now, goal: even to negative\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n .\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -goal: -even to negative\n .\n #PPx: PPI, SQH, bowel regimen\n .\n #Access: lost PIV this am, hard to get venous access. Place PICC today\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 06:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330615,
"text": "Pneumonia, other\n Assessment:\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\n suctioning\n Action:\n Aggressive pulm toileting , suctioning q 2hr\n Response:\n Pt maint sats 96-99%\n Plan:\n Cont ab tx, cont aggressive pulm toileting\n Alteration in Nutrition\n Assessment:\n Pt was taking po\ns in rehab along w/ nighttime supplement TF ,\n unable to take pos at this time\n Action:\n Pt tolerating cont TF at goal\n Response:\n No s/s malnutrition or weight loss\n Plan:\n Cont TF as ordered ,resume PO intake when indicated\n K of 3.5 repleted w/ 40 K via peg, as well as phos. Pt currently being\n evaluated for PICC for antibiotic course as well as blood draws\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330506,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 PM\n Metronidazole - 12:00 AM\n Ceftazidime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 12:34 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 07:00 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: 35.9\nC (96.6\n HR: 84 (57 - 132) bpm\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\n RR: 28 (16 - 37) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 5,549 mL\n 386 mL\n PO:\n TF:\n 33 mL\n IVF:\n 849 mL\n 353 mL\n Blood products:\n Total out:\n 3,950 mL\n 330 mL\n Urine:\n 3,950 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 92%\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 321 K/uL\n 11.3 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 143 mEq/L\n 34.0 %\n 20.8 K/uL\n [image002.jpg]\n 06:15 PM\n WBC\n 20.8\n Hct\n 34.0\n Plt\n 321\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 130\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history. Patient has copious\n respiratory secretions.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\n levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- follow up re: sputum cx\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n --suctioning Q1 hr., Chest PT.\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- d/c maintenance fluids\n -- obtain ECHO\n .\n #. HTN:\n -- restart home dose of metoprolol\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- holding TF pending improved respiratory status. Concern re:\n aspiration if patient requires BPAP.\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\n regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330507,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 PM\n Metronidazole - 12:00 AM\n Ceftazidime - 12:19 AM\n Infusions:\n Other ICU medications:\n Lansoprazole (Prevacid) - 10:17 AM\n Heparin Sodium (Prophylaxis) - 12:34 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 07:00 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: 35.9\nC (96.6\n HR: 84 (57 - 132) bpm\n BP: 110/61(105) {83/34(36) - 159/111(110)} mmHg\n RR: 28 (16 - 37) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 57 Inch\n Total In:\n 5,549 mL\n 386 mL\n PO:\n TF:\n 33 mL\n IVF:\n 849 mL\n 353 mL\n Blood products:\n Total out:\n 3,950 mL\n 330 mL\n Urine:\n 3,950 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,599 mL\n 56 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 92%\n ABG: ///22/\n Physical Examination\n Gen: aphasic, with residual right sided hemiparesis, repeating sounds\n incoherently.\n Lungs: diffuse rhonchi\n CV: rapid rate, regular rhythm, s1 & s2 nl, no m/r/g\n ABD: + bs, nt, nd, soft\n EXT: some LE edema bilat\n Labs / Radiology\n 321 K/uL\n 11.3 g/dL\n 130 mg/dL\n 0.5 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 112 mEq/L\n 143 mEq/L\n 34.0 %\n 20.8 K/uL\n [image002.jpg]\n 06:15 PM\n WBC\n 20.8\n Hct\n 34.0\n Plt\n 321\n Cr\n 0.5\n TropT\n 0.02\n Glucose\n 130\n Other labs: CK / CKMB / Troponin-T:264/11/0.02, ALT / AST:17/24, Alk\n Phos / T Bili:91/0.2, Ca++:8.3 mg/dL, Mg++:2.1 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n 81 yo F w/h/o aspiration PNA and COPD, admitted from NH with SOB,\n wheezing and hypoxia w/ possible LLL opacity on OSH film.\n #. Respiratory Distress: wheezy on exam; LLL infiltrate on CXR; WBC\n 22-28; resp status likely PNA (either NH/CAP vs. aspiration). \n have triggered COPD flare. Minimal evidence of CHF exacerbation on\n imaging, exam and labs, but does have CHF history. Patient has copious\n respiratory secretions.\n -- continue steroids; will start prednisone 40 mg QD in am\n -- standing albuterol and ipratropium nebs overnight; will consider\n changing to PRN in the am pending improvement\n -- on vanco/zosyn for NH/HAP broad coverage esp since she failed the\n levaquin tx\n -- deferring further w/u for PE given PNA likely cause\n -- UCx, BCx pending from ED\n -- follow up re: sputum cx\n -- low suspicion for MI, but will continue cycling enzymes with second\n set with am labs (first set negative)\n --suctioning Q1 hr., Chest PT.\n .\n #. COPD:\n -- management as above\n .\n #. CHF: no evidence of volume overload on exam; BNP 38 (negative) at\n OSH. No echo in file at the .\n -- d/c maintenance fluids\n -- obtain ECHO\n .\n #. HTN:\n -- restart home dose of metoprolol\n .\n #. Hypothyroidism\n -- continue levothyroxine 88 mcg QD\n .\n #. Dementia: not currently on medications\n .\n #. Depression: was on venlafaxine in past; held on last admission for\n c/f NMS. Nothing on med list currently.\n .\n #. Osteoporosis: currently on calcium supplements\n -- cont calcium; t/c starting Vit D\n -- fall precautions\n .\n #. FEN: takes ProBalance 65 ml/hr; on at 9 pm, off at 6 am. 200 cc\n free water flushes Qshift; unclear what she takes in PO if anything\n (confusion records vs. reports frm daughter)\n -- holding TF pending improved respiratory status. Concern re:\n aspiration if patient requires BPAP.\n -- has G tube; will obtain c/s for tube feeds in am\n -- Cr slightly above baseline (0.7 vs. 0.4-0.5); will place on gentle\n IVF overnight\n .\n #. PPX: PPI while on Steroids ; SHQ (wears boots at rehab); bowel\n regimen\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: to remain in ICU overnight for tx and observation\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 03:44 AM 10 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-06 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 330603,
"text": "Chief Complaint: Respiratory Failure/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 TRANSTHORACIC ECHO - At 11:33 AM\n Lasix given with diuresis effected overnight\n History obtained from Medical records\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Ceftazidime - 04:56 PM\n Metronidazole - 08:11 AM\n Vancomycin - 09:15 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 PM\n Heparin Sodium (Prophylaxis) - 08:11 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) Fever\n Cardiovascular: Tachycardia\n Psychiatric / Sleep: Delirious, MIld\n Flowsheet Data as of 12:06 PM\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: 36.1\nC (97\n HR: 98 (76 - 110) bpm\n BP: 116/53(69) {86/32(45) - 158/99(102)} mmHg\n RR: 26 (4 - 26) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 2,076 mL\n 980 mL\n PO:\n TF:\n 476 mL\n 560 mL\n IVF:\n 1,240 mL\n 420 mL\n Blood products:\n Total out:\n 2,317 mL\n 985 mL\n Urine:\n 2,317 mL\n 985 mL\n NG:\n Stool:\n Drains:\n Balance:\n -241 mL\n -5 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed, More withdrawn\n Labs / Radiology\n 11.5 g/dL\n 371 K/uL\n 103 mg/dL\n 0.6 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 16 mg/dL\n 108 mEq/L\n 142 mEq/L\n 35.0 %\n 17.4 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n 08:00 AM\n WBC\n 20.8\n 20.6\n 17.4\n Hct\n 34.0\n 34.6\n 35.0\n Plt\n \n Cr\n 0.5\n 0.5\n 0.6\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n 103\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.3 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 81 yo female with history of COPD now admit with acute exacerbation and\n has complicating issues of volume overload and signficiant aspiraiton\n risk contributing to clinical worsening\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n -Pred 40mg/d\ntaper to 30mg today\n -Continue with nebs\n PNEUMONIA, OTHER\n Vanco/Ceftaz/Flagyl/Azithro\n be aspiration triggering clinical worsening\nwill need 7 day Rx.\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:28 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT: Boots\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": "Nursing",
"chartdate": "2152-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330614,
"text": "Pneumonia, other\n Assessment:\n Pt w/ pneumonia presenting w/ large amt thick tan secretions upon\n suctioning\n Action:\n Aggressive pulm toileting , suctioning q 2hr\n Response:\n Pt maint sats 96-99%\n Plan:\n Cont ab tx, cont aggressive pulm toileting\n Alteration in Nutrition\n Assessment:\n Pt was taking po\ns in rehab along w/ nighttime supplement TF ,\n unable to take pos at this time\n Action:\n Pt tolerating cont TF at goal\n Response:\n No s/s malnutrition or weight loss\n Plan:\n Cont TF as ordered ,resume PO intake when indicated\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330576,
"text": "81 y/o female with h/o CVA,Dementia,Aspiration PNA,COPD presented to\n hospital from rehab centre with dyspnea.\n Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n On face mask with 70% Fio2,desats to 85% when mask is off ,LS coarse\n t/o,normal breathing efforts RR 20-26 sats 90-95%\n Action:\n Suctioned nasally 2-3 hrs for thick yellow secretions,pt has very\n weak cough,chest PT prior to suction and nebs as ordered.Gentlre\n diuresis with bolus dose,did receive Lasix 10mg at midnight with\n moderate effect.\n Response\n Pt was more comfortable after suction.Stas were maintained.\n Plan:\n DNR/DNI,monitor resp staus,ICU care at this time Pulmonary hygene,\n wean Fio2 as tolerated.\n Redness and bruises on lt hand MD was notified,Couldn\nt collect AM\n , try later.\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 330669,
"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 PICC LINE - START 04:16 PM\n Ventricular Tachycardia noted overnight--non sustained and\n approximately 9 events\n Diuresis effected with Lasix IV yesterday--but net fluid balance\n minimally negative for 24 hours\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:45 PM\n Ceftazidime - 08:00 AM\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 10:45 PM\n Heparin Sodium (Prophylaxis) - 07:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Flowsheet Data as of 10:07 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: 72 (64 - 111) bpm\n BP: 124/67(78) {98/42(60) - 144/105(110)} mmHg\n RR: 21 (13 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,607 mL\n 1,313 mL\n PO:\n TF:\n 1,267 mL\n 652 mL\n IVF:\n 1,140 mL\n 300 mL\n Blood products:\n Total out:\n 2,472 mL\n 761 mL\n Urine:\n 2,472 mL\n 761 mL\n NG:\n Stool:\n Drains:\n Balance:\n 135 mL\n 552 mL\n Respiratory support\n O2 Delivery Device: None, Aerosol-cool\n SpO2: 98%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished, No(t) Thin\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Wheezes : , Rhonchorous: Centrally)\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.3 g/dL\n 346 K/uL\n 108 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 18 mg/dL\n 105 mEq/L\n 142 mEq/L\n 34.8 %\n 16.0 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n 08:00 AM\n 04:32 PM\n 06:00 PM\n 03:50 AM\n WBC\n 20.8\n 20.6\n 17.4\n 16.0\n Hct\n 34.0\n 34.6\n 35.0\n 34.8\n Plt\n 46\n Cr\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n 103\n 200\n 190\n 108\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR----no significant change--some suggestion of mild\n clearing in left lung\n Assessment and Plan\n 81 yo female admit with respiratory failure in the setting of Chronic\n Obstructive Pulmonary Disease\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n Atrovent/Albuterol nebs given\n Prednisone at 30mg and will continue to taper tomorrow\n Will likely need prolonged rehab to return to independent status\n PNEUMONIA, OTHER--she has had some significant improvement in terms\n of secretion volume but still with significant limitation in capacity\n to mobilize secreations\n vanco/CTX/Flagyl\n Ventricular Tachycardia\nnon sustained, mono-morphic, not triggered\n -Follow Lytes\n -Maintain telemetry\n -Check ECG\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:16 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": "2152-06-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330583,
"text": "Chief Complaint: hypoxia/dyspnea\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 11:33 AM\n following cardiac enzymes\n CK 134 ->-264 -->224\n Trop .04 -->.02 -->.03\n diuresis overnight with lasix 10 x 3.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:12 AM\n Vancomycin - 10:00 AM\n Metronidazole - 04:00 PM\n Ceftazidime - 04:56 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Furosemide (Lasix) - 06:10 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 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 104 (76 - 109) bpm\n BP: 108/64(74) {89/32(47) - 158/99(102)} mmHg\n RR: 23 (10 - 32) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 63 Inch\n Total In:\n 2,076 mL\n 355 mL\n PO:\n TF:\n 476 mL\n 286 mL\n IVF:\n 1,240 mL\n 69 mL\n Blood products:\n Total out:\n 2,317 mL\n 785 mL\n Urine:\n 2,317 mL\n 785 mL\n NG:\n Stool:\n Drains:\n Balance:\n -241 mL\n -430 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 99%\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 330 K/uL\n 11.4 g/dL\n 91 mg/dL\n 0.5 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 111 mEq/L\n 143 mEq/L\n 34.6 %\n 20.6 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n WBC\n 20.8\n 20.6\n Hct\n 34.0\n 34.6\n Plt\n 321\n 330\n Cr\n 0.5\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n Other labs: PT / PTT / INR:12.9/26.0/1.0,\n CK / CKMB / Troponin-T:224/10/0.03,\n ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Imaging: CXR \n ECHO \n The left atrium is dilated. The left ventricle is not well seen. Due to\n suboptimal technical quality, a focal wall motion abnormality cannot be\n fully excluded. Overall left ventricular systolic function is normal\n (LVEF>55%). The aortic valve is not well seen. The mitral valve\n leaflets are not well seen.\n IMPRESSION: poor technical quality due to patient's body habitus. Left\n ventricular function is probably normal, a focal wall motion\n abnormality cannot be fully excluded. The right ventricle is not well\n seen. Valvular function could not be evaluated.\n Microbiology: urine cx neg\n urine leg neg\n blood cx neg\n sputum cx - contaminated\n Assessment and \n PROBLEM LIST:\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n summer ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT & PLAN:\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n # PNA\n Unimproved clinically with persistent leukocytosis (perhaps an\n element of reactive WBC from steroids) and copious purulent secretions\n -cont. vanco/ceftaz/flagyl (day 2), and start azithro (day 1) for\n atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n -consider bronch if suspect severe plugging or not improved\n .\n #COPD\n -cont. prednisone 40 mg, may taper if improves clinically\n -incr. freq. albuterol nebs q2h\n -atrovent nebs q6h\n .\n #.CHF - CXR reflects mild degree of volume overload\n -gentle diuresis, 10 mg lasix IV now, goal: -500 cc/day\n -TTE today, f/u final read\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n .\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -may consider S&S eval, G-tube study to eval. aspiration risk prior to\n giving anything PO\n -goal: -500 cc/day\n -- has G tube; will obtain c/s for tube feeds in am\n .\n #PPx: PPI, SQH, bowel regimen\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n .\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 06:00 AM 50 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 01:08 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330672,
"text": "Chief Complaint: hypoxia & dyspnea\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n 24 Hour Events:\n PICC LINE - START 04:16 PM\n lasix 10 mg 1V x2 yesterday. decreased UOP to 20-27 cc/hr x hrs this\n morning. no increase in BUN or Cr.\n Patient had multiple separate episodes of non-sustained VTACH \n beats of monomorphic VTACH each time. Occurred on approx 7 times\n overnight. Patients electrolytes were WNL at the time of these\n episodes. No intervention was taken.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:45 PM\n Ceftazidime - 11:37 PM\n Metronidazole - 11:58 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:11 AM\n Furosemide (Lasix) - 10:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.5\n HR: 94 (64 - 111) bpm\n BP: 129/74(88) {86/32(45) - 144/105(110)} mmHg\n RR: 22 (4 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,607 mL\n 763 mL\n PO:\n TF:\n 1,267 mL\n 453 mL\n IVF:\n 1,140 mL\n 70 mL\n Blood products:\n Total out:\n 2,472 mL\n 734 mL\n Urine:\n 2,472 mL\n 734 mL\n NG:\n Stool:\n Drains:\n Balance:\n 135 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool 40% FM\n SpO2: 98%\n Physical Examination\n GEN: patient is more alert this morning; she is making eye contact and\n following commands. Patient is aphasic.\n LUNGS: wheezing diffusely. Rhochi diffusely\n CV: RRR, s1 & s2 nl, no m/r/g\n ABD: + BS, nt, nd, soft, G-tube in place with dressing C-D-I.\n EXT: warm dry. No cyanosis, clubbing or edema.\n Labs / Radiology\n 346 K/uL\n 11.3 g/dL\n 108 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 18 mg/dL\n 105 mEq/L\n 142 mEq/L\n 34.8 %\n 16.0 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n 08:00 AM\n 04:32 PM\n 06:00 PM\n 03:50 AM\n WBC\n 20.8\n 20.6\n 17.4\n 16.0\n Hct\n 34.0\n 34.6\n 35.0\n 34.8\n Plt\n 46\n Cr\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n 103\n 200\n 190\n 108\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR: no significant interval change.\n Microbiology: blood cx neg x1\n urine legionella neg x2\n urine cx neg x1\n sputum contaminated.\n Problem :\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT & PLAN:\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n # PNA\n some clinical improvement with decreased secretions.\n leukocytosis trending down.\n -cont. vanco/ceftaz/flagyl (day 4)\n possible 10 day course, and start\n azithro (day ) for atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n .\n #COPD\n -cont. 30mg PO today\n possible taper regimen. continue for 2 days and\n then decrease to 20mg PO daily for 2days.\n -albuterol nebs at q2h\n -atrovent nebs q6h\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\n study but showed good overall LV fn so less likely to be playing a role\n in pt\ns dyspnea.\n -gentle diuresis, 10 mg lasix IV PRN with goal: even to negative\n # VTACH\n nonsustained and monomorphic with no precipitating cause. No\n intervention warranted.\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -goal: -even to negative\n .\n #PPx: PPI, SQH, bowel regimen, add ISS while patient is on steroids.\n .\n #Access: lost PIV this am, hard to get venous access. Place PICC today\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n #. Dispo: consider dispo to rehab facility.\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330680,
"text": "Pneumonia, other\n Assessment:\n Received pt on 70% cool neb mask. Rr in the 20-s t low 30\ns depending\n on her level of agitation. O2 sats> 93% rhoncherous bs bil on\n auscultation with crackles at tha bases.Congested but nonproductive\n cough.\n Action:\n O2 weaned as pt tolerates to keep o2 sats> 92%. Nasotracheally\n suctioned for sm to mod amts of thick yellow sputum.resp status\n monitored closely. When resp status drops to < 90% it indicates that pt\n needs to be suctioned . antibiotics administered as ordered.\n Vancomycin d/c\n Response:\n Pt presently tolerating 2l/m nasal cannula with adequate o2 sats. Pt\n tolerating chest pt and resp toileting. O2 sats improve with\n nasotracheal suctioning.\n Plan:\n Pt being transferred this afternoon to rehab facility to acute\n floor for aggressive resp toileting. manager notified pt\n daughter about pt\ns transfer to rehab.\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330574,
"text": "Chronic obstructive pulmonary disease (COPD, Bronchitis, Emphysema)\n with Acute Exacerbation\n Assessment:\n On face mask with 70% Fio2,desats to 85% when mask is off ,LS coarse\n t/o,normal breathing efforts RR 20-26 sats 90-95%\n Action:\n Suctioned nasally 2-3 hrs for thick yellow secretions,pt has very\n weak cough,chest PT prior to suction and nebs as ordered.\n Response\n Pt was more comfortable after suction.Stas were maintained.\n Plan:\n DNR/DNI,monitor resp staus,ICU care at this time Pulmonary hygene,\n wean Fio2 as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330655,
"text": "81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation. Pt with s/p L cva summer of with\n residual aphasia and dementia including Alzheimers, multi-infarct.\n Pneumonia, other\n Assessment:\n Scattered rhonchi t/o lungs at beginning of shit with sats in mid 90s\n on 70% cool neb.\n Action:\n Pt nt suctioned for moderate amts clear white/clear secretions. Chest\n pt given with turns.\n Response:\n 02 sats remaining stable on 70% cool neb. Pt developed crackles around\n 9:30pm and noted to have a drop in urine to 17cc/hr. pt was given 10mg\n iv lasix with good response. At this time, pt has also been having\n short runs v tach up to 10 beat runs. Pt asymptomatic other than more\n lethargic: responding only to sternal rub when crackles developed.\n Still lethargic but more easily arousable. Runs of v tach subsided\n after diuresed. Urine output slowed down again the last few hours of\n the shift. Repeat cxr improved from yesterday per team and pt with sats\n in upper 90s with no increased 02 need. Appears comfortable but still\n with crackles at bases, rhonchi in upper airways. K and phosphate\n repleted.\n Plan:\n Continue nt suction prn, chest pt with turns, monitor fluid status,\n replete lytes prn.\n Alteration in Nutrition\n Assessment:\n Nutren pulmonary increased to goal of 65cc/hr . 100cc free water\n boluses given q6hrs. large loose ob + brown stool.\n Action:\n Tolerating tube feedings well with no residuals.\n Response:\n Continues to tolerate tube feedings.\n Plan:\n Continue tube feedings with free water boluses. Hold colace as pt\n having loose stool.\n"
},
{
"category": "Physician ",
"chartdate": "2152-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 330660,
"text": "Chief Complaint: hypoxia & dyspnea\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n 24 Hour Events:\n PICC LINE - START 04:16 PM\n --> lasix 10 mg 1V x2 yesterday. decreased UOP to 20-27 cc/hr x hrs\n this morning. no increase in BUN or Cr.\n Allergies:\n Ciprofloxacin\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:45 PM\n Ceftazidime - 11:37 PM\n Metronidazole - 11:58 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:11 AM\n Furosemide (Lasix) - 10:45 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98.1\n Tcurrent: 36.4\nC (97.5\n HR: 94 (64 - 111) bpm\n BP: 129/74(88) {86/32(45) - 144/105(110)} mmHg\n RR: 22 (4 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 63 Inch\n Total In:\n 2,607 mL\n 763 mL\n PO:\n TF:\n 1,267 mL\n 453 mL\n IVF:\n 1,140 mL\n 70 mL\n Blood products:\n Total out:\n 2,472 mL\n 734 mL\n Urine:\n 2,472 mL\n 734 mL\n NG:\n Stool:\n Drains:\n Balance:\n 135 mL\n 29 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 98%\n ABG: ///30/\n Physical Examination\n GEN:\n HEENT:\n LUNGS\n CV:\n ABD\n EXT:\n Labs / Radiology\n 346 K/uL\n 11.3 g/dL\n 108 mg/dL\n 0.5 mg/dL\n 30 mEq/L\n 3.4 mEq/L\n 18 mg/dL\n 105 mEq/L\n 142 mEq/L\n 34.8 %\n 16.0 K/uL\n [image002.jpg]\n 06:15 PM\n 07:27 AM\n 08:00 AM\n 04:32 PM\n 06:00 PM\n 03:50 AM\n WBC\n 20.8\n 20.6\n 17.4\n 16.0\n Hct\n 34.0\n 34.6\n 35.0\n 34.8\n Plt\n 46\n Cr\n 0.5\n 0.5\n 0.6\n 0.6\n 0.5\n TropT\n 0.02\n 0.03\n Glucose\n 130\n 91\n 103\n 200\n 190\n 108\n Other labs: PT / PTT / INR:12.9/26.0/1.0, CK / CKMB /\n Troponin-T:224/10/0.03, ALT / AST:17/24, Alk Phos / T Bili:91/0.2,\n Ca++:8.2 mg/dL, Mg++:2.0 mg/dL, PO4:1.7 mg/dL\n Imaging: CXR: improved from previous. lung fields clearer bilat.\n hemidiaphragm seen more easily especially on left.\n Microbiology: blood cx neg x1\n urine legionella neg x2\n urine cx neg x1\n sputum contaminated.\n Assessment and Plan\n CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS, EMPHYSEMA)\n WITH ACUTE EXACERBATION\n PNEUMONIA, OTHER\n CVA (STROKE, CEREBRAL INFARCTION), OTHER\n ; residual aphasia\n DEMENTIA (INCLUDING ALZHEIMER'S, MULTI INFARCT)\n NH resident\n ASSESSMENT & PLAN:\n 81 y/o F NH resident h/o COPD and recurrent PNA and COPD a/w aspiration\n PNA and COPD exacerbation.\n # PNA\n Unimproved clinically with persistent leukocytosis (perhaps an\n element of reactive WBC from steroids) and copious purulent secretions\n -cont. vanco/ceftaz/flagyl (day 3), and start azithro (day ) for\n atypicals\n -freq. suctioning, chest PT\n -repeat sputum cx, urinary legionella AG\n -blood cx NGTD\n -consider bronch if suspect severe plugging or not improved\n .\n #COPD\n -cont. prednisone 40 mg, wrote to decrease to 30mg PO tomorrow AM.\n -incr. freq. albuterol nebs q2h\n -atrovent nebs q6h\n #.CHF - CXR reflects mild degree of volume overload. ECHO was limited\n study but showed good overall LV fn so less likely to be playing a role\n in pt\ns dyspnea.\n -gentle diuresis, 10 mg lasix IV now, goal: even to negative\n .\n #.HTN:\n -cont. lopressor\n .\n # Hypothyroidism\n - cont. levothyroxine\n .\n #.Osteoporosis: currently on calcium supplements\n - cont calcium; t/c starting Vit D\n - fall precautions\n .\n #F/E/N\n -TF via g-tube\n -goal: -even to negative\n .\n #PPx: PPI, SQH, bowel regimen\n .\n #Access: lost PIV this am, hard to get venous access. Place PICC today\n .\n #. Code: DNR/DNI, confirmed with family by ED staff.\n .\n #. Contacts: Spoke with daughter (HCP) \n for ICU consent and confirm code status.\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 11:00 PM 65 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 04:16 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2152-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330482,
"text": "81 y.o.female with h/o CVA, dementia, aspiration pneumonia, COPD\n presented to Hospital from with dyspnea.\n Tranferred to EW, diagnosed with pneumonia, sat 88% on 4 liters\n n/c, temp 102.4 HR 136, lactate 3.1 WBC 22..4 received Vanco,\n Cefepime, Azithromycin. Pt received 3-4 liters NS, urine output\n 1700 via foley. Pt is DNR/DNI, admitted to for further\n management of pneumonia.\n Pneumonia, other\n Assessment:\n Pt continues on 40% cool neb, CXR~ LLL infiltrate. Pt suctioned q 2\n -3 hours for thick yellow secretions, afebrile, WBC 20.8 pt remains\n on Vanco, Ceftazidime, and Flagyl. On prednisone 40 mg per G-tube qd.\n cpt done bp stable 109/50 HR 80\ns SR occ pvc, (4 beat run\n V-tach)\n Action:\n Suctioned q 2 hrs, nebs q 6 hrs, aggressive pulmonary toilet\n Response:\n Sx helps clear airway\n Plan:\n Continue current therapies, monitor for worsening resp status\n Dementia (including Alzheimer's, Multi Infarct)\n Assessment:\n Pt with Alzheimers dementia, parkinsonian behavior, repetitive\n speech, expressive aphasia\n Action:\n Support pt, occ pt will be lucid\n Response:\n Pt able to communicate at times, able to answer appropriately when\n asked if she needs to be changed\n Plan:\n Continue focused pt interaction with pt\n Alteration in Nutrition\n Assessment:\n Tube feeds started FS Nutren pulmonary at 10 cc/hr via G-tube at 12\n midnight according to team good urine output.\n Action:\n Tube feeds started at a low rate\n Response:\n No issues\n Plan:\n Increase as tolerated to 40 cc/hr flush with 100 cc water q 6 hrs.\n Impaired Skin Integrity\n Assessment:\n Pt turned frequently, left hip looks better\n stage 1\n Action:\n Pt turned freq, skin care\n Response:\n Plan:\n Continue to turn freq, good skin care.\n"
}
] |
65,956 | 104,972 | BRIEF HOSPITAL COURSE: 49yo male w/ EtOH cirrhosis with h/o multiple prior upper GI bleeds from esophageal varices and gastric ulcers transferred from with hematemesis. His Hct was stable and here he did not require further intervention. His course was complicated by grand mal seizure (toxic/metabolic vs EtOH w/d). He was discharged home with Hepatology and PCP . | Minor ST segment abnormality. Chr atrophy. Chr atrophy. Cerebellum is also mildly atrophic. Sinus rhythm. Sinus rhythm. Periventricular and subcortical white matter hypodensities reflect small vessel ischemic disease. Chronic atrophy and microvascular disease. Q-T interval prolongation. Noprevious tracing available for comparison.TRACING #1 Baseline artifact. IMPRESSION: No acute intracranial process. Since the previous tracing there is nosignificant change in previously noted findings.TRACING #2 The paranasal sinuses are well aerated. If clin indicated, MR would be more sensitive for subtle lesions. There are dense calcifications in the bilateral cavernous carotid arteries. The ventricles and sulci are prominent, consistent with age-related involutional changes and alcoholism. Midline structures are intact. Mastoid air cells and middle ear cavities are clear. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect, or vascular territorial infarct. No prior examinations for comparison. TECHNIQUE: Contiguous non-contrast axial images were obtained through the brain, and reconstructed at 5-mm intervals. WET READ VERSION #1 6:35 PM No ICH, mass effect, edema, or infarct. FINAL REPORT INDICATION: 49-year-old male with alcoholic cirrhosis, first episode of seizure. | 3 | [
{
"category": "Radiology",
"chartdate": "2158-12-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1220962,
"text": " 6:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for focal abnormality\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with alcoholic cirrhosis with first episode seizure\n REASON FOR THIS EXAMINATION:\n eval for focal abnormality\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:40 PM\n No ICH, mass effect, edema, or infarct. Chr atrophy.\n If clin indicated, MR would be more sensitive for subtle lesions.\n WET READ VERSION #1 6:35 PM\n No ICH, mass effect, edema, or infarct. Chr atrophy.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old male with alcoholic cirrhosis, first episode of\n seizure.\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.\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 and alcoholism. Cerebellum\n is also mildly atrophic. Periventricular and subcortical white matter\n hypodensities reflect small vessel ischemic disease. There are dense\n calcifications in the bilateral cavernous carotid arteries. Midline\n structures are intact.\n\n The paranasal sinuses are well aerated. Mastoid air cells and middle ear\n cavities are clear.\n\n IMPRESSION: No acute intracranial process. Chronic atrophy and microvascular\n disease.\n\n"
},
{
"category": "ECG",
"chartdate": "2158-12-27 00:00:00.000",
"description": "Report",
"row_id": 248202,
"text": "Baseline artifact. Sinus rhythm. Since the previous tracing there is no\nsignificant change in previously noted findings.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2158-12-26 00:00:00.000",
"description": "Report",
"row_id": 248203,
"text": "Sinus rhythm. Q-T interval prolongation. Minor ST segment abnormality. No\nprevious tracing available for comparison.\nTRACING #1\n\n"
}
] |
26,112 | 130,893 | This is a F c multiple comorbities with profound sepsis of unclear etiology (?PNA, cultures pending), who after lengthy discussion with the team and the family, was made comfort measures only. She was on morphine for pain control and respiration ease. She passed peacefully on . | start morphin gtt 1mg/hr.resp: non-rebris mask, given nebs, LC coarse bilat. Thoracic aorta is mildly unfolded. COMPARISON: Chest radiograph dated . pt unable to cough.cv: HR 90-100's, SR/NSR, with rare PVC's. SBP 90-105. temp 99.8, last lactate 3.3.gi/gu: foley in place. FINDINGS: The cardiac and mediastinal contours are unchanged compared to the prior study, including tortuous aorta. Tortuous aorta. There is some retrocardiac opacity identified. Right IJ line is terminating at the junction of SVC and right atrium. Sinus tachycardia with frequent atrial ectopy. LLL opacity and effusion. BAD distending, BS hypoactive. A PA and lateral chest radiograph is recommended for further evaluation. Opacity in left lower lobe with effusion. in ED temp 103.8, WBC 35K, lactate 4.6, put on MUST protokol, given Lasix, 3L fluid and levo/vanco/flagyl for sepsis/pna. The right costophrenic angle is excluded from the film. Pulmonary vasculature appears within normal limits. IMPRESSION: Right IJ line terminating at the junction of SVC and right atrium. Metallic opacity overlying the neck, probably outside of the patient, however, please correlate clinically. Note is made of opacity in left lower lobe, with small effusion. 7:40 PM CHEST (PORTABLE AP) Clip # Reason: SOB FINAL REPORT INDICATION: Shortness of breath. ?c/o to the floor. pt has stool x2. TECHNIQUE: Portable chest radiograph. IMPRESSION: Left lower lobe opacity may represent atelectasis or early pneumonia. There isotherwise, no diagnostic change. Check line placement. There is metallic opacity overlying the neck, probably outside of the body, however, clinical correlation is recommended. in ED family confirmed pt DNR/DNI, after discussion with family about poor prognosis of recovery from rofound sepsis, family decided to make pt comfort measures.in the unit stopped Must protokol.neuro: pt arousable to voice/stimul, does not follows commands, opens eyes spont/voice, pt does not c/o of pain. There continues to show non-specificST-T wave abnormalities which may be due in part, to the rapid rate. pt NPO.skin: abrasion on coccyx, open to air, skin cream protector applied.access: RIJ, 1piv.social: DNI/DNR, family make pt comfort to measuers. 9:29 PM CHEST PORT. Surrounding osseous and soft tissue structures demonstrate surgical material in the right upper quadrant of the abdomen. The wet read was faxed to the ED dashboard. please call son with changes phone number on the board.plan: cont morphine gtt for comfort. u/o 25-40cc/hr. Metalic opacity overlying the neck, probably outside, however please check. SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The heart is not enlarged. sat 97%. Since the previous tracingof the rate is more rapid and atrial ectopy is a new finding. No pneumothorax. COMPARISON: None. FINAL REPORT INDICATION: -year-old woman with fever and shortness of breath. LINE PLACEMENT; -76 BY SAME PHYSICIAN # Reason: line placement MEDICAL CONDITION: year old woman with fever, sob REASON FOR THIS EXAMINATION: line placement WET READ: MNIa FRI 10:08 PM Rt IJ line terminating at junction of SVC and rt atrium. Lungs are otherwise clear. No pneumothoraces are identified. | 4 | [
{
"category": "Nursing/other",
"chartdate": "2174-05-21 00:00:00.000",
"description": "Report",
"row_id": 1602339,
"text": " y.o female with h/o COPD, nursing home resident, who has decling mental status for 5 years and worsing past 6 month admitted ED d/t fever, cough, dyspnea,hypotension, pt fell in NH. in ED temp 103.8, WBC 35K, lactate 4.6, put on MUST protokol, given Lasix, 3L fluid and levo/vanco/flagyl for sepsis/pna. in ED family confirmed pt DNR/DNI, after discussion with family about poor prognosis of recovery from rofound sepsis, family decided to make pt comfort measures.\nin the unit stopped Must protokol.\nneuro: pt arousable to voice/stimul, does not follows commands, opens eyes spont/voice, pt does not c/o of pain. start morphin gtt 1mg/hr.\n\nresp: non-rebris mask, given nebs, LC coarse bilat. sat 97%. pt unable to cough.\n\ncv: HR 90-100's, SR/NSR, with rare PVC's. SBP 90-105. temp 99.8, last lactate 3.3.\n\ngi/gu: foley in place. u/o 25-40cc/hr. BAD distending, BS hypoactive. pt has stool x2. pt NPO.\n\nskin: abrasion on coccyx, open to air, skin cream protector applied.\n\naccess: RIJ, 1piv.\n\nsocial: DNI/DNR, family make pt comfort to measuers. please call son with changes phone number on the board.\n\nplan: cont morphine gtt for comfort.\n ?c/o to the floor.\n"
},
{
"category": "ECG",
"chartdate": "2174-05-20 00:00:00.000",
"description": "Report",
"row_id": 164497,
"text": "Sinus tachycardia with frequent atrial ectopy. Since the previous tracing\nof the rate is more rapid and atrial ectopy is a new finding. There is\notherwise, no diagnostic change. There continues to show non-specific\nST-T wave abnormalities which may be due in part, to the rapid rate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 914477,
"text": " 7:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: None.\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: The heart is not enlarged.\n Thoracic aorta is mildly unfolded. There is some retrocardiac opacity\n identified. Lungs are otherwise clear. Pulmonary vasculature appears within\n normal limits. The right costophrenic angle is excluded from the film. No\n pneumothoraces are identified. Surrounding osseous and soft tissue structures\n demonstrate surgical material in the right upper quadrant of the abdomen.\n\n IMPRESSION: Left lower lobe opacity may represent atelectasis or early\n pneumonia. A PA and lateral chest radiograph is recommended for further\n evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-05-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 914481,
"text": " 9:29 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fever, sob\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: MNIa FRI 10:08 PM\n Rt IJ line terminating at junction of SVC and rt atrium. LLL opacity and\n effusion. Metalic opacity overlying the neck, probably outside, however please\n check.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with fever and shortness of breath.\n\n Check line placement.\n\n TECHNIQUE: Portable chest radiograph.\n\n COMPARISON: Chest radiograph dated .\n\n FINDINGS: The cardiac and mediastinal contours are unchanged compared to the\n prior study, including tortuous aorta. Right IJ line is terminating at the\n junction of SVC and right atrium. No pneumothorax. Note is made of opacity\n in left lower lobe, with small effusion. There is metallic opacity overlying\n the neck, probably outside of the body, however, clinical correlation is\n recommended.\n\n IMPRESSION: Right IJ line terminating at the junction of SVC and right\n atrium. Tortuous aorta. Opacity in left lower lobe with effusion. Metallic\n opacity overlying the neck, probably outside of the patient, however, please\n correlate clinically.\n\n The wet read was faxed to the ED dashboard.\n\n"
}
] |
22,657 | 135,103 | The patient had a complicated hospital course due to the multiple sources of infection. In addition to the sources noted in the history of present illness the patient also was found to have multiple dental abscesses, the decubitus ulcers noted and pneumonia and a Methacillin sensitive staph aureus high grade bacteremia. He was treated initially with broad spectrum antibiotics and the coverage was later narrowed according to the sensitivities of the organisms, which grew out in the culture. The patient failed to progress on the floor and ultimately was transferred to the Intensive Care Unit on for respiratory failure and was intubated and supported with mechanical ventilation. The patient was found at that point to have large pleural effusions bilaterally and thoracentesis, however, revealed no active infection in the fluid. The patient was also found on CT to have a new fracture on the right iliac crest. The Orthopedic Service was consulted and felt that no surgical treatment was warranted given the patient's grave medical condition. The CT also revealed fluid collection in the right gluteal area, which was drained under CT guidance, however, this also did not reveal a source for the patient's high grade bacteremia. Ultimately the patient was extubated, however, his condition deteriorated and on the morning of the patient became acutely hypotensive and his respirations became labored and the patient's daughter was consulted who chose to make the patient comfort measures only. He expired on of respiratory failure secondary to sepsis and hypotension. | RECIEVED COZAAR THIS AM. R TLC P/I. HO in to asess, EKG done confirming Afib, ? Resp Care Note:Pt required NT suct for mod th brn sput. Lung sound prior to suct rhonchi improving w/ sx. RECTAL BAG REPLACED TODAY. Pt currently in NARD on cool mist aerosol @ .4FIO2. HCT STABLE AT 31.5 . ABG WNL.CV: SR ON MONITOR, VSS PER L RADIAL ALINE. ANASARCA NOTED UPPER AND LOWER EXT'S. NURSING PROGRESS NOTE:PT CONT TO DO WELL EXTUBATED. Diltiazem 5mg IVP by HO with rate down to 90's and SBP 120-130. NPN 7a-7p: RESP: Pt requiring NT x 3 this shift... copious to moderate amts thick tan/yellow secretions. LS very course, bronchial at bases... team aware that pt is also + 1L fb... to discuss dose lasix. found fit for extubation. POST ABG WNL. LUNGS COARSE THROUGHOUT, RECIEIVNG LASIX IV FOR DUIRESIS. Resp CarePressure support increased to during noc to rest pt. PT IS A DNR BUT WOULD BE REINTUBATED. wbc 9.0... as noted aline dc'd, and resited... cont on unasyn and oxacillin. K+ and Ca++ replaced this am.RESP: Remians orally intubated. PLAN IS TO EXTUBATE TODAY.GI: ABD SOFT WITH UMBILICAL HERNIA. Cards feels this is d/t abx therapy. Access: remains with TLC to R SC... to have PICC placed tomorrow by iv team.. please save L antecube.a/P: pt with tenuous resp status... large amts secretions.. desats easily, but perking up... to cont abx, follow abg's, cont skin care, pulmonary toilet.. PICC line tomorrow. Resp Care,Pt. RESP CARE,PT. F/E: lytes wnl. ?HYPOALBUMINEMIA. DNRSKIN CARE AS ORDEREDATTEMPT TO EXTUBATE POSS. BP 90s/30-40sPt is febrile with temp of 99.9 rectally.GI: Abdomen distended, soft. Prolonged QTC noted. GU: pt cont with clots via foley today. team to place new aline, as pt's resp status tenuous. ABG THIS AM 67/36/7.32/19. ON OXACILLIN AND AUGMENTIN. DSD WITH WOUND JELLY APPLIED.ID: OXACILLIN D18 OF 42. TOMMORROWCONT ANTIBX AS ORDEREDSUPPORT FAMILY PT MED WITH ATIVAN 1MG IVP WITH GOOD EFFECT.PT CONT ON GOAL RATE TUBE FEEDS WITH ACCEPTABLE RESIDUALS. P-MICU RNNOTECV: STABLE WITH DILTIAZEM.RESP: ENT CONSULTED FOR HOARSENESS. TF REMAIN ON HOLD...HIGH RESIDUALS (GASTRIC HEME +...PH 2). Lung sounds bilat rhonchi clearing significantly after suct. CVP 9-10.RESP: PT REMAINS ON AC/450/14/40%/PEEP DOWN TO 7.5. ABG DONE AND WNL. R RADIAL ALINE PLACED AND ABG AT THE TIME=7.15/96/81/35/1. LUNGS CLEAR WITH SCT RHONCHI THROUGHOUT BASES AND DECREASED BASES. Resp Care Note:Pt cont on mech vent aas per vent flowsheet. need to further wean ativan as pt essentually unresponsive.GI:Abdomen soft. Cont in sinus brady hr in 50's.Neuro: remains sedated on 1mg ativan. TEAM AWARE, BOLUS WITH MORE FLUID.INTEG: R IJ TLC P/I. Drs' and pronounced. WILL CONT TO CHECK RESIDUALS AND ATTEMPT TO RESTART TF.INTEG: R IJ TLC P/I...CVP OFF DISTAL PORT. PEJ DRSG FOR AMT OS SEROUS DRAINAGE. R RADIAL ALINE P/I. S1S2 ON AUSCULTATION.RESP: PT TO AC/40/450/10/14...BREATHING WITH VENT. RESP RATE REGULAR. O2 SAT'S IN HIGH 90'S.PT'S VITAL SIGNS STABLE, AFEBRILE. UO ADEQAUTE VIAFOLEY CATH . Received CPT q4h with NT suctioning. ALTERED REPS STATUSD: PT A&O AND FOLLWS SIMPLE COMMANDS. TF's held ~1hr with CPT and sxning. S2S1 murmur noted. Last ABG WNL.GI: NGT intact with + placement. Lung sounds rhonchi impr after suct mod th tan sput. S1S2 with murmur noted. Labs WNL.RESP: Remains vented. Troponin of yest negative. P-MICU NPN 7p-7aSystems Review:Resp: LS coarse bilat throughout. Hypoactive bowel sounds noted. Continue with abx regimine. Ca++ repleted.Resp: Vent settings unchanged. Resp Care Note:Pt cont on vent as per Carevue. F/E: pt with marginal UO this shift.. ? +bs, tolerating TF's with minimal residuals. Lytes wnl. EKG due this am. R hip wound debrided by plastics today. PT/RSD Re-evaluationS: IntubatedO: Please refer to initial evaluation for further information regarding PMH and HPILabs: 13.6>32.1<313Vent: PS 5/PEEP 5, Tv 450, 40%FiO2Pulmonary: Breath sounds coarse throughoutMobility: Pt sedated, no active movement at this timeROM: PROM all joints WFL although stiffness noted throughoutVital Signs: Pre-rx: 148/60 77 28 99% During/post-rx: 140/60 78-84 28 98-100%Rx: Gentle passive ROM bilateral upper and lower extremities.Percussion to right lung field in left sidelying followed by in line suctioning for minimal yellow secretions. There are simpleatheroma in the ascending aorta. Trace aortic regurgitation is seen. These changes are consistent with anterolateral myocardial infarctionof indeterminate age. Small bilateral pleural effusions with bibasilar atelectasis. Thereare simple atheroma in the aortic arch. There are simple atheroma inthe aortic arch. 2) Bibasilar atelectasis and pleural effusions. Pulmonary vascularity is indistinct, consistent with CHF. Prior anteroseptalmyocardial infarction. There is nosignificant aortic valve stenosis. Compared to the previous tracingof sinus rhythm has replaced rapid atrial fibrillation, low voltageis now present in the precordial leads and voltage appears decreased in thelimb leads. Prior anteroseptal myocardial infarction.Compared to the previous tracing of there is variation in precordiallead placement. There are simple atheroma in the aortic root.There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracicaorta.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Prioranteroseptal myocardial infarction. The appearance is consistent with a multiseptated collection/abscess. Left anterior fascicular block. Left atrial abnormality. Left atrial abnormality. PORTABLE UPRIGHT CHEST @ 10:08: Again seen are small bilateral pleural effusions, right greater than left. IMPRESSION: There is prominence of the interstitium, probably related to chronic process with a superimposed interstitial edema. A limited ultrasound of the right hemithorax revealed a pleural effusion. SINGLE AP PORTABLE VIEW OF THE CHEST: There is marked patient rotation, which alters cardiomediastinal borders. IMPRESSION: Persistent, mild interstitial edema with bilateral pleural effusions. There is prominence of the interstitium which probably relates to a chronic process, although superimposed interstitial edema will have a similar appearance. A CAPD catheter is incidentally noted. The catheter was removed and the MIC G-J tube was advanced over the wire and positioned with tip in proximal jejunum. CV line is in mid to distal SVC, probably obscured by spinal rod. There is bibasilar passive atelectasis associated with the effusions. There is persistent right basilar pleural thickening which may be chronic, or a loculated pleural effusion. Contrast was administered which documented intragastric location of the needle. There has been interval insertion of an orogastric feeding tube which projects below the level of the diaphragm. | 119 | [
{
"category": "Nursing/other",
"chartdate": "2131-09-16 00:00:00.000",
"description": "Report",
"row_id": 1558190,
"text": "MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT VERY LETHARGIC EARLY THIS AM AND WAS NOT RESPONDING TO VERBAL STIMULI. BY 1400, PT FOLLOWING COMMANDS AND MORE AWAKE. EXTUBATED AND DOING WELL. CONT TO FOLLOW COMMANDS, MOVING AROUND MORE AND INTERACTING WITH FAMILY. PT ABLE TO VERBALIZE ONE WORD ON OCCASSION. APPEARS TO BE ORIENTED TO FAMILY. AFEBRILE.\n\nCV: SR ON MONITOR, NO ECTOPY NOTED. VSS...BP HIGH ON OCCASSION PER ALINE, (170-190/60-70'S). RECIEVED COZAAR THIS AM. S1S2M ON AUSCULTATION. R TLC P/I. OVERALL ANASARCA NOTED, POOR PALPABLE PULSES ALL AROUND.\n\nRESP: PT EXTUBATED THIS AFTERNOON, ON 50%FM AND TOLERATING WELL. POST ABG WNL. RR 20-26. LUNGS REMAIN COARSE ANTERIORLY AND UPPER POST LOBES...CLEAR,DECREASED B/L BASES. ORALLY SUCTIONING SMALL AMT'S THICK YELLOW. NTSUCTIONED X1. O2SATS 99-100%.\n\nGI/GU: FOLEY CHANGED TODAY...LEAKING AROUND INSERTION SITE. #16 FR FOLEY PLACED AND DRAINING BLD TINGED URINE. LASIX GIVEN WITH GOOD RESULTS. IMMODIUM GAVE THIS AM X1..NO BM NOTED TODAY. ABD SLIGHTLY DISTENDED WITH POSITIVE BS..WHEN TF INFUSING, NO RESIDUALS WERE NOTED.\n\nCURRENTLY: D5NS @75CC/HR INFUSING VIA TLC. FAMILY AT BEDSIDE AND PT DOING WELL. TLC AND ALINE FROM ...TEAM AWARE AND WILL PT FOR PICC LINE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-17 00:00:00.000",
"description": "Report",
"row_id": 1558191,
"text": "NURSING PROGRESS NOTES:\nPT REMAINS EXTUBATED WITH 50%FACE MASK. O2 SAT'S MAINTAINED HIGH 90'S . LUNG SOUNDS COARSE AND IS ABLE TO COUGH UP SOME SECRETIONS WITH MUCH ENCOURAGEMENT. ABLE TO SUCTION THEM FROM BACK OF THE THROAT.\nPT VERY LETHARGIC AT START OF THE SHIFT BUT BECAME INCREASINGLY MORE ALERT AND OPENING EYES AND ATTEMPTING TO SPEAK. WILL COUGH A WEAK COUGH WHEN TOLD TO.\nVITAL SIGNS STABLE. LOW GRADE TEMP.\nFOLEY CATH DRAINING GOOD AMT'S OF PINK TINGED URINE AND OOZING CLOTS AROUND CATH FROM PENIS. CATH IRRIGATED TO CLEAR CLOTS. OCC WILL DRAIN LRG AMT'S OF URINE AROUND CATH IF CLOTS HAVE OBSTRUCTED CATH.\nHIP DSG CHG, WOUND LOOKS SLIGHTLY IMPROVED.\nFAMIL WENT HOME EARLY AND CHECKED IN DURING THE NIGHT.\nPT STARTED ON IV UNASYN SINCE UNABLE TO TAKE PO MEDS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-17 00:00:00.000",
"description": "Report",
"row_id": 1558192,
"text": "REHAB SERVICES/PT\nS: MOANING\nO: PT SEEN FOR PROBS/GOALS PER R/E \nMS: ALERT, ORIENTED TO NAME AND HOSPITAL, MIN VERBALIZATION T/O RX\nVS'S: 96 97%(50%FM) 20\nBS'S: DECREASED BILAT WITH CRACKLES LL'S\nCOUGH: WEAK, CONGESTED, INEFFECTIVE\nBR PATTERN: NON-LABORED\nRX: PROM X4 EXTREMITIES, POSITIONED S-S WITH HOB LEVEL FOR PERC/SHAKING TO BILAT LUNG FIELDS, PRE-OXYGENATED WITH 100% FIO2 AND NTS FOR MOD TO LARGE AMOUNTS THICK YELLOW SECRETIONS.\nCOMMUNICATION WITH RN AND MD RE: PTS STATUS\nA: PT DOING FAIRLY WELL S/P EXTUBATION BUT DOES HAVE A LOT OF SECRETIONS, UNABLE TO CLEAR ON OWN AND NEEDS FREQUENT NTS. PTS EXTREMITIES VERY STIFF WITH KNEE FLEXION CONTRACTURES PRESENT.\nP: CONTINUE TO FOLLOW FOR BPH, ROM AND MOBILITY AS ABLE\nPG \n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-21 00:00:00.000",
"description": "Report",
"row_id": 1558204,
"text": "Resp Care Note:\n\nPt requires frequent NT suct for mod to large amt th beige sput. Lung sound prior to suct rhonchi improving w/ sx. Pt currently in NARD on cool mist aerosol @ .4FIO2. Cont to encourage deep breathing and coughing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-21 00:00:00.000",
"description": "Report",
"row_id": 1558205,
"text": "NURSING PROGRESS NOTE:\nPT CONT TO DO WELL EXTUBATED. NASAL TRACHEAL SX X 1 FOR LRG AMT OF THICK TAN SECRETIONS. O2SAT'S IN HIGH 90'S. LUNG SOUNDS VERY COARSE THROUGHOUT.\nTUBE FEEDS TOL WELL VIA NGT. SM RESIDUALS. ABD DISTENDED BUT SOFT, BOWEL SOUNDS PRESENT. NO STOOL TONIGHT.\nHEPARIN INJ GIVEN AND PT OOZING FROM SITE MOST OF NIGHT.\nU/O ADEQUATE.\nFAMILY UPDATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1558200,
"text": "Rehabilitation Services/physical therapy\n\n8:30 - 9:15\n\nS: Speaking appropriately, tho difficult to understand secondary to upper airway sounds\n\nO: Seen to address problems and goals of \nVital signs: 81, 150/54, 98% on 40% face tent, 21\n with Sx: 98, 162/68, 85% with poor tracing on 100%\n p Rx: 82, 147//53, 98% on 40%\nBreath sounds: upper airway sounds throughout\n p Rx: mid to end expiratory wheezes, improved air movement\nRx: NTS for small amounts of bright red blood, difficult to enter airway. Used an oral airway for suctioning for large amounts of thick yellow secretions.\nPositioning: Patient's position changed to opposite sidelying p suctioning.\n\nA: Patient with increased secretions, cleared well with oral airway and deep suctioning. Unable to perform percussion and shaking second to right rib fractures. Nursing to discuss weight bearing status with team on rounds.\n\nP: Plan to be developed with input from team re: weight bearing status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-21 00:00:00.000",
"description": "Report",
"row_id": 1558206,
"text": "ALTERED RESP STATUS\nD: PT ALERT AND ORIENTED. FOLLOWS SIMPLE COMMANDS. ON INITIAL ASSESSMENT O2 AT=89%. ON 40% FACE TENT. SUCTIONE NASLLY VIA L NARE FOR MODERATE AMT OF THICK CREAMY YELLOW SPUTUM AND O2 SATS NOW 96-98%. COARSE BS BIL. CONTINUES ON PROMODE TUBE FDGS VIA NGT WITH MINIMAL RESIDUALS SO RATE NOW INCREASED TO GOAL RATE OF 60CC'S/HR WITH NO SIGNS OF ASPIRATION. INCONITNNENT OF MOD AMT OF LOOSE BROWN STOOL. AWAITING FAMILY'S CONSENT TO PLACE PEG AND ALSO AWAITING PALCEMENT AT OR . VSS. UO ADEQUATE. WILL CONTINUE WITH PRESENT MEDICAL TX. WILL CONTINUE TO UPDATE FAMILY AS NEEDED AND OFFER EMOTIONAL SUPPORT. PT IS A DNR BUT WOULD BE REINTUBATED IF RESP STATUS WERE TO WORSEN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-21 00:00:00.000",
"description": "Report",
"row_id": 1558207,
"text": "MICU NPN 11AM-7PM:\nNeuro: Awake and alert most of the day. Asked to get up OOB and stayed up for 2hrs or so and was most comfortable in the chair. Otherwise he has been restless, calling for me to reposition him frequently. I explained to him that it is not possible to repeostion him as frequently as he is asking and that every two hours would be the most frequent turn that is reasonable. His speech is very diffucult to understand since his voice is weak and he is congested in the upper airway.\n\nResp: Still requires close monitoring of his resp status for need to suction him. He is on 40% TM and his sats were best while in the chair. He was suctioned twice today for thick blood tinged yellow sputum. Lungs are coarse. RR in the 20's. O2 sat 96% most of the day but were 100% while in the chair.\n\nCardiac: Remains hypertensive in the 150's to 190's. Up with activity. Cozaar was increased to 50mg QD and extra 25mg was given as requested by the physician. 70-80's.\n\nGI: Two small stool today. Tolerates goal rate tube feeds.\n\nGU: Adequate UO via the foley.\n\nSocial: I spoke to pt's son via the phone today. Also MD updated pt's daughter and spoke to the ppt and to her about the need for PEG next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-22 00:00:00.000",
"description": "Report",
"row_id": 1558208,
"text": "Resp Care Note:\n\nPt required NT suct for mod th brn sput. Pt placed on FIO2 .4 via cool mist aerosol via face tent with stable O2 sats. Cont aggressive pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-15 00:00:00.000",
"description": "Report",
"row_id": 1558185,
"text": "MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT SLEEPING MOST OF DAY, OPENS EYES AND SQUEEZES HANDS ON COMMAND...OTHERWISE NOT MOVING AROUND OR AWAKE. NOT ANSWERING ANY QUESTIONS. TMAX 99.8 AX. TEAM AWARE. ATIVAN DC'D AND PRN FOR HALDOL IF NEEDED.\n\nCV: SR ON MONITOR, NO ECTOPY NOTED. BP SLIGHTLY HIGH AT TIMES, 140-160/50'S PER ALINE. ANASARCA NOTED UPPER AND LOWER EXT'S. S1S2M ON AUSCULTATION.\n\nRESP: VENT TO CPAP 40%/...ABG WNL. PLAN TO HOLD ON EXTUBATING SECONDARY TO LG AMT ORAL SECRETIONS. SUCTIONED SMALL AMT VIA ETT, THICK TAN, BLD TINGED. LUNGS CLEAR TO COARSE THROUGHOUT. VT 400-500, RR 20-30'S. FAMILY MADE AWARE OF DECISION TO WAIT ON EXTUBATION.\n\nGI/GU: CONT TO BE OF LOOSE STOOL, 3RD CDIFF CULTURE SENT. RECTAL BAG REPLACED TODAY. PLAN TO START IMMODIUM IF LAST CULTURE IS NEGATIVE. FOLEY NOT DRAINING THIS AM, CHANGED TO #14G AND DRAINING CLEAR BLD TINGED CLEAR YELLLW URINE. MIVF STARTED TO D5NS @75CC/HR. TF INFUSING WITHOUT DIFF. WILL FOLLOW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-15 00:00:00.000",
"description": "Report",
"row_id": 1558186,
"text": "resp. care note: pt received intubated with a 7.5 ett, secured at the 23cm mark. pt also mech. ventilated, current settings: cpap 5 psv 5 and 40%. pt received general ventilator management as well as suctioning when needed. pt is to remain intubated overnight secondary to excess oral secretions. possible plan to extubate tomorrow. rrt\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-16 00:00:00.000",
"description": "Report",
"row_id": 1558187,
"text": "Resp Care\nPressure support increased to during noc to rest pt. Settings will be returned to in morning, plan is to extubate on days. Sxn'd thick yellow moderate amts x2 during shift. No abgs drawn, will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1558201,
"text": "MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT APPEARS [email protected] WITH FAMILY, FOLLOWING COMMANDS. AFEBRILE.\n\nRESP: REMAINS ON FACE TENT 40% WITH O2SATS 96%. LUNGS COARSE THROUGHOUT, RECIEIVNG LASIX IV FOR DUIRESIS. ABG WNL.\n\nCV: SR ON MONITOR, VSS PER L RADIAL ALINE. NO AFIB NOTED. S1S2 ON AUSCULTATION. ANASARCA NOTED ALL AROUND.\n\nGI/GU: FOLEY OUTPUT DROPPED OFF, FOLEY IRRIGATED WITHOUT DIFF. WILL MONITOR OUTPUT. ABD S,NT,D...TOLERATING TF'S, RATE INCREASED TO 30CC/HR...NO RESIDUALS. WILL FOLLOW.\n\nTODAY; HCT DOWN TO 25...RECIEIVING ONE UNIT PRBC'S. L PICC PLACED, PLACEMENT OKAY PER XRAY; WILL PULL TLC AFTER BLOOD INFUSED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-20 00:00:00.000",
"description": "Report",
"row_id": 1558202,
"text": "Nursing Progress Note\nNeuro: Awake, calling out at times, remains difficult to understand with weak voice, upper airway congestion\nResp: Sats 92-96% on 40% cool neb face tent, BS coarse throughout, required N-P suctioning x4 overnight for thick tan sputum, has weak cough, at times can cough up to back of throat, can use Yankauer suctioning\nCV: Stable, remains in NSR, no ectopy noted, continues on Diltiazem 30mg via NGT q6hrs\nGI: Tol TF's at now 40ml/hr with minimal residuals. Blue dye in feeds, no evidence of aspiration overnight. scant amt soft brown stool\nGU: I/O neg ~700ml/24hrs after lasix dose given on day shift, continues with u/o >60ml/hr\nSkin: No change in hip wound, Duoderm intact on back area\nSocial: Telephone update to pt's daughter, overnight\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-20 00:00:00.000",
"description": "Report",
"row_id": 1558203,
"text": "ALTERED RESP STATUS\nD:PT AWAKE AND ALERT AND FOLLOWS SIMPLE COMMANDS APPROPRIATELY. CONVERSING WITH FAMILY IN FEW WORD SENTENCES. REMAINS ON 40% FACE TENT WITH ABG=7.35/49/87/28/0. SUCTIONED WITH DIFFICULTY VIA R NARE FOR COPIOUS AMTS OF THICK TAN SPUTUM AND THEN THICK YELLOW SPUTUM. THIS AFTERNOON PT ABLE TO COUGH AND RAISE TO BACK OF HIS THROAT THICK TAN SPUTUM. COARSE BS BIL ON AUSCULTATON. MAX TEMP=96.9 AXILLARY. SBP 160-179. AND RR 18-26. TUBE FDGS OF PROMODE INCREASED TO 50CC'S/HR WITH MINIMAL RESIDUALS. GOAL RATE FOR TUBE FDGS IS 60CC'S. PT STILL WITHOUT GAG AND THIS WAS VERIFIED BY SPEECH SWALLOW THERAPIST WHO RECOMMENDS THAT PT WILL NEED PEG. HCT STABLE AT 31.5 . K+ 3.6 AND REPLACED WITH 20 MEQ KCL VIA NGT. PT IS A DNR BUT WOULD BE REINTUBATED. PT EVALUATED AND SCREENED BY AND . PT BE TRANSFERED WHEN BED AVAILABLE TO REHAB AS EARLY AS MON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-16 00:00:00.000",
"description": "Report",
"row_id": 1558188,
"text": "NURSING PROGRESS NOTES:\nPT CONT TO BE INTUBATED AND VENTED. REMAINS ON PRESSURE SUPPORT AND PEEP, SEE FLOWSHEET FOR SETTINGS. SX OCC FOR MOD AMT'S OF THICK YELLOW SPUTUM. LUNG SOUNDS COARSE THROUGHOUT. O2 SAT'S IN THE HIGH 90'S.\nPT CONT TO BE QUITE SEDATED BARELY RESPONDING TO STIMULI.\nBP OCC GOING UP TO 180 RANGE WHEN STIMULATED WITH TURNING OR SUCTIONING.\nFOLEY CATH DRAINING ADEQUATE AMT'S OF YELLOW URINE. RECTAL BAG CHG'D, NOT DRAINING MUCH STOOL, IMODIUM HELD.\nTUBE FEEDS CONT AT 40/HR WITH SM RESIDUALS. BOWEL SOUNDS PRESENT AND ABD SOFT/DISTENDE.\nFAMILY VISITING TILL MIDNIGHT AND UPDATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-16 00:00:00.000",
"description": "Report",
"row_id": 1558189,
"text": "resp. care note: pt assessed for extubation by rrt, rn, and md. pt. found fit for extubation. pt extubated, and placed on a cool aerosol mask at 50%, which will be titrated to keep spo2 > than92%. following extubation there were no increases in resp. rate, heartrate, or decrease in spo2. all is well at this time. rrt\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-18 00:00:00.000",
"description": "Report",
"row_id": 1558196,
"text": "NPN 7a-7p:\n RESP: Pt requiring NT x 3 this shift... copious to moderate amts thick tan/yellow secretions. LS very course, bronchial at bases... team aware that pt is also + 1L fb... to discuss dose lasix. Cont on 50% csm with sats 99-100%... abg wnl.. po2 66-90's... po2 lower with pt on R side. RR 20's.\n ID: afebrile. abx changed... unasyn dc'd and po augmentin started.. cont on ox.\n F/E: fb + as noted.. repleted with Kcl, MG per med sheets. TF's reinstituted... now at 10cc/hr ... goal is 40cc/hr.. Discussion r/e peg for long term feeding.. Pt to have swallow study tomorrow... pending results of this, pt to decide r/e PEg.\n Access: IV team in to for PICC... state that arm is too edematous at this time.. if unable to place will need hickman.\n CV: no active issues.\n social: pt's daughter in to visit.. discussion held with team/pt/... pt statign would want to be reintubated... no cpr.\n A/P: pt with adequate abg'd, but cont with secretions although less.. cont to follow o/n.. line tomorrow for long term abx.. may diurese tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1558197,
"text": "Nursing Progress Note\nPt noted to convert to Afib rate up as high as 130's with compromised BP to as low as the 80's. HO in to asess, EKG done confirming Afib, ? new ischemic changes, cycling CK's. Given fluid bolus NS 250ml. Diltiazem 5mg IVP by HO with rate down to 90's and SBP 120-130. Orders received for Diltiazem via NGT q6hrs, initial dose given at 2400. Monitor showing Afib rate 90's-110's with SBP 120's at this time. HO called pt's daughter at pt's request, updated re: events. Pt's code status remains no CPR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-15 00:00:00.000",
"description": "Report",
"row_id": 1558183,
"text": "resp. care note:\n Pressure support increased to 10cmh2o. Pt's resp rate 30s-40s, decreased sats and increased BP. Pt suctioned for a moderate amount of thick tan secretions. Plan is to try to wean pressure support back to 5; then extubate. For further information please refer to carevue charting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-15 00:00:00.000",
"description": "Report",
"row_id": 1558184,
"text": "P-MICU NSG PROGRESS NOTE 7P-7A\nNEURO: PATIENT AWAKE AT TIMES WOULD OPEN EYES SPONTANEOUSLY AND TO VOICE. FOLLOW COMMANDS BY SQUEEZING HANDS. MOVING HEAD AND FEET AND OCCASIONALLY ARMS. GIVEN 0.5MG ATIVAN IV THIS AM AS PATIENT BP ^200 AND NOT COMING DOWN AS IT WAS DOING PREVIOUSLY IN THE SHIFT. THIS HAD GOOD EFFECT AS BP DECREASED AND PATIENT STILL RESPONDING.\n\nCARDIAC: HR 80'S IN SR WITH NO NOTED ECTOPY. BP 140-206/ 50-77. WHEN PEACEFUL AND SLEEPING SBP 140'S-150'S. PATIENT WITH SEVERAL EPISODES DURING THE SHIFT WHEN HE WOULD BE FULLY AWAKE WITH EYES OPEN AND BP WOULD INCREASED TO 190-200. THIS WOULD LAST FOR ~5MIN AND THEN RETURN TO BASELINE. THIS MORNING BP WOULD NOT DECREASE, COZAAR WAS STARTED AND THEN PATIENT GIVEN THE ATIVAN. HCT 29 THIS AM. PATIENT WITH PERIPHERAL EDEMA.\n\nRESP: STARTED SHIFT ON PS 5/5 AT 40%. BREATHING 30'S WAS CHANGED TO PS 10 WITH RR IN THE 20'S. SATS 89-96% RR20-40. TV'S 400'S. LS CLEAR TO COARSE. SXT FOR SMALL AMOUNTS ON TAN YELLOW TO BLOODTINGED THICK SPUTUM. ABG THIS AM 67/36/7.32/19. PLAN IS TO EXTUBATE TODAY.\n\nGI: ABD SOFT WITH UMBILICAL HERNIA. BS+ WITH BROWN LIQUID STOOL IN FIC BAG. OGT IN PLACE WITH PROMOTE W/FIBER AT 40CC/HR. NO RESUDUALS.\n\nGU: U/O TAPERING TO 0. 250CC FLB BOLUS X2 WITH NO EFFECT. FOLEY FLUSHED EASILY. URINE WAS YELLOW AND CLEAR.\n\nSKIN: RIGHT UPPER HIP 4X2.5X1CM WOUND. YELLOW SLOUGH AND PINK WOUND BASE. WOUND GEL AND W/D DSG APPLIED. ALSO DUODERM TO UPPER BACK.\n\nID: WBC 17.6. ON OXACILLIN AND AUGMENTIN. CULTURES PENDING. TMAX 99.3.\n\nACCESS: RIJ CL, LEFT ART LINE.\n\nSOCIAL: DAUGHTERS HAVE BEEN HERE ALL SHIFT. UNDERSTAND PLAN TO EXTUBATE TODAY AND WISH PATIENT TO BE REINTUBATED IF NECESSARY. PATIENT IS A DNR.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1558198,
"text": "Nursing Progress Note\n1:15 - 1:30\n\nPatient transferred out of bed to chair with supine slide transfer. Patient unable to assist with transfers. On rounds, MD confirm that patient is to maintain non-weightbearing status due to pelvic fractures\n\nA/P: As patient is unable to receive percussion and shaking due to rib fractures and unable to be weightbearing to progress activity, will d/c from service as this time. If patient is able to participate in activity progression in the future, please reconsult our service.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 1558199,
"text": "Nursing Progress Note\nNeuro: Awake, alert, difficult to understand what pt is saying most of the time d/t weak voice, secretions\nResp: BS coarse bilat, sats 95% on 40% cool neb mask. NP suctioned x3 for mod amt thick tan-yellow sputum\nCV: Converted to NSR 80's at 0530, receiving Diltiazem 30mg via NG tube BP back to baseline 130's-150's\nGI: Tube feedings at 10ml/hr with min residuals, +bowel sounds, no stool overnight\nGU: Adequate urine output, although still + ~1L/24hrs\nSkin: Hip packing changed, site without change from previous documentation\nSocial: No further contact with family overnight.\nPlan: Needs to be evaluated for PICC line insertion, venous access team aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-14 00:00:00.000",
"description": "Report",
"row_id": 1558178,
"text": "NURSING PROGRESS NOTES:\nPT STILL AND VENTED ON SAME SETTINGS. SEE FLOWSHEET. PT SX FOR LRG AMT'S OF YELLOW BLD TINGED SECRETIONS. O2SAT'S MAINTAINING HIGH 90'S WITH NO DROPS. LUNG SOUNDS COARSE THROUGHOUT.\nPT CONT TO BE VERY SEDATED BUT HAS PERIODS WHEN SBP GOES UP TO THE 170'S AND IS ATTEMPTING TO OPEN EYES BUT UNABLE. PT MED WITH ATIVAN 1MG IVP WITH GOOD EFFECT.\nPT CONT ON GOAL RATE TUBE FEEDS WITH ACCEPTABLE RESIDUALS. RECTAL BAG DRAINING SM AMT'S OF LIQ BROWN STOOL.\nRIGHT HIP DSG CHG WITH SM AMT OF YELLOW DRAINAGE. WOUND CLEANSED/WOUND GEL APPLIED AND PACKED WITH WET TO DRY DSG.\nDUODERM ON SPINE INTACT.\nFAMILY CHECKED IN BY PHONE AND WERE UPDATED.\nPT CONT ON ANTIBIOTICS AND IV FLUID DISCONTINUED.\nPT HAS SEVERE GENERALIZED PITTING EDEMA. FOLEY CATH DRAINING MOD AMT'S OF YELLOW URINE.\nPT HAS LOW GRADE TEMP AND VITAL SIGNS ARE STABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-14 00:00:00.000",
"description": "Report",
"row_id": 1558179,
"text": "Resp Care,\nPt. remains intubated on CPAP IPS 10/.4/5peep. VT 500, RR 20. Suctioned for yellow sputum. Cont. to wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-14 00:00:00.000",
"description": "Report",
"row_id": 1558180,
"text": "PT/RSD\nS: Intubated, opened eyes during chest physical therapy\nO: Pt seen to address goals set at re-evaluation on \nLabs: 15.6>29.1<353, Tm 99.8\nVent: 40%FiO2/PS 10/PEEP 5/TV 500\nVital Signs: Pre-rx: 128/41, 77, 95%, 23\n During rx: 170/60, 83, 98% 23\nBreath Sounds: Coarse anterior, diminished bilateral lower lobes\nRx: Chest PT, percussion and vibration, to bilateral anterior lung fields in supine, bilateral lower lobes in sidelying. Followed by in-line suction for minimal amount of yellow secretions. Mouth yank. suctioned for moderate amount yellow sputum.\nA: Pt continues to benefit from chest PT and mobility in the bed to assist with secretion clearance. Pt continues to have less secretions and require less frequent suctioning.\nP: F/U \nPager #\nTime Frame: 3:15-4:00pm\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-14 00:00:00.000",
"description": "Report",
"row_id": 1558181,
"text": "Respiratory Care Note\n\nPt weaned to CPAP with PSV 5 and PEEP 50. 40%. Pt tol wean well Vt 460 and RR 20-26. pt x2 for small/mod amount of white sputum. Bs with scattered rhonchi. Pt much more awake today...following some commands. Plan to ? extubate in next couple of days.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-14 00:00:00.000",
"description": "Report",
"row_id": 1558182,
"text": "s. ett\nO. NEURO PEARLA RESPONSE TO PAINFUL STIMULI AT 1800 PT MY HAND WITH HIS RT HAND WEAK OPENS EYES TO PAINFUL STIMULI\nCARDIAC HR 80'S NSR WITHOUT ECTOPY BP 130/-180/ EKG QT INTERVAL WNL AFTER D/C OF FLAGYL.\nRESP CPAP 40% PS 5 PEEP 5 ABG 75/42/7.36 LUNGS RHONCI TO CLEAR SX FOR SCANT AMT OF WHITE SPUTUM\nGI TF 40CC GOAL RESIDUALS MIN. BS+ STOOL DARK LIQ BROWN OB NEG ABD SNT UMBILICAL HERNIA UNCHANGED\nGU FOLEY U/O>40CC QHR CLEAR YELLOW\nSKIN RT HIP ANT 4X3CM .5-1CM DEEP POST SIZE DIME 1-2MM DEEP YELLOW DRAINAGE SCANT LUMBAR DECUB DUODERM INTACT PITTING EDEMA UE\nID AFEB ON OXACILLIN Q 4 IV\nCODE STATUS FAMILY HAS MADE PT DNR ATTENDING TO COSIGN ORDER\nA. ALT NEURO STATUS UNCLEAR IF RELATED TO ATIVAN STOPPED \nALT IN RESP VENT DEPENDENT\nS/P THORACENTESIS\nP. DNR\nSKIN CARE AS ORDERED\nATTEMPT TO EXTUBATE POSS. TOMMORROW\nCONT ANTIBX AS ORDERED\nSUPPORT FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-17 00:00:00.000",
"description": "Report",
"row_id": 1558193,
"text": "NPN 7a-7p:\n Review of Systems:\n Resp: pt sx for copious amts yellow/tan secretions this shift... q 2hrs.. CPT done x 1 by PT as well. Cont on 50% CSM, with sats 99%, although abg 68/44/.7.37/26. desats to 85% quickly with mask off. RR 16-28. Aline dc'd as was red and small amt puss at site... tip sent for cx. team to place new aline, as pt's resp status tenuous.\n CV: pt in NSR 80's-90's. BP 130's-150's. NGT placed to give meds.. ASA and Cozaar.\n GU: pt cont with clots via foley today. irrigated x 1 d/t pt reporting unable to \"Pee\".. large clot removed... 3 way foley placed and await GU irrigant to run o/n. uo 40-60cc/hr.\n F/E: lytes wnl. cont on maintanence ivf. Cont edematous.\n ID: afebrile. wbc 9.0... as noted aline dc'd, and resited... cont on unasyn and oxacillin.\n Integument: Skincare CNS in to evaluate R hip wound today... Per CNS report.. wound with slightly more yellow, \"dead\" tissue... sharp debrided by CNS, cleansed with wound cleanser, and filled with wound gel and moist 2x2's, dsd ... taped to duoderm border... also, small blister on upper back cleansed and duoderm replaced.\n Social: pt's daughter and son in all day.. met with team to discuss plan of care.. pt to remain DNR, but would be reintubated. family very attentive.\n NEuro: pt A+ O x ... more awake this afternoon, voice much more clear. asking to watch tv.\n Access: remains with TLC to R SC... to have PICC placed tomorrow by iv team.. please save L antecube.\na/P: pt with tenuous resp status... large amts secretions.. desats easily, but perking up... to cont abx, follow abg's, cont skin care, pulmonary toilet.. PICC line tomorrow. cont emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-18 00:00:00.000",
"description": "Report",
"row_id": 1558194,
"text": "NPN\n\nCV: SBP into the 180s, he was given his cozaar which decreased it to the 160s at times.\n\nPulm: Wet cough, not always able to get very much back from NT suctioning. Cool neb conts at 40% with SATs in the high 90s-100%, desats to the low 90s with his mask off .\n\nGI: TF on hold, to discuss with the team today.\n\nGU: He no longer has any blood in his foley, continuous flush has been stopped.\n\nNeuro: Weak, calling out when he wants assistance.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-18 00:00:00.000",
"description": "Report",
"row_id": 1558195,
"text": "Rehabilitation Services/physical Therapy\n10:15 - 10:45\n1:00 - 1:15\n\nS:\n\nO: Seen to address problems and goals of .\nVital signs: 84, 186/60, 99%, 24, Temp 97.1\nLabs: 90/48/7.34/27, WBC 7.9, Hct 25.4, CXR with Right rib fractures\nBreath sounds: rhonchi throughout, crackles at left base\nRx: NTS for large amounts of yellow/tan secretions. Perc and shaking not done secondary to rib fractures.\nMobility: Due to pelvic fractures, non weightbearing transfers out of bed to chair this am. Returned to bed this PM. Patient with stable vital signs throughout.\n\nA: Patient with rib fractures and airway secretions. NTS used to remove secretions with good results. Out of bed to chair.\n\nP: COntinue to follow for pulmonary care out of bed to chair\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-12 00:00:00.000",
"description": "Report",
"row_id": 1558172,
"text": "Resp. Care Note\nPt remains intubatd and vented on current settings CPAP 5 PSV 5 and 40%. Pt changed to these settings today from A/C and has done well with stable ABG's and RR 24 TV 450-500. RSBI today 66. Sxn for pale yellow secretions, decreased amount today. Pt with cough response and slight gag but still uresponsive to commands. Cont present settings, assess for ext. when Pt more alert.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-13 00:00:00.000",
"description": "Report",
"row_id": 1558173,
"text": "RESP CARE,\nPT. REMAINS ON CPAP IPS5/.4/5PEEP. VT 400, RR HIGH 20'S. RESTED COMFORTABLY, NO VENT CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-13 00:00:00.000",
"description": "Report",
"row_id": 1558174,
"text": "NURSING PROGRESS NOTES:\nPT REMAINED ON CPAP THROUGHOUT THE NIGHT. SX FOR MOD AMT'S OF THICK YELLOW SECRETIONS. LUNG SOUNDS VERY COARSE THROUGHOUT. MAINTAINING O2SAT'S IN THE HIGH 90'S.\nPT CONT TO BE VERY LETHARGIC AND BARELY RESPONSIVE WITH STIMULI.\nVITAL SIGNS STABLE. TEMP 99.8 PO.\nFOLEY CATH DRAINING ADEQ AMT'S OF CLOUDY URINE.\nDSG CHG TO R HIP. NO CHG' IN APPEARANCE.\nNO STOOL AND RECTAL APPLIANCE INTACT.\nFAMILY CALLED DURING THE NIGHT AND UPDATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-13 00:00:00.000",
"description": "Report",
"row_id": 1558175,
"text": "Rehabilitation services/physical therapy\n\nPatient traveling to CT for needle aspiration and having echo presently. Unable to see for pulmonary care, tho nursing has been able to position and suction patient throughout day.\n\nWill follow \n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-13 00:00:00.000",
"description": "Report",
"row_id": 1558176,
"text": "NPN\nNEURO: Tmax 99.4. Remains lethargic. PERRLA. Has not recieved Ativan since 6am on .\n\nCV: Monitor shows SR without ectopy. Prolonged QTC noted. Cards feels this is d/t abx therapy. PPx4. S1S2. VSS. K+ and Ca++ replaced this am.\n\nRESP: Remians orally intubated. Vent settings per flow. ABG pending. US guided tap done today. 750cc Fluid removed. Lungs remain coarse. Suctioning for large amounts of thick yellow secretions.\n\nGI: Tolerating TF well. Rectal bag remains intact. No stools.\n\nGU: Foley draining clear amber urine in adequate amounts.\n\nINTEG: Stoma RN following for R hip wound. CT of area done today, abcess not drained d/t risk of infection and location of abcess.\n\nSOCIAL: Family spoke with team today. updated on POC. Questions answered.\n\nPLAN: Wean from vent as tolerated. Pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-13 00:00:00.000",
"description": "Report",
"row_id": 1558177,
"text": "Respiratory Care Note\n\nPt remains on CPAP PSV 10 PEEP 5 40%. Vt 450-500 RR 24-28. Last ABG was 7.42/32/82. Pt seems comfortable on these settings. Pt transported to CT scan today for pelvic scan. Pt also had R sided pleural effusion tapped for 750cc. Pt sxnd for mod amount of thick tan secretions. BS much improved this evening. Will maintain current settings and wean when patient is more alert.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-06 00:00:00.000",
"description": "Report",
"row_id": 1558147,
"text": "MICU Admit note\n Pt admitted to MICU from 3 for increasing SOB. Mr. was admitted to for increasing confusion, weakness, and SOB on . This was increasing for several days, he was also having loose stools and decreased mobility. He was recently dc'd from TCU with prolonged stay of 99 days. He was home for one month. He lives at with 24 hour health aide.\nPMHX:\nRLL pneumonia with Staph bacteremia, HTN, Osteoprosis, prostate CA', GERD, s/p pelvic fx4/01, right arm fx , left hip decub ulcer, s/p back surgery '.\nDaughter is health care proxy. is very involved in care.\n Pt was admitted at 1300. Upon admission Mr. was on 100%NRB with NC at 6ltr. Pt's breathing was labored at 24-32 BPM. Pt was alert, nods yes and no to quesions appropriately, follows commands.\nFamily accompianied Mr. to unit. Pt's daughter spoke to ICU team. ICU team spoke with patient and family regarding intubation. Pt wishes to be intubated if necessary.\n TLC and Artline were placed at 1730 per ICU team. Consents obtained from patient and family.\nReview of systems:\nNeuro: Pt is awake, alert. Follows simple commands. Answers questions appropriately.\nResp: Lungs sounds coarse. Pt 2 94-97% on 100%NRB and 6ltr NC. Respirations labored, tachypneaic. ABG per lab flow sheet.\nCV: Heart rate SR with occcaisional PVC's/PAC's. BP 90s/30-40s\nPt is febrile with temp of 99.9 rectally.\nGI: Abdomen distended, soft. Positive bowel sounds. Pt is having frequent loose stools.\nGU: Foley catheter draining clear/yellow urine. Pt recieved a 120 lasix on floor this am and put out approx a liter of urine since then.\nPlan: Continue to monitor respiratory status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-23 00:00:00.000",
"description": "Report",
"row_id": 1558214,
"text": " RN NOTE\nMR HAD AN IMPROVED DAY TODAY. INITIALLY Q2 HOUR NT SUCTIONIGN. BUT HE WENT FROM 12NOON TO 1700 WITH SATS >95%. REMAINS ON 40% FT. NO IMPROVEMENT IN VOICE YET (ENT CONSULT FOR VOICE ON HOLD). THE CT REVEALE D INCREASING IN SIZE D/T ??HYPOALBUMINEMIA. POSSIBLE PLAN INCLUDES CT GUIDED TAP...MARK BROWNING (RESIDENT) WORKING ON THIS.\n\nHE HAS BEEN TIRED TODAY, SLEEPIING INTERMITTANLY AND AWAKENING APPROPRIATELY WHEN I GO IN ROOM OR CALL HIS NAME.\n\nGI/GU: STOOLS X3 TODAY. TOL GOAL PROMOTE WITH FIBER.\n\nSKINL RT HIP WOUND WITH TAN BASE. DSD WITH WOUND JELLY APPLIED.\n\nID: OXACILLIN D18 OF 42. AND AUGUMANTIN DAY8 OF 14. AWAITING SPUTUM AND URINE SENT YESTERDAY. PICC SINCE \n\nSOCIAL: I HAD AN EXTENSIVE DISCUSSION WITH DTR AND HER HUSBAND RE: , TRACH, HIS HOSPITAL STAY, A REHAB STAY, MANY QUESTIONS WERE ASKED AND ANSWERED FROM BOTH SHE AND I... THIS INFO COMMUNICATED IN DETAIL TO DR .\n\n\nPLAN: FAMILY MEETING TOMORROW AFTERNOON , PENDING A TIME FROM RESUMING ATTENDING DR . ----THIS TIME MUST BE DECIDED UPON DURING ROUNDS RN AND FAMILY CAN BE AVAILABLE. FAMILY IS COMING IN THE EARLY AFTERNOON ADN ARE AWARE THEY HAVE TO WAIT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-24 00:00:00.000",
"description": "Report",
"row_id": 1558215,
"text": "P-MICU NPN 7p-7a\nSystems Review:\n\nCV: Has been hemodynamically stable. BP 90's-120's, HR 70's SR, no ectopy. Received 20meq KCl last eve. AM labs drawn, awaiting results.\n\nResp: Aggressive pulmonary toilet cont's. Secretions thick and tan. Attempting to suction less this shift due to trauma and discomfort. LS coarse throughout.\n\nID: IV oxacillin, per ID, to con't until to complete 8wk coarse. Aumentin for oral infx. Will need oral surgery consult..\n\nF/E: Just about even at present.\n\nHeme: Hct up this am to 34.2 after receiving 2nd unit PRBC's.\n\nSocial: Son from called last eve. Wanted to know what meds pt was on and if steroids or inhalers/nebulizers would help.. He had spoken to a friend who suggested this. I told him that the MD's were aware of the meds. He said he has a good relationship with his sister, who has been updating him frequently. He is in agreement with her decisions and wants what is best for the pt. Also he was unclear whether or not pt would benefit from a trach. I asked him if his father would want this aggressive tx and he stated that if it gave him some quality of life, he believes he would. He is aware of the family meeting scheduled for today, and expects to be updated by sister.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-10 00:00:00.000",
"description": "Report",
"row_id": 1558159,
"text": "Resp Care Note:\n\nPt cont on mech vent aas per vent flowsheet. Lung sounds ess clear. No changes made this shift. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-10 00:00:00.000",
"description": "Report",
"row_id": 1558160,
"text": "NPN\n\nCV: conts on neo, his dose has needed to be increased through the night to maintain a SBP in the 100s. His HR has been in the 50s SB.\n\nPulm: Conts on the respirator no changes were made. LS cleared after suctioning, bronchial on the R. He has had a lg amount of tan, thick putum from the ETT and from the back of his throat.\n\nGI: Conts to have loose, golden stool. He had a 270cc residual from his NGT, they were OB pos, TFs were shut off.\n\nGU: U/O has increased from yesterday.\n\nNeuro: Well sedated on the propofol, appears comfortable.\n\nSkin: Dressing on his R hip changed no change in the wound during the last 2 days.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-10 00:00:00.000",
"description": "Report",
"row_id": 1558161,
"text": "RESP NOTE:PT REMAINS SEDATED AND VENTED WITH NO REMARKABLE CHANGES IN RESP STATUS.PRESENT VENT SETTINGS AC/450/14/40% WITH PEEP LOWERED TO 10 AND TOLERATING WELL.SECRETIONS MINIMAL AND PALE/YELLOW,B/S DIMINISHED BILAT,ABG\"S AVAILABLE IN CAREVUE.SATS BEING MAINTAINED AT 99/100% ON CURRENT SETTINGS,WILL CONTINUE TO MONITOR AND WEAN AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-10 00:00:00.000",
"description": "Report",
"row_id": 1558163,
"text": "NURSING PROGRESS NOTE:\nPT REMAINS /VENTED, NO FURTHER CHG'S MADE. FOLLOWING O2SAT'S, MAINTAINING SAT'S 95-97%. LUNG SOUNDS CONT TO BE VERY COARSE. SX FOR MOD AMT'S OF THICK YELLOW SECRETIONS.\nWEANING OFF PROPOFOL AND CONT ON ATIVAN WITH ADEQUATE LEVEL OF SEDATION.\nNEO REMAINS OFF, RECEIVED 500CC NS BOLUS TO KEEP SBP ELEV AND INC U/O.\nCONT ON ANTIBIOTICS.\nTUBE FEEDS REMAIN ON HOLD. PT INC SM AMT'S OF LIQ BROWN STOOL.\nHIP DSG CHG'D NO CHG IN APPEARANCE. WET TO DRY DSG APPLIED AFTER BEING CLEANED AND GEL APPLIED.\nFOLEY CATH DRAINING ADEQ AMT'S OF CLEAR DK YELLOW URINE.\nFAMILY SPOKE WITH HO ABOUT BRINGING IN A CONSULT FROM THE . HO SPOKE WITH DR. ABOUT THIS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-11 00:00:00.000",
"description": "Report",
"row_id": 1558164,
"text": "Resp Care Note:\n\nPt cont on mech vent as per Carevue. Lung sounds ess cl. No changes made this shift. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-11 00:00:00.000",
"description": "Report",
"row_id": 1558165,
"text": "Pmicu nsg progress note\nResp: remains /vented on ac 450x14 40% 10 peep with sats high 90's abg 79/37/7.36. suctioned for mimimal secretions. Remains afebrile.\nCardiac: bp stable 100-110/40-50 without further fluid boluses. Remains off neo. Cont in sinus brady hr in 50's.\nNeuro: remains sedated on 1mg ativan. Pt off propofol. ? need to further wean ativan as pt essentually unresponsive.\nGI:Abdomen soft. passing loose brown stool. Tube feeds remain on hold. ?restart today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-11 00:00:00.000",
"description": "Report",
"row_id": 1558166,
"text": "Resp. Care Note\nPt remains intubated with 7.5ETT secured at 23c lip. Current settings A/C 450x 14x 40% peep 7.5 with ABG 70/37/7.36/22/-3. Peep decreased today from 10-7.5 with adequate oxygenation. Pt occas assisting above vent, could probably be changed to PSV. Sxn for mod. amount of thick tannish secretions. Cont support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-10 00:00:00.000",
"description": "Report",
"row_id": 1558162,
"text": "MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT REMAINS SEDATED ON PROPOPHOL...ATIVAN JUST STARTED THIS EVENING. GOAL IS TO WHEEN PROPOPHOL OFF AND CONT WITH JUST ATIVAN. PT UNRESPONSIVE TO STIMULI...FACIAL GRIMACING WITH TACTILE STIMULI. AFEBRILE.\n\nCV: NEO TO OFF THIS AFTERNOON. BP RANGING FROM 90-110/40-50'S VIA R RADIAL ALINE. SB WITH NO ECTOPY NOTED. POOR PALPABLE PULSES ALL AROUND. S1S2 ON AUSCULTATION.\n\nRESP: PT TO AC/40/450/10/14...BREATHING WITH VENT. SUCTIONED FOR LG AMTS THICK YELLOW SECRETIONS ORALLY AND VIA ETT. PT HERE THIS EVENING AND WORKING WITH PT. LUNGS CLEAR WITH SCT RHONCHI THROUGHOUT BASES AND DECREASED BASES. WILL SEND ABG 30 MINS AFTER PT DONE SUCTIONING AND DOING CPT. ETT 23CM AT LIPLINE.\n\nGI/GU: FOLEY DRAINING CLOUDY YELLOW URINE. UO RANGES FROM 0-100CC/HR. NSS BOLUSES GIVEN THROUGHOUT DAY TO IMPROVE UO AND BP. TOLERATED WELL. TF REMAIN ON HOLD...HIGH RESIDUALS (GASTRIC HEME +...PH 2). TEAM AWARE. WILL START ON REGLAN. PT SEVERAL TIMES OF LIQUID BM...DULCOLAX GIVEN YEST D/T PT BARIUM IN CT SCAN. ABD S,D,NT...ACTIVE BSX4. WILL CONT TO CHECK RESIDUALS AND ATTEMPT TO RESTART TF.\n\nINTEG: R IJ TLC P/I...CVP OFF DISTAL PORT. R RADIAL ALINE P/I. R HIP WOUND REPACKED AND CLEANSED THIS AFTERNOON. TUNNELLING AREA YELLOW WITH PINK TISSUE SURROUNDING EDGES. ESCHAR NOTED IN CENTER APPROX 1MMX1MM. CONT TURNING PT Q2H. PT WITH NEW R HIP FRACTURE...ORTHO BY TO SEE PT.\n\nSOCIAL: SPOKE WITH DAUGHTER ON PHONE SEVERAL TIMES TODAY. SHE WAS UPDATED ON PT STATUS AND WILL BE STOPPING BY LATER TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-27 00:00:00.000",
"description": "Report",
"row_id": 1558224,
"text": "NURSING PROGRESS NOTE:\nPT ALERT AND ORIENTED. WEARING FACE MASK AND O2SAT'S IN THE HIGH 90'S. ABD DSG FOR PEJ TUBE DRY AND INTACT. GASTRIC PORT DRAINED 175CC BILE.\nTUBE FEEDS INF AT 30/HR WITH LOW RESIDUALS.\nPT CONT TO BE OF SM AMT'S OF LIQ GREEN STOOL.\nPERIANL AREA CONT TO BE VERY REDENED AND EXCORIATED. DESITIN OINT APPLIED AND SEEMS TO BE HELPING.\nPT RECEIVED LASIX ON EVENING SHIFT AND PT CONT TO DIURESE LRG AMT OF DILUTE URINE.\nPT CONT TO HAVE MUCH DIFF COUGHING AND RAISING SECRETIONS.\nHIP DSG CHG AS ORDERED NO CHG IN APPEARANCE OF WOUND.\nDAUGHTER CALLED AND WAS UPDATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-27 00:00:00.000",
"description": "Report",
"row_id": 1558225,
"text": "altered resp status\nD: ALERT WHEN AWAKE BUT VERY LETHARGIC TODAY AND SLEEPING IN LONG NAPS. COARSE BS . SUCTIONED X 2 FOR THICK TAN SPTUM AND O2 SATS93-98%. REMAINS ON 50% OPEN FACE TENT BECAUSE PT RECEIVING MORE MOISTURE WITH THIS MODE. PT'S DAUGHTER AND SON AT THE BEDSIDE. RECIVING PROMODE WITH FIBER AT GOAL RATE NOW OF 60CC'S/HR VIA NEW PEJ. PEJ DRSG FOR AMT OS SEROUS DRAINAGE. POS BOWEL SOUNDS AND PT HAS HAD 2 EPISODES OF SM AMTS BLUE STOOL. UO ADEQAUTE VIAFOLEY CATH . R HIP DRSG AS ORDERED AND NO CHANGE IN APPEARANCE. PT HAS REQUIRED LESS SUCTIONING TODAY AND DOES NOT NEED NURSING CARE THOUGH HIS RESP STATUS WILL NEED TO BE MONITORED CAREFULLY.. CONITNUE TO OFFER EMOTIONAL SUPPORT TO FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-11 00:00:00.000",
"description": "Report",
"row_id": 1558167,
"text": "MICU NURSING PROGRESS NOTE 7A-7P\nNEURO: PT REMAINS EXTREMELY SEDATED ON ATIVAN GTT...GTT DOWN TO 0.5MG/HR. CONVERT TO PRN ATIVAN IV...PLAN TO ASSESS PT AND SEDATION REQUIREMENTS. AFEBRILE.\n\nCV: PT REMAINS OFF NEO. ABP 110-120/40-50'S. L ALINE CORRELATING WELL. SB WITH 1ST AV AND BBB ON MONITOR. EKG THIS SHOWED NEW T WAVE ABNORMALITIES AND POSSIBLE NEW ISCHEMIA. TEE DONE...NEGATIVE FOR VEGETATION. CARDIAC ENZYMES SENT X2. RESULTS PENDING. S1S2M ON AUSCULTATION. POOR PALPABLE PULSES ALL AROUND. CVP 9-10.\n\nRESP: PT REMAINS ON AC/450/14/40%/PEEP DOWN TO 7.5. ABG DONE AND WNL. SUCTIONING OUT THICK TAN SECRETIONS ORALLY AND VIA ETT. LUNG SOUNDS COARSE, DECREASED LOWER LOBES. O2SATS 96% WHEN TRACKING.\n\nGI/GU: OGT PULLED FOR TEE. REPLACED AND XRAY DONE..WAITING TO HEAR IF PLACEMENT IS GOOD. ABLE TO START TF THIS AM AT 0900...RESIDUALS OF 10CC. TF ON HOLD SINCE NOON FOR TEE. ABD S,D, ACTIVE BSX4. CONT WITH FREQ LIQUID STOOLS. SENT FOR CDIFF. FOLEY DRAINING SMALL AMTS YELLOW URINE. TEAM AWARE, BOLUS WITH MORE FLUID.\n\nINTEG: R IJ TLC P/I. SKIN NURSE BY TO R HIP WOUND. TUNNELING WITH YELLOW AND ESCHAR TISSUE IN CENTER, PINK TISSUE SURROUNDING EDGES. ORTHO BY TO PT...SUSPECT HIP WOUND IS ACTUALLY A TUMOR VS ABSCESS. FAMILY NOT AWARE YET. CAST REMOVED FROM R HAND...SPLINT ON.\nCONT ON FIRST STEP MATTRESS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 1558229,
"text": "ALTERED HEMODYNAMICS\nD: PT THIS AM TALKING AND RECOGNIZED HIS CAREGIVER, . O2 SAT=93& SO PT SUCTIONED FOR LG AMT OF THICK YELLOW TO TAN SPUTUM. COARSE BS . O2 SATS AFTER SX'ING WERE 96%. TURNED PT AT 0930 FOR BACK CARE AND TO CHANGE R HIP DRSG. ALARM SOUNDED AND SBP DOWN TO 84 WITH HR 50 AND O2 SAT=93%. MD'S CALLED TO BEDSIDE. PT NOT RESPONDING. NS BOLUS OF 500CC'S GIVEN. O2 REMAINED AT 100% FACE TENT WITH 6L/M NC. HR THEN DROPPED TO 41 AND SBP DROPPED TO 74. R RADIAL ALINE PLACED AND ABG AT THE TIME=7.15/96/81/35/1. PT'S DAUGHTER CALLED AND AFTER DISCUSSION WITH DR. ,DAUGHTER AND MYSELF AS WELL AS PHONE CONVERSATION WITH PT'S SON IN THE DECISION WAS MADE TO KEEP PT COMFORTABLE. O2 SATS DROPPED TO A LOW OF 62% AND SBP 70'S. THIS AFTERNOON WITHOUT PT'S HR HAS RETURNED TO THE 50'S AND SBP 90'S. O2 SATS HAVE REAMINED 90-94%. PT HAS MINIMAL CORNEAL REFLEX AND DR. HAS SPOKEN TO PT'S FAMILY AND THEY UNDERSTAND HIS GRIM PROGNOSIS. PT HAS RECEIVED 2 MG IVP MSO4 X3 AND WILL START MSO4 GTT IF MSO4 NEED INCREASES. UO HAS ALSO DROPPED TO MINIMAL AMTS SINCE HYPOTENSION. FAMILY HAS REMAINED AT THE BEDSIDE. PT AND AWAITING THE ARRIVAL OF HIS SON.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 1558230,
"text": "addendum to above note: pt's son arrived and dr. met with famil. minimal corneal reflex to r and absent to l. unresponsive. family witnessed md's exam and aware of his status. o2 nc removed but continues with open tent mask. shortly after son arrived hr down to 43 and sbp 70's o2 sats dropped to 79-81%. mso gtt initated at 2 mg /hr and will continue to titrate as needed to keep pt comfortable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-29 00:00:00.000",
"description": "Report",
"row_id": 1558231,
"text": "Pmicu Nursing Note:\n\nPt expired on at 1:17am. Family in attendance. Drs' and pronounced.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-22 00:00:00.000",
"description": "Report",
"row_id": 1558209,
"text": "NURSING PROGRESS NOTE:\nPT CONT TO STAY EXTUBATED ON FACE MASK. LUNG SOUNDS VERY COARSE THROUGHOUT, COUGHING AND ABLE TO RAISE SECRETIONS TO BACK OF THROAT AT TIMES. NASOTRACH SX Q4/HR FOR THICK TAN SECRETIONS. O2 SAT'S IN HIGH 90'S.\nPT'S VITAL SIGNS STABLE, AFEBRILE. RESP RATE REGULAR. NO SOB.\nTUBE FEEDS CONT AT 60/HR MINIMAL RESIDUAL. BOWEL SOUNDS PRESENT AND PASSING SM AMT'S OF SOFT GREEN STOOL.\nPT HAS BEEN VERY ALERT AND TALKING. SLEPT VERY LITTLE DURING THE NIGHT.\nNO CHG IN R HIP DECUBITUS. DSG CHG' NO SIG SIGNS OF IMPROVEMENT.\nFAMILY CHECKED IN AND UPDATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 1558226,
"text": "PMICU Nursing Progress Note:\n\nResp/CV: Desat to 85% on 100% shovel mask. NT sx for min thick tan secretons. 5L NC added w/ O2 sats remain > 94%. Dropped sats again later in evening--required NT sx x 3 times for large amt of thick tan secretions with sats eventually >94%. Hemodynamically stable.\n\nGI/GU: 200cc output from gastric drainage. Cont on tf's at goal. Stool x 6 sm amts blue/grn. Buttocks excoriated, cream applied. U/O poor.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 1558227,
"text": "Chart re-reviewed this afternoon. Events noted. No further PT needs at this time, will defer further treatment.\nTime: 6:00pm\nPager: #\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-28 00:00:00.000",
"description": "Report",
"row_id": 1558228,
"text": "PT/RSD\nRe-consult received, pt known to physical therapy department. At this time we are unable to progress pt's mobility as he is NWB secondary to bilateral pelvic fractures. Will re-evaluate status on , deferred rx today as pt unstable this am.\nPager: #\nTime: 10:00am\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-22 00:00:00.000",
"description": "Report",
"row_id": 1558210,
"text": "P-MICU RNNOTE\nCV: STABLE WITH DILTIAZEM.\n\nRESP: ENT CONSULTED FOR HOARSENESS. FAILED SWALLOW STUDY YESTERDAY SECONDARY TO INABILITY TO BALL FOOD TO BACK OF MOUTH. AT 1800 ABG= 58/42/7.45...CHANGED TO NRB, NT SUCTIONED, SAMPLE SENT.\n\nPLAN: WILL REDO ABG\n CONT CPT Q4 HOURS.\n CONT NT SUCTIONING PRN\n\nGI/GU: FOLEY BAG CHANGED AND CULTURE SENT AS URINE DARKENED LATE TODAY. TOL GOAL RATE PROMOD WITH FIBER AT 60CC/HOUR. FREE WATER BOLUSES D/C' N ATTEMPT TO MAKE HIM ABOUT 500CC (-).\n\nID: AFEBRILE. OXACILLIN (D#17 OF 6WEEKS) AND AUGUMENTIN (D#7 OF 14). HE HAS MULTIPLE DENTAL ABCESSES THAT DENTAL HAS ASSESSED AND DOES NOT FEEL WILL SEED... OMF (ORAL MAXILOFACIAL SURGERY) DOES NOT HAVE O.R. PRIVELAGES, THUS HE WOULD NEED TO LEAVE , HAVE SURGERY AND RETURN.\nDSD TO RT HIP DECUBITUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-23 00:00:00.000",
"description": "Report",
"row_id": 1558211,
"text": "Resp Care Note:\n\nPt requires aggressive pulmonary toilet. Pt suct for copious th beige sput. Lung sounds bilat rhonchi clearing significantly after suct. Pt currently w/ O2 Sat ~ 95% breathing comfortably in NARD. Cont aggressive pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-23 00:00:00.000",
"description": "Report",
"row_id": 1558212,
"text": "P-MICU NPN 7p-7a\nSystems Review:\n\nResp: LS coarse bilat throughout. Aggressive CPT maintained throughout shift. Received CPT q4h with NT suctioning. Pt with large amts of tan thick secretions. O2 sats have been 94-97%, with rr in the 20's. ABG 63/47/7.39/30/2 on 40%CN. No further ABG's obtained, due to A-Line falling out with turning.\n\nCV: VS have remained stable.\n\nNeuro: extremely difficult to understand due to pt being very weak, he has not been able to expectorate any secretions.\n\nID: Afebrile, on IVABX. Sputum cx sent.\n\nGU; +fluid status by 12am, 330cc's + by 6am.\n\nSkin: Right hip decub drsg protocol.\n\nGI: Small amts green stool. +bs, tolerating TF's with minimal residuals. TF's held ~1hr with CPT and sxning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-23 00:00:00.000",
"description": "Report",
"row_id": 1558213,
"text": "P-MICU NPN 7p-7a\nPt's urine output has steadily been declining. 15-20cc's/hr House officer notified. Will con't to assess.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-12 00:00:00.000",
"description": "Report",
"row_id": 1558168,
"text": "PMICU NURSING PROGRESS NOTE:\n\nNeuro: all sedation off. unresponsive to stimuli.\n\nCV: stable, SBP 110-130. HR 60's BBB. Troponin of yest negative. TEE negative. EKG due this am. Ca++ repleted.\n\nResp: Vent settings unchanged. Sx x 3 for thick yellow mod amt. ^^oral secretions. LS crackle, coarse.\n\nID: afebrile. cont on Oxacillin, clinda for + bld cx\n\nSkin: buttocks excoriated from constant mucoid green stool. Rectal bag applied. R hip dsg x 2. Need to contact skin care RN for more appropriate chemical debriding gel (collagenase?), wound sloughing-tunneling.\n\nGI/GU: TF's restarted, now 35cc. U/O sporatic but averaging ~30cc/h.\n\nSocial: no calls from family. Remains full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-12 00:00:00.000",
"description": "Report",
"row_id": 1558169,
"text": "Resp Care Note:\n\nPt cont on vent as per Carevue. Lung sounds rhonchi impr after suct mod th tan sput. No changes made this shift. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-08 00:00:00.000",
"description": "Report",
"row_id": 1558152,
"text": "NPN\nNEURO: Remains sedated on Propofol gtt currently at 40 mcg/kg/min. Withdraws to painful stimuli. PERRLA. Afeb.\n\nCV: Monitor shows SR without ectopy. VSS. MAP>60. PPx4. S2S1 murmur noted. Lytes this am WNL.\n\nRESP: Orally intubated with 7.5 ETT 23 at the lip. AC / 450x10/ 50%/ 15peep. PAP 35-39. O2 sats 98-100%. Lungs very coarse. Suctioning for large amounts of thick yellow pasty secretions. Last ABG WNL.\n\nGI: NGT intact with + placement. Readicat given for CT of Abd scheduled for 5pm. Hypoactive bowel sounds noted. No stool today.\n\nGU: Borderline uop today. Foley flushed x1 with very slight increase in uop. UOP remains > 30cc/hr.\n\nSKIN: No edema noted. R hip wound debrided by plastics today. Recommend tid dressing changes. Duoderm to coccyx intact.\n\nSOCIAL: Daughter very involved in pt care. Very inquisitive. Questions answered.\n\nID: BC + staph aureus 4/4 bottles. Sensitive to Oxacillin and Clindamycin. Covered with both. No fevers. WBC count is down to 16.9. Plastics does not feel R hip is source of infestion.\n\nPLAN: Continue vent support. Abd CT this pm. Continue with abx regimine. Pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-08 00:00:00.000",
"description": "Report",
"row_id": 1558153,
"text": "NPN\nPt dropped SBP to 60's. Fluid bolus 500cc given and Neosynephrine started. BP now in the low 100's. CT on hold for now, will retry later.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-08 00:00:00.000",
"description": "Report",
"row_id": 1558154,
"text": "RESP NOTE:PT REMAINS INTUBATED AND VENTILATED AT THIS TIME WITH NO RESP DISTRESS NOTED.B/S DIMINISHED BILAT WITH SX FOR SMALL/LARGE AMOUNTS OF THICK TAN/YELLOW SECRETIONS DURING SHIFT.PRESENT VENT SETTINGS AC/450/10/50% PEEP15 AND TOLERATING WELL. ABG\"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH PRESENT COARSE AND WEAN AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-09 00:00:00.000",
"description": "Report",
"row_id": 1558155,
"text": "NPN\n\nCV: Pt still requiring neo, gtt increased a little due to low BP. he remains in a SR, HR 60-70s.\n\nPulm: LS bronchial on the R, clear on the L, very little sputum from his ETT. No changes were made in his vent.\n\nGI: Stooled x2, gelatonous, brown, OB neg. TF started Replete with fiber at 10cc/hr\n\nGU: decreased u/o\n\nNeuro: Remains on Propofol, he has been well sedated\n\nSkin: Decube on his R hip, dressing done, white base, very little drainage\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-09 00:00:00.000",
"description": "Report",
"row_id": 1558156,
"text": "Resp Care Note:\n\nPt cont on mech vent as per vent flowsheet. Lung sounds coarse. Sx mod th pale yellow. No changes made this shift. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-09 00:00:00.000",
"description": "Report",
"row_id": 1558157,
"text": "NPN\nNEURO: Remains sedated on Propofol gtt. PERRLA. Responds to painful stimuli.\n\nCV: Monitor shows SR without ectopy. VSS. Remains on Neo at 32mcg/min. S1S2. PPx4. Labs WNL.\n\nRESP: Remains vented. AC 450x10 40% 15peep. Lungs coarse. Suctioning for thick yellow sputum. Sats 100%.\n\nGI: CT done today. Results pending. Tol po well. Replete with fiber at 20cc/hr. Stooling today.\n\nGU: UOP decreased. Fluid bolus given with slight increase in uop. Continue to monitor closely.\n\nSKIN: R hip wound culture sent. Dressing change tid. Duoderm to coccyx intact.\n\nSOCIAL: Daughters into see pt. Spoke with team.\n\nPLAN: Wean vent as tolerated. Support BP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-09 00:00:00.000",
"description": "Report",
"row_id": 1558158,
"text": "RESP NOTE:PT REMAINS INTUBATED AND VENTILATED THOUGH SOME IMPROVEMENT IN RESP STATUS TODAY.FIO2 LOWERED TO 40% WITH PT MAINTAINING SATS 98-100% AND NO RESP DISTRESS EVIDENT.SECRETIONS MINIMAL AND PALE/YELLOW,B/S GEN CLEAR AND DECREASED R>L.ABG\"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH VENTILATORY SUPPORT AND WEAN AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-12 00:00:00.000",
"description": "Report",
"row_id": 1558170,
"text": "NPN\nNEURO: Afeb. Has received no sedation since 6 am. Will open eyes slightly verbal command. Not following any commands. BC x1 sent today. per orders.\n\nCV: Remains in SR without ectopy. VSS. Continue with d5.45NS at 75cc/hr. PPx4. S1S2 murmur. No edema noted. EKG unchanged from yesterday.\n\nRESP: Vent changed to CPAP 5/5 this am. Tolerating well. ABG WNL on this setting. Lungs coarse. Suctioning for thick yellow sputum.\n\nGI: Tolerating TF well. Replete with fiber at 40cc/hr. Stooling, rectal bag intact. ABS. ABD S/ND/NT.\n\nGU: Foley draining clear amber urine in adequate amounts. Remains + for this hospitalization.\n\nID: Remians on Oxacillin and Clindamycin. WBC this am was32.1. Remains Afeb.\n\nINTEG: R hip ulceration with yellow tissue. Continue with dressing changes TID. Coccyx with duoderm.\n\nSOCIAL: Family into visit today. Spoke with myself and Dr. . Questions answered. Asked to speak with social worker. Meeting arranged for tommorow afternoon.\n\nPLAN: Allow to wake up from sedation. Wean vent as tolerated. ? Tap pleural effusion today. Consent signed and on chart.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-12 00:00:00.000",
"description": "Report",
"row_id": 1558171,
"text": "PT/RSD Re-evaluation\nS: Intubated\nO: Please refer to initial evaluation for further information regarding PMH and HPI\nLabs: 13.6>32.1<313\nVent: PS 5/PEEP 5, Tv 450, 40%FiO2\nPulmonary: Breath sounds coarse throughout\nMobility: Pt sedated, no active movement at this time\nROM: PROM all joints WFL although stiffness noted throughout\nVital Signs: Pre-rx: 148/60 77 28 99%\n During/post-rx: 140/60 78-84 28 98-100%\nRx: Gentle passive ROM bilateral upper and lower extremities.\nPercussion to right lung field in left sidelying followed by in line suctioning for minimal yellow secretions. Pt positioned back in supine post rx.\nA: 85y.o male with staph aureus bacteremia and hypoxic respiratory failure. Pt presents with impaired respiration, ventilation and secretion clearance associated with respiratory failure. Pt tolerated chest PT well today and will benefit from continued pulmonary toileting. Should begin mobility when pt able to participate. Pt will require rehab placement once medically stable with guarded potential given prolonged hospitalization/bed rest.\nGoals(5-7 days):\n1.Pt will maintain O2 saturation >95% without mechanical ventilation\n2.Pt will be independent in secretion clearance\n2.Pt will transfer bed to chair with moderate assist of 2\nP: F/U \nPager #\nTime Frame:4:30-5:30pm\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-26 00:00:00.000",
"description": "Report",
"row_id": 1558222,
"text": "ALTERED REPS STATUS\nD: PT A&O AND FOLLWS SIMPLE COMMANDS. O2 AT 6L/M NC WITH O2 SATS>90%. COARSE BS AND PT SUCTIONED X1 FOR THICK TAN SPUTUM. COARSE BS . PT REMAINS NPO FOR PEJ PLACEMENT TO BE DONE TODAY. RECEIVING D 5 1/2 NS AT 60CC'S HR AND HOURLY URINE IS MARGINAL. PASSED MEDIUM SIZED GREENISH BLUE SOFT STOOL AND DESITIN OINTMENT APPLIED TO EXCORIATED BUTOCKS. R HIP DRSG AND OF THE WOUND IS UNCHANGED. PT'S DAUGHTER AT BEDSIDE AND UPDATED. CASE MANAGEMENT CALLED TO BEDSIDE PER DAUGHTER'S REQUEST.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-26 00:00:00.000",
"description": "Report",
"row_id": 1558223,
"text": "MICU NPN 11AM-11PM:\nNeuro: Pt awake and alert. Sometimes speech is difficult to understand. Today was talking about making a phone call but it was difficult due to his poor speech. Pt wanted to get up OOB but did not due to the placement procedure. He is very stiff, requires full lift and assist with all ADL's.\n\nCardiac: One dose of diltiazem held today due to HR in the 50's. BP stable 120-140. Pt was given a dose of 20mg IV lasix today. Has had good effect.\n\n\n\n\nResp: Had to go back to the 50% face tent due to pt desating and not coming up after suctioning. I suctioned him twice. Large amt secretions initially but small amt in the evening. Lungs are decreased and coarse. RR in the 20's. Current sat 95%.\n\nGI: Had a J-tube inserted in radiology today and tolerated this well. We can use it for meds and give him his tube feeds at half the normal goal rate until tomorrow afternoon when we can increase it back to the goal rate. Currently on promote w/fiber at 30cc/hr. The site is draining moderate to lrge amts serous drainage and the dressing was changed by myself twice. I caled the radiologist who inserted the tube and she feels as long as the bleeding is not grossly bloody and just clear to serous that it is probably due to his generalized body edema and may drain for a while. I have the Gastric port hooked up to gravity drainage and the j-port has the tube feeds. Gastric drainage is golden/yellow clear bile. Pt stooled three times today, green loose.\n\nGU: Foley draining drk urine at first but now clear yellow since he got the lasix. I did run the irrigant for a while but have it off now trying to get an accurate I+O.\n\nSkin: Unchanged. Buttocks are red and excoriated and I have been using triple cream ordered by team.\n\nSocial: Pt's daughter was in most of the day. Pleased at pt's progress today and will call later tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-07 00:00:00.000",
"description": "Report",
"row_id": 1558148,
"text": "NPN\n\nCV: BP stabalized, now in SN in the 70-80s, able to wean him off of the neo during the night.\n\nPulm: Resp status is still tenuous, he remains on 100% and 6 L NC, his SATs are in the upper 90s but when his mask comes off he quickly desats to the 70s-80s though this does return to the 90s as fast as he desaturated. He has a wet cough when he is encouraged to cough but no production. His ABG has slowly improved now with a Pa02 of 82. Oxacillian conts.\n\nGI: Drinking liquids, rather thirsty, sm amount of stool\n\nGU: fair u/o\n\nNeuro: A&Ox3, good memory, asking approapriate questions\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-07 00:00:00.000",
"description": "Report",
"row_id": 1558149,
"text": "NPN\nNEURO: A+Ox3. Afeb. Follows all commands. Asks appropriate questions.\n\nCV: Monitor shows SR without ectopy. VSS. PPx4. No edema noted. S1S2 with murmur noted. K+ this am was 2.9, replaced with 60meq IV. recheck was 4.1.\n\nRESP: Remains on 100% and 6LNC. Lungs very coarse. Has wet cough, but unable to produce any sputum. Sats are 98-100% while pt at rest, drops to 70-80's if mask removed. Also drops with anxiety. Sputum culture ordered but not sent d/t lack of specimen.\n\nGI: Taking po's well, although restricting to po fluids d/t possibility of intubation. ABSx4. Stoolsx2 today. OB-. Abd S/ND/NT.\n\nGU: Foley draining clear yellow urine in adequate amounts.\n\nSOCIAL: Family at bedside. Very inquisitive. Questions answered. Pt has home health aide at bedside ATC.\n\nPLAN: Monitor resp status. pulmonary toilet. Encouarge family to allow pt to rest. pt that he is not alone.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-08 00:00:00.000",
"description": "Report",
"row_id": 1558150,
"text": "NURSING PROGRESS NOTE:\nPT ON 100%NRBM AND 6LNC. PT HAVING MUCH DIFF BREATHING USING ALL ACCESSORY MUSCLES. HAVING MUCH DIFF RAISING SPUTUM. LUNG SOUNDS VERY COARSE. DOPPED 02 SAT'S OFF AND ON DURING THE NIGHT.\nPT SX FOR LRG AMT OF PASTEY YELLOW/TAN SECRETIONS WHICH DROPPED HIS O2 SAT'S TO THE LOW 80'S AND PT WAS UNABLE TO RECOVER FROM THIS AND WAS DECIDED AT THIS TIME TO INTUBATE PT AND PT AGREED.\nANESTHESIA CALLED, PT MED WITH ETOMADATE AND SUCCX IV. PT INTUBATED EASILY WITH #7.5 ETT AT 23CM AT THE LIP. TUBE PLACEMENT CHECKED BY XRAY. PLACEMENT GOOD. PT STARTED ON PROPOFOL DRIP TO MAINTAIN SEDATION AND COMFORT.\nFOLEY CATH DRAINING ADEQUATE AMT'S OF YELLOW URINE. INCON SM AMT'S OF SOFT STOOL DURING THE NIGHT.\nK 3.4 RECEIVED 60MEQ KCL.\nPT HAS REMAINED IN SR ALL SHIFT, BP STABLE BUT DROPPED SLIGHTLY WHEN STARTED ON PROPOFOL. RATE AND BP BACK UP TO ACCEPTABLE RANGE.\nFAMILY MADE AWARE OF INTUBATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-08 00:00:00.000",
"description": "Report",
"row_id": 1558151,
"text": "Resp Care Note:\n\nPt on NRB mask + 6L NC required NT sx due inability to clear secretions. Sx copious th yellow sput. Pt sats didn't recover after sx + A&A Tx. Pt intubated and placed on vent setting as per vent flowsheet. CXR confirmed ETT placement and ABG's stable. Pt sx after intub for mod th yellow. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-24 00:00:00.000",
"description": "Report",
"row_id": 1558216,
"text": "NPN 7a-7p:\n Review of Systems:\n RESP: Cont on 50% CSM, with weak, nonproductive, thickly congested cough. NT sx q 3-4 hrs for thick tan secretions. LS with exp wheezes, bronchial at bases... L thoracentesis done via bedside US for 900cc pleural fluid. RR 16-24. Sputum spec growing out yeast. Remains npo. Seen by Speech and swallow therapist who is to return to discess speach excercises with pt to strengthen voice... to be seen by eNT to evaluate vocal chords.\n ID: pt hyothermic this shift.. now on bearhugger with slow improvement. team aware.. in light of hypothermia, pt fully cx'd... sutum, blood with fungal isolator (peripheral), urine. cont on IV OX... po augmentin dc'd.\n F/E: pt with marginal UO this shift.. ? d/t No input, as TF's off for thoracentesis.. 250cc NS fluid bolus up over one hr... await effect. Lytes wnl. fluid bolus neg 600 today, + 2L yesterday... pt with peripheral edema throughout, + scrotal edema.\n GU: pt with yeast growing in urine... foley changed o/n... pt with intermittent BRB via foley.. irrigated with NS to clear.\n GI: pt with blue/green stool d/t dye in TF's... Butt bag placed as buttocks excoriated d/t frequent stooling. ab softly distended, BS + with + umbilical hernia.\n Integument: Skin care CNS to be paged tomorrow am to observe wound to R hip during dressing change... cont lined with yellow dead tissue.. dressing process unchanged. duoderm intact to upper back. wax placed to metal rod in tooth, R upper gumline.\n Social: family meeting held, attended by pt's daughter, son in law, Dr. , Dr. , and this RN.. Dr. explained to family that if pt wants to cont. aggressive treatment, then a trach and are recommended at this point... pt lethargic this afternoon, but when arouses, family to return to be present for discussion intern to have with pt... Pt prefers daughter to be present when he makes decisions about his care... also, pt would be reintubated at this point, but otherwise DNR.\nA/P: follow cx.. will follow MS/hypothermia carefully.. no further abx changes at this time. page skin care cns in am, and call family when pt more alert, in order to have discussion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-24 00:00:00.000",
"description": "Report",
"row_id": 1558217,
"text": "Brief NPN 7PM-11PM:\nPt awake, looking a little uncomfortable at 8PM. Unable to guess what the problem was so I turned him to the right at 9PM and he has looked more comfortable since then. RR 16-20. On 40% mask his sats have been 98%-100% most of the evening. UO was 20cc/hr early in the shift. Urine is grossly bloody, no clots noted. Last UO at 10PM was up to 50cc/hr. An order was written for 250cc NS bolus if UO drops below 30cc/hr for two consecutive hours tonight. Pt is on the tube feeds at goal rate. Vital signs are stable. Family was not present this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-25 00:00:00.000",
"description": "Report",
"row_id": 1558218,
"text": "NURSING PROGRESS NOTE:\nPT SLEPT OFF AND ON DURING THE NIGHT MAINTAINING GOOD O2 SAT'S AND GOOD VITAL SIGNS. PT AFEBRILE.\nU/O LOW FOR 2/HRS 250CC NS BOLUS X 1. U/O PICKED UP SLIGHTLY.\nTUBE FEEDS TURNED OFF AFTER MIDNIGHT, SX BLUE TUBE FEED OUT OF TRACHEA WHEN NASOTRACH SX.\nPT'S LUNG SOUNDS COARSE THROUGHOUT.\nFOLEY CATH DRAINING BROWN URINE WITH OCC CLOTS.\nHIP DSG CHG'D NO CHG IN APPEARANCE.\nPT' HAS GENERALIZED THIRD SPACING, WITH SCROTAL EDEMA.\nFIB REMOVED DUE TO LEAKAGE. PERIANAL AND PERINEAL AREA VERY REDENED.\nMICONAZOL POWDER AND SKIN CREAM APPLIED.\nPT SEEMS ORIENTED BUT CONT TO SCREAM OUT AT TIMES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-25 00:00:00.000",
"description": "Report",
"row_id": 1558219,
"text": "NPN 7a-7p:\n S/O: Cont with copious secretions via nts, blue tinged still. changed to 6L o2nc with sats 98%, rr 20.kept npo/npgt... Most likely to have interventional radiology to place a post pyloric tube for feeding. NO trach per pt/family at this point. Currently with ns with 60meq kcl up over 10 hrs via midline... UO very poor all am.. team aware and 250cc ns fluid bolus given. Urine also very bloody... 3way foley placed and irrigated for 1200cc.. now urine clear and yellow... has order for maintenance ivf once K repletion compelte.. cont with frequent loose stools. C-diff sent x 2.. after 3rd cdiff, can give lomotil. Skin on bottom very broken and excoriated... barrier cream applied. Daughter spoke at length with rn and md's.. many ?'s answered.\na/P: await feeding tube placement.. cont skin care, follow uO. needs one more c-diff and sputum spec with next sx. cont support to pt/family.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-26 00:00:00.000",
"description": "Report",
"row_id": 1558220,
"text": "Resp Care Note:\n\nPt required NT suct for large amt th white. Lung sounds rhonchi w/ significant improvement after suct. Cont with aggressive pulmonary toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-09-26 00:00:00.000",
"description": "Report",
"row_id": 1558221,
"text": "NURSING PROGRESS NOTE\"\nPT ALERT AND ORIENTED CONT TO MAINTAIN GOOD 02SAT'S AND GOOD VITAL SIGNS. LUNG SOUNDS CONT TO BE COARSE AND WHEEZY AT TIMES. NASOTRACH SX X 2 DURING THE NIGHT FOR THICK THICK TAN/YELLOW SECRETIONS.\nPT RUNNING VERY LOW TEMPS. PT CONT TO HAVE WORSENING THIRD SPACING GENERALIZED ESP IN SCROTUM. SCROTUM SUPPORTED WITH TOWEL.\nPT IV FLUID CONT AT 60/HR BUT U/O RUNNING ABOUT 20-25/HR.\nCONT OOZING SM AMT'S OF BLUE/GREEN STOOL. PERIANAL AREA VERY REDENED AND EXCORIATED, IMPROVING WITH DESITIN OINT.\nPT SCHEDULED FOR PLACEMENT, PT HAS BEEN NPO, NGT PLACED TO SX DRAINING SM AMT'S OF BILIOUS/ TINGED MATERIAL.\nDAUGHTER CALLED DURING NIGHT AND UPDATED. PT CONT TO BE DNR BUT WILL BE REINTUBATED IF NECESSARY.\n"
},
{
"category": "Echo",
"chartdate": "2131-09-11 00:00:00.000",
"description": "Report",
"row_id": 69100,
"text": "PATIENT/TEST INFORMATION:\nIndication: ?endocarditis\nHeight: (in) 66\nWeight (lb): 104\nBSA (m2): 1.52 m2\nBP (mm Hg): 111/43\nStatus: Inpatient\nDate/Time: at 13:57\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. There are simple atheroma in the\naortic root. The ascending aorta is normal in diameter. There are simple\natheroma in the ascending aorta. The aortic arch is normal in diameter. There\nare simple atheroma in the aortic arch. The descending thoracic aorta is\nnormal in diameter. There are simple atheroma in the descending thoracic\naorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. There is no\nsignificant aortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. There is mild thickening of the mitral valve\nchordae. The tips of the papillary muscles are calcified. Physiologic mitral\nregurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. There were no TEE related complications. The patient appears to be\nin sinus rhythm.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal. Right ventricular chamber size and\nfree wall motion are normal. There are simple atheroma in the aortic root.\nThere are simple atheroma in the ascending aorta. There are simple atheroma in\nthe aortic arch. There are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) are mildly thickened. There is no significant\naortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no pericardial effusion.\n\nNo masses, vegetations or thrombus seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-04 00:00:00.000",
"description": "Report",
"row_id": 158134,
"text": "Sinus rhythm. Wandering baseline makes adequate ST segment changes difficult to\ninterpret. There is no apparent diagnostic interim change as compared to the\nprevious tracing of . However, repeat tracing is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-03 00:00:00.000",
"description": "Report",
"row_id": 158135,
"text": "Sinus rhythm. Left ventricular hypertrophy. Left axis deviation. Prior\nanteroseptal myocardial infarction. Compared to the previous tracing\nof , no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-11 00:00:00.000",
"description": "Report",
"row_id": 157891,
"text": "Sinus rhythm. P-R interval is 0.20. Left atrial abnormality. Left axis\ndeviation. Incomplete right bundle-branch block pattern with Q waves in\nleads V2-V3 and slow R wave progression in leads V4-V5 consistent with an\nanterior myocardial infarction of indeterminate age, with persistent ST segment\ncoving and inverted T waves in the precordium. Low voltage in the precordial\nleads. The Q-T interval is prolonged. Compared to the previous tracing\nof sinus rhythm has replaced rapid atrial fibrillation, low voltage\nis now present in the precordial leads and voltage appears decreased in the\nlimb leads. The T waves are now inverted in the precordium and Q-T interval is\nmore prolonged. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-20 00:00:00.000",
"description": "Report",
"row_id": 157885,
"text": "Sinus rhythm. Axis to the left. Compared to the previous tracing of \nthere is clear evidence of anterior myocardial infarction of undetermined age,\nbecause of ST segment elevations in lead V3.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-19 00:00:00.000",
"description": "Report",
"row_id": 157886,
"text": "Sinus rhythm. Left atrial abnormality. Left axis deviation. Compared to the\nprevious tracing of there is more prominent ST-T wave flattening in\nleads I, aVL and V5-V6. No diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-16 00:00:00.000",
"description": "Report",
"row_id": 157887,
"text": "Sinus rhythm. Left axis deviation. Compared to the previous tracing\nof there is variation in the precordial lead placement and there are\nlow amplitude T waves. Otherwise, no change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-15 00:00:00.000",
"description": "Report",
"row_id": 157888,
"text": "Sinus rhythm. Left axis deviation. Prior anteroseptal myocardial infarction.\nCompared to the previous tracing of there is variation in precordial\nlead placement. Otherwise, no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-14 00:00:00.000",
"description": "Report",
"row_id": 157889,
"text": "Sinus rhythm. The P-R interval is 0.19. Left axis deviation. Prior anteroseptal\nmyocardial infarction. Compared to the previous tracing of the\nQ-T interval has normalized and there is improvement in the T wave\nabnormalities, previously recorded in the anterolateral leads, consistent with\nan active ischemic process. Followup and clinical correlation are suggested.\nThe rate is increased.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-12 00:00:00.000",
"description": "Report",
"row_id": 157890,
"text": "Sinus rhythm. Left anterior fascicular block. Q waves in leads V2-V3 with\ndelayed R wave progression in the remaining precordial leads and Q waves in\nlead aVL. These changes are consistent with anterolateral myocardial infarction\nof indeterminate age. Residual minimal ST segment elevations in leads V2-V3.\nT wave inversions in the anterolateral leads. The Q-T interval is 0.64 and the\nQ-Tc interval is 0.68 which is markedly prolonged. Low voltage persists in the\nprecordial leads. Compared to the previous tracing of the Q-T interval\nis more prolonged. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-09-06 00:00:00.000",
"description": "Report",
"row_id": 157892,
"text": "Atrial fibrillation with a rapid ventricular response, average rate 128.\nCompared to the previous tracing of atrial fibrillation with a rapid\nventricular response is new. There is new T wave inversion in leads I and aVL,\nmost likely related to the rapid rate, but lateral ischemia cannot be ruled\nout. Clinical correlation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740468,
"text": " 4:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation.\n\n FINDINGS: Comparison was made with the previous examination of .\n\n There has been interval placement of an ET tube, the distal end of which is\n approximately 2 cm above the carina. Allowing for marked patient rotation,\n the appearances in the chest are unchanged since with extensive\n bilateral interstitial infiltrates and a loculated right pleural effusion.\n The interstitial changes were not present on and most likely\n represent either acute fluid overload or pulmonary edema. Does this patient\n have clinical evidence of cardiac failure?\n\n IMPRESSION: Satisfactory position of ET tube. Pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-09 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 740508,
"text": " 8:36 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abcess\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n r/o abcess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of multiple pelvic fractures, decubitus ulcer,\n bacteremia, septic.\n\n CT OF THE ABDOMEN AND PELVIS WITH CONTRAST.\n\n COMPARISON: Comparison is made to prior study performed .\n\n TECHNIQUE: Contiguous serial axial images were obtained from the lung bases\n to the pubic symphysis after the administration of 150 cc of nonionic Optiray\n contrast.\n\n CT OF THE ABDOMEN WITH CONTRAST: The visualized lung bases demonstrate\n bilateral pleural effusions with associated left lower lobe\n collapse/consolidation. The liver, pancreas and spleen are unremarkable.\n There are small stones within the gallbladder, but no gallbladder wall\n thickening or pericholecystic fluid collections. Evaluation of the abdomen is\n somewhat limited by streak artifact from rods. There are bilateral\n renal cysts. There is a large abdominal hernia and loops of bowel are seen\n extending cephalad anterior to the ribs bilaterally. There is no focal bowel\n dilatation to suggest obstruction. There are dense vascular calcifications.\n\n CT OF THE PELVIS WITH CONTRAST: Air and a Foley catheter are seen within a\n mildly distended bladder. The rectum and intrapelvic loops of bowel are\n unremarkable. No intrapelvic fluid collections or abscesses are present.\n There are numerous small inguinal lymph nodes not significantly changed from\n prior study. A small amount of fluid is seen in the region of the right\n proximal femur as well as stranding of the right gluteal subcutaneous fat. A\n focal area of heterogeneous enhancement is seen within the right gluteus\n muscle measuring approximately 3 x 4.7 cm. The appearance is consistent with\n a multiseptated collection/abscess. This exists in close proximity to a right\n gluteal decubitus ulcer, although they appear separated by an intact fat\n plane. There is an adjacent right iliac fracture, not present on the prior\n study.\n\n Osseous structures are diffusely demineralized. Multiple pelvic fractures are\n noted as on the prior study. A new comminuted and impacted right iliac\n fracture is present. Sclerosis of the SI joints is again seen. \n rods have been placed since the prior exam. Marked degenerative changes are\n again noted in the lumbar spine.\n\n IMPRESSION:\n 1. Bilateral pleural effusions with left lower lobe collapse/consolidation.\n 2. Ventral hernia.\n 3. Dense vascular calcifications.\n (Over)\n\n 8:36 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abcess\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Multiple pelvic fractures. New right iliac fracture with associated right\n gluteal collection and edema within the right gluteal subcutaneous fat. The\n collection is multiloculated and demonstrates peripheral enhancement\n consistent with a small infected collection. Myositis osifficans less likely,\n but can not be excluded in the absence of non contrast evaluation.\n 5. Right decubitus gluteal ulcer.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740277,
"text": " 5:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: e/f failure, cardiomegaly\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\n REASON FOR THIS EXAMINATION:\n e/f failure, cardiomegaly\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dyspnea.\n\n PORTABLE CHEST: Comparison is made to . Paraspinal rods are noted\n in the lower thoracic and upper lumbar spine. The cardiac silhouette is\n largely obscured, limiting evaluation of heart size. There is upper zone\n redistribution of the pulmonary vasculature, but no pulmonary edema. There\n are small pleural effusions bilaterally, coinciding with chronic pleural\n changes, predominantly on the right. There is atelectasis at the lung bases;\n pneumonia cannot be excluded.\n\n IMPRESSION:\n 1) Pulmonary vascular redistribution without overt edema.\n 2) Bibasilar atelectasis and pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740372,
"text": " 9:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: shortness of breath\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\n REASON FOR THIS EXAMINATION:\n shortness of breath\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: SOB. Crackles. Hypoxia.\n\n COMPARISON: @ 16:55.\n\n PORTABLE UPRIGHT CHEST @ 10:08: Again seen are small bilateral pleural\n effusions, right greater than left. There is associated bibasilar atelectasis\n present. There is a more focal area of confluent opacity in the right mid lung\n zone which could represent an area of pneumonia vs. atelectasis. Pulmonary\n vascularity is indistinct, consistent with CHF. This is worsened since the\n previous examination. Spinal fusion rods are noted.\n\n IMPRESSION: Worsening CHF. Small bilateral pleural effusions with bibasilar\n atelectasis. Developing confluent opacity in the right mid lung zone which may\n represent atelectasis vs. pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 740327,
"text": " 10:14 AM\n CHEST (PA & LAT) Clip # \n Reason: H/O GRAM POS. COCCI BACTERIUM W/ HX OF BL PL EFFUSION W/ INC O2 REQ. SOB, SOB, R/O INFILTRATE, SOB, NO EWNW S.S.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with gram positive cocci bacteremia\n REASON FOR THIS EXAMINATION:\n 85 y/o male with gram positive cocci bacteremia with hx of BLL pleural\n effusions and increasing O2 requirement and SOB.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISONS: Prior study from .\n\n HISTORY: Increasing oxygen requirement. Rule out dissection.\n\n FINDINGS: There is increased density at the right base suggesting the\n accumulation of a right pleural effusion. There is a small left pleural\n effusion. There is increased vascular congestion bilateral suggesting\n increased pulmonary edema compared to the prior study.\n\n IMPRESSION: Cardiac failure compared to the prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-13 00:00:00.000",
"description": "RP PLEURAL ASP BY RADIOLOGIST RIGHT PORT",
"row_id": 740741,
"text": " 3:45 PM\n PLEURAL ASP BY RADIOLOGIST RIGHT PORT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n CHEST U.S.\n Reason: localize effusion for thoracentesis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with MSSA pneumonia, likely loculated\n REASON FOR THIS EXAMINATION:\n localize effusion for thoracentesis\n ______________________________________________________________________________\n FINAL REPORT\n REASON: Loculated MSRA pneumonia on intubated patient. Diagnostic and\n therapeutic tap requested.\n\n A limited ultrasound of the right hemithorax revealed a pleural effusion.\n Risks and benefits of the procedure were discussed with the patient's\n designated Power of Attorney, informed consent was obtained, and placed on\n the patient's chart. The patient was draped in a sterile fashion. An 18\n gauge catheter was placed in the right-sided pleural effusion under\n direct ultrasound guidance. 750 cc of clear, yellowish fluid was aspirated.\n Samples were provided to the house staff to send for laboratory analysis. The\n patient tolerated the procedure well. Dr. was present for and performed\n the procedure.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-24 00:00:00.000",
"description": "L PLEURAL ASP BY RADIOLOGIST LEFT",
"row_id": 741305,
"text": " 1:06 PM\n PLEURAL ASP BY RADIOLOGIST LEFT; GUIDANCE FOR /ABD/PARA CENTESIS USClip # \n CHEST U.S. PORT\n Reason: pt w/ large pleural effusions, needs therapeutic drainage\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with MSSA pneumonia, likely loculated; large pleural effusions,\n requires dainage.\n REASON FOR THIS EXAMINATION:\n pt w/ large pleural effusions, needs therapeutic drainage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia. Large pleural effusion. Needs therapeutic drainage.\n\n PROCEDURE: After informed consent was obtained, the left back was prepped and\n draped in the usual sterile fashion. 1% Lidocaine was administered as a local\n anesthetic. Under ultrasound guidance, a large left pleural effusion was\n localized and accessed using a 19 gauge needle. Approximately 900 cc of clear\n fluid was aspirated. No immediate complications occurred.\n\n Dr. was in attendance during the procedure.\n\n IMPRESSION: Successful ultrasound-guided left thoracentesis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-13 00:00:00.000",
"description": "CT LOC DRAINAGE",
"row_id": 740736,
"text": " 1:53 PM\n CT LOC DRAINAGE; CT FINE NEEDLE ASP Clip # \n CT RETROPERITONEAL DRAINAGE\n Reason: ABCESS DRAINAGE\n ______________________________________________________________________________\n FINAL REPORT\n CT LOCALIZATION AND ASPIRATION OF FLUID COLLECTION:\n\n INDICATION: History of pelvic fracture with focal fluid collection. Evaluate\n for drainage.\n\n COMPARISONS: CT of the abdomen and pelvis dated .\n\n CT LOCALIZATION: Axial helical images were obtained through the region of\n interest to the patient in the lateral/semisupine position.\n\n CT GUIDANCE: Using CT guidance and CT fluoroscopy, an 18 gauge spinal needle\n was advanced into the fluid collection in the region of the right buttock.\n Approximately 3 cc of serosanguinous fluid was aspirated and sent for\n cultures. The patient tolerated the procedure well without immediate\n complications.\n\n CT OF THE PELVIS: Again seen are multiple pelvic fractures. Pagetoid changes\n are seen in the bilateral ischium and sacrum. Calcifications are seen in the\n right buttock muscle. There has been interval reduction in size of the soft\n tissue mass in the right iliac fossa. The fluid collections in the right\n buttock region have also decreased. Again seen is the large decubitus ulcer\n in the right buttock region. This ulcer overlies the fracture and soft tissue\n change. A CAPD catheter is incidentally noted.\n\n IMPRESSION: Interval reduction in size of the soft tissue mass in the right\n iliac and fluid collections in the right buttock area. These changes are\n consistent with a resolving hemoatoma vs improving myositis. Given the\n proximity of the decubitus ulcer to the soft tissue changes, no bone biopsy\n was attempted (risk of introducing infection to this region). Serosanguinous\n fluid was aspirated from the buttock collection and sent for cultures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740401,
"text": " 4:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CENTRAL LINE PLACEMENT, POST FILM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam,\n hypoxia.\n REASON FOR THIS EXAMINATION:\n CENTRAL LINE PLACEMENT, POST FILM\n ______________________________________________________________________________\n FINAL REPORT\n Single view of the chest is compared to a prior study performed earlier today.\n\n HISTORY: Acute shortness of breath.\n\n There is a new right IJ line in the appropriate position. The\n cardiomediastinal contours are stable. There is persistent right basilar\n pleural thickening which may be chronic, or a loculated pleural effusion.\n There is prominence of the interstitium which probably relates to a chronic\n process, although superimposed interstitial edema will have a similar\n appearance. There is no pneumothorax. Bilateral posterior rods\n are visualized. The bones are demineralized.\n\n IMPRESSION: There is prominence of the interstitium, probably related to\n chronic process with a superimposed interstitial edema.\n\n Right basilar pleural thickening vs. loculated pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740349,
"text": " 4:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB, increasing respiratory effort and hypoxemia on ABG, SOB\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with gram positive cocci bacteremia, bilat pulmonary edema\n REASON FOR THIS EXAMINATION:\n SOB, increasing respiratory effort and hypoxemia on ABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bacteremia, pulmonary edema, SOB and increased respiratory\n effort.\n\n COMPARISON: at 10:21.\n\n PORTABLE UPRIGHT CHEST AT 16:55: The pulmonary vascularity is\n increased consistent with interstitial edema. There are bilateral pleural\n effusions, right greater than left. There is evidence of bibasilar\n atelectasis. The possibility of consolidation at the lung bases cannot be\n excluded.\n\n IMPRESSION: Persistent, mild interstitial edema with bilateral pleural\n effusions. Cannot exclude infectious process at the bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740626,
"text": " 3:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post placement of OG tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p intubation\n REASON FOR THIS EXAMINATION:\n post placement of OG tube\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Orogastric tube placement.\n\n Single frontal supine radiograph of the chest dated is compared\n to a prior study dated . There has been interval insertion of an\n orogastric feeding tube which projects below the level of the diaphragm. The\n film is very rotated, limiting evaluation of the lung parenchyma. Again noted\n is a loculated pleural effusion on the right. There is also a moderate-sized\n pleural effusion on the left. rods are noted overlying the spine.\n\n IMPRESSION:\n\n 1) Satisfactory placement of orogastric tube.\n\n 2) Continued bilateral pleural effusions with loculation on the right.\n\n 3) Repeat non-rotated film would be better suited for evaluation of the\n pulmonary parenchyma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-11 00:00:00.000",
"description": "BP PELVIS WITH JUDET VIEWS BILAT PORT",
"row_id": 740616,
"text": " 1:28 PM\n PELVIS WITH JUDET VIEWS BILAT PORT Clip # \n Reason: new pelvic fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with pelvic fx\n REASON FOR THIS EXAMINATION:\n new pelvic fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New pelvic fracture.\n\n COMPARISON: CT of .\n\n PELVIS WITH 2 OBLIQUE VIEWS: The distal end of spinal rods are\n seen. The images are markedly suboptimal in evaluation of the pelvis. The\n patient has Foley catheter. Multiple fractures seen on the prior CT of \n are not adequately assessed on these films.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-03 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 740278,
"text": " 5:42 PM\n PELVIS (AP ONLY) Clip # \n Reason: e/f fracture, dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\n also with new right hip pain, pain on lateral extention of right leg\n REASON FOR THIS EXAMINATION:\n e/f fracture, dislocation\n ______________________________________________________________________________\n FINAL REPORT\n PELVIS AP .\n\n INDICATION: Hip pain.\n\n FINDINGS:\n\n Evaluation of the pelvis is limited nonstandard patient\n posiitoning. There is a history of old bilateral inferior pubic ramus\n fractures, and SI joints fusion. There is lower lumbar spinal fusion with\n rods posteriorly. No acute fracture is appreciated.\n\n IMPRESSION:\n 1. Limited study.\n 2. No evidence of hip fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-03 00:00:00.000",
"description": "CHEST CTA WITH CONTRAST",
"row_id": 740280,
"text": " 7:10 PM\n CHEST CTA WITH CONTRAST Clip # \n Reason: e/f PE, also evaluate old pneumonia in RLL scar vx persiste\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with ?COPD presenting with acute SOB, crackles on exam, hypoxia\n also with new right hip pain, pain on lateral extention of right leg\n REASON FOR THIS EXAMINATION:\n e/f PE, also evaluate old pneumonia in RLL scar vx persistent pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST.\n\n INDICATION: 85 year old man with shortness of breath.\n\n TECHNIQUE: Contiguous helical imaging was obtained from the lung bases to the\n lung apices utilizing the CTA protocol for pulmonary embolus.\n\n CONTRAST: 150 cc of Optiray contrast used secondary to history of rapid rate\n of injection.\n\n CT SCAN OF THE CHEST WITH CONTRAST: There is no significant axillary,\n mediastinal or hilar lymphadenopathy. The contrast bolus was optimally timed\n for evaluation of the pulmonary arteries. No intraluminal filling defect is\n seen to suggest pulmonary embolus.\n\n The lung windows demonstrate bilateral large layering pleural effusions. There\n is also associated collapse/consolidation of the right lower lobe, as well as\n some partial collapse of the left lower lobe. Also noted is diffuse moderate\n centrilobular emphysema.\n\n BONE ELEMENTS: Multiple right-sided rib fractures are seen. rods\n are seen within the posterior elements. The patient is severely kyphotic.\n\n IMPRESSION:\n\n 1) No pulmonary embolus.\n\n 2) Bilateral large pleural effusions with consolidation/collapse of the right\n lower lobe and partial collapse/consolidation of the left lower lobe.\n\n 3) Moderate diffuse centrilobular emphysema.\n\n 4) Multiple old healed right-sided rib fractures. Severe kyphosis with\n rods seen in the posterior elements.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-22 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 741235,
"text": " 3:48 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: COPIOUS SECRETIONS, S/P PPNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with COPD, s/p pneumonia, still with thick copious secretions.\n REASON FOR THIS EXAMINATION:\n Please evaluate pleural effusions, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, copious secretions.\n\n TECHNIQUE: Helically-acquired axial images were obtained from the thoracic\n inlet through the lung bases without the administration of IV contrast.\n Contrast was not given due to inability to obtain IV access.\n\n CHEST CT WITHOUT CONTRAST: No significantly enlarged lymph nodes are seen\n within the mediastinum or axilla. It is difficult to assess for hilar\n adenopathy due to large bilateral pleural effusions and adjacent atelectasis.\n The size of the pleural effusions has increased since the previous exam of\n . There does appear to be a small loculated component on the right\n superolaterally.\n\n There is bibasilar passive atelectasis associated with the effusions. The\n aerated portions of the lungs are clear. Although the right main stem\n bronchus and bronchus to the right upper and middle lobes are narrowed, they\n are patent. It is difficult to assess the bronchi going to the lower lobes\n bilaterally due to the large pleural effusions and atelectasis.\n\n There is a PICC present in the distal SVC. There is an NG tube within the\n stomach. Limited images of the upper abdomen reveal a possible small low-\n attenuation lesion in the dome of the liver which cannot be characterized\n further. It is unchanged. The upper poles of the kidneys, imaged portions of\n the pancreatic tail and spleen are unremarkable.\n\n Several right-sided healed rib fractures are again noted. Fusion rods are\n seen along the posterior aspect of the thoracic spine.\n\n IMPRESSION:\n\n 1) Large bilateral pleural effusions with associated passive atelectasis.\n There is a loculated component on the right superolaterally. It is difficult\n to know if the pleural fluid is potentially infected without IV contrast. The\n effusions have increased since the previous exam from .\n\n 2) The aerated portions of the upper lobes appear clear.\n\n 3) Healed right-sided rib fractures are again noted.\n\n (Over)\n\n 3:48 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: COPIOUS SECRETIONS, S/P PPNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740967,
"text": " 4:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT placement; also eval for pna.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, s/p thoracentesis, newly dc'd from vent, with new NGT\n placement; please comment on change in pna, as well as NGT placement.\n REASON FOR THIS EXAMINATION:\n s/p NGT placement; also eval for pna.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: MSSA bacteremia, check NG tube placement and follow up\n pneumonia.\n\n Single AP supine chest radiograph dated is compared with prior chest\n radiograph dated .\n\n There is interval removal of the ET tube. The NG tube terminates in the\n stomach. Again a mild left convex scoliosis is demonstrated with \n rod in place.\n\n Extensive air space opacities are present bilaterally, of no significant\n interval change since the prior study. There is also no significant interval\n change of the previousl reported bilateral pleural effusions.\n\n IMPRESSION: NG tube terminates in the stomach. No significant interval\n change of the parenchymal opacities and pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740826,
"text": " 8:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, s/p thoracentesis, weaning from vent\n REASON FOR THIS EXAMINATION:\n assess infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess infiltrates. MRSA bactermia, status post thoracentesis,\n weaning from ventilator.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST: There is marked patient rotation, which\n alters cardiomediastinal borders. Allowing for this, the ET tube is present,\n tip 4.8 cm above the carina. AN NG tube is present, coiled in the stomach,\n with tip overlying the fundus. A right IJ central line is present, tip over\n proximal/mid SVC. There appear to be right sided rib fractures. There are\n layering left greater than right effusions with underlying collapse and/or\n consolidation. We cannot exclude underlying CHF. The patient's spinal rods\n are noted. Marked narrowing of the right shoulder acromiohumeral distance is\n compatible with a chronic rotator cuff tear.\n\n IMPRESSION: Bilateral layering left greater than right effusions with\n underlying collapse and/or consolidation overlying appearances, allowing for\n marked differences in position, are similar to those of one day earlier. There\n may have been some interval improvement in the left upper zone. Right sided\n rib fractures and associated pleural thickening/hematoma noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 741046,
"text": " 7:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess interval change in b/l airspace dz and pleural effusi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, s/p thoracentesis, please\n comment on change in pna, pleural effusions.\n REASON FOR THIS EXAMINATION:\n Assess interval change in b/l airspace dz and pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post thoracentesis.\n\n CHEST, SINGLE VIEW\n\n There are spinal rods seen to project over the lower thoracic upper lumbar\n region. There is a central venous catheter which enters from right IJ\n approach but tip is not visualized past the SVC/RA junction. There is a right\n IJ line also in place with tip not seen below the middle SVC. There are\n persistent bilateral effusions but have decreased in size since the prior\n study. The right effusion is much larger than the left.\n\n IMPRESSION:\n 1. PICC line in probable SVC/RA junction. Right IJ line with tip not clearly\n demonstrated due to overlying rods but seen as far as the middle SVC. No\n pneumothorax is seen. Findings communicated to IV team.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 741217,
"text": " 6:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for effusions and/or infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, still with copious secretions and oxygen requirements.\n REASON FOR THIS EXAMINATION:\n please evaluate for effusions and/or infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New fever and shortness of breath.\n\n FINDINGS: A single AP view of the chest compared to prior exams dated \n and demonstrates an interval increase in the size of the left pleural\n effusion since the exam. The size of the effusion appears comparable\n to the examination. In addition, abnormal ill-defined opacity in the\n right upper lobe appears increased since the exam. The left lung\n remains unchanged.\n\n IMPRESSION:\n\n 1. Interval increase in left pleural effusion since .\n\n 2. Bibasilar atelectasis/consolidation persists.\n\n 3. Right upper lobe opacity increased since the and suggests evolved\n right upper lobe pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-13 00:00:00.000",
"description": "CT PELVIS ORTHO W/O C",
"row_id": 740730,
"text": " 12:57 PM\n CT PELVIS ORTHO W/O C; CT,CORONAL,SAGITAL,OBL RECONSTRUCTION Clip # \n Reason: better characterize pelvis in patient with multiple pelvic f\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with MSSA bacteremia, respiratory failure, multiple pelvic\n fractures. On vent.\n REASON FOR THIS EXAMINATION:\n better characterize pelvis in patient with multiple pelvic fractures\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: fractures. For further evaluation.\n\n FINDINGS: Comparison CT scan and CT abdomen .\n\n In addition to the previously described pubic ramus and left sacral fractures\n seen on as reported on the abdominal CT there is a comminuted fracture\n of the right iliac involving the anterior portions of the ilium as well\n as the broad posterior and lateral portions of the iliac . In addition to\n the iliac fracture these thin cuts demonstrate an essentially undisplaced\n fracture through the anterior lip of the sacrum on the right.\n\n The iliac fracture while comminuted is not significantly displaced with only a\n few mm displacement of small fracture fragments from the main ilium.\n\n Note made that the enhancing collection seen on CT has been drained.\n Minimal linear hyperdensity in the soft tissues of the right gluteal region\n could represent residual contrast or possibly some soft tissue calcifications.\n\n IMPRESSION:\n 1. comminuted fracture right ilium and undisplaced fracture anterior lip of\n right sacrum in addition to previously described fractures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-26 00:00:00.000",
"description": "PERC PLCMT GASTROMY TUBE",
"row_id": 741429,
"text": " 12:25 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: FEEDING TUBE\n Contrast: OPTIRAY Amt: 60\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PLCT GJ TUBE *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT ENTROCLYSIS TUBE *\n * PERC PLCMT GASTROSOTMY TUBE NON-IONIC 50 CC *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post respiratory compromise requiring intubation from\n sepsis and pneumonia. Patient is an aspiration risk and failed swallowing\n study.\n\n RADIOLOGISTS: Dr. , supervising staff radiologist Dr. .\n\n TECHNIQUE: Patient was explained risks and benefits of procedure. Informed\n consent was obtained. An NG tube had been placed on low intermittent suction\n on night prior to the study. 1% Lidocaine was administered locally after air\n was insufflated into the stomach and appropriate location for puncture\n determined utilizing fluoroscopy. A T fastener needle system was introduced\n into the lumen in the body of the stomach under fluoroscopic guidance. The two\n T fasteners were deployed and the anterior wall of the stomach was tacked to\n the anterior abdominal wall. Subsequently a small incision was made into the\n skin between T fasteners securing anchors and the T fastener single wall\n needle was advanced into the lumen in the direction of the pylorus. Contrast\n was administered which documented intragastric location of the needle.\n Subsequently a .035 wire was introduced into the lumen of the stomach\n and was coiled. The single wall needle was removed and replaced with a 7 FR\n bright tipped long sheath which was positioned just proximal to the pylorus. A\n .035 glide wire was advanced in through the sheath. An attempt was made to\n cannulate the pylorus which was unsuccessful. Subsequently a 4 FR hockey stick\n catheter was advanced over the wire and utilizing the catheter and glide wire\n the catheter and glide wire were able to be positioned in a post pyloric\n location. The glide wire was exchanged for a .035 amplatz wire which was able\n to positioned past the ligament of Treitz into the proximal jejunum. The\n catheter was removed. Multiple dilatation were performed utilizing a 10 FR and\n 12 FR dilator, followed by placement of an 18 FR peal-away sheath. The MIC G-\n J tube was lubricated and an attempt was made to pass the tube over the\n amplatz wire. This was difficult secondary to dryness of the wire.\n Consequently the hockey stick catheter was readvanced over the amplatz wire\n and the amplatz wire was exchanged for a .035 stiff glide wire and was\n positioned within the proximal jejunum. The catheter was removed and the MIC\n G-J tube was advanced over the wire and positioned with tip in proximal\n jejunum. Initially 7 cc contrast was administered into the balloon which was\n documented on fluoroscopy to be present within the stomach. The contrast\n solution was replaced with saline. Contrast was administered through the\n gastric and jejunal ports and a post procedure radiograph was performed.\n\n FINDINGS: The G-J tip is located in proximal jejunum. The balloon is located\n within the stomach. Contrast is seen in the stomach as well as jejunum after\n administration.\n (Over)\n\n 12:25 PM\n PERC G/G-J TUBE PLMT Clip # \n Reason: FEEDING TUBE\n Contrast: OPTIRAY Amt: 60\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n MEDICATIONS/CONTRAST: 1% Lidocaine was administered locally. 50 cc optiray\n administered. Optiray was selected secondary to patient's debilitated state.\n\n COMPLICATIONS: No immediate complications.\n\n IMPRESSION: Status post placement of MIC G-J tube. It should be noted the\n outer disc is at marker #4. This was dressed and a flexitract system was\n applied to the external tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 741327,
"text": " 5:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pt is now s/p therapeutic thoracentesis - please check for p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n MSSA bacteremia, still with copious secretions and oxygen requirements - now\n s/p thoracentesis with removal of approx 900cc pleural fluid.\n REASON FOR THIS EXAMINATION:\n Pt is now s/p therapeutic thoracentesis - please check for pneumothorax s/p\n procedure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Thoracentesis.\n\n TECHNIQUE: Single view chest.\n\n Comparison is made with . There is limitation of evaluation of the\n examination due to overlying structures and low lung volumes. There is\n persistent bilateral pleural effusions. No pneumothorax is identified in\n either hemithorax.\n\n The NG tube is seen to course into the stomach but the tip is not included in\n the radiograph. There are bilateral patchy consolidations which are difficult\n to evaluate and compared from the prior study.\n\n IMPRESSION: Bilateral pleural effusions. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 740768,
"text": " 8:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for line position, pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p thoracentesis\n REASON FOR THIS EXAMINATION:\n eval for line position, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thoracentesis and line placement.\n\n CV line is in mid to distal SVC, probably obscured by spinal rod.\n Endotracheal tube is 3 cm above carina. NG tube extends below diaphragm. No\n pneumothorax. There are bilateral pleural effusions with possible loculation\n on the right.\n\n"
}
] |
18,054 | 138,511 | Due to the clinical findings the patient was admitted to the hospital and shortly after admission the patient had tongs applied with weights for extension of the neck and the patient tolerated the procedure and placement of the Well tongs quite well and he was seen in consultation by the Medicine Service and was admitted to the Neurosurgical Intensive Care Unit for stabilization and monitoring. He was subsequently taken to the Operating Room on the morning of the where under general endotracheal anesthetic the patient underwent a C7-T1 posterior wiring of the spinous process with good results and good positioning of the C7-T1 subluxation. The patient tolerated the procedure well. He returned to the Neurosurgical Intensive Care Unit for recovery in stable condition. However, the patient failed to awaken from anesthesia and was found to have no evidence of eye opening to noxious stimuli. The pupils were 6 mm and unreactive bilaterally. There was trace corneals bilaterally, but no movement of the arms or legs. The blood pressure was 200/70 and the patient emergently was taken for a CT scan to rule out intracranial hemorrhage or massive cerebrovascular accident or a pontine angle hemorrhage. The cranial CT demonstrated some blood in the bilateral occipital horns and a small amount of convexity traumatic subarachnoid hemorrhage. There was only mild ventriculomegaly and there was no mass effect or shift. However, due to the findings the patient was returned to the Neurosurgical Intensive Care Unit and after attempts to reach the patient's family were unsuccessful, the patient had a ventriculostomy drain placed and he tolerated this procedure well. His ventricular drain and intracerebral pressures remained in normal physiologic ranges and on the morning following surgery the patient began to awaken, he was easily arousable and began to show evidence of moving all extremities spontaneously. He was mouthing words over his endotracheal tube and following simple commands. Due to the improvement in his clinical condition, the ventricular drain was removed and the patient spent the next several days in the Neurosurgical Intensive Care Unit with stabilization of his mental status and he remained hemodynamically stable. The patient was subsequently transferred to the hospital floor where he began a rigorous course of physiotherapy and occupational therapy. He was seen in consultation by the Medicine and Hematology/Oncology Service for a persistent elevated white blood cell count and shortly prior to discharge the patient had a febrile episode and was found on cultures to have a positive sputum culture and was placed on Vancomycin and Levaquin. The patient was subsequently discharged to a rehab center with a PICC line in place for continuation of the Vancomycin antibiotic treatment for his positive culture and he was discharged to rehab on the with follow up to see Dr. in the clinic in approximately two weeks time. | NIPRIDE GTT D/C'D. Nipride gtt titrated to effect. BOLT D/C'D & EXTUBATED . SEROSANGUINOUS DRAINAGE. There is interval appearance of a small pleural effusion and a new retrocardiac density which may represent atelectasis although consolidation in this region cannot be excluded. ; C-SPINE (PORTABLE) IN O.R. The tract of the previous intraventricular drain is identified. CT of head done this AM. Compared to the previoustracing of sinus bradycardia has replaced atrial fibrillation andrepolarization abnormalities are now present. IMPRESSION: 1) Persistent bilateral pleural effusions. AMIODARONE FOR HX OF AFIB. Left bundle-branch block typeintraventricular conduction delay. LS clear with some upper airway congestion. FINDINGS: Duplex evaluation was performed of the right upper extremity venous system. Hypertensive when stimulated. SINUS BRADY BASELINE. Degenerative changes are seen in the spine and postoperative changes are noted in the cervicothoracic region. Stable intraventricular hemorrhage. clondine patch started. Intracranial and intraventricular gas, possibly related to recent intervention. There remains small bilateral pleural effusions. There is a superoanterior fragment from the T1 vertebral body which maintains anterior alignment with the anterior spinal margin, while the large posterior component of the body is retropulsed. Sinus bradycardia. poor appitite/tol clears. There is a nondisplaced fracture through the right posterolateral aspect of the C7 vertebral body. Stable pneumoencephaly. AFEBRILE. HEMOVAC DRAIN IN POSTERIOR NECK. FINAL REPORT CT C SPINE WITH RECONSTRUCTIONS . ABX PROX FOR DRAINS. DRAING PATENT AND DRAINING. IMPRESSION: Small bilateral pleural effusions and possible faint right lower lobe infiltrates. Subarachnoid hemorrhage. Small bilateral subdural hematomas. FINAL REPORT PA & LATERAL CHEST: HISTORY: Pleural effusions, follow up abnormal chest. Coronal and sagittal reformations were created. VITAL SIGNS PER FLOW SHEET. Visualized paranasal sinuses demonstrate mucosal thickening in bilateral maxillary sinuses and a retention cyst of right maxillary sinus. left hip drsg - hemovac dc from hip. There are bilateral pleural effusions and there is an infiltrate in the right lower lobe posteriorly. Please evaluate for hydrocephalus. CHEST, SINGLE VIEW: Comparison study dated . TECHNIQUE: Axial C spine CT was performed. TX WITH DROPERIDOL. BP STILL LABILE AND NIPRIDE BEING TITRATED. The width of the spinal canal is preserved by the retropulsion of the posterior elements of C7. 3 LPM NC. TECHNIQUE: Standard multiplanar T1 and T2 weighted imaging sequences were performed. Aline mildly positional. UO=QS. Status post cervical fusion. Nursing noteAlert/oriented x3. FX SPINE. drain out this AM. 11:19 AM CHEST (PA & LAT) Clip # Reason: Follow-up bilateral opacities. Left subclavian vein line with tip in mid SVC. Had c-spine fi FINAL REPORT (Cont) canal is wide. pt weaned to cpap+ps secondary to dyssynchrony w/vent. CT recommended. Again seen is an area of opacification in the right retrocardiac region. IMPRESSION: 1) Limited examination excluding the extreme right costophrenic angle. There remains bilateral small pleural effusions. There is interval clearing of the left retrocardiac region. of retrocardiac opacity. DRG. There is still gross anterolisthesis of C7 on T1. There is still gross anterolisthesis of C7 on T1. Bridging anterior osteophytes are again seen, unchanged. IMPRESSION: C7-T1 subluxation/fracture. COMINO BOLT PLACED PR MD. IMPRESSION: Stable appearance of C7-T1 spinal fusion and grade III anterolisthesis of C7 on T1. NPO x meds with sip. 2) Bilateral small pleural effusions. The spinous process of C7 appears posteriorly positioned. Paresthesias in hand. sxn tk tan. Abd soft with + BS. PORTABLE AP CHEST is compared with CXR of . lytes repleted prn. bolt in place/intact, ICP 5-11. The ET tube has been removed. 3) Widening of the left sternoclavicular joint of uncertain chronicity. FINDINGS: A preprocedural left upper extremity ultrasound shows a widely patent and compressible left basilic vein. The left subclavian central venous catheter has been removed. NSG PROGRESS NOTERETURNED FROM OR INTUBATED AND NONRESPONSIVE. Nursing notePt alert/oriented x3. AP AND TWO LATERAL VIEWS OF THE CERVICAL SPINE AND LATERAL THORACIC SPINE: There are bridging anterior osteophytes suggesting early DISH. Monitor traction, VS, neuro status. There is angulation of the spinal canal secondary to the displacement of C7 over T1. IMPRESSION: Interval spinal fusion C7-T1 area which is not adequately assessed in this series of radiographs. Pt states slight numbness/tingling of bil forearms conts. Subsequent CT scan was obtained. plan: cont w/mech support. IMPRESSION: 1) Persistent right retrocardiac density with interval improvement of the left retrocardiac density. IMPRESSION: Bilateral lower lobe collapse/consolidation. The left sternoclavicular joint is widened, of uncertain chronicity. There are bilateral basilar opacities, consistent with consolidation/collapse. There is calcification of the anterior longitudinal ligament. Neuro signs WNL. BUN/CR=45/1.9. At the C4-5 level there is mild canal and neural foraminal narrowing secondary to degenerative change. HCT 29. STARTED VENODYNES. FINDINGS: Two views of the chest worsen to . UO=QS. IMPRESSION: Probable fracture/dislocation at poorly assessed C7/T1 level. Gradient echo axial images were obtained from the C3 through the T1 levels. Afebrile. AFEBRILE. The mediastinal and hilar contours are normal. 8:32 AM PICC LINE PLACMENT SCH Clip # Reason: S/P cervical instrumentation.Needs vancomycin. There is osteopenia throughout the thoracic spine. Outside cervical spine radiographs inadequately assess C7-T1. A post procedural radiograph shows the tip of the PICC within the lower SVC. The tip is in the lower SVC. LATERAL XRAY. resp carept remains intubated and mech ventilated. The seven cervical vertebral bodies are normally aligned but there is a poorly visualized apparent fracture of T1 with grade spondylolisthesis of C7 body anteriorly on T1 body. | 33 | [
{
"category": "Nursing/other",
"chartdate": "2147-11-27 00:00:00.000",
"description": "Report",
"row_id": 1499671,
"text": "NURSING TRANSFER NOTE\nupdate transfer note - cont requiring nipride for bp control overnight. Increase pressure related to pain. mso4 pca started - pca currently at basal rate 0.5/hr and demand dose 1 mg q6min with 10mg/1 hr lockout. increase anxiety with activity. with anxiety rr inc to 30's w/o desaturation. sbp up to 190's. clondine patch started. somi on. hemovac x1 from neck incision. left hip drsg - hemovac dc from hip. poor appitite/tol clears. hydalazine po increase to 50 mg q6.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-25 00:00:00.000",
"description": "Report",
"row_id": 1499666,
"text": "Nursing note\nAlert/oriented x3. Anxious at times. drain out this AM. Sutures intact to scalp. No drainage. CT of head done this AM. Aspen collar on and tol well. MAE freely. move/position for comfort. Denies headache. LS clear with some upper airway congestion. Extubated without incident. Sats 96-98 with humidified O2 by mask. Cough/gag intact. Abd soft, nontender. No bowel sounds heard yet. Sips of clear liqs tol in PM. Able to swallow PO meds. Hypertensive when stimulated. Nipride gtt titrated to effect. Hydralazine started. Foley patent, draining QS yellow urine with sediment. Dsgs to c spine and L iliac crest intact with sm amt s/s drainage noted. Aline mildly positional. B/P correlated with cuff. Left TLC patent. Site benign. Family anxious. Cont to monitor B/P and titrate Nipride gtt to maintain B/P below 150. Monitor and treat pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-26 00:00:00.000",
"description": "Report",
"row_id": 1499667,
"text": "pain\nD: PT C/O OF PAIN IN SHOULDERS AND ACROSS BACK. PT ABLE TO MOVE ALL EXTREMITIES AND FOLLOW COMMANDS. HE IS HAVING OCCASIONAL EPISODES OF CONFUSION, WANTING TO MOVE HIS CAR WHICH IS PARKED IN THE STREET AND FIX THE TILE ON THE CEILING. HE IS EASILY REORIENTED AND REALIZES HE IS CONFUSED. NIPRIDE TITRATED FOR BP CONTROL.\nA: MORPHINE FOR PAIN WITH GOOD RELIEF. HYDRALIZINE INCREASED TO 30MG Q6. NIPRIDE TITRATED FOR BP\nR: DOING WELL POST FUSION. MORPHINE EFFECTIVE IN CONTROLLING PAIN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-26 00:00:00.000",
"description": "Report",
"row_id": 1499668,
"text": "FOCUS: CONDITION UPDATE\nD: PATIENT'S CONDITION CONTINUES TO IMPROVE. ALERT AND ORIENTED, GOOD STREGNTH IN ALL EXTREMITIES. ASPEN COLLAR REMAINS ON. COMPLAINING OF SHOULDER PAIN, MEDICATED TWICE WITH GOOD RELIEF. BEGINNING TO ADVANCE DIET--TOLERATING WELL. UNABLE TO WEAN SNP--BLOOD PRESSURE RISES WITH ANY INTERRUPTION IN NIRPIDE INFUSION. FAMILY IN/OUT MOST OF THE DAY. VITAL SIGNS PER FLOW SHEET. DRAING PATENT AND DRAINING. AWAITING PT CONSULT AND PLACEMENT OF SOMI BRACE TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-27 00:00:00.000",
"description": "Report",
"row_id": 1499669,
"text": "PAIN\nD: PT IS ALERT AND ORIENTED. NORMAL STRENGTH IN ALL EXTREMITIES. PT COMPLAINING OF PAIN BETWEEN SHOULDER BLADES. SBP STILL LABILE AND NIPRIDE TITRATED FOR BP. COUGHING AND RAISING THICK YELLOW SPUTUM.\nA: CONTINUE TO MEDICATE WITH MORPHINE FOR PAIN. CONTINUE TO ENCOURAGE AGGRESSIVE PULMONARY TOLIET. HYDRALAZINE INCREASED TO 40 MG\nR: MORPHINE EFFECTIVE IN CONTROLLING PAIN. PT APPEARS COMFORTABLE ON 4L NC. BP STILL LABILE AND NIPRIDE BEING TITRATED. PT WITH GOOD RESPONSE TO HYDRALAZINE BUT SHORT LIVED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-27 00:00:00.000",
"description": "Report",
"row_id": 1499670,
"text": "NURSING TRANSFER NOTE\nADMITTED S/P FALL FROM LADDER. FX SPINE. C7 TO T1 FUSION LAMINECTOMY. UNRESPONSIVE ON RETURN FROM OR. BOLT IN TO MEASURE ICP. BOLT D/C'D & EXTUBATED . NOW A&O. MOVES ALL EXTREMITIES. ASPEN COLLAR. SCHEDULED FOR TODAY. SINUS BRADY BASELINE. NIPRIDE GTT D/C'D. CONTROLLING SBP < 150 WITH HYDRALAZINE, LOPRESSOR, NITROPASTE. AFEBRILE. 3 LPM NC. UPPERAIRWAY CONGESTION. WEAK COUGH. INCENTIVE SPIROMETER. MRI OF HEAD DONE TODAY. TRIED PERCOCET FOR PAIN. NAUSEA. TX WITH DROPERIDOL. PRN ORDER CHANGED TO #3. NOT TRIED YET. ALSO MORPHINE IVP GIVEN FOR PAIN POST MRI. REGULAR DIET. EATING SMALL AMOUNTS. HEMOVAC DRAIN IN POSTERIOR NECK. SEROSANGUINOUS DRAINAGE. FOLEY. UO=QS. NO BM. ABX PROX FOR DRAINS. AMIODARONE FOR HX OF AFIB.\n"
},
{
"category": "ECG",
"chartdate": "2147-11-23 00:00:00.000",
"description": "Report",
"row_id": 119510,
"text": "Sinus bradycardia. Left axis deviation. Left bundle-branch block type\nintraventricular conduction delay. Prominent U waves. Compared to the previous\ntracing of sinus bradycardia has replaced atrial fibrillation and\nrepolarization abnormalities are now present. These may be due to electrolyte\nabnormalities or medication effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-30 00:00:00.000",
"description": "VENOUS DUP EXT UNI (MAP/DVT)",
"row_id": 748384,
"text": " 2:57 PM\n VENOUS DUP EXT UNI (MAP/DVT) Clip # \n Reason: 75 year old male with erythema and tenderness to the right u\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n 75 year old male with erythema and tenderness to the right upper extremity with\n also a high wbc count of 18 please assess for upper extremity DVT\n ______________________________________________________________________________\n FINAL REPORT\n REASON:\n Patient with pain and swelling right upper extremity.\n\n FINDINGS:\n Duplex evaluation was performed of the right upper extremity venous system.\n Due to the brace on her neck and shoulders her jugular vein cannot be scanned.\n\n The right subclavian, axillary, brachial, basilic, radial and ulnar veins are\n all patent without evidence of thrombus or obstruction. There is normal\n compression at those levels. Cephalic vein was not visualized.\n\n IMPRESSION:\n No evidence of right upper extremity DVT. As noted study was somewhat\n difficult due to the brace on the neck and shoulders.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 747974,
"text": " 2:55 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: NOT WAKING AFTER SURGERY S/P CERVICAL FUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n s/p cervical fusion\n ______________________________________________________________________________\n FINAL REPORT\n TECHNIQUE: Contiguous axial images were obtained from the foramen Magnum to\n the cranial vertex.\n\n HISTORY: Post op. Status post cervical fusion. Unable to walk.\n\n CT HEAD W/O CONTRAST: There is a large amount of intraventricular hemorrhage\n seen layering within the atria of the lateral ventricles. Additionally there\n is diffuse subarachnoid hemorrhage most prominent over the left parietal\n convexity. There are no definite attenuation abnormalities of the parenchyma.\n\n There is no fracture. Visualized paranasal sinuses demonstrate mucosal\n thickening in bilateral maxillary sinuses and a retention cyst of right\n maxillary sinus.\n\n IMPRESSION: Intraventricular and subarachnoid hemorrhage without\n hydrocephalus. No major vascular territorial infarction is noted. Follow up is\n recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 748016,
"text": " 8:38 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? HYDROCEPHALUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with see above\n REASON FOR THIS EXAMINATION:\n please perform a head CT s/p cervical fracture stabilization surgery w/ neuro\n changes and depressed mental status postop. Please evaluate for hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75 year old male with mental status changes, intracranial hemorrhage\n for follow up.\n\n Comparison to prior study from .\n\n TECHNIQUE: Axial noncontrast imaging was performed from the skull base to\n vertex.\n\n FINDINGS: Again seen is high density material layering posteriorly within both\n lateral ventricles consistent with hemorrhage and not significantly changed\n from prior study. Diffuse subarachnoid blood is also identified most prominent\n over the convexities. There is no mass effect. Gas is identified anterior to\n the right frontal lobe and anteriorly within the left lateral ventricle.\n Craniotomy defect is noted in the right frontal bone there is no\n hydrocephalus. Again noted is opacification of multiple ethmoid air cells and\n fluid within the maxillary sinuses.\n\n IMPRESSION:\n\n 1. Intraventricular and subarachnoid hemorrhage, not significantly changed\n from the prior study.\n\n 2. Intracranial and intraventricular gas, possibly related to recent\n intervention. Suggest clinical correlation.\n\n 3. No hydrocephalus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 748550,
"text": " 11:19 AM\n CHEST (PA & LAT) Clip # \n Reason: Follow-up bilateral opacities.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\n REASON FOR THIS EXAMINATION:\n Follow-up bilateral opacities.\n ______________________________________________________________________________\n FINAL REPORT\n PA & LATERAL CHEST:\n\n HISTORY: Pleural effusions, follow up abnormal chest.\n\n The inferolateral aspect of the right lung is not included on the examination.\n The heart is normal in size. There are bilateral pleural effusions and there\n is an infiltrate in the right lower lobe posteriorly. There are no other\n significant findings.\n\n IMPRESSION: Small bilateral pleural effusions and possible faint right lower\n lobe infiltrates.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-22 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 747812,
"text": " 6:34 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: 75 y/o male s/p fall from tree earlier today. Had c-spine fi\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with as abive\n REASON FOR THIS EXAMINATION:\n 75 y/o male s/p fall from tree earlier today. Had c-spine films with\n ?involvement of T1. several X rays taken but without definitive results. Please\n evaluate.\n ______________________________________________________________________________\n FINAL REPORT\n CT C SPINE WITH RECONSTRUCTIONS .\n\n INDICATION: Trauma, neck pain and paresthesias.\n\n TECHNIQUE: Axial C spine CT was performed. Coronal and sagittal reformations\n were created.\n\n CT C SPINE: At the C7 level, there is a complete transverse fracture through\n the laminae bilaterally, with approximately 1.6 cm posterior displacement of\n the posterior elements. There is a nondisplaced fracture through the right\n posterolateral aspect of the C7 vertebral body. A small chip fracture is\n retropulsed approximately 4 mm into the central canal.\n\n There is a grade 3 anterolisthesis of C7 on T1. There are bilateral C7 pars\n interarticularis fractures, with diasthesis of the C7-T1 facet articulations.\n The width of the spinal canal is preserved by the retropulsion of the\n posterior elements of C7.\n\n At T1, there is a severe anterior wedge compression fracture. There is a\n superoanterior fragment from the T1 vertebral body which maintains anterior\n alignment with the anterior spinal margin, while the large posterior component\n of the body is retropulsed.\n\n There is also a superoanterior endplate fracture of T2. The remainder of this\n vertebra is not completely imaged.\n\n There is degenerative change at multiple levels. Specifically, there is\n anterior osteophyte formation at C2-3 and to a lesser extent C3-4, C4-5 and\n C5-6. There is narrowing of the intervertebral disc spaces at all levels,\n degenerative in appearance.\n\n There is also a small fracture of the posterior limb of the right foramen\n transversarium at C5.\n\n There is degenerative narrowing of the right C5-6 neural foramen secondary to\n uncovertebral degeneration.\n\n\n IMPRESSION: Fracture dislocation of the C7-T1 interspace with T1 anterior\n wedge compression fracture and posterior elements fracture at C7. There is\n likely to be cord injury, secondary to the dislocation, though the spinal\n (Over)\n\n 6:34 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: 75 y/o male s/p fall from tree earlier today. Had c-spine fi\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n canal is wide. These findings were communicated emergently to Dr. \n , at the time of the exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-23 00:00:00.000",
"description": "C-SPINE (PORTABLE)",
"row_id": 747858,
"text": " 10:02 AM\n C-SPINE (PORTABLE) Clip # \n Reason: C7-T1 spinal fracture with sublux, now in traction, please e\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with as above\n REASON FOR THIS EXAMINATION:\n C7-T1 spinal fracture with sublux, now in traction, please eval for\n alignment/reduction of subluxation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fracture of C7 and T1 with anterolisthesis of C7 on the cervical\n spine CT of .\n\n CERVICAL SPINE 2 VIEWS: 2 lateral views of the cervical spine are provided. C7\n and T1 are not well visualized due to overlapping osseous structures. The\n degree of anterolisthesis of C7 on T1 is probably unchanged from the cervical\n spine CT of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747993,
"text": " 5:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CVL L SCLV\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cervical fracture\n REASON FOR THIS EXAMINATION:\n s/p CVL L SCLV\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post central line placement.\n\n CHEST, SINGLE VIEW: Comparison study dated . There is now an ET tube\n whose tip is approximately 8.2 cm above the carina. There is a new left\n subclavian vein line with its tip in the mid SVC, no pneumothorax is\n detected. There is interval appearance of a small pleural effusion and a new\n retrocardiac density which may represent atelectasis although consolidation in\n this region cannot be excluded. There are marked degenerative changes\n identified in the thoracic spine and metallic staples are seen projecting over\n the lower cervical spine and thoracic inlet.\n\n IMPRESSION: 1. Left subclavian vein line with tip in mid SVC. No\n pneumothorax. 2. New small left effusion and retrocardiac density likely\n representing left lobe atelectasis but consolidation cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-27 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 748131,
"text": " 1:30 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: 2:15P\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p cervical fracture stabilization surgery\n REASON FOR THIS EXAMINATION:\n please eval with diffusion weighted images for infarction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post cervical fracture stabilization and mental status\n change.\n\n TECHNIQUE: Standard multiplanar T1 and T2 weighted imaging sequences were\n performed. Additional diffusion weighted imaging sequences were also\n performed.\n\n MRI OF THE HEAD WITHOUT CONTRAST: Bilateral subdural hematomas are identified.\n There is a small amount of pneumoencephaly seen just anterior to the right\n frontal lobe. Additional intraventricular hemorrhage is seen layering and the\n atria bilateral lateral ventricles. There is also susceptibility-induced\n artifact or signal loss within the septum related to prior drain placement.\n Additionally, susceptibility-induced signal loss is seen within the left\n temporal related to gas in this location. The tract of the previous\n intraventricular drain is identified. A craniotomy defect is seen in the\n right frontal lobe. Also again seen is subarachnoid hemorrhage, not changed\n from prior CT. No measured vascular territorial infarction is seen and no\n acute ischemic event is identified on diffusion-weighted imaging sequences.\n There is some minimal mucosal thickening in bilateral maxillary sinuses. There\n is air-fluid level seen in bilateral mastoid air cells. Soft tissue\n structures are unremarkable.\n\n IMPRESSION:\n 1. Small bilateral subdural hematomas. Stable intraventricular hemorrhage.\n Septal hemorrhage related to drain placement. Subarachnoid hemorrhage.\n\n 2. Stable pneumoencephaly.\n\n 3. No ventriculomegaly.\n\n 4. Minimal mucosal thickening in the maxillary sinuses and fluid seen within\n the mastoid air cells.\n\n 5. No acute infarction.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 748390,
"text": " 3:26 PM\n CHEST (PA & LAT) Clip # \n Reason: 75 yr old male s/p C7 and T1 fusion please assess chest for\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n 75 yr old male s/p C7 and T1 fusion please assess chest for infiltrate with\n patient with high wbc count\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: S/P cervical spine surgery. Assess for infiltrate. High white\n blood cell count.\n\n Comparison is made to recent postoperative study of 2 days earlier.\n\n Cardiac and mediastinal contours are stable. There remains small bilateral\n pleural effusions. There is some improving increased opacity in the\n retrocardiac region bilaterally. Degenerative changes are seen in the spine\n and postoperative changes are noted in the cervicothoracic region.\n\n IMPRESSION: 1) Persistent bilateral pleural effusions. 2) Improving bibasilar\n opacities, likely due to atelectasis, but infection is not excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-24 00:00:00.000",
"description": "O C-SPINE (PORTABLE) IN O.R.",
"row_id": 747939,
"text": " 9:11 AM\n C-SPINE (PORTABLE) IN O.R.; C-SPINE (PORTABLE) IN O.R. Clip # \n Reason: POST.CERV.FUSION\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE 2 LATERAL FILMS IN OR:\n\n For localization prior to cervical fusion.\n\n 2 posterior marker clamps are present. The superior of these overlies the\n spinous process of CV4 and the more inferior overlies the interspinous space\n of C5 and 6 directed towards the C5/6 disc.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748195,
"text": " 9:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p spine surgery w/ productive cough and increased WBC coun\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cervical fracture\n REASON FOR THIS EXAMINATION:\n s/p spine surgery w/ productive cough and increased WBC count\n please eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: S/P Spinal surgery with productive cough and elevated wbc.\n\n PORTABLE AP CHEST is compared with CXR of .\n\n The ET tube has been removed. The left subclavian central venous catheter has\n been removed. There are bilateral basilar opacities, consistent with\n consolidation/collapse. Pleural effusions cannot be excluded. Surgical\n staples and surgical wires are noted overlying the upper cervical spine.\n\n IMPRESSION: Bilateral lower lobe collapse/consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-29 00:00:00.000",
"description": "C-SPINE, NON-TRAUMA",
"row_id": 748278,
"text": " 10:20 AM\n C-SPINE, NON-TRAUMA; T-SPINE Clip # \n Reason: s/p cervical fracture and fusion\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P cervical fracture and fusion.\n\n AP AND TWO LATERAL VIEWS OF THE CERVICAL SPINE AND LATERAL THORACIC SPINE:\n There are bridging anterior osteophytes suggesting early DISH. The lower\n cervical spine and upper thoracic spine are not visualized. There are\n posterior skin staples and wires overlying the posterior cervical spine. The\n patient is wearing an external fixation device.\n\n IMPRESSION: Interval spinal fusion C7-T1 area which is not adequately\n assessed in this series of radiographs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-23 00:00:00.000",
"description": "C-SPINE (PORTABLE)",
"row_id": 747911,
"text": " 7:05 PM\n C-SPINE (PORTABLE) Clip # \n Reason: S/P traction,reduction of subluxed Ti\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with as above\n REASON FOR THIS EXAMINATION:\n S/P traction,reduction of subluxed Ti\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is in traction for C7 and T1 fractures. Evaluate\n alignment of the lower cervical spine.\n\n CERVICAL SPINE, 2 VIEWS: Two swimmer's views were provided. Evaluation of\n C7-T1 is difficult due to overlapping osseous structures. There is still\n gross anterolisthesis of C7 on T1.\n\n IMPRESSION: The C7-T1 relationship is difficult to evaluate due to\n overlapping osseous structures. There is still gross anterolisthesis of C7 on\n T1. If clinically indicated, the C7-T1 relationship could be better evaluated\n on CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-22 00:00:00.000",
"description": "C-SPINE, TRAUMA",
"row_id": 747806,
"text": " 5:21 PM\n C-SPINE, TRAUMA Clip # \n Reason: 75 y/o male s/p fall from tree, had x rays at outside hospit\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with as above\n REASON FOR THIS EXAMINATION:\n 75 y/o male s/p fall from tree, had x rays at outside hospital with ?T1\n involvement. please do b/l oblique neck films for a better look at C7-T1.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fall. Outside cervical spine radiographs inadequately assess C7-T1.\n\n Exam consists of swimmers view of the lower cervical spine and bilateral\n oblique views. The oblique views include only the mid portion of the spine\n and are inadequate for assessment. The seven cervical vertebral bodies are\n normally aligned but there is a poorly visualized apparent fracture of T1 with\n grade spondylolisthesis of C7 body anteriorly on T1 body. The posterior\n elements cannot be assessed with presumed C7 spondylolysis. This exam was\n interpreted at the time of the study but is available for official one\n week later. Subsequent CT scan was obtained.\n\n IMPRESSION: C7-T1 subluxation/fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-22 00:00:00.000",
"description": "C-SPINE, TRAUMA (WITH OBLS)",
"row_id": 747794,
"text": " 2:04 PM\n C-SPINE, TRAUMA (WITH OBLS); T-SPINE Clip # \n Reason: NECK & MID-BACK PAIN W/ BILATERAL RADICULOPATHY & PARESTHESIAS HANDS S/P FELL 6 FT WHILE TRIMMING A TREE TODAY R/O FX,DISLOCATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n do not remove collar, fell 6 feet, has paresthesias in hand, pain over T1, C8\n processes, no flexion or extension of neck until ap and lateral cleared\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Six-foot fall. Paresthesias in hand.\n\n These radiographs were preliminarily interpretated at time they were obtained\n but are not available for official interpretation until several weeks later\n (interval patient hospital admission). The thoracic spine exam was ordered &\n apparently obtained but these radiographs not available for itnerpretation.\n There are eight radiographs of the C-spine including obliques and attempted\n spot radiographs of the cervical-thoracic junction. There is a poorly\n visualized apparent grade 2 anterolisthesis of C7 on T1, and the T1 body is\n poorly visualized with possible fracture. There is a large bridging\n osteophyte anteriorly at the C2/3 level, suggesting ossifying diaphysis and\n possible DISH elswhere in the spine. No fractures or dislocations seen C1\n through C6, although even these vertebral bodies are poorly assessed. The\n spinous process of C7 appears posteriorly positioned.\n\n IMPRESSION: Probable fracture/dislocation at poorly assessed C7/T1 level. CT\n recommended. Thoracic spine radiographs not available for interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-22 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 747827,
"text": " 10:51 PM\n MR CERVICAL SPINE Clip # \n Reason: 75 yo fell out of tree onto outstretched arms, sustained\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with fractured neck with C7-T1 subluxation\n REASON FOR THIS EXAMINATION:\n 75 yo fell out of tree onto outstretched arms, sustained C7-T1 grade 3\n subluxation and fractures of bilateral pedicles, please evaluate spinal cord as\n well as ligaments, etc.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess spinal cord and ligaments in patient with known cervical\n fractures after fall from tree.\n\n No prior MR studies are available for comparison.\n\n TECHNIQUE: T1 and T2 weighted images were obtained through the cervical\n spine. Gradient echo axial images were obtained from the C3 through the T1\n levels.\n\n FINDINGS: The fracture of the T7 and T1 vertebrae are seen with\n anterolisthesis of the C7 over the T1 vertebral body. For detailed\n description of these fractures, please see the report on the cervical spine CT\n scan obtained on (clip #).\n\n Sagittal images reveal rupture of the anterior spinal ligament at the C7-T1\n level. Additionally there is likely rupture of the posterior longitudinal\n ligament, however this is not well visualized. There is angulation of the\n spinal canal secondary to the displacement of C7 over T1. The cord\n transverses this dislocation with a bend but there are no signal abnormalities\n of the cord at this level. Additionally the cord is normal in its caliber.\n\n On the axial images, there is disruption of the soft tissues immediately\n posterior to the cord at the C7-T1 level however it is difficult to evaluate\n the thecal sac at this level due to image blurring. There are degenerative\n changes in the cervical spine superior to the known fractures. At the C4-5\n level there is mild canal and neural foraminal narrowing secondary to\n degenerative change. At C5-6, again there is mild canal narrowing at this\n level; however there is severe narrowing of the left neural foramina at this\n level.\n\n High signal on T2 weighted images show swelling of the soft tissues posterior\n to the spinous processes of the cervical spine, associated with the known\n injuries.\n\n IMPRESSION: Despite fracture and angulation of the spinal canal, the spinal\n cord is normal in signal intensity and caliber suggesting that there is\n minimal if any cord injury.\n\n\n\n (Over)\n\n 10:51 PM\n MR CERVICAL SPINE Clip # \n Reason: 75 yo fell out of tree onto outstretched arms, sustained\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747867,
"text": " 11:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pre-op CXR for OR on \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cervical fracture\n REASON FOR THIS EXAMINATION:\n Pre-op CXR for OR on \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pre-op for cervical spine fracture.\n\n No prior studies are available for comparison.\n\n PORTABLE AP CHEST: Please note that the extreme right costophrenic angle is\n not included in this film. The cardiomediastinal silhouette is normal. The\n pulmonary vasculature is normal. There is no consolidation or effusion on the\n left. The left sternoclavicular joint is widened, of uncertain chronicity.\n\n IMPRESSION: 1) Limited examination excluding the extreme right costophrenic\n angle. This examination will be repeated at no additional charge.\n\n 2) No acute cardiopulmonary abnormality apparent.\n\n 3) Widening of the left sternoclavicular joint of uncertain chronicity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-05 00:00:00.000",
"description": "C-SPINE, NON-TRAUMA",
"row_id": 748716,
"text": " 3:38 PM\n C-SPINE, NON-TRAUMA Clip # \n Reason: 75 yr old male s/p C7-T1 decopression please do ap and lat f\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n 75 yr old male s/p C7-T1 decopression please do ap and lat films standing in\n brace with swimmers view if necessary must view top of T1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post C7-T1 decompression, follow-up study.\n\n Comparison is made to the prior study of .\n\n Three views of the cervical spine demonstrate fixation wires overlying the\n posterior cervical spine at the C5 through T1 levels and skin staples. Grade\n III anterolisthesis is demonstrated on the swimmer's view and is unchanged\n compared to prior studies. Bridging anterior osteophytes are again seen,\n unchanged.\n\n IMPRESSION: Stable appearance of C7-T1 spinal fusion and grade III\n anterolisthesis of C7 on T1.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 748715,
"text": " 3:38 PM\n CHEST (PA & LAT) Clip # \n Reason: Elevated white cell couynt and low spo2.Evaluate for progre\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\n REASON FOR THIS EXAMINATION:\n Elevated white cell couynt and low spo2.Evaluate for progression of\n effusion/infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Rising white count with question of retrocardiac density.\n\n FINDINGS:\n Two views of the chest worsen to . Again seen is an area of\n opacification in the right retrocardiac region. There is interval clearing of\n the left retrocardiac region. There remains bilateral small pleural effusions.\n There is no congestive heart failure. There is artifact from overlying\n metallic device. No pneumothorax is seen.\n\n IMPRESSION:\n 1) Persistent right retrocardiac density with interval improvement of the left\n retrocardiac density.\n 2) Bilateral small pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-08 00:00:00.000",
"description": "CVL/PICC",
"row_id": 748910,
"text": " 8:32 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: S/P cervical instrumentation.Needs vancomycin.\n ********************************* CPT Codes ********************************\n * CVL/PICC UD GUID FOR NEEDLE PLACMENT *\n * CHEST AP ONLY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with\n REASON FOR THIS EXAMINATION:\n S/P cervical instrumentation.Needs vancomycin.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75 y/o man with recent cervical spine trauma and instrumentation.\n He is now infected and requires IV access for longterm antibiotics.\n\n RADIOLOGISTS: Dr. and Dr. , staff Radiologist, was present for\n the entire procedure.\n\n CONTRAST/MEDICATIONS: 1% Lidocaine for local anesthesia.\n\n PROCEDURE/TECHNIQUE: Informed and signed consent was obtained from the\n patient. The patient was placed in a supine position on the angiographic table\n and the left upper extremity was prepped and draped in the usual sterile\n fashion. A left upper extremity ultrasound was performed as no superficial\n palpable veins could be found. After administration of local anesthesia, the\n left basilic vein was accessed with a 21 gauge needle under son\n guidance. A .018 wire was then advanced through the needle to the level of the\n lower SVC under continuous fluoroscopy. The needle was then exchanged for a 4\n FR dilator and peelaway sheath. The dilator was removed and a 4 FR single\n lumen PICC, trimmed to 47 cm, was advanced to the lower SVC under continuous\n fluoroscopy. The peelaway sheath was simultaneously removed. The guide wire\n was then removed and a radiograph obtained to confirm PICC position. The skin\n was cleaned and the PICC secured to the skin using a stat lock and overlying\n dressing. The patient tolerated the procedure well.\n\n COMPLICATIONS: None.\n\n FINDINGS: A preprocedural left upper extremity ultrasound shows a widely\n patent and compressible left basilic vein. A post procedural radiograph shows\n the tip of the PICC within the lower SVC. There is no pneumothorax.\n\n IMPRESSION: Technically successful placement of a 47 cm long, 4 FR single\n lumen PICC via the left basilic vein. The tip is in the lower SVC. The line\n is ready for immediate use.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-12-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 748869,
"text": " 3:29 PM\n CHEST (PA & LAT) Clip # \n Reason: 75 yr old male with question of retrocardiac opacity on cxr\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with pleural effusions, ?retrocardiac densities and rising WBC\n REASON FOR THIS EXAMINATION:\n 75 yr old male with question of retrocardiac opacity on cxr from please\n assess for progress or improvemtn of this ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with rising WBC, ? of retrocardiac opacity.\n\n FINDINGS: PA and lateral radiographs are compared with the PA and lateral\n study dated . The heart size is normal. No retrocardiac opacities\n are appreciated on the current study. The mediastinal and hilar contours are\n normal. The pulmonary vascularity appears normal. The lungs appear clear.\n There are no pleural effusions.\n\n There is osteopenia throughout the thoracic spine. There is calcification of\n the anterior longitudinal ligament.\n\n IMPRESSION: 1) No evidence for retrocardiac opacities or pleural effusions.\n No evidence for pneumonia.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-23 00:00:00.000",
"description": "Report",
"row_id": 1499661,
"text": "Nursing note\nPt alert/oriented x3. VSS. Afebrile. Aspen cervical collar in place. Tongs to scalp in place with 27 lbs traction. Pt verbalizes understanding of traction and need for immobility. Neuro signs WNL. MAE. Pt states slight numbness/tingling of bil forearms conts. LS clear. Sats 96-97 on room air. Abd soft with + BS. Foley patent, draining QS clear yellow urine.\n#20 IV intact in right forearm, infusing LR at 100cc/h. #18 IV intact in left AC infusing Solumedrol at 22cc/h. Sites benign. Denies pain. NPO x meds with sip. Monitor traction, VS, neuro status. Maintain traction. Maintain position with no movement/logrolling. For OR in AM. Family in to visit.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-24 00:00:00.000",
"description": "Report",
"row_id": 1499662,
"text": "NURSING PROGRESS NOTE\n12/6-7 B-SHIFT. A&O. MAE. CONSISTENT STRENGTH IN EXTREMS THROUGHOUT THE NITE. ASPEN COLLAR. HEAD/BACK IN TRACTION. VSS. BRADYCARDIA. AFEBRILE. RA. CLEAR LUNGS. NPO EXCEPT SIPS FOR MEDS. FOLEY. UO=QS. LR @ 100/HR. LATERAL XRAY. STARTED VENODYNES. BUN/CR=45/1.9. WBC=22.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-24 00:00:00.000",
"description": "Report",
"row_id": 1499663,
"text": "NSG PROGRESS NOTE\nRETURNED FROM OR INTUBATED AND NONRESPONSIVE. SOLUMEDROL GTT ON PR ANESTHESIA AT 5.4MG/KG/HR. TO RUN CONT GTT X23 HRS. NIPRIDE GTT STARTED FOR SBP 180-200. GOAL SBP < 150. NOT MOVING EXT OR FOLLOWING COMMAND INITIALLY ON ARRIVAL BEGINNING TO MOVE LOWER EXT, SQEEZE HANDS ON COMMAND AND ATTEMPT TO OPEN EYES AFTER 2-3 HRS IN SICU. HCT 29. RECEIVED 1 UNIT PRBC IN SICU. HAD RECEIVED 3 UNITS IN OR AS WELL AS 4 FFP. ASPEN COLLAR ON. HEMOVAC X2 WITH SANG. DRG. COMINO BOLT PLACED PR MD. UNABLE TO PLACE VENT DRAIN. ICP 4-10. HAD HEAD CT POST OP - POS INTRAVENT BLEED PR MD, BUT \"2ND TO BLEED FROM INITIAL FALL). FAMILY AT BEDSIDE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-25 00:00:00.000",
"description": "Report",
"row_id": 1499664,
"text": "Nursing note:\nNEURO: Opening eyes spont, MAE, following commands inconsistently, PERRLA. bolt in place/intact, ICP 5-11. Hemovac drains x 2 draining bloody drainage. Remains on 23hour Solumedrol gtt.\nRESP: No vent changes overnight, remains on SIMV/PS 5, 35%, RR 12-16 w/spont. TVs of 500. Lung sounds coarse, sxn'd via ETT for thick tan secretions. Biting on tube.\nCV: NSR 60-75, no ectopy. lytes repleted prn. Nipride gtt titrated to keep SBP <150, BP labile. Becomes hypertensive w/agitation.\nGI: abdomen softly distended, -bs.\nGU: foley patent adequate amounts yellow urine w/sediment.\nACT: no turning/repositioning overnight per HO. Neurosurg to reevaluate in am. Aspen collar on, collar care done. no areas of breakdown noted. neck not to be flexed.\nSOCIAL: supportive family at bedside much of evening.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-11-25 00:00:00.000",
"description": "Report",
"row_id": 1499665,
"text": "resp care\n\npt remains intubated and mech ventilated. pt weaned to cpap+ps secondary to dyssynchrony w/vent. ps 8 peep 5 fio2 35%. vt 500-600's rr teens to low 20's. b/s coarse. sxn tk tan. plan: cont w/mech support. wean as tolerated. pt to be tx to ct scan today.\n"
}
] |
28,671 | 125,868 | Pt was admitted and taken to the OR for left pneumonectomy for lung cancer. An epidural was placed for pain control w/ good effect. Pt was transferred to the ICU for post op management including brief IV vasopressor support. drain was placed in the left chest at the time of the operation and was d/c'd on POD#1. POD#1 an NGT was placed for decompression of a large gastric bubble and was removed w/in 24 hrs. Pt was started on sips and diet was progressed and well. POD#3 epidural was d/c'd and pt was transferred out of the ICU. He progressed well and steadily w/his post op recovery. On POD#4 pt had brief non-sustained episodes of Afib. Cardiology was consulted and pt was treated w/ lopressor and amiodarone w/ good response and conversion to NSR. Anticoag w/ IV heparin was initiated for known PE. Pt had been on lovenox prior to surgery. At the time of discharge pt was on coumadin w/ lovenox bridge. He was ambulatory w/ sats 97% on room air. | son in this aft, updates provided.a/p: remains hypotensive d/t epidural infusion, orthostatic with any movement. NC 02 REMAINS BUT CAN BE WEANED OFF PER THORACICS. hypotensive w/ infusion, neo dose maintaining goal sbp as per thoracics. COMMENCED ON CLEAR LIQUIDS PER THORACICS THIS PM.GU: U/O ADEQUATE. (-) fluid balance for day, given fluid bolus x1 this am w/ little effect and albumin bolus this pm x1. L chest tube clamped this am by thoracics, plan to d/c this pm.cv: as above, remains hypotensive w/ epidural infusion. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Since the previous tracing of atrial fibrillation is absent, T wave changes are seen and the QTc intervalappears longer.TRACING #1 Pt remains on sm amt of neo despite attempts to wean off.Pt SV on 2L NC, sats 97-100%, LS clear to coarse in upper R lobe and RLL diminished. 0700-1900SEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.EVENTS: EPIDURAL REMOVED. Transmitral Doppler E>A and TDI E/e' <8 suggestingnormal diastolic function, and normal LV filling pressure (PCWP<12mmHg).LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). FINDINGS: On this upright study, there is a long air-fluid level slightly above the mid portion of the left hemithorax, consistent with the previous pneumonectomy. Pt requiring neo d/t epidural (as described by RN/team giving report to this RN).CV: NSR, HR 90-110, no ectopy, ABP goal >90's, maintained by neo-currently .6mg/kg/min. Dsg d & i, drainage to CT is serosanguinous. pt receiving last dose of Kefzol this AM, T max 99.8 PO.Endo- blood sugar wnl's, no sliding scale.Skin- left incision intact w/ durabond, superior midsternal incision intact w/ durabond as well.A/ pt w/ post-op arrythmias , BP further compromised by Afib, rate responding to dilt yet thoracic team requests switch to amiodarone this AM. FINDINGS: Status post left-sided pneumonectomy. Epidural at level T7/8 w/ dilaudid & bupivicane infusing at 3cc/hr, pt c/o minimal discomfort. HOLS AM HEPARIN PER APS FOR EPIDURAL REMOVAL IN AM. 0700-1900SEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.EVENTS: AMIODARONE DRIP COMMENCED. following trend w/ correlating nibp.gi: ngt placed for post op gastric distention on cxr, sm amts bilious output draining. Now on Dilt gtt as well.Current ROS pt alert and oriented even w/ low BP w/ afib. with moderate globalfree wall hypokinesis. Pneumonectomy space remains partially filled with fluid with similar level of air-fluid level to recent examination at the level of the interspace between the left sixth and seventh posterior ribs. CT to H2O seal, +fluctuation/+leak/+crepitous. FOLEY REMOVED @ 1600HRS AND PT HAS VOIDED SINCE REMOVAL.SKIN: THORACOTOMY INCISION CLEAN AND DRY. denies sob/distress.cv: as above, hypotensive w/ epidural infusion, per thoracics, to continue for pain control, using phenylephrine drip to maintain sbp>90. Easily palpable pedal pulses, heparin sc, Pboots on.Resp: Right lung sounds clear throughout, no adventitious sounds. LS CLEAR/COARSE ON R. ABSENT ON L. RR WNL.GI: NGT REMOVED THIS AM. true dermatome level around T7.resp: weaned to 4L nc o2, ls clear to R, dimin to L. L chest tube to h2o seal w/ bloody drainage for shift. HR 70-80, SBP 77-110, neo infusing at 0.4mcg/kg/min- attempted to wean off mult times, however pts BP cont to be labile. The MPIstayed 0.9 to 1.0 after pnemonectomy.LV function normal with cardiac output of 4.5-5l/min.LEFT ATRIUM: Mild LA enlargement. Con't on epidural of bupivicaine and dilaudid, rate decreased to 3cc's hr w/ hypotension and rhythm issues. INDICATION: Status post left pneumonectomy. The mitral valve appears structurally normal withtrivial mitral regurgitation. NEO WEANED FROM 1.0MCG/KG/MIN TO OFF. Left ventricularhypertrophy. Pt denies nausea. Mild RV free wallhypokinesia with trace TR. hypotension w/ drip, changed to 0.05% bupivicaine w/ same effect to bp only not quite as much so. FINAL REPORT INDICATION: Status post pneumonectomy. Since the previous tracingearlier the same date atrial flutter is present.TRACING #2 FINDINGS: As compared to the previous examination, the nasogastric tube has been removed. Compared to the previous tracing rapid atrial fibrillation isnew.TRACING #1 LYTES REPLETED.NEURO: A&O X3. true dermatome level approx T6-T9 level. The small amount of left supraclavicular subcutaneous emphysema is slowly resorbing. Family updated as to pts POC and status.POC: Wean supplemental O2, encourage CDB & use of IS, hemodynamics, titrate neo to maintain MAP >60, cont to manage Afib/Aflutter with amio gtt at 1mg/min x6 hrs, followed by 0.5mg/min x18 hrs. pt denies nausea, bs present x4 quads. D/c epidural today, ? DRIP STILL ATTACHED IF NEEDED.RESP: 02 SATS >99% ON 2L NC. epidural in place for pain control w/ 0.5% bupiv&dilaudid effective. NOW ON AMIOFARONE REGIMEN. One fluid bolus of 250cc's NS given as well for hypotension. There is a continued slow reabsorption of the left supraclavicular subcutaneous emphysema. CHEST DRAIN DRESSING LEFT INTACT. Foley patent, draining adequate amts of c/y/u- uop 30-50cc/hr. APS TO REMOVE EPIDURAL IN AM. Wean off neo as tolerated. The ascending, transverse and descending thoracic aortaare normal in diameter and free of atherosclerotic plaque . pain improved at rate 12cc/h 0.1% bupiv&dilaudid. wbc stable this am.skin: thoracotomy approach incision c/d/i, dermabond glue remains intact, area OTA. NGT REMOVED.NEURO: A&O X3. ALL APPROPRIATE AND RESPECTFUL OF PT NEEDING REST.PLAN: WEAN 02 TO OFF. TDI of tricuspid annulus MPI 1.4 on three readings.MPI stayed 1.2 after two lung ventilation on left lateral position. ++ FLATUS PASSED. BOWELS MOVED X 1 SMALL CONSTIPATED. | 20 | [
{
"category": "Radiology",
"chartdate": "2151-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005590,
"text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval fluid collection in L hemithorax\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p L pneumonectomy\n REASON FOR THIS EXAMINATION:\n please eval fluid collection in L hemithorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left pneumonectomy to evaluate for fluid collection.\n\n FINDINGS: In comparison with the study of , there is little change in the\n left hemithorax. There is elevation of the hemidiaphragm with some shift of\n the mediastinal contents to this side. The residual spaces are filled with\n gas.\n\n Gas is seen subcutaneously adjacent to the lower left neck and upper thorax.\n The thick band of atelectasis on the right seen previously is not appreciated\n at this time. The prominence of interstitial markings most likely represents\n the fact that all pulmonary blood flow is now on the right.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1006319,
"text": " 9:31 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate left thorax fluid level\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p left pneumonectomy\n REASON FOR THIS EXAMINATION:\n evaluate left thorax fluid level\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST X-RAY DATED \n\n COMPARISON: .\n\n INDICATION: Status post left pneumonectomy.\n\n There is persistent expected shift of the mediastinum towards the left\n following left pneumonectomy. Pneumonectomy space remains partially filled\n with fluid with similar level of air-fluid level to recent examination at the\n level of the interspace between the left sixth and seventh posterior ribs.\n However, the amount of fluid has gradually increased over time compared to\n earlier postoperative radiographs. Within the right lung, there is mild\n vascular engorgement and a subtle interstitial pattern attributed to\n interstitial edema. No right pleural effusion is identified. Subcutaneous\n emphysema is again demonstrated in the left chest wall.\n\n IMPRESSION:\n 1. Similar appearance of left pneumonectomy space compared to recent\n postoperative radiograph but gradual increase in fluid since earlier\n radiographs.\n\n 2. Mild interstitial edema within the right lung.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-09 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1006130,
"text": " 6:11 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion/atelectasisobtain at 6AM\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with left pneumonectomy\n REASON FOR THIS EXAMINATION:\n evaluate for effusion/atelectasisobtain at 6AM\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left pneumonectomy, to compare with previous studies.\n\n FINDINGS: On this upright study, there is a long air-fluid level slightly\n above the mid portion of the left hemithorax, consistent with the previous\n pneumonectomy. The right lung remains clear. There is a continued slow\n reabsorption of the left supraclavicular subcutaneous emphysema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005983,
"text": " 6:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for fluid level\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p pneumonectomy\n REASON FOR THIS EXAMINATION:\n please eval for fluid level\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man status post pneumonectomy.\n\n COMPARISON: .\n\n FRONTAL CHEST RADIOGRAPH: The patient is status post pneumonectomy and the\n amount of fluid within the left hemithorax is unchanged. The small amount of\n left supraclavicular subcutaneous emphysema is slowly resorbing. The right\n lung is unremarkable.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005493,
"text": " 12:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for fluid level and PTX\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p L pneumonectomy\n REASON FOR THIS EXAMINATION:\n Please eval for fluid level and PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left pneumonectomy to evaluate for fluid level and pneumothorax.\n\n FINDINGS: In comparison with study of , there has been resection of the\n left lung. Loss of volume in the left hemithorax is seen with primarily gas\n filling the cavity. Small amount of fluid is seen at the base. Subcutaneous\n gas is seen along the left lateral chest wall.\n\n Dense streak of atelectasis is seen in the right lower lung zone.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005878,
"text": " 7:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p pneumonectomy \n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: , 5:29 a.m.\n\n FINDINGS: As compared to the previous examination, the nasogastric tube has\n been removed. The left-sided hemithorax is slowly filling with fluid (status\n post left-sided pneumectomy). The small air collection in the suprascapular\n region, left is unchanged in extent. The right lung is unremarkable, no\n evidence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005746,
"text": " 4:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p pneumoectomy\n REASON FOR THIS EXAMINATION:\n f/u\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: Status post left-sided pneumonectomy. Subtle air collection in the\n left-sided soft tissues. Moderate pleural effusion. Empty pneumectomy space.\n The right lung shows subtle suprabasal atelectasis, but no evidence of opacity\n or effusion. No nasogastric tube in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2151-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1005697,
"text": " 5:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ct removal - ngt placement\n Admitting Diagnosis: LEFT LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p pneumoectomy\n REASON FOR THIS EXAMINATION:\n ct removal - ngt placement\n ______________________________________________________________________________\n WET READ: BTCa FRI 9:31 PM\n Very limited study due to overpenetration. NGT appears to terminate just\n below the GE junction and should be advanced. Lung fields cannot be assessed\n and repeat radiographs are recommended. Findings discussed with Dr. \n at 9 pm on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post pneumonectomy. Check NG tube placement.\n\n COMPARISON: at 6 a.m.\n\n FINDINGS: Cardiac silhouette is unchanged. The NG tube tip is at the GE\n junction and the patient may benefit from advancement. Findings were\n communicated to Dr. _____ at 9 p.m. on by Dr. .\n Limited assessment for the lungs due to hyperinflation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2151-03-04 00:00:00.000",
"description": "Report",
"row_id": 86056,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Left ventricular function. Right ventricular function.\nStatus: Inpatient\nDate/Time: at 15:11\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n57 years old man for L thoracotomy and pneumonectomy. Mild RV free wall\nhypokinesia with trace TR. TDI of tricuspid annulus MPI 1.4 on three readings.\nMPI stayed 1.2 after two lung ventilation on left lateral position. MPI\ndropped to 1.1 on one lung ventilation after 5 minutes, 10 minutes. The MPI\nstayed 0.9 to 1.0 after pnemonectomy.\nLV function normal with cardiac output of 4.5-5l/min.\nLEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the\nLAA. All four pulmonary veins identified and enter the left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Low normal LVEF. Transmitral Doppler E>A and TDI E/e' <8 suggesting\nnormal diastolic function, and normal LV filling pressure (PCWP<12mmHg).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Moderate global RV free wall hypokinesis.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope.\n\nConclusions:\nThe left atrium is mildly dilated. No spontaneous echo contrast is seen in the\nleft atrial appendage. No atrial septal defect is seen by 2D or color Doppler.\nOverall left ventricular systolic function is low normal (LVEF 50-55%).\nTransmitral and tissue Doppler imaging suggests normal diastolic function, and\na normal left ventricular filling pressure (PCWP<12mmHg). with moderate global\nfree wall hypokinesis. The ascending, transverse and descending thoracic aorta\nare normal in diameter and free of atherosclerotic plaque . The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-04 00:00:00.000",
"description": "Report",
"row_id": 1635634,
"text": "nursing admit/progress note\n\npt is a 57 yo male w/ recent diagnosis of squamous cell CA of L lung, found in . pt is s/p chemotx treatment, admitted today to TSICU after L thoracotomy, pneumonectomy. intraop course uneventful, minimal blood loss noted. pt to ICU for observation extubated, on supplemental o2 w/ epidural catheter in place at T7-8.\n\nsee h+p for full medical hx and meds.\n\nneuro: initially sleepy post op, clearing over afternoon, pain initially not well controlled, epidural infusion increased slowly after bolus dosing as per APS. pain improved at rate 12cc/h 0.1% bupiv&dilaudid. due to signif. hypotension w/ drip, changed to 0.05% bupivicaine w/ same effect to bp only not quite as much so. pt currently comfortable w/ rate 6cc/h. true dermatome level around T7.\n\nresp: weaned to 4L nc o2, ls clear to R, dimin to L. L chest tube to h2o seal w/ bloody drainage for shift. no crepitus, no air leak. denies sob/distress.\n\ncv: as above, hypotensive w/ epidural infusion, per thoracics, to continue for pain control, using phenylephrine drip to maintain sbp>90. extrem warm, pulses intact. sinus brady to nsr, no ectope noted. lytes, hct stable post op.\n\ngi: npo, taking ice chips. belly soft/nt/nd. bs present. denies nausea.\n\ngu: foley patent clear yellow urine, qs.\n\nendo: glucose levels stable.\n\nid: afebrile, wbc 9.9 post op. ancef dosing x3 days post op.\n\nskin: L thoracotomy incision c/d/approximated, dermabond glue to entire line, OTA.\n\nsocial: pt's son and daughter in to visit, very supportive. son is HCP.\n\na/p: 57 yo male s/p L thoracotomy, pneumonectomy. doing well, pain well controlled w/ epidural. hypotensive w/ infusion, neo dose maintaining goal sbp as per thoracics. breathing unlabored, cough and deep breathing improving. plan for epidural overnight, wean neo as tol. follow chest tube output, hemodynamics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-05 00:00:00.000",
"description": "Report",
"row_id": 1635636,
"text": "nursing progress note\n\nneuro: a+ox3, mae. epidural in place for pain control w/ 0.5% bupiv&dilaudid effective. pt rates pain for shift when moving, zero when at rest. true dermatome level approx T6-T9 level. attempted to sit on edge of bed today w/ pt becoming very dizzy/lightheaded and hypotensive. unable to stand to get into chair.\n\nresp: ls mildly coarse to upper fields this morning, clearing well this pm w/ i/s usage and pulm exercise. weaned fio2 to 2l nc w/out incident. L chest tube clamped this am by thoracics, plan to d/c this pm.\n\ncv: as above, remains hypotensive w/ epidural infusion. thoracics and ICU teams aware. cont to require neo drip to maintain goal sbp >90. titrated to effect as ordered, rotating peripheral infusion sites per protocol. extrem warm, pulses intact, no edema. (-) fluid balance for day, given fluid bolus x1 this am w/ little effect and albumin bolus this pm x1. will monitor and titrate neo as able. lytes repleted this am, wnl this pm. a line positional, waveform at times dampened. following trend w/ correlating nibp.\n\ngi: ngt placed for post op gastric distention on cxr, sm amts bilious output draining. pt denies nausea, bs present x4 quads. belly soft/nt/nd. remains strictly npo.\n\ngu: autodiuresis slowing throughout morning, hourly output 30-80cc this pm. foley patent for clear yellow, qs.\n\nendo: glucose levels stable.\n\nid: tmax 99.4, ancef dosing x2 more doses per orders. wbc stable this am.\n\nskin: thoracotomy approach incision c/d/i, dermabond glue remains intact, area OTA. small anterior neck incision from pre op bx healing well, dermabond glue intact to area as well.\n\nsocial: many family in for visits today, very supportive. son in this aft, updates provided.\n\na/p: remains hypotensive d/t epidural infusion, orthostatic with any movement. pain very well controlled. doing well w/ pulm toileting, using i/s well. albumin dosing for this afternoon, will follow bp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-06 00:00:00.000",
"description": "Report",
"row_id": 1635637,
"text": "TSICU NPN 7p-7a\nEvents of the shift: Pt con't neo dependent attempts to wean unsucessful, Pt went into rapid afib w/ rate 150's at 3am, had received lopressor 5mg w/ no effect, followed by esmolol bolus by Dr. and ultimately Diltiazam bolus w/ decreased HR into the 80's, still afib initially then converted to SR yet still with frequent APC's, neo requirement increased back up during this time, one fluid bolus of 250cc's as well. Now on Dilt gtt as well.\n\nCurrent ROS\n\n pt alert and oriented even w/ low BP w/ afib. Con't on epidural of bupivicaine and dilaudid, rate decreased to 3cc's hr w/ hypotension and rhythm issues. Pt still rates pain at 2-3 on scale of with activity yet no pain at rest. Pt still c/o dizziness at times so unable to mobilize from bed, epidural level to mid sternum.\n\nCV- rapid afib as above w/ rates up to 150's, BP as low as 68/45, neo titrated up as high as 1.5mcg/kg/min and dilt gtt started after bolus as above, please see flow sheet for exact pressures. One fluid bolus of 250cc's NS given as well for hypotension. Lytes wnl's, hct stable, pt 1200cc's negative for the day yesterday, weight 68.8kg.\n\n pt on 2 l NP w/ RR 14-20 non labored, sats 95-98%, pt cough more congested this AM, CHXray pnd. Con't to do IS up to 750cc's, denies any SOB. Breath sounds absent on left and clear on right with slight crackles at right base towards the AM.\n\nGI- NGT advanced by HO, abd soft non distended, NGT draining small amts green bilious output. Pt denies nausea.\n\n pt con't w/ brisk u/o .\n\n pt receiving last dose of Kefzol this AM, T max 99.8 PO.\n\nEndo- blood sugar wnl's, no sliding scale.\n\nSkin- left incision intact w/ durabond, superior midsternal incision intact w/ durabond as well.\n\nA/ pt w/ post-op arrythmias , BP further compromised by Afib, rate responding to dilt yet thoracic team requests switch to amiodarone this AM. Lung sounds slightly more congested this AM, still doing IS well, good pain control even with decreased epidural rate. Con't to wean neo as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-06 00:00:00.000",
"description": "Report",
"row_id": 1635638,
"text": "0700-1900\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nEVENTS: AMIODARONE DRIP COMMENCED.\n NEO WEANED TO OFF.\n OOB TO CHAIR X2.\n NGT REMOVED.\n\nNEURO: A&O X3. MAE WELL.\n\nCV: AMIODARONE LOADING DOSE 150MG IV GIVEN. NOW ON AMIOFARONE REGIMEN. CURRENTLY @ 0.5MG/HR FOR 18HRS COMMENCED @ 1415HRS. MAINLY IN SR 70-80'S WITH PAC'S OCCASIONAL RATE CONTROLLED AFIB. NEO WEANED FROM 1.0MCG/KG/MIN TO OFF. GOAL SBP >90. CURRENTLY BORDERLINE SBP 86-92. WAS ON 0.4MCGS PRIOR TO SWITCHING OFF. DRIP STILL ATTACHED IF NEEDED.\n\nRESP: 02 SATS >99% ON 2L NC. COUGHING UP CLEAR/WHITE WITH OCCASIONAL BLOOD TINGED SPUTUM. LS CLEAR/COARSE ON R. ABSENT ON L. RR WNL.\n\nGI: NGT REMOVED THIS AM. ICE CHIPS AND PO MEDS TOLERATED WELL. COMMENCED ON BOWEL REGIMEN. HYPOACTIVE BOWEL SOUNDS. NO GAS PER PT REPORT. ABDOMEN SOFT NON TENDER.\n\nGU: FOLEY DRAINING CLEAR AMBER URINE 30-50ML/HR. CURRENTLY EVEN BALANCE.\n\nSKIN: THORACOTOMY INCISION CLEAN, DRY AND INTACT. OPEN TO AIR. EPIDURAL SITE REDRESSED AT THE EDGES AS DRESSING ROLLING UP. APS TO REMOVE EPIDURAL IN AM. PLEASE HOLD AM HEPARIN PER APS TEAM. REMIANING SKIN INTACT.\n\nSOCIAL: DAUGHTER TELEPHONED AND VISITED AND UPDATED ON PT CONDITION AND CURRENT PLANNED CARE.\n\nPLAN: WEAN NEO TO OFF WHILST MAINTAININS SBP >90.\n CONTINUE AMIODARONE DRIP FOR DURATION.\n ENSURE PT COMFORT AND SAFETY.\n HOLS AM HEPARIN PER APS FOR EPIDURAL REMOVAL IN AM.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-05 00:00:00.000",
"description": "Report",
"row_id": 1635635,
"text": "Nursing Progress Note\nSee Carevue for Specific Data.\n\nSignificant Events: Epidural increased to 9cc/hr d/t increased pain at incision site. BP dropped to 80's systolic 1-2 times during early evening, neo was down to .2mcg/kg/min, had to be increased to .6mcg/kg/min to maintain adequate BP.\n\nNeuro: Pt alert and oriented x3, follows commands, communicates effectively.\n\nPain: Pt has epidural, WNL, level checked with ice at T6 (xyphoid to hips). Pt still c/o pain overnight, rate increased to 9cc/hr. Pt requiring neo d/t epidural (as described by RN/team giving report to this RN).\n\nCV: NSR, HR 90-110, no ectopy, ABP goal >90's, maintained by neo-currently .6mg/kg/min. Easily palpable pedal pulses, heparin sc, Pboots on.\n\nResp: Right lung sounds clear throughout, no adventitious sounds. 4L nc, maintaining sats >96%. weak nonproductive cough. CT to H2O seal, +fluctuation/+leak/+crepitous. Dsg d & i, drainage to CT is serosanguinous. Incision d & i, no drainage, approximated with dermabond.\n\nGI: Abdomen soft, not distended, +BS, -BM since Tuesday according to pt. NPO, goal to keep pt dry. Maintenance fluid: LR 10cc/hr.\n\nGU: Pt autodiuresing->100cc/hr clear, light yellow urine through foley.\n\nEndo: No insulin administered, checking BS qid.\n\nID: Tmax 100.4, continues on cefazolin.\n\nSkin: Incision intact, approximated with dermabond, no drainage. back intact. Pt turning onto right side only.\n\nSocial: Son, daughter-in-law, and brother in to visit in evening, very supportive, joking with pt, appropriate. No calls overnight.\n\nPlan: ?Change epidural to PCA so pt can regulate pain management more effectively? Wean off neo as tolerated. Encourage IS/coughing/deep breathing. Transfer to floor when off neo.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-07 00:00:00.000",
"description": "Report",
"row_id": 1635639,
"text": "Nursing Progress Note, 1900-0730\nPlease refer careview for specifics.\n\nSHIFT EVENTS: Pt went into rapid Afib with HR in the 160s with significant decrease in BP- 70/30s. Pt given 150mg bolus of amio with no effect in rate control, followed by 10mg diltiazem ivp. Pt given second 150mg amio bolus 3 hours later with return to SR. Amio gtt continues at 1mg/min. Pt remains on sm amt of neo despite attempts to wean off.\n\nPt SV on 2L NC, sats 97-100%, LS clear to coarse in upper R lobe and RLL diminished. Productive cough noted, able to expectorate secretions. Denies SOB. Pt in SR at beginning of shift and converted into rapid Afib w/ HR 130-160s at 1045, pt bolused with 150mg amio twice and given 10mg diltiazem ivp whereupon pt converted back into SR. Pt conts on amio gtt at 1mg/min x6 hrs. HR 70-80, SBP 77-110, neo infusing at 0.4mcg/kg/min- attempted to wean off mult times, however pts BP cont to be labile. Afebrile, no anbx coverage at this time. PIV x2 for access. L radial aline dampened, positional, & difficult to draw blood off of. 4 AM SC heparin held for removal of epidural, heparin to be changed to lovenox later today. Pt alert and oriented x3, no neuro deficits noted, OOB to chair with one assist, gait steady. Epidural at level T7/8 w/ dilaudid & bupivicane infusing at 3cc/hr, pt c/o minimal discomfort. Plan to d/c epidural today and start dilaudid PCA for pain control. Abd soft, + BS, no BM, on bowel regimen, NPO- tol ice chips/PO meds well. Foley patent, draining adequate amts of c/y/u- uop 30-50cc/hr. Lytes pnding.\n\nSOCIAL: Son and daughter into visit pt last night, will be in later today. Family updated as to pts POC and status.\n\nPOC: Wean supplemental O2, encourage CDB & use of IS, hemodynamics, titrate neo to maintain MAP >60, cont to manage Afib/Aflutter with amio gtt at 1mg/min x6 hrs, followed by 0.5mg/min x18 hrs. D/c epidural today, ? start po diet today if ok by thoracics, cont to provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2151-03-07 00:00:00.000",
"description": "Report",
"row_id": 1635640,
"text": "0700-1900\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nEVENTS: EPIDURAL REMOVED.\n NEO WEANED OFF BY 11AM.\n CLEAR LIQUID DIET COMMENCED.\n BOWELS MOVED.\n FOLEY REMOVED.\n REMAINED IN SR ALL SHIFT.\n LYTES REPLETED.\n\nNEURO: A&O X3. NO NEUROLOGICAL DEFICITS.\n\nRESP: COUGHING ALL DAY WITH SOME SPUTUM PRODUCTION. NC 02 REMAINS BUT CAN BE WEANED OFF PER THORACICS. CXR DONE THIS AM. REMAINING R LUNG CLEAR. NO C/O PAIN SINCE EPIDURAL REMOVAL.\n\nCV: REMAINED IN SR 80'S ALL SHIFT. AMIODARONE DRIP DUE FOR COMPLETION @ 2300HRS. SBP MAINTAINED >90 AND MEAN >60 OFF NEO SINCE 1100HRS.\n\nGI: + BOWEL SOUNDS. BOWELS MOVED X 1 SMALL CONSTIPATED. ++ FLATUS PASSED. COMMENCED ON CLEAR LIQUIDS PER THORACICS THIS PM.\n\nGU: U/O ADEQUATE. FOLEY REMOVED @ 1600HRS AND PT HAS VOIDED SINCE REMOVAL.\n\nSKIN: THORACOTOMY INCISION CLEAN AND DRY. CHEST DRAIN DRESSING LEFT INTACT. NO SEEPAGE. REMAINING SKIN INTACT. NO C/O OF PAIN.\n\nSOCIAL: ++ FAMILY AND FRIENDS INTO VISIT PT. ALL APPROPRIATE AND RESPECTFUL OF PT NEEDING REST.\n\nPLAN: WEAN 02 TO OFF.\n COMPLETE AMIODARONE DRIP REGIMEN AND CONVERT TO PO DOSE.\n TX TO FLOOR WITH TELEMETRY ON COMPLETION OF AMIODARONE DRIP.\n ENSURE PT COMFORT AND SAFETY.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2151-03-08 00:00:00.000",
"description": "Report",
"row_id": 217882,
"text": "Atrial flutter with rapid ventricular response. Left ventricular hypertrophy\nby voltage. Non-specific ST-T wave changes. Since the previous tracing\nearlier the same date atrial flutter is present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2151-03-08 00:00:00.000",
"description": "Report",
"row_id": 217883,
"text": "Rhythm may be initially atrial flutter followed by sinus rhythm. Consider\nleft ventricular hypertrophy by voltage. The QTc interval appears prolonged\nbut it is difficult to measure. ST-T wave changes. Findings are non-specific.\nClinical correlation is suggested. Since the previous tracing of \natrial fibrillation is absent, T wave changes are seen and the QTc interval\nappears longer.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2151-03-06 00:00:00.000",
"description": "Report",
"row_id": 217884,
"text": "Atrial fibrillation versus atrial flutter with a variable block. Left\nventricular hypertrophy. Compared to the previous tracing the rate is slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2151-03-06 00:00:00.000",
"description": "Report",
"row_id": 217885,
"text": "Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy. Compared to the previous tracing rapid atrial fibrillation is\nnew.\nTRACING #1\n\n"
}
] |
98,089 | 179,750 | 75 year old man with colon cancer s/p hemicolectomy and s/p bilateral ureteral stent placement initially admitted to the for UGIB in setting of constipation and hematuria. Was transferred to the floor once hemodynamically stable. UGIB resolved, but constipation persisted. After an extensive workup, was found to have a partial LBO likely secondary to malignancy. . #1. Partial LBO: The patient reported chronic constipation (BM q 7 days) worsening over the prior 3 weeks. Had + flatus, but passing only very small stools. KUB was suggestive of obstruction. Flex sig and colonoscopy were initially attempted but failed to pass beyond 20 cm with poor visualization due to stool. The patient did not tolerate NGT decompression. A PET/CT showed dilated loops of small and large bowel with no VDG avid foci. A second attempt at colonoscopy showed an obstruction at approximately 30 cm beyond which the scope could not pass. Gastrografin enemas were refused by the patient. MR d marked small and large bowel dilation with a transition point at the colosigmoid junction. This is likely due to external compression from metastatic disease. Clinically, the patient's abdomen remains distended and tympanic, but soft and nontender. He continues to have flatus and very small, liquid stools. There is no abdominal pain and no nausea/vomiting. He was placed on TPN for persistent poor PO intake. He was taken to the OR on for palliative ileostomy. . #2. UGIB: The patient initially presented with coffee grounds emesis in setting of constipation. Etiology of UGIB thought to be likely tear from repeated emesis. NG tube was placed to suction with Gastroccult positive. Stable hemodynamically during stay. The patient has not had a dramatic drop in Hct. Remained HD stable during stay without current evidence of active bleed. GI consulted performed EGD showing food in the esophagus without evidence of active bleed. Hct was trended upwards and the patient was maintained on PPIs. . #3. UTI/Hematuria: Likely related to Foley and recent stent placement. Was treated as complicated UTI for 7 days with Ciprofloxacin per Urology. Course has been completed. Blood and urine cultures were negative. Foley has since been D/Ced and there is no evidence of UTI. The patient is urinary incontinent. . #4. Ureteral obstruction/s/p stent placement: The patient's creatinine has improved, max 2.5, down to 1.2 currently, since placement of bilateral stents and passing adequate UOP. Post void residuals have been <200. Per Urology recs, if >200, should give prophylactic antibiotics. . #5. s/p CVA: The patient was kept on Aggrenox. It was held on in anticipation of surgical intervention. . #6. HTN: Lisinopril was held in the setting of normal BPs. . #7. Hyperlipidemia: Statin was discontinued on in the setting of LBO. . #8.8 Diabetes: Diet controlled at home. Had FS QID and Insulin Sliding Scale. . #9. h/o prostate cancer: The patient was continued on his home dose of Flomax. He has been urinary incontinent. . #10. Depression: the patient was continued on his home does of SSRIs. . PPx: Pneumoboots, Heparin SC CODE: DNR/DNI EMERGENCY CONTACT: Wife Surgery: Patient continue to have symptoms of partial small bowel obstruction, poor food tolerance, abdominal distension and pain. He had A MRI that showed extensive dilated loops of small bowel and colon with apparent transition deep in the pelvis at distal colon. The decision was made to take him to the operating room. On for exploratory laparotomy, we founded a copious amount of clear ascitic fluid in the abdominal cavity. Palpation of the abdomen revealed carcinomatosis studding the mesentery, the small bowel, the residual large bowel and the liver. There was a loop of small bowel in the right lower quadrant that was solidly adherent to the retroperitoneum. He had a loop ileostomy in order to try to decrease acute symptoms of bowel obstruction. The patient was admitted to the General Surgical Service for evaluation and treatment. After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids and antibiotics, with a Foley catheter. The patient was hemodynamically stable. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropiate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Palliative care was consulted, they had an extensive meeting with patient and family. They both understand the goals of care are palliative and comfort oriented, patient and family decided they would like to have hospice involvement. Ostomy nurse service was consulted, they worked extensively on Ostomy care teaching and management. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. Patient was discharge to hospice for pain management and comfort. Medications on Admission: lipitor 10mg PO daily Flomax 0.4mg PO daily Keflex 500mg PO TID since Tylenol #3 prn Lisinopril 10mg PO daily Effexor XR 37.5mg PO daily Cipro 250mg PO daily? wife denies 100mg PO TID Mag citrate OFF AGGRENOX x 1 week . Medications on Transfer: Bisacodyl PR Pantoprazole 40mg IV Q12H Cephalexin 500mg Q8H (day 6) Zofran PRN Insulin SS Ciprofloxacin 400mg IV Q12H (day 2) 100mg Venlafaxine 37.5mg QD Tylenol PRN Atorvastatin 10mg QD Discharge Medications: 1. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:*85 Tablet(s)* Refills:*0* 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 2 weeks. 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 8. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 10. Insulin Sliding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 1 Units 1 Units 1 Units 1 Units 201-250 mg/dL 2 Units 2 Units 2 Units 2 Units 251-300 mg/dL 3 Units 3 Units 3 Units 3 Units 301-350 mg/dL 4 Units 4 Units 4 Units 4 Units 351-400 mg/dL 5 Units 5 Units 5 Units 5 Units 11. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* 12. Morphine 20 mg/5 mL Solution Sig: 5mg PO every four (4) hours as needed for Severe pain or breathlessness: Comfort care. Disp:*30 ml* Refills:*0* 13. Lorazepam 2 mg/mL Concentrate Sig: One (1) PO every six (6) hours as needed for anxiety or agitation: Comfort care. Disp:*30 ml* Refills:*0* 14. Atropine 1 % Drops Sig: Two (2) drops Ophthalmic every four (4) hours as needed for secretions: S/L Comfort Care. Disp:*5 ml* Refills:*0* Discharge Disposition: Extended Care Facility: Hospice at Discharge Diagnosis: Partial Large Bowel Obstruction Discharge Condition: Mental Status:Confused - sometimes Level of Consciousness:Lethargic but arousable Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Monitoring Ostomy output/Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Appointment #1 MD: Dr. Specialty: Surgery Please schedule an appointment in 2 week. ( Appointment #2 MD: Dr Specialty: Urology Date/ Time: at 3:45pm Location: , bldg, Phone number: Appointment #3 MD: Dr Specialty: Primary Care Date/ Time: at 10am Location: , Phone number: MD, Completed by:[**2201-2-25** | HTN: Hold antihypertensives in setting of GIB #. HTN: Hold antihypertensives in setting of GIB #. HTN: Hold antihypertensives in setting of GIB #. HTN: Hold antihypertensives in setting of GIB #. - continue PPI drip for now, change to dosing in am - maintain PIVs x 2 - monitor HCT q8, next HCT likely to be lower since has received IVF but transfuse for HCT <27 or active bleed - maintain NPO with IVF - appreciate GI recommendations, possible EGD in am - guaiac all stool - continue NGT to wall suction - NS bolus x 1 L now #. - continue PPI drip for now, change to dosing in am - maintain PIVs x 2 - monitor HCT q8, next HCT likely to be lower since has received IVF but transfuse for HCT <27 or active bleed - maintain NPO with IVF - appreciate GI recommendations, possible EGD in am - guaiac all stool - continue NGT to wall suction - NS bolus x 1 L now #. - continue PPI drip for now, change to dosing in am - maintain PIVs x 2 - monitor HCT q8, next HCT likely to be lower since has received IVF but transfuse for HCT <27 or active bleed - maintain NPO with IVF - appreciate GI recommendations, possible EGD in am - guaiac all stool - continue NGT to wall suction - NS bolus x 1 L now #. WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? Hematuria: Likely related to foley and recent stent placement - appreciate urology recommendations who will see in am # ?UTI: Patient has foley catheter in place and positive UA although is asymptomatic other than urinary urgency related to foley catheter. Hematuria: Likely related to foley and recent stent placement - appreciate urology recommendations who will see in am # ?UTI: Patient has foley catheter in place and positive UA although is asymptomatic other than urinary urgency related to foley catheter. HTN: Hold antihypertensives in setting of GIB #. Action: Pt medicated again with dulcolax suppose. Action: Pt medicated again with dulcolax suppose. Right hemicolectomy changes. FINDINGS: Right hemicolectomy changes are noted. Hematemesis (upper GI bleed, UGIB) Assessment: Action: Response: Plan: Constipation (Obstipation, FOS) Assessment: Action: Response: Plan: There is no (Over) 2:08 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval for obstruction FINAL REPORT (Cont) point of transition seen. WBC mildly elevated which may be related to UTI - cipro for now as below - follow up urine cx - continue keflex, ? Bilateral ureteral obstruction s/p b/l stent placement ; unclear etiology of obstruction per review of notes 3. Interval placement of bilateral ureteral stents with resolution of previously noted hydronephrosis. UTI hematuria, possibly related to recent stent placement. He received 1LNS, pantoprazole, levofloxacin, flagyl and Zofran. - continue PPI drip for now, change to dosing in am - maintain PIVs x 2 - monitor HCT q8, next HCT likely to be lower since has received IVF but transfuse for HCT <27 or active bleed - maintain NPO with IVF - appreciate GI recommendations, possible EGD in am - guaiac all stool - continue NGT to wall suction - NS bolus x 1 L now #. FINDINGS: The left-sided PICC line has been removed in the interim. Received protonix iv,flagyl and started with protonix drip and transffered to for further management. Received protonix iv,flagyl and started with protonix drip and transffered to for further management. Received protonix iv,flagyl and started with protonix drip and transffered to for further management. Received protonix iv,flagyl and started with protonix drip and transffered to for further management. for stent placement, will d/w urology #. Hematuria: Likely related to foley and recent stent placement - appreciate urology recommendations who will see in am # ?UTI: Patient has foley catheter in place and positive UA although is asymptomatic other than urinary urgency related to foley catheter. | 22 | [
{
"category": "Physician ",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 514705,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Tap Water enema that he did not retain\n - Bisacodyl suppository without effect\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:11 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.1\n HR: 79 (68 - 86) bpm\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 95%\n Total In:\n 1,702 mL\n 613 mL\n PO:\n TF:\n IVF:\n 1,702 mL\n 613 mL\n Blood products:\n Total out:\n 250 mL\n 670 mL\n Urine:\n 250 mL\n 520 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.4 g/dL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n HEMATEMESIS (UPPER GI BLEED, UGIB)\n CONSTIPATION (OBSTIPATION, FOS)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 514707,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Tap Water enema that he did not retain\n - Bisacodyl suppository without effect\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:11 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.1\n HR: 79 (68 - 86) bpm\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 95%\n Total In:\n 1,702 mL\n 613 mL\n PO:\n TF:\n IVF:\n 1,702 mL\n 613 mL\n Blood products:\n Total out:\n 250 mL\n 670 mL\n Urine:\n 250 mL\n 520 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 226 K/uL\n 10.4 g/dL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 75 year old man with colon cancer s/p hemicolectomy and s/p\n bilateral ureteral stent placement now admitted to with UGIB in\n setting of constipation and hematuria\n #. UGIB: Patient presented with coffee grounds emesis in setting of\n constipation. Differential diagnosis includes gastritis, \n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\n prior history of varices or liver disease. He is guaiac negative from\n below and has been constipated which would be atypical for brisk GIB\n especially given still passing flatus and no clear obstruction on CT\n scan. Most likely scenario would be constipation leading to nausea and\n vomiting and possible tear related to emesis. Remains HD\n stable without current evidence of active bleed and HCT as well as BUN\n are currently improved from baseline. He denies recent NSAID or steroid\n use that would increase risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, possible EGD in am\n - guaiac all stool\n - continue NGT to wall suction\n - NS bolus x 1 L now\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n PPX:\n -DVT ppx with pneumoboots in setting of GIB\n -Bowel regimen with enemas, home regimen\n -Pain management with tylenol\n ACCESS: PIV's\n .\n CODE STATUS: DNR/DNI\n .\n EMERGENCY CONTACT: Wife \n .\n DISPOSITION: ICU for now, likely call out if stable in am\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 514811,
"text": "Chief Complaint: 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 24 Hour Events:\n Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. This BM was hard\n but brown and not black or tarry. Has continued to pass flatus. Denies\n abdominal pain, melena, hematochezia, chest pain, SOB, fever, chills,\n lightheadedness, decreased PO intake, NSAID or steroid use. His wife\n called ambulance to take him to ED for weakness and consripation and he\n had coffee grounds emesis x 2 in ambulance and subsequently in ED. He\n also reprots hematuria since stents and foley placed 4 days prior.\n Denies any prior h/o GIB or similar symptoms.\n .\n In the emergency department, initial vitals were: 97.8 91 142/79 16\n 98%RA. NG lavage was positive for hemoccult positive coffee grounds\n which did not clear after 1L. He was guaiac negative but was noted to\n have abdominal tenderness so CT abdomen/pelvis was obtained and\n revealed distended small and large bowel with air fluid levels\n suggestive of gastroenteritis. GI and Surgery evaluated patient and\n recommended decompressing from above with NGT and enemas from below but\n no urgent indication for scope since HD stable. UA was positive and\n blood cx x 2 were drawn. He received 1LNS, pantoprazole, levofloxacin,\n flagyl and Zofran. Labs significant for HCT 34 from baseline 32 and Cr\n 1.7 from baseline 2.0.\n .\n Vitals prior to transfer were: 77 131/78 16 95%RA\n Passed brown stool overnight.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 07:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\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: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 84 (68 - 95) bpm\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\n RR: 19 (12 - 24) insp/min\n SpO2: 98%\n Total In:\n 1,702 mL\n 1,003 mL\n PO:\n 180 mL\n TF:\n IVF:\n 1,702 mL\n 823 mL\n Blood products:\n Total out:\n 250 mL\n 870 mL\n Urine:\n 250 mL\n 720 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.4 g/dL\n 226 K/uL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\n stent placement, now admitted to with UGIB.\n GI BLEED -- with coffee grounds emesis concern for .\n in setting of constipation. Differential diagnosis includes gastritis,\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have\n varices given no prior history of varices or liver disease. He is\n guaiac negative from below and has been constipated which would be\n atypical for brisk GIB especially given still passing flatus and no\n clear obstruction on CT scan. Most likely scenario would be\n constipation leading to nausea and vomiting and possible \n tear related to emesis. Remains HD stable without current evidence of\n active bleed and HCT as well as BUN are currently improved from\n baseline. He denies recent NSAID or steroid use that would increase\n risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, possible EGD in am\n - guaiac all stool\n - continue NGT to wall suction\n - NS bolus x 1 L now\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "General",
"chartdate": "2201-02-03 00:00:00.000",
"description": "Generic Note",
"row_id": 514600,
"text": "MICU ATTENDING ADM ISSION 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 Dr\n \ns note above, including the assessment and plan. I would\n emphasize and add the following points:\n Mr was recently admitted to the for evaluation of bilateral\n hydro-uretero-nephrosis of unclear etiology. He had placement of\n bilateral stents and was discharged home with an indwelling foley and\n PO antibiotics. He now presents with weakness, coffee ground emesis and\n hematuria. He denies abdominal pain but does admit to significant\n thirst. He has not had a syncopal event or fevers.\n His PMH is notable for a right hemicoleectomy with R/A by Dr in\n for Stage 3B colon Cancer. He had a pelvic nodule excised at the\n time of laparotomy which revealed fat necrosis. He has also had a prior\n CVA and CRI ( with creatinine close to 2.0) in the past. His recent Hct\n on D/C was 28. His CEA has been rising.\n Exam notable for Tm of 98, BP of 142/80 HR of 90 RR of 16 with sats of\n 98% on RA . He has significantly diminished skin turgor and coffee\n grounds on NG lavage. He has clear lung fields and a soft belly. His\n foley catheter is draining dark urine.\n Labs notable for WBC 11.8K, HCT of 24 ( 28) , K+ of 4.7, Cr of 1.7 (\n 2.0) , lactate of 1.4. CXR with elevated left hemidiaphragm and\n distended loops of bowel without free air. His Abd CT shows air fluid\n levels in colon and extensive fecal material in colon. There does not\n appear to be migration of stents either.\n He is severely volume deplete and made worse with his h/o chronic\n constipation. He has likely had an UGI bleed ( gastritis vs esophagitis\n vs M-W tear) but is hemodynamically stable with no concerns regarding\n ongoing active bleeding. He does not appear septic either but we will\n need to monitor closely for this. He has received 1 L NS thus far in\n addition to IV PPI and antibiotics. He will need continued fluid\n rescucitation and decompression of colon with enemas to allow for\n improvement of colonic/ small bowel distension/ emesis. GI staff to see\n in am regarding need for EGD. Appreciate surgical and urology input. If\n there are no hemodynamic issues overnight, he will leave the ICU in am\n . Oncology staff to provide further advise regarding concerns\n for rising CEA and possibly recurrent/ metastatic colon Ca once acute\n issues have resolved.\n Remainder of plan as outlined above.\n Patient is chronically ill\n Total time: 50 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n"
},
{
"category": "Physician ",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 514756,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Tap Water enema that he did not retain\n - Bisacodyl suppository without effect\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:11 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.3\nC (99.1\n HR: 79 (68 - 86) bpm\n BP: 122/92(97) {122/67(84) - 157/92(103)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 95%\n Total In:\n 1,702 mL\n 613 mL\n PO:\n TF:\n IVF:\n 1,702 mL\n 613 mL\n Blood products:\n Total out:\n 250 mL\n 670 mL\n Urine:\n 250 mL\n 520 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n -58 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///25/\n Physical Examination\n GENERAL: Pleasant, well appearing elderly gentleman in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. Dry MM. OP clear with dried blood in posterior\n OP. NGT in place with gastroccult positive coffee grounds material in\n canister.\n Neck: Supple, No LAD, No thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur heard best RUSB. No rubs or . JVP=7-8cm\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Distended abdomen. Well healed midline scar. Hyperactive BS.\n Palpable peristalsis. TTP with involuntary guarding LLQ. No rebound or\n HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses. Scar R knee\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Speech slow and deliberate. Initially reported was in\n but later reoriented to in , MA. Oriented\n to self and wife and able to relate her phone number. Oriented to month\n and year but not date. Appropriate. CN 2-12 intact. 5/5 strength\n throughout. + reflexes, equal BL. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n 226 K/uL\n 10.4 g/dL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 75 year old man with colon cancer s/p hemicolectomy and s/p\n bilateral ureteral stent placement now admitted to with UGIB in\n setting of constipation and hematuria\n #. UGIB: Patient presented with coffee grounds emesis in setting of\n constipation. Differential diagnosis includes gastritis, \n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\n prior history of varices or liver disease. He is guaiac negative from\n below and has been constipated which would be atypical for brisk GIB\n especially given still passing flatus and no clear obstruction on CT\n scan. Most likely scenario would be constipation leading to nausea and\n vomiting and possible tear related to emesis. Remains HD\n stable without current evidence of active bleed and HCT as well as BUN\n are currently improved from baseline. He denies recent NSAID or steroid\n use that would increase risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, EGD in several days\n - guaiac all stool\n - continue NGT to wall suction\n .\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n PPX:\n -DVT ppx with pneumoboots in setting of GIB\n -Bowel regimen with enemas, home regimen\n -Pain management with tylenol\n ACCESS: PIV's\n .\n CODE STATUS: DNR/DNI\n .\n EMERGENCY CONTACT: Wife \n .\n DISPOSITION: ICU for now, likely call out if stable HCT at Noon\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 514743,
"text": "Chief Complaint: 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 24 Hour Events:\n Passed brown stool overnight.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 07:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\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: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 84 (68 - 95) bpm\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\n RR: 19 (12 - 24) insp/min\n SpO2: 98%\n Total In:\n 1,702 mL\n 1,003 mL\n PO:\n 180 mL\n TF:\n IVF:\n 1,702 mL\n 823 mL\n Blood products:\n Total out:\n 250 mL\n 870 mL\n Urine:\n 250 mL\n 720 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.4 g/dL\n 226 K/uL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\n stent placement, now admitted to with UGIB.\n GI BLEED -- with coffee grounds emesis concern for .\n in setting of constipation. Differential diagnosis includes gastritis,\n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have\n varices given no prior history of varices or liver disease. He is\n guaiac negative from below and has been constipated which would be\n atypical for brisk GIB especially given still passing flatus and no\n clear obstruction on CT scan. Most likely scenario would be\n constipation leading to nausea and vomiting and possible \n tear related to emesis. Remains HD stable without current evidence of\n active bleed and HCT as well as BUN are currently improved from\n baseline. He denies recent NSAID or steroid use that would increase\n risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, possible EGD in am\n - guaiac all stool\n - continue NGT to wall suction\n - NS bolus x 1 L now\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 514627,
"text": "Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 514667,
"text": "Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt c/o nausea and vomitted once watery mixed with coffee ground\n particles early am. denies any pain,abd firm,BS hypoactive.\n Action:\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 514671,
"text": "Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt c/o nausea and vomitted once watery mixed with coffee ground\n particles early am. denies any pain,abd firm,BS hypoactive. Foley to\n gravity, bloody urine initially,but more clear later on.\n Action:\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\n Response:\n Crit drop from 41 to 29 with am labs. VSS. No further vomiting or\n .\n Plan:\n f/u with am labs and monitor further .\n Constipation (Obstipation, FOS)\n Assessment:\n Pt without BM for last ~ 10 days. Abd firm,BS hypo, NGT tube in place,\n connected to LWIS .\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 514673,
"text": "Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt c/o nausea and vomitted once watery mixed with coffee ground\n particles early am. denies any pain,abd firm,BS hypoactive. Foley to\n gravity, bloody urine initially,but more clear later on.\n Action:\n NPO except ice chips and meds. Zofran 4mg iv given . am labs drawn .\n Response:\n Crit drop from 41 to 29 with am labs. VSS. No further vomiting or\n .\n Plan:\n f/u with am labs and monitor further .\n Constipation (Obstipation, FOS)\n Assessment:\n Pt without BM for last ~ 10 days. Abd firm,BS hypo, NGT tube in place,\n connected to LWIS .\n Action:\n Tried for tap water enema ,but not retained. Bisacodyl PR given . NPO\n except meds and ice chips. On docusate .\n Response:\n Pt stayed on bedpan for long time, but No BM yet.\n Plan:\n need another dose of PR medication or any strong bowel regimen\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 514664,
"text": "Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 514874,
"text": "Chief Complaint: 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 24 Hour Events:\n Passed brown stool overnight.\n No new complaints this AM.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 07:40 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:40 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: 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, Hematemesis\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: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.1\nC (98.8\n HR: 84 (68 - 95) bpm\n BP: 130/100(105) {122/66(80) - 157/100(105)} mmHg\n RR: 19 (12 - 24) insp/min\n SpO2: 98%\n Total In:\n 1,702 mL\n 1,003 mL\n PO:\n 180 mL\n TF:\n IVF:\n 1,702 mL\n 823 mL\n Blood products:\n Total out:\n 250 mL\n 870 mL\n Urine:\n 250 mL\n 720 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 1,452 mL\n 133 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///25/\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, 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: Absent, 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): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 10.4 g/dL\n 226 K/uL\n 166\n 1.6 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 25 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.9 %\n 11.7 K/uL\n [image002.jpg]\n 11:08 PM\n 04:13 AM\n 06:00 AM\n WBC\n 11.7\n Hct\n 41.8\n 29.9\n Plt\n 226\n Cr\n 1.5\n 1.6\n Glucose\n 165\n 125\n 166\n Other labs: PT / PTT / INR:13.3/23.4/1.1, Ca++:8.4 mg/dL, Mg++:2.0\n mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 75 yom colon cancer (s/p hemicolectomy ), s/p bilateral ureteral\n stent placement, now admitted to with GI bleed.\n GI BLEED -- with coffee grounds emesis concern for upper source.\n Concerns include gastritis, PUD, - tear, Dieulafoys ulcer,\n AVM. No clnical concern for varices. Plan maintain iv access, monitor\n serial Hct, PPI infusion, GI consultation to assess for EGD.\n FLUIDS\n hypovolemia; plan to net replete.\n CONSTIPATION\n chronic. Signs of mild ileus. Monitor abd exam.\n General surgery to follow.\n UTI\n hematuria, possibly related to recent stent placement. Possible\n UTI. Ciprofloxicin. Urology to follow up.\n s/p CVA -- Hold aggrenox in setting of GIB\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 514780,
"text": "Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Action:\n Response:\n Plan:\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 514782,
"text": "Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt presented to ed with coffee grounds in the setting of\n constipation( no stool x 10 days). Differential dx included gastritis,\n tear. No clear obstruction on ct scan. Most likely\n scenarion would be constipation leading to nausea and vomiting and\n possible tear related to emesis. Pt hemodynamically\n stable since admit with hr 80-90\ns and sbp 121-149. ngt to low\n continuous sx has drained about 500cc\n colored drainage with\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\n presently off.\n Action:\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\n maintained. Ngt continued to low wall suction.\n Response:\n Stable hct and hemodynamics.\n Plan:\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\n hemodynamics. Maintain 2 piv\ns and keep pt npo except for meds. Gi\n consult team following pt and will most likely pt will have endoscopy\n in days.ppi changed to pantoprazole iv .\n Constipation (Obstipation, FOS)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 514784,
"text": "Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt presented to ed with coffee grounds in the setting of\n constipation( no stool x 10 days). Differential dx included gastritis,\n tear. No clear obstruction on ct scan. Most likely\n scenarion would be constipation leading to nausea and vomiting and\n possible tear related to emesis. Pt hemodynamically\n stable since admit with hr 80-90\ns and sbp 121-149. ngt to low\n continuous sx has drained about 500cc\n colored drainage with\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\n presently off.\n Action:\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\n maintained. Ngt continued to low wall suction.\n Response:\n Stable hct and hemodynamics.\n Plan:\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\n hemodynamics. Maintain 2 piv\ns and keep pt npo except for meds. Gi\n consult team following pt and will most likely pt will have endoscopy\n in days.ppi changed to pantoprazole iv .\n Constipation (Obstipation, FOS)\n Assessment:\n Constipation likely related to chronic constipation as pt reports that\n he typically has bm q 7 days. This constipation may be worsened by\n recent surgery and Tylenol with codeine use as well as dehydratons\n given his dry appearance on exam. Abd firm and distended with few bowel\n sounds on auscultation. Ct neg for obstruction. Pt given sse on noc\n shift which he was unable to retain and dulocolax supp . pt has passed\n sm soft brown stool.\n Action:\n Pt medicated again with dulcolax suppose. Ngt to wall suction to\n decompress from above.\n Response:\n Still with little stool output.\n Plan:\n Continue to follow stool output and guiac all stools. Continue with\n aggressive bowel regimen and administer colace as ordered. Maintain ngt\n to low wall suction in order to decompress from above. Avoid narcotics.\n"
},
{
"category": "Nursing",
"chartdate": "2201-02-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 514785,
"text": "Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. His wife called\n ambulance to take him to ED for weakness and consripation and he had\n coffee grounds emesis x 2 in ambulance and subsequently in ED. He also\n reprots hematuria since stents and foley placed 4 days prior. Denies\n any prior h/o GIB or similar symptoms. Received protonix iv,flagyl\n and started with protonix drip and transffered to for further\n management.\n Hematemesis (upper GI bleed, UGIB)\n Assessment:\n Pt presented to ed with coffee grounds in the setting of\n constipation( no stool x 10 days). Differential dx included gastritis,\n tear. No clear obstruction on ct scan. Most likely\n scenarion would be constipation leading to nausea and vomiting and\n possible tear related to emesis. Pt hemodynamically\n stable since admit with hr 80-90\ns and sbp 121-149. ngt to low\n continuous sx has drained about 500cc\n colored drainage with\n flecks of coffee grounds. No c/o nv. Hct this am=29.9 and when\n rechecked at 12 noon hct=30. pt on protonix gtt overnoc which is\n presently off.\n Action:\n Hct checked q 6 hrs as ordered. Hemodynamics monitored closely. 2 piv\n maintained. Ngt continued to low wall suction.\n Response:\n Stable hct and hemodynamics.\n Plan:\n Continue to check hct q 6 hrs and transfuse ofr hct < 27. follow\n hemodynamics. Maintain 2 piv\ns and keep pt npo except for meds. Gi\n consult team following pt and will most likely pt will have endoscopy\n in days.ppi changed to pantoprazole iv .\n Constipation (Obstipation, FOS)\n Assessment:\n Constipation likely related to chronic constipation as pt reports that\n he typically has bm q 7 days. This constipation may be worsened by\n recent surgery and Tylenol with codeine use as well as dehydratons\n given his dry appearance on exam. Abd firm and distended with few bowel\n sounds on auscultation. Ct neg for obstruction. Pt given sse on noc\n shift which he was unable to retain and dulocolax supp . pt has passed\n sm soft brown stool.\n Action:\n Pt medicated again with dulcolax suppose. Ngt to wall suction to\n decompress from above.\n Response:\n Still with little stool output.\n Plan:\n Continue to follow stool output and guiac all stools. Continue with\n aggressive bowel regimen and administer colace as ordered. Maintain ngt\n to low wall suction in order to decompress from above. Avoid narcotics.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n UPPER GASTROINTESTINAL BLEED\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: Colon cancer, stage IIIB, status post hemicolectomy\n on in the setting of bowel obstruction, received 7 cycles of\n Xeloda, stopped concern for progression of disease ,\n Bilateral ureteral obstruction s/p b/l stent placement ; unclear\n etiology of obstruction per review of notes , CVA with residual R\n sided weakness and R facial droop , Hypertension , Diabetes (diet\n controlled) , Hyperlipidemia , Prostate cancer s/p treatment with\n external beam radiation \"many years ago\" -,\n Surgery / Procedure and date: hemicolectomy \n bilateral uretral stent placement \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:78\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 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 FiO2 set:\n 24h total in:\n 1,003 mL\n 24h total out:\n 1,030 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 04:13 AM\n Potassium:\n 3.5 mEq/L\n 04:13 AM\n Chloride:\n 103 mEq/L\n 04:13 AM\n CO2:\n 25 mEq/L\n 04:13 AM\n BUN:\n 25 mg/dL\n 04:13 AM\n Creatinine:\n 1.6 mg/dL\n 04:13 AM\n Glucose:\n 166\n 06:00 AM\n Hematocrit:\n 30.0 %\n 11:36 AM\n Finger Stick Glucose:\n 209\n 12:00 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 409\n Transferred to: 1184\n Date & time of Transfer: 1430\n"
},
{
"category": "Physician ",
"chartdate": "2201-02-03 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 514604,
"text": "Chief Complaint: Hematemesis\n HPI:\n Mr. is a 75 year old man with colon CA s/p hemicolectomy ,\n s/p bilateral ureteral stent placement now presenting with\n constipation, coffee grounds emesis and hematuria. He had been in USOH\n until today when he noted \"weakness\" and dizziness with standing. He\n also has been constipated with last BM 10 days prior. This BM was hard\n but brown and not black or tarry. Has continued to pass flatus. Denies\n abdominal pain, melena, hematochezia, chest pain, SOB, fever, chills,\n lightheadedness, decreased PO intake, NSAID or steroid use. His wife\n called ambulance to take him to ED for weakness and consripation and he\n had coffee grounds emesis x 2 in ambulance and subsequently in ED. He\n also reprots hematuria since stents and foley placed 4 days prior.\n Denies any prior h/o GIB or similar symptoms.\n .\n In the emergency department, initial vitals were: 97.8 91 142/79 16\n 98%RA. NG lavage was positive for hemoccult positive coffee grounds\n which did not clear after 1L. He was guaiac negative but was noted to\n have abdominal tenderness so CT abdomen/pelvis was obtained and\n revealed distended small and large bowel with air fluid levels\n suggestive of gastroenteritis. GI and Surgery evaluated patient and\n recommended decompressing from above with NGT and enemas from below but\n no urgent indication for scope since HD stable. UA was positive and\n blood cx x 2 were drawn. He received 1LNS, pantoprazole, levofloxacin,\n flagyl and Zofran. Labs significant for HCT 34 from baseline 32 and Cr\n 1.7 from baseline 2.0.\n .\n Vitals prior to transfer were: 77 131/78 16 95%RA\n .\n REVIEW OF SYSTEMS:\n (+)ve: Urinary urgency since foley catheter placed.\n (-)ve: As above. Denies fever, chills, night sweats, loss of appetite,\n weight loss, palpitations, nasal congestion, cough, sputum production,\n hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, focal\n numbness, focal weakness, myalgias, arthralgias\n Patient admitted from: ER\n History obtained from Patient, Family / Friend\n Allergies:\n Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 08:11 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n Home Meds:\n Lipitor 10mg PO daily\n Flomax 0.4mg PO daily\n Keflex 500mg PO TID since \n Tylenol #3 prn\n Lisinopril 10mg PO daily\n Effexor XR 37.5mg PO daily\n Colace 100mg PO TID\n Mag citrate prn\n OFF AGGRENOX x 1 week\n Past medical history:\n Family history:\n Social History:\n 1. Colon cancer, stage IIIB, status post hemicolectomy on in\n the setting of bowel obstruction, received 7 cycles of Xeloda, stopped\n concern for progression of disease\n 2. Bilateral ureteral obstruction s/p b/l stent placement ;\n unclear etiology of obstruction per review of notes\n 3. CVA with residual R sided weakness and R facial droop\n 4. Hypertension\n 5. Diabetes (diet controlled)\n 6. Hyperlipidemia\n 7. Prostate cancer s/p treatment with external beam radiation \"many\n years ago\" -\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is married with two children. He is a retired\n electrician from in and currently lives in ,\n MA with wife. denies tobacco, alcohol or drug abuse.\n Review of systems:\n Flowsheet Data as of 11:32 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.2\nC (98.9\n HR: 84 (77 - 86) bpm\n BP: 134/70(85) {132/70(85) - 157/91(103)} mmHg\n RR: 14 (12 - 24) insp/min\n SpO2: 97%\n Total In:\n 601 mL\n PO:\n TF:\n IVF:\n 601 mL\n Blood products:\n Total out:\n 0 mL\n 250 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 351 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GENERAL: Pleasant, well appearing elderly gentleman in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. Dry MM. OP clear with dried blood in posterior\n OP. NGT in place with gastroccult positive coffee grounds material in\n canister.\n Neck: Supple, No LAD, No thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2/6 systolic\n murmur heard best RUSB. No rubs or . JVP=7-8cm\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: Distended abdomen. Well healed midline scar. Hyperactive BS.\n Palpable peristalsis. TTP with involuntary guarding LLQ. No rebound or\n HSM\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses. Scar R knee\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Speech slow and deliberate. Initially reported was in\n but later reoriented to in , MA. Oriented\n to self and wife and able to relate her phone number. Oriented to month\n and year but not date. Appropriate. CN 2-12 intact. 5/5 strength\n throughout. + reflexes, equal BL. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n Imaging: CT A/P:Distended large and small bowel suggestive of\n gastroenteritis\n CXR: (my read): NGT in stomach. No infiltrate or effusion. Normal\n cardiac silhouette. Large stomach gas bubble and dilated loops of bowel\n with elevated left hemidiaphragm. Blunted rigth costophrenic angle\n Microbiology: Urine cx: Pending\n Blood cx x 2 pending\n ECG: ECG:NSR HR 75. Normal axis and intervals with slight IVCD QRS\n 90msec. Q waves in V5-V6. No acute ST or T wave changes. ? U waves\n Assessment and Plan\n ASSESSMENT AND PLAN:\n 75 year old man with colon cancer s/p hemicolectomy and s/p\n bilateral ureteral stent placement now admitted to with UGIB in\n setting of constipation and hematuria\n #. UGIB: Patient presented with coffee grounds emesis in setting of\n constipation. Differential diagnosis includes gastritis, \n tear, PUD, Dieulafoys ulcer, AVM. Unlikely to have varices given no\n prior history of varices or liver disease. He is guaiac negative from\n below and has been constipated which would be atypical for brisk GIB\n especially given still passing flatus and no clear obstruction on CT\n scan. Most likely scenario would be constipation leading to nausea and\n vomiting and possible tear related to emesis. Remains HD\n stable without current evidence of active bleed and HCT as well as BUN\n are currently improved from baseline. He denies recent NSAID or steroid\n use that would increase risk of bleeding.\n - continue PPI drip for now, change to dosing in am\n - maintain PIVs x 2\n - monitor HCT q8, next HCT likely to be lower since has received IVF\n but transfuse for HCT <27 or active bleed\n - maintain NPO with IVF\n - appreciate GI recommendations, possible EGD in am\n - guaiac all stool\n - continue NGT to wall suction\n - NS bolus x 1 L now\n #. Constipation: Likely related to chronic constipation (reports\n typically has BM q 7 days) worsened by recent surgery and Tylenol with\n codeine use as well as dehydration given dry appearance on exam. Per\n surgery, no signs of obstruction on CT related to -enteric\n anastamoses and has fluid passing through. He continues to pass flatus\n so not fully obstructed and is relatively asymptomatic.\n - NGT to wall suction to decompress from above\n - tap water enema and bisacodyl suppository, continue colace\n - appreciate surgery recs\n - serial abdominal exams\n - avoid narcotics\n #. Hematuria: Likely related to foley and recent stent placement\n - appreciate urology recommendations who will see in am\n # ?UTI: Patient has foley catheter in place and positive UA although is\n asymptomatic other than urinary urgency related to foley catheter. WBC\n mildly elevated which may be related to UTI\n - cipro for now as below\n - follow up urine cx\n - continue keflex, ? for stent placement, will d/w urology\n #. Ureteral obstruction: Cr improved since placement of bilateral\n stents and passing adequate UOP\n - continue to monitor\n # ? Gastroenteritis: ? gastroenteritis on CT but no evidence of\n diarrhea or fever or chills. Appearance may just be secondary to\n inflammation from obstruction and/or ileus.\n - continue cipro/flagyl for now, likely d/c if no further evidence of\n infection\n # s/p CVA: Continue to hold aggrenox in setting of GIB\n #. HTN: Hold antihypertensives in setting of GIB\n #. Hyperlipidemia: Continue statin\n # Diabetes: Diet controlled.\n - FS QID and HISS\n #. h/o prostate cancer\n - hold flomax given GIB, consider restart in am if HD stable\n FEN: NPO with IVF\n PPX:\n -DVT ppx with pneumoboots in setting of GIB\n -Bowel regimen with enemas, home regimen\n -Pain management with tylenol\n ACCESS: PIV's\n .\n CODE STATUS: DNR/DNI\n .\n EMERGENCY CONTACT: Wife \n .\n DISPOSITION: ICU for now, likely call out if stable in am\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:25 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "ECG",
"chartdate": "2201-02-03 00:00:00.000",
"description": "Report",
"row_id": 252773,
"text": "Sinus rhythm. Tracing may be within normal limits but unstable baseline makes\nassessment difficult. Since the previous tracing of there may be no\nsignificant change but unstable baseline makes comparison difficult.\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-02-03 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 1118239,
"text": " 2:08 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with left sided abdominal pain\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine;\n ______________________________________________________________________________\n WET READ: ASpf 4:36 PM\n Distended small and large bowel with air fluid levels suggestive of\n gastroenteritis.\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE ABDOMEN AND PELVIS PERFORMED ON .\n\n CLINICAL HISTORY: 75-year-old male with left-sided abdominal pain, question\n obstruction.\n\n Comparison is made with a prior CT abdomen and pelvis dated .\n\n TECHNIQUE: MDCT was used to obtain contiguous axial images through the\n abdomen and pelvis without oral or IV contrast material. IV contrast was\n withheld due to patient's elevated creatinine. Coronal and sagittal\n reformations were provided.\n\n FINDINGS:\n\n LUNG BASES: There is slight interval increase in the layering\n simple-appearing right-sided pleural effusion. Mild compressive atelectasis\n is also noted at the right lung base. There is a 3-mm focus of nodularity\n along the major fissure on series 2, image 10. Additional tiny vague areas of\n nodularity in the right middle lobe are seen on series 2, image 12, likely as\n well as image 14, which may be inflammatory. An NG tube courses into the\n upper abdomen with the distal side-port at the level of the GE junction. A\n small hiatal hernia is noted. Coronary artery calcifications are noted.\n\n ABDOMEN: Non-contrast appearance of the liver is unremarkable. There is a\n small amount of perihepatic free fluid. Gallbladder is collapsed. The spleen\n is unremarkable. Adrenal glands appear normal bilaterally. The pancreas is\n grossly normal. Kidneys have been internally decompressed with bilateral\n ureteral stents in place with proximal coils well positioned in the bilateral\n renal pelves and distal coils in the urinary bladder. Nonspecific perinephric\n stranding is stable. The abdominal aorta contains atherosclerotic\n calcifications notably at the origin of the major branch vessel. There is no\n aneurysm seen. Retroperitoneal lymph nodes do not appear enlarged.\n\n The stomach is decompressed. The duodenum appears grossly unremarkable.\n\n PELVIS: There is diffuse fluid distention of small bowel with numerous\n air-fluid levels and bowel measuring up to 3.4 cm in diameter. There is no\n (Over)\n\n 2:08 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n point of transition seen. An anastomosis in the right mid abdomen is noted in\n this patient with prior right colonic resection. Distal to the anastomosis\n there is gaseous distention and mild dilation of the large bowel without\n discrete point of obstruction though note is made of the significant fecal\n loading of the sigmoid colon. There is no gross bowel wall thickening seen.\n The urinary bladder is decompressed with a Foley catheter in place. Small\n amount of free fluid extends into the pelvis.\n\n BONES: Degenerative changes are noted in the lower lumbar spine. Significant\n facet arthropathy is also noted at the lumbosacral junction.\n\n IMPRESSION:\n 1. Diffuse distention and mild dilation of small and large bowel without\n transition and with numerous air-fluid levels seen. Overall, the\n configuration suggests a diagnosis of gastroenteritis, though clinical\n correlation is strongly advised.\n 2. Slight interval increase in right-sided simple-appearing pleural effusion.\n 3. Stable volume of small abdominal ascites.\n 4. Interval placement of bilateral ureteral stents with resolution of\n previously noted hydronephrosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-02-16 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1120454,
"text": " 3:23 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: r picc 50cm\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n G I bleed\n REASON FOR THIS EXAMINATION:\n r picc 50cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with right-sided PICC placement, evaluate for\n PICC placement.\n\n COMPARISON: Portable chest radiograph, at 12:53 p.m.\n\n TECHNIQUE: Portable chest radiograph, at 15:33 p.m.\n\n FINDINGS: The left-sided PICC line has been removed in the interim. A new\n right-sided PICC line tip terminates within the mid SVC. Opacification within\n the right lower lobe is most likely due to layering right-sided pleural\n effusion. The cardiac, mediastinal, and hilar contours appear unchanged from\n most recent prior and are normal.\n\n IMPRESSION: Right-sided PICC tip projects over the mid SVC. IV nurse, \n , was notified of the results on . Dr. was\n also notified of the results at 17:11 on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-02-16 00:00:00.000",
"description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS",
"row_id": 1120422,
"text": " 12:29 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: MR enterography - ? mass, stricture\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with h/o colon cancer, now with obstruction seen on\n colonoscopy. Please perform MR enterography\n REASON FOR THIS EXAMINATION:\n MR enterography - ? mass, stricture\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MON 9:58 PM\n 1. Markedly dilated small bowel and large bowel loops compatible with\n obstruction. Apparent transition point at colosigmoid junction. Distal\n collapse of bowel demonstrates markedly thickened wall - however, difficult to\n delineate for underlying discrete mass or stricture. ? adhesions.\n 2. Right hemicolectomy changes area of anastomosis in right mid abdomen\n appears okay.\n 3. Moderate ascites. Further evaluation for bowel perforation would be\n better assessed on upright x-ray or CT.\n ______________________________________________________________________________\n FINAL REPORT\n MR ABDOMEN WITHOUT AND WITH CONTRAST\n\n INDICATION: 75-year-old male with history of colon cancer with right\n hemicolectomy in and remote history of prostate cancer with external beam\n radiation treatment presents with obstruction seen on colonoscopy. Evaluate\n for underlying mass or stricture.\n\n COMPARISON: CT abdomen and pelvis exam date .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained on a 1.5\n Tesla magnet including dynamic 3D imaging obtained prior to, during, and after\n the uneventful IV administration of 0.1 mmol/kg of gadolinium-DTPA (17 cc\n Magnevist). A total of 1800 ml VoLumen was orally administered. No\n intramuscular glucagon was given. Multiplanar 2D and 3D reformations and\n subtraction images were generated on an independent workstation.\n\n FINDINGS: Right hemicolectomy changes are noted. Extensive and diffuse\n dilated small bowel and colon is identified with apparent transition point at\n the colosigmoid junction deep within the pelvis. In the pelvis, multiple\n collapsed and clustered bowel loops are noted with extensive wall thickening\n and vague enhancement. Regional inflammatory changes and enhancement are seen\n in the pelvis with some areas of nodular enhancement in the adjacent\n peritoneum. Note is made on dynamic SSFSE images of diffusely sluggish bowel\n motility, but with virtually none in these abnormal-appearing pelvic loops.\n These findings are suggestive of an obstruction of unclear etiology. Given\n the peritoneal enhancement and lack of FDG avidity in this region upon\n correlation with recent PET exam findings suggest a fibrotic process, possibly\n from prior radiation treatment with, or without changes due to prior ischemic\n episodes.\n (Over)\n\n 12:29 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: MR enterography - ? mass, stricture\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n A few prominent pelvic lymph nodes are noted, the largest seen anteromedial to\n the left psoas, measuring 12 mm. None of these are accessible for biopsy due\n to location, with surrounding dilated bowel loops as well as osseous\n structures.\n\n A moderate amount of ascites is present. Bilateral renal cysts are noted.\n The bladder wall is diffusely thickened measuring 4 mm. Ureteral stents are\n not clearly visualized, but is as expected for MRI.\n\n 2D reformations and 3D volume rendered images were reviewed at interpretation,\n supporting these findings.\n\n IMPRESSION:\n\n 1. Extensive dilated loops of small bowel and colon with apparent transition\n deep in the pelvis at distal colon. Diffuse surrounding enhancement and\n suggestion of wall thickening of the colon is of unclear etiology, but given\n the lack of preferential FDG uptake on PET findings, this more likely is\n attributed to a fibrotic process from prior radiation treatment and/or\n stricturing from superimposed ischemic episodes than a high grade tumor.\n However, given the presumed recent onset of these findings, with the\n remoteness of regional radiation treatment, neoplasm as a cause of this\n stricture cannot be excluded based on imaging.\n\n A dedicated MRI pelvis with rectal contrast and glucagon to reduce bowel\n motion artifacts may be considered in attempts obtain higher resolution\n imaging of the abnormal pelvic loops.\n\n 2. Prominent pelvic lymph nodes, inaccessible for biopsy.\n\n 3. Bilateral renal cysts.\n\n 4. Right hemicolectomy changes.\n\n Findings discussed with Dr. at 1115hrs via telephone\n report by Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-02-16 00:00:00.000",
"description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS",
"row_id": 1120423,
"text": ", N. MED 11R 12:29 PM\n MRI ABDOMEN W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: MR enterography - ? mass, stricture\n Admitting Diagnosis: UPPER GASTROINTESTINAL BLEED\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with h/o colon cancer, now with obstruction seen on\n colonoscopy. Please perform MR enterography\n REASON FOR THIS EXAMINATION:\n MR enterography - ? mass, stricture\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Markedly dilated small bowel and large bowel loops compatible with\n obstruction. Apparent transition point at colosigmoid junction. Distal\n collapse of bowel demonstrates markedly thickened wall - however, difficult to\n delineate for underlying discrete mass or stricture. ? adhesions.\n 2. Right hemicolectomy changes area of anastomosis in right mid abdomen\n appears okay.\n 3. Moderate ascites. Further evaluation for bowel perforation would be\n better assessed on upright x-ray or CT.\n\n"
}
] |
13,545 | 156,780 | On the the patient was brought to the Operating Room where he underwent an aortic valve replacement with a #25 prosthetic valve and coronary artery bypass grafting with saphenous vein graft to the posterior descending coronary artery. He tolerated the operation well and was transferred to the Operating Room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period. he was weaned from all cardioactive drugs. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated on postoperative day one. The patient continued to do well. His chest tubes were removed and he was transferred from the Cardiothoracic Intensive Care Unit to Far Two for continuing postoperative care and cardiac rehabilitation. Over the next several days the patient continued to do well on the floor. He was assisted with his physical activity by physical therapy and the nursing staff. He gradually improved to the point where on postoperative day four it was deemed that he was stable and ready for discharge to home. | of residual pnuemothorax. Sinus rhythmRight bundle branch blockInferior/lateral ST-T changes may be due to myocardial ischemia - clinicalcorrelation is suggestedLeft atrial abnormalitySince previous tracing of : no significant change Sinus rhythmConduction defect of RBBB typeAnterolateral ST-T changes may be due to myocardial ischemia - clinicalcorrelation is suggestedLeft atrial abnormalitySince previous tracing of : probably no significant change Baseline artifactSinus rhythmConduction defect of RBBB typeAnterolateral ST-T changes may be due to myocardial ischemia - clinicalcorrelation is suggestedConsider left atrial abnormalitySince previous tracing : further ST-T wave changes present and QRSvoltage less prominent Sinus rhythm- premature ventricular contractionsLeft atrial abnormalityRight bundle branch blockLateral ST-T changes may be due to myocardial ischemia - clinical correlationis suggestedSince previous tracing of : no significant change S/P aortic valve replacement. There is a retrocardiac opacity which likely represents atelectasis. Minimal left subcutaneous emphysema. S/P CABG/AVRNSR. ETT SUCTIONED FOR SOME THICK SECRETIONS ~ 1HR PRIOR TO EXTUBATION. PRBC ORDERED BY DR. .BREATHSOUNDS CLEAR. FINAL REPORT INDICATION: Crepitus over left chest, evaluate for residual pneumothorax. WEANED FROM VENTILATOR AND EXTUBATED @ 2100. CHEST, PA AND LATERAL: The patient is s/p aortic valve replacement. There is a small amount of subcutaneous emphysema on the left. H/O PROLONGED QT INTERVAL. There is blunting of both costophrenic angles posteriorly and laterally suggesting small pleural effusions. IMPRESSION: Small bilateral pleural effusions. A chest tube and mediastinal drain are present. NTG GTT TITRATED TO KEEP MBP <90. 2 LITERS LR GIVEN EARLIER. NEURO ALERT ORIENTED NO DEFECITS NOTEDC/V APACED WITH FREQ PVCS A NOT ALWAYS SENSING CORRECTLY SENSITIVITY DECREASE TO .8 WITH LITTLE EFFECT CONTINUES TO NOT SENSE AT TIMES 4AM INCREASE DIFFICULTY WITH SENSING NOT SENSING CORRECTLY FREQ POLARITY CHANGED WITH NO EFFECT PACER DECREASE TO BACKUP RATE OF 50 WITH LOWEST MA SETTING TO USE AS NEEDED MP NSR SB HR 55-66 OCC PVC MAG REPLACED B/P STABLE ON NITRO 2MCGS B/P INREASE TO MAP 88 5AM WITH NO B/P CHANGE WITH HR CHANGE NTG INCREASE TO 2.2MCG MS GIVEN WITH GOOD EFFECTRESP NC 4L SATS 98% NONPRODUCTIVE LUNGS CLEAR CHEST TUBES PATENT 10-20CC SEROSANGACTIVITY TURNING IN BED WITH ONE ASSIST TOL WELLPLAN CONTINUE TO MONITOR FOR HEMODYNAMIC STABLITY ? PLAN TO MONITOR QT INTERVAL. IMPRESSION: 1) No pneumothorax. Comparison is made to the prior study from . SEMI-UPRIGHT AP CHEST RADIOGRAPH: A right internal jugular Swan-Ganz catheter is present with the tip in the main pulmonary artery. 63 PKG/YR SMOKING HISTORY NOTED IN CHART. DIFFICULTY GETTING V WIRE TO SENSE APPROPRIATELY. PLAN TO CHECK K/ION CA/ Q/4HRS TONIGHT PER DR. . HR DOWN TO 55 (SINUS) TONIGHT. NO NAUSEA TONIGHT.FOLEY DRAINING CLEAR YELLOW.PT DENIES PAIN BUT ADMITS TO A SENSATION OF HEAVINESS IN HIS INCISIONAL AREA.ORIENTED X 3. SHE WILL CHECK IN BY PHONE.GLASSES AND UPPER PLATE AND BRIDGE LEFT AT BEDSIDE.PLAN TO RECHECK PRBC AND ELECTROLYTES. 8:28 AM CHEST (PORTABLE AP) Clip # Reason: s/p CABG and now has crepitus over left chest despite presen MEDICAL CONDITION: 75 year old man with s/p CABG/AVR REASON FOR THIS EXAMINATION: s/p CABG and now has crepitus over left chest despite presence of CT, please evaluate adequacy of chest tube and ? A PACING INITIATED @ 80. HCT DOWN TO ~22 BUT IMMEDIATE REPEAT ^25. Sternal wires are present. METABOLIC ACIDOSIS NOTED AND TREATED WITH IV VOLUME.OGT DRAINING GREEN BILIOUS PRIOR TO REMOVAL. 2) Moderate congestive heart failure, increased since the prior study. CI GOOD. SEEN BY EPS LAB HERE AT . The heart and vascularity are normal. There is increased cardiomegaly, along with increased lung opacity indicating worsening congestive heart failure. 10:54 AM CHEST (PA & LAT) Clip # Reason: s/p chest tubes out MEDICAL CONDITION: 75 year old man with critical AS pre op REASON FOR THIS EXAMINATION: s/p chest tubes out FINAL REPORT INDICATION: S/P chest tube removal. MAE. OOB TO CHAIR TODAY The osseous structures are unremarkable. There is no pneumothorax. No pneumothorax is seen. NAPPING MOST OF SHIFT.WIFE IN TO VISIT. | 8 | [
{
"category": "Radiology",
"chartdate": "2140-12-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 777608,
"text": " 10:54 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p chest tubes out\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with critical AS pre op\n\n REASON FOR THIS EXAMINATION:\n s/p chest tubes out\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P chest tube removal.\n\n CHEST, PA AND LATERAL: The patient is s/p aortic valve replacement.\n There is blunting of both costophrenic angles posteriorly and laterally\n suggesting small pleural effusions. No pneumothorax is seen. There is a\n small amount of subcutaneous emphysema on the left. The heart and vascularity\n are normal.\n\n IMPRESSION: Small bilateral pleural effusions. Minimal left subcutaneous\n emphysema. S/P aortic valve replacement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-12-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 777508,
"text": " 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG and now has crepitus over left chest despite presen\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with s/p CABG/AVR\n REASON FOR THIS EXAMINATION:\n s/p CABG and now has crepitus over left chest despite presence of CT, please\n evaluate adequacy of chest tube and ? of residual pnuemothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Crepitus over left chest, evaluate for residual pneumothorax.\n\n Comparison is made to the prior study from .\n\n SEMI-UPRIGHT AP CHEST RADIOGRAPH: A right internal jugular Swan-Ganz catheter\n is present with the tip in the main pulmonary artery. A chest tube and\n mediastinal drain are present. Sternal wires are present. There is no\n pneumothorax. There is increased cardiomegaly, along with increased lung\n opacity indicating worsening congestive heart failure. There is a\n retrocardiac opacity which likely represents atelectasis. The osseous\n structures are unremarkable.\n\n IMPRESSION:\n 1) No pneumothorax.\n 2) Moderate congestive heart failure, increased since the prior study.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-12-29 00:00:00.000",
"description": "Report",
"row_id": 172828,
"text": "Sinus rhythm\nRight bundle branch block\nInferior/lateral ST-T changes may be due to myocardial ischemia - clinical\ncorrelation is suggested\nLeft atrial abnormality\nSince previous tracing of : no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2140-12-28 00:00:00.000",
"description": "Report",
"row_id": 172829,
"text": "Sinus rhythm\n- premature ventricular contractions\nLeft atrial abnormality\nRight bundle branch block\nLateral ST-T changes may be due to myocardial ischemia - clinical correlation\nis suggested\nSince previous tracing of : no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2140-12-27 00:00:00.000",
"description": "Report",
"row_id": 172830,
"text": "Sinus rhythm\nConduction defect of RBBB type\nAnterolateral ST-T changes may be due to myocardial ischemia - clinical\ncorrelation is suggested\nLeft atrial abnormality\nSince previous tracing of : probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2140-12-26 00:00:00.000",
"description": "Report",
"row_id": 172831,
"text": "Baseline artifact\nSinus rhythm\nConduction defect of RBBB type\nAnterolateral ST-T changes may be due to myocardial ischemia - clinical\ncorrelation is suggested\nConsider left atrial abnormality\nSince previous tracing : further ST-T wave changes present and QRS\nvoltage less prominent\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-12-27 00:00:00.000",
"description": "Report",
"row_id": 1438525,
"text": "NEURO ALERT ORIENTED NO DEFECITS NOTED\n\nC/V APACED WITH FREQ PVCS A NOT ALWAYS SENSING CORRECTLY SENSITIVITY DECREASE TO .8 WITH LITTLE EFFECT CONTINUES TO NOT SENSE AT TIMES 4AM INCREASE DIFFICULTY WITH SENSING NOT SENSING CORRECTLY FREQ POLARITY CHANGED WITH NO EFFECT PACER DECREASE TO BACKUP RATE OF 50 WITH LOWEST MA SETTING TO USE AS NEEDED MP NSR SB HR 55-66 OCC PVC MAG REPLACED B/P STABLE ON NITRO 2MCGS B/P INREASE TO MAP 88 5AM WITH NO B/P CHANGE WITH HR CHANGE NTG INCREASE TO 2.2MCG MS GIVEN WITH GOOD EFFECT\n\nRESP NC 4L SATS 98% NONPRODUCTIVE LUNGS CLEAR CHEST TUBES PATENT 10-20CC SEROSANG\n\nACTIVITY TURNING IN BED WITH ONE ASSIST TOL WELL\n\nPLAN CONTINUE TO MONITOR FOR HEMODYNAMIC STABLITY ? OOB TO CHAIR TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-12-26 00:00:00.000",
"description": "Report",
"row_id": 1438524,
"text": "S/P CABG/AVR\nNSR. HR DOWN TO 55 (SINUS) TONIGHT. A PACING INITIATED @ 80. NTG GTT TITRATED TO KEEP MBP <90. DIFFICULTY GETTING V WIRE TO SENSE APPROPRIATELY. H/O PROLONGED QT INTERVAL. SEEN BY EPS LAB HERE AT . PLAN TO CHECK K/ION CA/ Q/4HRS TONIGHT PER DR. . CI GOOD. 2 LITERS LR GIVEN EARLIER. HCT DOWN TO ~22 BUT IMMEDIATE REPEAT ^25. PRBC ORDERED BY DR. .\n\nBREATHSOUNDS CLEAR. WEANED FROM VENTILATOR AND EXTUBATED @ 2100. ETT SUCTIONED FOR SOME THICK SECRETIONS ~ 1HR PRIOR TO EXTUBATION. 63 PKG/YR SMOKING HISTORY NOTED IN CHART. METABOLIC ACIDOSIS NOTED AND TREATED WITH IV VOLUME.\n\nOGT DRAINING GREEN BILIOUS PRIOR TO REMOVAL. NO NAUSEA TONIGHT.\n\nFOLEY DRAINING CLEAR YELLOW.\n\nPT DENIES PAIN BUT ADMITS TO A SENSATION OF HEAVINESS IN HIS INCISIONAL AREA.\n\nORIENTED X 3. MAE. NAPPING MOST OF SHIFT.\n\nWIFE IN TO VISIT. SHE REPORTED THAT SHE WILL NOT BE IN TO VISIT BECAUSE SHE DOES NOT DRIVE IN THE CITY. SHE WILL CHECK IN BY PHONE.\n\nGLASSES AND UPPER PLATE AND BRIDGE LEFT AT BEDSIDE.\n\nPLAN TO RECHECK PRBC AND ELECTROLYTES. PLAN TO MONITOR QT INTERVAL.\n"
}
] |
43,450 | 177,207 | 40F unknown past medical history with Insulin dependant DM2 transferred to for severe acidosis and hypokalemia in setting of DKA. Patient managed in the MICU for 6 days with resolution of her acidosis noted. Patient was called out to the floor on hospital day 6 after being stable on SubQ insulin. Course complicated by new sensory-motor polyneuropathy of left upper extremity and bilateral lower extremities. Transfered to neurology service after EMG concerning for axonal neuropathy on hospital day 11, ultimately determined to be a compressive neuropathy vs. multiple root radiculopathy. # Severe acidosis likely DKA Patient has severe acidosis on ABG with both primary metabolic non-gap and gap acidoses with superimposed respiratory acidosis. Etiology of primary metabolic non-gap acidosis may be from NS volume resuscitation, diarrhea, or other etiologies. The likely cause of the anion gap acidosis is DKA with no other apparent MUDPILES etiologies based on urine/serum toxicology. Osmolar gap initially 51, so methanol, polyethylene glycol or other exogenous substance may explain extra osmoles that would not be accounted for by DKA alone. Patient started on Insulin drip and Bicarb which were rate limited so as not to drop K+ faster than it could be repleted. Over the course of hospital day 1 patient was noted to have progressive improvement of her acidosis. In setting of severe acidosis and osmolar gap, patient received a single episode of hemodialysis. In the evening of hospital day 1 the patient's anion gap was noted to re-open to 24, patient was given additional IV fluids and insulin drip was continued with resolution of anion gap noted on repeat Chem7. Patient tolerated a PO diet on hospital day 4 and was started on SubQ insulin. Following initiation of SubQ insulin the insulin drip was discontinued. The patient was observed in the MICU following discontinuation of the insulin drip and her anion gap was noted to remain closed. Once the patient was fully awake she endorsed poor medication compliance with regards to her insulin. She states that she was on vacation prior to onset of DKA and that she did not utilize her insulin at all during a period of time during her vacation making medication non-compliance the most likely etiology of her DKA. After transfer to the general medicine, her blood sugars remained in the 120-250 range and she was kept on Lantus 50 units in the am and humalog sliding scale. She was followed closely by the service. Insulin dose on discharge was Lantus 40qam and 16qhs along with sliding scale. Instructed patient about importance of insulin compliance and establishing care with a primary care doctor upon return to . # Leukocytosis/hypothermia/MRSA bacteremia Initial concern for hypothermic sepsis given marked leukocytosis. Careful skin exam did not reveal any skin/soft tissue infection. CXR showing ? atelectasis vs. developing LL infiltrate after fluid resuscitation. CT Abdomen could suggest colitis although indefinite. Host factors include DM2 - no recent healthcare exposure- vancomycin/cefepime/flagyl given empirically as patient critically ill pending culture results. Patient's antibiotics discontinued on hospital day 3 as all cultures acquired were negative. On hospital day 5, repeat CXR concerning for new pneumonia and UA concerning for UTI. Repeat cultures sent and patient re-started on vanc and cefepime. Cultures sendt noted to grow out gram positive cocci in clusters, central line discontinued and patient continued on vanc and cefepime. She remained on Vancomycin after confirmed MRSA bacteremia to complete a 2 week course ending . A PICC was placed via IR guidance after an initial failed attempt. She also had a TTE which did not show evidence of vegetation, thus low suspicion of endocarditis. She completed a course of Vancomycin per recommendations of the infectious disease team on . # ? Pancreatitis The patient had elevated pancreatic enzymes, which may reflect either pancreatitis or increased pancreatic enzyme activities in the setting of DKA. Her abdominal exam appears to be bengin. A CT Abd/pelvis showed bowel wall thickening mainly involving the proximal small bowel (duodenum and jejunum) which could represent peristalsis, enteritis (such as infectious, inflammatory or ischemic) with mild blurring of pancreatic margins with minimal mesenteric stranding. It also shows multiple transient intussusception of jejenum, little bit of fluid in mesenetery and pancreas consistent with ? focal pancreatitis. Patient was evaluated by surgery for questionable CT abdomen findings, no surgical intervention indicated per surgery. TG mildly elevated, but unclear if high enough to have precipitated pancreatitis. Ca within normal limits; no evidence of CBG/gallstone pancreatitis on CT Abd. As patient's mental status improved appeared to be in pain with apparent tenderness to palpation of epigastrum, in setting of elevated lipase we have increased suspiscion of pancreatitis as cause of pain and possibly as etiology of DKA. Treated with IV Dilaudid PRN pain. Patient subsequently noted to have improvement of pain and tenderness likely representing resolution of acute pancreatitis episode. There was no further abdominal pain/tenderness while on the floor. # Respiratory failure Patient was intubated secondary to depressed mental status for airway protection. Patient passed spontaneous breathing test on hospital day two and was extubated. No further respiratory distress. # Shock Patient likely had septic shock from underlying infection, hypovolemic shock from osmotic diuresis in setting of DKA. Doubt cardiogenic or distributive shock. Her opening CVP was 11 with good urine output, normal lactate, and exam consistent with good perfusion. ScVO2 is ~ 90 suggestive of likely tissue mitochondrial dysfunction in setting of severe acidosis. She has been responsive to IVF resuscitation. By hospital day 2 patient was noted to have improvement in hemodynamics and was weaned off of phenylephrine. # Elevated LFTs Patient had mild elevated LFTs at OSH and on admission at . Uncertain etiology - abdominal CT not showed elevated Tbili or other overt abnormalities. Could be from toxidrome vs. early shock liver given hypotension or other causes. Patient's LFTs were trended and returned to baseline. # Thrombocytopenia Admission platelets with thrombocytopenia. Etiology is likely marrow suppresion from acute sepsis/illness. No evidence of sequestration or destruction - firinogen and coagulation is within normal limits speaking against DIC. Was noted to have improvement of platelet count during ICU stay. Normal platelet counts while on the floor. She was seen by heme/onc who recommended a skeletal survey which was normal. Also recommended HIV, which is pending at time of discharge. Considered bone marrow biopsy, but deferred given abnormalities likely in setting of acute illness. Asked patient to seen a hematologist/oncologist in 3 months and have them re-check SPEP, free kappa/lambda chains. Also, re-consider a bone marrow biopsy if values have not normalized. | COMPARISON: Non-contrast CT head on . Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. Minimal fluid is noted extending in the pericholecystic region, however the gallbladder is within normal limits. The mitral valve appears structurally normal withtrivial mitral regurgitation. The mitral valve appears structurally normal withtrivial mitral regurgitation. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. IMPRESSION: Very minimal disc buldge of L5-S1. Cannot assess RA pressure.LEFT VENTRICLE: Normal LV wall thickness and cavity size. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. The sacroiliac joints are grossly within normal limits. There is no pericardial effusion.IMPRESSION: Normal biventricular cavity sizes with preserved regional andhyperdynamic global biventricular systolic function. There is minimal spurring at the anterior aspect of several lower thoracic vertebral bodies. Minimal spurring at the L4 and L5 vertebral bodies are seen anteriorly. Hypoinflation of the lungs is unchanged. A small disc buldge is present at L5-S1 with very minimal compression of the thecal sac, but no contact with traversing nerve roots. There is a trace of free pelvic fluid, within physiologic limits for age. Left ventricular wall thicknesses arenormal. IMPRESSION: Tip of a right-sided PICC line remains in the left brachiocephalic vein. Sepsis.Height: (in) 60Weight (lb): 186BSA (m2): 1.81 m2BP (mm Hg): 91/43HR (bpm): 118Status: InpatientDate/Time: at 10:00Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. mild gallbladder wall edema. Tissue Doppler imaging suggests anormal left ventricular filling pressure (PCWP<12mmHg). No restingLVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Normal aortic valve leaflets (?#). FINDINGS: As compared to the previous radiograph, the previously placed left internal jugular vein catheter has been removed. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 62Weight (lb): 186BSA (m2): 1.86 m2BP (mm Hg): 110/80HR (bpm): 104Status: InpatientDate/Time: at 14:42Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. The left ventricular cavity size is normal. The aortic valve leaflets (3)appear structurally normal with good leaflet excursion and no aortic stenosisor aortic regurgitation. IMPRESSION: No acute intracranial pathology. Normal regional LVsystolic function. TECHNIQUE: Contiguous axial images were obtained through the head without the administration of IV contrast. There is trace fluid in the right maxillary sinus and right mastoid air cells and sphenoid sinuses but the remaining paranasal sinuses are clear. Left ventricular wall thicknesses andcavity size are normal. LowQRS voltages in the precordial leads. ST-T wave changes in the anterior andlateral leads are non-specific. AP PELVIS AND BILATERAL FEMORA: No focal lytic or blastic lesions are seen. The aortic valve leaflets (?#) appear structurally normalwith good leaflet excursion. Regional left ventricular wall motion is normal. Minimal edema within the fat in the groove between the pancreas and duodenum which may represent focal acute pancreatitis with extension of edema to the pericholecystic region. The patient is mechanicallyventilated. Right ventricularchamber size and free wall motion are normal. Right ventricular chamber size and free wallmotion are normal. There is evidence of minimal edema within the fat in the groove between the pancreas and duodenum which may represent focal pancreatitis. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (3). FINDINGS: A single semi-erect portable chest radiograph is obtained. Normal LV cavity size. Bilateral hip joint spaces demonstrate mild spurring in the superolateral aspect, consistent with early degenerative changes. Tricuspid valve not wellvisualized. FINDINGS: In comparison with the earlier study of this date, there has been placement of a left IJ catheter that extends to about the junction with the superior vena cava. There is a small mucus retention cyst in the left sphenoid sinus. THORACIC SPINE: No compression deformities are seen. Ventricles and sulci are normal in size and configuration. Vertebral body heights are maintained and show normal signal. TECHNIQUE: MR of the lumbar spine without contrast. COMPARISON: PORTABLE AP CHEST RADIOGRAPH: Bilateral low lung volumes are noted with crowding of bronchovascular markings. The ventricles and sulci are normal in size and symmetric in configuration. T wave abnormalities persist. There are no new abnormal cardiac or mediastinal contours. 2. mild blurring of pancreatic margins with minimal mesenteric straning, very early pancreatitis cannot be excluded, although no CT evidence of florid pancreatitis or pancreatitis related complications. IMPRESSION: No evidence of acute intracranial pathology. Multiple transient intussceptions are noted along the jejunum (uncertain significance). Multiple transient intussceptions are noted along the jejunum (uncertain significance). Visualized osseous structures show no suspicious lesions. Diffuse ST-T wave changes that are non-specific. Otherwise, the radiograph is unremarkable. No valvular pathology orpathologic flow identified.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. Evaluate for cerebral edema. If there is concern for polyneuritis, post gadolineum imaging can be obtained. There is no pericardial effusion.No vegetation seen (cannot definitively exclude).Compared with the prior study (images reviewed) of , findings aresimilar. LATERAL SKULL: No focal lytic or blastic lesions are seen. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Feeding tube is noted in the post-pyloric position with tip not clearly visualized. Low voltage throughout. No pleural effusion, or pneumothorax. Voltage is lesspriominent. The uterus appears unremarkable. Left IJ catheter extends to the mid-to-lower portion of the SVC. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). Probable sinus tachycardia. Tip of a right-sided PICC line is positioned more centrally within the left brachiocephalic vein. | 17 | [
{
"category": "Echo",
"chartdate": "2156-09-21 00:00:00.000",
"description": "Report",
"row_id": 60118,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 62\nWeight (lb): 186\nBSA (m2): 1.86 m2\nBP (mm Hg): 110/80\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 14:42\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: 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 Doppler imaging suggests a\nnormal left ventricular filling pressure (PCWP<12mmHg). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion and no aortic stenosis\nor aortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is no pericardial effusion.\n\nNo vegetation seen (cannot definitively exclude).\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar. The heart rate is now slower.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2156-09-14 00:00:00.000",
"description": "Report",
"row_id": 60121,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Sepsis.\nHeight: (in) 60\nWeight (lb): 186\nBSA (m2): 1.81 m2\nBP (mm Hg): 91/43\nHR (bpm): 118\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The patient is mechanically\nventilated. Cannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. Estimated cardiac index is high\n(>4.0L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Tricuspid valve not well\nvisualized. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%). The estimated cardiac\nindex is high (>4.0L/min/m2). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (?#) appear structurally normal\nwith good leaflet excursion. There is no aortic valve stenosis. No aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved regional and\nhyperdynamic global biventricular systolic function. No valvular pathology or\npathologic flow identified.\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": "2156-09-18 00:00:00.000",
"description": "Report",
"row_id": 108882,
"text": "Baseline artifact. Sinus tachycardia. ST-T wave changes in the anterior and\nlateral leads are non-specific. Repeat tracing is suggested given the baseline\nartifact. Compared to the previous tracing of the lateral precordial\nST-T wave changes are slightly more pronounced. The sinus rate has increased\nby 8 beats per minute.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-09-14 00:00:00.000",
"description": "Report",
"row_id": 108883,
"text": "Probable sinus tachycardia. Low voltage throughout. T wave abnormalities.\nSince the previous tracing of the rate is faster. Voltage is less\npriominent. ST segments have improved. T wave abnormalities persist.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-09-14 00:00:00.000",
"description": "Report",
"row_id": 108884,
"text": "Sinus rhythm. Diffuse ST-T wave changes that are non-specific. Low\nQRS voltages in the precordial leads. No previous tracing available for\ncomparison.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1251957,
"text": " 3:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with severe DKA now with signs concerning for new infection\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe DKA with signs concerning for new infection.\n\n FINDINGS: In comparison with the study of , all of the monitoring and\n support devices have been removed except for the left IJ catheter, which\n extends to the mid portion of the SVC. Very low lung volumes may account for\n the prominence of interstitial markings, though some elevation of pulmonary\n venous pressure could be present. Some atelectatic changes are seen at the\n bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1251391,
"text": " 3:48 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for right IJ\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 40F with right IJ\n REASON FOR THIS EXAMINATION:\n eval for right IJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ catheter.\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 about the junction with the\n superior vena cava. Otherwise, little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1251381,
"text": " 12:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for pancreatitis, ICH, cerebral edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 40F with intubated, sedated; likely pancreatitis\n REASON FOR THIS EXAMINATION:\n eval for pancreatitis, ICH, cerebral edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 1:47 AM\n no acute ich\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female who presented to Hospital with rapid\n deterioration in mental status and hypotension. Now intubated, sedated, with\n possible pancreatitis. Evaluate for intracranial pathology and cerebral edema.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained through the head without the\n administration of IV contrast. Multiplanar reformats were generated and\n reviewed.\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass\n effect or loss of /white matter differentiation. Ventricles and sulci are\n normal in size and configuration. Basal cisterns are not compressed.\n\n Bilateral mastoid air cells and pneumatized petrous apices are well aerated.\n There are secretions within the nasopharynx, likely secondary to intubation\n and supine positioning. There is a small mucus retention cyst in the left\n sphenoid sinus.\n\n IMPRESSION: No evidence of acute intracranial pathology.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-14 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1251382,
"text": " 12:56 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for pancreatitis, ICH, cerebral edema\n Field of view: 50 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 40F with intubated, sedated; likely pancreatitis\n REASON FOR THIS EXAMINATION:\n eval for pancreatitis, ICH, cerebral edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 2:17 AM\n 1. bowel wall thickening mainly invol the prox small bowel (duod and jejunum),\n while this may represent peristalsis, enteritis (infectious, inflammatory,\n ischemia cannot be excluded).\n 2. mild blurring of pancreatic margins with minimal mesenteric straning, very\n early pancreatitis cannot be excluded, although no CT evidence of florid\n pancreatitis or pancreatitis related complications.\n 3. pericholecystic fluid. mild gallbladder wall edema.\n 4. fatty deposition within the liver.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female intubated, sedated, likely pancreatitis.\n Evaluate for pancreatitis.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis\n with the administration of IV contrast. Multiplanar reformats were generated\n and reviewed.\n\n FINDINGS:\n\n CT OF THE ABDOMEN: Bilateral breast prostheses are noted. The visualized\n lung bases show bilateral trace pleural effusions with adjacent opacification\n which likely represents predominantly atelectasis; however, a component of\n aspiration versus infectious process such as pneumonia cannot be completely\n excluded. A nasogastric tube is seen within the post-pyloric stomach.\n\n The liver demonstrates diffuse and significant fatty change. The spleen is\n unremarkable. Note is made of a tiny splenule. There is evidence of minimal\n edema within the fat in the groove between the pancreas and duodenum which may\n represent focal pancreatitis. Minimal fluid is noted extending in the\n pericholecystic region, however the gallbladder is within normal limits.\n Bilateral adrenal glands and both kidneys enhance and excrete contrast\n symmetrically. A hypodensity within the interpolar region of the left kidney\n measuring 17 x 15 mm likely represents a renal cyst.\n\n Multiple transient intussceptions are noted along the jejunum (uncertain\n significance). There is no free air or free fluid within the abdomen.\n Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria for\n pathology.\n (Over)\n\n 12:56 AM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for pancreatitis, ICH, cerebral edema\n Field of view: 50 Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS: The rectum and sigmoid colon appear unremarkable. Mild\n prominance of the colonic wall may be secondary to third-spacing. A Foley\n catheter is present within the bladder. Air within the bladder likely relates\n to Foley. The uterus appears unremarkable. There is a trace of free pelvic\n fluid, within physiologic limits for age. Pelvic lymph nodes do not meet CT\n size criteria for pathology.\n\n Visualized osseous structures show no suspicious lesions.\n\n IMPRESSION:\n\n 1. Visualized lung bases show bilateral trace pleural effusions with adjacent\n opacification which likely represents atelectasis; however, a component of\n aspiration versus infectious process such as pneumonia cannot be completely\n excluded.\n 2. Minimal edema within the fat in the groove between the pancreas and\n duodenum which may represent focal acute pancreatitis with extension of edema\n to the pericholecystic region.\n 3. Multiple transient intussceptions are noted along the jejunum (uncertain\n significance).\n 4. Significantly fatty liver.\n\n Updated findings were discussed with Dr. at 9:12 am on \n via telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-14 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1251461,
"text": " 12:48 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Evaluate line placement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with new central line placed\n REASON FOR THIS EXAMINATION:\n Evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Central line placement.\n\n FINDINGS: No previous images. Right IJ sheath extends to the lower portion\n of the SVC. Left IJ catheter extends to the mid-to-lower portion of the SVC.\n Nasogastric tube extends to at least the distal stomach.\n\n There are low lung volumes. Hazy opacification at the right base raises the\n possibility of consolidation. Probable atelectatic changes at the left base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1251388,
"text": " 2:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 40F with attempted left subclavian\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old female with attempted left subclavian, evaluate for\n pneumothorax.\n\n COMPARISON:\n\n PORTABLE AP CHEST RADIOGRAPH: Bilateral low lung volumes are noted with\n crowding of bronchovascular markings. No pleural effusion, or pneumothorax.\n Opacification at the left lung base may represent atelectasis, less likely\n infection. ET tube is noted approximately 2.8 cm above the carina with chin in\n raised position, recommend pulling ETT back by another 1cm to prevent it\n touching the carina with neck flexion. Feeding tube is noted in the\n post-pyloric position with tip not clearly visualized.\n\n Findings discussed with RN, Israeli Demenezes at 9:15am and Dr. at 9:20\n am on via telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1251553,
"text": " 11:13 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for cerebral edema\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with DKA, profound acidemia, now with altered mental status\n REASON FOR THIS EXAMINATION:\n evaluate for cerebral edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman, with DKA and profound acidemia. Now with altered\n mental status. Evaluate for cerebral edema.\n\n COMPARISON: Non-contrast CT head on .\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\n major vascular territorial infarct. The ventricles and sulci are normal in\n size and symmetric in configuration. Basal cisterns are patent. There is no\n shift of normally midline structures. The -white matter differentiation\n is preserved. The visualized mastoid air cells are clear. There is trace\n fluid in the right maxillary sinus and right mastoid air cells and sphenoid\n sinuses but the remaining paranasal sinuses are clear. No acute skull\n fracture is noted. This study is essentially unchanged from the study one day\n before.\n\n IMPRESSION: No acute intracranial pathology. Unchanged exam from yesterday.\n If clinical concerns remain high, consider MRI brain to further assess.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1252358,
"text": " 9:47 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 44cm iv \n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r picc 44cm iv \n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Right PICC line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the previously placed left\n internal jugular vein catheter has been removed. New is a right PICC line.\n The line crosses the midline and the tip projects over the left subclavian\n vein. This malposition requires replacement of the PICC line. There is no\n evidence of complication, notably no pneumothorax. Otherwise, the radiograph\n is unremarkable. The observation was made on 8:26 a.m., on .\n At 8:27 a.m., on the same day, the referring physician, . , was paged\n for notification.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-10-01 00:00:00.000",
"description": "SKELETAL SURVEY (INCLUD LONG BONES)",
"row_id": 1253453,
"text": " 10:05 AM\n SKELETAL SURVEY (INCLUD LONG BONES) Clip # \n Reason: please assess for bone involvement\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with IgG elevation, c/f MGUS vs myeloma. New anemia\n REASON FOR THIS EXAMINATION:\n please assess for bone involvement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Skeletal survey, .\n\n CLINICAL HISTORY: 40-year-old woman with IgG elevation, history of MGUS\n versus myeloma, now with new anemia.\n\n FINDINGS: No previous studies skeletal survey-wise for a direct comparison.\n Comparison is made to the scan from .\n\n LATERAL SKULL: No focal lytic or blastic lesions are seen.\n\n BILATERAL HUMERI: There is a portion of a central venous catheter seen in the\n right arm. There are no focal lytic or blastic lesions or significant\n degenerative changes.\n\n THORACIC SPINE: No compression deformities are seen. There is minimal\n spurring at the anterior aspect of several lower thoracic vertebral bodies.\n Visualized lung fields are clear. There is a central venous catheter with\n distal lead tip at the cavoatrial junction.\n\n LUMBAR SPINE: There are five non-rib-bearing lumbar-type vertebral bodies.\n There is no compression deformity. Minimal spurring at the L4 and L5\n vertebral bodies are seen anteriorly.\n\n AP PELVIS AND BILATERAL FEMORA: No focal lytic or blastic lesions are seen.\n The sacroiliac joints are grossly within normal limits. Bilateral hip joint\n spaces demonstrate mild spurring in the superolateral aspect, consistent with\n early degenerative changes.\n\n IMPRESSION:\n\n No focal lytic or blastic lesions in the skeleton to indicate definite\n myelomatous deposits.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1252372,
"text": " 11:25 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 44cm crossed chest, pulled back 2cm, power flushed. r\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r picc 44cm crossed chest, pulled back 2cm, power flushed. repeat x-ray iv \n \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old woman with right-sided PICC line.\n\n COMPARISON: 10 a.m. this morning.\n\n FINDINGS: A single semi-erect portable chest radiograph is obtained. Tip of\n a right-sided PICC line is positioned more centrally within the left\n brachiocephalic vein. Hypoinflation of the lungs is unchanged. There is no\n new consolidation, effusion, or pneumothorax. There are no new abnormal\n cardiac or mediastinal contours.\n\n IMPRESSION: Tip of a right-sided PICC line remains in the left\n brachiocephalic vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-22 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 1252421,
"text": " 4:05 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC line\n Admitting Diagnosis: PANCREATITIS\n Contrast: OMNIPAQUE Amt: 5\n This is a power pick\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with hx of MRSA bacteremia and DKA who had failed bedside\n picc today.\n REASON FOR THIS EXAMINATION:\n please place PICC line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40-year-old woman with history of MRSA bacteremia and DKA, failed\n bedside PICC.\n\n RADIOLOGISTS: Dr. (resident), Dr. (fellow), Dr. \n (attending).\n\n PICC LINE EXCHANGE/REPOSITIONING\n The procedure was explained to the patient. A timeout was performed.\n\n TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was\n advanced through the indwelling right arm PICC line, and subsequently into the\n SVC under fluoroscopic guidance. The old PICC line was then removed and a\n peel-away sheath was placed over the guidewire. A new single-lumen PICC line\n measuring 42 cm in length was then placed through the peel-away sheath with\n its tip positioned in the SVC. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n The peel-away sheath and guidewire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a\n new 4 French single-lumen PICC line. Final internal length is 42 cm, with the\n tip positioned in the SVC. The line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-09-23 00:00:00.000",
"description": "MR L SPINE W/O CONTRAST",
"row_id": 1252586,
"text": " 9:37 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: Evaluate for radiculopathy\n Admitting Diagnosis: PANCREATITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman who presented with DKA requiring intubation, now with severe\n acute axonal sensory-motor polyneuropathy by EMG.\n REASON FOR THIS EXAMINATION:\n Evaluate for radiculopathy\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 40-year-old woman presenting with DKA, requiring intubation, now with\n acute axonal sensory and motor polyneuropathy by EMG. Please evaluate for\n radiculopathy.\n\n COMPARISON: None.\n\n TECHNIQUE: MR of the lumbar spine without contrast.\n\n FINDINGS: Intervertebral disc heights and signals are maintained. There is\n no signal abnormality in the cord. Vertebral body heights are maintained and\n show normal signal. Imaged portions of the soft tissues are unremarkable. A\n small disc buldge is present at L5-S1 with very minimal compression of the\n thecal sac, but no contact with traversing nerve roots.\n\n IMPRESSION: Very minimal disc buldge of L5-S1. If there is concern for\n polyneuritis, post gadolineum imaging can be obtained.\n\n"
}
] |
26,156 | 184,187 | Patient was managed in the CCU for the embolic stroke, which occurred during her cardiac catheterization. She was started on a Heparin drip. A Neuro consult, which was called during the cardiac catheterization continued to follow her progress. However, the patient continued to have an oxygen requirement. She did have a pulmonary capillary wedge pressure less than 18, pAO2/FIO2 of less than 200, which was consistent with an ARDS picture. For this, she was transferred to the Medical Intensive Care Unit for further management of possible ARDS. The etiology of this ARDS was initially unclear. It was possibly related to amiodarone, which she had been on for quite a long time. She also has extensive smoking history and COPD. This could also have been maybe secondary to a sepsis in the setting of possible pneumonia. She did have a bronchoscopy done, which was unrevealing and with diuresis, her pulmonary status improved dramatically. She was quickly weaned off oxygen, and it was believed that her pulmonary function was secondary to pulmonary edema and not an ARDS picture. The amiodarone continued to be held and her Solu-Medrol, which was initially started of COPD was discontinued. She did have a repeat head CT for further evaluation of the stroke. That repeat head CT showed a hypodensity and loss of the -white differentiation in the left frontal lobe. There was no evidence of shift of midline structures or ventricular dilation. These findings were consistent with an evolving infarct within the distribution of the superior division of the left middle cerebral artery. For this, the patient was continued on her Heparin drip, her aspirin, and she was started on Coumadin. Patient does have atrial fibrillation and this could be predisposition for stroke. The patient did have improvement of her neurological status. She did regain some ability of speech and she was seen by the Speech and Swallow service. Her verbal abilities have been improving slowly. Speech and Swallow evaluation was done, and they felt that she was not aspirating at this time. They did recommend soft solids as her dentures were not available here. Once the patient was euvolemic with diuresis, her diuresis was held in the setting of her aortic stenosis as she is preload dependent. She did complete a full course of ceftazidime for UTI and hydronephrosis in the setting of placement of her ureteral stent in . In terms of her cardiac status, she was continued on her beta-blocker, her ACE inhibitor, her calcium-channel blocker, and she was also started on a statin in the setting of her stroke and her known coronary artery disease. She was also restarted on her amiodarone for her atrial fibrillation once ARDS and her pulmonary status had resolved. Patient will need outpatient followup for her cardiac disease including her aortic stenosis. Patient will also followup with Dr. with the Clinic here at the . She was also instructed to followup with her primary care provider weeks. Of note, the patient did have Hemoccult positive stools in the setting of her therapeutic INR, however, her hematocrit had remained stable during the course of her hospitalization on anticoagulation. Patient obviously needs to be continued on her anticoagulation in the setting of her stroke and her atrial fibrillation. On the day of discharge, her INR was therapeutic at 2.4 and her Heparin drip was discontinued. | Nebs by RT x1 s/p bronch. vea, am lytes pnd. on ceftaz.RESP: LS clear, dim. ?d/c in am. Conts on Heparin/Coumadin. S/P bronch . ccu npn 7p-7aS: incomprehensible soundsO: Please see carevue for VS and objective data.CVS: Hemodynamically stable with HR 70's NSR no vea noted. RR 23-31. shallow breathes. Heparin dc'd for bronch in amResp - ls are clear, and decreased upper. am Na pnd. abd soft +BS. TO BE TACHYPNEIC WITH RR 32-38 & SHALLOW. PA line remains in R fem. On lopressor + lisinopril - new parameters - hold if BP <130. to start clear liquids in am. Copd. Cont to monitor resp. Right groin D/I with dsg. "O: Please see carevue for VS and objective data.CVS: Hemodynamically stable with HR 60-70's NSR, rare APC noted, no sign. Hct 29.9Resp; s/p bronch from previous shift. Decreased Fio2 requirement this shift. +BS. Pt. Pt. Pt. Pt. Pt. Pt. ON CEFTAZADIME IV FOR UTI.ENDO: BS 156->137. SPONT. BS+. CONT. CONT. Distal pulses palp. Encouraged Pt. PTT 70.GI: NPO. keep SBP >130. Resp status stable. PERL. Again seen within the subcortical white matter are multiple regions of hypodensity, unchanged from the previous examination and most likely represent small vessel ischemic changes. REMAINS NPO. There has been interval removal of a Swan-Ganz catheter and nasogastric tube. HEPARIN GTT INFUS- ING AT 1750U/HR. Moving UE equally. solumedrol d/ced.GU: urine no longer bloody now that heparin is off. RR 20, HR 67. Cont on Lopressor and Lisinopril. initially with normal speech, as above statement. U/O 50-75CC/HR.ID: AFEBRILE. Small brown, formed stool x1, guaic positive.ID: afebrile on IV Ceftazidime q 12hours. 7.42/39/249. Frequent observations.A: stable, neuro assessment varies, at times with clear speech, other times aphasic. BP 142-162/59-68. Please r/o evolving ichemia/bleed. Boop vs Amiodarone toxicity. WBC 6.7Neuro: Pt. Is only oriented x1 at this time. NGT CLAMPED FOR MEDS. Lungs coarse to clear with diminished breathe sounds in bases. +gag/cough. APHASIC. BP 138-156/60. ABD. COMPARISONS: . con't abx. The ventricles are symmetric and nondilated. remains calm.ID: afebrile. Respiratory Care:Patient given Albuterol/Atrovent nebs X 2 this shift. pt encouraged to cough. taken off NRB and placed on NC but desatted to mid 80s. pt does nod head and obeys simple commands - inconsistently. NGT patent for meds.PLAN: wean O2 as tolerated. Awaiting results of bronch from . K+3.5 GIVEN 60 MEQ PO KCL. ??? Follow up with am labs, pnd. RR 30's. BP ranges via right radial aline 140-160's/60's. pulling on foley. Tolerating meds as ordered. TECHNIQUE: Noncontrast CT of the head. status closely. BP ranges via right radial aline 150-160/60's. only received lisinopril and lopressor not norvasc.Resp: lungs clear diminshed at bases. BS COARSE BUT DIMINISHED AT BASES. to notify RN for bedpan, Pt. leaving in place, am abg 140/41/7.41/27/1 96%, therefore face tent removed, Pt. amount urine, therefore dc'd. found to be incont. to con't to wean in am. At 2am, pt found to be oob, despite side rales up, self dc'd ngt and was steady on her feet. There is moderateaortic valve stenosis. Anterior, septal, apicial andposterior hypokinesis is present.3. In comparison with prior chest radiographs, this appears to be an acute process. Mild (1+) aortic regurgitation is seen.4. Mild (1+) mitral regurgitation is seen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. Mild (1+) aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Prior inferior myocardial infarction.Q-T interval prolongation. COMPARISON: SINGLE VIEW CHEST, AP SEMIUPRIGHT: There has been interval formation of diffuse interstitial and alveolar opacification within both lungs. Overallleft ventricular systolic function is moderately depressed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are moderately thickened. occ wheeze noted. FINDINGS: The patient is status post median sternotomy. Left ventricular function.BP (mm Hg): 158/72HR (bpm): 80Status: InpatientDate/Time: at 09:51Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: The left ventricular cavity is moderately dilated. lytes replaced this am. There ismoderate aortic valve stenosis. The patient is status-post median sternotomy and CABG. There is mildmitral annular calcification. recheck lytes tonite. Small pericardial effusion and small bilateral pleural effusions. The patient is status post median sternotomy and CABG. Delayed precordial R wave progression consistentwith prior anterior myocardial infarction. Cont to follow and cov with SS Reg.A/P: pt remains tachypneic, sl improvement in po2, Enc C&DB, IV solumedrol, hemodynamically stable, neuro status somewhat improved, now verbalizing, head CT consistant with stroke, awaiting official report, check PTT at 1AM. Mild (1+) mitralregurgitation is seen.5. Levo d/c'd. 2) Interval re- positioning of the NG tube which now extends beyond the limits of the radiograph in the stomach. Levoflox changed to Ceftazidime. placement checked by xray + auscultation. The patient is status post CABG. AP SUPINE VIEW OF THE CHEST: There is an NG tube with the tip located in the esophagocardiac junction. A small pericardial effusion is present. monitor resp status. There is again noted a Swan-Ganz catheter in unchanged position. ?stroke + encephalopathy? There is a calcified granuloma at the right lung base. There is mild pulmonary artery systolic hypertension.6. CT CHEST WITHOUT CONTRAST: There is moderate polychamber cardiac enlargement. The NG tube was re-positioned and now extends beyond the limitations of the radiograph in the stomach. The left atrium is mildly dilated.2. admin meds via ngt. Sinus rhythm. Calm, cooperative, wrist restraints removed.CV: HR 70's NSR, BP 150-160's/60, up to 170-180's right before Lopressor dose due. repeat lytes this pm.GI/GU: foley patent, cloudy/sediment dk urine. The left ventricular cavity is moderately dilated. There are multiple lacunar infarcts unchanged from MRI of . The thoracic aorta is enfolded with vascular calcifications. Findings are consistent with pulmonary edema. There is mildpulmonary artery systolic hypertension.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. IMPRESSION: 1) There is slight interval improvement in the lung inflation and possibly in the diffuse bilateral pulmonary infiltrates. | 22 | [
{
"category": "Radiology",
"chartdate": "2159-04-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 821739,
"text": " 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess infiltrates/chf\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for\n change\n REASON FOR THIS EXAMINATION:\n please assess infiltrates/chf\n ______________________________________________________________________________\n FINAL REPORT\n Compared to .\n\n CLINICAL INDICATION: Pulmonary edema.\n\n There has been interval removal of a Swan-Ganz catheter and nasogastric tube.\n The cardiac silhouette is mildly enlarged. The previously present pattern of\n pulmonary edema has significantly improved with residual areas of perihilar\n haziness and peribronchial cuffing remaining. No new or worsening areas of\n opacification are observed.\n\n IMPRESSION: Resolving congestive heart failure pattern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-04-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 821400,
"text": " 6:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o stroke progression\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n FINAL ADDENDUM\n There is moderate mucosal thickening in the right sphenoid air cell, also seen\n on the prior study, likely inflammatory in origin.\n\n\n\n 6:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o stroke progression\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new aphasia after cardiac cath. would not tolerate MRI.\n Please r/o evolving ichemia/bleed.\n REASON FOR THIS EXAMINATION:\n r/o stroke progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New aphasia after cardiac cath cannot tolerate MRI please evaluate\n for evolving ischemia or hemorrhage.\n\n COMPARISONS: .\n\n TECHNIQUE: Noncontrast CT of the head.\n\n CT OF THE HEAD WITHOUT CONTRAST: Within the left frontal lobe, there is a 3 by\n 5cm area of loss of / white differentiation and hypodensity consistent\n with a subacute infarct. This extends to involve the left insular region.\n There is mass effect upon the sulci of the left frontal lobe and insula;\n however, there is no shift of normally midline structures. The ventricles are\n symmetric and nondilated. There is no intracranial hemorrhage. No other areas\n of loss of / white differentiation are identified. Again seen within the\n subcortical white matter are multiple regions of hypodensity, unchanged from\n the previous examination and most likely represent small vessel ischemic\n changes. The density values of the brain parenchyma are otherwise within\n normal limits. The surrounding osseous structures appear unremarkable, without\n evidence of fracture. The paranasal sinuses and mastoid air cells are normally\n pneumatized.\n\n IMPRESSION: Hypodensity and loss of white differentiation within the left\n frontal lobe extending to the left insula, with local mass effect but without\n evidence of shift of midline structures or ventricular dilatation. These\n findings are consistent with an evolving infarct within the distribution of\n the superior division of the left middle cerebral artery. No acute hemorrhage.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-13 00:00:00.000",
"description": "Report",
"row_id": 1603427,
"text": "CCU NPN: Please see flowsheet for objective data\n\nCardiac: HR 60's NSR BP 140-170's/50-68 BP did drop transiently to 90's/when ambulated to chair with PT. only received lisinopril and lopressor not norvasc.\n\nResp: lungs clear diminshed at bases. sats mid 90's on 4l. bronched in afternoon recieved 2mg versed and 25mcg fent,now wearing 50% CN with 4l NP. solumedrol d/ced.\n\nGU: urine no longer bloody now that heparin is off. uo 35-50cc/hr -190cc.\n\nGI: NPO prior to bronch. was able to swallow pills without difficulty prior to bronch. no stool. +BS. attempt po meds and diet once versed and fent wear off\n\nID: afebrile continues on ceftazidine\n\nEndocrine: has not required any insulin\n\nNeuro: equal strength in all ext. ambulates with minimal assistance.has cognitive deficits,when asked someones name,gave a phone number. asked her name,spells her name. oriented x1\nfollows commands. when she does speak her speech is clear. answering more questions verbally today than yesterday.\n\nSocial: daughter in visiting today.\n\nA/P: to restart heparin at 9pm\n wean O2 as tolerated\n provide for safety,did climb out of bed last night\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-14 00:00:00.000",
"description": "Report",
"row_id": 1603428,
"text": "ccu npn micu border 7p-7a\nS:\"I'm home, I'm in Nashau.\"\n\nO: Please see carevue for VS and objective data.\n\nCVS: Hemodynamically stable with HR 60-70's NSR, rare APC noted, no sign. vea, am lytes pnd. BP ranges via right radial aline 140-160's/60's. Tolerating meds as ordered. IV Heparin restarted at 1100u/hour at as ordered without bolus, PTT at 0230 56.5, Pt. started on 5mg po Coumadin at . am PT 14.2. Hct 29.9\n\nResp; s/p bronch from previous shift. Initially on 5l n/c with cool neb at 70%, however, Pt. cont to remove face mask and sats 90-93% on n/c, therefore changed to 5L n/c with face tent at 50%. Pt. leaving in place, am abg 140/41/7.41/27/1 96%, therefore face tent removed, Pt. now on 5l n/c with sats 96-98%. Lungs coarse to clear with diminished breathe sounds in bases. Nebs by RT x1 s/p bronch. RR 23-31. shallow breathes. Weak, non-productive cough.\n\nGI:GU: Taking free H20 with meds, +gag, swallowing pills without any difficultly, sipping independently from straw in cup. Unable to give free h20 bolus secondary to no NGT, encouraged to drink H20. MICU team aware. am Na pnd. Pt. to start clear liquids in am. At change of shift, foley catheter noted to be leaking urine around insertion, ? Pt. pulling on foley. Attempted to add sterile H20 to balloon, foley cont'd to leak mod. amount urine, therefore dc'd. Encouraged Pt. to notify RN for bedpan, Pt. found to be incont. of moderate amount urine, therefore foley replaced with 16Fr, urine pink with sediment, irrigated with sterile H20, no clots noted. U/O 10-80cc/hour. Small brown, formed stool x1, guaic positive.\n\nID: afebrile on IV Ceftazidime q 12hours. WBC 6.7\n\nNeuro: Pt. initially with normal speech, as above statement. Alert and oriented to person only, stated she was at home and month was , unable to name president or current events. Unaware she is in the hospital. At times speech is clear but confused, repetitive statements. \"It all happened around the corner\" Unable to elaborate or explain. Other times Pt. is aphasic, focusing on RN, nodding head appropriately to simple questions but not able to speak, despite encouragement; this was during the middle of the night, when Pt. was woken from sleep for labs and neuro assessment. Micu team aware. Pt. MAE, following commands. PERL 3mm, . +gag/cough. Sleeping comfortably most of night, no attempts to get OOB. Frequent observations.\n\nA: stable, neuro assessment varies, at times with clear speech, other times aphasic. Confused at baseline.\n\nP: Cont to monitor neuro status closely. Maintain safety measures. Conts on Heparin/Coumadin. Follow up with am labs, pnd. Awaiting results of bronch from . Cont to monitor resp. status and hemodynamics. Comfort and emotional support to Pt. and family\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-14 00:00:00.000",
"description": "Report",
"row_id": 1603429,
"text": "Respiratory Care:\n\nPatient given Albuterol/Atrovent nebs X 2 this shift. Bs remain clear bilaterally. RR 20, HR 67. Decreased Fio2 requirement this shift. Pt. weaned to 5lpm nasal prongs. O2 sats 98%. Resp status stable. Copd. S/P bronch . ? Boop vs Amiodarone toxicity. No change with bronchodilator rx's. Plan: Will follow and re evaluate frequency of therapy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-11 00:00:00.000",
"description": "Report",
"row_id": 1603423,
"text": "ccu npn 7p-7a\nS: incomprehensible sounds\n\nO: Please see carevue for VS and objective data.\n\nCVS: Hemodynamically stable with HR 70's NSR no vea noted. BP ranges via right radial aline 150-160/60's. Tolerated 25mg po Lopressor at . Right groin D/I with dsg. Distal pulses palp. IV Heparin at 1750u/hour with PTT pnd.\n\nResp; Sats 92-95% on 50% face tent. Lungs coarse and diminished in bases. RR 30's. To have chest CT tonight.\n\nGI:GU: NPO, meds via NGT in good placement. Abdomen soft with active bowel sounds. No stool. Foley to drainage with amber urine, total I/O per flow.\n\nID: afebrile\n\nNeuro: Pt. alert, aphasic, some incomprehensible sounds noted when changing IV site for rountine change. Nodding head appropriately to simple questions. States she hears nurse and understands. Denied pain. PERL 2-3mm. Weak non-productive cough. Follows simple commands, weak hand grasp but equal, wiggles toes, lifts and holds LE. Moving UE equally. Does not attempt to pull off mask or NGT. Resting comfortably when left alone.\n\nA: stable, awaiting chest CT for pulmonary w/u.\n\nP: Cont to assess neuro status, monitor hemodynamics and resp. status closely. Pt. to have chest CT tonight. Comfort and emotional support to PT. and family. Dr. called daughter this shift to inform her of plan for chest CT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-12 00:00:00.000",
"description": "Report",
"row_id": 1603425,
"text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: HR 60-70's BP 155-180's/55-74 norvasc increased to 10mg and lisinopril increased to 20mg.lopressor 25mg .\n\nFluid/electrolytes: K 3.2 this am repleted with 80po KCL.repeat 4.6,NA 147 in am now 144.free water boluses now 250 q4. UO has been 60-150/hr +56cc.\n\nRenal: BUN/Creat 43/0.7.had been diuresed initially\n\nResp: on 50% face tent with sats 88-98. lungs coarse and diminished at bases. CT of chest today,poor study and bronch tomorrow.weak non productive cough,tachypnic at times rr 32-36.ASA d/ced to do bronch\n\nActivity: OOB to chair at 5pm with PT,minimal assist. did not seem to understand all directions,bending knees only partly,then resisted when PT attemped to bend her knees more.\n\nNeuro: alert and oriented x1,when she does speak her speech is clear. repeats questions when asked,called the window a wall. with encouragement is able to answer questions.\n\nID: afebrile,on ceftazidine for e-coli UTI\n\nHeme: PTT in am 86.6,hep gtt decreased to 1600,repeat at 4pm PTT 80 heparin drip decreased to 1450 at 5pm. urine is red with clots\n\nEndocrine: no insulin coverage required\n\nGI: TF's started at 2pm promote with fiber at 10cc/hr,residuals checked at 6pm,less than 10cc.TF rate increased to 20/hr. goal is 60/hr. has one small loose OB- stool\n\nSocial: daughter visited and team called daughter . signed consent for bronch.\n\nA/P: encourage to speak\n check PTT at 11pm\n follow uo and I&O's\n provide emotional support to pt and family\n NPO after midnight for bronch\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-13 00:00:00.000",
"description": "Report",
"row_id": 1603426,
"text": "CCU NURSING PROGRESS NOTE 7PM-7AM\nS: I'm in the hospital\n\nO: Through eve, pt is oriented x2 (-time), is pleasant and cooperative. She is encouraged to verbalize, rather than nod her head and does so with encouragement. MAE purposefully. At 2am, pt found to be oob, despite side rales up, self dc'd ngt and was steady on her feet. She was attempting to look out the window. Pt back to bed with 2 nurse assist. Is only oriented x1 at this time. Pt sleeping through most of shift.\n\nAfebrile - cont on Ceftazadime\nCV - HR 60's nsr with no vea. BP 138-156/60. Cont on Lopressor and Lisinopril. Heparin dose changed from 1450u/ to 1300u/hr, for PTT 79. Heparin dc'd for bronch in am\nResp - ls are clear, and decreased upper. non productive cough. O2 had been on with face tent at 50%, but pt is taking off. Sats down to 82% on ra. O2 placed at 4ln/p and sats up to 97-100%\ngi- TF off at 12 am d/t NPO for bronch\nGU - uo cont bloody @ 40-75cc/hr\nDM - Fingersticks wnl\n\nA: Improved neuro status early in evening. Increased confusion during night resulting in dc/ing of NGT\n\nP: NPO for bronch, Restart Heparin post, ? possible replacement of NGT vs. assessment of swallow, Increase activity as pt tolerates, cont to reorient as necessary and encourage verbalization by pt, Maintain safe environment.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-12 00:00:00.000",
"description": "Report",
"row_id": 1603424,
"text": "NEURO: AWAKE & ALERT. MAKES EYE CONTACT & TRACTS WITH EYES. PERL.\n APHASIC. FOLLOWS SIMPLE COMMANDS CONSISTENTLY. MAE. ABLE TO\n LIFT & HOLD LE. PURPOSEFUL MOVEMENTS WITH UE. HAND GRASPS = BUT\n WEAK.\nRESP: O2->50% OFT. O2 SATS 94-98%. BS COARSE BUT DIMINISHED AT BASES.\n CONT. TO BE TACHYPNEIC WITH RR 32-38 & SHALLOW. WEAK NON-PROD-\n UCTIVE COUGH.\nCARDIAC: HR 65-73 SR, NO ECTOPY. BP 142-162/59-68. HEPARIN GTT INFUS-\n ING AT 1750U/HR. PTT 70.\nGI: NPO. NGT CLAMPED FOR MEDS. ABD. SOFT. BS+. NO STOOL.\nGU: FOLEY->CD PATENT & DRAINING BLOOD-TINGED URINE. U/O 50-75CC/HR.\nID: AFEBRILE. CONT. ON CEFTAZADIME IV FOR UTI.\nENDO: BS 156->137. INSULIN PER SLIDING SCALE.\nAM LABS PENDING.\n\nPLAN: CHEST CT EARLY THIS AM, THEN ?????BRONCH DEPENDING WHAT IS SEEN\n ON CT SCAN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-11 00:00:00.000",
"description": "Report",
"row_id": 1603421,
"text": "CCU progress note 11p-7a MICU team\nNEURO: pt remains aphasic, occasionally saying words. unable to assess orientation. pt does nod head and obeys simple commands - inconsistently. wrist restraints remain off, pt occasionally taking off face mask but leaves in NGT, pt not tugging at lines. remains calm.\n\nID: afebrile. on ceftaz.\n\nRESP: LS clear, dim. continues to have shallow rapid breathing. 7.42/39/249. taken off NRB and placed on NC but desatted to mid 80s. placed on 5L w/ 70% cool neb face tent for sats >98%. to con't to wean in am. pt encouraged to cough. CXR due in am - last CXR showed ARDS.\n\nCARDIAC: SR 60-70s. On lopressor + lisinopril - new parameters - hold if BP <130. Neuro goal BP >130. PA line remains in R fem. PADs 15. ?d/c in am. R radial Aline patent - maps >80. Heparin gtt increased to 1550u at 2am - repeat PTT at 8am.\n\nGI/GU: foley patent, cloudy amber urine ~ 30cc/hr. abd soft +BS. no BM. NGT patent for meds.\n\nPLAN: wean O2 as tolerated. keep SBP >130. monitor neuro status. con't abx. recheck PTT at 8am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-11 00:00:00.000",
"description": "Report",
"row_id": 1603422,
"text": "NURSING PROGRESS NOTE 0700-1500\nNEURO---MUCH IMPROVED NEURO STATUS SINCE 0700. PT IS ABLE TO CLEARLY SAY A FEW WORDS INCLUDING HER NAME. SHE HAS PROBLEMS WITH REPETITION. WHEN ASK PT TO COUGH AND DEMONSTRATION IS SHOWN, SHE WILL SAY THE WORDS 'COUGH,COUGH' IN THE SAME CADENCE THAT SHE IS HEARING . BILAT ARM STR IS 5+ . SHE HAS A WEAK GRASP. NOT ABLE TO FOLLOW ACTION COMMANDS,\"TOUCH YR NOSE,POINT TO LIGHT\".BILAT LE LIFT AND HOLD ON BED. SHE MOVES ALL 4 EXT. SPONT. SPEECH AT TIMES IS CLEAR, OTHER TIMES IT IS GARBLED. PEARL AT 3-4 MM.\n\nCARDIAC--SBP 150-160. HR SR 70'S WITH OCCAS UNIFOCAL PVC. RECEIVED ALL ANTI HTN DRUGS. K+3.5 GIVEN 60 MEQ PO KCL. ON HEPARIN GTT AT 1550. PTT TO BE CHECKED AT 1400.\n\nRESP--O2 WEANED DOWN TO 50% FACE TENT. SPONT RESP 34-42. LUNGS COARSE BILATERALLY AND DECREASED IN UPPER LOBES. PT COUGHS SPONT AND IT IS PRODUCTIVE. SAO2 90-95%.\n\nGI--NGT PATENT. REMAINS NPO. NO STOOL AT PRESENT.\n\nGU--FOLEY CATH PATENT DRAINING >40 CC HR OF CLOUDY URINE.\n\nENDO--NO SSRI COVERAGE NEEDED.\n\nSKIN--GROSSLY INTACT.\n\nID--AFEBRILE AT PRESENT. ON ABX FOR E COLI IN URINE.\n\n RN HAS SPOKEN WITH DAUGHTER , AND HAS UPDATED HER REGARDING HER CONDITION AND PLANS FOR THE DAY. SHE WOULD LIKE TO BE CALLED PRIOR TO ANY TESTS THAT WILL BE DONE. PT HAS NODDED IN THE AFFIRMATIVE WHEN ASKED IF SHE IS FRIGHTENED. SHE DOES WELL WITH REINFORCEMENT.\n\nA--IMPROVED NEURO STATUS. AFEBRILE.\n\nP--CON'T TO ASSESS NEURO STATUS. PROVIDE SAFETY AND REASSURANCE TO PT. OFFER SUPPORT TO FAMILY AND PT. CHECK RESULTS OF LABS DRAWN AT 1400.\n"
},
{
"category": "Echo",
"chartdate": "2159-04-10 00:00:00.000",
"description": "Report",
"row_id": 69585,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congestive heart failure. Coronary artery disease. H/O cardiac surgery. Left ventricular function.\nBP (mm Hg): 158/72\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 09:51\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 mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity is moderately dilated. Overall\nleft ventricular systolic function is moderately depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is\nmoderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. The left ventricular cavity is moderately dilated. Overall left ventricular\nsystolic function is moderately depressed. Anterior, septal, apicial and\nposterior hypokinesis is present.\n3. The aortic valve leaflets are moderately thickened. There is moderate\naortic valve stenosis. Mild (1+) aortic regurgitation is seen.\n4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n5. There is mild pulmonary artery systolic hypertension.\n6. Compared with the findings of the prior study (tape reviewed) of ,\nthere is no significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 821430,
"text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: am CXR to be done for 730am Rounds.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for\n change\n REASON FOR THIS EXAMINATION:\n am CXR to be done for 730am Rounds.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with coronary artery disease and acute\n pulmonary edema. Please evaluate for change.\n\n COMPARISON: .\n\n FINDINGS: AP portable supine single view of the chest. There is cardiomegaly\n which is stable. Mediastinal and hilar contours are stable when compared to\n the previous study. In the interval, there is slight improvement in the lung\n inflation and possibly in the bilateral diffuse infiltrates. The Swan-Ganz\n catheter is in an unchanged position. There is a new central line with the\n tip in the left brachiocephalic vein. The NG tube was re-positioned and now\n extends beyond the limitations of the radiograph in the stomach. The patient\n is status-post median sternotomy and CABG.\n\n IMPRESSION: 1) There is slight interval improvement in the lung inflation and\n possibly in the diffuse bilateral pulmonary infiltrates. 2) Interval re-\n positioning of the NG tube which now extends beyond the limits of the\n radiograph in the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-04-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 821289,
"text": " 6:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for evidence of ICH.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new aphasia after cardiac cath.\n REASON FOR THIS EXAMINATION:\n Evaluate for evidence of ICH.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71 year old, aphasia post-cath.\n\n CT SCAN of the brain(following cardiac catheterization)\n\n Findings: Contrast enhancement is seen in the circle of vessels\n consistent with the patient's post-cath status. There are no extra or\n intracranial hemorrhage, shift of normally mid- line structures, or\n hydrocephalus. - white differentiation is preserved. There are multiple\n lacunar infarcts unchanged from MRI of . The osseous structures are\n unremarkable. The mastoid air cells are clear. Mucosal thickening is seen in\n the sphenoid sinus. The remaining visualized paranasal sinuses are clear.\n\n IMPRESSION: No acute hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-04-12 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 821543,
"text": " 7:55 AM\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for interstitial lung disease. ?ARDS vs, amio lung tox\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with incr. O2 req, bilat infil on CXR, PaO2/FiO2 of 60.\n\n REASON FOR THIS EXAMINATION:\n eval for interstitial lung disease. ?ARDS vs, amio lung toxicitiy.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increasing oxygen requirement, bilateral infiltrates on chest\n radiographs, evaluate for ARDS versus amiodarone lung toxicity.\n\n TECHNIQUE: Contiguous axial images were obtained through the chest without IV\n contrast. Additional images in expiration were obtained. Coronal reformations\n were performed.\n\n CT CHEST WITHOUT CONTRAST: There is moderate polychamber cardiac enlargement.\n Dense coronary arterial and aortic calcifications are present. Scattered nodes\n are noted throughout the mediastinum which do not meet CT criteria for\n pathologic enlargement. The NG tube extends into the stomach. A small\n pericardial effusion is present. There are bilateral small pleural effusions.\n Within the imaged portion of the upper abdomen, the liver is noted to be of\n high attenuation, measuring up to 79 Hounsfield units. Multiple splenic\n granulomas are identified.\n\n Lung windows demonstrate diffuse lung disease with relative sparring of the\n lung bases. There are diffuse areas of ground glass attenuation as well the\n presence of intralobular septal thickening. In comparison with prior chest\n radiographs, this appears to be an acute process. There is evidence for\n moderate air trapping. There is a calcified granuloma at the right lung base.\n\n Bone windows demonstrate no suspicious lytic or sclerotic abnormalities. The\n patient is status post CABG.\n\n IMPRESSION:\n 1. Diffuse lung disease with extensive areas of ground glass opacification as\n well as centrilobular septal thickening. There is relative sparring of the\n bases. Differential considerations are broad and include pulmonary edema,\n cryptogenic organizing pneumonia, chronic eosinophylic pneumonia, vasculitis,\n desquamative interstitial pneumonitis, drug-induced lung disease, diffuse\n alveolar damage secondary to amiodarone, and pulmonary alveolar proteinosis.\n Less likely considerations include bronchiol-alveolar cell carcinoma and\n lymphoma.\n 2. Small pericardial effusion and small bilateral pleural effusions.\n 3. Evidence for prior granulomatous disease.\n\n (Over)\n\n 7:55 AM\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for interstitial lung disease. ?ARDS vs, amio lung tox\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-04-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 821309,
"text": " 6:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for change\n REASON FOR THIS EXAMINATION:\n please eval for change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 71 y/o woman with coronary artery disease and acute pulmonary\n edema.\n\n PORTABLE AP CHEST: Comparison is made to the study from at 9:15 p.m.\n\n FINDINGS: The patient is status post median sternotomy. There is again noted a\n Swan-Ganz catheter in unchanged position. There are diffuse bilateral alveolar\n opacities consistent with pulmonary edema. It is possibly slightly\n improved when compared to the previous study. There is slight blunting of the\n left costophrenic angle that could represent a small pleural effusion. The\n cardiac, mediastinal and hilar contours are unchanged.\n\n IMPRESSION: There is possible slight improvement in the pulmonary edema in the\n interval. The findings are consistent with pulmonary edema. Correlate with\n Swan-Ganz measurements.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 821294,
"text": " 8:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulm edema/infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema\n REASON FOR THIS EXAMINATION:\n assess for pulm edema/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, shortness of breath.\n\n COMPARISON: \n\n SINGLE VIEW CHEST, AP SEMIUPRIGHT: There has been interval\n formation of diffuse interstitial and alveolar opacification within both\n lungs. There has also been interval placement of a right femoral Swan-Ganz\n catheter with the tip lying within the left interlobar pulmonary artery. No\n pleural effusions are identified. The patient is status post median\n sternotomy and CABG. The cardiac size is enlarged with left ventricular\n prominence. The thoracic aorta is enfolded with vascular calcifications.\n\n IMPRESSION:\n 1. Interval placement of right femoral Swan-Ganz catheter with the tip lying\n within the left interlobar artery.\n 2. Marked interstitial and alveolar opacification within both lung fields.\n Findings are consistent with pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-04-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 821332,
"text": " 8:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for ngt placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with CAD, acute pulm edema vs ARDS, please eval for change\n\n REASON FOR THIS EXAMINATION:\n evaluate for ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NG tube placement.\n\n COMPARISON: X ray done 1 hour and ago.\n\n AP SUPINE VIEW OF THE CHEST: There is an NG tube with the tip located in the\n esophagocardiac junction. There is 1 side hole of the NG tube that is located\n in the distal esophagus. Recommend advancing the NG tube approximately 7 cm.\n Otherwise the appearance of the chest radiograph is essentially unchanged.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-10 00:00:00.000",
"description": "Report",
"row_id": 1603419,
"text": "CCU progress note 7a-3p\nNEURO: PERLA 3mm , , normal strength, obeys commands inconsistently. opens eyes to voice. occasional garbled sounds, unable to speak, shakes head no when asked to speak. startles very easily. nods head yes and no inconsistently to commands. Neuro on consult. ?stroke + encephalopathy? pt to have MRI if she stays calm/unmoving for scan or repeat CT of head without contrast for diagnostic purposes.\n\nID: afebrile. Tmax 98.8 ax. Levo d/c'd. to be started on Ceftaz. +ecoli UTI. urine cx sent today for legionella screen. need to obtain induced sputum cx and nasal swabs this evening. Pan Cx . no skin breakdown noted.\n\nRESP: LS clear, dim. occ wheeze noted. CXR shows ARDS. Tachypneic 20-30s. sats 96-99% on NRB 100%. attempted to wean off to 6L n/c but sats dropped to 87%.\n\nCARDIAC: SR 70s. given lopressor 25mg as ordered via NGT today. Heparin gtt increased to 1250u/hr - next PTT due after 3pm. R fem PA line intact. stable BP. PA 43/19 Pasat 69% CO 6.4 CI 3.03. con't to have R leg immobilizer on d/t PA line in R fem. palpable pedal pulses. lytes replaced this am. repeat lytes this pm.\n\nGI/GU: foley patent, cloudy/sediment dk urine. >60cc/hr. abd soft distended. +BS. NGT inserted today for po meds. placement checked by xray + auscultation. no BM. remains NPO.\n\nSOCIAL: daughters called multiple times during day. RN + HO talked to family. keep up to date. family to call back this evening w/ med list.\n\n\nPLAN: con't monitoring hemodynamics/vs. admin meds via ngt. monitor resp status. keep pt from getting out of bed - R leg immobilizer on. less agitated during day shift today. rechekc PTT after 3pm. recheck lytes tonite. con't abx. keep pt comfortable.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-10 00:00:00.000",
"description": "Report",
"row_id": 1603420,
"text": "CCU NPN 3-11pm\nNeuro: alert, following commands consistantly, nodding appropriately, PERL, MAE and has normal strength. By later in shift becoming more verbal. Asked daughters where her washing machine was. When I encouraged her to cough, she wouldn't saying oh, it will be alright. Would not answer orientation questions. Had head CT this eve. Calm, cooperative, wrist restraints removed.\n\nCV: HR 70's NSR, BP 150-160's/60, up to 170-180's right before Lopressor dose due. Denies any pain. Swan-ganz in R fem, PA 40/17-20. Daughter brought in all meds from home, list given to resident. A-line placed in R radial. Hep gtt increased to 1450U/hr for PTT 37.\n\nResp: LS crackles in upper lobes, clear at bases bilaterally. cont on 100% NRB with sats 90-100%, ABG improved with po2 in 80's. Weak cough, sounds conjested at times, unable to expectorate. Cont tachypneic with RR high 30's-40, shallow.\n\nGI: NPO, no stool.\n\nID: afebrile. Levoflox changed to Ceftazidime. Nasal swabs sent for culture and viral tests.\n\nSkin: intact.\n\nEndocrine: BS 148, no coverage required. Cont to follow and cov with SS Reg.\n\nA/P: pt remains tachypneic, sl improvement in po2, Enc C&DB, IV solumedrol, hemodynamically stable, neuro status somewhat improved, now verbalizing, head CT consistant with stroke, awaiting official report, check PTT at 1AM.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-04-10 00:00:00.000",
"description": "Report",
"row_id": 1603418,
"text": "CCU NSG ADMIT/PROGRESS NOTE 7:30P- 7A/ RESP DISTRESS\n\nS- NONVERBAL\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT ARRIVED TO CCU S/P CATH WITH BILATERAL SHEATHS IN PLACE AND 100% NR ON FOR 02 SATS MID 86%.\nINITIALLY ON TNG GTT FOR PRELOAD REDUCTION R/O PULMONARY EDEMA- ONCE CXR INDICATED ARDS- WEANED TO OFF.\nRT FEMORAL ALINE D/C AND LEFT IN PA LINE- HEPARIN GTT 1100U NO BOLUS STARTED 1AM 4 HOURS AFTER SHEATH D/C.\nHEMODYNAMICS STABLE- HR- 70'S SR, MINIMAL VEA- BP- 140/60-150/70'S.\nUNABLE TO GIVE PO B BLOCKERS/MEDS D/T ALTERED MENTAL STATUS.\n\nMS- SEE PT NONVERBAL, STARTED ON HEPARIN GTT PER NEURO TEAM FOR R/O EMBOLIC STROKE, R/O PE FOR ACUTE RESP DISTRESS.\nPT LOOKING BUT NO WORDS, UNABLE TO ASSESS LEVEL OF ORIENTATION\nNO CHANGE IN NEURO SIGNS THIS SHIFT.\nBILATERAL WRIST RESTRAINTS AND POSEY AND NEED FOR CLOSE MONITORING FOR AGITATION. ATTEMPTING OOB AND TRYING TO PULL AT PA LINE. PULL OFF O2 MASK WITH O2 SATS DROPPING TO 68%.\nDAUGHTER IN TO SPEAK WITH TEAM/STAFF AND REINFORCED THIS BEHAVIOR IS NEW.\n\n PT INITIALLY ON 100%- INCREASED TO 100% NR AND 6L NP- ABLE TO WEAN OFF NC- KEEPING O2 SATS >93%- SOME WHEEZING- STARTED NEBS AND STRESS DOSE STEROIDS TID.\nNO COUGH, DROPPING SATS WHEN SELF D/C MASK IN SPITE OF REPEATED WRIST RESTRAINING..REQUIRING CLOSE WATCH.\n\nID- AFEBRILE- RESUMED DAY LEVO FOR (+) ECOLI UTI.\nPAN CULTURED THIS EVE\n\nGU- GOOD REPSONSE TO CATH LAB LASIX AND REPEATED 40 LASIX 12AM- 1 LITER OUT TO THAT DOSE\nCXR REVEALING ARDS PICTURE.\nI/O EVEN AS OF MN IN SPITE OF GOOD DIURESIS AND PAD # LOW NORMAL.\n\nGI- NPO- TOO SOMNOLENT (+) BS\n\n\nLYTES- REPLETED K AND CA WITH 40 KCL AND 2 AMPS CA GLUC\n\nLINES- BILATERAL HEPLOCKS, RT FEMORAL PA LINE WITH VENOUS SIDEARM.\n\nA/ PT ADMITTED TO CCU S/P CATH WITH CHF VS COPD FLARE VS ARDS\n\n\nCONTINUE TO CLOSELY MONITOR NEURO STATUS, NOTE ANY CHANGE IN MS.\nSAFETY- WRIST RESTRAINTS, POSEY, ATTEMPT TO REORIENT.\nPLAN FOR MRI TODAY\nCONTINUE HEPARIN.\nDISCUSS NEED FOR NG TUBE FOR PO MEDS.\nDISCUSS POSSIBILITY TO D/C PA LINE WITH NO CHANGE IN PA # OR CO/CI\nAND IN SETTING OF AGITATED PT.\nCHECK PTT 7AM ON 1100U HEPARIN.\nCONTINUE TO DIURESE AS NEEDED AND REPLETE LYTES.\nCONTINUE ANTIBX AS ORDERED.KEEP NPO UNTIL MS CLEARS, LESS SOMNOLENT.\n"
},
{
"category": "ECG",
"chartdate": "2159-04-15 00:00:00.000",
"description": "Report",
"row_id": 164113,
"text": "Sinus rhythm. A-V conduction delay. Prior inferior myocardial infarction.\nQ-T interval prolongation. Delayed precordial R wave progression consistent\nwith prior anterior myocardial infarction. Compared to the previous tracing\nof the rate has increased. Otherwise, no diagnostic interim change.\n\n"
}
] |
6,854 | 123,406 | She was admitted preoperatively for cardiac cath which showed patent bypass grafts x 3. She was then taken to the operating toom on where she underwent a redo-sternotomy, excision of left atrial mass/myxoma. She was tranferred to the SICU in critical but stable condition. A CXR immediately post operatively showed right sided collapse for which she underwent a bronchoscopy which showed secretions, a post bronch xray showed marked improvement. She was extubated and weaned from her vasoactive drips by POD #1. She was transferred to the floor on POD #2. She did well postoperatively, and was ready for discharge on . | Normaldescending aorta diameter. Normal ascending aorta diameter. Aorta intact post decannulation. Right ventricular conduction delay. Cardiomediastinal silhouette has a normal postoperative appearance and mediastinal vasculature is less engorged. Normal regional LVsystolic function. Sternal drsg w/old serosang drng small amt.Resp: Lungs clear and diminished in the bases. repleted lytes prn. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There are simple atheroma in the descending thoracic aorta.6. PERCOCET FOR PAIN.CV: SR, NO ECTOPY. Mediastinal and hilar contours are normal. NO CT.RESP: L/S CLEAR WITH DIM BASES. Small bilateral pleural effusions unchanged. IMPRESSION: Slight increase and small right pleural effusion. A small focus of air is present in the retrosternal region, likely postoperative. Biventricular systolic function is unchanged.2. Left atrial myxoma has been resected.3. Standard position of tubes and lines. Chest tubes removed. CSRU NPNNEURO: GROSSLY INTACT. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). Right ventricular chamber size and free wall motion are normal.4. Has peripheral IV. B/P STABLE. vital signs stable. Right upper lobe atelectasis. No AR.MITRAL VALVE: Normal mitral valve leaflets. Peripheral pulses palpable. The mediastinal drain tip is just above the right hemidiaphragm. No resp distress noted, = rise and fall of chest. by m.d. Reexpansion of collapse part of right upper lung. sl gen edemaresp: ls diminished rll, crackes lll. PEARRLACV: RSR w/o ectopy. Normal LV wall thicknesses and cavity size. Heart size is borderline normal. Mild (1+) mitralregurgitation is seen.8. CHEST, TWO VIEWS: There are median sternotomy wires and mediastinal clips in place. Probable mild pulmonary edema. nursing 7a-3ppt neurologically intact. Monitor, tx, support, and comfort. There is resolution of bilateral reticular opacities of the lung. pt post op for sm-mod amt of clear secretions. Discrete atelectasis is limited to the right lower lobe. skin w/d. calm, cooperativeid: afebrile, p/o atbcv: apaced at 70. bp good. ROS:Neuro: A+O x's 3. Overall left ventricular systolic functionis normal (LVEF>55%).3. Left ventricular wall thicknesses and cavity size are normal. The right lower lung is clear. Regional leftventricular wall motion is normal. Lungs otherwise clear. The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation.7. The overall cardiac size is normal. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. INDICATION: Status post myxoma resection. IMPRESSION: 1. IMPRESSION: 1. Pulmonary toileting. The mitral valve leaflets are structurally normal. pulm toilet. palapabled pulses. There is no pericardial effusion.Post Bypass1. Postioned for comfort. no distressgi: tol sip cl liquid w/o difficultyendo: con't insulin gttgu: adquate huowound: chest wound dsd w sm amt serosang drg. Compared to the previoustracing of no major change. PULMONARY HYGIENE. provide support/tlc to pta/p: s/p excision of l atrial mass/myxoma. Sinus bradycardia. percocet for pain control w/ good effect. for little secretions but repeat cxr much improved. maex 4 to command, no deficit. The patient appears to be in sinus rhythm. good index. 3LNC. Sinus bradycardiaIncomplete RBBBNo previous tracing available for comparison provided w cough pillow & cognizant of use.pain controlled w morphine,repositioned freq. There are mild degenerative changes of the spine. Improving heart failure. bronch d/t r lung collapse ->atelectasis.Deline. FINDINGS: There has been resolution of collapse of right upper lung with complete aeration. no apparent skin breakdowncomfort: medicated w morphine prn w adequate sternal incis pain relief. Endotracheal tube is 3.7 cm above carina. The patient was under general anesthesia throughout theprocedure. vss, a paced for underlying sb 50's with decreased bp,great svo2,ci. The heart size is normal as well as the pulmonary vascularity. MAE x's 4. support. NG tube has its tip in the distal stomach. Portable AP chest radiograph compared to the preoperative study from , . IMPRESSION: AP chest compared to and 27: Lung volumes are lower since following extubation. A patent foramen ovale is present which wasdemonstrated with bubble study using valsalva.2. extubated on to np's w/o incident. closely monitor -> ? midazolam given & precedex planned for extubation attempt. HISTORY: Myxoma resection. for lt. shoulder discomfort. Itmeasure 3.6 cms.5. 3. 3. I certifyI was present in compliance with HCFA regulations. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for left atrial myxoma resectionHeight: (in) 66Weight (lb): 208BSA (m2): 2.04 m2BP (mm Hg): 134/78HR (bpm): 86Status: InpatientDate/Time: at 09:37Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV. cooperative w deep breathing,coughing. PFO is present.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. The left lung is grossly clear, and there is no left pleural effusion. No AS. a line inadvertently removed by patient while drinking,cuff bp acceptable.pacing rate adjusted as indicated for bp support or control,stable hemodynamics. Left atrial myxoma seen with pedicle attached to the interatrial septum. + BS, NO BM.GU: AUTODIURESING, > 150CC/HR.ENDO: CSRU SSRI.PLAN: TRANSFER TO 2. 2. 2. ^diet and act. Plan at this time is to lighten sedation and wean to extuabe at tolerated while monitoring ABGs to maintain adequate oxygenation and ventilkation. pain control. The Swan-Ganz tip is in the pulmonary outflow tract. no ectopies. Resp CarePt intubated with 7.5 ETT 20 @lip on SIMV+ PS. continues with underlying of sb 50's.see flow sheet. shift cover 2300-0700neuro: pt a+ox3. There is perihilar haziness on the left with some engorgement of the pulmonary vessels, which may represent a mild asymmetric pulmonary edema. OOB > CHAIR. Results were personallyreviewed with the MD caring for the patient.Conclusions:Prebypass1. addenum:Lower body w scatter sm areas of pink coloration, groin and abd fold sl red -> powder dry, use non-bleach linens. Overall normal LVEF (>55%). cco svo2 recal high 60s-70, ci>2.5. | 16 | [
{
"category": "Nursing/other",
"chartdate": "2148-07-04 00:00:00.000",
"description": "Report",
"row_id": 1353000,
"text": "extubated on to np's w/o incident. cooperative w deep breathing,coughing. provided w cough pillow & cognizant of use.pain controlled w morphine,repositioned freq. for lt. shoulder discomfort. a line inadvertently removed by patient while drinking,cuff bp acceptable.pacing rate adjusted as indicated for bp support or control,stable hemodynamics. continues with underlying of sb 50's.see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-07-05 00:00:00.000",
"description": "Report",
"row_id": 1353001,
"text": "shift cover 2300-0700\n\nneuro: pt a+ox3. maex 4 to command, no deficit. calm, cooperative\n\nid: afebrile, p/o atb\n\ncv: apaced at 70. bp good. no ectopies. repleted lytes prn. cco svo2 recal high 60s-70, ci>2.5. skin w/d. palapabled pulses. sl gen edema\n\nresp: ls diminished rll, crackes lll. sat>96% on 4lnc. is reinforced->pt used ^500ml. no distress\ngi: tol sip cl liquid w/o difficulty\nendo: con't insulin gtt\ngu: adquate huo\nwound: chest wound dsd w sm amt serosang drg. no apparent skin breakdown\ncomfort: medicated w morphine prn w adequate sternal incis pain relief. no family call. provide support/tlc to pt\n\na/p: s/p excision of l atrial mass/myxoma. good index. bronch d/t r lung collapse ->atelectasis.\n\nDeline. pulm toilet. ^diet and act. pain control. support. to f2 today\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-07-05 00:00:00.000",
"description": "Report",
"row_id": 1353002,
"text": "addenum:\n\nLower body w scatter sm areas of pink coloration, groin and abd fold sl red -> powder dry, use non-bleach linens. closely monitor -> ? need miconazole powder order\n\ndeline per am team round. to f2 today\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-07-05 00:00:00.000",
"description": "Report",
"row_id": 1353003,
"text": "nursing 7a-3p\npt neurologically intact. vital signs stable. percocet for pain control w/ good effect. can be anxious at times. awaiting bed on 2. see nursing transfer note in chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-07-05 00:00:00.000",
"description": "Report",
"row_id": 1353004,
"text": "ROS:\n\nNeuro: A+O x's 3. MAE x's 4. Postioned for comfort. PEARRLA\n\nCV: RSR w/o ectopy. Epicardial wires and pacer in place no pacing requirments. Peripheral pulses palpable. Has peripheral IV. Sternal drsg w/old serosang drng small amt.\n\nResp: Lungs clear and diminished in the bases. No resp distress noted, = rise and fall of chest. O2 3 L NP, sats 95% or >.\n\nGI: Taking diet and po fluids w/o c/o NV. Soft form stool.\n\nGU: Foley patent draining clear y ellow urine in QS.\n\nSocial: Friend this eveining.\n\nPlan: Await floor bed. Mobilize. Pulmonary toileting. Monitor, tx, support, and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-07-06 00:00:00.000",
"description": "Report",
"row_id": 1353005,
"text": "CSRU NPN\nNEURO: GROSSLY INTACT. PERCOCET FOR PAIN.\n\nCV: SR, NO ECTOPY. B/P STABLE. NO VASOACTIVE GTTS. NO CT.\n\nRESP: L/S CLEAR WITH DIM BASES. 3LNC. CONGESTED COUGH, OCCASIONALLY PRODUCTIVE WHITE SPUTUM.\n\nGI: TOLERATING CLEAR LIQUIDS W/O NAUSEA. + BS, NO BM.\n\nGU: AUTODIURESING, > 150CC/HR.\n\nENDO: CSRU SSRI.\n\nPLAN: TRANSFER TO 2. OOB > CHAIR. PAIN MANAGEMENT. PULMONARY HYGIENE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-07-04 00:00:00.000",
"description": "Report",
"row_id": 1352998,
"text": "vss, a paced for underlying sb 50's with decreased bp,great svo2,ci. waking thru high dose propofol even at rest with decreased svo2 into the 50's,high pip's,biting on ett,thrashing. midazolam given & precedex planned for extubation attempt. son reports prior difficult extubation with severe agitation after 1st cabg in req. sitters & physical restraint.cxr revealed rll collapse with decreased breath breath sounds rt > lt. recently(this month)quit smoking. by m.d. for little secretions but repeat cxr much improved. plan to initiate weaning soon.glucoses treated w protocol,see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-07-04 00:00:00.000",
"description": "Report",
"row_id": 1352999,
"text": "Resp Care\nPt intubated with 7.5 ETT 20 @lip on SIMV+ PS. pt post op for sm-mod amt of clear secretions. Plan at this time is to lighten sedation and wean to extuabe at tolerated while monitoring ABGs to maintain adequate oxygenation and ventilkation.\n"
},
{
"category": "Echo",
"chartdate": "2148-07-04 00:00:00.000",
"description": "Report",
"row_id": 81225,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for left atrial myxoma resection\nHeight: (in) 66\nWeight (lb): 208\nBSA (m2): 2.04 m2\nBP (mm Hg): 134/78\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 09:37\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA.\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: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thicknesses and cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\ndescending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Mild (1+) 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: 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. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPrebypass\n\n1. No spontaneous echo contrast or thrombus is seen in the body of the left\natrium or left atrial appendage. A patent foramen ovale is present which was\ndemonstrated with bubble study using valsalva.\n\n2. Left ventricular wall thicknesses and cavity size are normal. Regional left\nventricular wall motion is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\n3. Right ventricular chamber size and free wall motion are normal.\n\n4. Left atrial myxoma seen with pedicle attached to the interatrial septum. It\nmeasure 3.6 cms.\n\n5. There are simple atheroma in the descending thoracic aorta.\n\n6. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation.\n\n7. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen.\n\n8. There is no pericardial effusion.\n\n\nPost Bypass\n\n1. Biventricular systolic function is unchanged.\n\n2. Left atrial myxoma has been resected.\n\n3. Aorta intact post decannulation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2148-07-04 00:00:00.000",
"description": "Report",
"row_id": 200926,
"text": "Sinus bradycardia. Right ventricular conduction delay. Compared to the previous\ntracing of no major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-07-03 00:00:00.000",
"description": "Report",
"row_id": 200927,
"text": "Sinus bradycardia\nIncomplete RBBB\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921708,
"text": " 2:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval collapse, s/p bronch\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman scheduled for myxoma resection \n\n REASON FOR THIS EXAMINATION:\n eval collapse, s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR THE STUDY: Evaluation for collapse and status post bronchoscopy in\n a patient that is prescheduled for myxoma resection.\n\n TECHNIQUE: Chest portable PA view, and this study is compared to the previous\n study done on same day three hours earlier.\n\n FINDINGS: There has been resolution of collapse of right upper lung with\n complete aeration. The right internal jugular Swan-Ganz catheter has its tip\n in right ventricle and needs to be advanced at least 5cm in order to be in\n main pulmonary artery . Endotracheal tube is 3.7 cm above carina. NG tube\n has its tip in the distal stomach. There are no pleural effusion or\n pneumothoraxes. Heart size is borderline normal. There is resolution of\n bilateral reticular opacities of the lung.\n\n IMPRESSION:\n\n 1. Reexpansion of collapse part of right upper lung.\n\n 2. Right internal jugular Swan-Ganz catheter in right ventricle and needs to\n be advanced further.\n\n 3. Improving heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-07-03 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 921590,
"text": " 8:23 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman scheduled for myxoma resection \n REASON FOR THIS EXAMINATION:\n pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for myxoma resection on .\n\n There are no prior studies for comparison.\n\n CHEST, TWO VIEWS: There are median sternotomy wires and mediastinal clips in\n place. The overall cardiac size is normal. Mediastinal and hilar contours\n are normal. No consolidation or vascular congestion within the lungs. No\n pleural effusions or pneumothorax. There are mild degenerative changes of the\n spine.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-07-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 922152,
"text": " 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: eval post op\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman s.p myxoma resection\n REASON FOR THIS EXAMINATION:\n eval post op\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW, CHEST X-RAY, \n\n COMPARISON: .\n\n INDICATION: Status post myxoma resection.\n\n Midline surgical staples overlie the sternotomy site. The heart size is\n normal as well as the pulmonary vascularity. A small right pleural effusion\n appears slightly larger, but the degree of right basilar atelectasis has\n improved. The left lung is grossly clear, and there is no left pleural\n effusion. A small focus of air is present in the retrosternal region, likely\n postoperative.\n\n IMPRESSION: Slight increase and small right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-07-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 921660,
"text": " 12:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx, effusion\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with s/p Redo Sternotomy, Removal of Left Atrial Myxoma\n REASON FOR THIS EXAMINATION:\n ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Immediate postoperative evaluation in a patient after\n a removal of left atrial myxoma.\n\n Portable AP chest radiograph compared to the preoperative study from , .\n\n The ET tube tip is 4 cm above the carina. The Swan-Ganz tip is in the\n pulmonary outflow tract. The NG tube is within the stomach. The mediastinal\n drain tip is just above the right hemidiaphragm. There is complete\n atelectasis of the right upper lobe, most probably due to muceous plugg. The\n right lower lung is clear. There is perihilar haziness on the left with some\n engorgement of the pulmonary vessels, which may represent a mild asymmetric\n pulmonary edema. There is no pleural effusion or pneumothorax.\n\n IMPRESSION:\n\n 1. Right upper lobe atelectasis. These findings were discussed with Dr.\n .\n\n 2. Standard position of tubes and lines.\n\n 3. Probable mild pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921830,
"text": " 10:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: CORONARY ARTERY ARTHROSCLEROSIS\\RE-DO STERNOTOMY, MYXOMA RESECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman scheduled for myxoma resection \n\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest 10:36 a.m. on .\n\n HISTORY: Myxoma resection. Chest tubes removed.\n\n IMPRESSION: AP chest compared to and 27:\n\n Lung volumes are lower since following extubation. Discrete\n atelectasis is limited to the right lower lobe. Lungs otherwise clear. Small\n bilateral pleural effusions unchanged. Cardiomediastinal silhouette has a\n normal postoperative appearance and mediastinal vasculature is less engorged.\n No pneumothorax.\n\n\n"
}
] |
17,544 | 186,843 | The patient was admitted to the ICU. Aspirin was held as per Stroke Team management as was heparin while the patient was in the ICU. A TEE was ordered to rule out emboli with head of the bed greater than 30 degrees and blood pressure control to keep the systolic blood pressure less than 185. Given the patient's history of medical problems, the patient has hypercholesterolemia, hypertension, and anxiety with a 40-80 pack year history of tobacco. The patient had high pretest probability for an ischemic event. Repeat MRI of the head was performed in the ICU with resumption of Coumadin after the patient was cleared for any bleed on repeat MRI of the head. The patient had a TEE negative for any thrombus. The transesophageal echocardiogram did show a small PFO with a left-to-right shunt. In addition, there were hypermobile atheromata in the aorta Cardiology was then consulted for a clam shell to close the patent foramen ovale. The patient also was very anxious during this admission and outpatient medications were continued with p.r.n. Ativan having to be written for episodes of anxiety. A Psychiatry consult was also obtained with the suggestion to workup anxiety and check up TSH which was normal before discharge. The patient was continued on Celexa and Klonopin after psychiatry consultation. The patient's physical examination and neurologic examination improved status post TPA administration and the patient had increased strength in the left upper extremity and lower extremity prior to discharge. The patent foramen ovale was found on transesophageal echocardiogram. Heparin IV was started. The patient could leave on therapeutic Coumadin INR. The patient was scheduled for TEE on Monday but the patient was frustrated that she was not being discharged sooner than her expectations and the patient refused the examinations and was noncompliant with the advice of the neurologic team. The patient then agreed to be discharged on Monday, with Coumadin follow-up for PFO and follow-up with Dr. in the Clinic on and follow-up with primary care physician for INR to keep between 2 and 2.5. An outpatient TEE was scheduled on . The patient was advised to consider Wellbutrin instead of Celexa to assist with smoking cessation to reduce risk factors for further stroke. The patient then had follow-up with Dr. of Cardiology for TEE on Thursday, . The patient also had follow-up with Dr. for PFO evaluation for which the patient was given the phone number. The patient then had follow-up with Dr. for Coumadin monitoring on Wednesday, , and finally follow-up with Dr. on Thursday, at 1:00 p.m. in the Clinic in office clinical center. | IMPRESSION: 1) Normal bilateral venous studies of lower extremities without evidence of deep venous thrombosis. Physiologic mitral regurgitation is seen (withinnormal limits).TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:1. Regional left ventricular wall motion isnormal.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: The mitral valve leaflets are mildly thickened. TECHNIQUE: Routine noncontrast head CT. FINDINGS: Duplex and color Doppler demonstrate normal carotid systems bilaterally. No significant changes are seen in the right MCA distribution, corresponding to the diffusion abnormality seen by recent MRI. Source of embolism.Height: (in) 65Weight (lb): 150BSA (m2): 1.75 m2BP (mm Hg): 158/79Status: InpatientDate/Time: at 11:19Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. MAE'S AND HAS STRONG GRASP NOTED, SLIGHT UNCORDINATION NOTED IN UPPER EXT'S. FINDINGS: The right common femoral vein, greater saphenous vein, superficial femoral vein, lesser saphenous vein and popliteal vein are normal in flow and compressibility with normal response to augmentation. bleed No contraindications for IV contrast FINAL REPORT INDICATION: Acute stroke, status post TPA. The mediastinal and hilar contours are normal. IMPRESSION: Resolution of previously seen areas of signal loss in the right middle cerebral artery possibly secondary to resolution of a thrombus. There are two small areas of low attenuation in the region of the right caudate head and thalamus, which could relate to prior lacunar infarcts. MRA OF THE HEAD: The head MRA demonstrates resolution of previously seen filling defect within the right middle cerebral artery. CONCLUSION: Right insular cortex and adjacent white matter acute infarction with stenosis or embolus at the right MCA bifurcation. IS A/A/O AND C/O FRONTAL HEADACHE AT A SCORE OF "" CT SCAN PERFORMED WITH NO BLEED EVIDENT. The area of restricted diffusion in the occipital region appears to be in the watershed distribution between the right middle cerebral and posterior cerebral arteries. Regional left ventricular wall motion is normal.2. FINDINGS BRAIN MRI: On diffusion weighted images again restricted diffusion is seen in the right insular cortex indicating acute right middle cerebral artery infarct. IVF OF NORMAL SALINE IS INFUSING AT 100CC/HR.SKIN: IS BENIGN IN ASSESSMENT, WITH NO BREAKDOWN NOTED. There is mildmitral annular calcification. No new significant abnormalities on the MRA of the head. The left common femoral vein, greater saphenous vein, superficial femoral vein, deep femoral vein, and popliteal veins are also normal in flow and compressibility with normal response to augmentation. Normal sinus rhythm. acute stroke vs bleed ? A patentforamen ovale is present.LEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolicfunction are normal (LVEF>55%). In addition, several new small areas of restricted diffusion are identified in the right posterior temporal parietal and occipital regions. The acute infarct involving the right MCA distribution seen by diffusion- weighted imaging on the recent MRI is not well visualized by CT. IMPRESSION: No significant abnormalities identified. stenosis FINAL REPORT HISTORY: Acute CVA. FINDINGS: There is no intra- or extra-axial hemorrhage. In addition, there is normal antegrade flow in both vertebral arteries. There is mild polypoid mucosal thickening of the visualized portion of the maxillary sinuses. These findings are compatible with a stenosis, or embolus, at the MCA bifurcation with severe reduction in flow in the superior division and a resulting insular infarction. Possible small infarct in the left cerebellar hemisphere. There is a focus of hyperintensity on the diffusion-weighted images in the anterior left cerebellar hemisphere. Normal tracing. The pulmonary vasculature is unremarkable. ASSESSMENT BENIGN.G.U: FOLEY CATHETER INPLACE WHILE DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE.I.V: PT. The right deep femoral vein also is normal in flow and compressibility. FINDINGS: The diffusion images demonstrate hyperintensity in the right insular cortex and right frontal and parietal white matter suggesting acute ischemia. The lungs are clear and there are no pleural effusions. No osseous abnormalities are identified. HAS BEEN NSR WITH RATE IN THE 60-70'S WITH NO NOTED ECTOPY. Hyperlipidemia question stroke of hemorrhage. PORTABLE CHEST: The heart size is normal. TECHNIQUE: T1 sagittal and axial, and FLAIR, T2, susceptibility and diffusion axial images of the brain were obtained. The above mentioned infarcts are in the distribution of the right middle cerebral artery. No abnormalities are detected in this region on the FLAIR images. A tiny PFO is seen (a few bubbles) with cough manuevers on contrastechocardiography. HAS EXHIBITED LOW GRADE TEMP. The MRA images demonstrate a filling defect at the MCA bifurcation with severe attenuation of the superior division of the MCA. Improved visualization of sylvian branches of right middle cerebral artery. Comparison was made with the previous MRI study of . BOTH LOWER EXT'S ARE STRONG, WITH PT. 3D time of flight MRA of the circle of was acquired. PATIENT/TEST INFORMATION:Indication: Cerebrovascular event/TIA. NEURO: PT. PULSES REMAIN STRONG.RESP: LUNGS ARE CLEAR THROUGHOUT AND O2 SATS ARE 100% on 2l/Min via nasal cannula.G.I: PT. Evaluate for hemorrhage. There is improved visualization of the sylvian branches of the right middle cerebral artery. ABLE TO LIFT AND HOLD LOWER EXTREMITIES, WITHOUT DIFFICULTIES. Again, this may represent a small focus of infarction, perhaps embolic. The visualized osseous structures are unremarkable. The mitral valve leaflets are mildly thickened.3. | 9 | [
{
"category": "Radiology",
"chartdate": "2188-06-05 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 795200,
"text": " 9:25 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: ACUTE SX OF LEFT FACIAL, SLURRED SPEECH AND LEFT HEMIPARESIS FACE ARM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with hyperlipidemia\n ? acute stroke vs bleed ? MCA clot\n REASON FOR THIS EXAMINATION:\n 59 y/o woman with pmh high cholesterol and anxiety now with acute sx of left\n facial, slurred speech and left hemiparesis face and arm > leg\n ACUTE STROKE PROTOCOL thanks\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left facial weakness, slurred speech and left hemiparesis.\n Hyperlipidemia question stroke of hemorrhage.\n\n Diffusion imaging was performed through the brain. In addition, axial gradient\n echo images for susceptibility contrast and axial FLAIR imaging was performed.\n A three-dimensional time of flight arteriogram was performed. No prior studies\n are available for comparison.\n\n FINDINGS: The diffusion images demonstrate hyperintensity in the right insular\n cortex and right frontal and parietal white matter suggesting acute ischemia.\n No abnormalities are detected in this region on the FLAIR images. The MRA\n images demonstrate a filling defect at the MCA bifurcation with severe\n attenuation of the superior division of the MCA. These findings are compatible\n with a stenosis, or embolus, at the MCA bifurcation with severe reduction in\n flow in the superior division and a resulting insular infarction. There is no\n evidence of hemorrhage.\n\n There is a focus of hyperintensity on the diffusion-weighted images in the\n anterior left cerebellar hemisphere. Again, this may represent a small focus\n of infarction, perhaps embolic.\n\n CONCLUSION: Right insular cortex and adjacent white matter acute infarction\n with stenosis or embolus at the right MCA bifurcation. Possible small infarct\n in the left cerebellar hemisphere.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-06-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 795211,
"text": " 12:24 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: MVA\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with acute stroke s/p tpa, right MCA ? bleed\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute stroke, status post TPA. Evaluate for hemorrhage.\n\n TECHNIQUE: Routine noncontrast head CT.\n\n COMPARISON: MRI from four hours earlier.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage. There is no mass\n effect or shift of the normally midline structures. There are two small areas\n of low attenuation in the region of the right caudate head and thalamus, which\n could relate to prior lacunar infarcts. No significant changes are seen in\n the right MCA distribution, corresponding to the diffusion abnormality seen by\n recent MRI. The ventricles, cisterns, and sulci are unremarkable, without\n effacement. There is mild polypoid mucosal thickening of the visualized\n portion of the maxillary sinuses. The visualized osseous structures are\n unremarkable.\n\n IMPRESSION:\n 1. No evidence for hemorrhage.\n 2. The acute infarct involving the right MCA distribution seen by diffusion-\n weighted imaging on the recent MRI is not well visualized by CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-06-05 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 795205,
"text": " 10:46 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pt w/ acute stroke\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with\n REASON FOR THIS EXAMINATION:\n pt w/ acute stroke\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute stroke.\n\n PORTABLE CHEST: The heart size is normal. The mediastinal and hilar contours\n are normal. The lungs are clear and there are no pleural effusions. The\n pulmonary vasculature is unremarkable. No osseous abnormalities are\n identified.\n\n IMPRESSION: No significant abnormalities identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-06-06 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 795249,
"text": " 9:58 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: ACUTE STROKE, S/P TPA\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with acute stroke s/p tpa\n REASON FOR THIS EXAMINATION:\n ? stenosis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute CVA.\n\n FINDINGS: Duplex and color Doppler demonstrate normal carotid systems\n bilaterally. In addition, there is normal antegrade flow in both vertebral\n arteries.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-06-09 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 795557,
"text": " 2:30 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please evaluate for DVT.\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with R embolic CVA s/p tpa with patent PFO\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT.\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND OF THE BILATERAL LOWER EXTREMITIES:\n\n HISTORY: This is a 59 year old female with a right embolic cerebral vascular\n accident, s/p thrombolytic therapy.\n\n FINDINGS: The right common femoral vein, greater saphenous vein, superficial\n femoral vein, lesser saphenous vein and popliteal vein are normal in flow and\n compressibility with normal response to augmentation. The right deep femoral\n vein also is normal in flow and compressibility.\n\n The left common femoral vein, greater saphenous vein, superficial femoral\n vein, deep femoral vein, and popliteal veins are also normal in flow and\n compressibility with normal response to augmentation.\n\n IMPRESSION:\n 1) Normal bilateral venous studies of lower extremities without evidence of\n deep venous thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-06-06 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 795325,
"text": " 9:25 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: please do mri head with perfusion and dwi to assess for any\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old woman with right mca stroke had tpa administration\n REASON FOR THIS EXAMINATION:\n please do mri head with perfusion and dwi to assess for any bleed or new\n infarct\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with right MCA infarct status post TPA\n administration for assessment of bleed or new infarct.\n\n TECHNIQUE: T1 sagittal and axial, and FLAIR, T2, susceptibility and diffusion\n axial images of the brain were obtained. 3D time of flight MRA of the circle\n of was acquired. Comparison was made with the previous MRI study of\n .\n\n FINDINGS\n\n BRAIN MRI:\n\n On diffusion weighted images again restricted diffusion is seen in the right\n insular cortex indicating acute right middle cerebral artery infarct. In\n addition, several new small areas of restricted diffusion are identified in\n the right posterior temporal parietal and occipital regions. The area of\n restricted diffusion in the occipital region appears to be in the watershed\n distribution between the right middle cerebral and posterior cerebral\n arteries. No evidence of hemorrhage is seen in these areas or other parts of\n the brain. No evidence of mass effect midline shift or hydrocephalus is\n identified.\n\n IMPRESSION: Several new areas of acute infarct are now appreciated on the\n diffusion weighted images since the previous study of . No evidence of\n hemorrhage is seen. The above mentioned infarcts are in the distribution of\n the right middle cerebral artery.\n\n MRA OF THE HEAD:\n\n The head MRA demonstrates resolution of previously seen filling defect within\n the right middle cerebral artery. There is improved visualization of the\n sylvian branches of the right middle cerebral artery.\n\n IMPRESSION: Resolution of previously seen areas of signal loss in the right\n middle cerebral artery possibly secondary to resolution of a thrombus.\n Improved visualization of sylvian branches of right middle cerebral artery. No\n new significant abnormalities on the MRA of the head.\n (Over)\n\n 9:25 PM\n MR HEAD W/O CONTRAST; MR-ANGIO HEAD Clip # \n Reason: please do mri head with perfusion and dwi to assess for any\n Admitting Diagnosis: CEREBROVASCULAR ACCIDENT;TELEMETRY\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Echo",
"chartdate": "2188-06-06 00:00:00.000",
"description": "Report",
"row_id": 102513,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Source of embolism.\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 158/79\nStatus: Inpatient\nDate/Time: at 11:19\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: Saline\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. A patent\nforamen ovale is present.\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.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Physiologic mitral regurgitation is seen (within\nnormal limits).\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The mitral valve leaflets are mildly thickened.\n3. A tiny PFO is seen (a few bubbles) with cough manuevers on contrast\nechocardiography.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2188-06-06 00:00:00.000",
"description": "Report",
"row_id": 292756,
"text": "Normal sinus rhythm. Normal tracing. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2188-06-06 00:00:00.000",
"description": "Report",
"row_id": 1492185,
"text": "NEURO: PT. IS A/A/O AND C/O FRONTAL HEADACHE AT A SCORE OF \"\" CT SCAN PERFORMED WITH NO BLEED EVIDENT. PT. MAE'S AND HAS STRONG GRASP NOTED, SLIGHT UNCORDINATION NOTED IN UPPER EXT'S. BOTH LOWER EXT'S ARE STRONG, WITH PT. ABLE TO LIFT AND HOLD LOWER EXTREMITIES, WITHOUT DIFFICULTIES. PT. HAS EXHIBITED LOW GRADE TEMP. WITH TMAX 100.4. PT. HAS NOT BEEN CULTURED AT THIS TIME.\n\nC.V: PT. HAS BEEN NSR WITH RATE IN THE 60-70'S WITH NO NOTED ECTOPY. SBP HAS BEEN 130-180'S WITH LABETOLOL GTT STARTED FOR SBP>180 AND THEN SHUT OFF AFTER 20 MINS DUE TO SBP DROPPING INTO THE 130'S. PULSES REMAIN STRONG.\n\nRESP: LUNGS ARE CLEAR THROUGHOUT AND O2 SATS ARE 100% on 2l/Min via nasal cannula.\n\nG.I: PT. REMAINS NPO, WITH ABD. ASSESSMENT BENIGN.\n\nG.U: FOLEY CATHETER INPLACE WHILE DRAINING AMPLE AMT'S OF CLEAR YELLOW URINE.\n\nI.V: PT. HAS BILAT #18'S IN LEFT WRIST AND RIGHT AC. IVF OF NORMAL SALINE IS INFUSING AT 100CC/HR.\n\nSKIN: IS BENIGN IN ASSESSMENT, WITH NO BREAKDOWN NOTED.\n"
}
] |
48,391 | 128,847 | 80yo F presented to on w/ n/v, ataxia, and disorientation several days following a suspected MI. She collapsed and was found to be in shock. After reperfusing an occluded circumflex in cathlab she remained in cardiogenic shock. A TEE revealed a left ventricular free wall rupture. In Cardiothoracic OR she underwent clot evacuation without any identifiable bleeding source, surmising a contained rupture. She was post-operatively managed on CCU for the following problems: #Delayed presentation of posterior wall STEMI: The patient had endorsed several days of pain radiation to the jaw. She initally presented to an OSH where she was found to be in cardiogenic shock. She was intubated and placed on pressors and transfered to where she was taken to the cardiac cath lab where she was found to have a fully occuled LCx artery and a free wall rupture of the LV. She was taken to the OR by CT surgery who performed an emergent mediastinal re-exploration and drainage of pericardial effusion. They discovered a clot that tampanaded the free wall rupture. She was taken to the ICU following surgery where the patient SBPs were initially in the 80s and continued to require pressor support. She had an IABP that had been placed at time of cardiac cath and she was maintained on pressor support and IABP. She developed shock liver and her renal function deteriorated. Her cardiac output initially worsened but were stabilized with the addition of inotropic support. In this setting she was able to be weaned off the IABP. Following the removal she became hypertensive and became less reactive to stimuli. There was growing concern for a septic component to shock as WBC count bumped and temp persisted. Sputum culture notable for gram neg rods and WBC increased to 19 so pt started on renally dosed cefepime and vancomycin. On after a family meeting and in keeping with the patients wishes and given the clinical status of the patient the decision was made to make her CMO. She was extubated and given fentanyl and morphine. The family was present and the patient passed peacefully on . # Ventricular Rupture. Good hemostasis achieved in OR, w/CT placement then removed . Repeat echo confirmed effusion-free and good hemostasis. Clopidogrel held due to rebleeding risk. CXR showed vascular congestion. Patient diuresed furosemide and metolazone. After several liters removed, diuretics were scaled back with target net negative .5L daily. A repeat echo on showed continued hemostasis with no new effusion. There was no observed pulsus paradoxis. He recovery was complicated by the above issues issues. | There is left atrial diastolic collapse.Drs. Normalascending aorta diameter. There is evidence of a lateral free wallrupture and contained hematoma.4. There is mildregional left ventricular systolic dysfunction with severe hypokinesis of thebasal inferolateral wall. Regional left ventricular systolicdysfunction c/w CAD. Left ventricularhypertrophy. No PS.Physiologic PR.PERICARDIUM: Moderate pericardial effusion. Shortness of breath.Status: InpatientDate/Time: at 17:17Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: LA not well visualized. Mildlydepressed LVEF.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque. There is mild regional left ventricularsystolic dysfunction with severe hypo/akinesis of the basal inferolateral wallwith a discontuity and the basal wall at the annulus level with apparentcommunication with the pericardial space. There is moderate symmetric left ventricular hypertrophy. The Swan-Ganz catheter inserted through the right internal jugular approach terminates at the level of the low right ventricle. Mild regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferolateral - akinetic; mid inferolateral - hypo;PERICARDIUM: Moderate pericardial effusion. Normal aortic arch diameter. Normal aortic diameter at the sinus level. There is mild symmetric left ventricularhypertrophy with normal cavity size. Right precordial ST segment depression. An ET tube is present, grossly unchanged in position, with its tip at the lower level of the clavicular heads. Aortic contour is normal postdecannulation. Suboptimal image quality.Conclusions:The posterior and lateral walls of the left ventricle are akinetic. Compared to the previous tracing of atrial ectopy hasappeared. There is ST segment elevation inleads I and aVL and ST segment depression in leads V1-V4 consistent withanterolateral ischemia, rule out infarction. Left atrial abnormality. Left atrial abnormality. Right thoracostomy and mediastinal drains. A right IJ sheath is present, tip overlying the lower IJ proximal to the SVC, at the level of the thoracic inlet. No AS.PERICARDIUM: Moderate pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. There is unchanged evidence of bilateral pleural fluid collections and relatively extensive retrocardiac atelectasis. Suboptimal image quality - poor echo windows.Conclusions:Left ventricular wall thicknesses and cavity size are normal. Reduced size of pericardial effusionwith significant compression of left atrium. Right ventricular function. Intubated.Height: (in) 64Weight (lb): 170BSA (m2): 1.83 m2BP (mm Hg): 130/60HR (bpm): 91Status: InpatientDate/Time: at 13:35Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Left ventricular function. There is a moderate sized circumferentialpericardial effusion. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The Swan-Ganz catheter is terminating in the proximal right ventricular outflow tract. FINDINGS: Compared to the previous radiograph, there is a newly appeared mild to moderate right pleural effusion and an increasing left pleural effusion. Endotracheal tube seats 2.5 cm above the carina and appears unchanged, however, the cuff appears to be overinflated. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. Left pleural effusion and left lower lung consolidation is noted. Stable pulmonary vascular congestion and pleural effusions. There is a moderate sized pericardial effusion. FINDINGS: In comparison with the earlier study of this date, the endotracheal tube has been removed. The mediastinal drains and the right chest tube has been removed. S-G terminating at the proximal right ventricular outflow tract. Mild regional LVsystolic dysfunction. Small left pleural effusion. These findings arenew as compared to the previous tracing of and are consistent withactive posterolateral ischemic process, rule out myocardial infarction. Emergency study.Conclusions:The left atrium is normal in size. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Moderate symmetric LVH. The possibility of a small right apical pneumothorax cannot be excluded. Mild regional LVsystolic dysfunction.RIGHT VENTRICLE: RV not well seen. Frequent atrial ectopy. However, dilated vascular structures suggest the presence of mild to moderate pulmonary edema. Resting tachycardia (HR>100bpm). Tamponade.Height: (in) 64Weight (lb): 170BSA (m2): 1.83 m2BP (mm Hg): 212/59HR (bpm): 104Status: InpatientDate/Time: at 14:43Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. ST segment depressions in leads V3-V6 which are worrisome formyocardial ischemia. The ET tube tip is grossly unchanged at the level of lower clavicular heads. Suboptimalimage quality - ventilator. PATIENT/TEST INFORMATION:Indication: s/p clot removal, lv ruptureHeight: (in) 64Weight (lb): 151BSA (m2): 1.74 m2BP (mm Hg): 105/38HR (bpm): 95Status: InpatientDate/Time: at 15:27Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: LV pseudoaneursym.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferolateral - akinetic; mid inferolateral - akinetic; basal anterolateral -akinetic; mid anterolateral - akinetic;MITRAL VALVE: MR present but cannot be quantified.GENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads orelectrodes. A right IJ sheath is present, tip overlying lower IJ above the level of the clavicle. No RVdiastolic collapse.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. There is obscuration of the right inferior lung likely reflecting combination of pleural fluid and underlying collapse and/or consolidation. Probable small left effusion. The effusion appearsloculated. PATIENT/TEST INFORMATION:Indication: s/p ventricular rumpture. No definite extravasation of blood is identified.IMPRESSION: Suboptimal image quality. REASON FOR THIS EXAMINATION: Please assess for any consolidation, pnumothorax, pleural effusions. Normal RV chamber size.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets. Pericardial effusion.Height: (in) 65Weight (lb): 151BSA (m2): 1.76 m2BP (mm Hg): 153/70HR (bpm): 84Status: InpatientDate/Time: at 15:01Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: OptisonTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Normal LV wall thickness and cavity size. | 19 | [
{
"category": "Echo",
"chartdate": "2134-08-17 00:00:00.000",
"description": "Report",
"row_id": 70571,
"text": "PATIENT/TEST INFORMATION:\nIndication: s/p clot removal, lv rupture\nHeight: (in) 64\nWeight (lb): 151\nBSA (m2): 1.74 m2\nBP (mm Hg): 105/38\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 15:27\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: LV pseudoaneursym.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - akinetic; mid inferolateral - akinetic; basal anterolateral -\nakinetic; mid anterolateral - akinetic;\n\nMITRAL VALVE: MR present but cannot be quantified.\n\nGENERAL COMMENTS: Suboptimal image quality - bandages, defibrillator pads or\nelectrodes. Suboptimal image quality as the patient was difficult to position.\nSuboptimal image quality - ventilator. Suboptimal image quality.\n\nConclusions:\nThe posterior and lateral walls of the left ventricle are akinetic. Findings\nare suggestive of a pseudoaneurysm at the basal posterolateral wall. Mitral\nregurgitation is present but cannot be quantified. The overall left\nventricular ejection fraction is relatively well-preserved despite the\nposterior and lateral akinesis.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-08-16 00:00:00.000",
"description": "Report",
"row_id": 70647,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. S/p Arrest. Intubated.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 130/60\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 13:35\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction.\n\nRIGHT VENTRICLE: RV not well seen. Normal RV chamber size.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.\n\nPERICARDIUM: Moderate pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus. Emergency study.\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 severe hypo/akinesis of the basal inferolateral wall\nwith a discontuity and the basal wall at the annulus level with apparent\ncommunication with the pericardial space. Color flow Doppler is inadequate to\ndefine flow. The remaining segments contract normally (LVEF = 45-50 %). Right\nventricular chamber size is normal. The free wall is not well seen. The aortic\nvalve leaflets are mildly thickened (?#). There is no aortic valve stenosis.\nThere is a moderate sized circumferential pericardial effusion. Tamponade\ncould not be assessed.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-08-20 00:00:00.000",
"description": "Report",
"row_id": 70561,
"text": "PATIENT/TEST INFORMATION:\nIndication: s/p ventricular rumpture. Pericardial effusion.\nHeight: (in) 65\nWeight (lb): 151\nBSA (m2): 1.76 m2\nBP (mm Hg): 153/70\nHR (bpm): 84\nStatus: Inpatient\nDate/Time: at 15:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Optison\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. Mild-moderate regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - hypo; mid inferolateral - hypo;\n\nMITRAL VALVE: Mitral valve leaflets not well seen.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Suboptimal image quality - poor echo windows.\n\nConclusions:\nLeft ventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with severe hypokinesis of the\nbasal inferolateral wall. The remaining segments contract normally (LVEF >50\n%). The mitral valve leaflets are not well seen. There is no definite\npericardial effusion. No definite extravasation of blood is identified.\n\nIMPRESSION: Suboptimal image quality. Regional left ventricular systolic\ndysfunction c/w CAD. No definite pericardial effusion identified.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-08-16 00:00:00.000",
"description": "Report",
"row_id": 70612,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Tamponade.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 212/59\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 14:43\nTest: TTE (Focused views)\nDoppler: Limited 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 VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferolateral - akinetic; mid inferolateral - hypo;\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No RV\ndiastolic collapse.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator. Resting tachycardia (HR>100bpm). Emergency study\nperformed by the cardiology fellow on call. Results were personally reviewed\nwith the MD caring for the patient.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is mild regional left ventricular systolic dysfunction with akinesis of\nthe basal inferolateral wall. There appears to be a rupture of the basal\ninferolateral wall immediately apical to the mitral annulus with color flow\nDoppler through this area in to the pericardial space. The remaining segments\ncontract normally (LVEF = 55 %). There is a moderate sized circumferential\npericardial effusion. No right ventricular diastolic collapse is seen.\n\nCompared with the prior study (images reviewed) of earlier in the day of\n, the pericardial effusion is slightly larger and flow from the left\nventricle into the pericardial space is now more clearly defined.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-08-16 00:00:00.000",
"description": "Report",
"row_id": 70572,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Chest pain. Coronary artery disease. Hypertension. Left ventricular function. Pericardial effusion. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 17:17\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: LA not well visualized. No spontaneous echo contrast is seen in\nthe LAA. No thrombus in the LAA. All four pulmonary veins not identified.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mildly\ndepressed LVEF.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque. Normal aortic diameter at the sinus level. Normal\nascending aorta diameter. Normal aortic arch diameter. Normal descending aorta\ndiameter.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion is loculated. \n collapse.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The patient received antibiotic\nprophylaxis. The TEE probe was passed with assistance from the anesthesioology\nstaff using a laryngoscope. No TEE related complications. Results were\npersonally reviewed with the MD caring for the patient.\n\nConclusions:\nPRE-CPB:The patient was brought to the operating room on IABP with infusions\nof norepinephrine and dopamine.\n1. No spontaneous echo contrast is seen in the left atrial appendage. No\nthrombus is seen in the left atrial appendage.\n2. No atrial septal defect is seen by 2D or color Doppler.\n3. There is moderate symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis mildly depressed (LVEF= 50 %). There is evidence of a lateral free wall\nrupture and contained hematoma.\n4. Right ventricular chamber size and free wall motion are normal.\n5. The ascending, transverse and descending thoracic aorta are normal in\ndiameter and free of atherosclerotic plaque. The IABP is in good positoipn 3\ncm below the LSCA.\n6. There are three aortic valve leaflets. There is no aortic valve stenosis.\nNo aortic regurgitation is seen.\n7. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral doppler evidence for mitral stenosis.\n8. There is a moderate sized pericardial effusion. The effusion appears\nloculated. There is left atrial diastolic collapse.\nDrs. and notified in person of the results.\n\nPOST CPB: On infusion of epinephrine. Reduced size of pericardial effusion\nwith significant compression of left atrium. The lateral free wall has a\nsmaller rupture than pre bypass. LVEF = 60%. Aortic contour is normal post\ndecannulation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2134-08-16 00:00:00.000",
"description": "Report",
"row_id": 70573,
"text": "PATIENT/TEST INFORMATION:\nIndication: s/p myocardial infarction with concern for ventricular wall rupture. Pericardial effusion.\nHeight: (in) 64\nWeight (lb): 170\nBSA (m2): 1.83 m2\nBP (mm Hg): 212/59\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 14:55\nTest: Portable TEE (Unsuccessful Placement) (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nSedation per cath lab team. Unsuccessful TEE as unable to pass probe past the\nposterior pharynx.\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). The patient was under general anesthesia throughout the procedure.\nUnsuccessful esophageal intubation.\n\nConclusions:\nThe TEE probe could not be passed into the esophagus due to resistance in the\nposterior pharynx.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249291,
"text": " 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for intrathoracic pathology and line placement\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with LV rupture now with IABP\n REASON FOR THIS EXAMINATION:\n Please eval for intrathoracic pathology and line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Left ventricular rupture, evaluation for placement of monitoring\n devices.\n\n COMPARISON: , 7:19 p.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Extensive bilateral parenchymal opacities with pleural effusions and\n moderate cardiomegaly are constant. The monitoring and support devices,\n including the aortic balloon pump and Swan-Ganz catheter, are in virtually\n unchanged position. There is no evidence of pneumothorax or other new\n complication. The sternal wires show unchanged alignment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249200,
"text": " 9:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with S/P tamponade evac\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Tamponade, evaluation for pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is little overall\n change. The mediastinal drains and the right chest tube has been removed.\n There is unchanged evidence of bilateral pleural fluid collections and\n relatively extensive retrocardiac atelectasis. The position of the\n intraaortic balloon pump is constant. No newly appeared parenchymal\n opacities. No convincing evidence for pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249263,
"text": " 7:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate line placement\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with ventricular rupture, s/p sterotomy and evacuation\n REASON FOR THIS EXAMINATION:\n please evaluate line placement\n ______________________________________________________________________________\n WET READ: LLTc WED 9:02 PM\n ET tube 3.9 cm above the carina. S-G terminating at the proximal right\n ventricular outflow tract. OG tube within the stomach. Intraaortic balloon\n pump remains appropriately positioned.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Ventricular rupture, status post sternotomy, evaluation of line\n placement.\n\n COMPARISON: , 9:59 a.m.\n\n FINDINGS: The tip of the endotracheal tube projects 3.9 cm above the carina.\n The Swan-Ganz catheter is terminating in the proximal right ventricular\n outflow tract. The nasogastric tube is within the stomach. The intra-aortic\n balloon pump remains approximately positioned at a distance of 6 cm from the\n top of the aortic arch. The appearance of the lung parenchyma and of the\n heart show no substantial change. No evidence of pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249052,
"text": " 9:07 PM\n CHEST (PORTABLE AP); CHEST (PORTABLE AP) Clip # \n -76 BY SAME PHYSICIAN; CHEST (PORTABLE AP)\n -76 BY SAME PHYSICIAN\n : check swan placement\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with `MI\n REASON FOR THIS EXAMINATION:\n check swan placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with Swan-Ganz placement,\n assessment for position.\n\n AP radiograph of the chest\n\n As compared to prior study obtained the same day earlier, the Swan-Ganz\n catheter has been slightly advanced with its tip currently at the level of the\n upper portion of the right ventricle close to the right ventricle outflow\n tract. The intra-aortic balloon pump remains low. No other changes have been\n demonstrated except for minimal interval development of interstitial pulmonary\n edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249181,
"text": " 7:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulm edema\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with s/p tamponade evac/myocardial rupture\n REASON FOR THIS EXAMINATION:\n pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post tamponade, myocardial rupture, evaluation for\n pulmonary edema.\n\n COMPARISON: .\n\n FINDINGS: Compared to the previous radiograph, there is a newly appeared mild\n to moderate right pleural effusion and an increasing left pleural effusion.\n The appearance of the cardiac silhouette is unchanged. However, dilated\n vascular structures suggest the presence of mild to moderate pulmonary edema.\n The position of the tubes and lines is constant. Unchanged alignment of the\n sternal wires.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1249043,
"text": " 7:48 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman s/p Repair of RV Rupture\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n WET READ: LLTc MON 8:53 PM\n Right IJ catheter terminating within the right ventricle. ET tube 3.4 cm above\n the carina. OG tube extending to at least the stomach. Right thoracostomy and\n mediastinal drains. No pneumothorax. Left basilar opacity may reflect severe\n atelectasis. Small left pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after repair of the right\n ventricular rupture.\n\n AP radiograph of the chest was reviewed in comparison to .\n\n The ET tube tip is approximately 4.3 cm above the carina. The intra-aortic\n balloon pump is very low, at least 8 cm below the roof of the aortic arch.\n Mediastinal drains are in place. The Swan-Ganz catheter inserted through the\n right internal jugular approach terminates at the level of the low right\n ventricle. Right chest tube is in place. Mediastinal drains are in place.\n Heart size and mediastinum are grossly stable. Left pleural effusion and left\n lower lung consolidation is noted.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2134-08-22 00:00:00.000",
"description": "Report",
"row_id": 161611,
"text": "Atrial fibrillation with rapid ventricular response. Left ventricular\nhypertrophy. ST segment depressions in leads V3-V6 which are worrisome for\nmyocardial ischemia. The atrial fibrillation is new compared to the previous\ntracing of , as are the ST segment abnormalities. Clinical correlation\nis highly suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2134-08-18 00:00:00.000",
"description": "Report",
"row_id": 161612,
"text": "Sinus rhythm. Left atrial abnormality. Frequent atrial ectopy. Low limb lead\nvoltage. Compared to the previous tracing of atrial ectopy has\nappeared. The A-V interval has decreased. There is ST segment elevation in\nleads I and aVL and ST segment depression in leads V1-V4 consistent with\nanterolateral ischemia, rule out infarction. Followup and clinical correlation\nare suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2134-08-16 00:00:00.000",
"description": "Report",
"row_id": 161613,
"text": "Sinus rhythm. Left atrial abnormality. A-V conduction delay. Diminished\nvoltage as compared to the previous tracing of and increase in rate.\nThere is ST segment elevation in leads I and aVL with biphasic T waves in\nleads I and aVL. Right precordial ST segment depression. These findings are\nnew as compared to the previous tracing of and are consistent with\nactive posterolateral ischemic process, rule out myocardial infarction. There\nis Q-T interval prolongation. Clinical correlation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249579,
"text": " 12:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for edema/effusion or infectious process\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with STEMI c/b ventricular rupture and \n REASON FOR THIS EXAMINATION:\n Please eval for edema/effusion or infectious process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: STEMI, complicated by ventricular rupture and .\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n An ET tube is present, tip approximately 5.9 cm above the carina. NG tube is\n present, tip extends beneath the diaphragm, off the film. A right IJ sheath\n is present, tip overlying lower IJ above the level of the clavicle.\n\n The patient is status post sternotomy, with a prominent cardiomediastinal\n silhouette. There is upper zone redistribution and diffuse vascular blurring,\n asymmetrically more pronounced on the right. There is obscuration of the\n right inferior lung likely reflecting combination of pleural fluid and\n underlying collapse and/or consolidation. There is increased retrocardiac\n density, consistent with left lower lobe collapse and/or consolidation, likely\n with a small amount of pleural fluid. Some subcutaneous emphysema is noted\n over the right greater than left chest. The possibility of a small right\n apical pneumothorax cannot be excluded. Linear lucency traversing the right\n posterior third rib may represent artifact due to subcutaneous emphysema, but\n the differential diagnosis would include a non-displaced rib fracture.\n\n Compared with at 8:27 a.m., lung findings are similar. Right apical\n pneumothorax and possible right posterior third rib fracture, if real, are\n new.\n\n Findings discussed with Dr. at ~11:23 am on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249528,
"text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: position of tubes and lines\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with MI, intubated and sedated\n REASON FOR THIS EXAMINATION:\n position of tubes and lines\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MI, intubated, check tubes and lines.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n An ET tube is present, grossly unchanged in position, with its tip at the\n lower level of the clavicular heads. The crania itself is not well\n demonstrated. An NG tube is present, tip extending beneath diaphragm off film.\n A right IJ sheath is present, tip overlying the lower IJ proximal to the SVC,\n at the level of the thoracic inlet. The ET tube tip is grossly unchanged at\n the level of lower clavicular heads.\n\n The patient is status post sternotomy. The cardiomediastinal silhouette is\n prominent, but unchanged. There is upper zone redistribution and diffuse\n vascular blurring, with patchy alveolar opacities, consistent with CHF and\n pulmonary edema. There is increased retrocardiac density, consistent with\n left lower lobe collapse and/or consolidation. Probable small left effusion.\n Likely also right effusion, with underlying collapse and/or consolidation.\n\n Overall, the appearance is similar to at 16:39 p.m. CHF\n findings may be very slightly worse.\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-20 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1249465,
"text": " 4:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please assess for any consolidation, pnumothorax, pleural ef\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock. Currently on ventilation with high\n o2 requirement.\n REASON FOR THIS EXAMINATION:\n Please assess for any consolidation, pnumothorax, pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiogenic shock.\n\n FINDINGS: In comparison with the earlier study of this date, the endotracheal\n tube has been removed. The Swan-Ganz catheter has been removed and replaced\n with a jugular shunt. Nasogastric tube remains in place. IABP has been\n removed.\n\n There are still hazy opacifications bilaterally, more prominent on the right,\n consistent with bilateral pleural effusions and pulmonary vascular congestion.\n\n No evidence of acute pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2134-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1249392,
"text": " 7:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess placement of IABP.\n Admitting Diagnosis: ST ELEVATED MYOCARDIAL INFARCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenci shock now on IABP.\n REASON FOR THIS EXAMINATION:\n Please assess placement of IABP.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old woman with cardiogenic shock, now on IABP. Please\n assess placement of IABP.\n\n COMPARISON: .\n\n FINDINGS: Portable AP radiograph of the chest is obtained. Endotracheal tube\n seats 2.5 cm above the carina and appears unchanged, however, the cuff appears\n to be overinflated. Swan-Ganz tip is in the pulmonary outflow tract and also\n remains unchanged. Tip of the intra-aortic balloon pump is seen in the mid\n descending thoracic aorta approximately 7 cm below the arch. A more desirable\n location for this device would be 3-4 cm higher. Cardiomediastinal silhouette\n and pulmonary vascular congestion is stable. Small pleural effusions and no\n pneumothorax.\n\n IMPRESSION:\n 1. IABP sits 7 cm below the aortic arch; 3-4 cm below its desirable location.\n 2. Endotracheal tube cuff is overinflated, stretching the tracheal wall and\n needs to be slightly deflated.\n 3. Stable pulmonary vascular congestion and pleural effusions.\n\n"
}
] |
92,287 | 106,961 | 59 year old male with a past medical history of systolic congestive heart failure (last EF 55-60%), atrial fibrillation on coumadin, transaminitis secondary to cirrhosis, chronic lower extremity stasis dermatitis (recent admission for cellulitis on ), history of pulmonary embolus and atrial thrombus who presented from clinic with with a significant hyponatremia, elevated lactate, and acute kidney injury. | Atrial fibrillation with a controlled ventricular response. Compared to the previous tracingof the anterolateral ST segment abnormality is slightly more prominent.No other significant change.TRACING #1 Compared to theprevious tracing the anterolateral ST segment abnormality is less prominent.TRACING #3 Atrial fibrillation with fast ventricular response. Hyponatremia. Mild cardiomegaly is unchanged. Atrial fibrillation with rapid ventricular response. FINDINGS AND IMPRESSION: The lungs are clear. Non-specificanterolateral ST segment depression. Compared to the previoustracing there is no diagnostic change.TRACING #2 COMPARISON: Multiple prior examinations, most recent dated . No pleural effusion, pulmonary edema or pneumothorax is present. TECHNIQUE: Two views of the chest. | 4 | [
{
"category": "ECG",
"chartdate": "2173-08-03 00:00:00.000",
"description": "Report",
"row_id": 194737,
"text": "Atrial fibrillation with a controlled ventricular response. Compared to the\nprevious tracing the anterolateral ST segment abnormality is less prominent.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-03 00:00:00.000",
"description": "Report",
"row_id": 194738,
"text": "Atrial fibrillation with fast ventricular response. Compared to the previous\ntracing there is no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-03 00:00:00.000",
"description": "Report",
"row_id": 194995,
"text": "Atrial fibrillation with rapid ventricular response. Non-specific\nanterolateral ST segment depression. Compared to the previous tracing\nof the anterolateral ST segment abnormality is slightly more prominent.\nNo other significant change.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2173-08-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1249758,
"text": " 12:58 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 59M with hyponatremia, leukocytosis\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Leukocytosis. Hyponatremia.\n\n TECHNIQUE: Two views of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS AND IMPRESSION: The lungs are clear. No pleural effusion, pulmonary\n edema or pneumothorax is present. Mild cardiomegaly is unchanged.\n\n"
}
] |
87,949 | 167,925 | 73 RHM with recently diagnosed PD started on Sinemet 1 month before admission, HTN, HLD, CAD s/p CABG and multiple stents, right hand weakness, s/p C5 corpectomy and C4-C6 instrumented fusion, T2DM on insulin presented with acute onset of left sided weakness and aphasia, found to have hypodensities in the R superior frontal lobe on NCHCT (unable to do an MRI given PPM) which were felt to be old. He was markedly hypertensive and this was controlled initially with an IV nicardipine drip and latterly with po medications. LP was unremarkable and infectious studies and cytology were negative. He had fevers for which no source was found, and one episode of possible seizure with no clear epileptiform changes on EEG telemetry. Left sided weakness resolved and were felt likely due to a seizure. He was commenced on AEDs and these were decreased during his course and discharged on keppra. He was found to have dysphagia and placed on a modified diet. He initially required ICU level care and was admitted on and transferred to the floor on , discharged to rehab on . Pending issues are persistent hyperextension and diabetes control. . . # Neurology: Patient had recently been diagnosed with possible PD for bilateral tremor (not present here) and gait disturbance by Dr at and started on Sinemet 1 month prior to admission. Patient presented initially to an OSH with acute left sides weakness and confusion as well as language difficulties and intermittent chest pain and was transferred to the on for possible tPA. He was markedly hypertensive on admission with SBP >200 and he was given labetalol 10mg IV with decrease in BP. He required ICU level care due to his poor conscious level. Initial concern was for stroke and initial examination revealed that he was inattentive, could not repeat, speech was slightly dysarthric and was nonsensical. There was also evidence of left arm>leg hemiparesis. Initial NIHSS was 16. CT head showed likely old hypodensities in the right thalamus and right occipital lobe. CTA showed no significant vessel abnormalities. Due to the presence of chest pain in the ED he had a CT- revealed no aortic dissection or aneurysm or PE and multiple subcentimeter thyroid nodules with trace bilateral effusions. BP was treated with an IV nicardipine infusion while in the ICU and latterly was managed with po antihypertensives on transfer to the floor. He was felt to be very encephalopathic with a WCC that increased to maximum 20 (no source found) and returned to and the concern was then for infective encephalitis. He was therefore initially started on vanc/ceftriaxone/ampicillin/acyclovir. LP was performed and CSF results were negative with 1 RBC 1 WBC Pr 47 and normal Glc. HSV/entero/VZV PCR were negative as was cryptococcal Ag and cultures. Cytology was negative. Abx and antiviral were then stopped. The patient had an episode of right sided gaze deviation and rhythmic shaking of his R arm and leg suspicious for a seizure on admission to the ICU and he was placed on EEG telemetry. He was commenced on IV phenytoin->fosphenytoin and due to low phenytoin levels fosphenytoin was increased to 150mg Q8H in addition to IV keppra 1g . EEG was initially obscured by artifact and latterly showed changes compatible with encephalopathy with no epileptiform features seen. As his hospital course progressed, his EEG became less encephalopathic in tandem with his improving conscious level. He was also assessed by speech and swallow who found aspiration and he went on to have a video swallow which showed intermittent aspiration with thin liquids as well as penetration with thin liquids and nectar. He was placed on a modified diet and this will have to be reviewed at rehab for possible advancement. On he was persistently agitated, requiring IV haloperidol. He also had one episode of fever to 101.3 and blood and urine cultures were sent which returned negative. His agitation subsequently improved and by , his mental status was improving. He was still somewhat lethargic but oriented x with fluent speech and able to follow commands. Still with some LUE weakness, neuro exam otherwise intact. He was transferred to the floor on . In the ICU he was also found to have apneic episodes and desaturations on sleeping and was presumptively started on CPAP at night and subsequently did well. He had an inpatient sleep study and was seen by sleep medicine. The results of this are pending. He was continued on CPAP at night for likely OSA. On the floor, his conscious level cleared and normalised per family. He was still hypertensive and had no episodes of agitation. Patient noted painful calves and doppler U/S showed no DVTs bilaterally. The likely cause of his symptoms was felt to be hypertensive encephalopathy causing seizures given encephalopathy without infective features on LP and markedly high BP with left hemiparesis which completely resolved. It is unclear what impact his Sinemet had on this but due to temporal relationship and no clear Parkinsonian features, Sinemet was not continued during his hospital stay. His anti-hypertensives were uptitrated and this will have to be further uptitrated as necessary at rehab. He also had variable BGlc levels and his HISS was changed. Due to no epileptiform changes on EEG and no further seizures, his phenytoin was tapered and stopped on and will continue keppra until advised in neurology clinic. He was assessed by PT, OT and S&S and was deemed to require rehab. He will have to be reassessed by Speech and Swallow at rehab with the hopes that his diet can be advanced. He was discharged to rehab on . He has neurology follow-up and should see his PCP on discharge from rehab. . # CVS: Patient was very hypertensive initially requiring IV nicardipine. Cardiology were consulted for pacer interrogation and found a normally functioning dual chamber pacemaker and he was not pacemaker dependent. We continued aspirin 325mg daily and clopidogrel 75mg daily for CAD/stents. He was monitored on tele. CE's were negative. Echo showed no source of cardioembolism and a normal EF. Lipid profile revealed Chol 127 TGCs 125 LDL 61 and were continued home simvastatin 20mg qd and fenofibrate. Patient initially had a dose reduction of his losartan and this was uptitrated to his home dose of 100mg qd on discharge. We changed metoprolol XL to metoprolol tartrate 25mg tid. Due to persistent hypertension we added amlodipine 5mg qd on and he will need his anti-HTN uptitrated at rehab an closely monitor BP and goal is normotension. . # PULM: In the ICU he was also found to have apneic episodes and desaturations (70s-80s) on sleeping and was presumptively started on CPAP at night and subsequently did well. He had an inpatient sleep study 1/5-6 and was seen by sleep medicine. The results of this are pending. He was continued on CPAP at night for likely OSA. His respiratory status was stable on discharge. Dr will follow-up these results and will coordinate follow-up. . # ID: Patient had one fever as above and was otherwise afebrile. WBC initially peaked at 20 and fell without treatment (following discontinuation of Abx and anti-virals) to normal range 10.2 on discharge and had no further fevers. The reason for this rise is unclear and may be reactive but is quite high for this. All microbiology was unremarkable. CSF infection studies were all negative. . # ENDO: Patient has T2DM on 70/30 and Januvia in the community. His BGlc was difficult to control in house and required a considerable sliding scale. He was seen by endocrinologists on and recommended a change to his sliding scale given am hypoglycemic events. He was discharged on Lantus 20 units and this will need to be uptitrated based on his diabetic control. Januvia and 70/30 were held. HbA1C 9.8%. We continued home levothyroxine 75mcg daily . # Psych: We held Cymbalta in house and this can be restarted as felt necessary by his PCP. . Transitional issues: Patient to continue keppra as an outpatient unless directed to stop this after his neurology follow-up with Dr . He will need sleep follow-up which will be coordinated by Dr is still hypertensive and his anti-hypertensives will need to be uptitrated at rehab. Patient has poor diabetic control and his insulin regimen will have to be uptitrated at rehab. Patient will need reassessment by speech and swallow at rehab with a view to advancing his diet. Patient had low phosphate and was started on neutraphos and PO4 will need to be monitored at rehab. Patient was started on a trial of sinemet in the community and this was stopped in house and should not be restarted given temporal association to his admission symptoms. . Pending labs: One pending blood cultures and all other cultures negative | Unchanged hypodensities in the right thalamus and right occipital region which likely represent subacute infarcts. Hypodensities within the right thalamus and in the right occipital region appear unchanged compared to recent prior examinations and likely reflect infarcts that are probably subacute. Mild (1+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. There is a trivial/physiologic pericardial effusion.IMPRESSION: Suboptimal image quality. Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Right-sided PICC line present, tip not optimally visualized but likely overlying the distal SVC near the RA junction. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) mitral regurgitation is seen. Trace left pleural effusion is present (2:63). Left atrial abnormality. No PS.Physiologic PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. No resting LVOT gradient.RIGHT VENTRICLE: RV not well seen.AORTIC VALVE: Mildly thickened aortic valve leaflets. Low precordial lead voltage isnew. Limited head CT shows hypodensity in the right thalamus and right occipital region due to infarcts of undetermined age. The thoracic aorta demonstrates minimal atherosclerotic calcification, and is normal in caliber. There is symmetric left ventricularhypertrophy. Two ventricular premature beats are noted.A-V conduction delay. Suboptimal image quality - patient unable to cooperate.Conclusions:The left atrium is mildly dilated. Cardiomediastinal silhouette is prominent,but unchanged. Mild mitral annularcalcification. Trace left pleural effusion with adjacent atelectasis. Chronic parietal lobe focal encephalomalacia unchanged from the reference CT exam performed earlier. Chronic parietal lobe focal encephalomalacia unchanged from the reference CT exam performed earlier. There is unchanged moderate proportional enlargement of the ventricles and sulci, findings consistent with age-related cortical atrophy. Since the prior radiograph, there has been resolution of the right pleural effusion. Compared to the previous tracing of the rate is slowerand ventricular ectopy is no longer present. Possible small left pleural effusion. Resolution of right pleural effusion. The mitral valve leaflets are mildlythickened. FINDINGS: There is hypodensity in the right thalamus and right occipital lobe which could be due to infarcts of undetermined age. Left atrialabnormality. Allowing for low lung volumes, I doubt overt CHF. Mild-to-moderate cardiomegaly and mild mediastinal vascular engorgement are unchanged. FINAL REPORT INDICATION: Left-sided weakness and neglect with concerning EKG changes and chest tightness. PATIENT/TEST INFORMATION:Indication: Cerebrovascular event/TIA.Height: (in) 66Weight (lb): 231BSA (m2): 2.13 m2BP (mm Hg): 135/93HR (bpm): 129Status: InpatientDate/Time: at 10:22Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Symmetric LVH. Q waves in the anterior leads consistent with myocardialinfarction. No obvious area of hemorrhage noted. Left DVT REASON FOR THIS EXAMINATION: ? Persistent left pleural effusion. Moderate atherosclerotic calcification of the coronary vessels is seen. The pulmonary artery systolic pressure couldnot be determined. No PE detected to the subsegmental levels. Please note that multiple leads and tubes overlie the neck and superior mediastinum, which are of unknown etiology or significance. No acute hemorrhage. No acute hemorrhage. No obvious intracardiac source ofthromboembolism identified in the setting of very limited echocardiographicviews. Suboptimal technicalquality, a focal LV wall motion abnormality cannot be fully excluded. Low voltage in theprecordial leads. Normal caliber main pulmonary arteries, with no pulmonary embolus detected to the subsegmental levels. Q waves in leads V1-V3indicating an anterior myocardial infarction of undetermined age. FINDINGS: The PICC ends at the junction of the upper and middle SVC, and has been pulled back since the prior radiograph. OSSEOUS STRUCTURES: There is no acute fracture. Tricuspid regurgitation ispresent but cannot be quantified. Right lower chest and lateral right hemidiaphragm excluded from the film. PICC ends at upper to mid SVC. Scattered axillary and mediastinal lymph nodes do not meet CT criteria for lymphadenopathy. Pleural effusion is small if any. Increased retrocardiac density and atelectasis in the right cardiophrenic region are unchanged compared with at 4:27 a.m. Cervical fusion hardware again noted. Small left pleural effusion is probably present. Frequent single ventricular premature beats.Probable old anteroseptal myocardial infarction. TECHNIQUE: Axial images of the head were obtained without contrast. CHEST, SINGLE AP PORTABLE VIEW, LORDOTIC POSITIONING: The extreme left costophrenic angle and left lung base are excluded from the film. Possible non-specific ST-T wave changes. CHEST, SINGLE AP PORTABLE VIEW. interval change No contraindications for IV contrast WET READ: GMSj 5:24 PM -No acute intracranial process -Stable hypodensities in the right thalamic and occipital regions - likely infarcts of indeterminate age -No hemorrhage, midline shift or acute large territorial infarction -Moderate mucosal thickening of the ethmoid air cells and sphenoid sinuses (R>L). A PICC line is present -- the tip is not optimally visualized due to underpenetration. There are low inspiratory volumes. TR present - cannot bequantified. NCCT: No acute territorial infarct detected. NCCT: No acute territorial infarct detected. Suboptimal image quality - poorsuprasternal views. COMMENT: This report provided without the availability of 3D reformatted images. No pulmonary embolus is detected to the subsegmental levels. IMPRESSION: No evidence of deep vein thrombosis in either leg. A left-sided pacemaker generator projects leads into the right atrium and ventricle. The left ventricular cavity size is normal. Otherwise, I doubt significant interval change. The intracranial anterior circulation demonstrates patency without stenosis, occlusion or an aneurysm greater than 3 mm in size. FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, femoral, popliteal and tibial veins. Mild central pulmonary vascular congestion with mild interstitial edema. There is mild dependent atelectasis bilaterally, slightly worse at the left base, where there is is pleural thickening and calcifications, probably reflecting chronic post-surgical hemothorax (2:56). Status post sternotomy with mediastinal clips. The aorticvalve leaflets are mildly thickened (?#). Suboptimalimage quality - poor subcostal views. There is marked left ventricular hypertrophy with rapid thinning at the apex. Transvenous right atrial and right ventricular pacer leads are in standard placements. Check Dobbhoff tube placement. No pneumothorax. No pneumothorax. There is mild-to-moderate vallecular residue with solids. | 15 | [
{
"category": "Radiology",
"chartdate": "2189-01-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1222040,
"text": " 3:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? interval change\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 w poss encephalitis\n REASON FOR THIS EXAMINATION:\n ? interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GMSj 5:24 PM\n -No acute intracranial process\n -Stable hypodensities in the right thalamic and occipital regions - likely\n infarcts of indeterminate age\n -No hemorrhage, midline shift or acute large territorial infarction\n -Moderate mucosal thickening of the ethmoid air cells and sphenoid sinuses\n (R>L).\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with possible encephalitis. Evaluation for\n interval change.\n\n COMPARISON: CTA of the head and neck from at 4:25 a.m. and\n outside hospital head CT from at 1:09 a.m.\n\n TECHNIQUE: 64 MDCT axial images of the brain were obtained without\n intravenous contrast.\n\n NON-CONTRAST HEAD CT: There is no evidence of hemorrhage, mass, pr mass\n effect. Hypodensities within the right thalamus and in the right occipital\n region appear unchanged compared to recent prior examinations and likely\n reflect infarcts that are probably subacute. There is unchanged moderate\n proportional enlargement of the ventricles and sulci, findings consistent with\n age-related cortical atrophy. There is no shift of the usually midline\n structures. The suprasellar and basilar cisterns are widely patent. There is\n no scalp hematoma or acute skull fractures. There is moderate mucosal\n thickening of the ethmoid air cells and bilateral sphenoid sinuses, right\n greater than left. The mastoid air cells are well aerated.\n\n IMPRESSION:\n 1. Unchanged hypodensities in the right thalamus and right occipital region\n which likely represent subacute infarcts.\n 2. No evidence of hemorrhage.\n 3. Moderate mucosal thickening of the ethmoid air cells and sphenoid sinuses,\n right greater than left.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1221995,
"text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumonia\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with acute altered mental status, rising WBC\n REASON FOR THIS EXAMINATION:\n evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:59 A.M. \n\n HISTORY: Altered mental status. Rising white count.\n\n IMPRESSION: AP chest compared to :\n\n Low lung volumes and supine positioning make it difficult to say whether mild\n interstitial edema has developed, but I doubt it. Leftward rotation probably\n accounts for increase in size and change in contour of the cardiomediastinal\n silhouette, but mild cardiomegaly is presumed. Transvenous right atrial and\n right ventricular pacer leads are in standard placements. Small left pleural\n effusion is probably present. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-28 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1222371,
"text": " 3:40 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: BILAT LEG PAIN, R/O DVT\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with tenderness in left calf and on foot dorsiflexion.\n Previously had left sided weakness and has been bed bound for several days. ?\n Left DVT\n REASON FOR THIS EXAMINATION:\n ? Left DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 73-year-old man with left calf tenderness and extended bed\n bound. Evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral\n common femoral, femoral, popliteal and tibial veins. Normal flow,\n compression, and augmentation is seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222132,
"text": " 3:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval placement of new Dobhoff tube\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with delirium\n REASON FOR THIS EXAMINATION:\n Eval placement of new Dobhoff tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Delirium, evaluate the new placement of Dobbhoff tube.\n\n CHEST, 1 VW\n\n Compared with earlier the same day, the Dobbhoff tube has been replaced. The\n radiopaque tip now lies in the region of the gastric fundus and GE junction.\n Otherwise, I doubt significant interval change. Please note that multiple\n leads and tubes overlie the neck and superior mediastinum, which are of\n unknown etiology or significance.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222082,
"text": " 4:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 M w/ aseptic meningitis\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Aseptic meningitis. Question interval change.\n\n CHEST, SINGLE AP PORTABLE VIEW, LORDOTIC POSITIONING:\n\n The extreme left costophrenic angle and left lung base are excluded from the\n film.\n\n A PICC line is present -- the tip is not optimally visualized due to\n underpenetration. A left-sided dual-lead pacemaker is present, with lead tips\n over right atrium and right ventricle.\n\n There are low inspiratory volumes. The patient is status post sternotomy, with\n mediastinal clips. There is increased retrocardiac density, consistent with\n left lower lobe collapse and/or consolidation and patchy opacity in the right\n cardiophrenic region. Mild prominence of pulmonary vasculature is noted, but\n likely accentuated due to technique and low lung volumes. Possible small left\n pleural effusion. Incidental note is made of fusion hardware in the lower\n cervical spine.\n\n Compared with at 10:07 a.m., I doubt significant interval change.\n\n"
},
{
"category": "Echo",
"chartdate": "2189-01-26 00:00:00.000",
"description": "Report",
"row_id": 90008,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA.\nHeight: (in) 66\nWeight (lb): 231\nBSA (m2): 2.13 m2\nBP (mm Hg): 135/93\nHR (bpm): 129\nStatus: Inpatient\nDate/Time: at 10:22\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: Symmetric LVH. Normal LV cavity size. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Overall\nnormal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. TR present - cannot be\nquantified. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality - poor\nsuprasternal views. Suboptimal image quality - patient unable to cooperate.\n\nConclusions:\nThe left atrium is mildly dilated. There is 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%). The aortic\nvalve leaflets are mildly thickened (?#). There is no aortic valve stenosis.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is\npresent but cannot be quantified. The pulmonary artery systolic pressure could\nnot be determined. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. No obvious intracardiac source of\nthromboembolism identified in the setting of very limited echocardiographic\nviews.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222512,
"text": " 1:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: To assess line position\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with PICC on right now 3cm out ? Midline vs central\n REASON FOR THIS EXAMINATION:\n To assess line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess PICC line.\n\n COMPARISONS: Chest radiograph, .\n\n FINDINGS: The PICC ends at the junction of the upper and middle SVC, and has\n been pulled back since the prior radiograph. A pacemaker is in place with the\n leads seen in the left ventricle and right atrium. Sternal wires are intact\n and midline. Multiple clips are seen within the mediastinum. Since the prior\n radiograph, there has been resolution of the right pleural effusion.\n Opacification of the left base likely represents a persistent left effusion.\n There is no evidence of pulmonary edema.\n\n IMPRESSION:\n 1. PICC ends at upper to mid SVC.\n 2. Persistent left pleural effusion. Resolution of right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-24 00:00:00.000",
"description": "CTA NECK W&W/OC & RECONS",
"row_id": 1221885,
"text": " 4:25 AM\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \n Reason: Dissection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with symptoms of left-sided weakness and neglect along with\n concerning EKG changes and chest tightness\n REASON FOR THIS EXAMINATION:\n Dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SAT 4:57 AM\n Limited examination due to patient motion. NCCT: No acute territorial infarct\n detected. Chronic parietal lobe focal encephalomalacia unchanged from the\n reference CT exam performed earlier. No acute hemorrhage. CTA: No dissection,\n flow limiting stenosis, or aneurysm detected. Multiple subcentimeter thyroid\n nodules. 3D reconstructions pending.\n WET READ VERSION #1 LLTc SAT 4:56 AM\n Limited examination due to patient motion. NCCT: No acute territorial infarct\n detected. Chronic parietal lobe focal encephalomalacia unchanged from the\n reference CT exam performed earlier. No acute hemorrhage. CTA: No dissection,\n flow limiting stenosis, or aneurysm detected. 3D reconstructions pending.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CTA of the head and neck.\n\n CLINICAL INFORMATION: Patient with left-sided weakness and neglect concerning\n for EKG changes, for further evaluation.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Following this using departmental protocol CT angiography of the head and neck\n was acquired.\n\n FINDINGS: There is hypodensity in the right thalamus and right occipital lobe\n which could be due to infarcts of undetermined age. The examination is\n limited due to patient motion, evaluation for the upper part of the brain is\n limited. Moderate to severe brain and medial temporal atrophy seen. No\n obvious area of hemorrhage noted.\n\n CT ANGIOGRAPHY OF THE NECK: There is a tortuous proximal left vertebral\n artery seen. Both vertebral arteries otherwise are patent of the neck with\n normal appearance of the distal intracranial vertebral and basilar arteries.\n\n\n The carotid arteries are patent bilaterally without stenosis, occlusion or\n dissection. There are post-operative changes identified in the neck.\n\n The intracranial anterior circulation demonstrates patency without stenosis,\n occlusion or an aneurysm greater than 3 mm in size.\n\n IMPRESSION:\n 1. Limited head CT shows hypodensity in the right thalamus and right\n occipital region due to infarcts of undetermined age. MRI could provide more\n (Over)\n\n 4:25 AM\n CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS Clip # \n Reason: Dissection\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n information but patient may not likely be able to get it secondary to presence\n of a pacemaker. Followup study could be helpful.\n 2. CT angiography of the head and neck demonstrates no evidence of high-grade\n stenosis or occlusion. Vascular calcifications seen.\n 3. Tracheal calcifications and post-operative changes in cervical spine are\n noted in the neck.\n\n COMMENT: This report provided without the availability of 3D reformatted\n images. When these images are available and if additional information is\n obtained, an addendum will be given to this report.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-24 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1221886,
"text": " 4:25 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evidence of dissection\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with symptoms of left-sided weakness and neglect along with\n concerning EKG changes and chest tightness\n REASON FOR THIS EXAMINATION:\n Evidence of dissection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc SAT 5:27 AM\n 1. No dissection. No PE detected to the subsegmental levels.\n 2. Trace left pleural effusion with adjacent atelectasis.\n 3. Mild central pulmonary vascular congestion with mild interstitial edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left-sided weakness and neglect with concerning EKG changes and\n chest tightness.\n\n No comparison studies available.\n\n TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were obtained\n following the uneventful administration of 70 mL of Omnipaque intravenous\n contrast. Coronal and sagittal reformations were performed at 5-mm slice\n thickness.\n\n CHEST CT WITH IV CONTRAST:\n Multiple subcentimeter thyroid nodules are present (2:5). The thyroid gland\n is not enlarged. Scattered axillary and mediastinal lymph nodes do not meet\n CT criteria for lymphadenopathy.\n\n A left-sided pacemaker generator projects leads into the right atrium and\n ventricle. There is marked left ventricular hypertrophy with rapid thinning\n at the apex. Moderate atherosclerotic calcification of the coronary vessels is\n seen. There is no pericardial effusion. The left atrium is mildly enlarged.\n\n The thoracic aorta demonstrates minimal atherosclerotic calcification, and is\n normal in caliber. There is no dissection. The main pulmonary arteries are\n normal in caliber. No pulmonary embolus is detected to the subsegmental\n levels.\n\n Trace left pleural effusion is present (2:63). There is mild dependent\n atelectasis bilaterally, slightly worse at the left base, where there is is\n pleural thickening and calcifications, probably reflecting chronic\n post-surgical hemothorax (2:56). There is no pneumothorax.\n\n The patient is status post cholecystectomy. Included views of the liver,\n pancreas, stomach, spleen, adrenal glands, and splenic flexure are normal.\n\n OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or\n lytic lesions are identified. Extensive bridging anterior osteophytosis\n throughout thoracic spine is compatible with DISH (401B:27).\n (Over)\n\n 4:25 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Evidence of dissection\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. No aortic dissection or aneurysm. Normal caliber main pulmonary arteries,\n with no pulmonary embolus detected to the subsegmental levels.\n 2. Multiple subcentimeter thyroid nodules.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1222019,
"text": " 10:14 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 47 cm Picc in right brachial vein, need Picc tip placement\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 47 cm Picc in right brachial vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:07 A.M., \n\n HISTORY: Evaluate PICC line placement.\n\n IMPRESSION: AP chest compared to at 4:59 a.m.\n\n New right PICC line ends in the mid SVC. Mild-to-moderate cardiomegaly and\n mild mediastinal vascular engorgement are unchanged. Lungs are low in volume\n but clear. Pleural effusion is small if any. No pneumothorax. No pulmonary\n edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222109,
"text": " 11:35 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Check placement of Dobhoff tube\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with confusion, agitation, weakness, unable to take PO.\n REASON FOR THIS EXAMINATION:\n Check placement of Dobhoff tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Confusion, agitation, weakness. Check Dobbhoff tube placement.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Right lower chest and lateral right hemidiaphragm excluded from the film.\n\n Dobbhoff tube is present. However, it is looped over the level of the fundus,\n with the radiopaque tip now superimposed over the lower neck and\n it requires repositioning.\n\n Right-sided PICC line present, tip not optimally visualized but likely\n overlying the distal SVC near the RA junction.\n\n Dual-lead left-sided pacemaker present with lead tips over right atrium and\n right ventricle. Status post sternotomy with mediastinal clips.\n Cardiomediastinal silhouette is prominent,but unchanged. Allowing for low\n lung volumes, I doubt overt CHF. Increased retrocardiac density and\n atelectasis in the right cardiophrenic region are unchanged compared with\n at 4:27 a.m. Cervical fusion hardware again noted.\n\n IMPRESSION:\n\n Abnormal placement of Dobbhoff tube -- the tube reaches the gastric fundus,\n where there is a \"hairpin\" bend of the tube, then courses back up the\n esophagus, so that the radiopaque tube tip overlies the neck.\n\n Findings discussed with Dr. at approximately 1:45 p.m. on\n the day of the exam (, phone).\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-28 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1222338,
"text": " 1:23 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for aspiration\n Admitting Diagnosis: QUESTION OF STROKE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with 73 year old man with acute mental status change, clinical\n evidence of aspiration\n REASON FOR THIS EXAMINATION:\n eval for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute mental status change and clinical evidence of aspiration.\n\n SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing videofluoroscopy was\n performed in conjunction with speech and swallow division. Multiple\n consistencies of barium were administered. There was intermittent aspiration\n of thin liquids as well as penetration with thin and nectar thin liquids and\n nectar. There is mild-to-moderate vallecular residue with solids.\n\n IMPRESSION: Intermittent aspiration with thin liquids as well as penetration\n with thin liquids and nectar. For details, please refer to speech and swallow\n note in OMR.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2189-01-29 00:00:00.000",
"description": "Report",
"row_id": 237317,
"text": "Artifact is present. Sinus rhythm. The P-R interval is prolonged. Left atrial\nabnormality. Q waves in the anterior leads consistent with myocardial\ninfarction. Possible non-specific ST-T wave changes. Low voltage in the\nprecordial leads. Compared to the previous tracing of the rate is slower\nand ventricular ectopy is no longer present. Low precordial lead voltage is\nnew.\n\n"
},
{
"category": "ECG",
"chartdate": "2189-01-26 00:00:00.000",
"description": "Report",
"row_id": 237550,
"text": "Regular supraventricular rhythm - because of baseline artifact, atrial activity\ncannot be clearly determined. Frequent single ventricular premature beats.\nProbable old anteroseptal myocardial infarction. Compared to the previous\ntracing of rate is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2189-01-24 00:00:00.000",
"description": "Report",
"row_id": 237551,
"text": "Sinus rhythm. Baseline artifact. Two ventricular premature beats are noted.\nA-V conduction delay. Left atrial abnormality. Q waves in leads V1-V3\nindicating an anterior myocardial infarction of undetermined age. The baseline\nartifact makes further interpretation difficult. Compared to the previous\ntracing the Q waves in leads V1 and V2 are new but could be again related to\nlead placement. Previously, only Q waves in lead V1 were noted. The\npreviously noted Q waves in leads III and aVF are there but difficult to\ndiscern due to the baseline artifact.\n\n"
}
] |
21,202 | 104,041 | 57-year-old man with AML s/p matched unrelated allogeneic stem cell transplant in , complicated by GVHD on chronic prednisone with multiple admission for infections now presents with somnolence in the setting if increased sedative medication use, hypercarbic respiratory distress, cough and CXR with LLL consolidation found to have segmental PE. | Mild symmetric left ventricular hypertrophy withpreserved global biventricular systolic function.Compared with the prior study (images reviewed) of , the rightventricular cavity is now dilated with free wall hypokinesis c/w an acutepulmonary process (e.g., pulmonary embolism, bronchospasm, etc. Bilateral small pleural effusions, left greater than right, with bilateral lower lobe compressive atelectasis are redemonstrated. The right ventricular cavity is mildly dilated with moderateglobal free wall hypokinesis. Resting tachycardia(HR>100bpm).Conclusions:The left atrium is mildly dilated. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - ventilator. Dual-channel right supraclavicular central venous set ends close to the superior cavoatrial junction. Sinus tachycardia persists. Incidental note of retro-aortic left renal vein is made. Hepatic steatosis. Hepatic steatosis. Regular narrow complex rhythm, probably sinus or atrialtachycardia. Right ventricular cavity dilation withfree wall hypokinesis. There appears to bemore ST segment depression in leads V3-V6 without diagnostic interim change. Extensive bilateral consolidation and peribronchovascular nodular opacities consistent with multifocal infection and aspiration and bilateral small effusions have not significantly changed since the prior study. Bilateral small effusions and right lower lobe pulmonary emboli. Moderate coronary arterial calcification is present. The liver demonstrates diffuse hypoattenuation, consistent with hepatic steatosis. Moderate body wall edema, and asymmetric left lateral abdominal wall edema, relate to third spacing. FINDINGS: In comparison with the study of , the diffuse bilateral pulmonary opacification is essentially unchanged, presenting a pattern of multifocal pneumonia. Bilateral small pleural effusions have slightly worsened. Bilateral femoral head avascular necrosis is unchanged. Pulmonary emboli within the right lower lobar and segmental arteries are redemonstrated. Coronary arteries are moderately calcified. An infrarenal IVC filter is present. No resting LVOT gradient.RIGHT VENTRICLE: Mildly dilated RV cavity. Stable lung base findings include, lingular pneumonia and bibasal peribronchovascular nodular opacities suggestive of aspiration. Known right lower lobe pulmonary emboli not evaluated on this examination. 2:52 PM CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # Reason: VENOGRAM to eval IVC filter Admitting Diagnosis: ALTERED MENTAL STATUS MEDICAL CONDITION: RLL PE REASON FOR THIS EXAMINATION: VENOGRAM to eval IVC filter No contraindications for IV contrast WET READ: FRI 7:03 PM 1. Moderate global RV free wallhypokinesis.AORTIC VALVE: Normal aortic valve leaflets (?#). TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal notch to the upper abdomen without administration of IV contrast and 1.25 mm slice collimation. Pulmonary edema is less likely. New confluent ground-glass opacities in the apical right and left upper lobes. Areas of consolidation in the left upper lobe, lingula, and lower lobes has not worsened; however, there is developing bronchiectasis in lower lobes consistent with post-infectious bronchiectasis. FINDINGS: Status post removal of right subclavian vascular catheter. FINDINGS: Right sided dialysis catheter tip terminates in the low SVC. Dual-channel right supraclavicular central venous set ends in the region of the superior cavoatrial junction. Filling defects compatible with pulmonary embolism are seen in a lobar, segmental and subsegmental level in the right lower lobe. FINAL REPORT CHEST CTA WITH CONTRAST INDICATION: Patient with AML, tachycardia, hypotension, somnolence, rule out PE. COMPARISON: Left lower extremity venous ultrasound of . TECHNIQUE: Bilateral lower extremity venous ultrasound. Mild bronchial wall thickening and interstitial abnormalities secondary to GVHD persist. Mild enlargement of the main pulmonary arteries. There is near-complete opacification of the right and partial opacification of the left mastoid air cells. PE Admitting Diagnosis: ALTERED MENTAL STATUS Contrast: OMNIPAQUE Amt: 100 FINAL REPORT (Cont) Small bilateral pleural effusions are new. FINDINGS: Grayscale, color, and spectral Doppler images were obtained of the right and left common femoral, femoral, and popliteal veins. Both the initial and repeat images were degraded by patient motion artifact . FINDINGS: Portable radiograph of the chest demonstrates a new right subclavian line in standard position, terminating in the upper-to-mid SVC. Slight interval improvement in previously noted airspace disease within the right upper lobe. The most proximal portion of the pulmonary embolus is peripheral raising the question if this pulmonary embolism could be chronic. PE No contraindications for IV contrast WET READ: KKgc WED 11:41 PM Pulmonary emboli seen in the right lower lobar pulmonary artery extending into two segmental arteries. CONCLUSION: New right PICC line in standard position, terminating in the mid-to-upper SVC. DVT FINAL REPORT INDICATION: Tachycardia and hypoxemia, evaluate for DVT. Smaller region of consolidation in the right lower lung medially is either a second focus of pneumonia or atelectasis. Right lower lobe lobar to subsegmental pulmonary acute embolism. COMPARISON: Head CT dated . OSSEOUS STRUCTURES: Post-surgical changes and compression deformities of the thoracic spine are stable. There is fluid in the bilateral mastoid air cells as well as mucosal thickening in the right maxillary sinus, in the anterior ethmoid air cells and mild mucosal thickening in the frontal sinuses. Paranasal sinus disease and bilateral mastoid air cell fluid. Also, bilateral pleural effusions, with left greater than right, are again demonstrated on this study. Small left and possible small right pleural effusions are unchanged. Mild mucosal thickening is seen in both maxillary, ethmoid and frontal sinuses. Mild mid thoracic vertebral compressions and thoracic spine fixation hardware, stable. | 21 | [
{
"category": "Echo",
"chartdate": "2148-10-02 00:00:00.000",
"description": "Report",
"row_id": 84148,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary embolus. Right ventricular function.\nHeight: (in) 64\nWeight (lb): 250\nBSA (m2): 2.15 m2\nBP (mm Hg): 101/70\nHR (bpm): 125\nStatus: Inpatient\nDate/Time: at 15:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\npt supine, intubated on vent\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator. Resting tachycardia\n(HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and global systolic function (LVEF>55%).\nDue to suboptimal technical quality, a focal wall motion abnormality cannot be\nfully excluded. The right ventricular cavity is mildly dilated with moderate\nglobal free wall hypokinesis. The aortic valve leaflets (?#) appear\nstructurally normal with good leaflet excursion. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The pulmonary artery\nsystolic pressure could not be determined. There is an anterior space which\nmost likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Right ventricular cavity dilation with\nfree wall hypokinesis. Mild symmetric left ventricular hypertrophy with\npreserved global biventricular systolic function.\n\nCompared with the prior study (images reviewed) of , the right\nventricular cavity is now dilated with free wall hypokinesis c/w an acute\npulmonary process (e.g., pulmonary embolism, bronchospasm, etc.).\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256591,
"text": " 1:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fluid overload vs. pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57-year-old man with AML s/p matched unrelated allogeneic stem cell transplant\n in , complicated by GVHD on chronic prednisone with multiple admission for\n infections now presents with somnolence in the setting if increased sedative\n medication use, hypercarbic respiratory distress, cough and CXR with LLL\n consolidation.\n REASON FOR THIS EXAMINATION:\n fluid overload vs. pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:58 P.M. ON \n\n HISTORY: 57-year-old man with AML and stem cell transplant.\n Graft-versus-host disease, on prednisone. Now somnolent.\n\n IMPRESSION: AP chest compared to :\n\n Progressive heterogeneous opacification in the left mid and lower lung zone is\n most likely pneumonia worsening since . There could be a second\n focus of right infrahilar pneumonia, also advancing. Cardiomediastinal\n silhouette is essentially unchanged over several years. Dual-channel right\n supraclavicular central venous set ends close to the superior cavoatrial\n junction. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2148-10-09 00:00:00.000",
"description": "Report",
"row_id": 225516,
"text": "Baseline artifact. Regular narrow complex rhythm, probably sinus or atrial\ntachycardia. Borderline intraventricular conduction delay. Probable\nST-T wave abnormalities. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-10-06 00:00:00.000",
"description": "Report",
"row_id": 225517,
"text": "Sinus tachycardia persists. Diffuse non-specific ST-T wave changes. No\nsignificant change compared to previous tracing of .\n\n"
},
{
"category": "ECG",
"chartdate": "2148-10-02 00:00:00.000",
"description": "Report",
"row_id": 225518,
"text": "Sinus tachycardia with increase in rate as compared to the previous tracing\nof . Diffuse non-specific ST-T wave changes are more prominent in the\ncontext of wandering baseline and much baseline artifact. There appears to be\nmore ST segment depression in leads V3-V6 without diagnostic interim change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256959,
"text": " 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? Interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with likely fungal PNA.\n REASON FOR THIS EXAMINATION:\n ? Interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Likely fungal pneumonia, to assess for change.\n\n FINDINGS: In comparison with the study of , the diffuse bilateral\n pulmonary opacification is essentially unchanged, presenting a pattern of\n multifocal pneumonia. Some element of elevated pulmonary venous pressure may\n be present.\n\n Extensive fixation devices about the cervical and upper thoracic spine are\n again seen.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-04 00:00:00.000",
"description": "CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS",
"row_id": 1256771,
"text": " 2:52 PM\n CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # \n Reason: VENOGRAM to eval IVC filter\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n RLL PE\n REASON FOR THIS EXAMINATION:\n VENOGRAM to eval IVC filter\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 7:03 PM\n 1. No evidence of IVC or iliac vein thrombosis. IVC filter in place.\n 2. Extensive bilateral consolidation and peribronchovascular nodular\n opacities consistent with multifocal infection and aspiration and bilateral\n small effusions have not significantly changed since the prior study.\n 3. Hepatic steatosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with pulmonary embolism with an IVC filter in\n place, to assess for IVC thrombosis.\n\n COMPARISON: CT abdomen and pelvis without contrast and CTA of the\n chest .\n\n DLP: .80 mGy-cm.\n\n TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained\n prior to and after the intravenous administration of 150 cc of Omnipaque\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: Multiple heterogeneous areas of consolidation in the lingula, is\n most suggestive of pneumonia. Peribronchial nodular opacities in both lung\n bases are likely due to aspiration. Bilateral small pleural effusions, left\n greater than right, with bilateral lower lobe compressive atelectasis are\n redemonstrated. Pulmonary emboli within the right lower lobar and segmental\n arteries are redemonstrated. These findings have not significantly changed\n since the prior study. Moderate coronary arterial calcification is present.\n There is no pericardial effusion.\n\n The liver demonstrates diffuse hypoattenuation, consistent with hepatic\n steatosis. There is no intra- or extra-hepatic biliary dilatation.\n Hyperdense material within the gallbladder may reflect vicarious excretion of\n contrast or gallbladder sludge. The adrenal glands, spleen, and pancreas are\n normal. Mild fat stranding in the retroperitoneum, likely relates to third\n spacing. An infrarenal IVC filter is present. The IVC is patent throughout\n without evidence of thrombosis. The common iliac and external iliac veins are\n patent, without evidence of deep venous thrombosis. Incidental note of\n retro-aortic left renal vein is made. The stomach, small and large bowel\n loops, including the appendix is normal. There is no intra-abdominal free\n fluid or air. Moderate body wall edema, and asymmetric left lateral abdominal\n wall edema, relate to third spacing.\n (Over)\n\n 2:52 PM\n CT ABD & PELVIS W & W/O CONTRAST, ADDL SECTIONS Clip # \n Reason: VENOGRAM to eval IVC filter\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is decompressed with\n wall thickening. Small locules of air within the bladder relates to the Foley\n catheter. The prostate, rectum, and sigmoid colon are unremarkable. No\n significant pelvic lymphadenopathy or free fluid is seen.\n\n BONES AND SOFT TISSUES: Multiple bilateral healing rib fractures are seen in\n the imaged lower ribs. Dense sclerosis at the right iliac , likely a bone\n island is unchanged. Old fractures of bilateral inferior pubic rami are seen.\n Multiple thoracic and lumbar vertebral body compressions involving L3, L1,\n T12, and T7 vertebral bodies are similar. Post-vertebroplasty changes are\n seen in L5 vertebra. Bilateral femoral head avascular necrosis is unchanged.\n\n IMPRESSION:\n 1. No evidence of IVC or iliac vein thrombosis. IVC filter in place.\n 2. Stable lung base findings include, lingular pneumonia and bibasal\n peribronchovascular nodular opacities suggestive of aspiration. Bilateral\n small effusions and right lower lobe pulmonary emboli.\n 3. Hepatic steatosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256909,
"text": " 4:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with intubation\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation.\n\n FINDINGS: In comparison with the study of , there may be further\n increase in the bilateral pulmonary opacifications, especially at the right\n base. The findings are again consistent with widespread pneumonia, though\n there could be some element of vascular congestion. Extensive spinal fixation\n devices are again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256827,
"text": " 5:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA vs Edema\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man s/p air embolism, continued poor respiratory status\n REASON FOR THIS EXAMINATION:\n PNA vs Edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Radiograph of one day earlier.\n\n FINDINGS: Widespread combined alveolar and interstitial opacities affecting\n the left lung to a greater degree than the right have progressed in the\n interval, particularly in the right lower lung where there is also an\n increasing pleural effusion with adjacent consolidation and/or atelectasis.\n Small left pleural effusion also appears increased from prior radiograph.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256838,
"text": " 11:21 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate for rib fracture, pneumothorax\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man immunocompromised with pneumonia, s/p air embolism ,\n continued poor respiratory status now with sudden L sharp chest pain with\n movement reproducable with palpation\n REASON FOR THIS EXAMINATION:\n please evaluate for rib fracture, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, WITH COMPARISON STUDY OF EARLIER THE SAME\n DATE\n\n FINDINGS: Right pleural effusion has decreased in size with associated\n improvement in adjacent right basilar atelectasis. Multifocal areas of\n heterogeneous consolidation involving the left lung to a greater degree than\n the right, have slightly improved. A small hyperlucency is present in the\n periphery of the left upper lobe at the level of the second and third anterior\n ribs, but no discrete visceral pleural line is identified. This may represent\n an area of spared lung parenchyma from the presumed multifocal pneumonia, but\n attention to this area on short-term followup radiograph may be helpful to\n exclude an atypical presentation of pneumothorax, given clinical suspicion for\n this entity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-06 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1256851,
"text": " 5:45 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please evaluate for fungal pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man immunocompromised with PE, pneumonia, and respiratory distress\n REASON FOR THIS EXAMINATION:\n please evaluate for fungal pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GMSj SUN 8:01 PM\n rogressive multilobar consolidation concerning for worsening pneumonia. New\n confluent ground-glass opacities in the apical right and left upper lobes.\n New tree-in- opacities predominantly in the right upper and right middle\n lobe. Persistent bibasilar consolidation may be a combination of pneumonia\n and atelectasis given signs of volume loss. Unchanged small bilateral pleural\n effusions. Known right lower lobe pulmonary emboli not evaluated on this\n examination. Findings are non-specific for a particular pathogen and overall\n reflect endobronchial spread of infection. Fungal pneumonia remains within\n the differential though CT findings are non-specific. The presence of pleural\n effusions makes PCP much less likely. D/w Dr. at 7:55 pm on\n by telephone. GSenapati \n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST WITHOUT CONTRAST\n\n INDICATION: Patient immunocompromised with PE, pneumonia, respiratory\n distress, evaluation for fungal pneumonia.\n\n COMPARISON: Multiple chest CTs from to recent CTA of .\n\n TECHNIQUE:\n\n Axial helical MDCT images were obtained from the suprasternal notch to the\n upper abdomen without administration of IV contrast and 1.25 mm slice\n collimation. Multiplanar reformatted images in coronal and sagittal axes were\n generated.\n\n FINDINGS:\n\n LUNG AND AIRWAYS:\n\n There is increase of ground-glass opacities with interlobular septal\n thickening, mainly in upper lobes but also in the lingula.\n\n Bilateral widespread tree-in- has also increased.\n\n Areas of consolidation in the left upper lobe, lingula, and lower lobes has\n not worsened; however, there is developing bronchiectasis in lower lobes\n consistent with post-infectious bronchiectasis.\n\n (Over)\n\n 5:45 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please evaluate for fungal pneumonia\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Secretions are seen in the airways, but the airways are patent until\n subsegmental level.\n\n MEDIASTINUM:\n\n There is no pathologic superclavicular, mediastinal, or axillary lymph node\n enlargement by CT size criteria, all the small lymph nodes are unchanged.\n\n Mediastinal lipomatosis is probably explained by corticosteroid. Bilateral\n small pleural effusions have slightly worsened. There is no pericardial\n effusion. Coronary arteries are moderately calcified.\n\n UPPER ABDOMEN: Liver steatosis is severe. The spleen is not enlarged.\n\n OSSEOUS STRUCTURES: Multiple costal fractures and compression fractures of\n the spine are stable. There is no new lesion.\n\n CONCLUSION:\n\n Patient is known with AML and fever.\n\n 1. Bilateral ground-glass opacities with interlobular septal thickening have\n significantly worsened since . They are predominant in upper\n lobes. The most likely diagnosis is an infectious process (pneumocystis,\n viral) considering that they were already present on , /.\n Pulmonary edema is less likely. Although bacterial or fungal infection cannot\n be excluded, the radiologic features are not classic for those pathogens.\n\n 2. Developing post-infectious bronchiectasis are new in lower lobes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1256882,
"text": " 1:06 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 42cm right basilic. \n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with new picc\n REASON FOR THIS EXAMINATION:\n 42cm right basilic. \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 58-year-old man with new right PICC placement.\n\n COMPARISON: Comparison is made to same-day radiograph of the chest from 8\n hours prior. This study is read in conjunction with CT of the chest from\n .\n\n FINDINGS: Portable radiograph of the chest demonstrates a new right\n subclavian line in standard position, terminating in the upper-to-mid SVC.\n There is no pneumothorax. Low lung volumes persist and are unchanged since\n the prior study along with widespread bilateral opacifications with the left\n greater than right. Also, bilateral pleural effusions, with left greater than\n right, are again demonstrated on this study.\n\n CONCLUSION: New right PICC line in standard position, terminating in the\n mid-to-upper SVC. Otherwise, unchanged since the prior radiograph.\n\n The above findings were communicated to IV nurse, , at 13:38 via\n telephone by Dr. , at the time of discovery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-02 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1256635,
"text": " 12:49 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with tachycardia, hypoxemia\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachycardia and hypoxemia, evaluate for DVT.\n\n COMPARISON: Left lower extremity venous ultrasound of .\n\n TECHNIQUE: Bilateral lower extremity venous ultrasound.\n\n FINDINGS: Grayscale, color, and spectral Doppler images were obtained of the\n right and left common femoral, femoral, and popliteal veins. Normal flow,\n compressibility, augmentation, and waveforms are demonstrated. No\n intraluminal thrombus is identified. Normal color flow is visualized in the\n posterior tibial and peroneal veins bilaterally. Visualization of the\n peroneal veins is somewhat limited due to calf edema and limited acoustic\n penetration.\n\n IMPRESSION: No deep venous thrombosis in right or left lower extremity.\n Bilateral calf edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-07 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1256892,
"text": " 3:21 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: ? fungal process\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: GADAVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with fungemia, HA, decreased hearing\n REASON FOR THIS EXAMINATION:\n ? fungal process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 58-year-old man with fungemia, headache, decreased\n hearing. Question of fungal process.\n\n COMPARISON: Head CT dated .\n\n TECHNIQUE: MRI of the head was performed prior to and following the\n intravenous administration of 10 mL Gadovist utilizing standard department\n protocol.\n\n FINDINGS: There is a small punctate focus of slow diffusion in the left\n parietal lobe deep white matter. Elsewhere, there are a few scattered\n punctate foci of FLAIR signal abnormality in the periventricular and\n subcortical white matter bilaterally which are non-specific. There is no\n evidence of hemorrhage. The images are degraded by motion artifact,\n particularly on the post-contrast sequences, but there is no obvious area of\n abnormal enhancement.\n\n There is fluid in the bilateral mastoid air cells as well as mucosal\n thickening in the right maxillary sinus, in the anterior ethmoid air cells and\n mild mucosal thickening in the frontal sinuses. The orbital contents are\n unremarkable.\n\n IMPRESSION:\n 1. Punctate focus of slow diffusion in the left parietal lobe deep white\n matter compatible with infarct.\n 2. Images are degraded by motion artifact, but there is no evidence for\n abnormal enhancement. No definite findings to suggest fungal infection.\n 3. Paranasal sinus disease and bilateral mastoid air cell fluid.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256522,
"text": " 11:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pneumonia vs chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 58M with sob\n REASON FOR THIS EXAMINATION:\n eval pneumonia vs chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n TECHNIQUE: Upright AP view of the chest.\n\n COMPARISON: Chest radiograph and chest CTA from .\n\n FINDINGS:\n\n Right sided dialysis catheter tip terminates in the low SVC. Lung volumes are\n low. Heart size is normal. The mediastinal and hilar contours are unchanged.\n There is crowding of the bronchovascular structures, but no frank pulmonary\n edema is present. Previously noted patchy opacities in the right upper lobe\n have improved. There is worsening ill-defined opacification within the left\n lung base. No large pleural effusion or pneumothorax is demonstrated.\n Bronchial wall thickening is most pronounced within the left lung base and\n likely reflective of bronchitis. Areas of callus formation are noted\n involving multiple bilateral ribs. Partially imaged is fusion hardware within\n the cervical and thoracic spine.\n\n IMPRESSION:\n\n 1. Worsening opacification in the left lung base with associated bronchial\n wall thickening concerning for infection.\n\n 2. Slight interval improvement in previously noted airspace disease within the\n right upper lobe.\n\n 3. No definite pulmonary edema.\n\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-05 00:00:00.000",
"description": "REMOVE TUNNELED CENTRAL W/O PORT",
"row_id": 1256901,
"text": " 6:27 PM\n DIALYSIS REMOVE Clip # \n Reason: Please remove tunnel line. Patient had placed in by\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ********************************* CPT Codes ********************************\n * REMOVE TUNNELED CENTRAL W/O PO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old BMT patient in FOR THIS EXAMINATION:\n Please remove tunnel line. Patient had placed in by IR. Must be\n removed for yeast growing in blood, sputum and urine.\n ______________________________________________________________________________\n FINAL REPORT\n 15:15\n Request for a triple lumen tunneled line removal for septic\n patient was placed on evening. As patient was on heparin,\n and this has to be stopped for procedure, arrangements were made\n to stop it morning . Case was discussed with attending Dr\n , who suggested to remove the line on the\n floor. The case was reviewed, as well as potential complications.\n\n After the heparin was stopped for 3.5 hours on the 20th, I came\n into the ICU for removal of the line. Procedure was explained for the patient.\n\n\n Steril field was created, 10 ml of local lidocaine were injected for\n anesthesia, and blunt dissection with was performed around the cuff.\n Singificant fibrosis was noted and gentle traction was applied.\n As the traction was applied, I continued dissection with the\n . At a point, the catheter ripped, and the proximal piece\n just came out. Imediatelly pressure was applied in the distal\n burried fragment, at the level of the clavicle. Following,\n oxygen saturation of the patient dropped, and a nurse came in and\n also helped holding the burried piece of the catheter. Patient\n was placed on left lateral decubitus (right side up). Dr was\n immediately informed. Following, oxygen saturation of the patient improved\n and sat was 98% on oxygen mask. Vascular surgery was also\n immediately contact who came in and perfomed blunt dissection and\n the whole catheter was removed. Tip was sent to culture. Catheter piece was\n sent to analysis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256610,
"text": " 10:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Worsening/new infiltrate?\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with pneumonia, now febrile, somnolent most of day after pain\n meds so concern for aspiration.\n REASON FOR THIS EXAMINATION:\n Worsening/new infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:22 P.M. ON \n\n HISTORY: 58-year-old man with pneumonia, febrile and somnolent.\n\n IMPRESSION: AP chest compared to , 1:58 p.m.:\n\n Previous pulmonary vascular congestion has improved, but there is still very\n extensive consolidation in the left lung due to pneumonia, without\n improvement, possibly worsened. Smaller region of consolidation in the right\n lower lung medially is either a second focus of pneumonia or atelectasis.\n Mild cardiomegaly is stable. Dual-channel right supraclavicular central\n venous set ends in the region of the superior cavoatrial junction. No\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256813,
"text": " 5:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: air embolism, line location\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with AML had hypoxia during right tunnelled line removal\n REASON FOR THIS EXAMINATION:\n air embolism, line location\n ______________________________________________________________________________\n WET READ: MDAg SAT 7:39 PM\n no evidence of retained fragment. bilateral opacities L>R may be edema or\n infection\n -MAgarwal d/w Dr. by phone at 7:30pm .\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n FINDINGS: Status post removal of right subclavian vascular catheter.\n Widespread heterogeneous combined alveolar and interstitial opacities\n affecting the left lung to a greater degree than the right, have progressed in\n the interval, and may represent a multifocal pneumonia with or without\n coexisting pulmonary edema. Pulmonary hemorrhage is also possible in the\n appropriate clinical setting.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1256667,
"text": " 9:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? hemorrhage or mass lesion\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with AML, headaches, tachycardia, hypotension, somnolence, TTE\n with large hypokinetic RV concerning for PE\n REASON FOR THIS EXAMINATION:\n ? hemorrhage or mass lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:40 AM\n 1. Extremely limited study due to motion artifact, within this limitation, no\n acute intracranial pathology.\n 2. Multifocal paranasal sinus and bilateral mastoid air cell opacification.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with AML, tachycardia, hypotension and\n somnolence.\n\n COMPARISON: CT head without contrast, .\n\n TECHNIQUE: Multidetector CT imaging of the head was obtained without\n intravenous contrast. Sagittal and coronal reformations were performed and\n reviewed. Both the initial and repeat images were degraded by patient motion\n artifact\n .\n FINDINGS: Limited study due to motion artifact. Within this limitation,\n there is no large intracranial hemorrhage, edema, mass or mass effect. The\n -white matter differentiation is preserved. The ventricles and sulci are\n mildly enlarged, consistent with mild involutional changes. Basal cisterns\n are normal. Mild mucosal thickening is seen in both maxillary, ethmoid and\n frontal sinuses. Bilateral symmetric exophthalmos is unchanged. Bilateral\n intraocular lens implants are noted.\n There is near-complete opacification of the right and partial opacification of\n the left mastoid air cells.\n\n IMPRESSION:\n 1. Limited study due to motion artifact, within this limitation, no acute\n intracranial pathology.\n 2. Multifocal paranasal sinus and bilateral mastoid air cell opacification.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-02 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1256669,
"text": " 10:48 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with AML, tachycardia, hypotension, somnolence, TTE with large\n hypokinetic RV concerning for PE\n REASON FOR THIS EXAMINATION:\n ? PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc WED 11:41 PM\n Pulmonary emboli seen in the right lower lobar pulmonary artery extending into\n two segmental arteries. Assessment of upper lobe vessels significantly limited\n by motion. No evidence of right heart strain. Mild enlargement of the main\n pulmonary arteries. Multifocal new areas of heterogeneous parenchymal\n consolidation seen in both lungs,predominantly the left lung, are worrisome\n for infection. Dense bilateral lower lobe consolidations with small pleural\n effusions. Mild bronchial wall thickening and interstitial abnormalities\n secondary to GVHD persist. Bilateral healing rib fractures. Mild mid thoracic\n vertebral compressions and thoracic spine fixation hardware, stable.\n Kkaliannan d/w Dr. at 11:35 p.m, immediately after discovery.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CTA WITH CONTRAST\n\n INDICATION: Patient with AML, tachycardia, hypotension, somnolence, rule out\n PE.\n\n COMPARISON: Multiple chest CTs from to .\n\n TECHNIQUE:\n\n Axial helical MDCT images were obtained from the suprasternal notch to the\n upper abdomen with administration of IV contrast following the CTPA protocol.\n Multiplanar reformatted images were generated.\n\n FINDINGS:\n\n HEART AND GREAT VESSELS:\n\n Multiple motion artifacts are mostly in bilateral upper lobe arteries.\n Filling defects compatible with pulmonary embolism are seen in a lobar,\n segmental and subsegmental level in the right lower lobe. The most proximal\n portion of the pulmonary embolus is peripheral raising the question if this\n pulmonary embolism could be chronic. This is new since . There is\n no dilatation of main pulmonary artery or right heart chamber. There is no\n acute aortic syndrome. Coronary artery calcification is stable. There is no\n pericardial effusion.\n\n MEDIASTINUM:\n (Over)\n\n 10:48 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: ? PE\n Admitting Diagnosis: ALTERED MENTAL STATUS\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Small bilateral pleural effusions are new. There is no pathologic\n superclavicular, mediastinal or axillary lymph node enlargement by CT size\n criteria. Mediastinal lipomatosis is unchanged.\n\n LUNGS AND AIRWAYS:\n\n Worsening of multifocal consolidations, more severe in left upper lobe and\n bilateral lower lobes, is compatible with an infectious process. Small\n residual nodules in right middle lobe and right lower lobe described on\n previous exam is hard to assess throughout those changes.\n\n The airways are patent to the subsegmental level.\n\n UPPER ABDOMEN:\n\n This study is not tailored for assessment for intra-abdominal organs. Liver\n steatosis is severe. The spleen is not enlarged.\n\n OSSEOUS STRUCTURES:\n\n Post-surgical changes and compression deformities of the thoracic spine are\n stable. There are also bilateral rib fractures.\n\n CONCLUSION:\n\n 1. Right lower lobe lobar to subsegmental pulmonary acute embolism. The most\n proximal portion of the filling defect is peripheral in the artery raising the\n question if this could be chronic but new since . There is no\n dilatation of main pulmonary artery or right heart .\n\n 2. Worsening of bilateral multifocal pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1256859,
"text": " 4:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for worsening pna vs. pulmonary edema\n Admitting Diagnosis: ALTERED MENTAL STATUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man immunocompromised with pneumonia, s/p air embolism, continued\n poor respiratory status. Worsening CXR on .\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening pna vs. pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: Radiograph of one day earlier.\n\n FINDINGS: Lung volumes are slightly lower compared to prior study.\n Cardiomediastinal contours are stable in appearance allowing for this factor.\n Widespread heterogeneous pulmonary opacities affecting the left lung to a\n greater degree than the right have worsened in the lower lung since the prior\n study, and likely represent a multilobar pneumonia. Small left and possible\n small right pleural effusions are unchanged.\n\n\n"
}
] |
7,136 | 194,998 | Upon admission to the the patient went immediately to cardiac catheterization. At that time his cardiac output was 4.3, a cardiac index of 2.47, pulmonary capillary wedge pressure of 7, pulmonary artery pressure of 22/16, left ventricular end-diastolic pressure of 11, right atrium of 10, right ventricle of 23/10, AO of 122/75. His ejection fraction was calculated at 40% with anterior apical dyskinesis. His coronaries showed the left anterior descending artery had mild haziness in the mid portion but no focal stenosis. His left circumflex and right coronary arteries had no disease. The patient was extubated on without complications and started on a steroid taper for his chronic obstructive pulmonary disease flare. He was continued on his 10-day course of levofloxacin started at for presumed community-acquired bronchitis. He responded well to these therapies with a respiratory examination significant for good air movement and only occasional wheezes by the time of discharge. After catheterization, the patient was given post catheterization heparin for approximately 48 hours to treat for presumed unstable angina in the setting of no occlusion noted on catheterization. He tolerated the institution of beta blocker well and was discharged on p.o. atenolol without evidence of bronchospasm. | PT S/P CATH- RT GROIN STABLE/PULSES PALPABLE- VSS.HR- 60-70'S SR, BP- 118-126/65.REMAINS ON CAPTOPRIL 6.25/LOPRESSOR 12.5/ASA.CYCLING CPK'S. ECG done. EXTUBATE THIS AM AS CHF/COPD/ABG'S ALLOW. DeepT wave inversions in leads V1-V6 consistent with anterior ischemia.TRACING #1 The tip of the orogastric tube is again seen to be well past mid-line, possibly post-pyloric. remains intubated and on vent. Q-T interval prolongation. Q-T interval prolongation. albuterol/atrovent given for copd hx. Heart size and mediastinal and hilar contours are within normal limits. First degree A-V block. First degree A-V block. Given Ativan 1mg x 1 for discomfort from ETT.Neuro: A&Ox3, cooperative. Found to be in hypercarbic resp failure ABG: 241/66/7.27, improved initially on Bipap, then again had increased SOB, required intubation. CCU NSG PROGRESS NOTE 11P-7A/ R/I MI; S/P CATHS- INUTUBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA. EKG changes found on evaluation of SOB, T wave changes seen, ruled in for MI by and Troponin level. resp. PT REMAINS REMAINS STABLE ON PRESSURE SUPPORT.MINIMAL SUCTIONING - BRONCHOSPASTIC WITH ANY SX.I/E WHEEZES.CHANGED TO ELIXIR , REMAIN ON NEBS/O2 SATS 99-100% CURRENTLY.GOOD U.O-= NO DIURESIS THIS SHIFT.GU- SEE ABOVE= UO- 50-60/HOUR.IVF S/P CATH DECREASED TO 75/HOUR.ID AFEBRILE. IMPRESSION: 1) Satisfactory position of ET tube. carept. weaned to psv 10/5 with good vols. Heart size and mediastinal and hilar contours are within normal limits and stable. Cath today showed questionable lesion in LAD otherwise clean.PMH: HTN, COPDAll: NKDAReview of systems:CV: returned from cath lab, alert, VS stable,(see careveiw for objective data), R groin with venous and art sheath, pulled at 7PM. PORTABLE CHEST: The endotracheal tube is in satisfactory position, unchanged. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. 2) NG tube tip may be post-pyloric. Started on captopril and will get lopressor at MN. Deep T wave inversions inthe limb leads and V2-V6. The orogastric tube courses below the diaphragm and crosses mid-line, with the tip possibly in the post-pyloric position. bbs wheezes. HEPARIN GTT RESTARTED AFTER SHEATH PULL.HEMODYNAMICS STABLE CURRENTLY.RECEIVED 80 KCL FOR K- 2.9 ON EVES. Intubated at OSH for COPD flare. BP 110/60, HR 60. Marked Q-T interval prolongation.Compared to the previous tracing of the Q-T interval has diminished butremains markedly prolonged.TRACING #2 Pulses palpable. FINAL REPORT HISTORY: COPD, intubated for respiratory distress. PT VERY ALERT= ASKING FOR MEDICATION FOR SLEEP- GIVEN 1 ATIVAN- SHORT ACTING.ASKING FOR BEDPAN LATER IN SHIFT- NO SUCCESS.GI- NEW OG TUBE PLACED- OLD ONE GUMMED OUT.CXR (+) GOOD PLACEMENT.A/ PT HEMODYNAMICALLY STABLE S/P CARDIAC CATH.R/I FOR MIPLAN TO ?INTERVENE ON HAZY LAD. Soft restraints for protection of tubes.GI: ogt in place. plan to wean and possible extubate this a.m. PORTABLE CHEST: The endotracheal tube is in satisfactory position approximately 3-4 cm above the carina. Suctioned for minimal white secretions. FINAL REPORT HISTORY: 81-year-old male with COPD flair, endotracheal and orogastric tube placement. IMPRESSION: 1) Stomach is distended with gas, possibly due to post-pyloric positioning of orogastric tube tip. Was presumed to have bronchitis, treated with abx and steroids. Denies CP/SOB. K+ 2.9, 40 mEq in maintainance fluid, 40 mEq po x2 to be given.Resp: Vented initially on AC, changed to PS 15/5PEEP, RR 16-20 with VT 5-600. CONTINUE TO MAXIMIZE RPP - INCREASE CAPTOPRIL AS TOLERATED.KEEP PT COMFORTABLE/SAFE.INFORM PT/FAMILY AS TO PLAN OF CARE/PROGRESS.INCREASE ACTIVITY PER R/O MI PROTOCOL ONCE EXTUBATED. Left axis deviation. The stomach is distended with gas. Comparison to prior study from . The lungs are clear and there are no effusions. The lungs are clear and there are no effusions. REASON FOR THIS EXAMINATION: SP OGT placement in man with COPD intubated for resp distres. Compared to the previous tracingof there are no diagnostic interim changes. Wife in this eve.Status: full code. No complications. BS(+)GU: foleySoc: married, no children. very much awake and following commands. 3) No evidence of pneumonia. Please evaluate for ET/OG tube placement and evidence of pneumonia. 2) No evidence of failure, pneumonia or other acute cardiopulmonary disease. The right costophrenic angle is off the film and cannot be evaluated. REASON FOR THIS EXAMINATION: 81 yo man admitted to CCU from cath lab. 6:16 PM CHEST (PORTABLE AP) Clip # Reason: 81 yo man admitted to CCU from cath lab. 1:20 AM CHEST (PORTABLE AP) Clip # Reason: SP OGT placement in man with COPD intubated for resp distres MEDICAL CONDITION: 81 year old man with COPD flare and acute coronary syndrome. Intubated at OSH fo MEDICAL CONDITION: 81 year old man with COPD flare and acute coronary syndrome. There are no prior studies for comparison. No stool. | 8 | [
{
"category": "Nursing/other",
"chartdate": "2143-08-16 00:00:00.000",
"description": "Report",
"row_id": 1357281,
"text": "resp. care\npt. remains intubated and on vent. weaned to psv 10/5 with good vols. very much awake and following commands. albuterol/atrovent given for copd hx. bbs wheezes. plan to wean and possible extubate this a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2143-08-15 00:00:00.000",
"description": "Report",
"row_id": 1357279,
"text": "CCU Nursing Adm note:\n81 yr old male transfered from Hospital today for cath, S/P non Q-wave MI, adm to OSH on after 3-4 days of cough and increased SOB. Found to be in hypercarbic resp failure ABG: 241/66/7.27, improved initially on Bipap, then again had increased SOB, required intubation. EKG changes found on evaluation of SOB, T wave changes seen, ruled in for MI by and Troponin level. Was presumed to have bronchitis, treated with abx and steroids. Cath today showed questionable lesion in LAD otherwise clean.\n\nPMH: HTN, COPD\n\nAll: NKDA\n\nReview of systems:\n\nCV: returned from cath lab, alert, VS stable,(see careveiw for objective data), R groin with venous and art sheath, pulled at 7PM. Pulses palpable. No complications. Denies CP/SOB. ECG done. Started on captopril and will get lopressor at MN. BP 110/60, HR 60. K+ 2.9, 40 mEq in maintainance fluid, 40 mEq po x2 to be given.\n\nResp: Vented initially on AC, changed to PS 15/5PEEP, RR 16-20 with VT 5-600. Suctioned for minimal white secretions. Given Ativan 1mg x 1 for discomfort from ETT.\n\nNeuro: A&Ox3, cooperative. Soft restraints for protection of tubes.\n\nGI: ogt in place. No stool. BS(+)\n\nGU: foley\n\nSoc: married, no children. Wife in this eve.\n\nStatus: full code.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2143-08-16 00:00:00.000",
"description": "Report",
"row_id": 1357280,
"text": "CCU NSG PROGRESS NOTE 11P-7A/ R/I MI; S/P CATH\n\nS- INUTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT S/P CATH- RT GROIN STABLE/PULSES PALPABLE- VSS.\nHR- 60-70'S SR, BP- 118-126/65.\nREMAINS ON CAPTOPRIL 6.25/LOPRESSOR 12.5/ASA.\nCYCLING CPK'S. HEPARIN GTT RESTARTED AFTER SHEATH PULL.\nHEMODYNAMICS STABLE CURRENTLY.RECEIVED 80 KCL FOR K- 2.9 ON EVES.\n\n PT REMAINS REMAINS STABLE ON PRESSURE SUPPORT.\nMINIMAL SUCTIONING - BRONCHOSPASTIC WITH ANY SX.\nI/E WHEEZES.CHANGED TO ELIXIR , REMAIN ON NEBS/\nO2 SATS 99-100% CURRENTLY.\nGOOD U.O-= NO DIURESIS THIS SHIFT.\n\nGU- SEE ABOVE= UO- 50-60/HOUR.\nIVF S/P CATH DECREASED TO 75/HOUR.\n\nID AFEBRILE.\n\n PT VERY ALERT= ASKING FOR MEDICATION FOR SLEEP- GIVEN 1 ATIVAN- SHORT ACTING.\nASKING FOR BEDPAN LATER IN SHIFT- NO SUCCESS.\n\nGI- NEW OG TUBE PLACED- OLD ONE GUMMED OUT.\nCXR (+) GOOD PLACEMENT.\n\nA/ PT HEMODYNAMICALLY STABLE S/P CARDIAC CATH.\nR/I FOR MI\n\nPLAN TO ?INTERVENE ON HAZY LAD. EXTUBATE THIS AM AS CHF/COPD/ABG'S ALLOW. CONTINUE TO MAXIMIZE RPP - INCREASE CAPTOPRIL AS TOLERATED.\nKEEP PT COMFORTABLE/SAFE.\nINFORM PT/FAMILY AS TO PLAN OF CARE/PROGRESS.\nINCREASE ACTIVITY PER R/O MI PROTOCOL ONCE EXTUBATED.\n"
},
{
"category": "ECG",
"chartdate": "2143-08-17 00:00:00.000",
"description": "Report",
"row_id": 152773,
"text": "Normal sinus rhythm. Q-T interval prolongation. Deep T wave inversions in\nthe limb leads and V2-V6. Left axis deviation. Compared to the previous tracing\nof there are no diagnostic interim changes.\n\n"
},
{
"category": "ECG",
"chartdate": "2143-08-16 00:00:00.000",
"description": "Report",
"row_id": 152774,
"text": "Normal sinus rhythm. First degree A-V block. Marked Q-T interval prolongation.\nCompared to the previous tracing of the Q-T interval has diminished but\nremains markedly prolonged.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2143-08-15 00:00:00.000",
"description": "Report",
"row_id": 152775,
"text": "Normal sinus rhythm. First degree A-V block. Q-T interval prolongation. Deep\nT wave inversions in leads V1-V6 consistent with anterior ischemia.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-08-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 743098,
"text": " 6:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 81 yo man admitted to CCU from cath lab. Intubated at OSH fo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with COPD flare and acute coronary syndrome.\n REASON FOR THIS EXAMINATION:\n 81 yo man admitted to CCU from cath lab. Intubated at OSH for COPD flare.\n Please evaluate for ET/OG tube placement and evidence of pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 81-year-old male with COPD flair, endotracheal and orogastric tube\n placement.\n\n There are no prior studies for comparison.\n\n PORTABLE CHEST: The endotracheal tube is in satisfactory position\n approximately 3-4 cm above the carina. The orogastric tube courses below the\n diaphragm and crosses mid-line, with the tip possibly in the post-pyloric\n position. Heart size and mediastinal and hilar contours are within normal\n limits. The lungs are clear and there are no effusions.\n\n IMPRESSION:\n\n 1) Satisfactory position of ET tube.\n\n 2) NG tube tip may be post-pyloric.\n\n 3) No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2143-08-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 743110,
"text": " 1:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SP OGT placement in man with COPD intubated for resp distres\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with COPD flare and acute coronary syndrome.\n REASON FOR THIS EXAMINATION:\n SP OGT placement in man with COPD intubated for resp distres.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: COPD, intubated for respiratory distress.\n\n Comparison to prior study from .\n\n PORTABLE CHEST: The endotracheal tube is in satisfactory position, unchanged.\n The tip of the orogastric tube is again seen to be well past mid-line,\n possibly post-pyloric. The stomach is distended with gas. Heart size and\n mediastinal and hilar contours are within normal limits and stable. The lungs\n are clear and there are no effusions. The right costophrenic angle is off the\n film and cannot be evaluated.\n\n IMPRESSION:\n\n 1) Stomach is distended with gas, possibly due to post-pyloric positioning of\n orogastric tube tip.\n\n 2) No evidence of failure, pneumonia or other acute cardiopulmonary disease.\n\n"
}
] |
75,001 | 181,537 | 63 y/o F w/ CAD on /, hx ovarian CA, hep C, BRCA s/p modified radical mastectomy c/b hematoma, on wound vac. | Left ventricular conduction delay withleft axis deviation. Non-specific ST-T wave changewith QTc interval prolongation. Left atrial abnormality. Right axillary clips are visualized. Compared to the previous tracing of atrialfibrillation is not seen. rt axillary surgical clips. Baseline artifact. Lt presumed chest wall drain. coronary stent. , M.D. , M.D. Intraventricular conductiondelay with QRS duration of 122 milliseconds. Sinus bradycardia. minimal pleuroparenchymal scarring at apices. Clinicalcorrelation is suggested. REASON FOR THIS EXAMINATION: New afib with RVR. Leftward axis at minus 26 degrees.Left bundle-branch block. Coronary stent is visualized. Slow R wave progression could be due to theintraventricular conduction delay, although underlying anterior wall myocardialinfarction is not excluded. Compared to the previous tracing of thepatient has gone from sinus bradycardia at 58 per minute to atrialfibrillation. Atrial fibrillation, average ventricular rate 134. The heart is upper limits normal in size. There is some minimal biapical scarring. 7:36 PM CHEST (PORTABLE AP) Clip # Reason: New afib with RVR. Approved: MON 3:26 PM RADLINE ; A radiology consult service. The above described findings are consistent with no evidence of metastatic osseous lesions. A drain is seen overlying the left anterior chest. QTc interval prolongation is more apparent. IMPRESSION: No evidence for metastatic osseous lesions. There is mild focus of uptake around bilateral shoulder joints and along the left knee consistent with degenerative changes. To hear preliminary results, prior to transcription, call the Radiology Listen Line . FINAL REPORT CHEST ON HISTORY: Modified radical mastectomy with AFib FINDINGS: There are no old films available for comparison. The kidneys and urinary bladder are visualized, the normal route of tracer excretion. There is no other diagnostic interval change. INTERPRETATION: Whole body images of the skeleton were obtained in anterior and posterior projections There is mild scoliosis with stress related degenerative changes. WET READ: AGLc SUN 12:52 AM no pna or pulm edema seen. There is no infiltrate or effusion. No comparisons are available. Admitting Diagnosis: LEFT BREAST CANCER/SDA MEDICAL CONDITION: 63 year old woman with modified radical mastectomy, now with afib with RVR. | 4 | [
{
"category": "Radiology",
"chartdate": "2178-05-08 00:00:00.000",
"description": "BONE SCAN",
"row_id": 1137799,
"text": "BONE SCAN Clip # \n Reason: 63 YR OLD WOMAN WITH BREAST CANCER STAGING\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 20.5 mCi Tc-m MDP ();\n HISTORY: 63 yo woman with breast cancer staging.\n\n INTERPRETATION:\n\n Whole body images of the skeleton were obtained in anterior and posterior\n projections\n There is mild scoliosis with stress related degenerative changes. There is mild\n focus of uptake around bilateral shoulder joints and along the left knee\n consistent with degenerative changes.\n\n The above described findings are consistent with no evidence of metastatic\n osseous lesions.\n\n No comparisons are available.\n\n The kidneys and urinary bladder are visualized, the normal route of tracer\n excretion.\n\n IMPRESSION: No evidence for metastatic osseous lesions.\n\n\n\n\n\n , M.D.\n , M.D. Approved: MON 3:26 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": "2178-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1135991,
"text": " 7:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: New afib with RVR.\n Admitting Diagnosis: LEFT BREAST CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with modified radical mastectomy, now with afib with RVR.\n REASON FOR THIS EXAMINATION:\n New afib with RVR.\n ______________________________________________________________________________\n WET READ: AGLc SUN 12:52 AM\n no pna or pulm edema seen. minimal pleuroparenchymal scarring at apices. rt\n axillary surgical clips. Lt presumed chest wall drain. coronary stent.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Modified radical mastectomy with AFib\n\n FINDINGS: There are no old films available for comparison. A drain is seen\n overlying the left anterior chest. Coronary stent is visualized. There is\n some minimal biapical scarring. Right axillary clips are visualized. The\n heart is upper limits normal in size. There is no infiltrate or effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2178-05-08 00:00:00.000",
"description": "Report",
"row_id": 231062,
"text": "Baseline artifact. Sinus bradycardia. Left ventricular conduction delay with\nleft axis deviation. Left atrial abnormality. Non-specific ST-T wave change\nwith QTc interval prolongation. Slow R wave progression could be due to the\nintraventricular conduction delay, although underlying anterior wall myocardial\ninfarction is not excluded. Compared to the previous tracing of atrial\nfibrillation is not seen. QTc interval prolongation is more apparent. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2178-04-25 00:00:00.000",
"description": "Report",
"row_id": 231266,
"text": "Atrial fibrillation, average ventricular rate 134. Intraventricular conduction\ndelay with QRS duration of 122 milliseconds. Leftward axis at minus 26 degrees.\nLeft bundle-branch block. Compared to the previous tracing of the\npatient has gone from sinus bradycardia at 58 per minute to atrial\nfibrillation. There is no other diagnostic interval change.\n\n"
}
] |